Download OB H & P (TITLE T3 H&P) Date / Time

OB H & P (TITLE T3 H&P)
Date / Time
LMP: / /
EDD: / /
U/S: @ EGA on /
+ cwd (or f cwd)
(if not cwd, then
â EDD: / /
/
CC: in patient’s own words
HPI: Pt is a 24 yo G4P2012 @ 376/7 weeks who presents to obs ed c/o ctxs q 5 mins. Pt reports ± FM.
Address the following: ± Vaginal bleeding, ± leakage of fluid/ROM (at what time and consistency i.e. clear,
green), ± D/C, ± dysuria (If elevated BP’s be sure to document, pertinent positive and negatives i.e. HA, blurry
vision, RUQ pain)
Summary of prenatal course thus far or any complications/high risk conditions during pregnancy and
management:
Pt with + PNC with Tulane OB since 10 weeks (or pt with no PNC, limited PNC, 1 obs visit),
uncomplicated.
Or complicated by chronic hypertension. Her BPs’s throughout pregnancy have been in mild range,
not requiring any BP medications. Her baseline laboratory workup and end-organ workup were negative.
She has been in antenatal testing since 32 weeks and fetus has remained reassuring with normal
amniotic fluid.
Interval growth U/S shows fetus to have adequate growth. Last U/S was at 36 weeks and EFW was
3000 grams (>50th percentile).
PMH: DM, HTN, Asthma, lung, liver, heart, kidney, thyroid Dz
If Asthma (last hospitalization, frequency of ER visits, Intubations, steroid use, meds/inhalers, how often,
# of attacks/week)
If + for any medical illness, when and how diagnosed, who follows condition pre-pregnancy
PSH: (include any C/S or D&C, as well as hx of transfusions)
OBHx: Include Month/Year, Type of Delivery (if C/S ask indication)/Sex/Birth Weight/gestational age –full
term or preterm
Hospital/Comp
e.g. G1 5/93 NSVD F 6#10oz FT
@ TMC no comp
G2 7/95 C/S 2° breech M 8# FT @ UH
G3 96 Sab @ 10 weeks with/without D & C
GynHx: Menarche/IR or R (irregular or regular)/ duration of cycle, hx of STDs (you may need to specifically
ask about gonorrhea, chlamydia, syphilis, HIV, trich, genital warts, etc), hx of abnl paps, last pap? any hx of
hormonal contraception prior to conception, if so what and when last used
Meds; Include PNV, Fe
All: NKDA, if allergy à reaction
SocHx: Tob/ETOH/Drugs, tattoos, social situation; father involvement, marital status, education, employment
FHx: Hx of DM, HTN, Birth Defects, Twins, Mental Retardation, Sickle cell, bleeding d/o, cancers
and note which family member has disease and age of diagnosis if pertinent to disease
ROS:
Review of Systems
The following list illustrates the content of a complete review of systems.
You indicate whether a symptom is “negative” or “positive”. This is a just an example of a ROS – you do not
have to indicate each symptom.
General/Constitutional
Average weight, weight loss or gain, general state of health, sense of well-being, strength, ability to conduct
usual activities, exercise tolerance
Skin/Breast
Rash, itching, pigmentation, moisture or dryness, texture, changes in hair growth or loss, nail changes
Breast lumps, tenderness, swelling, nipple discharge
Eyes/Ears/Nose/Mouth/Throat
Headaches (location, time of onset, duration, precipitating factors), vertigo, lightheadedness, injury
Vision, double vision, tearing, blind spots, pain
Nose bleeding, colds, obstruction, discharge
Dental difficulties, gingival bleeding, dentures
Neck stiffness, pain, tenderness, masses in thyroid or other areas
Cardiovascular
Precordial pain, substernal distress, palpitations, syncope, dyspnea on exertion, orthopnea, nocturnal
paroxysmal dyspnea, edema, cyanosis, hypertension, heart murmurs, varicosities, phlebitis, claudication
Respiratory
Pain (location, quality, relation to respiration), shortness of breath, wheezing, stridor, cough (time of day, of
productive, amount in tablespoons or cups per day and color of sputum), hemoptysis, respiratory infections,
tuberculosis (or exposure to tuberculosis), fever or night sweats
Gastrointestinal
Appetite, dysphagia, indigestion, food idiosyncrasy, abdominal pain, heartburn, eructation, nausea, vomiting,
hematemesis, jaundice, constipation, or diarrhea, abnormal stools (clay-colored, tarry, bloody, greasy, foul
smelling), flatulence, hemorrhoids, recent changes in bowel habits
Genitourinary
Urgency, frequency, dysuria, nocturia, hematuria, polyuria, oliguria, unusual (or change in) color of urine,
stones, infections, nephritis, hesitancy, change in size of stream, dribbling, acute retention or incontinence,
libido, potency, genital stores, discharge, venereal disease
(Female) Age of onset of menses, regularity, last period, dysmenorrhea, menorrhagia, or metrorrhagia, vaginal
discharge, post-menopausal bleeding, dyspareunia, number and results of pregnancies (gravida, para)
Musculoskeletal
Pain, swelling, redness or heat of muscles or joints, limitation of motion, muscular weakness, atrophy, cramps
Neurologic/Psychiatric
Convulsions, paralyses, tremor, incoordination, parathesias, difficulties with memory of speech, sensory or
motor disturbances, or muscular coordination (ataxia, tremor)
Predominant mood "nervousness" (define), emotional problems, anxiety, depression, previous psychiatric care,
unusual perceptions, hallucinations
Allergic/Immunologic/Lymphatic/Endocrine
Reactions to drugs, food, insects, skin rashes, trouble breathing
Anemia, bleeding tendency, previous transfusions and reactions, Rh incompatibility
Local or general lymph node enlargement or tenderness. -Polydipsia, polyuria, asthenia, hormone therapy,
growth, secondary sexual development, intolerance to heat or cold
PE: VS: BP:
P:
T:
R:
Weight:
Gen:
Lungs:
CV:
ABD: gravid, nontender, FH (fundal height), Leopolds
Height:
(always include an assessment of fetal weight/presentation by leopolds if sonogram is not done)
Ext:
EFM:
TOCO:
CVX:
Speculum exam (if indicated)
SONO Results (limited to position);
SONO Results: only if one is done,
On all antenatal or multifetal gestation admits, Ultrasound should be done by
HO III or HO IV
LABS: (ones done in obs)
Prenatal labs usually are written in the left hand margin of progress note/ or NOW
Sign at bottom of each page
TITLE – H/P (continued)
A/P: Address each assessment with plan underneath
Example:
IUP @ 35 weeks
-Cont PNV,FE
-PTL precautions
-GBS Cx done today
CHTN
-Cont Aldomet
-U/S for interval growth q 3-4 weeks
-Continue to monitor BP’s r/o superimposed preE
-Continue Antenatal testing
OR
Put in list form
Example:
A. 1.24 yo G4P2012 @ 38 weeks in Active Labor
2. Hx of Doc LTCS, Desires VBAC
3. GBS+
4. Rubella non-immune
5. Abnl PAP
P:
1. Admit to L&D for delivery
2. Admit labs with consents– Patient counseled on risks, benefits,
alternatives to trial of labor versus repeat cesarean section
3. Start PCN
4. Rubivax pp
5. PP Colpo
Always sign work/ E-sign
ADMIT ORDERS:
Admit orders to L&D are pre-printed. You just need to fill in the blanks and add
orders as it applies to the management.
Example for routine laboring patient:
Admit to L & D
Dx: IUP at 38 weeks in active labor
Condition: stable
Vitals: per routine
Activity: Bed rest
All: NKDA
Nursing: per routine
Diet: NPO
IVF: D5LR at 125 cc/hr
Labs: CBC, RPR, T & S
Meds: Epidural per anesthesia
PROGRESS NOTES:
These are usually written every two hours on routine laboring patients and each time
something is done/assessed with the patient even if less than two hours has gone by
(i.e. if you just evaluated the patient 30 minutes ago and now the nurse calls you into
the room for decelerations and you re-evaluated the patient and checked her cervix or
performed an amniotomy, you need to write another note or addendum reflecting this)
Example for routine laboring patient:
HO-I L&D PN
S: Pt without c/o s/p epidural or pt c/o ctxs or no major complaints
O: VS: BP: ranges T: P:
GEN: In mild distress secondary to ctxs. Comfortable in NAD
FHTs:
TOCO:
CVX:
(or cvx deferred)
Labs: (new labs or admit labs)
A: 26 yo G3P2002 at 38 5/7 in Active Labor, progressing well
P: 1. Continue to follow
2. F/u on pending labs
DELIVERY NOTE:
Pt progressed to C/C/+1. Fetal heart rate was overall reassuring. Pt was placed in dorsal lithotomy position,
prepped and draped in sterile fashion. Pt was encouraged to push and
baby’s head in (type of position—
ROA, LOA, OP, etc.) was delivered over _________ (intact perineum/midline episiotomy). Nuchal cord (x1 or
x2) present (or no nuchal cord noted,
reduced. (If not reduced, then cord clamped times two and cut at
this time). Anterior then Posterior shoulders delivered without complication followed by delivery of rest of
body. The
mouth and nose were bulb suctioned. Cord clamped times two and cut in between. The infant
was handed to the waiting nurse/pediatrician. Cord blood obtained and sent. The placenta was
then
delivered (intact, spontaneous/manually, Schultze/Duncan with three vessel cord present). The fundus
massaged until firm and hemostasis noted. Cervix, Vagina, Perineum explored for any tears and none was
observed. (Note type of laceration, location, hemostatic?, repaired with type of suture) Rectal exam – intact.
Pitocin 20 units/30 units in 1L LR given. Viable male/female infant with apgars of __ and __ at one and five
minutes, weight, cord ph( if applicable) was transferred to nursery in a stable condition. Mother was transferred
to recovery room in stable condition.
EBL:
Comp:
Name of Residents present for delivery
Name of Staff present/available for delivery
• Please adjust your delivery note if operative vaginal delivery to provide indications and procedures
done/steps taken prior to placing vacuum or forceps
• For shoulder dystocia provide which maneuvers performed
• Don’t forget to include local anesthesia if provided or regional with pudendal block
POSTPARTUM ORDERS:
Postpartum orders for vaginal deliveries are preprinted at University Hospital, Tulane, and HPL. Just fill in any
necessary information or added orders and sign.
At UH most postpartum patients are housed on 3W unless pt is on MgSO4 or underwent delivery of an IUFD,
then they may go to 4E.
The following routinely need to be added:
Motrin 800 mg one tab po q 8 hours prn pain/cramping
Pitocin (# Units in 1 L LR at 125 cc/hr)
If applicable: Magnesium Sulfate @ 2 gms/hr
Also, in the section with post CBC order indicate the date (the morning after delivery)
GYNECOLOGY
GYN H & P – TITLE (T3 H/P)
As OB H&P except for the following in bold:
Date/Time:
CC: in patient’s own words
HPI: Pt is a 48 yo G3P3003 LMP 5/6/03 who presents to ER c/o
vaginal bleeding x 5 days. Heavier in nature, requiring about 10 pads/day.
Pt reports lightheadedness and weakness. Denies SOB/CP/abdominal pain.
Summarize onset of problem, previous episodes, previous therapies.
PMH: DM, HTN, Asthma, lung, liver, heart, kidney, thyroid Dz
If + for any medical illness, when diagnosed
PSH: (include any hx of transfusions), indication for hysterectomy
OBHx: Types of Delivery, Weight of Biggest Baby,
and complications during pregnancies?
Example: NSVD x 3, C/S x 1, Sab x 1, Largest baby was 9#
GynHx: Menarche/IR or R (irregular or regular)/ duration, hx of
STDs, hx of abnl paps, last PAP, last mammogram, any hx of hormonal
contraception, if so what and when last used, duration of use, sexual history
If postmenopausal, how many years? Hx of HRT?
Meds: dosage, rout, frequency
All: NKDA, if allergy à reaction
SocHx: Tob/ETOH/Drugs; social situation, employment, relationship
FHx: Hx of DM, HTN, Other Medical Illnesses, Gyn Malignancy
Review of Symptoms/ Systems: (ROS)
Review of Systems
The following list illustrates the content of a complete review of systems.
You indicate whether a symptom is “negative” or “positive”. This is a just an example of a ROS – you do not
have to indicate each symptom.
General/Constitutional
Average weight, weight loss or gain, general state of health, sense of well-being, strength, ability to conduct
usual activities, exercise tolerance
Skin/Breast
Rash, itching, pigmentation, moisture or dryness, texture, changes in hair growth or loss, nail changes
Breast lumps, tenderness, swelling, nipple discharge
Eyes/Ears/Nose/Mouth/Throat
Headaches (location, time of onset, duration, precipitating factors), vertigo, lightheadedness, injury
Vision, double vision, tearing, blind spots, pain
Nose bleeding, colds, obstruction, discharge
Dental difficulties, gingival bleeding, dentures
Neck stiffness, pain, tenderness, masses in thyroid or other areas
Cardiovascular
Precordial pain, substernal distress, palpitations, syncope, dyspnea on exertion, orthopnea, nocturnal
paroxysmal dyspnea, edema, cyanosis, hypertension, heart murmurs, varicosities, phlebitis, claudication
Respiratory
Pain (location, quality, relation to respiration), shortness of breath, wheezing, stridor, cough (time of day, of
productive, amount in tablespoons or cups per day and color of sputum), hemoptysis, respiratory infections,
tuberculosis (or exposure to tuberculosis), fever or night sweats
Gastrointestinal
Appetite, dysphagia, indigestion, food idiosyncrasy, abdominal pain, heartburn, eructation, nausea, vomiting,
hematemesis, jaundice, constipation, or diarrhea, abnormal stools (clay-colored, tarry, bloody, greasy, foul
smelling), flatulence, hemorrhoids, recent changes in bowel habits
Genitourinary
Urgency, frequency, dysuria, nocturia, hematuria, polyuria, oliguria, unusual (or change in) color of urine,
stones, infections, nephritis, hesitancy, change in size of stream, dribbling, acute retention or incontinence,
libido, potency, genital stores, discharge, venereal disease
(Female) Age of onset of menses, regularity, last period, dysmenorrhea, menorrhagia, or metrorrhagia, vaginal
discharge, post-menopausal bleeding, dyspareunia, number and results of pregnancies (gravida, para)
Musculoskeletal
Pain, swelling, redness or heat of muscles or joints, limitation of motion, muscular weakness, atrophy, cramps
Neurologic/Psychiatric
Convulsions, paralyses, tremor, incoordination, parathesias, difficulties with memory of speech, sensory or
motor disturbances, or muscular coordination (ataxia, tremor)
Predominant mood "nervousness" (define), emotional problems, anxiety, depression, previous psychiatric care,
unusual perceptions, hallucinations
Allergic/Immunologic/Lymphatic/Endocrine
Reactions to drugs, food, insects, skin rashes, trouble breathing
Anemia, bleeding tendency, previous transfusions and reactions, Rh incompatibility
Local or general lymph node enlargement or tenderness. -Polydipsia, polyuria, asthenia, hormone therapy,
growth, secondary sexual development, intolerance to heat or cold
PE: VS: BP:
P:
Gen:
Lungs:
CV:
ABD:
Ext:
Pelvic:
Rectal/Rectovaginal:
T:
R:
Weight:
Height:
BMI:
LABS: CBC, Chem-7, Ultrasound findings, UA, UPT or BHCG, etc.
A: (put in list form) Example:
1. 48 yo G3P3 with Menorraghia
2. Symptomatic Anemia
P: (put in list form) Example:
1. Admit to 8W
2. Blood transfusion
3. TSH, Fe Studies
4. EMB/ECC
Always sign work (E-sign)
GENERAL ADMIT ORDERS: (ADC VANDALISM)
Admit to Floor/Service/Staff/Resident or Intern on service
Dx:
Condition: (good, stable, guarded, critical)
Vitals: (per routine, q4h, q6h, or q1hr while on MgSo4)
Activity: (as tolerated, BR, BR with BRP, ad lib)
Nursing: (per routine, accuchecks, FTG with Strict I/O’s)
Diet: (NPO, Clear liquids, Diabetic, Low Na)
Allergies: NKDA
Labs:
IVF: (Heplock, LR @ 125 cc/hr)
Special: (pelvic U/S, CT scan, etc.)
Meds:
Call HO for T>100.4/38, BP>180/110, <80/40, UO<30 cc/hr x 2 hrs, HR>120)
SCDS/ted hose or plexipulses to BLE (for DVT prophylaxis after surgery or pt on prolonged bed rest)
PRE OP NOTE
Preop Notes are to be done on each patient going to surgery at least the day prior.
Example of Pre-Op Note
Diagnosis
Planned procedure
Relevant history (mini H&P)
Labs including (work up labs of disease/condition assisting with decision of surgery and Pre-Op labs)
CBC
B-hcg
CXR (Smoker or as indicated by physical exam or medical history),
EKG (>40 yo or as indicated by physical exam or medical history)
T&S
Chem-7
PAP
EMB, ECC
Ultrasound
Consents for blood and procedure signed and in chart or BTL consents
POSTOP NOTE
• To be written at least 6h post op
• Like a SOAP note, but pay particular attention to the following:
Example:
S: Patient states pain controlled with meds. No flatus. Denies N/V.
O: VS: BP: HR:
T:
I & O’s (UOP) since surgery, EBL/UOP/IVF in surgery
PE: GEN: Note general appearance
LUNGS:
CV:
ABD: Note any distention, incision/dressing/bowel sounds
EXT: calf tenderness, are plexipulses/SCD’s on?
A/P: 1. 45 yo G0 s/p TAH secondary to SUF, POD#0, doing well
Adequate UO and pain control
Continue routine post op care
Encourage ambulation and incentive spirometry
ROUTINE POSTOP DAY #1 ORDERS
For Cesearean Sections
D/C Foley (once noting adequate urine output overnight, on average >30 cc/hr)
Advance to clears, then regular as tolerated
Heplock IV once tolerating po
D/C IV pain meds after 24 hours and D/C IVF
Change to the following po pain meds after 24 hours of IV pain mgmt;
Motrin 800 mg 1 tab po q 8 hours prn pain
Percocet 5/325 1 to 2 tabs po q 4 – 6 hours prn breakthrough pain
PNV 1 tab po qd
Fergon 325 mg 1 tab po qd/bid
Ambulate > tid, first time with assistance
Incentive Spirometer to bedside (if not already ordered)
Also, leave bandage on for at least 24 hours postop, but note whether bandage was
saturated with blood. If you need to take off dressing to assess for bleeding and/or
infection, replace dressing if it has been lass than 24 hours.
POSTOP ORDERS for Minor Surgeries (D&C/ Lap BTL)
• Usually same day discharge
• Postop orders and Rx should try and be written immediately after surgery
• Pt needs to be seen by the resident before d/c to give Discharge instructions and d/w pt the
surgical findings
Need to be with the patient in the holding area and while going to the OR room
Admit
Diagnosis
Condition
VS
Activity
Allergy
Nursing
Diet
IVF
Meds
Transfer to RR then 2E, T-Gyn, Staff, Resident
s/p D&C (procedure)
stable
per routine
as tolerated
PCN- hives
d/c foley, if not done in RR or in the OR
advance to regular as tolerated
Heplock IV, then d/c when tolerating po
Motrin 800mg 1po q8h prn
±Tylenol #3 1 po q8h prn or percocet 5/325 1 po q 4-6h prn
±Methergine 0.2mg 1 po q6h x 24h (D&C)
±Doxycycline 100mg 1 po bid x 3 d (D&C)
D/C home when tolerating po, voiding and ambulating without difficulty
Notify MD prior to d/c patient
Rx on chart
• Note if patient has a vaginal packing. Need to write an order reflecting this: Vaginal packing in place,
to be removed by MD prior to d/c.
POSTOP ORDERS for Major Surgeries (TAH/Ex lap/ TVH)
TAH usually stays 2-3 days, advance diet as tolerated if uncomplicated.
TVH usually stays overnight and diet can usually be advanced quickly since there is very little,
if any, bowel manipulation.
TVH Vaginal Packing if placed usually taken out at Post-op check (4-6 hours) or POD#1
Admit
Diagnosis
Condition
VS
Activity
Allergy
Nursing
Diet
IVF
Meds
to RR then 4E/staff/ resident/intern
47 yo s/p TAH 2º SUF
stable
per routine
bed rest
NKDA
FTG with strict I&O’s
NPO (May advance as tolerated if TVG/LAVH)
LR 125cc/h
Toradol 30mg IM q6h x 24h
Demerol 50mg IM/IV q 4-6 h prn
Phenergan12.5-25mg IM/IV q 4-6 h prn
Or
Morphine 2-4mg IV q4-6 h prn
Labs
Post CBC in am (Write date desired)
Call MD for BP>160/110 or <80/40, P>120 or <60, increased VB, T>100.4
If TVH, Vag packing in place, to be removed by MD
Common Abbreviations
Ab
abortion, antibody
Abx
antibiotics
abdominal
AC
abdominal Circumference
ACOG American College of Obstetrics & Gynecology
AFI
amniotic fluid index
AMA advanced maternal age
Amnio amniocentesis
Amp Ampicillin
AFP
alpha fetal protein
AGA appropriate for gestational age
ARO artificial rupture of membranes
BME bimanual exam
BPD
biparietal diameter
BPM beats per minute
BPP
biophysical profile
BTL
bilateral tubal ligation
CHTN chronic hypertension
Clinda clindamycin
CMT cervical motion tenderness
CPD
cephalopelvic disproportion
C/S
caesarean section
Ccaesarean section
Ctx
contractions
CVS
chorionic villus sampling
d/c
discharge (vaginal, hospital)
Depo Depo-Provera
DM
diabetes mellitus
EAB
elective abortion
EDC
estimated date of confinement
EFW estimated fetal weight
EGA
estimated gestational age
FSE
fetal scalp electrode
FeSO4 iron sulfate
FH
fundal height
FGT
fetal heart tones
FL
femur length
FLM
fetal lung maturity
FM
FSH
G
GBS
Gent
Gluc
HbsAg
HC
fetal movement
fallicle stimulating hormone
gravid
Group B Streptococcus
gentamicin
glucola
hepatitis B surface antigen
head circumference
HELLP hemolysis, elevated liver enzymes,
low platelets
HPV
human papilloma virus
HSV
herpes simplex virus
IUFD intrauterine fetal demise
IUGR intrauterine growth restriction
IUP
intrauterine pregnancy
IUPC intrauterine pressure catheter
LBW low birth weight
LGA
large for gestational age
LH
luteinizing hormone
LMP last menstrual period
L/S
lecithin/spinomyelin ration
LT C/S low transverse C-Section
LV C/S low vertical C-Section
pPROM preterm premature rupture of membranes
PROM premature rupture of membranes
PTL
preterm labor
Pyelo pyelonephritis
Qβhcg quantitavitve beta human chorionic
gonadotropin
RI
rubella immune
RPR
rapid plasma reagent
Sab
spontaneous abortion
U/S
ultrasound
UTI
urinary tract infection
VB
vaginal bleeding
VBAC vaginal birth after caesarean
Vtx
vertex
Tulane University
School of Medicine
Dept. of Obstetrics & Gynecology
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Tulane University
School of Medicine
Dept. of Obstetrics & Gynecology
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Tulane University
School of Medicine
Dept. of Obstetrics & Gynecology
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