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HISTORY TAKING AND EXAMINATIONDr MUSA MARENA
OBGYN
OBGYN
Crucial issue during history taking areRespect PrivacyConfidentiality
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 04/07/232 UTG OBGYN
GETTING READYIntroduce yourself with a friendly greeting
Give your name and status
Explain the purpose of your interview
Maintain good eye contact
Listen attentively
Facilitate verbally and non verbally communication
Ask for a background information about the patient, which includes
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PERSONAL AND DEMOGRAPHIC DATA
NameAgeSexOccupationGravidity & ParityFirst day of last (normal)
menstrual period LMP.Gestational AgeExpected day of Delivery
EDDMarital statusTribeRace
ResidenceNationalityReligionAddressLevel of educationReferral center; sometime
date and time of referralDate/time of
presentation/clerkingInformantReliability 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) Para a,b,c,d (a=full term, b=preterm, c=miscarriages d=living children)
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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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Gestational age
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Gestational age in weeks can be calculated in two waysusing number of days from LMP to Date of seeing the patient divided by
sevenExample if a client has her LMP of 12th august 2010 and she
is seen or clerk 15th march 2011 then her gestational age is20+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
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=1W5Do April 1st-30th =30days=4W2Do May 1st-19th =19days=2W5Do Total =8W5Do Gestational age=40W0D-8W5D=31W2D
CALCULTION OF EXPECTED DAY OF DELIVERY
Using Nagaele ruleAssumptions made
28 day cycleOvulation occurs 14days before start of next menses
Two methods:Add 7days and 9months to the date of the 1st day of last menstrual
periodAdd 7days, subtract 3months and add 1year to the date of the 1st day
of last menstrual periodCycles longer than 28days, add the difference to the calculated
EDDCycles less than 28days subtract the difference from the
calculated EDD 04/07/239UTG OBGYN
Presenting Complaint
SymptomsMain complaints in order of occurrence; 1st symptom(s)
written or reported firstIn the patients own wordsTwo 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 Direct questioning of related symptoms and signs
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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 pregnancy including any Assisted Reproduction Technology in cases of
infertility Supported by partner/spouse (welcome by the couple) Day of ovulation, Fertilization, conception. {assisted conception), ‘quickening’ Illness and complications during this pregnancy Antenatal care
When booking/registration Number and frequency of visits Type of care History and type examination done Investigation done and results
Haematology urine Screening for infections and genetic anomalies' Imaging
Immunization and medications (type and when received)Elicit likely exposure to hazard/teratogens including medications
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Past ObstetricsDate/years ago of
confinement in chronological order
Antenatal illness, care and complications
Maturity (preterm/term)Onset of labour
(spontaneous/induced)Place & Mode of deliveryoutcomeBaby’s sexBaby’s birth weightResuscitations, PPH etc
Postnatal complicationsNeonatal outcomeMode of feedingType and duration of infant
feedingHealth status age of the child
presently.
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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 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 vacinations
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:
Coitarche and number of partners since coitarche
orientation, frequency Satisfaction Problems (dyspareuna, 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)
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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, 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
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Drug HxMedications taking before onset of or not related this illness both
orthodox and traditonal medicines (esp those ingested)
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
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.
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Social HxMarital status, duration of relationship and spouse support.Occupation of coupleTobacco intake, alcohol intake and drug abuse (type, quantity
per day and duration of intake)Family incomeMeans of paying for medical care including insuranceHousingNumber of occupants in the roomHousing environment ( sanitation, feeding and food preparation
and storage, waste disposal, bed nets, water availability)
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Systemic Review
Direct questioningNervous: headache, dizziness, blurred vision, fever, convulsion,
CVS: orthopnae, palpitation, leg swelling paroxysmal nocturnal dyspnaoe, exertional dyspnaoe
Respiratory: cough, dyspnoae tachypnae, chest pain, sputum, anosmia
Digestive: vomiting, dysphagia, odnyphagia, abdominal pain, diarrhoea, jaundice, haematochezia, melenae,
Urinary: incontinence, dysuria, frequency, urgency, precipitancy, retention, haematuria, loin pain
Reproductive: bleeding PV relationship to menses (menorrhagia, dymenorrhoea, metrorrhagia, oligomenoorhea and polymenorrhea) and sex
(postcoital bleeding), dysmenorrhea, abnormal vaginal discharge, vulva ulcers, papules or pustules, sexual dysfunction (dyspareunia/apareunia, frigidity, premature orgasm, nyphomania), rare sexual deversion (homo, bi or transexuality), infertility
Musculoskeletal: joint pain, joint stiffness, joint swelling, muscle and bone deformity , pain or atrophy
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EXAMINATION
INSPECTION (I)PALPATION(P)PERCUSSION(P)AUSCULTATION(P)
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GENERAL EXAMINATIONBuilt: obese, average or thinStriking feature (most obvious thing about the patient upon first
seeing her)Nutritional status: adequate or poorMental status and conscious levelLevels of Pallor, cyanoses, jaundice, pedal or sacral oedema, and
palpable peripheral lymphadenopathyMeasurements (anthropometry)
Weight, height, body mass index (BMI), temperature
Sometimes: pulse, blood pressure, respiratory rate, SO2
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HEAD & NECK
HeadNeckthyroid
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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 sounds and murmurs with their radiation 04/07/2324 UTG OBGYN
ABDOMENContour, SymmetryStraie, scar, skin pigmentation, linear nigra, fetal
movements, prominent masses/veinsTenderness, consistency, contractions, fetal movementsLiver, spleen, bladder, hernia orifices, bladderUterus
using leopald Maneuvers 1st identify the upper limit of fundus and fetal pole occupying the
fundus Fundal Height: determine with ulna border of left hand Measurement symphysis-fundal height after 20weeks because uterus
rises at a rate of 1cm every week after twentieth week using land marks Superior border of symphysis Pubis 12wks Distance between symphysis and umbilicus is divided into 3 equal
parts. Lower 3rd is reach at 16wks, 2/3rd is reach at 20wks Umbilicus24wks Distance between umbilicus and xiphisternum is divided into 3 equal
parts. Lower 3rd is reach at 28wks, 2/3rd is reach at 32wks Xisphisternum is reach 36wks Thereafter uterus descend and at 40ks fundus occupies the height at
32wks04/07/2325 UTG OBGYN
OBSTETRIC PALPATION
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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.
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
VAGINAVulva & 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
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 Adnexals Direct rectal examination:DRE for rectal mucosa and pelvic organs
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SUMMARYPertinent 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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INVESTIGATIONSWe 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 04/07/2331 UTG OBGYN
TREATMENTNon Medical (Advice) also may be expectant (observe progress
without intervention
MedicalMedicineSurgery
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Follow up
WhenFrequencyReasonDeposition (to where the patient was discharge to)
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SAMPLE./TEMPLATE
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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 selfShe is reliableNote in some instances religion, tribe, nationality,
residence and education may be placed under social history
PRESENTING COMPLAINING
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Complains ofDizziness 1day prior to presentationBlurred 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 questioningFetal movement +,Headache+ ‘ dizziness+ ,
palpitation+ , blurred vision+ , epigastric pain+ , abdominal pain- , bleeding PV-, difficulty in breathing-, easy fatiguability- , dysuria- , frequency-
INDEX PREGNANCY
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Pregnancy was planned, spontaneously conceived and support by her husband.
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 has 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 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.
OBSTETRICS HISTORY
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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 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
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Menarche occurs at age of 12yrsHas regular monthly cycle of 28days with 4days of menstrual
blood flowIts not assoc with dysmenorrhea, menorrhagia intermenstrual
bleeding or post coital bleedingHas knowledge of contraceptive but never used one beforeHer last pap’s smear was 4yrs ago and it was normal but she
had not receive HPV vaccineCoitarche 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.
PAST MEDICAL HISTORY
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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 under 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
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Has no know allergy to food, medicine or other substances
FAMILY HISTORY
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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 wellThere is no history of HPT, DM, Asthma,
heart disease or renal disease in the family.
SOCIAL HISTORY
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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.
SYSTEMIC REVIEW
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Nervous system: slight headache, dizziness, blurred vision had subsided, no fever,
Cardiovascular system: no dyspnoea, othopnoea, 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 dysuira, no frequency, no hesitency, 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.
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.
EXAMINATION
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UPON EXAMINATION SHE IS Medium size well dressed and adequately nourish lady
sitting comfortably on the bedNot in any obvious distress, not pale, acyanosed,
anicteric, bilateral non tender pitting pedal odema up to ankles, no palpable peripheral lymphadenopathy, afebril 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 150/100mmHgNormal head with well plaited hairs, slightly puffy face
with normal skin.Normal neck, with normal thyroid gland and no
distended vessels
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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: precodium 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 a 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.
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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
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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.
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 clotthing time of 6mins
Diagnosis
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ProblemsSymptoms of imminent eclampsiaHigh blood pressureTwin gestationPreterm pregnancy
DDX imminent eclampsia with preterm twin pregnancy
Differential Diagnosis Chronic Hypertension with Super Imposed Pre-eclampsiaHELLPRenal dx (Nephrotic Syndrome)
Investigations
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Pelvic Ultrasound Scan: To confirm twin pregnancy fetal number, gestational age, fetal viability, placental position
and maturity, liquor volumeComplete 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, 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
Renal function test: (exclude renal Disease)Urine analysis, culture and sensitiveUrea, creatinine, uric acid
24 hours protein (exclude renal disease)
Management
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MotherPrevent convulsions
MAG NESIUM SULPHATEControl blood pressure
IV HYDRALAZINE METHYL DOPA
Continue managemt post deliverfetal well being
Fetal lung maturationFetal heart monitoring
INTERMITTENT CONTINUOUS
CARDIOTOCOGRAPHYDelivery of fetus as soon as possible
GYN HISTORY TAKING29YO lawyer, P0+1, LMP 15 April 2011, Informant self and husbandReliableC/O unable to conceived for 3yrs
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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 growthon 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. 04/07/23UTG OBGYN55
On Direct Questioning(ODQ)Headache- galactorrhea- ,visual
disturbance- ,normal smell+, heat intolerance-, polyuria-, polyphagia- , abnormal vaginal discharge- , dyspareunia-, consummation+, painful menses-
GYNAEMenarch occurred at 13yrsShe has regular menstrual cycle of 30days with 4days of menstraul blood
flow.She has no dysmen, menorrh, PCB or inter bleedingShe has a 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 diaphram during fertile periods.
Her last pap’s smear was a year ago and its was normal she had completed her HPV vaccination 1yr ago.
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PAST MEDICAL HISTORYShe had no past history of diabetes,
hypertension, asthma, sickle cell, tuberculosis, thyroid disease.her last HIV test was 7yrs ago and its was negative.
She had no past history of intra-abdominal operation or other operations. She had never received blood tansfusion and had no severe illness requiring admission in hospital.
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DRUG HISTORYShe had not taken any orthodox, traditional
or herbal medicine. She is presently on multivitamine and folic acids
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FAMILY HISTORYShe 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, chromosomal abnormality, HPT, DM, asthma in the family.
All family members are well.
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SOCIAL HISTORYShe 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 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. 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.
04/07/23UTG OBGYN61
SYSTEMIC REVIEWNervous system: no headache, no dizziness, no blurred vision had
subsided, no fever,Cardiovascular system: no dyspnoea, othopnoea, exertional
dyspnoea, or chest pain, no heat intolerance, Respiratory system: no cough, no chest pain, no dyspnoea Digestive system: no vomiting, no dysphagia, no nausea,
abdominal pain subsided, good appetite, no diarrhoea, no constipation, no polyphagia, no polydypsia.
Urinary system: no dysuira, no frequency, no hesitency, no incontinence, no polyuria no loin pain,
Reproductive system: no sores, no vaginal discharge, no vaginal bleeding, no dyspareunia, no loss of libido, no galactorrhea
Musculoskeletal system: no joint pain no muscle pain no joint swelling or stiffness, slight back pain, intermittent abdominal pain main associated with fetal movements, has swelling of both feet.
04/07/23UTG OBGYN62
ExaminationWell 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 resp rate 16cycles/min, pulse 80beats/min full and regular, blood pressure 110/70mmHg, temp 36.7oC
Normal thyroid that moves with glutition 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
04/07/23UTG OBGYN63
Quiet precodium, 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 labias, normal urethra meatus, normal fourchette , hymen discontinue with about 4 corincular mitrifomis, normal fossa navicularis, normal vaginal wall ruggae and cervix with no discharges and has nulliparous Os.
Normal size non pregnant anterior-verted uterus, no cervical motion or adnexal tenderness or adnexal mass
04/07/23UTG OBGYN64
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 normalNormal extremities including normal size
head jaws, face and hands.
04/07/23UTG OBGYN65
Examination of spouseAn adequately nourished well dress man average build
and not in any obvious distress.Not pale acyanosed, anicteric, no peripheral odema, no
palpable lymphadenopathyGCS 15/15, respiratory rate15cycles/min, pulse
80beats/min full and regular blood pressure 120/70mmHgNo baldness, normal thyroid and normal chest with
normal male breast and normal male hair distibution on chest and no tenderness or swelling, has normal tactil and vocal fremitus and resonant percussion notes with vesicular breath sounds
Precodium quiet, apex beat 5ICSMCL, I & II are normal and no murmurs
04/07/23UTG OBGYN66
Abdomen full moves with respiration, male pattern pubic and abd hair distribution, Right para-midline scar. Abd is soft non tender LSK not palpable and no other palpable mass, typanitic percussion and 3 bowel sounds in 1min.
Normal circumcised penis, no discharges ulcers, nodules or pustules and is about 8cm long in non erect position, urethra meatus is at the tip of the glans penis no epi- or hypospedias, no palpable cord with the urethra has normal scrotum with both testis inside and each about 4cm diameter with not other palpable masses, vas differens are paalpble connected to the testis and normal epididymis, no tenderness felt.
Penis was easily stimulated into harden and erection with no deformity seen
04/07/23UTG OBGYN67
Summary 29YO lawyer, P0+1 unable to conceive
for 3yrs despite regular unprotected sexShe has had abnormal vaginal disharge
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 a normal female appearances with normal menstrual cycle.
ProblemsUnable to conceivePrevious abnormal vaginal discharge and
douchingPrevious induce abortion with instruementation
IMPRESSION: Secondary Infertility (tubal block)
DIFFERENTIALSPeritoneal AdhesionsAsherman Syndrome ( Endometrial Synechia)Azoospermia/ Oligozoospermia
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INVESTIGATIONspouse
Pelvic ultrasonography Hysterosalpingography Hormone profile
Follicular stimulating hormone Luteinizing hormone Thyroid stimulating hormone Serum prolactine Luteal phase progesterone
(21day) Androgen estrogen
Laparascopy and chromotubation Hysterosalpinsonography hysteroscopy Karyotype Computer tomography/magnetic
resonance imaging
Cervical smear Pap’s smear Complete blood count Fasting blood sugar Urinalysis microscopy, culture
and sensitivity
CouplePostcoital test
SpouseSemen analysis Hormone profileKaryotypeTesticular biopsyVasography 04/07/23UTG OBGYN70
OBGYN INTERNSHIPSURVIVAL
DR MUSA MARENADEPARTMENT OF OBGYN
RVTH
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/hematocrit04/07/23UTG OBGYN72
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/EtOH/Drugs
04/07/23UTG OBGYN73
Physical exam (focused): General and Vital signs Lungs Cardiovascular – (Many pregnant women have a grade 1-2/6 systolic ejection murmur Abdomen – Gravid, fundus non-tender (NT), fundal height (FH) 38cm, Leopold maneuvers: Fetus is vertex (VTX), estimated fetal weight (EFW) 3300 gm Sterile speculum examination if indicated to rule out spontaneous rupture of membranes (SROM) Sterile vaginal exam (SVE) = 4cm/80%/VTX/ –1 as per Dr. Smith/time Extremities – No Cyanosis, clubbing or edema (C/C/E), NT
Pertinent Labs: Ultrasound:
Date: 10 wks by crown-rump length (CRL) Date: 20 wks, no anomalies
Assessment: 26yo G3P1 at term, in labor fetal heart rate tracing (FHRT) reassuring Intrauterine pregnancy (IUP) at 39 weeks gestation FHRT – Baseline 140’s, accelerations present, no decelerations Contractions – q 4-5 min Any pertinent past medical or surgical history
Plan: Admit to L&D NPO except ice chips IV – D5LR at 125 cc/hr Continuous electronic fetal monitoring CBC, T&S, RPR Anticipate NSVD 04/07/23UTG OBGYN74
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
04/07/23UTG OBGYN75
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
04/07/23UTG OBGYN76
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, drainsEXAM: physical findingsMED: pertinent routine or new medicationsINVEST: new lab or procedure results
• ASSESSMENT: A: assessment based on above data• PLAN P: Medication change, Lab Tests, Procedures,
Consults(other disciplines), Discharge04/07/2377 UTG OBGYN
POSTPARTUM NOTE• Subjective: Patient’s comments or complaints, nursing comments
CHECK pain control, breast tenderness, quality of vaginal bleeding, urination, flatus, bowel movement, lower extremity swelling, ambulation, breast or bottle feed, birth control type
• Objective: VITALS: blood pressure, pulse, respirations, temperature INS/OUTS: IV fluids, PO intake, emesis, urine, stool, drains EXAM: breath sounds, bowel sounds, fundal height/consistency, incision/episiotomy condition, lower extremity
oedema, Homan’s sign. MEDS: RhoGAM, pain med, iron, vitamins, laxative, contraceptive LAB: CBC, RH status
• Assessment: Assessment based on data above
• Plan: Medication change, lab tests, procedures, consults, discharge04/07/23UTG OBGYN78
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 04/07/23UTG OBGYN79
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
04/07/23UTG OBGYN80
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: 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
04/07/23UTG OBGYN81
Sample Postoperative Cesarean Section Orders/NoteSample C/S Orders
Admit to Recovery Room, then postpartum floor Diagnosis: Status post (s/p) C/S for failure to progress (FTP) Condition: Stable, Fair, Guarded Vitals: Routine, q shift, q4hours Allergies: None Activity: Ambulate with assistance this PM, then up ad lib Nursing: Strict input and output (I&O), Foley to catheter drainage, call MD for
Temp > 38.4, pulse > 110, BP < 90/60 or > 140/90, encourage breastfeeding, pad count, dressing checks, and Ted’s leg stockings until ambulating
Diet: Regular as tolerated; some hospitals only allow ice chips or clear liquids, semi solids IV: Lactated ringers (LR) or D5LR at 125 cc/hr, with 20 units of Pitocin x 1-2 Liters Labs: CBC in AM Medications:
Morphine sulfate PCA (patient controlled analgesia) per protocol (1 mg per dose with 10 minute lockout, not to exceed 20 mg/4 hours)
Percocet 1-2 tabs PO q 4-6 hours prn pain, when tolerating PO well Vistaril 25 mg IM or PO q 6 hours prn nausea Ibuprofen 800 mg PO q 8 hours prn pain, when tolerating PO well Prophylactic antibiotics if indicated Thromboprohylaxis for high-risk patients Rhogam, if Rh-negative 04/07/23UTG OBGYN82
Sample post operation (C/S) Note
Date and Time: Day #1 (Post-op day POD#1) Subjective: Ask patient about:
Pain – relieved with medication? Nausea/vomiting Passing flatus (rare this early post-op), stool
Objective: Vital signs and note tachycardia, elevated or low BP, maximum and current
temperature Input and output Focused physical exam including
Heart Lungs Breasts: engorged? Nipples – Is skin intact? Incision: Clean and dry? sutures intact? odema? haematoma? Abd: Soft? Location of the uterine fundus – below umbilicus? Firm? Tender? Perineum: Assess lochia (blood on pad, how old is pad? Frequency of
changing?) Visually inspect perineum – Hematoma? Edema? Sutures intact? Extremities: Edema? Cords? Tender?
Postpartum labs: Hemoglobin or hematocrit Fluids ins/outs; 04/07/23UTG OBGYN83
Assessment/Plan: POD#1 status post (S/P) C/S or repeat C/S (indication for the C/S) Afebrile, tolerating pain with medication, oral intake, adequate urine output (>30cc/hr) Routine post-op care Discharge Foley Discharge PCA or IV pain medications and PO pain Meds when tolerating PO Out of bed (OOB) Advance diet as tolerated Discharge IV when tolerating PO Check hematocrit or CBC
04/07/23UTG OBGYN84