Clerkship Practical Tools
The Ob-Gyn Clerkship: Your Guide to Success
Tools for the Clerkship, contained in this document:
1. 2. 3. 4. 5. 6. 7. 8. Sample obstetrics admission note Sample delivery note Sample operative note Sample postpartum note a. Vaginal delivery b. Cesarean section orders/note Sample gynecologic history & physical (H&P) Admission orders Commonly-used abbreviations Spanish lesson
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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 Physical exam (focused): General and Vital signs Lungs CV – (Many pregnant women have a grade 1-2/6 systolic ejection murmur Abd – 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 Ext – 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
Tools for the Clerkship, contained in this document:
1. 2. 3. 4. 5. 6. 7. 8. Sample obstetrics admission note Sample delivery note Sample operative note Sample postpartum note a. Vaginal delivery b. Cesarean section orders/note Sample gynecologic history & physical (H&P) Admission orders Commonly-used abbreviations Spanish lesson
1
1.
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 Physical exam (focused): General and Vital signs Lungs CV – (Many pregnant women have a grade 1-2/6 systolic ejection murmur Abd – 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 Ext – 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