HISTORY:
Gestational Age: weeks /7, last menstrual period on
G P A
Blood type: Rh
First trimester ultrasound:
First trimester bleeding for
Type: , clots
Pattern:
, , ,
Other elements:
EXAM:
General appearance:
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Abdomen: , , ,
Pelvic:
- External genitalia: ,
- Vagina: , discharge ,
- Cervix:
- Uterus: ,
- Adnexa: -R , -L
- Tests performed: , , , , vaginal pH , whiff test with KOH
- Performed with chaperone
ASSESSMENT:
DDx:
PLAN:
- Blood work: , , ,
- Pelvic ultrasound
- Rest
- Expectant management
-
-
-
- Dilation and curettage
- Repeat βhCG in 48 hours
- Referral to obstetrician
- Referral to psychologist
- Follow-up in
- Return if symptoms worsen, if new symptoms develop such as heavy bleeding or fever, or if emotional distress occurs
- Go to ER if severe abdominal pain, severe bleeding, or fever occurs