2. Crucial issue during history taking are
Respect
Privacy
Confidentiality
Information should flow in a
Logical
Chronological sequence in a paragraph format ( as in writing/telling
story).
History taking should not be simply translating the patient’s
words into Medical English Language, but should get the
clinician to
Ask further questions for clarification.
Form a provisional diagnosis that he/she would
Plan the examination
Investigations
Treatment accordingly 7/14/20152 UTG OBGYN
3. GETTING READY
Introduce yourself with a friendly greeting
Give your name and status
Explain the purpose of your interview
Maintain good eye contact
Listen attentively
Facilitate verbally and non verbally communication
Ask for a background information about the patient, which
includes 7/14/20153UTG OBGYN
4. PERSONAL AND DEMOGRAPHIC DATA
Name
Age
Gravidity & Parity
First day of last (normal)
menstrual period LMP.
Expected day of Delivery
EDD
Gestational Age
Referral center; sometime
date and time of referral
Reasons for referal
Informant
Reliability of information
7/14/20154 UTG OBGYN
5. Systems of Terminology
Gravidity: order of the current pregnancy (if pregnant now)
Gravidity: is total number of present and previous pregnancies
Parity: outcome of previous pregnancies
Parity: is the number of pregnancies resulting in a live birth (at whatever gestation)
together with all stillbirths plus the number of miscarriages, terminations and ectopic
pregnancies. A multiple pregnancy is counted as one.
Delivery: >28weeks
Term Delivery:>37weeks
Preterm: <38weeks
Miscarriage/Abortion: <28weeks
Notations
GDA written as GaPb+c
GTPAL written as GaPbcde G=gravidity T=term deliveries P=preterm deliveries
A=abortions including ectopic pregnancies L=number of living children
Gravida……., Para……….
Para b+c (b=delivery c=miscarriage including ectopic preg)
Para a,b,c,d (a=full term, b=preterm, c=miscarriages d=living children)
7/14/201
5
5 UTG OBGYN
6. CASE EXAMPLES/Exercises
A woman who is not pregnant and has a term single live birth,
one miscarriage and one termination =G3P1+2 or G3P1020
A woman who is pregnant with singleton pregnancy and has had
two previous pregnancies resulting in a premature live birth and
term stillbirth=G3P2+0 or G3P1101
A woman who has a singleton pregnancy and has had live twins
at term and previous ectopic= G3P1+1 or G3P1012
A woman who is not pregnant but had a twin pregnancy resulting
in live preterm births=G1P1+0 or G1P0102
7/14/20156 UTG OBGYN
7. DELIVERY
Using Nagaele rule
Assumptions made
Regular 28 day cycle not using contraceptives
Ovulation occurs 14days before start of next menses
Two methods:
Add 7days and 9months to the date of the 1st day of last menstrual
period
Add 7days, subtract 3months and add 1year to the date of the 1st day
of last menstrual period
Cycles longer than 28days, add the difference to the calculated
EDD
Cycles less than 28days subtract the difference from the
calculated EDD 7/14/20157UTG OBGYN
8. Gestational age
7/14/2015UTG OBGYN8
Gestational age in weeks is calculated using expectted date of delivery
as references
Example if a client has her LMP of 12th august 2014 then EDD will
be 19th may 2015 and she is seen or clerk 15th march 2011 then
her gestational age is( TWO METHODS)
1: Count number of days from clerking date to date of expected
delivery 21(March)+30(April)+19(May)=70/7=10W0D
Normal gestation 280days (40weeks0days) from LMP.
then GA=40W0D – 10W0D=30W0D
2: Divide the days of each month by 7 then adding the results. note
addition of the remainders (days) should be in base 7.
March 15th-31st=21days=3W0D
April 30days = 4W2D
May 19th 19days = 2W5D
TOTAL = 10W0D
Hence GA= 40W0D - 10W0D
= 30W0D
9. Presenting Complaint
Symptoms
Main complaints in order of occurrence; 1st symptom(s)
written or reported first
In the patients own words
Two ways
Duration of the complaints (duration of symptom)
Time of onset of symptom to time of patient presentation.
(duration prior to presentation)
7/14/20159 UTG OBGYN
10. History of Presenting Complaint
Elicit the evolution of the disease
Progression of symptoms
Appearances of new symptoms including treatments obtained and Response to treatment
Spontaneous remissions and exacerbations and other related phenomena
Onset: acute or insidious
Time and duration
Character
Volume, colour and consistency (fluids/liquids)
location
Progression
Relieving
Aggravating
Associated factors
Onset, location, course, severity, duration
What increase/decrease the symptoms
Associated symptoms
Others symptoms to prove or disprove provisional diagnosis
Investigations done(date, place and results)
Treatment received both traditional and orthodox (details & response)
Any complications
7/14/201510 UTG OBGYN
11. Direct Questioning
Helps to ask symptoms associated and also help
in confirming presume diagnosis and exclude
differentials.
7/14/2015UTG OBGYN11
12. Systemic Review
Direct questioning
Nervous: headache, dizziness, blurred vision, fever, convulsion,
CVS: orthopnae, palpitation, leg swelling paroxysmal nocturnal dyspnaoe, exertional dyspnaoe
Respiratory: cough, dyspnoae tachypnae, chest pain, sputum, anosmia
Digestive: vomiting, dysphagia, odnyphagia, abdominal pain, diarrhoea, jaundice, haematochezia, melenae,
Urinary: incontinence, dysuria, frequency, urgency, precipitancy, retention, haematuria, loin pain
Reproductive: bleeding PV relationship to menses (menorrhagia, dymenorrhoea, metrorrhagia, oligomenoorhea and polymenorrhea) and sex
(postcoital bleeding), dysmenorrhea, abnormal vaginal discharge, vulva ulcers, papules or pustules, sexual dysfunction (dyspareunia/apareunia, frigidity, premature
orgasm, nyphomania), rare sexual deversion (homo, bi or transexuality), infertility
Musculoskeletal: joint pain, joint stiffness, joint swelling, muscle and bone deformity , pain or atrophy
7/14/201512 UTG OBGYN
13. Index Pregnancy
A chronological and concise account of the events in present pregnancy: is best
obtained by enquiring about her pregnancy in the first, second and third trimester.
If she was in postnatal period details of labour and delivery are relevant
Planned / unplanned but welcome pregnancy including any Assisted Reproduction
Technology in cases of infertility
Supported by partner/spouse
Day of ovulation, Fertilization, conception. {assisted conception), ‘quickening’
Illness and complications during this pregnancy
Antenatal care
When booking/registration
Number and frequency of visits
Type of care
History and type examination done
Investigation done and results
Haematology
urine
Screening for infections and genetic anomalies'
Imaging
Immunization and medications (type and when received)
Elicit likely exposure to hazard/teratogens including medications
7/14/201513 UTG OBGYN
14. Past Obstetrics
Date/years ago of
confinement in chronological
order including abortions and
ectopics
Antenatal illness, care and
complications
Maturity(preterm/term)
Onset of labour
(spontaneous/induced)
Place & Mode of delivery
outcome
Baby’s sex
Baby’s birth weight
Resuscitations, PPH etc
Postnatal complications
Neonatal outcome
Mode of feeding
Type and duration of infant
feeding
Health status age of the child
presently.
Abortions and ectopic age
of termination, mode of
termination post
termination complications
7/14/201514 UTG OBGYN
15. Gynaecological History
Age at menarche
LMP (was it conform to the usual in terms
of timing, volume, and appearance)
Previous menses
When
Cycle length
Duration of menses
Sure
Reliable
Symptoms: premenstrual tension,
dysmenorrhoea, menorrhagia,
intermenstrual, postcoital bleeding etc
Previous Menstrual Period PMP
Pap’s Smear:
Last Smear
when,
Where
results
Awareness and compliance on follow up
Contraceptives/birth Control Methods:
current method, what, when started,
satisfaction and any side effects.
Previous methods: what, when and why
stopped
Sexual Transmitted Infections and
treatments
Sexual History:
Number of life time partners
orientation,
frequency
Satisfaction
problems(dyspareuna, premature
ejaculation, impotence)
Hx of Infertility
Future fertility desires
Self breast examination
Gynae Operations: cone biopsy, cerclage,
endometrial ablation etc
7/14/201515 UTG OBGYN
16. Medical history
Some medical conditions may have impact on the course of the
pregnancy or
the pregnancy may have an impact on the medical condition
examples HPT, DM, Sickle cell, heart dx, liver dx, renal dx, thyroid
dx etc
Previous and Present Significant Illness not related to symptoms
Medical: Mostly chronic illness e.g. diabetes, hypertension, asthma,
tuberculosis, sickle cell and other genetic diseases, renal dx, liver dx,
thyroid dx, psychiatric disorders, HIV etc
Previous Surgical & Anesthesia Experiences
Previous Hospital Admissions
7/14/2015UTG OBGYN16
17. Drug Hx
Medications taking before onset of or not related this illness
Type, dose, duration and for what
Transfusions when and for what
7/14/201517 UTG OBGYN
19. Family Hx
Family Pedigree and health of members
Patient’s position in the family, type of family, number of members
in the family.
Similar conditions as to patients complaints.
Diseases afflicting family members (familial disease, genetic
diseases, congenital malformations, fetal anomalies or inborn errors
of metabolism, malignancy, infections).
Multiple pregnancies.
7/14/201519 UTG OBGYN
20. Social Hx
Marital status, duration of relationship, level of education
occupation, religion and believe towards blood transfusion
Spouse age occupation financial support
Tobacco intake, alcohol intake and drug abuse (type, quantity
per day and duration of intake)
Family income
Tribe race nationality residency, address
Housing (use of insecticide treated nets)
Number of occupants in the room
Housing environment (sanitation, feeding and food preparation
and storage, waste disposal, bed nets, water availability)
Dietary history 7/14/201520 UTG OBGYN
23. GENERAL EXAMINATION
Built: obese, average or thin
Striking feature (most obvious thing about the patient upon first
seeing her)
Nutritional status: adequate or poor
Mental status and conscious level
Levels of Pallor, cyanoses, jaundice, pedal or sacral oedema, and
palpable peripheral lymphadenopathy
Measurements (anthropometry)
Weight, height, body mass index (BMI), temperature
Sometimes: pulse, blood pressure, respiratory rate, SO2
7/14/201523 UTG OBGYN
24. HEAD & NECK
Head
Neck
thyroid
7/14/201524 UTG OBGYN
25. CHEST
Breast: (IPPA) normal (nulliparous or parous breast fed) or
abnormal (nipple, areola, lumps abnormal discharges)
Chest wall: (symmetry, deformities, lesions and scars
expansion
Lungs: (palpation, percussion and auscultation)
Heart: precordiun activity, position of apex beat, auscultate
four valves for the normal I and II heart sounds and
murmurs with their radiation
7/14/201525 UTG OBGYN
26. ABDOMEN
Contour, Symmetry
Straie, scar, skin pigmentation, linear nigra, fetal movements,
prominent masses/veins
Tenderness, consistency, contractions, fetal movements
Liver, spleen, bladder, hernia orifices, bladder
Uterus
using leopald Maneuvers
1st identify the upper limit of fundus and fetal pole occupying the fundus
Fundal Height: determine with ulna border of left hand
Measurement symphysis-fundal height after 20weeks because uterus rises at a
rate of 1cm every week after twentieth week
using land marks
Superior border of symphysis Pubis 12wks
Distance between symphysis and umbilicus is divided into 3 equal parts. Lower
3rd is reach at 16wks, 2/3rd is reach at 20wks
Umbilicus24wks
Distance between umbilicus and xiphisternum is divided into 3 equal parts.
Lower 3rd is reach at 28wks, 2/3rd is reach at 32wks
Xisphisternum is reach 36wks
Thereafter uterus descend and at 40ks fundus occupies the height at 32wks
7/14/201526 UTG OBGYN
27. OBSTETRIC PALPATION
7/14/2015UTG OBGYN27
Fundal Grip: gently pressed of fundal area between the two hands in
an attempt to determine which pole of fetus is occupying the fundal
area
2nd manoeuvre Umbilical Grip: hands are gently slip along the side of
the uterus to the umbilical. Steadying one hand to stabilized the uterus,
the other hand is use to palpate the other side to identify the back as a
smooth elongated firm mass round area and the limbs as small
irregular shapes in an area which is relatively empty.
3rd manoeuvre Pelvic Grip: obstetrician then turn to face the patients
feet and place his hands with fingers extended he gently presses
downward on the lower part of uterus along its sides and from side to
side attempting to recognise the presenting part. Unless its fixed in the
pelvic it can be balloted from side to side between the fingers.
28. 7/14/2015UTG OBGYN28
If the presenting part cannot be easily identify bec it fixed in the
pelvis, the fingers are slipped further downwards and inwards
until they dip into the pelvis brim.
If the hand which is on the same side as the fetal back slips more
deeply than the other into the pelvis it can be assumed that the
head is well fixed. It helps in determine the descent, engagement
and position
Pawlik.
Is not always necessary and unless performed gently may be painful.
Facing the patient’s head the right hand spread widely and pressed
into the suprapubic area above the inguinal ligament.
When the fingers and thumb are approximated the presenting part
can be felt between them and its mobility above the pelvic brim
determine. Also helps in determining engagement and ballotment of
the head.
29. VAGINA
Vulva & Perineum
Discharges, ulcers, papules and pustules, bleeding and blood stain, hair
distributions and infestation.
shape and size of labia majora, minora, clitoris hood and prepuce (be
aware of circumcision). Bartholin gland and duct
Vestibular
Urethra orifice, paraurethra opening(skene glands), integrity of frenulum
and fourchette, presence and shape of hymen including vagina orifice and
opening of bartholin duct
Speculum:
vaginal wall and
Cervix with fornix
Digital
cervix
Uterus
Adnexals
7/14/201529 UTG OBGYN
30. SUMMARY
Pertinent Information that helped you to arrive at a specific
diagnosis and differentials. Not more than three lines or sentence.
1st sentence: Demographic, Presenting Complaint and History of
Presenting Complaint in one sentence
2nd sentence: Obst, gynae, PMHx, Drug Hx, FHx, and SHx in one
sentence
3rd sentence: Examination finding in one sentence
7/14/201530 UTG OBGYN
31. Diagnosis
Base on your findings from the patient through Interview and
Examination.
Most likely cause of the Complaints and Additional History with
Physical Findings
Atleast three Differentials with Similar Presentations
7/14/201531 UTG OBGYN
32. INVESTIGATIONS We investigate to
Confirm Diagnosis and Exclude Differentials
Know Baseline Values and Extent of the Disease
Monitor the Treatment
Order of the request should follow the above criteria
What disease does the patient have?
How serious or severe is the disease?
Is the treatment working?
Priority of request(investigations) will depends on
Necessity
Availability and cost
Includes
Haematology
Serology
Biochemistry
Microbiology
Cytology and Histopathology
Imaging
7/14/201532 UTG OBGYN
34. Follow up
When
Frequency
Reason
Deposition (to where the patient was discharge to)
7/14/201534 UTG OBGYN
35. SAMPLE./TEMPLATE
7/14/2015UTG OBGYN35
28YO Madam Marie Gomez, G5P3+1,
LMP 22 July 2014, EDD 29 April 2015, GA 29wks
referred from Brikama health Centre on 10/feb/11 at
0900hrs on accounts of High Blood Pressure. Was
admitted on 10th February 2011. date of clerking 15th
February 2011
37. HISTORY OF PRESENTING COMPLAIN
7/14/2015UTG OBGYN37
Was apparently well until a day ago when she began to experience a frontal
headache. It was throbbing and doesn’t radiates, it’s aggravated by bending head
forward and prevented her from doing her daily chaos. It’s relieved by taking
paracetamol. It was not associated with fever, joint pain, cough, dysuria, or diarrheoa
About 12 hours later she realises that her vision was getting blurred and she couldn’t
see certain objected at far. She also felt dizzy and has had realises that her upper
abdomen begins to pain. The dizziness and blurred visions were not associated with
difficulty in breathing, easy fatigue, chest pain or fatigue on exercise.
She decided to go to Brikama Health Centre for consultation. There she was
interviewed and her blood pressure was taken. She was told it was very high and was
given some medicine to put under her tongue and was given two injections on her
thigh. She was then referred to Royal Victoria Teaching Hospital (RVTH)
She was again interviewed at RVTH, examined, her urine and blood samples were
taken and she was given some intravenous injections. She was told that she would
be admitted and adviced to have completely bed rest.
Ultrasound scan was done for her and she was inform that her baby is find but she
needs close monitoring because her condition is serious but manageable.
Since admission she had be receiving regular oral medications and IV injections but
the injections only lasted for only her admission day. Now her vision is normal,
dizziness and upper abdominal pain has subsided. She is only experiencing slight
headache.
38. On direct questioning
Feels Fetal movement +,Headache+ ‘ dizziness+
, palpitation+ , blurred vision+ , epigastric pain+ ,
abdominal pain- , bleeding PV-, difficulty in
breathing-, easy fatiguability- , dysuria- ,
frequency- feverˉ loosing liquorˉ
7/14/2015UTG OBGYN38
39. SYSTEMIC REVIEW
7/14/2015UTG OBGYN39
Nervous system: slight headache, dizziness, blurred vision had
subsided, no fever, weakness
Cardiovascular system: no dyspnoea, othopnoea, exertional
dyspnoea, or chest pain, cough, syncope
Respiratory system: no cough, no chest pain, no dyspnoea
Digestive system: no vomiting, no dysphagia, no nausea,
abdominal pain subsided, good appetite, no diarrhoea, no
constipation, haematochezia, dyschezia, melane, weight loss
Urinary system: no dysuira, no frequency, no hesitency, no
incontinence, no polyuria no loin pain, no haematuria
Reproductive system: no sores, no vaginal discharge, no
vaginal bleeding, no draining liquor, no dyspareunia, fetal
movement present.
Musculoskeletal system: no joint pain no muscle pain no joint
swelling or stiffness, slight back pain, intermittent abdominal
pain main associated with fetal movements, has swelling of both
feet.
40. OBSTETRICS HISTORY
7/14/2015UTG OBGYN40
She is P3+1:Has had three previous deliveries and one
abortions (confinements/pregnancies)
First was 8yrs ago was twin pregnancy, planned and naturally
conceived. booked for antenatal care at 3mth and developed
HPT at 5mths gestation which was controlled with oral
medications taking daily and she had spontaneous vertex
delivery at 9mnths in hospital. . Resulted in twin delivery both
male weighing 2.5kg and 2.6kg respectively and all are males.
She had normal puerperium and high BP resolved after delivery
without medication, babies were exclusively breast fed for 4mth
and completely wean at 2yrs. They are in primary school and
doing well.
Second was 5yrs ago and 3rd was 3yrs ago. Their pregnancy
were planned naturally conceived and uneventful, both
deliveries were spontaneous vertex at term in a hospital and are
male and female weighing 2.5kg and 2.8kg respectively. their
puerperiums were normal with exclusive breast feeding for 4mth
and weaned completely at 2yrs. They are in grade 1 and
nursery school respectfully and doing well.
41. INDEX PREGNANCY
7/14/2015UTG OBGYN41
Pregnancy was planned, naturally conceived and welcomed by the
couple. Diagnosed with UPT after 1/12 amenorrhea. Had only one
USS at 2/12 which gives her an EDD 22nd may 2015 and was told she
is carrying twins and they are fine.
Had normal early pregnancy and was not taking any medication or
had no x-rays during early weeks of this pregnancy
Booked for antenatal care at 3mths gestation and has had four visits
so far on appointment.
At booking visit, a brief history was taken, she was examined and her
blood, urine and stool test were done and was told all her results were
normal.
Subsequent visits, she was examined and quizz about any problems
she might have had experienced or is experiencing now and given
advices on food, exercises including daily activities, taking only
prescribed medications and health living.
She had received one dose of tetanus toxoid vaccine. And two doses
of sulpadoxine and pyrimethamine
42. GYNAE HISTORY
7/14/2015UTG OBGYN42
Menarche occurs at age of 12yrs
Has regular monthly cycle of 28days with 4days of
menstrual blood flow
Its not assoc with dysmenorrhea, heavy menses,
intermenstrual bleeding
Had Coitarche 18yrs. Had 2 life time partners. She is
heterosexual. No dyspareuna, postcoital bleeding or
sexual dysfunction. She never had abnormal vaginal
discharge or sores and has never been treated for sexual
transmitted disease
Has knowledge of contraceptive but never used one before
Her last pap’s smear was 4yrs ago and it was normal
she does regular self breast examination and hasn’t felt
any lumps or seen any abnormal breast discharge.
She has future fertility desire and plans to have her next
confinement after two years
43. PAST MEDICAL HISTORY
7/14/2015UTG OBGYN43
Has no history of HPT, DM, SCDx, Asthma,
chronic cough, heart disease, renal disease, or
liver disease, HIV
Has never been admitted for any ailment nor has
she ever under gone surgery or anesthesia or
transfusion
44. Drug History
7/14/2015UTG OBGYN44
She is on routine haematenics
Has had not been taken any medication both
orthodox and tradition in the past
46. FAMILY HISTORY
7/14/2015UTG OBGYN46
Is 3rd of 6 children from the mother in a
polygamous marriage of three co-wives and 15
children
Father died of chronic cough 5yrs ago and
mother is a known HPT and on medication.
One of her full sister and her paternal half had
twins
The rest of the family are well
No history of pregnancy induced hypertension in
family, asthma, SCDx, DM
47. SOCIAL HISTORY
7/14/2015UTG OBGYN47
She has been married for 10yrs in a monogamous
relationship. She is a christian and has no objection to
blood transfusion. she has high school education, she is
nursery sch teacher. She neither take tobacco in any form,
nor drink alcohol or take hard drugs.
Husband 30yrs high school teacher and smokes half pack
of cigarette a day and a social drinker but doesn’t take hard
drugs. he gives her about D50 daily for her upkeeping.
She lives with her husband and 3 children in brikama.They
are a tenant in a 4 bedroom house with electricity and pipe
water supply with a flush toilet. she seldomly use mosquito
nets and is not insecticide treated.
24hrs dietary recall: took bread with beans and tea for
breakfast, stew with meat of good ample and rice for lunch,
48. SUMMARY
YO HW G5P3+1 with twin gestation at GA 29wk,
who was referred because of high blood
pressure, presented 1day history of severe
continuous throbbing frontal headache associated
with dizziness, blurred vision and epigastric pain.
She has had hx of twin deliveries and pregnancy
induce hypertension in the past with family history
of twin pregnancy and hypertension
7/14/2015UTG OBGYN48
49. EXAMINATION
7/14/2015UTG OBGYN49
UPON EXAMINATION SHE IS
Young average size lady, looks ill with slightly puffy face,
sitting on the bed
Not in any obvious distress, not pale, acyanosed, anicteric,
bilateral non tender pitting pedal odema up to ankles, no
palpable peripheral lymphadenopathy, not warm to touch.
Good oral hygiene.
Weight 70kg, height 168cm, Body mass index 24.8kg/m2
(normal)
No anterior neck swelling, with normal thyroid gland and no
distended vessels
Breast: Normal parous (pendulous) breast with normal
nipple and areola, non tender with no palpable mass or
50. 7/14/2015UTG OBGYN50
CHEST: respiratory rate 15cycle/min, Normal chest, with
no scars or lesions or tenderness , symmetrical expanding,
equal normal tactile and vocal fremitus. vesicular breath
sounds and good air entry.
CVS: pulse rate 70bpm regular good volume and non
collapsing. BP-150/100mmHg. HEART: precodium quiet,
Apex 4ICSMCL, I &II normal sounds and no murmurs
heard
ABDOMEN: symmetrically enlarged, moves with
respiration, linear nigra extending from hypogastrium to
about 3cm above the umbilicus, unbilicus is inverted, straie
gravidarium diffuse distributed infra umbilically, visible fetal
movements seen, no surgical scars or scarifications and
normal hernia orifices
Light palpation: abdomen is soft, non tender with no
guarding, felt a mass presume is the gravid uterus.
51. 7/14/2015UTG OBGYN51
Deep palpation: (liver, right and left lobe), spleen and kidneys
are not palpable.
GRAVID UTERUS: symphysiofundal height is 50cm which
corresponds to 50weeks plus or minus 2wks which is not
consistent/does not commensurate with her gestational age of
29weeks (larger than her gestational age)
Fundal two Fetus poles felt (one hard and other soft)
Lateral multiple fetal parts on left, smooth round part on the
right.
Pawlik hard mass ballotable
Pelvic grip two poles leading one hard not engaged (5/5) occiput
to right of mother
Fetal heart beat: two fetal heart beats 130bpm below umbilicus
140bpm above. Both are regular
both longitudinal lie leading one in cephalic descend 5/5 back
on mothers right with FHR 130bpm regular and other breech
presentation back on left of mother with fetal heart rate of
52. Summary
7/14/2015UTG OBGYN52
YO HW G5P3+1 at GA 29wk, who was referred because of
high blood pressure, presented 1day history of severe
continuous throbbing frontal headache associated with
dizziness, blurred vision and epigastric pain.
She has had twin deliveries and pregnancy induce
hypertension in the past with family history of twin
pregnancy and hypertension.
Examination reveals puff face with odema of both feet and
a high blood pressure, fundal height larger than gestational
age with double fetal parts and heart sounds and a
proteinuria of +3
53. Diagnosis
7/14/2015UTG OBGYN53
Preclampsia with twin pregnancy
Differential Diagnosis
Chronic Hypertension with Super Imposed Pre-
eclampsia
HELLP
Renal dx (Nephrotic Syndrome)
54. Investigations
7/14/2015UTG OBGYN54
Pelvic Ultrasound Scan: To confirm twin pregnancy
fetal number, gestational age, fetal viability, placental position and
maturity, liquor volume
Complete blood count: (exclude HELLP syndrome)
Haemoglobin level Hb, platelet counts, white blood cell counts
WBC, red blood cell count RBC, mean corpuscle volume MCV,
mean corpuscle haemoglobin MCH, mean copsuscle haemoglobin
concentration
Blood for malaria parasite
Liver enzymes: (Exclude HELLP)
Alanine transferase ALT, aspartate transaminase AST, lactate
dehydrogenase LDH.
Liver function test: exclude HELLP)
Total serum bilirubin, conjugated serum bilirubin and unconjugated
serum bilirubin,
Renal function test: (exclude renal Disease)
Urea, creatinine, urates ur
55. Management
7/14/2015UTG OBGYN55
Prevent convulsions
MAG NESIUM SULPHATE
Control blood pressure
IV HYDRALAZINE
METHYL DOPA
Monitor fetal well being
INTERMITTENT
CONTINUOUS
CARDIOTOCOGRAPHY
56. GYN HISTORY TAKING
29YO Madam Isatou Saine, P0+1, LMP 15 April
2011,
C/O unable to conceived for 3yrs
7/14/2015UTG OBGYN56
57. Despite regular unprotected sexual intercourse of 3 times
per week for 3years she is unable to conceive.
There is adequate vaginal penetration with intravaginal
ejaculation during each sexual contact and has normal
libido. There is no use of lubricant during sex and no
douching after sex.
She hasn’t seek any medical care for this problem and
hasn’t receive any non treatment.
7/14/2015UTG OBGYN57
59. SYSTEMIC REVIEW
Nervous system: no headache, no dizziness, no blurred vision
had subsided, no fever,
Cardiovascular system: no dyspnoea, othopnoea, exertional
dyspnoea, or chest pain, no heat intolerance,
Respiratory system: no cough, no chest pain, no dyspnoea
Digestive system: no vomiting, no dysphagia, no nausea,
abdominal pain subsided, good appetite, no diarrhoea, no
constipation, no polyphagia, no polydypsia.
Urinary system: no dysuira, no frequency, no hesitency, no
incontinence, no polyuria no loin pain,
Reproductive system: no sores, no vaginal discharge, no
vaginal bleeding, no dyspareunia, no loss of libido, no
galactorrhea
Musculoskeletal system: no joint pain no muscle pain no joint
swelling or stiffness, slight back pain, intermittent abdominal7/14/2015UTG OBGYN59
60. GYNAE
Menarch occurred at 13yrs
She has regular menstrual cycle of 30days with 4days of
menstraul blood flow.
She has no dysmen, menorrh, PCB or intermenstrual bleeding
She has a satisfactory sexual relationships and is heterosexual
and coitarche occurs at 18yrs. she had 3 life time sexual
partners.
She had abnormal vaginal discharge 5yrs ago around 2weeks
after meeting her 2nd partner and this was treated
She used loop for 5yrs prior to marriage. Her earlier methods
were combination of rhythm, withdrawal and condom, foam or
diaphram during fertile periods.
Her last pap’s smear was a year ago and its was normal
no lumps found during her regular self breast examinations
7/14/2015UTG OBGYN60
61. Obst hx
P0+1
She had an induced abortion using both
medication then suction evacuation at around
3months gestation 7yrs ago at a private clinic.
No post abortal complication
7/14/2015UTG OBGYN61
62. PAST MEDICAL HISTORY
She had no past history of diabetes,
hypertension, tuberculosis, thyroid disease or HIV
infection.
She had no past history of intra-abdominal
operation or other operations
7/14/2015UTG OBGYN62
63. DRUG HISTORY
She is or was not taking any orthodox, traditional
or herbal medicine.
7/14/2015UTG OBGYN63
64. FAMILY HISTORY
She 4th of 4 children with two brothers and one sister from a
monogamous marriage.
All family members are well
There is no history of infertility in family, no history of
tuberculosis, chromosomal abnormality, HPT DM SCDx
Asthma in the family.
7/14/2015UTG OBGYN64
65. SOCIAL HISTORY
She has been married for 3yrs in a monogamous marriage.
Wollof, muslim. she has no objection to blood
transfusion.The couple do not take tobacco in any form nor
do they drink alcohol. She does take any receational drugs
too.
Her spouse is 33yrs old doctor, P0+0, he has had right
herniorrhape 5yrs ago, both of his testis are in his scrotum
with no other palpable mass, he has no history of orchitis,
mumps, tuberculosis, thyroid disease, diabetes,
hypertension or recurrent rhinitis/respiratory tract infection.
He doesn’t take warm bath top or wear tight under wear.
He has no family history of infertility, chromosomal or
genetic disease.
Their marriage has been consummated for 3yrs now and7/14/2015UTG OBGYN65
66. 24hrs dietary: bread sauce for breakfast with
meat/ fish of good, rice and stew or soup for
lunch with meat fish or chicken of good, tea and
bread butter/mayoniase/jam with egg for dinner
7/14/2015UTG OBGYN66
67. SUMMARY
I presents Madam29YO Madam Isatou Saine,
P0+1, LMP 15 April 2011,
C/O unable to conceived for 3yrs
Had hx of abnormal vaginal discharge was
treated. Had MVA for incomplete abortion and
used IUD
Partner had herniography
7/14/2015UTG OBGYN67
68. Examination
Young lady, looks well, of average sized .
Not in any obvious distress, not pale, acyanosed, anicteric,
no palpable peripheral lymphadenopathy, no pedal or
sacral odema and not warm to touch with temp 36.7ºC
Height 168cm weight 75kg giving BMI 26.6kg/m2
No beard mustache acne or acanthosis nigra seen.Normal
thyroid that moves with glutition and no anterior neck
swelling, no distended neck veins
Normal nulliparous breast with well form nipples and
areola, no discharges from nipple and no palpable mass.
Normal symmetrical chest, no abnormal hair growth, no
palpable mass or tenderness, vesicular breath sounds
7/14/2015UTG OBGYN68
69. Pulse rate 68bpm RVG non collapsing BP 100/70mmHg.
Quiet precodium, apex beat 4ICSMCL, no thrill or heaves
1st and 2nd heart sounds normal and no murmur heard
full abdomen which moves with respiration, umbilicus is
inverted, no surgical scar or scarifications, straies, and
normal female pubic hair pattern, no hernia. Abd is soft,
non tender, LSK not palpable and no other palpable mass.
Circumcised (clitorectomy) scar (FGM Type I) no
discharges, normal labias, normal urethra meatus, normal
fourchette , hymen discontinue with about 4 corincular
mitrifomis, normal fossa navicularis, normal vaginal wall
ruggae and cervix with no discharges and has nulliparous
Os.
Normal size non pregnant anterior-verted uterus, no
7/14/2015UTG OBGYN69
70. Normal sense of smell through each
nostrils,Visual acuity is 6/6 and normal visual
fields elicited through confrontation, no colour
blindness, normal retina
All other cranial nerves are normal
Normal extremities including normal size head
jaws, face and hands.
7/14/2015UTG OBGYN70
71. Examination of spouse
Young man looks well average build and not in any obvious
distress.
Not pale acyanosed, anicteric, no peripheral odema, no
palpable lymphadenopathy
No baldness, normal thyroid no anterior neck swelling and
normal chest with normal male breast no lumps or
discharges and normal male hair distibution on chest and
no tenderness or swelling,
Respiratory rate 18cycles/min regular normal tactil and
vocal fremitus and resonant percussion notes with
vesicular breath sounds
Pulse rate 80bpm RGV non collapsing BP 120/70mmHg,
Precodium quiet, apex beat 5ICSMCL, I & II are normal
and no murmurs
7/14/2015UTG OBGYN71
72. Abdomen full moves with respiration, umbilicus inverted,
male pattern pubic and abd hair distribution, Right para-
midline scar. Abd is soft non tender LSK not palpable and
no other palpable mass, typanitic percussion and 3 bowel
sounds in 1min.
Normal circumcised penis, no discharges ulcers, nodules
or pustules and is about 8cm long in non erect position,
urethra meatus is at the tip of the glans penis no epi- or
hypospedias, no palpable cord with the urethra has normal
scrotum with both testis inside and each about 4cm
diameter with not other palpable masses, vas differens are
paalpble connected to the testis and normal epididymis, no
tenderness felt. 7/14/2015UTG OBGYN72
73. SUMMARY
I presents Madam29YO Madam Isatou Saine,
P0+1, LMP 15 April 2011,
C/O unable to conceived for 3yrs
Had hx of abnormal vaginal discharge was
treated. Had MVA for incomplete abortion and
used IUD
Partner had herniography
7/14/2015UTG OBGYN73
77. Admission Orders
These vary a little from case to case, but the following are fairly general (format is ADC VAN DISMAL):
Admit: To the specific service or team
Diagnosis: List the diagnosis and the names of any associated surgeries or procedures
Condition: Such as Stable vs. Fair vs. Guarded
Vitals: Frequency
Activity: Ambulation, showering
Nursing:
Foley catheter management parameters
Prophylaxis for deep venous thrombosis
Incentive spirometry protocols
Call orders:
Vital sign parameters for notifying the team
Urine output parameters
Diet: Oral intake management
IV FLUID: Rates are typically set at 125 cc per hour
Special: Drain management
Oxygen management
Meds:
Pain medications
Prophylactic orders, such as for sleep or nausea
The patients' regular medications
Allergies:
Labs: Typically includes hemoglobin/hematocrit
7/14/2015UTG OBGYN77
78. PROGRESS NOTES
• Uses the SOAP Mnemonics
• SUBJECT S: patient comment or complains, nursing comments
• OBJECTIVE O:
VITALS: blood pressure, pulse, respiratory rate, temps, weight,
O2 sat
INS/OUTS: IV fluids, PO intake, emesis, urine, stool, drains
EXAM: physical findings
MED: pertinent routine or new medications
INVEST: new lab or procedure results
• ASSESSMENT: A: assessment based on above data
• PLAN P: Medication change, Lab Tests, Procedures,
Consults(other disciplines), Discharge
7/14/201578 UTG OBGYN
79. Sample Admission to Labor and Delivery Note
• Date & time
• Identification: (includes age, gravidity, parity, estimated gestational age, and reason for
admission):
• 26yo G3P1A1 @ 38W5D EGA presents with painful contractions since noon. Pt reports
good fetal movement, and denies rupture of membranes or vaginal bleeding.
• LMP:
• Estimated date of confinement (EDC):
• Chief complaint:
• History of present illness (includes Prenatal Care (PNC): Labs, including HIV, GBS,
GDM/HTN, # PNC visits, wt gain, s=d, etc.
• Past history:
Obstetrics:
List each pregnancy (NSVD, wt 4000 grams, complicated by gestational diabetes and
shoulder dystocia)
Gynecology:
• PMH and PSH:
Medications: PNV, FeSO4
Allergies: No Known Drug Allergies (NKDA)
Social history: Ask about Tobacco/alcohol/Drugs
7/14/2015UTG OBGYN79
80. Physical exam (focused):
General and Vital signs
Lungs
Cardiovascular – (Many pregnant women have a grade 1-2/6 systolic ejection murmur
Abdomen – Gravid, fundus non-tender (NT), fundal height (FH) 38cm, Leopold maneuvers:
Fetus is vertex (VTX), estimated fetal weight (EFW) 3300 gm
Sterile speculum examination if indicated to rule out spontaneous rupture of membranes (SROM)
Sterile vaginal exam (SVE) = 4cm/80%/VTX/ –1 as per Dr. Smith/time
Extremities – No Cyanosis, clubbing or edema (C/C/E), NT
Pertinent Labs:
Ultrasound:
Date: 10 wks by crown-rump length (CRL)
Date: 20 wks, no anomalies
Assessment:
26yo G3P1 at term, in labor fetal heart rate tracing (FHRT) reassuring
Intrauterine pregnancy (IUP) at 39 weeks gestation
FHRT – Baseline 140’s, accelerations present, no decelerations
Contractions – q 4-5 min
Any pertinent past medical or surgical history
Plan:
Admit to L&D
NPO except ice chips
IV – D5LR at 125 cc/hr
Continuous electronic fetal monitoring
CBC, T&S, RPR
Anticipate NSVD 7/14/2015UTG OBGYN80
81. DELIVERY NOTE
• On (delivery date, time), this (age, race) female under(epidural, pudendal,
local, no) anesthesia delivered a viable (male, female) infant weighing
(weight) with APGAR scores of (0-10) and (0-10) at 1 and 5minutes.
• Delivery was via (SVD, LTCS, classical CS) to a sterile field. (Nuchal cord
reduced) infant was (bulb, DeLee) suctioned at (perineum, delivery). Cord
clamped and cut and infant handed to waiting (paediatrician, Nurse). (Cord
blood send for analysis). (weight) (intact, fragmented, meconium stained)
placenta with (2,3) vessel cord delivered (spontaneously, with manual
extraction) at (time). (amount) of (carboprost, methylrgonovine, oxytocin)
given. (uterus, cervix, vagina, rectum) explored and (midline episiotomy, nth
degree laceration, uterus and abdominal incision) repaired in a normal
fashion with (type) suture. EBL (amount). Patient send to RR in stable
condition. Infant taken to NBN in stable condition. Dr (name) attending
• Note: SVD=spontaneous vaginal delivery, LTCS= low transverse C-section,
CS= C-section, EBL= estimated blood loss, RR=recovery room,
NBN=newborn nursery
7/14/2015UTG OBGYN81
82. Sample Delivery Note
Date and time:
Summary:
Normal spontaneous vertex delivery (NSVD) of a live male, 3000 gm and Apgars
9/9. Delivered left occiputo-anterior (LOA), no nuchal cord, light meconium.
Nose and mouth bulb suctioned at perineum; body delivered without difficulty.
Cord clamped and cut. Baby handed to nurse. Placenta delivered spontaneously,
intact. Fundus firm, minimal bleeding. Placenta appears intact with 3 vessel cord.
Perineum and vagina inspected – small 2nd degree perineal laceration repaired
under local anesthesia with 2-0 and 3-0 chromic suture in the usual fashion.
Estimated Blood Loss (EBL) 350cc. Hemostasis. Pt tolerated procedure well,
recovering in Labour & Delivery Room (LDR). Infant to WBN
7/14/2015UTG OBGYN82
83. SAMPLE POSTPARTUM NOTES (SOAP FORMAT)
Subjective: Patients complaints, comments/ nurses’ comments .Ask every
patient about the 5 B’s:
Breast or bottle feeding – Breastfeeding/planning to? How is it going? Tenderness?
Birth Control plans – Consider breastfeeding status
Bleeding (lochia) – Clots? How many pads?
Baby – Healthy? Do you plan circumcision for baby boy?
Bottom – Having any complaints related to urination/defecation? Flatus?
Baby blues (depression) – Ask about signs or symptoms of depression.
Pain – cramps/perineal pain/leg pain? Does medication control it? ambulation
Objective:
Vital signs and note tachycardia, elevated or low BP, temperature
Focused physical exam including
Heart
Lungs
Abd: Soft? Location of the uterine fundus – below umbilicus? Firm? Tender?
Extremities: Edema? Cords? Tender?
Breasts/Perineum: evaluate with help of resident if specific complaints regarding
breasts/perineum
Postpartum labs: Hemoglobin, Blood type, Rubella status
Assessment/Plan: PPD#_ S/P NSVD or Vacuum or Forceps (with 4th-degree
laceration, with pre-eclampsia s/p Magnesium Sulfate)
General assessment – Afebrile, doing well, tolerating diet
Contraception plans (must discuss before patient goes home)
Rubella vaccine prior to discharge?
Breastfeeding? Does she need lactation consultant?
7/14/2015UTG OBGYN83
84. POSTPARTUM NOTE
• Subjective: Patient’s comments or complaints, nursing comments
CHECK
pain control,
breast tenderness,
quality of vaginal bleeding,
urination,
flatus,
bowel movement,
lower extremity swelling,
ambulation,
breast or bottle feed,
birth control type
• Objective:
VITALS: blood pressure, pulse, respirations, temperature
INS/OUTS: IV fluids, PO intake, emesis, urine, stool, drains
EXAM: breath sounds, bowel sounds, fundal height/consistency, incision/episiotomy condition, lower extremity
oedema, Homan’s sign.
MEDS: RhoGAM, pain med, iron, vitamins, laxative, contraceptive
LAB: CBC, RH status
• Assessment: Assessment based on data above
• Plan: Medication change, lab tests, procedures, consults, discharge
7/14/2015UTG OBGYN84
85. Sample Postpartum Notes (Soap
format)
• Date and Time:
• Subjective: Ask every patient about:
Breastfeeding – are they breastfeeding/planning to? How is it going? Baby able to latch on? breast tenderness?
Contraceptive plan with relevant sexual history
Lochia (vaginal bleeding) – Clots? How many pads?
Pain – cramps/perineal pain/leg pain? Relief with medication? Do they need more pain meds?
Urination/bowel movement- have they had urine, flatus or had bowl movement? Pain? Colour? Frequency?
• Objective:
• Vital signs and note tachycardia, elevated or low BP, maximum and current temperature
• Focused physical exam including
Heart
Lungs
Breasts: engorged? Nipples – skin intact?
Abd: Soft? Location of the uterine fundus – below umbilicus? Firm? Tender?
Perineum: Assess lochia (blood on pad, how old is pad?)
Visually inspect perineum – Hematoma? Edema? Sutures intact?
Extremities: Edema? Cords? Tender?
• Postpartum labs: Hemoglobin or hematocrit
Assessment/Plan: PPD#_ S/P NSVD or Vacuum or Forceps (with 4th-degree laceration, with pre-eclampsia
s/p Magnesium Sulfate)
General assessment – Afebrile, doing well, tolerating diet
Contraception plans (must discuss before patient goes home)
Vaccines – does pt need rubella vaccine prior to discharge?
Breastfeeding? Problems? Encourage.
Rhogam, if Rh-negative
Discharge and follow-up plan
Patients usually go home if uncomplicated 24-48 hours postpartum
Follow-up appointment scheduled in 2-6 weeks postpartum
7/14/2015UTG OBGYN85
87. OPERATION NOTE DATE AND TIME:
SURGEONS: Attending, residents, students who scrubbed
ANESTHESIA: General endotracheal (GETA), spinal, local, etc
PRE-OPERATIVE DIAGNOSIS:
POST OPERATIVE DIAGNOSIS:
PROCEDURE: Surgery performed
FINDINGS: Rupture right cornual ectopic pregnancy with dead fetus intraperitoneal about
20wks GA, haemoperitoneum, 4cm follicular cyst, etc
COMPLICATIONS: Tear to colon which was repaired
ESTIMATED BLOOD LOSS: Amount in cc
FLUIDS: Amount and type (electrolyte, blood, etc, in cc or units)
URINE: amount and colour at end of operation
DRAINS: Type and location
SPECIMENS: Type send to pathology (right fallopian tube and fetus with placenta)
CONDITIONS: Stable, Fair, Guarded, extubated, etc
DISPOSITION: transfer to recovery room, postpartum room, Surgical ICU, etc
7/14/2015UTG OBGYN87
88. Sample Operation Note
Date and Time:
Pre-op Diagnosis: Symptomatic uterine fibroids or Pregnancy at term, failure to progress`
Post op Diagnosis: Same
Surgeon: Attending, Residents, students
Anesthesia: GET (general endotracheal, others include spinal, LMA, IV sedation)
Procedure: TAH/BSO or Cesarean Section
Findings: Exam under anesthesia (EUA) and operative findings
Complication: injury to bladder which was repaired
EBL: 300 cc
Urine Output: 200 cc, clear at the end of procedure
Fluids: 2,500 cc crystalloid (include blood or blood products here)
Drains: If placed
Specimen: Cervix/uterus, placenta and cord.
Condition: Fair, Stable, Guarded, extubated
Disposition: Recovery room, Surgical ICU, postpartum room, etc
7/14/2015UTG OBGYN88
89. Sample Postoperative Cesarean Section Orders/Note
Sample C/S Orders
Admit to Recovery Room, then postpartum floor
Diagnosis: Status post (s/p) C/S for failure to progress (FTP)
Condition: Stable, Fair, Guarded
Vitals: Routine, q shift, q4hours
Allergies: None
Activity: Ambulate with assistance this PM, then up ad lib
Nursing: Strict input and output (I&O), Foley to catheter drainage, call MD for
Temp > 38.4, pulse > 110, BP < 90/60 or > 140/90, encourage breastfeeding,
pad count, dressing checks, and Ted’s leg stockings until ambulating
Diet: Regular as tolerated; some hospitals only allow ice chips or clear liquids, semi solids
IV: Lactated ringers (LR) or D5LR at 125 cc/hr, with 20 units of Pitocin x 1-2 Liters
Labs: CBC in AM
Medications:
Morphine sulfate PCA (patient controlled analgesia) per protocol (1 mg per dose with 10 minute lockout,
not to exceed 20 mg/4 hours)
Percocet 1-2 tabs PO q 4-6 hours prn pain, when tolerating PO well
Vistaril 25 mg IM or PO q 6 hours prn nausea
Ibuprofen 800 mg PO q 8 hours prn pain, when tolerating PO well
Prophylactic antibiotics if indicated
Thromboprohylaxis for high-risk patients
Rhogam, if Rh-negative
7/14/2015UTG OBGYN89
90. Sample post operation (C/S) Note
Date and Time:
Day #1 (Post-op day POD#1)
Subjective: Ask patient about:
Pain – relieved with medication?
Nausea/vomiting
Passing flatus (rare this early post-op), stool
Objective:
Vital signs and note tachycardia, elevated or low BP, maximum and current
temperature
Input and output
Focused physical exam including
Heart
Lungs
Breasts: engorged? Nipples – Is skin intact?
Incision: Clean and dry? sutures intact? odema? haematoma?
Abd: Soft? Location of the uterine fundus – below umbilicus? Firm? Tender?
Perineum: Assess lochia (blood on pad, how old is pad? Frequency of changing?)
Visually inspect perineum – Hematoma? Edema? Sutures intact?
Extremities: Edema? Cords? Tender?
Postpartum labs: Hemoglobin or hematocrit
Fluids ins/outs;
7/14/2015UTG OBGYN90
91. Assessment/Plan:
POD#1 status post (S/P) C/S or repeat C/S (indication for the C/S)
Afebrile, tolerating pain with medication, oral intake, adequate urine output (>30cc/hr)
Routine post-op care
Discharge Foley
Discharge PCA or IV pain medications and PO pain Meds when tolerating PO
Out of bed (OOB)
Advance diet as tolerated
Discharge IV when tolerating PO
Check hematocrit or CBC
7/14/2015UTG OBGYN91
92. Sample Postoperative Cesarean Section Orders
Sample C/S Orders
Admit to: Recovery Room, then postpartum floor
Diagnosis: Status post (s/p) C/S for arrest of descent
Condition: Stable
Vitals: Routine, q shift
Allergies: None
Activity: Ambulate with assistance this PM, then up ad lib
Nursing: Strict input and output (I&O), Foley to catheter drainage, call M.D. for Temp > 38.0, pulse > 110, BP < 90/60
or > 140/90, encourage breastfeeding, pad count, dressing checks, and Ted hose until ambulating
Diet: Regular as tolerated; some hospitals only allow ice chips or clear liquids
IV: Lactated ringers (LR) or D5LR at 125 cc/hr, with 20 units of Pitocin x 1-2 Liters
Labs: CBC in AM
Medications:
• Morphine sulfate PCA (patient controlled analgesia) per protocol (1 mg per dose with 10 minute lockout, not to
exceed 20 mg/4 hours)- only if no Duramorph in Spinal anesthetic
• Percocet 1-2 tabs PO q 4-6 hours prn pain, when tolerating PO well
• Zofran/Compazine prn nausea
• Ibuprofen 800 mg PO q 8 hours prn pain, when tolerating PO well
• Prophylactic antibiotics if indicated
• Thromboprohylaxis for high-risk patients
• Rhogam, if Rh-negative
Your name and date/time
7/14/2015UTG OBGYN92
93. SAMPLE C/S POSTPARTUM NOTE
Day #1 (Post-op day POD#1)
SUBJECTIVE: Ask every patient about the 5 B’s, also:
Pain – relieved with medication?
Nausea/vomiting
Passing flatus (rare this early post-op)
OBJECTIVE:
Vital signs and note tachycardia, elevated or low BP, temperature
Input and output
Focused physical exam including
Heart and Lungs
Abd: Soft? Location of the uterine fundus – below umbilicus? Firm? Tender?
Incision: Clean and dry, intact? Staples or not?
Extremities: Edema? Cords? Tender?
Breasts/Perineum: evaluate with help of resident if specific complaints regarding breasts/perineum
Postpartum labs: Hemoglobin, Blood type, Rubella status
ASSESSMENT/PLAN: POD#1 status post (S/P) C/S or repeat C/S
Afebrile, tolerating pain, oral intake, adequate urine output (>30cc/hr)
Routine post-op care
Discontinue Foley
Discontinue PCA or IV pain medications and convert to PO pain Meds when tolerating PO
Ambulate TID
Advance diet as tolerated
Discontinue IV when tolerating PO
Check Hgb or CBC on POD #1
Anticipate discharge on POD#3 or 4
Your name and date/time
7/14/2015UTG OBGYN93
94. Sample Operation Note
Pre-op Diagnosis: Symptomatic uterine fibroids or Pregnancy at ___wks, failure to progress
Post-op Diagnosis: Same
Procedure: TAH/BSO, Cesarean Section
Surgeon (Attending):
Residents:
Anesthesia: General endotracheal (GET), Spinal, LMA, IV sedation
Complications: None
EBL: 300 cc
Urine Output: 200 cc, clear at the end of procedure
Fluids: 2,500 cc crystalloid (include blood or blood products here)
Findings: Exam under anesthesia (EUA) and operative findings OR Viable M/F infant in cephalic/breech
presentation weighing ___grams, Apgars of ___. Cord gases ____. Infant to newborn nursery/NICU.
Specimen: Cervix/uterus
Drains: If placed
Disposition: Recovery room, Surgical ICU, etc
Your name and date/time
31
7/14/2015UTG OBGYN94