MDM - Ovarian Torsion

[##]-year-old female with history and exam consistent with [right/left-sided] ovarian torsion.

Initial consideration in this patient included ovarian torsion, ovarian cyst (functional, follicular, and hemorrhagic), ovarian neoplasm, polycystic ovarian syndrome (PCOS), pregnancy, ectopic pregnancy, appendicitis, diverticulitis, other intra-abdominal etiologies, urinary tract infection (UTI), ureteral stone and pyelonephritis, and vaginitis among others.

Patient presented with [right-sided/left-sided] abdominal and pelvic pain [with/without] a history of prior ovarian cyst.  Patient was noted to have [no] evidence of peritonitis on exam in the ED [prompting early discussion with gynecology due to concern for ovarian torsion/bedside FAST exam due to concern for ruptured ectopic].  [Due to evidence of acute abdomen and high likelihood of ovarian torsion, gynecology was consulted prior to obtaining imaging.]  A pelvic [speculum/bimanual] exam was performed and notable for [right-sided/left-sided tenderness/mass/cervical motion tenderness (CMT)].  A pregnancy test was obtained and noted to be negative making pregnancy-related complications unlikely [specify torsion in pregnant patient].  A pelvic ultrasound was obtained and [notable for ## cm right-sided/left-sided ovarian cyst/evidence of dminished blood flow on Doppler ultrasound concerning for torsion/increased ovarian size concerning for ovarian torsion].  Patient [noted to have evidence of torsion on ultrasoungd/felt to be high risk for torsion despite equivocal findings on ultrasound/based on history and exam] with case discussed with Dr. [Name] of Gynecology who examined the patient in the ED.  

Patient noted to have no evidence of significant anemia on [exam/hemoglobin and hematocrit].  Patient noted to have no evidence of coagulopathy on [history/exam/labs].  No evidence of UTI on urinalysis in the ED.  Vaginitis considered unlikely based on history and exam.

We discussed plan for [confirmatory ultrasound/admission for likely operative management in the OR/admission for serial exams and further management per gynecology].  Patient reported improvement in pain with [treatment] in the ED, and demonstrated understanding and agreement with planned admission.

MDM - Ovarian Cyst

[##]-year-old female with [right/left lower quadrant abdominal/pelvic pain] with history and exam consistent with [right/left hemorrhagic] ovarian cyst.

Initial consideration in this patient included ovarian cyst (functional, follicular, and hemorrhagic), ovarian mass, polycystic ovarian syndrome (PCOS), ovarian neoplasm, pregnancy, ectopic pregnancy, appendicitis, diverticulitis, other intra-abdominal etiologies, urinary tract infection (UTI), ureteral stone and pyelonephritis, and vaginitis among others.

Patient presented with [right-sided/left-sided] abdominal and pelvic pain [with/without] a history of prior ovarian cyst.  Patient was noted to have [no] evidence of peritonitis on exam in the ED [prompting early discussion with gynecology due to concern for ovarian torsion/bedside FAST exam due to concern for ruptured ectopic].  A pelvic [speculum/bimanual] exam was performed and notable for [right-sided/left-sided tenderness/mass/cervical motion tenderness (CMT)].  A pregnancy test was obtained and noted to be negative making pregnancy-related complications unlikely.  A pelvic ultrasound was obtained and [notable for ## cm follicular/hemorrhagic right-sided/left-sided ovarian cyst/free fluid and findings consistent with ruptured ovarian cyst without evidence of ovarian torsion].  Patient felt to be at [low/moderate] risk for ovarian torsion based on ovarian cyst size [less than 2 cm (very low risk)/less than 4 cm (lower risk)/greater than 4 cm (higher risk)/greater than 6 cm (high risk consider discussion with gynecology)] with discussion [of specific return precautions/with Dr. Name of Gynecology with recommendations].  Ovarian neoplasm felt to be [unlikely/less likely/possible] in patient who is [still having regular menses/postmenopausal] with discussion of appropriate follow up.

Patient noted to have no evidence of significant anemia on [exam/hemoglobin and hematocrit].  Patient noted to have no evidence of coagulopathy on [history/exam/labs].  No evidence of UTI on urinalysis in the ED.  Vaginitis considered unlikely based on history and exam.  Patient noted to have improvement in pain with [NSAIDs/etc.] in the ED prior to discharge.

Prior to discharge, we discussed return precautions, specifically for evidence of anemia from significant bleeding and ovarian torsion, symptomatic treatment [with specify interventions], and follow up with [primary care doctor/Gynecology] within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement with this plan.

https://www.aafp.org/afp/2016/0415/p676.html

MDM - Dysfunctional Uterine Bleeding (DUB)

[##]-year-old female with history and exam consistent with likely dysfunctional uterine bleeding.

Initial consideration in this patient included pregnancy, ectopic pregnancy, non-structural (coagulopathy, ovulatory dysfunction, endometrial, iatrogenic) and structural causes (polyp, adenomyosis, leiomyoma, malignancy or hyperplasia), urinary tract infection (UTI), vaginitis, [differentia diagnosis], and vaginal, perineal, and cervical trauma among others.

Patient presented with [menorrhagia (>7 days (prolonged) or >80 mL/day (excessive) uterine bleeding at regular intervals/metrorrhagia (irregular vaginal bleeding outside the normal cycle)/menometrorrhagia (excessive irregular vaginal bleeding)] suggestive of likely dysfunctional uterine bleeding.  Pelvic exam performed with [dark red blood in vaginal vault without evidence of brisk or active bleeding].  A pregnancy test was obtained and noted to be negative making pregnancy-related complications unlikely. 

Given evidence of [mild/moderate/severe] uterine bleeding on evaluation in the ED, we [discussed/initiated] treatment with [iron supplementation and Ibuprofen/initiation of oral contraceptive/Medroxyprogesterone intramuscular injection/tranexamic acid (TXA) and consulted Gynecology].

Patient noted to have no evidence of significant anemia on [exam/hemoglobin and hematocrit].  Patient noted to have no evidence of coagulopathy on [history/exam/labs].  Patient noted to have no evidence of endocrine disorder on history or exam.  No evidence of UTI on urinalysis in the ED.  Vaginitis considered unlikely based on history and exam.

Prior to discharge, we discussed return precautions, specifically for evidence of worsening or persistent bleeding, treatment [with specify interventions], and follow up with [primary care doctor/Gynecology] within [2-3 days/1 week] for further evaluation, and the patient demonstrated understanding and agreement with this plan.

https://wikem.org/wiki/Vaginal_Bleeding_(Non-Pregnant)
http://www.emdocs.net/non-pregnant-vaginal-bleeding/

MDM - Ectopic Pregnancy

[##]-year-old female G[#]P[####] at [##] weeks and [##] days gestational age with history and exam consistent with ectopic pregnancy.

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] and [known/unknown] pregnancy.  Patient was deemed to be [hemodynamically stable/unstable] on arrival in the ED [and initial resuscitation initiated].  A bedside FAST exam was performed and [noted to be negative/noted to be positive increasing concern for ectopic pregnancy].  Initial labs were obtained to include a urine pregnancy test, a serum quantitative hCG, ]and type and screen/cross/etc.].  A [bedside/formal] ultrasound was obtained [with no clear evidence of intrauterine pregnancy (IUP)/free fluid in pelvis/etc.].

Cervix noted to be closed on exam making inevitable abortion unlikely.  No mass or focal tenderness on bimanual or ultrasound.  No evidence of brisk active bleeding on pelvic exam in the ED.  Patient noted to have [A/B/O +/-] blood type with [no indication for RhoGAM/RhoGAM given prior to discharge from ED].

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.

Ectopic pregnancy [confirmed/highly suspected] based on findings noted on ultrasound.  Quantitative hCG of [###] mIU/mL noted to be [above/below] the discriminatory zone.  Case discussed with Dr. [NAME] of Obstetrics with discussion of [plan to evaluate the patient for possible laparotomy given evidence of instability/plan to evaluate the patient for potential medical management with Methotrexate].

[After discussion with Dr. NAME of Obstetrics the patient was felt to be appropriate for outpatient medical management given absence of absolute contraindications (including current breastfeeding, underlying hepatic, renal, hematologic, cardiac or pulmonary disease, or known hypersensitivity) or relative contraindications (adnexal mass >3.5 cm in largest diameter, presence of fetal heart rate, free fluid in the pouch of Douglas, quantitative hCG >5000 mIU/mL).  We discussed strict return precautions for worsening pain, syncope, or other symptoms suggestive of ruptured ectopic pregnancy with the patient who demonstrated understanding.  We discussed the importance of follow up at 4 and 7 days for repeat hCG levels to ensure satisfactory decline in hCG level (at least 15% between days 4 and 7).  Close follow up was planned with Obstetrics prior to discharge.]

[After discussion with Dr. NAME of Obstetrics the patient was deemed to be appropriate for operative management.  The patient was counseled on the risks, benefits and alternatives to operative management, and demonstrated understanding with planned admission/Given emergent nature of illness and noted instability on presentation, emergency consent was felt to be implied.  Crossmatched/Emergency release blood transfusion was initiated in the ED prior to transfer.]

http://www.emdocs.net/obcast-ectopic-pregnancy/

https://www.mdcalc.com/pregnancy-due-dates-calculator

MDM - Threatened Abortion (Miscarriage)

[##]-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.

https://www.mdcalc.com/pregnancy-due-dates-calculator

Discharge Instructions - Hyperemesis Gravidarum

As discussed in the Emergency Department prior to discharge, you have been diagnosed with hyperemesis gravidarum.  Hyperemesis gravidarum is a condition that causes frequent vomiting (throwing up) in pregnant women.  It is like morning sickness, except the symptoms are much more severe.

Morning sickness is the nausea and vomiting that many women have during pregnancy.  Even though it is called "morning" sickness, symptoms can happen any time of day.

Women with hyperemesis gravidarum vomit every day, often many times a day.  Women can lose weight and get dehydrated because they are vomiting so much.

Symptoms of dehydration include:

    -Urinating less often than usual

    -Having dark yellow urine

    -Feeling dizzy when standing up

    -Weight loss

Symptoms of hyperemesis gravidarum usually start during the first 2 to 3 months of pregnancy.  Most women feel better by the middle of their pregnancy.  But some women feel sick until late in the pregnancy.

To feel better, you can try the following:

-Eat as soon as you feel hungry, or even before you feel hungry.

-Snack often and eat small meals.  The best foods to eat are high in protein or carbohydrates, and low in fat.  These include crackers, bread, pretzels, nuts, and low-fat yogurt.

-Avoid foods that are spicy, greasy, or acidic (such as oranges).

-Drink cold, clear beverages, such as sports drinks and ginger ale.  Avoid coffee.  Also, try to drink between meals, rather than with a meal.

-Suck on popsicles or ginger-flavored lollipops.

-Brush your teeth right after you eat.

-Avoid lying down right after you eat.

-Take your vitamins at bedtime with a snack, not in the morning

-Avoid things in your environment that upset your stomach, such as stuffy rooms, strong smells, hot places, or loud noises.

-Have someone make your meals for you.

-Wear "acupressure" bands on your wrists.  These are special bands that can help with morning or motion sickness.

Treatment depends on how severe your symptoms are.  If you are dehydrated or have lost a lot of weight, you will probably need to be treated in the hospital with:

    -Fluids that go into your vein through a tube called an "IV"

    -Medicines to help stop your nausea and vomiting

If this treatment doesn't work, your doctor can feed you through a tube that goes in your nose and down into your stomach or through a vein.

Babies born to women with hyperemesis gravidarum for the entire pregnancy are a little more likely to be smaller than average.  But otherwise, the condition doesn't seem to cause problems.  Taking medicines for nausea and vomiting during the pregnancy should not affect the baby either since your doctor will select medications that are safe in pregnancy.

Return to the Emergency Department for inability to tolerate fluids by mouth despite treatment, abdominal or pelvic pain, vaginal bleeding, not passing urine for more than 6 hours despite multiple attempts, or any new or concerning symptoms.

Discharge Instructions - Pregnancy Nausea and Vomiting

As discussed in the Emergency Department prior to discharge, you have been diagnosed with nausea and vomiting in pregnancy.  Morning sickness is the nausea and vomiting that many women have during pregnancy.  Even though it is called "morning" sickness, symptoms can happen any time of day.  Nausea and vomiting of pregnancy commonly occur between 5 and 18 weeks of pregnancy.  Between 50 and 90 percent of women with normal pregnancies have some degree of nausea, with or without vomiting.  The severity of these symptoms can vary.

Women with nausea and vomit every day or many times a day are at risk of becoming dehydrated.  

Symptoms of dehydration include:

    -Urinating less often than usual

    -Having dark yellow urine

    -Feeling dizzy when standing up

    -Weight loss

To feel better, you can try the following:

-Eat as soon as you feel hungry, or even before you feel hungry.

-Snack often and eat small meals.  The best foods to eat are high in protein or carbohydrates, and low in fat.  These include crackers, bread, pretzels, nuts, and low-fat yogurt.

-Avoid foods that are spicy, greasy, or acidic (such as oranges).

-Drink cold, clear beverages, such as sports drinks and ginger ale.  Avoid coffee.  Also, try to drink between meals, rather than with a meal.

-Suck on popsicles or ginger-flavored lollipops.

-Brush your teeth right after you eat.

-Avoid lying down right after you eat.

-Take your vitamins at bedtime with a snack, not in the morning

-Avoid things in your environment that upset your stomach, such as stuffy rooms, strong smells, hot places, or loud noises.

-Have someone make your meals for you.

-Wear "acupressure" bands on your wrists.  These are special bands that can help with morning or motion sickness.

Return to the Emergency Department for inability to tolerate fluids by mouth despite treatment, abdominal or pelvic pain, vaginal bleeding, not passing urine for more than 6 hours despite multiple attempts, or any new or concerning symptoms.