OBGYN

HISTORY TAKING AND EXAMINATION

Dr MUSA MARENA
OBGYN

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 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
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Treatment
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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
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PERSONAL AND DEMOGRAPHIC DATA

Name
Age
Gravidity & Parity
First day of last (normal)

menstrual period LMP.

Expected day of Delivery
EDD
Gestational Age

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Referral center; sometime date and time of referral

Reasons for referal
Informant
Reliability of information

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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)
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Para a,b,c,d (a=full term, b=preterm, c=miscarriages d=living children)

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

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CALCULTION OF EXPECTED DAY OF 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
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Gestational age
Gestational age in weeks is calculated using expectted date of delivery as references
Example if a client has her LMP of 12 th august 2014 then EDD will be

19th may 2015 and she is seen or clerk 15 th 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
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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)

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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
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Direct Questioning
Helps to ask symptoms associated and also

help in confirming presume diagnosis and

exclude differentials.

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Systemic Review
Direct questioning
Nervous: headache, dizziness, blurred vision, fever, convulsion,
CVS: orthopnae, palpitation, leg swelling paroxysmal nocturnal dyspnaoe, exertional dyspnaoe
Respiratory:
Digestive:
Urinary:

cough, dyspnoae tachypnae, chest pain, sputum, anosmia

vomiting, dysphagia, odnyphagia, abdominal pain, diarrhoea, jaundice, haematochezia, melenae,

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:

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joint pain, joint stiffness, joint swelling, muscle and bone deformity , pain or atrophy

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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)
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Elicit likely exposure to hazard/teratogens including medications

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

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

Babys sex
Babys birth weight
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Resuscitations,
PPH etc

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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

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:

Sure
Reliable
Symptoms: premenstrual tension,

dysmenorrhoea, menorrhagia, intermenstrual,

postcoital bleeding etc

Number of life time partners

orientation,
frequency

Previous Menstrual Period PMP

Satisfaction

Paps Smear:

problems(dyspareuna, premature

Last Smear

ejaculation, impotence)

when,

Hx of Infertility

Where

Future fertility desires

results
Awareness and compliance on follow up

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Self breast examination

Gynae Operations: cone biopsy, cerclage, endometrial ablation etc

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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

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Previous Hospital Admissions

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Drug Hx
Medications taking before onset of or not related this illness
Type, dose, duration and for what
Transfusions when and for what

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Allergies
To medications
To food
others

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Family Hx
Family Pedigree and health of members
Patients 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.
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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
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Summary of history

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EXAMINATION
INSPECTION (I)
PALPATION(P)
PERCUSSION(P)
AUSCULTATION(P)

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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

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HEAD & NECK

Head
Neck
thyroid

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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

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sounds
and murmurs with their radiation

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 3 rd
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
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OBSTETRIC PALPATION
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.
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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 patients 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.
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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

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Adnexals

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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

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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

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We investigate to

INVESTIGATIONS

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
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TREATMENT
Non Medical (Advice)
Medical
Medicine
Surgery

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Follow up
When
Frequency
Reason
Deposition (to where the patient was discharge to)

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SAMPLE./TEMPLATE
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

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PRESENTING COMPLAINING
Complains of
Dizziness 1day prior to presentation
Blurred vision12hrs prior

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HISTORY OF PRESENTING COMPLAIN

Was apparently well until a day ago when she began to experience a frontal headache.

It was throbbing and doesnt radiates, its aggravated by bending head forward and
prevented her from doing her daily chaos. Its 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 couldnt
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.
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On direct questioning
Feels Fetal movement +,Headache+

dizziness+ , palpitation+ , blurred vision+ ,

epigastric pain+ , abdominal pain- ,
bleeding PV-, difficulty in breathing-, easy
fatiguability- , dysuria- , frequency- fever
loosing liquor

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SYSTEMIC REVIEW
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.
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OBSTETRICS HISTORY
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.
She had a spontaneous one yr ago.at 2/12 which was completed
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through
curretage and she had no post abortal

INDEX PREGNANCY
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 22 nd 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
She felt
fetal
movement 2/12 ago and feels the movements
everyday. she
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felt it today too

GYNAE HISTORY
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 paps smear was 4yrs ago and it was normal
she does regular self breast examination and hasnt felt any
lumps or seen any abnormal breast discharge.
She has future fertility desire and plans to have her next
confinement after two years
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PAST MEDICAL HISTORY

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

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Drug History
She is on routine haematenics
Has had not been taken any medication

both orthodox and tradition in the past

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Allergy
Has no know allergy to food, medicine or

other substances

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FAMILY HISTORY
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
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SOCIAL HISTORY
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
doesnt 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
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toilet.
she seldomly use mosquito nets

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
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EXAMINATION
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
49Breast:
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breast with

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
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abdomen is soft, non
tender with

 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
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other breech presentation back on left of mother with

Summary
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
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Diagnosis
Preclampsia with twin pregnancy
Differential Diagnosis
Chronic Hypertension with Super Imposed

Pre-eclampsia
HELLP
Renal dx (Nephrotic Syndrome)

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Investigations
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

24 hours
protein (exclude renal disease)
UTG OBGYN
54

7/14/15

Management
Prevent convulsions
MAG NESIUM SULPHATE

Control blood pressure

IV HYDRALAZINE
METHYL DOPA

Monitor fetal well being

INTERMITTENT
CONTINUOUS
CARDIOTOCOGRAPHY

55

UTG OBGYN

7/14/15

GYN HISTORY TAKING

29YO Madam Isatou Saine, P0+1, LMP 15

April 2011,
C/O unable to conceived for 3yrs

56

UTG OBGYN

7/14/15

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 hasnt seek any medical care for this problem
and hasnt receive any non treatment.

57

UTG OBGYN

7/14/15

Direct questioning
Abnormal hair growth0, bladeness0, hoarse

voice0 blurred vision0 headache0 recurrent

cough0 midcycle pain0 abdominal mass0
galactorrhea0 polyuria0, polydypsia0,
polypahgia0, frequency0, LAP0,dyspareunia0,
vaginal discharge0 fever0, heat intolerance0,
neck swelling0, recent weight changed0

58

UTG OBGYN

7/14/15

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 loss of libido,
UTG OBGYN bleeding, no dyspareunia, 7/14/15
59 no vaginal
no galactorrhea

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.
60Her last
paps smear was a year ago and
its was normal
UTG OBGYN
7/14/15

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

61

UTG OBGYN

7/14/15

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

62

UTG OBGYN

7/14/15

DRUG HISTORY
She is or was not taking any orthodox,

traditional or herbal medicine.

63

UTG OBGYN

7/14/15

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.

64

UTG OBGYN

7/14/15

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 doesnt take
warm bath top or wear tight under wear. He has no
family history of infertility, chromosomal or genetic
disease.
UTG OBGYN
7/14/15
65

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

66

UTG OBGYN

7/14/15

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

67

UTG OBGYN

7/14/15

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 36.7C
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
UTG OBGYN
7/14/15
68
growth, no palpable mass or tenderness, vesicular

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,
UTG OBGYN
7/14/15
69
normal
vaginal wall ruggae and cervix
with no

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.

70

UTG OBGYN

7/14/15

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
UTG OBGYN
7/14/15
71
5ICSMCL, I & II are normal and no murmurs

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
UTG OBGYN
7/14/15
72
other palpable masses, vas differens
are paalpble

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

73

UTG OBGYN

7/14/15

IMPRESSION:
Secondary Infertility (tubal block)

DIFFERENTIALS
Peritoneal Adhesions
Asherman Syndrome ( Endometrial Synechia)
Azoospermia/ Oligozoospermia

74

UTG OBGYN

7/14/15

INVESTIGATION

spouse

Pelvic ultrasonography
Hysterosalpingography
Hormone profile
Follicular stimulating hormone
Luteinizing hormone
Thyroid stimulating hormone
Serum prolactine
Luteal phase progesterone

(21day)
Androgen
estrogen
Karyotype

Semen analysis
Hormone profile
Karyotype
Testicular biopsy
Vasography

Computer tomography/magnetic

resonance imaging
Cervical smear
Paps smear
Complete blood count
Fasting blood sugar
Urinalysis
microscopy, culture and
UTG OBGYN
75
sensitivity

7/14/15

OBGYN INTERNSHIP
SURVIVAL
DR MUSA MARENA
OBGYN

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:
UTG OBGYN
Labs: Typically includes hemoglobin/hematocrit

77

7/14/15

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
78

UTG OBGYN

7/14/15

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
79

UTG OBGYN

7/14/15

 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 140s, 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

UTGNSVD
OBGYN
80 Anticipate

7/14/15

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
81

UTG OBGYN

7/14/15

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

82

UTG OBGYN

7/14/15

SAMPLE POSTPARTUM NOTES (SOAP FORMAT)

Subjective: Patients complaints, comments/ nurses comments .Ask

every patient about the 5 Bs:

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

83

Contraception plans (must discuss before patient goes

home)
UTGOBGYN
7/14/15
Rubella vaccine prior to discharge?

POSTPARTUM NOTE

Subjective: Patients 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, Homans 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

UTG OBGYN
84

7/14/15

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

85

UTG OBGYN

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PRE OPERATION NOTE

86

UTG OBGYN

7/14/15

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
87

UTG OBGYN

7/14/15

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

88

UTG OBGYN

7/14/15

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 Teds 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

89

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
UTG OBGYN
7/14/15
Rhogam,
if Rh-negative

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

90

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?
UTG
OBGYN
7/14/15
Postpartum labs: Hemoglobin or hematocrit

 Assessment/Plan:

91

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

UTG OBGYN

7/14/15

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

UTG OBGYN

7/14/15

SAMPLE 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

OBGYN
YourUTG
name
and date/time
93

7/14/15

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

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