Pregnant Vag Bleed MDM and DCI

Assessment & Plan Elements
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[textarea]This patient in the first trimester of pregnancy presented to the emergency department with complaints of vaginal bleeding and abdominal pain. VSS. Os is closed.[/textarea]

A pelvic ultrasound demonstrated [select value="normal intrauterine gestation with normal FHT.|failure to identify a gestational sac.|blighted ovum.|subchorionic hemorrhage."] Rh was [checkbox value="positive.|negative and patient administered Microrogham."] UA was [checkbox value="positive|negative"] for infection.

Clinical Impression: [select value="Threatened Miscarriage|UTI|Early Pregnancy vs. Ectopic|Missed Abortion"] [text]
Anticipatory guidance, supportive measures and return indications discussed with patient. See DCI.


DCI:
Bed rest. Pelvic Rest.
Drink plenty of fluids.
[checkbox value="Take the antibiotics prescribed for urinary tract infection|Follow up with your OB/GYN in 1-2 days|Return here or with your OB in 48 hours for repeat BHCG level|Bring a copy of your results from today's visit"]
Return to the ER for increased bleeding (more than 1 pad an hour for consecutive hours), increased abdominal cramping, fever, passage of products of conception, lightheadedness or any other concerns.


A pelvic ultrasound demonstrated Rh was UA was for infection.

Clinical Impression:
Anticipatory guidance, supportive measures and return indications discussed with patient. See DCI.


DCI:
Bed rest. Pelvic Rest.
Drink plenty of fluids.

Return to the ER for increased bleeding (more than 1 pad an hour for consecutive hours), increased abdominal cramping, fever, passage of products of conception, lightheadedness or any other concerns.
Result - Copy and paste this output:

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