history taking and examination
DESCRIPTION
Clerking and history taking made simpler for medical studentsTRANSCRIPT
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HISTORY TAKING AND EXAMINATION
Dr MUSA MARENA
OBGYN
Crucial issues 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
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 include
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PERSONAL AND DEMOGRAPHIC DATA
Name
Age
Sex
Occupation
Gravidity & Parity
First day of last (normal) menstrual period LMP.
Gestational Age
Expected day of Delivery EDD
Marital status
Tribe
Race
Residence
Nationality
Religion
Address
Level of education
Referral center; sometime date and time of referral
Date/time of presentation/clerking
Informant
Reliability of information
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SYSTEMS OF TERMINOLOGY
Gestation—pregnancy or maternal condition of having a developing fetus in the body.
Embryo—human conceptus up to the 10th week of gestation (8th week postconception).
Fetus—human conceptus from 10th week of gestation (8th week postconception) until
delivery.
Viability—capability of living, usually accepted as 24 weeks, although survival is rare.
Gravida (G)—woman who is or has been pregnant, regardless of pregnancy outcome.
Nulligravida—woman who is not now and never has been pregnant.
Primigravida—woman pregnant for the first time.
Multigravida—woman who has been pregnant more than once.
Para (P)—refers to past pregnancies that have reached viability.
Nullipara—woman who has never completed a pregnancy to the period of viability. The
woman may or may not have experienced an abortion.
Primipara—woman who has completed one pregnancy to the period of viability
regardless of the number of infants delivered and regardless of the infant being live or
stillborn.
Multipara—woman who has completed two or more pregnancies to the stage of viability.
Living children—refers to the number of children a woman has delivered who are living.
A woman who is pregnant for the first time is a primigravida and is described as Gravida 1 Para
0 (or G1P0). A
Woman who delivered one fetus carried to the period of viability and who is pregnant again is
described as Gravida 2, Para 1. A woman with two pregnancies ending in abortions and no viable
children is Gravida 2, Para 0.
OBSTETRIC HISTORY
TPAL
In some obstetric services, a woman's obstetric history is summarized by a series of four digits,
such as 5-0-2-5. These digits correspond with the abbreviation TPAL.
T—represents full-term deliveries, 37 completed weeks or more.
P—represents preterm deliveries, 20 to less than 37 completed weeks.
A—represents abortions, elective or spontaneous loss (miscarriage) of a pregnancy
before the period of viability.
L—represents the number of children living. If a child has died, further explanation is
needed for clarification.
If, for example, a particular woman's history is summarized as G 7, P 5-0-2-5, then she
has been pregnant seven times, had five term deliveries, zero preterm deliveries, two
abortions, and five living children.
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GTPALM
In some institutions a woman's obstetric history can also be summarized as GTPALM, especially
when multiple gestations or births are involved.
G—represents gravida.
T—represents full-term deliveries, 37 completed weeks or more.
P—represents preterm deliveries, 20 to less than 37 completed weeks.
A—represents abortions, elective or spontaneous loss of a pregnancy before the period of
viability.
L—represents the number of children living. If a child has died, further explanation is
needed for clarification.
M—represents the number of multiple gestations and births (not the number of neonates
delivered).
If, for example, a particular woman's history is summarized as G 5, P 5-0-0-6-1, then she has
been pregnant five times, had five term deliveries, zero preterm deliveries, zero abortions, six
living children, and one multiple gestation/birth.
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: GPA, GPTAL, GPTALM
GPA 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
GESTATIONAL AGE
Gestational age in weeks can be calculated in two ways
using number of days from LMP to Date of seeing the patient divided by seven
Example if a client has her LMP of 12th august 2010 and she is seen or clerk 15th march
2011 then her gestational age is
20+30+31+30+31+31+28+15=216/7=30weeks 6days
August 11th-31st=20days =2W6D
September 1st-30th= 30days=4W2D
October 1st-31st=31days =4W3D
November 1st-30th=30days =4W2D
December1st-31st= 31days =4W3D
January 1st-31st=31days =4W3D
February 1st-28th=28days =4W0D
March 1st-15th=15days =2W1D
Total =30W6D
Using 40ks as references, subtract number of weeks between date you seeing the patient and
the EDD from 40weeks
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In previous example LMP 12th August 2010 hence EDD will be 19th may 2011 and date of
consultation is 15th march 2011
o March 19th-31=12days=1W5D
o April 1st-30th =30days=4W2D
o May 1st-19th =19days=2W5D
o Total =8W5D
o Gestational age=40W0D-8W5D=31W2D
CALCULTION OF EXPECTED DAY OF DELIVERY
Using Nagaele rule
Assumptions made
28 day cycle
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
PRESENTING COMPLAINT
Symptoms
Main complaints in order of occurrence; 1st symptom(s) written or reported first
In the patient’s 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)
Elicit the evolution of the disease
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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
Direct questioning of related symptoms and signs
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 pregnancy including any Assisted Reproduction Technology in cases of infertility
Supported by partner/spouse (welcome by the couple)
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Day of ovulation, Fertilization, conception. {assisted conception), ‘quickening’
How was the pregnancy diagnosed; presumptive(subjective), probable(objective) or
positive(diagnostic) changes
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
PAST OBSTETRICS
Date/years ago of confinement in chronological order
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
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Postnatal complications
Neonatal outcome
Mode of feeding
Type and duration of infant feeding
Health status age of the child presently.
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
HPV vaccinations
Contraceptives/birth Control Methods:
current method, what, when started, satisfaction and any side effects.
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Previous methods: what, when and why stopped
Sexual Transmitted Infections and treatments
Sexual History:
Coitarche and number of partners since coitarche
orientation,
frequency
Satisfaction
Problems (dyspareunia, premature ejaculation, impotence)
Hx of Infertility
Douching
Abortions including ectopic pregnancies (when, gestational age and mode of termination)
Gynae Operations: cone biopsy, cerclage, endometrial ablation etc.
Regular breast examination (self or health worker)
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, HIV 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
Previous hx of blood transfusion
Drug HISTORY
Medications taking before onset of or not related this illness both orthodox and traditional
medicines (esp. those ingested)
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Type, dose, duration and for what
Transfusions when and for what
Allergies
To medications
To food
Others
FAMILY HISTORY
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,
infertility).
Multiple pregnancies.
SOCIAL HISTORY
Marital status, duration of relationship and spouse support.
Occupation of couple
Tobacco intake, alcohol intake and drug abuse (type, quantity per day and duration of intake)
Family income
Means of paying for medical care including insurance
Housing
Number of occupants in the room
Housing environment ( sanitation, feeding and food preparation and storage, waste disposal,
bed nets, water availability)
SYSTEMIC REVIEW
Direct questioning
Nervous: headache, dizziness, blurred vision, fever, convulsion,
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CVS: orthopnea, 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 diversion (homo, bi or transexuality), infertility
Musculoskeletal: joint pain, joint stiffness, joint swelling, muscle and bone deformity ,
pain or atrophy
EXAMINATION
INSPECTION (I)
PALPATION(P)
PERCUSSION(P)
AUSCULTATION(P)
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
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: precordium activity, position of apex beat, auscultate four valves for the normal I and II
heart 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
3rd is reach at 16wks, 2/3rd is reach at 20wks
Umbilicus24wks
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Distance between umbilicus and xiphisternum is divided into 3 equal parts.
Lower 3rd is reach at 28wks, 2/3rd is reach at 32wks
Xiphisternum is reach 36wks
Thereafter uterus descend and at 40ks fundus occupies the height at 32wks
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 patient’s 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 it’s fixed in the pelvic
it can be balloted from side to side between the fingers.
If the presenting part cannot be easily identify because 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.
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
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
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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
Sterile speculum examination: SSS
vaginal wall appearance
Cervix appearance with Os closed or open
Fornix esp. posterior whether its appears full and bulging
Digital
cervix
Uterus
Adnexal
Direct rectal examination (DRE) for rectal mucosa and pelvic organs
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
PROBLEMS
Sometimes its beneficial to list the problems identified from history and examination. This helps in
coming up with a diagnosis and a management plan.
DIAGNOSIS
Base on your findings from the patient through Interview and Examination.
Most likely cause of the Complaints and Additional History with Physical Findings
At least three Differentials with Similar Presentations
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INVESTIGATIONS
We investigate for three reasons 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
Cost
Includes
Haematology
Serology
Biochemistry
Microbiology
Cytology and Histology
Imaging
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TREATMENT
Non Medical (Advice)
Expectant/conservative (observe progress without intervention)
Active/intervention
Medical
Surgery
Follow up
When
Frequency
Reason
Deposition (to where the patient was discharge to)
SAMPLE/TEMPLATE
28YO Housewife, G5P3+1,
LMP 22 July 2010, EDD 29 April 2011, GA 29W0D, a Christian, a Mandinka, a Gambian, resides at
Brikama
with high school level of education
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
Informant self
She is reliable
Note in some instances religion, tribe, nationality, residence and education may be placed under
social history
PRESENTING COMPLAINING
Complains of
Dizziness 1day prior to presentation
Blurred vision12hrs prior
HISTORY OF PRESENTING COMPLAIN
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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.
ON DIRECT QUESTIONING
Fetal movement +,Headache+ ‘ dizziness+ , palpitation+ , blurred vision+ , epigastric pain+ ,
abdominal pain- , bleeding PV-, difficulty in breathing-, easy fatiguability- , dysuria- , frequency-
SYSTEMIC REVIEW
Nervous system: slight headache, dizziness, blurred vision had subsided, no fever,
Cardiovascular system: no dyspnoea, orthopnea, exertional dyspnoea, or chest pain.
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
Urinary system: no dysuria, no frequency, no hesitancy, no incontinence, no polyuria no loin
pain
Reproductive system: no sores, no vaginal discharge, no vaginal bleeding, no draining liquor, no
dyspareunia, fetal movement present.
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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.
INDEX PREGNANCY
Pregnancy was planned, spontaneously conceived and support by her husband.
Pregnancy was diagnosed via urine positive urine HCG test which she performed after she
missed her menses for 3weeks
Had no problems 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 have had four visits so far and which were on
appointment.
At first visit, a brief history was taken, she was examined and her urine and blood samples were
taken and was told all her results were normal
She had received one injection on her shoulder which I assumed was tetanus toxoid vaccine.
She was given some iron tablets to drink daily and during her last visit she was given three white
tablets to drink at once which I assume is fansidar and given health educations.
Subsequent visits, she was examined and quiz 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.
OBSTETRICS HISTORY
She is Para 2+1.
Has had three previous deliveries and one abortions (confinements/pregnancies)
First was 8yrs ago and booked for antenatal care at 3mth and subsequent visits were on
appointments. Had high blood pressure during the pregnancy which was controlled with oral
medications taking daily and she had spontaneous vertex delivery at 9mnths in hospital. Labour
lasted for 18hrs and membranes were ruptured just before delivery. Resulted in twin delivery
weighing 2.5kg and 2.6kg respectively and all are males. She had normal puerperium, babies
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were exclusively breast fed for 4mth and completely wean at 2yrs. They are in grade 3 and doing
well.
Second was 5yrs ago and 3rd was 3yrs ago. Their pregnancy was uneventful, has had regular
antenatal care and both deliveries were spontaneous vertex at term in a hospital and are male
and female respectively. Labour lasted for 16hr and 18hrs respectfully with membranes
ruptured just before delivery and 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
GYNAE HISTORY
Menarche occurs at age of 12yrs
Has regular monthly cycle of 28days with 4days of menstrual blood flow
It’s not assoc with dysmenorrhea, menorrhagia intermenstrual bleeding or post coital bleeding
Has knowledge of contraceptive but never used one before
Her last pap’s smear was 4yrs ago and it was normal but she had not receive HPV vaccine
Coitarche occurs at 20yrs with her present husband and he has been her only partner since
then. She never had abnormal vaginal discharge or sores and has never been treated for sexual
transmitted disease
She has satisfactory heterosexual relationship with her spouse and has had no dyspareunia, she
doesn’t douche. She regularly does self breast examinations and hasn’t felt any mass yet.
Has had one spontaneous abortion 5yrs ago at 4mths gestation which was completed through
evacuation of the uterus and has had not post abortion complications.
PAST MEDICAL HISTORY
Has no history of HPT, DM, asthma, sickle cell disease, chronic cough, heart disease or renal
disease.
She had a HIV test at booking visit and was told its negative
Has never been admitted for any ailment nor has she ever undergo surgery or anesthesia
She has never been transfuse with blood before.
DRUG HISTORY
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Apart from her routine antenatal iron and folic acids she has had not been taken any medication
both orthodox and tradition in the past.
ALLERGY
Has no know allergy to food, medicine or other substances
FAMILY HISTORY
Is 3rd of 6 children from the mother in a polygamous marriage of three 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
There is no history of HPT, DM, Asthma, heart disease or renal disease in the family
SOCIAL HISTORY
She is marry for 10yrs in a monogamous relationship.
Her 3 children are alive and doing well in school.
She doesn’t take tobacco in any form, drink alcohol or take hard drugs.
Husband is a high school teacher and smokes half pack of cigarette a day and a social drinker but
doesn’t take hard drugs.
They are a tenant in a 4 bedroom house with electricity and pipe water supply with a flush
toilet. They seldomly use mosquito nets which is insecticide treated and have 3 basic meals a
day
She doesn’t have health insurance and fund her medicare from the family’s income. Her
husband gives her approx $2 a day for feeding and family upkeeping.
EXAMINATION
UPON EXAMINATION SHE IS
Medium size well dressed and adequately nourish lady sitting comfortably on the bed
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Not in any obvious distress, not pale, acyanosed, anicteric, bilateral non tender pitting pedal
odema up to ankles, no palpable peripheral lymphadenopathy, afebrile to touch and hydration
satisfactory
Weight 70kg, height 168cm, Body mass index 24.8kg/m2 (normal)
Respiratory rate 15cycles/min, pulse 70beats/min regular and full, blood pressure
150/100mmHg
Normal head with well plaited hairs, slightly puffy face with normal skin.
Normal neck, with normal thyroid gland and no distended vessels
CHEST: Normal chest, with no scars or lesions or tenderness , symmetrical expanding, equal
normal tactile and vocal fremitus. vesicular breath sounds and good air entry.
Breast: Normal parous (pendulous) breast with normal nipple and areola, non tender with no
palpable mass or abnormal discharges
HEART: precordium quiet, Apex 4ICSMCL, I &II normal sounds and no murmurs heard
ABDOMEN: symmetrically enlarged, linear nigra extending from superior border symphysis
pubis to about 3cm above the umbilicus, straie gravidarium diffuse distributed infra umbilically,
visible fetal movements, no scars and normal hernia orifices
soft non tender with no guarding, liver, spleen and kidneys are not palpable. She has an
abdominopelvic which I presume is the gravid uterus.
symphysiofundal height is 40cm which corresponds to 40weeks plus or minus 2wks which does not
commensurate with her gestational age of 29weeks.
Multiple Fetus poles felt one in cephalic and other breech presentation, longitudinal lie, head
engagement 5/5 and ballotable, two fetal heart sounds heard with one above has rate of
120beats/min and the other below the umbilicus has a rate of 130beats/min and both are
normal.
Urinalysis: pH6, Sugar –ve, Protein +3, nitrite –ve, blood +2
Bedside clotting time is 6mins
SUMMARY
YO HW G5P3+1 with 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.
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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 with
bedside clothing time of 6mins
PROBLEMS
Preterm pregnancy
Symptoms of imminent eclampsia
High blood pressure
Previous Twin gestation
DIAGNOSIS
imminent eclampsia with preterm twin pregnancy
Differential Diagnosis
Chronic Hypertension with Super Imposed Pre-eclampsia
HELLP
Renal dx (Nephrotic Syndrome)
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
corpuscle haemoglobin concentration, platelet count, clotting profile
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
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Renal function test: (exclude renal Disease)
Urine analysis, culture and sensitive
Urea, creatinine, uric acid
24 hours protein (exclude renal disease)
MANAGEMENT
Mother
Prevent convulsions
MAG NESIUM SULPHATE
Control blood pressure
IV HYDRALAZINE
METHYL DOPA
Continue management post deliver
fetal well being
Fetal lung maturation
Fetal heart monitoring
INTERMITTENT
CONTINUOUS
CARDIOTOCOGRAPHY
Delivery of fetus as soon as possible
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GYN HISTORY TAKING
29YO lawyer, P0+1, LMP 15 April 2011,
Informant self and husband
Reliable
PRESENTING COMPLAINT
C/O unable to conceived for 3yrs
HISTORY OF PRESENTING COMPLAINT
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 has no male pattern hair growth on her legs, thighs, chest, beard or mustarche, no
hoarseness of voice or recent weight gain. No acnes
She has no recent blurred visions, headaches or discharges from her breast
She has no heat or cold intolerances, no excessive appetite, easy fatigue or weight lost
She has no excessive thirst, no frequent large urination, or frequent urination at night.
ON DIRECT QUESTIONING(ODQ)
Headache- galactorrhoea- ,visual disturbance- ,normal smell+, heat intolerance-, polyuria-,
polyphagia- , abnormal vaginal discharge- , dyspareunia-, consummation+, painful menses-
SYSTEM REVIEW
Nervous system: no headache, no dizziness, no blurred vision/changes in vision, no fever,
Cardiovascular system: no dyspnoea, orthopnoea, 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.
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Urinary system: no dysuria, no frequency, no hesitancy, no incontinence, no polyuria no loin
pain,
Reproductive system: no sores, no vaginal discharge, no vaginal bleeding, no dyspareunia, no
loss of libido, no galactorrhoea
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
GYNAE HISTORY
Menarche occurred at 13yrs
She has regular menstrual cycle of 30days with 4days of menstrual blood flow.
She has no dysmenorrhoae, menorrhagia, PCB or inter bleeding
She has satisfactory sexual relationships with mild deep dyspareunia and is heterosexual and
coitarche occurs at18yrs. She had 3 lifetime partners.
She had abnormal vaginal discharge 5yrs ago around 2weeks after meeting her 2nd partner and
this was treated. She used to douche regularly with soap water but has stopped about yr ago.
She had her best examine by a doctor 6mhts ago and was inform its normal.
She had an induced abortion using both oral and vaginal medication then suction evacuation at
around 3months gestation 7yrs ago at a private clinic.
She used loop for 5yrs prior to marriage. Her earlier methods were combination of rhythm,
withdrawal and condom, foam or diaphragm during fertile periods.
Her last pap’s smear was a year ago and it’s was normal she had completed her HPV vaccination 1yr
ago
PAST MEDICAL HISTORY
She had no past history of diabetes, hypertension, asthma, sickle cell, tuberculosis, thyroid
disease. Her last HIV test was 7yrs ago and it’s was negative.
She had no past history of intra-abdominal operation or other operations. She had never
received blood transfusion and had no severe illness requiring admission in hospital.
DRUG HISTORY
She had not taken any orthodox, traditional or herbal medicine. She is presently on multivitamin
and folic acids
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ALLERGY
No known allergy
FAMILY HISTORY
She 4th of 4 children with two brothers and one sister from a monogamous marriage.
There is no history of infertility in family, no history of tuberculosis, congenital abnormality,
genetic disease, HPT, DM, asthma in the family.
All family members are well
SOCIAL HISTORY
She is married for 3yrs in a monogamous marriage. The couple do not take tobacco in any form
nor do they drink alcohol. She does not take any illicit drugs too. She is a Muslim, wollof,
Gambian and lives at pipeline. She has health insurance and her husband gives her approx
$15/day as feeding and her upkeeping
Her spouse is 33yrs old doctor, he has had right herniorrhaphy 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. He doesn’t have 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 and they have been living together all these
3yrs.
They live in 3 bedroom house, with flush toilet and pipe born water supply and electricity supply
with an indoor kitchen
EXAMINATION
Neatly dressed, adequately nourished average sized young lady.
Not in any obvious distress, not pale, acyanosed, anicteric, no palpable peripheral
lymphadenopathy, no pedal or sacral odema and afebrile to touch and hydration satisfactory.
GCS 15/15 respiratory rate 16cycles/min, pulse 80beats/min full and regular, blood pressure
110/70mmHg, temp 36.7oC
Normal thyroid that moves with deglutition and no other palpable neck swelling,
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
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Quiet precordium, apex beat 4ICSMCL, no thrill or heaves 1st and 2nd heart sounds normal and
no murmur heard
Symmetrical full abdomen which moves with respiration, umbilicus is inverted, no scars, 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, no discharges, normal labia, 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 cervical motion or adnexal tenderness or
adnexal mass
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
Examination of spouse
An adequately nourished well dress man average build and not in any obvious distress.
Not pale acyanosed, anicteric, no peripheral odema, no palpable lymphadenopathy
GCS 15/15, respiratory rate15cycles/min, pulse 80beats/min full and regular blood pressure
120/70mmHg
No baldness, normal thyroid and normal chest with normal male breast and normal male hair
distribution on chest and no tenderness or swelling, has normal tactile and vocal fremitus and
resonant percussion notes with vesicular breath sounds
Precordium quiet, apex beat 5ICSMCL, I & II are normal and no murmurs
Abdomen full moves with respiration, male pattern pubic and abdominal 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 no other palpable masses, vas deferens are palpable connected to the testis and
normal epididymis, no tenderness felt.
Penis was easily stimulated into harden and erection with no deformity seen
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Summary
29YO lawyer, P0+1 unable to conceive for 3yrs despite regular unprotected sex
She has had abnormal vaginal discharge and used to douche in the past. She had induced
abortion with instrumentation and now mild deep dyspareunia. her spouse appears normal
male
She has normal female appearances with normal menstrual cycle
DIAGNOSIS
Problems
Unable to conceive
Previous abnormal vaginal discharge and douching
Previous induce abortion with instrumentation
IMPRESSION:
Secondary Infertility secondary to pelvic adhesions
DIFFERENTIALS
Peritoneal Adhesions
Asherman Syndrome ( Endometrial Synechia)
Azoospermia/ Oligozoospermia
INVESTIGATION
Pelvic ultrasonography
Hysterosalpingography
Hormone profile
Follicular stimulating hormone
Luteinizing hormone
Thyroid stimulating hormone
Serum prolactin
Luteal phase progesterone (21day)
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Androgen
estrogen
Laparoscopy and chromotubation
Hysterosalpinsonography
Hysterocontrast sonography
hysteroscopy
Karyotype
Computer tomography/magnetic resonance imaging
Cervical smear
Pap’s smear
Complete blood count
Fasting blood sugar
Urinalysis microscopy, culture and sensitivity
Couple
Postcoital test
Spouse
Semen analysis
Hormone profile
Karyotype
Testicular biopsy
Vasography
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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
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SAMPLE ADMISSION TO LABOUR WARD 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/EtOH/Drugs
• 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
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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
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.
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• Delivery was via (SVD, LTCS, and 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 sends 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 sends 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
SAMPLE DELIVERY NOTE
Date and time:
Summary:
Normal spontaneous vertex delivery (NSVD) of a live male, 3000g and Apgars 9/9.
Delivered left occiputo-anterior (LOA), no nuchal cord, and 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
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
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• ASSESSMENT: A: assessment based on above data
• PLAN P: Medication change, Lab Tests, Procedures, Consults(other disciplines), Discharge
POSTPARTUM NOTES
• 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
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SAMPLE POSTPARTUM NOTE
• 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
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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
OPERATION NOTES
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
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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
SAMPLE OPERATION NOTES
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: Tear 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
SAMPLE OPST CAESAREAN SECTION ORDER/NOTES
Admit to Recovery Room, then postpartum floor
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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
SAMPLE POSTOPERATION NOTE (CS)
Date and Time:
Day #1 (Post-op day POD#1)
Subjective: Ask patient about:
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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? odaema? 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;
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
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Discharge IV when tolerating PO
Check hematocrit or CBC