Ectopic pregnancy soap note

First Trimester Bleeding: Evaluation and Management

Caitlin Goodwin is a Certified Nurse-Midwife and birth nerd with 12 years in obstetric nursing. Proper charting is an essential form of communication among healthcare professionals. Healthcare providers need to be fluent in SOAP notes because it provides concise and complete documentation that should describe what you observed, what data you collected, and what you did. Take full credit for your hard work! General appearance: Is the patient alert and oriented? Is the patient in mild, moderate, or severe distress? Does the patient appear healthy and well-nourished? Labs: Write down the results of any labs that are relevant and available today Urinalysis, blood sugar, labs and available from the prior visit. Imaging: Include any imaging results from the prior visit like the dating, Nuchal Translucency NTAnatomy or growth ultrasounds. The diagnosis can be as simple as intrauterine pregnancy and gestational age or specific to a disease process. If you are concerned about differentials, these should be listed too. CC: Unintended pregnancy, pt is accepting but overwhelmed. Unmarried, FOB involved. Presenting for OB care as a new patient, first antepartum visit. Unsure intercourse timing. Amenorrhea, increased frequency of urination, fatigue and breast tenderness began about four weeks ago. Denies dizziness, HA, visual disturbances, edema. Denies vaginal discharge, odor, bleeding, and cramping. Eats fruits and hydrates appropriately. Pt is not currently exercising. Never smoker. Christian, non-denominational No domestic violence. Does not have a cat, no litter box. Personal — Denies History of abuse, mental illness, depression, anxiety, or eating disorders. The sinuses are nontender. Pupils are equal and reactive. The nares are patent. The oropharynx is clear without lesions. Fetus: Bimanual exam presents as approximately 9 wks gestation.

The Diagnosis and Treatment of Ectopic Pregnancy


Patient information: See related handout on bleeding in early pregnancywritten by the authors of this article. Approximately one-fourth of pregnant women will experience bleeding in the first trimester. The differential diagnosis includes threatened abortion, early pregnancy loss, and ectopic pregnancy. Pain and heavy bleeding are associated with an increased risk of early pregnancy loss. Treatment of threatened abortion is expectant management. Bed rest does not improve outcomes, and there is insufficient evidence supporting the use of progestins. Ultrasound findings diagnostic of early pregnancy loss include a mean gestational sac diameter of 25 mm or greater with no embryo and no fetal cardiac activity when the crown-rump length is 7 mm or more. Treatment options for early pregnancy loss include expectant management, medical management with mifepristone and misoprostol, or uterine aspiration. Established criteria should be used to determine treatment options for ectopic pregnancy, including expectant management, medical management with methotrexate, or surgical intervention. Physical examination findings, laboratory testing, and ultrasonography can be used to diagnose the cause of first trimester bleeding and provide appropriate management. A glossary of terms used in this article is available in Table 1. A meta-analysis evaluating the accuracy of a single progesterone test to predict pregnancy outcomes for women with first trimester bleeding showed that a progesterone level less than 6 ng per mL Guidelines for ultrasound diagnosis of early pregnancy loss have been established to decrease the likelihood of false diagnosis and of intervening in a desired viable pregnancy. Oral mifepristone Mifeprexmg, followed 24 hours later by misoprostol, mcg vaginally, is the most effective regimen for medical management of early pregnancy loss and, when available, should be recommended over misoprostol alone. Rh o D immune globulin Rhogam should be administered to Rh-negative women with early pregnancy loss, especially when it occurs later in the first trimester. Early pregnancy loss can be definitively diagnosed in women with ultrasound findings of a mean gestational sac diameter of 25 mm or greater and no embryo or embryonic cardiac activity when the crown-rump length is at least 7 mm. Bed rest or progestins should not be recommended to prevent early pregnancy loss in patients with first trimester bleeding because these interventions have not been proven effective. Expectant management, medical management, and uterine aspiration are safe methods for treating anembryonic gestations and fetal demise. Patient preference should guide treatment decisions. Treatment for incomplete abortion should rely on shared decision making. Transvaginal ultrasonography shows intrauterine gestational sac with no embryonic cardiac activity and no findings of definite pregnancy failure [ Table 2 ]. Pregnancy that cannot result in live birth e. Positive urine or serum pregnancy test with no intrauterine or ectopic pregnancy shown on transvaginal ultrasonography.

How to Write a SOAP Note With Obstetric Examples


Medical Transcription Samples and Examples. Circumcision Medical Transcription Sample Report. Delivery Note Transcription Sample Report. Laparoscopic Appendectomy Operative Sample Report. Laparoscopic Transverse Colectomy Sample Report. Laparoscopic Varicocele Ligation Sample Report. Neurology Consultation Transcription Example Report. Neuropsychological Testing Transcription Sample Report. Privacy Policy. Psychiatric Discharge Summary Sample Report. Thyroid Lobectomy Operative Sample Report. Tonsillectomy Transcription Sample Report. Trabeculectomy Medical Transcription Sample Report. Tympanoplasty with Mastoidectomy Operative Sample Report. Right ectopic pregnancy located in the cornual section of the fallopian tube. This patient is a XX -year-old gravida 4, para 2, AB 1 at approximately 7 weeks' gestation who presented with vaginal bleeding and cramping. An ultrasound performed in the emergency department showed right ectopic pregnancy. After discussion with the patient, decision was made to perform laparoscopic surgery to remove the ectopic pregnancy. Full details and risks of the procedure were discussed at length with the patient, and the patient was in full agreement. The patient was taken to the operating room, placed under general anesthesia and prepped and draped in the usual sterile manner. Speculum was placed in the vagina and the anterior lip of the cervix was grasped with a single tooth tenaculum.

Ectopic pregnancy: A 5-step plan for medical management


Pregnancy is an occasion worth celebrating. The formation of a new life inside of a woman is a miracle to behold and should be experienced by women who want to seek the fulfillment you have always wanted. However, no matter how you handle a pregnancy with care there are still instances that it is compromised. Nurses promote life and well-being, so it is a must for us to educate our clients with regards to the complications they could experience during pregnancy. It is important for both the pregnant woman and the health care provider to identify any signs and symptoms of an ectopic pregnancy before rupture occurs. However, most ectopic pregnancy does not show any unusual signs and symptoms at the time of implantation, so it would be difficult to identify them at first. Tests to determine the possibility of ectopic pregnancy must be performed first before the diagnosis. The medical management of a woman with an ectopic pregnancy should be initiated the moment she is brought to the emergency room. Just a few moments of interval for action would cause a big difference in the safety of the patient. Surgical interventions would be performed after the rupture of the ectopic pregnancy to ensure that the reproductive system would still be functional and no complications would arise. Nurses must also have their own function when it comes to ectopic pregnancy, even without a direct order from the physician. Ectopic pregnancy is a menace for both the mother and the zygote. However much we want to save the zygote, it would be impossible because it has grown outside the usual site of implantation. This article helps me a lot in making my case analysis in ectopic pregnancy. A lot of useful informations are cited. A lot information on ectopic pregnancy is being found here. Thank you very much. May Allah reward you. The information on ectopic pregnancy is very useful here. Since we started inNurseslabs has become one of the most trusted nursing sites helping thousands of aspiring nurses achieve their goals. Our ultimate goal is to help address the nursing shortage by inspiring aspiring nurses that a career in nursing is an excellent choice, guiding students to become RNs, and for the working nurse — helping them achieve success in their careers. Sign in. Log into your account.

Ectopic Pregnancy

Aka: Ectopic PregnancyTubal Pregnancy. These images are a random sampling from a Bing search on the term "Ectopic Pregnancy. Search Bing for all related images. The uterus, or womb, is an important female reproductive organ. It is the place where a baby grows when a woman is pregnant. If you have an ectopic pregnancy, the fertilized egg grows in an abnormal place, outside the uterus, usually in the fallopian tubes. The result is usually a miscarriage. Get medical care right away if you have these signs. Doctors use drugs or surgery to remove the ectopic tissue so it doesn't damage your organs. Many women who have had ectopic pregnancies go on to have healthy pregnancies later. Started inthis collection now contains interlinked topic pages divided into a tree of 31 specialty books and chapters. Content is updated monthly with systematic literature reviews and conferences. Although access to this website is not restricted, the information found here is intended for use by medical providers. Patients should address specific medical concerns with their physicians. Toggle navigation. Antepartum Disorders Chapter. From Related Chapters. Page Contents Definition Implantation of fertilized ovum outside of the Uterus. Symptoms Pregnancy Symptoms e. Images: Related links to external sites from Bing. Related Studies. Trip Database TrendMD. Ontology: Ectopic Pregnancy C Ectopic pregnancy can be a medical emergency if it ruptures. Signs of ectopic pregnancy include Abdominal pain Shoulder pain Vaginal bleeding Feeling dizzy or faint Get medical care right away if you have these signs. Symptoms include sharp pain on one side of the abdomen and bleeding from the vagina. Definition CSP development of a fertilized ovum outside of the uterine cavity. Ontology: Pregnancy, Tubal C Definition NCI An abnormal pregnancy in which the conception is implanted in the fallopian tube. Related Topics in Antepartum Disorders. Obstetrics Chapters. Obstetrics - Antepartum Disorders Pages. Back Links pages that link to this page. Search other sites for 'Ectopic Pregnancy'. An abnormal pregnancy in which the conception is implanted outside the endometrial cavity. A condition in which a fertilized egg grows outside of the uterus, usually in one of the fallopian tubes.

My Second Ectopic Pregnancy Loss -- Third Miscarriage -- 14 DPO Beta Results



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