Date: [DATE]
Patient: [Patient Name]
MRN: [Medical Record Number]
Reason for Visit:
Document the reason for this visit. Is this a patient with a suspected ectopic pregnancy presenting with symptoms, a patient with a positive pregnancy test and risk factors for ectopic pregnancy, or a follow-up visit after diagnosis?
History of Present Illness:
Pregnancy status (last menstrual period, estimated gestational age).
Symptoms suggestive of ectopic pregnancy (if present):
Abdominal pain (may be sharp, one-sided)
Pelvic pain
Vaginal bleeding (may be scant or heavy)
Shoulder pain (uncommon)
Risk factors for ectopic pregnancy (if applicable):
History of pelvic inflammatory disease (PID)
Previous tubal surgery
History of ectopic pregnancy
Intrauterine device (IUD) use (although uncommon)
Past Medical History:
Briefly document any relevant past medical conditions, surgeries, or allergies, especially those mentioned as risk factors.
Social History:
Tobacco use (can increase risk of ectopic pregnancy).
Medications:
List all current medications, including any hormonal contraceptives.
Allergies:
Document any known allergies, especially allergies to medications used in treatment.
Physical Exam:
Vital Signs: Include blood pressure, temperature (if concerning for infection).
Abdominal Exam:
Assess for abdominal tenderness, mass, or guarding (involuntary muscle tensing).
Pelvic Exam:
Assess for adnexal tenderness (tenderness in the area of the ovaries and fallopian tubes).
Uterine size may be smaller than expected for gestational age in ectopic pregnancy.
Cervical motion tenderness (pain with movement of the cervix) may be present but is not specific to ectopic pregnancy.
Laboratory:
Document any laboratory tests performed, such as:
Quantitative hCG (human chorionic gonadotropin): Serial measurements of hCG levels can be helpful in diagnosis. A slower rise than expected may suggest ectopic pregnancy.
Complete blood count (CBC): May show anemia if there is internal bleeding.
Imaging:
Imaging studies are crucial for diagnosis:
Pelvic ultrasound (transvaginal preferred): First-line imaging modality to visualize an intrauterine pregnancy (absence suggests ectopic pregnancy). May also identify an adnexal mass suggestive of ectopic pregnancy.
Abdominal/pelvic CT scan with IV contrast (if ultrasound inconclusive): May be used to confirm the location of the ectopic pregnancy and assess for bleeding.
Assessment:
Suspected ectopic pregnancy: Based on clinical presentation, risk factors, and laboratory/imaging results.
Confirmed ectopic pregnancy: Based on definitive visualization of the ectopic pregnancy on ultrasound or CT scan.
Consider differential diagnoses depending on the presenting symptoms (e.g., ovarian cyst rupture, miscarriage).
Plan:
The goal of treatment is to remove the ectopic pregnancy tissue and minimize blood loss.
Treatment options will depend on factors such as:
Location and size of the ectopic pregnancy
Patient’s hemodynamic stability (blood pressure, blood loss)
Patient’s desire for future fertility
Discuss treatment options with the patient, including:
Salpingostomy (laparoscopic or robotic): Surgical removal of the ectopic pregnancy tissue while preserving the affected fallopian tube (preferred if future fertility is desired).
Salpingectomy (laparoscopic or robotic): Surgical removal of the entire affected fallopian tube along with the ectopic pregnancy.
Methotrexate (medication): An alternative for some unruptured ectopic pregnancies, especially small ones. This medication works to stop the growth of the ectopic tissue.
Pain Management: Provide pain medication as needed.
Blood Transfusion: May be necessary if there is significant internal bleeding.
Emotional Support: Ectopic pregnancy can be a stressful experience. Provide emotional support and resources for counseling.
Follow-up:
Depending on the treatment chosen, follow-up will vary.
Close monitoring of hCG levels is essential to ensure resolution of the ectopic pregnancy.
Arrange follow-up appointments to monitor recovery and hCG levels.
Discuss contraception options if desired.
Note: This is a template and should be