[##]-year-old female G[#]P[####] at
[##] weeks and [##] days gestational age with history and exam consistent with
threatened abortion.
Initial consideration in this patient
included ectopic pregnancy, inevitable, incomplete, active or threatened
spontaneous abortion, septic abortion, subchorionic hemorrhage, hematoma, endometritis, pelvic inflammatory disease (PID), and
urinary tract infection (UTI) among others.
Patient presented with [vaginal
bleeding/pelvic pain] without evidence of hemodynamic instability or
symptomatic anemia. Patient
[reported/denied] previous ultrasound with evidence of intrauterine
pregnancy. Patient noted to have [A/B/O
+/-] blood type with [no indication for RhoGAM/RhoGAM given prior to discharge
from ED]. No evidence of brisk active
bleeding on pelvic exam in the ED.
Cervix noted to be closed on exam making inevitable abortion
unlikely. No mass or focal tenderness on
bimanual or ultrasound. [Formal/Bedside]
ultrasound with [no clear] evidence of intrauterine pregnancy [with reassuring
fetal heart rate and gross movement]. Doubt septic abortion based on absence of fever, significant uterine tenderness on exam, or evidence of purulent vaginal discharge. Doubt significant ovarian cyst or torsion at this time based on
[history/exam/ultrasound]. No evidence
of cervical motion tenderness to suggest PID at this time. [Case discussed with Dr. NAME of Obstetrics with PLAN.]
Discussed return precautions, specifically for evidence of
worsening bleeding or pain, symptomatic treatment, and follow up with
Obstetrics within [2-3 days/1 week] for further evaluation, and the patient
demonstrated understanding and agreement.
