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HISTORY TAKING AND EXAMINATION
Dr MUSA MARENA
OBGYN
OBGYN
Crucial issue during history taking are
Respect
 Privacy
Confidentiality
 Information should flow in a
 Logical
Chro...
GETTING READY
 Introduce yourself with a friendly greeting
 Give your name and status
 Explain the purpose of your inte...
PERSONAL AND DEMOGRAPHIC DATA
 Name
 Age
 Gravidity & Parity
 First day of last (normal)
menstrual period LMP.
 Expec...
Systems of Terminology
 Gravidity: order of the current pregnancy (if pregnant now)
 Gravidity: is total number of prese...
CASE EXAMPLES/Exercises
 A woman who is not pregnant and has a term single live birth,
one miscarriage and one terminatio...
DELIVERY
 Using Nagaele rule
 Assumptions made
Regular 28 day cycle not using contraceptives
Ovulation occurs 14days b...
Gestational age
7/14/2015UTG OBGYN8
 Gestational age in weeks is calculated using expectted date of delivery
as reference...
Presenting Complaint
 Symptoms
Main complaints in order of occurrence; 1st symptom(s)
written or reported first
In the ...
History of Presenting Complaint
 Elicit the evolution of the disease
 Progression of symptoms
 Appearances of new sympt...
Direct Questioning
 Helps to ask symptoms associated and also help
in confirming presume diagnosis and exclude
differenti...
Systemic Review
 Direct questioning
Nervous: headache, dizziness, blurred vision, fever, convulsion,
CVS: orthopnae, pa...
Index Pregnancy
 A chronological and concise account of the events in present pregnancy: is best
obtained by enquiring ab...
Past Obstetrics
 Date/years ago of
confinement in chronological
order including abortions and
ectopics
 Antenatal illnes...
Gynaecological History
 Age at menarche
 LMP (was it conform to the usual in terms
of timing, volume, and appearance)
 ...
Medical history
 Some medical conditions may have impact on the course of the
pregnancy or
 the pregnancy may have an im...
Drug Hx
 Medications taking before onset of or not related this illness
 Type, dose, duration and for what
 Transfusion...
Allergies
 To medications
 To food
 others
7/14/201518 UTG OBGYN
Family Hx
 Family Pedigree and health of members
Patient’s position in the family, type of family, number of members
in ...
Social Hx
 Marital status, duration of relationship, level of education
occupation, religion and believe towards blood tr...
Summary of history
7/14/2015UTG OBGYN21
EXAMINATION
 INSPECTION (I)
 PALPATION(P)
 PERCUSSION(P)
 AUSCULTATION(P)
7/14/201522 UTG OBGYN
GENERAL EXAMINATION
 Built: obese, average or thin
 Striking feature (most obvious thing about the patient upon first
se...
HEAD & NECK
 Head
 Neck
 thyroid
7/14/201524 UTG OBGYN
CHEST
 Breast: (IPPA) normal (nulliparous or parous breast fed) or
abnormal (nipple, areola, lumps abnormal discharges)
...
ABDOMEN
 Contour, Symmetry
 Straie, scar, skin pigmentation, linear nigra, fetal movements,
prominent masses/veins
 Ten...
OBSTETRIC PALPATION
7/14/2015UTG OBGYN27
 Fundal Grip: gently pressed of fundal area between the two hands in
an attempt ...
7/14/2015UTG OBGYN28
 If the presenting part cannot be easily identify bec it fixed in the
pelvis, the fingers are slippe...
VAGINA
 Vulva & Perineum
 Discharges, ulcers, papules and pustules, bleeding and blood stain, hair
distributions and inf...
SUMMARY
 Pertinent Information that helped you to arrive at a specific
diagnosis and differentials. Not more than three l...
Diagnosis
 Base on your findings from the patient through Interview and
Examination.
Most likely cause of the Complaints...
INVESTIGATIONS We investigate to
 Confirm Diagnosis and Exclude Differentials
 Know Baseline Values and Extent of the D...
TREATMENT
 Non Medical (Advice)
 Medical
Medicine
Surgery
7/14/201533 UTG OBGYN
Follow up
 When
 Frequency
 Reason
 Deposition (to where the patient was discharge to)
7/14/201534 UTG OBGYN
SAMPLE./TEMPLATE
7/14/2015UTG OBGYN35
 28YO Madam Marie Gomez, G5P3+1,
 LMP 22 July 2014, EDD 29 April 2015, GA 29wks
 ...
PRESENTING COMPLAINING
7/14/2015UTG OBGYN36
 Complains of
Dizziness 1day prior to presentation
Blurred vision12hrs prior
HISTORY OF PRESENTING COMPLAIN
7/14/2015UTG OBGYN37
 Was apparently well until a day ago when she began to experience a f...
On direct questioning
 Feels Fetal movement +,Headache+ ‘ dizziness+
, palpitation+ , blurred vision+ , epigastric pain+ ...
SYSTEMIC REVIEW
7/14/2015UTG OBGYN39
 Nervous system: slight headache, dizziness, blurred vision had
subsided, no fever, ...
OBSTETRICS HISTORY
7/14/2015UTG OBGYN40
 She is P3+1:Has had three previous deliveries and one
abortions (confinements/pr...
INDEX PREGNANCY
7/14/2015UTG OBGYN41
 Pregnancy was planned, naturally conceived and welcomed by the
couple. Diagnosed wi...
GYNAE HISTORY
7/14/2015UTG OBGYN42
 Menarche occurs at age of 12yrs
 Has regular monthly cycle of 28days with 4days of
m...
PAST MEDICAL HISTORY
7/14/2015UTG OBGYN43
 Has no history of HPT, DM, SCDx, Asthma,
chronic cough, heart disease, renal d...
Drug History
7/14/2015UTG OBGYN44
 She is on routine haematenics
 Has had not been taken any medication both
orthodox an...
Allergy
7/14/2015UTG OBGYN45
 Has no know allergy to food, medicine or other
substances
FAMILY HISTORY
7/14/2015UTG OBGYN46
 Is 3rd of 6 children from the mother in a
polygamous marriage of three co-wives and ...
SOCIAL HISTORY
7/14/2015UTG OBGYN47
 She has been married for 10yrs in a monogamous
relationship. She is a christian and ...
SUMMARY
 YO HW G5P3+1 with twin gestation at GA 29wk,
who was referred because of high blood
pressure, presented 1day his...
EXAMINATION
7/14/2015UTG OBGYN49
 UPON EXAMINATION SHE IS
 Young average size lady, looks ill with slightly puffy face,
...
7/14/2015UTG OBGYN50
 CHEST: respiratory rate 15cycle/min, Normal chest, with
no scars or lesions or tenderness , symmetr...
7/14/2015UTG OBGYN51
 Deep palpation: (liver, right and left lobe), spleen and kidneys
are not palpable.
 GRAVID UTERUS:...
Summary
7/14/2015UTG OBGYN52
 YO HW G5P3+1 at GA 29wk, who was referred because of
high blood pressure, presented 1day hi...
Diagnosis
7/14/2015UTG OBGYN53
 Preclampsia with twin pregnancy
 Differential Diagnosis
Chronic Hypertension with Super...
Investigations
7/14/2015UTG OBGYN54
 Pelvic Ultrasound Scan: To confirm twin pregnancy
 fetal number, gestational age, f...
Management
7/14/2015UTG OBGYN55
 Prevent convulsions
MAG NESIUM SULPHATE
 Control blood pressure
IV HYDRALAZINE
METHY...
GYN HISTORY TAKING
 29YO Madam Isatou Saine, P0+1, LMP 15 April
2011,
 C/O unable to conceived for 3yrs
7/14/2015UTG OBG...
 Despite regular unprotected sexual intercourse of 3 times
per week for 3years she is unable to conceive.
 There is adeq...
Direct questioning
 Abnormal hair growth0, bladeness0, hoarse voice0
blurred vision0 headache0 recurrent cough0
midcycle ...
SYSTEMIC REVIEW
 Nervous system: no headache, no dizziness, no blurred vision
had subsided, no fever,
 Cardiovascular sy...
GYNAE
 Menarch occurred at 13yrs
 She has regular menstrual cycle of 30days with 4days of
menstraul blood flow.
 She ha...
Obst hx
 P0+1
 She had an induced abortion using both
medication then suction evacuation at around
3months gestation 7yr...
PAST MEDICAL HISTORY
 She had no past history of diabetes,
hypertension, tuberculosis, thyroid disease or HIV
infection.
...
DRUG HISTORY
 She is or was not taking any orthodox, traditional
or herbal medicine.
7/14/2015UTG OBGYN63
FAMILY HISTORY
 She 4th of 4 children with two brothers and one sister from a
monogamous marriage.
 All family members a...
SOCIAL HISTORY
 She has been married for 3yrs in a monogamous marriage.
Wollof, muslim. she has no objection to blood
tra...
 24hrs dietary: bread sauce for breakfast with
meat/ fish of good, rice and stew or soup for
lunch with meat fish or chic...
SUMMARY
 I presents Madam29YO Madam Isatou Saine,
P0+1, LMP 15 April 2011,
 C/O unable to conceived for 3yrs
 Had hx of...
Examination
 Young lady, looks well, of average sized .
 Not in any obvious distress, not pale, acyanosed, anicteric,
no...
 Pulse rate 68bpm RVG non collapsing BP 100/70mmHg.
Quiet precodium, apex beat 4ICSMCL, no thrill or heaves
1st and 2nd h...
 Normal sense of smell through each
nostrils,Visual acuity is 6/6 and normal visual
fields elicited through confrontation...
Examination of spouse
 Young man looks well average build and not in any obvious
distress.
 Not pale acyanosed, anicteri...
 Abdomen full moves with respiration, umbilicus inverted,
male pattern pubic and abd hair distribution, Right para-
midli...
SUMMARY
 I presents Madam29YO Madam Isatou Saine,
P0+1, LMP 15 April 2011,
 C/O unable to conceived for 3yrs
 Had hx of...
 IMPRESSION:
Secondary Infertility (tubal block)
 DIFFERENTIALS
Peritoneal Adhesions
Asherman Syndrome ( Endometrial ...
INVESTIGATION
spouse
 Pelvic ultrasonography
 Hysterosalpingography
 Hormone profile
 Follicular stimulating hormone
...
OBGYN INTERNSHIP
SURVIVAL
DR MUSA MARENA
OBGYN
Admission Orders
 These vary a little from case to case, but the following are fairly general (format is ADC VAN DISMAL):...
PROGRESS NOTES
• Uses the SOAP Mnemonics
• SUBJECT S: patient comment or complains, nursing comments
• OBJECTIVE O:
VITAL...
Sample Admission to Labor and Delivery Note
• Date & time
• Identification: (includes age, gravidity, parity, estimated ge...
 Physical exam (focused):
 General and Vital signs
 Lungs
 Cardiovascular – (Many pregnant women have a grade 1-2/6 sy...
DELIVERY NOTE
• On (delivery date, time), this (age, race) female under(epidural, pudendal,
local, no) anesthesia delivere...
Sample Delivery Note
 Date and time:
 Summary:
 Normal spontaneous vertex delivery (NSVD) of a live male, 3000 gm and A...
SAMPLE POSTPARTUM NOTES (SOAP FORMAT)
 Subjective: Patients complaints, comments/ nurses’ comments .Ask every
patient abo...
POSTPARTUM NOTE
• Subjective: Patient’s comments or complaints, nursing comments
 CHECK
 pain control,
 breast tenderne...
Sample Postpartum Notes (Soap
format)
• Date and Time:
• Subjective: Ask every patient about:
 Breastfeeding – are they b...
PRE OPERATION NOTE
7/14/2015UTG OBGYN86
OPERATION NOTE DATE AND TIME:
 SURGEONS: Attending, residents, students who scrubbed
 ANESTHESIA: General endotracheal ...
Sample Operation Note
 Date and Time:
 Pre-op Diagnosis: Symptomatic uterine fibroids or Pregnancy at term, failure to p...
Sample Postoperative Cesarean Section Orders/Note
Sample C/S Orders
 Admit to Recovery Room, then postpartum floor
 Diag...
Sample post operation (C/S) Note
 Date and Time:
 Day #1 (Post-op day POD#1)
 Subjective: Ask patient about:
 Pain – r...
 Assessment/Plan:
 POD#1 status post (S/P) C/S or repeat C/S (indication for the C/S)
 Afebrile, tolerating pain with m...
 Sample Postoperative Cesarean Section Orders
 Sample C/S Orders
 Admit to: Recovery Room, then postpartum floor
 Diag...
SAMPLE C/S POSTPARTUM NOTE
 Day #1 (Post-op day POD#1)
 SUBJECTIVE: Ask every patient about the 5 B’s, also:
 Pain – re...
 Sample Operation Note
 Pre-op Diagnosis: Symptomatic uterine fibroids or Pregnancy at ___wks, failure to progress
 Pos...
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History taking and examination

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Transcript of "History taking and examination"

  1. 1. HISTORY TAKING AND EXAMINATION Dr MUSA MARENA OBGYN OBGYN
  2. 2. Crucial issue during history taking are Respect  Privacy Confidentiality  Information should flow in a  Logical Chronological sequence in a paragraph format ( as in writing/telling story).  History taking should not be simply translating the patient’s words into Medical English Language, but should get the clinician to  Ask further questions for clarification.  Form a provisional diagnosis that he/she would  Plan the examination  Investigations  Treatment accordingly 7/14/20152 UTG OBGYN
  3. 3. GETTING READY  Introduce yourself with a friendly greeting  Give your name and status  Explain the purpose of your interview  Maintain good eye contact  Listen attentively  Facilitate verbally and non verbally communication  Ask for a background information about the patient, which includes 7/14/20153UTG OBGYN
  4. 4. PERSONAL AND DEMOGRAPHIC DATA  Name  Age  Gravidity & Parity  First day of last (normal) menstrual period LMP.  Expected day of Delivery EDD  Gestational Age  Referral center; sometime date and time of referral  Reasons for referal  Informant  Reliability of information 7/14/20154 UTG OBGYN
  5. 5. Systems of Terminology  Gravidity: order of the current pregnancy (if pregnant now)  Gravidity: is total number of present and previous pregnancies  Parity: outcome of previous pregnancies  Parity: is the number of pregnancies resulting in a live birth (at whatever gestation) together with all stillbirths plus the number of miscarriages, terminations and ectopic pregnancies. A multiple pregnancy is counted as one.  Delivery: >28weeks  Term Delivery:>37weeks  Preterm: <38weeks  Miscarriage/Abortion: <28weeks  Notations  GDA written as GaPb+c  GTPAL written as GaPbcde G=gravidity T=term deliveries P=preterm deliveries A=abortions including ectopic pregnancies L=number of living children  Gravida……., Para……….  Para b+c (b=delivery c=miscarriage including ectopic preg)  Para a,b,c,d (a=full term, b=preterm, c=miscarriages d=living children) 7/14/201 5 5 UTG OBGYN
  6. 6. CASE EXAMPLES/Exercises  A woman who is not pregnant and has a term single live birth, one miscarriage and one termination =G3P1+2 or G3P1020  A woman who is pregnant with singleton pregnancy and has had two previous pregnancies resulting in a premature live birth and term stillbirth=G3P2+0 or G3P1101  A woman who has a singleton pregnancy and has had live twins at term and previous ectopic= G3P1+1 or G3P1012  A woman who is not pregnant but had a twin pregnancy resulting in live preterm births=G1P1+0 or G1P0102 7/14/20156 UTG OBGYN
  7. 7. DELIVERY  Using Nagaele rule  Assumptions made Regular 28 day cycle not using contraceptives Ovulation occurs 14days before start of next menses  Two methods: Add 7days and 9months to the date of the 1st day of last menstrual period Add 7days, subtract 3months and add 1year to the date of the 1st day of last menstrual period  Cycles longer than 28days, add the difference to the calculated EDD  Cycles less than 28days subtract the difference from the calculated EDD 7/14/20157UTG OBGYN
  8. 8. Gestational age 7/14/2015UTG OBGYN8  Gestational age in weeks is calculated using expectted date of delivery as references  Example if a client has her LMP of 12th august 2014 then EDD will be 19th may 2015 and she is seen or clerk 15th march 2011 then her gestational age is( TWO METHODS)  1: Count number of days from clerking date to date of expected delivery 21(March)+30(April)+19(May)=70/7=10W0D  Normal gestation 280days (40weeks0days) from LMP.  then GA=40W0D – 10W0D=30W0D  2: Divide the days of each month by 7 then adding the results. note addition of the remainders (days) should be in base 7. March 15th-31st=21days=3W0D April 30days = 4W2D May 19th 19days = 2W5D TOTAL = 10W0D Hence GA= 40W0D - 10W0D = 30W0D
  9. 9. Presenting Complaint  Symptoms Main complaints in order of occurrence; 1st symptom(s) written or reported first In the patients own words Two ways  Duration of the complaints (duration of symptom)  Time of onset of symptom to time of patient presentation. (duration prior to presentation) 7/14/20159 UTG OBGYN
  10. 10. History of Presenting Complaint  Elicit the evolution of the disease  Progression of symptoms  Appearances of new symptoms including treatments obtained and Response to treatment  Spontaneous remissions and exacerbations and other related phenomena  Onset: acute or insidious  Time and duration  Character  Volume, colour and consistency (fluids/liquids)  location  Progression  Relieving  Aggravating  Associated factors  Onset, location, course, severity, duration  What increase/decrease the symptoms  Associated symptoms  Others symptoms to prove or disprove provisional diagnosis  Investigations done(date, place and results)  Treatment received both traditional and orthodox (details & response)  Any complications 7/14/201510 UTG OBGYN
  11. 11. Direct Questioning  Helps to ask symptoms associated and also help in confirming presume diagnosis and exclude differentials. 7/14/2015UTG OBGYN11
  12. 12. Systemic Review  Direct questioning Nervous: headache, dizziness, blurred vision, fever, convulsion, CVS: orthopnae, palpitation, leg swelling paroxysmal nocturnal dyspnaoe, exertional dyspnaoe Respiratory: cough, dyspnoae tachypnae, chest pain, sputum, anosmia Digestive: vomiting, dysphagia, odnyphagia, abdominal pain, diarrhoea, jaundice, haematochezia, melenae, Urinary: incontinence, dysuria, frequency, urgency, precipitancy, retention, haematuria, loin pain Reproductive: bleeding PV relationship to menses (menorrhagia, dymenorrhoea, metrorrhagia, oligomenoorhea and polymenorrhea) and sex (postcoital bleeding), dysmenorrhea, abnormal vaginal discharge, vulva ulcers, papules or pustules, sexual dysfunction (dyspareunia/apareunia, frigidity, premature orgasm, nyphomania), rare sexual deversion (homo, bi or transexuality), infertility Musculoskeletal: joint pain, joint stiffness, joint swelling, muscle and bone deformity , pain or atrophy 7/14/201512 UTG OBGYN
  13. 13. Index Pregnancy  A chronological and concise account of the events in present pregnancy: is best obtained by enquiring about her pregnancy in the first, second and third trimester.  If she was in postnatal period details of labour and delivery are relevant  Planned / unplanned but welcome pregnancy including any Assisted Reproduction Technology in cases of infertility  Supported by partner/spouse  Day of ovulation, Fertilization, conception. {assisted conception), ‘quickening’  Illness and complications during this pregnancy  Antenatal care  When booking/registration  Number and frequency of visits  Type of care  History and type examination done  Investigation done and results  Haematology  urine  Screening for infections and genetic anomalies'  Imaging  Immunization and medications (type and when received)  Elicit likely exposure to hazard/teratogens including medications 7/14/201513 UTG OBGYN
  14. 14. Past Obstetrics  Date/years ago of confinement in chronological order including abortions and ectopics  Antenatal illness, care and complications  Maturity(preterm/term)  Onset of labour (spontaneous/induced) Place & Mode of delivery outcome Baby’s sex Baby’s birth weight Resuscitations, PPH etc  Postnatal complications Neonatal outcome Mode of feeding Type and duration of infant feeding Health status age of the child presently.  Abortions and ectopic age of termination, mode of termination post termination complications 7/14/201514 UTG OBGYN
  15. 15. Gynaecological History  Age at menarche  LMP (was it conform to the usual in terms of timing, volume, and appearance)  Previous menses  When  Cycle length  Duration of menses  Sure  Reliable  Symptoms: premenstrual tension, dysmenorrhoea, menorrhagia, intermenstrual, postcoital bleeding etc  Previous Menstrual Period PMP  Pap’s Smear:  Last Smear  when,  Where  results  Awareness and compliance on follow up  Contraceptives/birth Control Methods:  current method, what, when started, satisfaction and any side effects.  Previous methods: what, when and why stopped  Sexual Transmitted Infections and treatments  Sexual History:  Number of life time partners  orientation,  frequency  Satisfaction  problems(dyspareuna, premature ejaculation, impotence)  Hx of Infertility  Future fertility desires  Self breast examination  Gynae Operations: cone biopsy, cerclage, endometrial ablation etc 7/14/201515 UTG OBGYN
  16. 16. Medical history  Some medical conditions may have impact on the course of the pregnancy or  the pregnancy may have an impact on the medical condition examples HPT, DM, Sickle cell, heart dx, liver dx, renal dx, thyroid dx etc  Previous and Present Significant Illness not related to symptoms  Medical: Mostly chronic illness e.g. diabetes, hypertension, asthma, tuberculosis, sickle cell and other genetic diseases, renal dx, liver dx, thyroid dx, psychiatric disorders, HIV etc  Previous Surgical & Anesthesia Experiences  Previous Hospital Admissions 7/14/2015UTG OBGYN16
  17. 17. Drug Hx  Medications taking before onset of or not related this illness  Type, dose, duration and for what  Transfusions when and for what 7/14/201517 UTG OBGYN
  18. 18. Allergies  To medications  To food  others 7/14/201518 UTG OBGYN
  19. 19. Family Hx  Family Pedigree and health of members Patient’s position in the family, type of family, number of members in the family. Similar conditions as to patients complaints. Diseases afflicting family members (familial disease, genetic diseases, congenital malformations, fetal anomalies or inborn errors of metabolism, malignancy, infections). Multiple pregnancies. 7/14/201519 UTG OBGYN
  20. 20. Social Hx  Marital status, duration of relationship, level of education occupation, religion and believe towards blood transfusion  Spouse age occupation financial support  Tobacco intake, alcohol intake and drug abuse (type, quantity per day and duration of intake)  Family income  Tribe race nationality residency, address  Housing (use of insecticide treated nets)  Number of occupants in the room  Housing environment (sanitation, feeding and food preparation and storage, waste disposal, bed nets, water availability)  Dietary history 7/14/201520 UTG OBGYN
  21. 21. Summary of history 7/14/2015UTG OBGYN21
  22. 22. EXAMINATION  INSPECTION (I)  PALPATION(P)  PERCUSSION(P)  AUSCULTATION(P) 7/14/201522 UTG OBGYN
  23. 23. GENERAL EXAMINATION  Built: obese, average or thin  Striking feature (most obvious thing about the patient upon first seeing her)  Nutritional status: adequate or poor  Mental status and conscious level  Levels of Pallor, cyanoses, jaundice, pedal or sacral oedema, and palpable peripheral lymphadenopathy  Measurements (anthropometry) Weight, height, body mass index (BMI), temperature  Sometimes: pulse, blood pressure, respiratory rate, SO2 7/14/201523 UTG OBGYN
  24. 24. HEAD & NECK  Head  Neck  thyroid 7/14/201524 UTG OBGYN
  25. 25. CHEST  Breast: (IPPA) normal (nulliparous or parous breast fed) or abnormal (nipple, areola, lumps abnormal discharges)  Chest wall: (symmetry, deformities, lesions and scars expansion  Lungs: (palpation, percussion and auscultation)  Heart: precordiun activity, position of apex beat, auscultate four valves for the normal I and II heart sounds and murmurs with their radiation 7/14/201525 UTG OBGYN
  26. 26. ABDOMEN  Contour, Symmetry  Straie, scar, skin pigmentation, linear nigra, fetal movements, prominent masses/veins  Tenderness, consistency, contractions, fetal movements  Liver, spleen, bladder, hernia orifices, bladder  Uterus  using leopald Maneuvers  1st identify the upper limit of fundus and fetal pole occupying the fundus  Fundal Height: determine with ulna border of left hand  Measurement symphysis-fundal height after 20weeks because uterus rises at a rate of 1cm every week after twentieth week  using land marks  Superior border of symphysis Pubis 12wks  Distance between symphysis and umbilicus is divided into 3 equal parts. Lower 3rd is reach at 16wks, 2/3rd is reach at 20wks  Umbilicus24wks  Distance between umbilicus and xiphisternum is divided into 3 equal parts. Lower 3rd is reach at 28wks, 2/3rd is reach at 32wks  Xisphisternum is reach 36wks  Thereafter uterus descend and at 40ks fundus occupies the height at 32wks 7/14/201526 UTG OBGYN
  27. 27. OBSTETRIC PALPATION 7/14/2015UTG OBGYN27  Fundal Grip: gently pressed of fundal area between the two hands in an attempt to determine which pole of fetus is occupying the fundal area  2nd manoeuvre Umbilical Grip: hands are gently slip along the side of the uterus to the umbilical. Steadying one hand to stabilized the uterus, the other hand is use to palpate the other side to identify the back as a smooth elongated firm mass round area and the limbs as small irregular shapes in an area which is relatively empty.  3rd manoeuvre Pelvic Grip: obstetrician then turn to face the patients feet and place his hands with fingers extended he gently presses downward on the lower part of uterus along its sides and from side to side attempting to recognise the presenting part. Unless its fixed in the pelvic it can be balloted from side to side between the fingers.
  28. 28. 7/14/2015UTG OBGYN28  If the presenting part cannot be easily identify bec it fixed in the pelvis, the fingers are slipped further downwards and inwards until they dip into the pelvis brim.  If the hand which is on the same side as the fetal back slips more deeply than the other into the pelvis it can be assumed that the head is well fixed. It helps in determine the descent, engagement and position  Pawlik. Is not always necessary and unless performed gently may be painful. Facing the patient’s head the right hand spread widely and pressed into the suprapubic area above the inguinal ligament. When the fingers and thumb are approximated the presenting part can be felt between them and its mobility above the pelvic brim determine. Also helps in determining engagement and ballotment of the head.
  29. 29. VAGINA  Vulva & Perineum  Discharges, ulcers, papules and pustules, bleeding and blood stain, hair distributions and infestation.  shape and size of labia majora, minora, clitoris hood and prepuce (be aware of circumcision). Bartholin gland and duct  Vestibular  Urethra orifice, paraurethra opening(skene glands), integrity of frenulum and fourchette, presence and shape of hymen including vagina orifice and opening of bartholin duct  Speculum:  vaginal wall and  Cervix with fornix  Digital  cervix  Uterus  Adnexals 7/14/201529 UTG OBGYN
  30. 30. SUMMARY  Pertinent Information that helped you to arrive at a specific diagnosis and differentials. Not more than three lines or sentence. 1st sentence: Demographic, Presenting Complaint and History of Presenting Complaint in one sentence 2nd sentence: Obst, gynae, PMHx, Drug Hx, FHx, and SHx in one sentence 3rd sentence: Examination finding in one sentence 7/14/201530 UTG OBGYN
  31. 31. Diagnosis  Base on your findings from the patient through Interview and Examination. Most likely cause of the Complaints and Additional History with Physical Findings Atleast three Differentials with Similar Presentations 7/14/201531 UTG OBGYN
  32. 32. INVESTIGATIONS We investigate to  Confirm Diagnosis and Exclude Differentials  Know Baseline Values and Extent of the Disease  Monitor the Treatment  Order of the request should follow the above criteria  What disease does the patient have?  How serious or severe is the disease?  Is the treatment working?  Priority of request(investigations) will depends on  Necessity  Availability and cost  Includes  Haematology  Serology  Biochemistry  Microbiology  Cytology and Histopathology  Imaging 7/14/201532 UTG OBGYN
  33. 33. TREATMENT  Non Medical (Advice)  Medical Medicine Surgery 7/14/201533 UTG OBGYN
  34. 34. Follow up  When  Frequency  Reason  Deposition (to where the patient was discharge to) 7/14/201534 UTG OBGYN
  35. 35. SAMPLE./TEMPLATE 7/14/2015UTG OBGYN35  28YO Madam Marie Gomez, G5P3+1,  LMP 22 July 2014, EDD 29 April 2015, GA 29wks  referred from Brikama health Centre on 10/feb/11 at 0900hrs on accounts of High Blood Pressure. Was admitted on 10th February 2011. date of clerking 15th February 2011
  36. 36. PRESENTING COMPLAINING 7/14/2015UTG OBGYN36  Complains of Dizziness 1day prior to presentation Blurred vision12hrs prior
  37. 37. HISTORY OF PRESENTING COMPLAIN 7/14/2015UTG OBGYN37  Was apparently well until a day ago when she began to experience a frontal headache. It was throbbing and doesn’t radiates, it’s aggravated by bending head forward and prevented her from doing her daily chaos. It’s relieved by taking paracetamol. It was not associated with fever, joint pain, cough, dysuria, or diarrheoa  About 12 hours later she realises that her vision was getting blurred and she couldn’t see certain objected at far. She also felt dizzy and has had realises that her upper abdomen begins to pain. The dizziness and blurred visions were not associated with difficulty in breathing, easy fatigue, chest pain or fatigue on exercise.  She decided to go to Brikama Health Centre for consultation. There she was interviewed and her blood pressure was taken. She was told it was very high and was given some medicine to put under her tongue and was given two injections on her thigh. She was then referred to Royal Victoria Teaching Hospital (RVTH)  She was again interviewed at RVTH, examined, her urine and blood samples were taken and she was given some intravenous injections. She was told that she would be admitted and adviced to have completely bed rest.  Ultrasound scan was done for her and she was inform that her baby is find but she needs close monitoring because her condition is serious but manageable.  Since admission she had be receiving regular oral medications and IV injections but the injections only lasted for only her admission day. Now her vision is normal, dizziness and upper abdominal pain has subsided. She is only experiencing slight headache.
  38. 38. On direct questioning  Feels Fetal movement +,Headache+ ‘ dizziness+ , palpitation+ , blurred vision+ , epigastric pain+ , abdominal pain- , bleeding PV-, difficulty in breathing-, easy fatiguability- , dysuria- , frequency- feverˉ loosing liquorˉ 7/14/2015UTG OBGYN38
  39. 39. SYSTEMIC REVIEW 7/14/2015UTG OBGYN39  Nervous system: slight headache, dizziness, blurred vision had subsided, no fever, weakness  Cardiovascular system: no dyspnoea, othopnoea, exertional dyspnoea, or chest pain, cough, syncope  Respiratory system: no cough, no chest pain, no dyspnoea  Digestive system: no vomiting, no dysphagia, no nausea, abdominal pain subsided, good appetite, no diarrhoea, no constipation, haematochezia, dyschezia, melane, weight loss  Urinary system: no dysuira, no frequency, no hesitency, no incontinence, no polyuria no loin pain, no haematuria  Reproductive system: no sores, no vaginal discharge, no vaginal bleeding, no draining liquor, no dyspareunia, fetal movement present.  Musculoskeletal system: no joint pain no muscle pain no joint swelling or stiffness, slight back pain, intermittent abdominal pain main associated with fetal movements, has swelling of both feet.
  40. 40. OBSTETRICS HISTORY 7/14/2015UTG OBGYN40  She is P3+1:Has had three previous deliveries and one abortions (confinements/pregnancies)  First was 8yrs ago was twin pregnancy, planned and naturally conceived. booked for antenatal care at 3mth and developed HPT at 5mths gestation which was controlled with oral medications taking daily and she had spontaneous vertex delivery at 9mnths in hospital. . Resulted in twin delivery both male weighing 2.5kg and 2.6kg respectively and all are males. She had normal puerperium and high BP resolved after delivery without medication, babies were exclusively breast fed for 4mth and completely wean at 2yrs. They are in primary school and doing well.  Second was 5yrs ago and 3rd was 3yrs ago. Their pregnancy were planned naturally conceived and uneventful, both deliveries were spontaneous vertex at term in a hospital and are male and female weighing 2.5kg and 2.8kg respectively. their puerperiums were normal with exclusive breast feeding for 4mth and weaned completely at 2yrs. They are in grade 1 and nursery school respectfully and doing well.
  41. 41. INDEX PREGNANCY 7/14/2015UTG OBGYN41  Pregnancy was planned, naturally conceived and welcomed by the couple. Diagnosed with UPT after 1/12 amenorrhea. Had only one USS at 2/12 which gives her an EDD 22nd may 2015 and was told she is carrying twins and they are fine.  Had normal early pregnancy and was not taking any medication or had no x-rays during early weeks of this pregnancy  Booked for antenatal care at 3mths gestation and has had four visits so far on appointment.  At booking visit, a brief history was taken, she was examined and her blood, urine and stool test were done and was told all her results were normal.  Subsequent visits, she was examined and quizz about any problems she might have had experienced or is experiencing now and given advices on food, exercises including daily activities, taking only prescribed medications and health living.  She had received one dose of tetanus toxoid vaccine. And two doses of sulpadoxine and pyrimethamine
  42. 42. GYNAE HISTORY 7/14/2015UTG OBGYN42  Menarche occurs at age of 12yrs  Has regular monthly cycle of 28days with 4days of menstrual blood flow  Its not assoc with dysmenorrhea, heavy menses, intermenstrual bleeding  Had Coitarche 18yrs. Had 2 life time partners. She is heterosexual. No dyspareuna, postcoital bleeding or sexual dysfunction. She never had abnormal vaginal discharge or sores and has never been treated for sexual transmitted disease  Has knowledge of contraceptive but never used one before  Her last pap’s smear was 4yrs ago and it was normal  she does regular self breast examination and hasn’t felt any lumps or seen any abnormal breast discharge.  She has future fertility desire and plans to have her next confinement after two years
  43. 43. PAST MEDICAL HISTORY 7/14/2015UTG OBGYN43  Has no history of HPT, DM, SCDx, Asthma, chronic cough, heart disease, renal disease, or liver disease, HIV  Has never been admitted for any ailment nor has she ever under gone surgery or anesthesia or transfusion
  44. 44. Drug History 7/14/2015UTG OBGYN44  She is on routine haematenics  Has had not been taken any medication both orthodox and tradition in the past
  45. 45. Allergy 7/14/2015UTG OBGYN45  Has no know allergy to food, medicine or other substances
  46. 46. FAMILY HISTORY 7/14/2015UTG OBGYN46  Is 3rd of 6 children from the mother in a polygamous marriage of three co-wives and 15 children  Father died of chronic cough 5yrs ago and mother is a known HPT and on medication.  One of her full sister and her paternal half had twins  The rest of the family are well  No history of pregnancy induced hypertension in family, asthma, SCDx, DM
  47. 47. SOCIAL HISTORY 7/14/2015UTG OBGYN47  She has been married for 10yrs in a monogamous relationship. She is a christian and has no objection to blood transfusion. she has high school education, she is nursery sch teacher. She neither take tobacco in any form, nor drink alcohol or take hard drugs.  Husband 30yrs high school teacher and smokes half pack of cigarette a day and a social drinker but doesn’t take hard drugs. he gives her about D50 daily for her upkeeping.  She lives with her husband and 3 children in brikama.They are a tenant in a 4 bedroom house with electricity and pipe water supply with a flush toilet. she seldomly use mosquito nets and is not insecticide treated.  24hrs dietary recall: took bread with beans and tea for breakfast, stew with meat of good ample and rice for lunch,
  48. 48. SUMMARY  YO HW G5P3+1 with twin gestation at GA 29wk, who was referred because of high blood pressure, presented 1day history of severe continuous throbbing frontal headache associated with dizziness, blurred vision and epigastric pain.  She has had hx of twin deliveries and pregnancy induce hypertension in the past with family history of twin pregnancy and hypertension 7/14/2015UTG OBGYN48
  49. 49. EXAMINATION 7/14/2015UTG OBGYN49  UPON EXAMINATION SHE IS  Young average size lady, looks ill with slightly puffy face, sitting on the bed  Not in any obvious distress, not pale, acyanosed, anicteric, bilateral non tender pitting pedal odema up to ankles, no palpable peripheral lymphadenopathy, not warm to touch. Good oral hygiene.  Weight 70kg, height 168cm, Body mass index 24.8kg/m2 (normal)  No anterior neck swelling, with normal thyroid gland and no distended vessels  Breast: Normal parous (pendulous) breast with normal nipple and areola, non tender with no palpable mass or
  50. 50. 7/14/2015UTG OBGYN50  CHEST: respiratory rate 15cycle/min, Normal chest, with no scars or lesions or tenderness , symmetrical expanding, equal normal tactile and vocal fremitus. vesicular breath sounds and good air entry.  CVS: pulse rate 70bpm regular good volume and non collapsing. BP-150/100mmHg. HEART: precodium quiet, Apex 4ICSMCL, I &II normal sounds and no murmurs heard  ABDOMEN: symmetrically enlarged, moves with respiration, linear nigra extending from hypogastrium to about 3cm above the umbilicus, unbilicus is inverted, straie gravidarium diffuse distributed infra umbilically, visible fetal movements seen, no surgical scars or scarifications and normal hernia orifices  Light palpation: abdomen is soft, non tender with no guarding, felt a mass presume is the gravid uterus.
  51. 51. 7/14/2015UTG OBGYN51  Deep palpation: (liver, right and left lobe), spleen and kidneys are not palpable.  GRAVID UTERUS: symphysiofundal height is 50cm which corresponds to 50weeks plus or minus 2wks which is not consistent/does not commensurate with her gestational age of 29weeks (larger than her gestational age)  Fundal two Fetus poles felt (one hard and other soft)  Lateral multiple fetal parts on left, smooth round part on the right.  Pawlik hard mass ballotable  Pelvic grip two poles leading one hard not engaged (5/5) occiput to right of mother  Fetal heart beat: two fetal heart beats 130bpm below umbilicus 140bpm above. Both are regular  both longitudinal lie leading one in cephalic descend 5/5 back on mothers right with FHR 130bpm regular and other breech presentation back on left of mother with fetal heart rate of
  52. 52. Summary 7/14/2015UTG OBGYN52  YO HW G5P3+1 at GA 29wk, who was referred because of high blood pressure, presented 1day history of severe continuous throbbing frontal headache associated with dizziness, blurred vision and epigastric pain.  She has had twin deliveries and pregnancy induce hypertension in the past with family history of twin pregnancy and hypertension.  Examination reveals puff face with odema of both feet and a high blood pressure, fundal height larger than gestational age with double fetal parts and heart sounds and a proteinuria of +3
  53. 53. Diagnosis 7/14/2015UTG OBGYN53  Preclampsia with twin pregnancy  Differential Diagnosis Chronic Hypertension with Super Imposed Pre- eclampsia HELLP Renal dx (Nephrotic Syndrome)
  54. 54. Investigations 7/14/2015UTG OBGYN54  Pelvic Ultrasound Scan: To confirm twin pregnancy  fetal number, gestational age, fetal viability, placental position and maturity, liquor volume  Complete blood count: (exclude HELLP syndrome)  Haemoglobin level Hb, platelet counts, white blood cell counts WBC, red blood cell count RBC, mean corpuscle volume MCV, mean corpuscle haemoglobin MCH, mean copsuscle haemoglobin concentration  Blood for malaria parasite  Liver enzymes: (Exclude HELLP)  Alanine transferase ALT, aspartate transaminase AST, lactate dehydrogenase LDH.  Liver function test: exclude HELLP)  Total serum bilirubin, conjugated serum bilirubin and unconjugated serum bilirubin,  Renal function test: (exclude renal Disease)  Urea, creatinine, urates ur
  55. 55. Management 7/14/2015UTG OBGYN55  Prevent convulsions MAG NESIUM SULPHATE  Control blood pressure IV HYDRALAZINE METHYL DOPA  Monitor fetal well being INTERMITTENT CONTINUOUS  CARDIOTOCOGRAPHY
  56. 56. GYN HISTORY TAKING  29YO Madam Isatou Saine, P0+1, LMP 15 April 2011,  C/O unable to conceived for 3yrs 7/14/2015UTG OBGYN56
  57. 57.  Despite regular unprotected sexual intercourse of 3 times per week for 3years she is unable to conceive.  There is adequate vaginal penetration with intravaginal ejaculation during each sexual contact and has normal libido. There is no use of lubricant during sex and no douching after sex.  She hasn’t seek any medical care for this problem and hasn’t receive any non treatment. 7/14/2015UTG OBGYN57
  58. 58. Direct questioning  Abnormal hair growth0, bladeness0, hoarse voice0 blurred vision0 headache0 recurrent cough0 midcycle pain0 abdominal mass0 galactorrhea0 polyuria0, polydypsia0, polypahgia0, frequency0, LAP0,dyspareunia0, vaginal discharge0 fever0, heat intolerance0, neck swelling0, recent weight changed0 7/14/2015UTG OBGYN58
  59. 59. SYSTEMIC REVIEW  Nervous system: no headache, no dizziness, no blurred vision had subsided, no fever,  Cardiovascular system: no dyspnoea, othopnoea, exertional dyspnoea, or chest pain, no heat intolerance,  Respiratory system: no cough, no chest pain, no dyspnoea  Digestive system: no vomiting, no dysphagia, no nausea, abdominal pain subsided, good appetite, no diarrhoea, no constipation, no polyphagia, no polydypsia.  Urinary system: no dysuira, no frequency, no hesitency, no incontinence, no polyuria no loin pain,  Reproductive system: no sores, no vaginal discharge, no vaginal bleeding, no dyspareunia, no loss of libido, no galactorrhea  Musculoskeletal system: no joint pain no muscle pain no joint swelling or stiffness, slight back pain, intermittent abdominal7/14/2015UTG OBGYN59
  60. 60. GYNAE  Menarch occurred at 13yrs  She has regular menstrual cycle of 30days with 4days of menstraul blood flow.  She has no dysmen, menorrh, PCB or intermenstrual bleeding  She has a satisfactory sexual relationships and is heterosexual and coitarche occurs at 18yrs. she had 3 life time sexual partners.  She had abnormal vaginal discharge 5yrs ago around 2weeks after meeting her 2nd partner and this was treated  She used loop for 5yrs prior to marriage. Her earlier methods were combination of rhythm, withdrawal and condom, foam or diaphram during fertile periods.  Her last pap’s smear was a year ago and its was normal  no lumps found during her regular self breast examinations 7/14/2015UTG OBGYN60
  61. 61. Obst hx  P0+1  She had an induced abortion using both medication then suction evacuation at around 3months gestation 7yrs ago at a private clinic. No post abortal complication 7/14/2015UTG OBGYN61
  62. 62. PAST MEDICAL HISTORY  She had no past history of diabetes, hypertension, tuberculosis, thyroid disease or HIV infection.  She had no past history of intra-abdominal operation or other operations 7/14/2015UTG OBGYN62
  63. 63. DRUG HISTORY  She is or was not taking any orthodox, traditional or herbal medicine. 7/14/2015UTG OBGYN63
  64. 64. FAMILY HISTORY  She 4th of 4 children with two brothers and one sister from a monogamous marriage.  All family members are well  There is no history of infertility in family, no history of tuberculosis, chromosomal abnormality, HPT DM SCDx Asthma in the family. 7/14/2015UTG OBGYN64
  65. 65. SOCIAL HISTORY  She has been married for 3yrs in a monogamous marriage. Wollof, muslim. she has no objection to blood transfusion.The couple do not take tobacco in any form nor do they drink alcohol. She does take any receational drugs too.  Her spouse is 33yrs old doctor, P0+0, he has had right herniorrhape 5yrs ago, both of his testis are in his scrotum with no other palpable mass, he has no history of orchitis, mumps, tuberculosis, thyroid disease, diabetes, hypertension or recurrent rhinitis/respiratory tract infection. He doesn’t take warm bath top or wear tight under wear. He has no family history of infertility, chromosomal or genetic disease.  Their marriage has been consummated for 3yrs now and7/14/2015UTG OBGYN65
  66. 66.  24hrs dietary: bread sauce for breakfast with meat/ fish of good, rice and stew or soup for lunch with meat fish or chicken of good, tea and bread butter/mayoniase/jam with egg for dinner 7/14/2015UTG OBGYN66
  67. 67. SUMMARY  I presents Madam29YO Madam Isatou Saine, P0+1, LMP 15 April 2011,  C/O unable to conceived for 3yrs  Had hx of abnormal vaginal discharge was treated. Had MVA for incomplete abortion and used IUD  Partner had herniography 7/14/2015UTG OBGYN67
  68. 68. Examination  Young lady, looks well, of average sized .  Not in any obvious distress, not pale, acyanosed, anicteric, no palpable peripheral lymphadenopathy, no pedal or sacral odema and not warm to touch with temp 36.7ºC  Height 168cm weight 75kg giving BMI 26.6kg/m2  No beard mustache acne or acanthosis nigra seen.Normal thyroid that moves with glutition and no anterior neck swelling, no distended neck veins  Normal nulliparous breast with well form nipples and areola, no discharges from nipple and no palpable mass.  Normal symmetrical chest, no abnormal hair growth, no palpable mass or tenderness, vesicular breath sounds 7/14/2015UTG OBGYN68
  69. 69.  Pulse rate 68bpm RVG non collapsing BP 100/70mmHg. Quiet precodium, apex beat 4ICSMCL, no thrill or heaves 1st and 2nd heart sounds normal and no murmur heard  full abdomen which moves with respiration, umbilicus is inverted, no surgical scar or scarifications, straies, and normal female pubic hair pattern, no hernia. Abd is soft, non tender, LSK not palpable and no other palpable mass.  Circumcised (clitorectomy) scar (FGM Type I) no discharges, normal labias, normal urethra meatus, normal fourchette , hymen discontinue with about 4 corincular mitrifomis, normal fossa navicularis, normal vaginal wall ruggae and cervix with no discharges and has nulliparous Os.  Normal size non pregnant anterior-verted uterus, no 7/14/2015UTG OBGYN69
  70. 70.  Normal sense of smell through each nostrils,Visual acuity is 6/6 and normal visual fields elicited through confrontation, no colour blindness, normal retina  All other cranial nerves are normal  Normal extremities including normal size head jaws, face and hands. 7/14/2015UTG OBGYN70
  71. 71. Examination of spouse  Young man looks well average build and not in any obvious distress.  Not pale acyanosed, anicteric, no peripheral odema, no palpable lymphadenopathy  No baldness, normal thyroid no anterior neck swelling and normal chest with normal male breast no lumps or discharges and normal male hair distibution on chest and no tenderness or swelling,  Respiratory rate 18cycles/min regular normal tactil and vocal fremitus and resonant percussion notes with vesicular breath sounds  Pulse rate 80bpm RGV non collapsing BP 120/70mmHg, Precodium quiet, apex beat 5ICSMCL, I & II are normal and no murmurs 7/14/2015UTG OBGYN71
  72. 72.  Abdomen full moves with respiration, umbilicus inverted, male pattern pubic and abd hair distribution, Right para- midline scar. Abd is soft non tender LSK not palpable and no other palpable mass, typanitic percussion and 3 bowel sounds in 1min.  Normal circumcised penis, no discharges ulcers, nodules or pustules and is about 8cm long in non erect position, urethra meatus is at the tip of the glans penis no epi- or hypospedias, no palpable cord with the urethra has normal scrotum with both testis inside and each about 4cm diameter with not other palpable masses, vas differens are paalpble connected to the testis and normal epididymis, no tenderness felt. 7/14/2015UTG OBGYN72
  73. 73. SUMMARY  I presents Madam29YO Madam Isatou Saine, P0+1, LMP 15 April 2011,  C/O unable to conceived for 3yrs  Had hx of abnormal vaginal discharge was treated. Had MVA for incomplete abortion and used IUD  Partner had herniography 7/14/2015UTG OBGYN73
  74. 74.  IMPRESSION: Secondary Infertility (tubal block)  DIFFERENTIALS Peritoneal Adhesions Asherman Syndrome ( Endometrial Synechia) Azoospermia/ Oligozoospermia 7/14/2015UTG OBGYN74
  75. 75. INVESTIGATION spouse  Pelvic ultrasonography  Hysterosalpingography  Hormone profile  Follicular stimulating hormone  Luteinizing hormone  Thyroid stimulating hormone  Serum prolactine  Luteal phase progesterone (21day)  Androgen  estrogen  Karyotype  Computer tomography/magnetic resonance imaging  Cervical smear  Pap’s smear  Complete blood count  Fasting blood sugar  Semen analysis  Hormone profile  Karyotype  Testicular biopsy  Vasography 7/14/2015UTG OBGYN75
  76. 76. OBGYN INTERNSHIP SURVIVAL DR MUSA MARENA OBGYN
  77. 77. Admission Orders  These vary a little from case to case, but the following are fairly general (format is ADC VAN DISMAL):  Admit: To the specific service or team  Diagnosis: List the diagnosis and the names of any associated surgeries or procedures  Condition: Such as Stable vs. Fair vs. Guarded  Vitals: Frequency  Activity: Ambulation, showering  Nursing:  Foley catheter management parameters  Prophylaxis for deep venous thrombosis  Incentive spirometry protocols  Call orders:  Vital sign parameters for notifying the team  Urine output parameters  Diet: Oral intake management  IV FLUID: Rates are typically set at 125 cc per hour  Special: Drain management  Oxygen management  Meds:  Pain medications  Prophylactic orders, such as for sleep or nausea  The patients' regular medications  Allergies:  Labs: Typically includes hemoglobin/hematocrit 7/14/2015UTG OBGYN77
  78. 78. PROGRESS NOTES • Uses the SOAP Mnemonics • SUBJECT S: patient comment or complains, nursing comments • OBJECTIVE O: VITALS: blood pressure, pulse, respiratory rate, temps, weight, O2 sat INS/OUTS: IV fluids, PO intake, emesis, urine, stool, drains EXAM: physical findings MED: pertinent routine or new medications INVEST: new lab or procedure results • ASSESSMENT: A: assessment based on above data • PLAN P: Medication change, Lab Tests, Procedures, Consults(other disciplines), Discharge 7/14/201578 UTG OBGYN
  79. 79. Sample Admission to Labor and Delivery Note • Date & time • Identification: (includes age, gravidity, parity, estimated gestational age, and reason for admission): • 26yo G3P1A1 @ 38W5D EGA presents with painful contractions since noon. Pt reports good fetal movement, and denies rupture of membranes or vaginal bleeding. • LMP: • Estimated date of confinement (EDC): • Chief complaint: • History of present illness (includes Prenatal Care (PNC): Labs, including HIV, GBS, GDM/HTN, # PNC visits, wt gain, s=d, etc. • Past history:  Obstetrics:  List each pregnancy (NSVD, wt 4000 grams, complicated by gestational diabetes and shoulder dystocia)  Gynecology: • PMH and PSH:  Medications: PNV, FeSO4  Allergies: No Known Drug Allergies (NKDA)  Social history: Ask about Tobacco/alcohol/Drugs 7/14/2015UTG OBGYN79
  80. 80.  Physical exam (focused):  General and Vital signs  Lungs  Cardiovascular – (Many pregnant women have a grade 1-2/6 systolic ejection murmur  Abdomen – Gravid, fundus non-tender (NT), fundal height (FH) 38cm, Leopold maneuvers:  Fetus is vertex (VTX), estimated fetal weight (EFW) 3300 gm  Sterile speculum examination if indicated to rule out spontaneous rupture of membranes (SROM)  Sterile vaginal exam (SVE) = 4cm/80%/VTX/ –1 as per Dr. Smith/time  Extremities – No Cyanosis, clubbing or edema (C/C/E), NT  Pertinent Labs:  Ultrasound:  Date: 10 wks by crown-rump length (CRL)  Date: 20 wks, no anomalies  Assessment:  26yo G3P1 at term, in labor fetal heart rate tracing (FHRT) reassuring  Intrauterine pregnancy (IUP) at 39 weeks gestation  FHRT – Baseline 140’s, accelerations present, no decelerations  Contractions – q 4-5 min  Any pertinent past medical or surgical history  Plan:  Admit to L&D  NPO except ice chips  IV – D5LR at 125 cc/hr  Continuous electronic fetal monitoring  CBC, T&S, RPR  Anticipate NSVD 7/14/2015UTG OBGYN80
  81. 81. DELIVERY NOTE • On (delivery date, time), this (age, race) female under(epidural, pudendal, local, no) anesthesia delivered a viable (male, female) infant weighing (weight) with APGAR scores of (0-10) and (0-10) at 1 and 5minutes. • Delivery was via (SVD, LTCS, classical CS) to a sterile field. (Nuchal cord reduced) infant was (bulb, DeLee) suctioned at (perineum, delivery). Cord clamped and cut and infant handed to waiting (paediatrician, Nurse). (Cord blood send for analysis). (weight) (intact, fragmented, meconium stained) placenta with (2,3) vessel cord delivered (spontaneously, with manual extraction) at (time). (amount) of (carboprost, methylrgonovine, oxytocin) given. (uterus, cervix, vagina, rectum) explored and (midline episiotomy, nth degree laceration, uterus and abdominal incision) repaired in a normal fashion with (type) suture. EBL (amount). Patient send to RR in stable condition. Infant taken to NBN in stable condition. Dr (name) attending • Note: SVD=spontaneous vaginal delivery, LTCS= low transverse C-section, CS= C-section, EBL= estimated blood loss, RR=recovery room, NBN=newborn nursery 7/14/2015UTG OBGYN81
  82. 82. Sample Delivery Note  Date and time:  Summary:  Normal spontaneous vertex delivery (NSVD) of a live male, 3000 gm and Apgars 9/9. Delivered left occiputo-anterior (LOA), no nuchal cord, light meconium. Nose and mouth bulb suctioned at perineum; body delivered without difficulty. Cord clamped and cut. Baby handed to nurse. Placenta delivered spontaneously, intact. Fundus firm, minimal bleeding. Placenta appears intact with 3 vessel cord. Perineum and vagina inspected – small 2nd degree perineal laceration repaired under local anesthesia with 2-0 and 3-0 chromic suture in the usual fashion. Estimated Blood Loss (EBL) 350cc. Hemostasis. Pt tolerated procedure well, recovering in Labour & Delivery Room (LDR). Infant to WBN 7/14/2015UTG OBGYN82
  83. 83. SAMPLE POSTPARTUM NOTES (SOAP FORMAT)  Subjective: Patients complaints, comments/ nurses’ comments .Ask every patient about the 5 B’s:  Breast or bottle feeding – Breastfeeding/planning to? How is it going? Tenderness?  Birth Control plans – Consider breastfeeding status  Bleeding (lochia) – Clots? How many pads?  Baby – Healthy? Do you plan circumcision for baby boy?  Bottom – Having any complaints related to urination/defecation? Flatus?  Baby blues (depression) – Ask about signs or symptoms of depression.  Pain – cramps/perineal pain/leg pain? Does medication control it? ambulation  Objective:  Vital signs and note tachycardia, elevated or low BP, temperature  Focused physical exam including  Heart  Lungs  Abd: Soft? Location of the uterine fundus – below umbilicus? Firm? Tender?  Extremities: Edema? Cords? Tender?  Breasts/Perineum: evaluate with help of resident if specific complaints regarding breasts/perineum  Postpartum labs: Hemoglobin, Blood type, Rubella status  Assessment/Plan: PPD#_ S/P NSVD or Vacuum or Forceps (with 4th-degree laceration, with pre-eclampsia s/p Magnesium Sulfate)  General assessment – Afebrile, doing well, tolerating diet  Contraception plans (must discuss before patient goes home)  Rubella vaccine prior to discharge?  Breastfeeding? Does she need lactation consultant? 7/14/2015UTG OBGYN83
  84. 84. POSTPARTUM NOTE • Subjective: Patient’s comments or complaints, nursing comments  CHECK  pain control,  breast tenderness,  quality of vaginal bleeding,  urination,  flatus,  bowel movement,  lower extremity swelling,  ambulation,  breast or bottle feed,  birth control type • Objective:  VITALS: blood pressure, pulse, respirations, temperature  INS/OUTS: IV fluids, PO intake, emesis, urine, stool, drains  EXAM: breath sounds, bowel sounds, fundal height/consistency, incision/episiotomy condition, lower extremity oedema, Homan’s sign.  MEDS: RhoGAM, pain med, iron, vitamins, laxative, contraceptive  LAB: CBC, RH status • Assessment: Assessment based on data above • Plan: Medication change, lab tests, procedures, consults, discharge 7/14/2015UTG OBGYN84
  85. 85. Sample Postpartum Notes (Soap format) • Date and Time: • Subjective: Ask every patient about:  Breastfeeding – are they breastfeeding/planning to? How is it going? Baby able to latch on? breast tenderness?  Contraceptive plan with relevant sexual history  Lochia (vaginal bleeding) – Clots? How many pads?  Pain – cramps/perineal pain/leg pain? Relief with medication? Do they need more pain meds?  Urination/bowel movement- have they had urine, flatus or had bowl movement? Pain? Colour? Frequency? • Objective: • Vital signs and note tachycardia, elevated or low BP, maximum and current temperature • Focused physical exam including  Heart  Lungs  Breasts: engorged? Nipples – skin intact?  Abd: Soft? Location of the uterine fundus – below umbilicus? Firm? Tender?  Perineum: Assess lochia (blood on pad, how old is pad?)  Visually inspect perineum – Hematoma? Edema? Sutures intact?  Extremities: Edema? Cords? Tender? • Postpartum labs: Hemoglobin or hematocrit  Assessment/Plan: PPD#_ S/P NSVD or Vacuum or Forceps (with 4th-degree laceration, with pre-eclampsia  s/p Magnesium Sulfate)  General assessment – Afebrile, doing well, tolerating diet  Contraception plans (must discuss before patient goes home)  Vaccines – does pt need rubella vaccine prior to discharge?  Breastfeeding? Problems? Encourage.  Rhogam, if Rh-negative  Discharge and follow-up plan  Patients usually go home if uncomplicated 24-48 hours postpartum  Follow-up appointment scheduled in 2-6 weeks postpartum 7/14/2015UTG OBGYN85
  86. 86. PRE OPERATION NOTE 7/14/2015UTG OBGYN86
  87. 87. OPERATION NOTE DATE AND TIME:  SURGEONS: Attending, residents, students who scrubbed  ANESTHESIA: General endotracheal (GETA), spinal, local, etc  PRE-OPERATIVE DIAGNOSIS:  POST OPERATIVE DIAGNOSIS:  PROCEDURE: Surgery performed  FINDINGS: Rupture right cornual ectopic pregnancy with dead fetus intraperitoneal about 20wks GA, haemoperitoneum, 4cm follicular cyst, etc  COMPLICATIONS: Tear to colon which was repaired  ESTIMATED BLOOD LOSS: Amount in cc  FLUIDS: Amount and type (electrolyte, blood, etc, in cc or units)  URINE: amount and colour at end of operation  DRAINS: Type and location  SPECIMENS: Type send to pathology (right fallopian tube and fetus with placenta)  CONDITIONS: Stable, Fair, Guarded, extubated, etc  DISPOSITION: transfer to recovery room, postpartum room, Surgical ICU, etc 7/14/2015UTG OBGYN87
  88. 88. Sample Operation Note  Date and Time:  Pre-op Diagnosis: Symptomatic uterine fibroids or Pregnancy at term, failure to progress`  Post op Diagnosis: Same  Surgeon: Attending, Residents, students  Anesthesia: GET (general endotracheal, others include spinal, LMA, IV sedation)  Procedure: TAH/BSO or Cesarean Section  Findings: Exam under anesthesia (EUA) and operative findings  Complication: injury to bladder which was repaired  EBL: 300 cc  Urine Output: 200 cc, clear at the end of procedure  Fluids: 2,500 cc crystalloid (include blood or blood products here)  Drains: If placed  Specimen: Cervix/uterus, placenta and cord.  Condition: Fair, Stable, Guarded, extubated  Disposition: Recovery room, Surgical ICU, postpartum room, etc 7/14/2015UTG OBGYN88
  89. 89. Sample Postoperative Cesarean Section Orders/Note Sample C/S Orders  Admit to Recovery Room, then postpartum floor  Diagnosis: Status post (s/p) C/S for failure to progress (FTP)  Condition: Stable, Fair, Guarded  Vitals: Routine, q shift, q4hours  Allergies: None  Activity: Ambulate with assistance this PM, then up ad lib  Nursing: Strict input and output (I&O), Foley to catheter drainage, call MD for  Temp > 38.4, pulse > 110, BP < 90/60 or > 140/90, encourage breastfeeding,  pad count, dressing checks, and Ted’s leg stockings until ambulating  Diet: Regular as tolerated; some hospitals only allow ice chips or clear liquids, semi solids  IV: Lactated ringers (LR) or D5LR at 125 cc/hr, with 20 units of Pitocin x 1-2 Liters  Labs: CBC in AM  Medications:  Morphine sulfate PCA (patient controlled analgesia) per protocol (1 mg per dose with 10 minute lockout, not to exceed 20 mg/4 hours)  Percocet 1-2 tabs PO q 4-6 hours prn pain, when tolerating PO well  Vistaril 25 mg IM or PO q 6 hours prn nausea  Ibuprofen 800 mg PO q 8 hours prn pain, when tolerating PO well  Prophylactic antibiotics if indicated  Thromboprohylaxis for high-risk patients  Rhogam, if Rh-negative 7/14/2015UTG OBGYN89
  90. 90. Sample post operation (C/S) Note  Date and Time:  Day #1 (Post-op day POD#1)  Subjective: Ask patient about:  Pain – relieved with medication?  Nausea/vomiting  Passing flatus (rare this early post-op), stool  Objective:  Vital signs and note tachycardia, elevated or low BP, maximum and current temperature  Input and output  Focused physical exam including  Heart  Lungs  Breasts: engorged? Nipples – Is skin intact?  Incision: Clean and dry? sutures intact? odema? haematoma?  Abd: Soft? Location of the uterine fundus – below umbilicus? Firm? Tender?  Perineum: Assess lochia (blood on pad, how old is pad? Frequency of changing?)  Visually inspect perineum – Hematoma? Edema? Sutures intact?  Extremities: Edema? Cords? Tender?  Postpartum labs: Hemoglobin or hematocrit  Fluids ins/outs; 7/14/2015UTG OBGYN90
  91. 91.  Assessment/Plan:  POD#1 status post (S/P) C/S or repeat C/S (indication for the C/S)  Afebrile, tolerating pain with medication, oral intake, adequate urine output (>30cc/hr)  Routine post-op care  Discharge Foley  Discharge PCA or IV pain medications and PO pain Meds when tolerating PO  Out of bed (OOB)  Advance diet as tolerated  Discharge IV when tolerating PO  Check hematocrit or CBC 7/14/2015UTG OBGYN91
  92. 92.  Sample Postoperative Cesarean Section Orders  Sample C/S Orders  Admit to: Recovery Room, then postpartum floor  Diagnosis: Status post (s/p) C/S for arrest of descent  Condition: Stable  Vitals: Routine, q shift  Allergies: None  Activity: Ambulate with assistance this PM, then up ad lib  Nursing: Strict input and output (I&O), Foley to catheter drainage, call M.D. for Temp > 38.0, pulse > 110, BP < 90/60 or > 140/90, encourage breastfeeding, pad count, dressing checks, and Ted hose until ambulating  Diet: Regular as tolerated; some hospitals only allow ice chips or clear liquids  IV: Lactated ringers (LR) or D5LR at 125 cc/hr, with 20 units of Pitocin x 1-2 Liters  Labs: CBC in AM  Medications:  • Morphine sulfate PCA (patient controlled analgesia) per protocol (1 mg per dose with 10 minute lockout, not to exceed 20 mg/4 hours)- only if no Duramorph in Spinal anesthetic  • Percocet 1-2 tabs PO q 4-6 hours prn pain, when tolerating PO well  • Zofran/Compazine prn nausea  • Ibuprofen 800 mg PO q 8 hours prn pain, when tolerating PO well  • Prophylactic antibiotics if indicated  • Thromboprohylaxis for high-risk patients  • Rhogam, if Rh-negative  Your name and date/time 7/14/2015UTG OBGYN92
  93. 93. SAMPLE C/S POSTPARTUM NOTE  Day #1 (Post-op day POD#1)  SUBJECTIVE: Ask every patient about the 5 B’s, also:  Pain – relieved with medication?  Nausea/vomiting  Passing flatus (rare this early post-op)  OBJECTIVE:  Vital signs and note tachycardia, elevated or low BP, temperature  Input and output  Focused physical exam including  Heart and Lungs  Abd: Soft? Location of the uterine fundus – below umbilicus? Firm? Tender?  Incision: Clean and dry, intact? Staples or not?  Extremities: Edema? Cords? Tender?  Breasts/Perineum: evaluate with help of resident if specific complaints regarding breasts/perineum  Postpartum labs: Hemoglobin, Blood type, Rubella status  ASSESSMENT/PLAN: POD#1 status post (S/P) C/S or repeat C/S  Afebrile, tolerating pain, oral intake, adequate urine output (>30cc/hr)  Routine post-op care  Discontinue Foley  Discontinue PCA or IV pain medications and convert to PO pain Meds when tolerating PO  Ambulate TID  Advance diet as tolerated  Discontinue IV when tolerating PO  Check Hgb or CBC on POD #1  Anticipate discharge on POD#3 or 4  Your name and date/time 7/14/2015UTG OBGYN93
  94. 94.  Sample Operation Note  Pre-op Diagnosis: Symptomatic uterine fibroids or Pregnancy at ___wks, failure to progress  Post-op Diagnosis: Same  Procedure: TAH/BSO, Cesarean Section  Surgeon (Attending):  Residents:  Anesthesia: General endotracheal (GET), Spinal, LMA, IV sedation  Complications: None  EBL: 300 cc  Urine Output: 200 cc, clear at the end of procedure  Fluids: 2,500 cc crystalloid (include blood or blood products here)  Findings: Exam under anesthesia (EUA) and operative findings OR Viable M/F infant in cephalic/breech presentation weighing ___grams, Apgars of ___. Cord gases ____. Infant to newborn nursery/NICU.  Specimen: Cervix/uterus  Drains: If placed  Disposition: Recovery room, Surgical ICU, etc  Your name and date/time  31 7/14/2015UTG OBGYN94
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