OBGYN

HISTORY TAKING AND EXAMINATIONDr MUSA MARENAOBGYNOBGYNCrucial issue during history taking areRespect PrivacyConfidentialityInformation should flow in a Logical Chronological sequence in a paragraph format ( as in writing/telling story).History taking should not be simply translating the patients 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 accordingly6/30/20152UTG OBGYNGETTING READYIntroduce 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 includes6/30/20153UTG OBGYN3PERSONAL AND DEMOGRAPHIC DATANameAgeGravidity & ParityFirst day of last (normal) menstrual period LMP.Expected day of Delivery EDDGestational Age

Referral center; sometime date and time of referralReasons for referalInformantReliability of information

6/30/20154UTG OBGYNSystems of TerminologyGravidity: order of the current pregnancy (if pregnant now)Gravidity: is total number of present and previous pregnancies

Parity: outcome of previous pregnanciesParity: 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: >28weeksTerm Delivery:>37weeksPreterm: 38.4, pulse > 110, BP < 90/60 or > 140/90, encourage breastfeeding,pad count, dressing checks, and Teds leg stockings until ambulatingDiet: Regular as tolerated; some hospitals only allow ice chips or clear liquids, semi solidsIV: Lactated ringers (LR) or D5LR at 125 cc/hr, with 20 units of Pitocin x 1-2 LitersLabs: CBC in AMMedications: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 wellVistaril 25 mg IM or PO q 6 hours prn nauseaIbuprofen 800 mg PO q 8 hours prn pain, when tolerating PO wellProphylactic antibiotics if indicatedThromboprohylaxis for high-risk patientsRhogam, if Rh-negative

6/30/2015UTG OBGYN89Sample post operation (C/S) NoteDate and Time:Day #1 (Post-op day POD#1)Subjective: Ask patient about:Pain relieved with medication?Nausea/vomitingPassing flatus (rare this early post-op), stoolObjective:Vital signs and note tachycardia, elevated or low BP, maximum and current temperatureInput and outputFocused physical exam includingHeartLungsBreasts: 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 hematocritFluids ins/outs;6/30/2015UTG OBGYN90Assessment/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 careDischarge FoleyDischarge PCA or IV pain medications and PO pain Meds when tolerating POOut of bed (OOB)Advance diet as toleratedDischarge IV when tolerating POCheck hematocrit or CBC6/30/2015UTG OBGYN91Sample 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/time6/30/2015UTG OBGYN92SAMPLE C/S POSTPARTUM NOTE Day #1 (Post-op day POD#1) SUBJECTIVE: Ask every patient about the 5 Bs, 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 6/30/2015UTG OBGYN93Sample 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

6/30/2015UTG OBGYN94