Uniformed Services University Obstetrics and Gynecology Core ...

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Outpatient Note28 year old G3 P1112 LMP: 2 June 2002 using Depo-Provera for contraception presents forannual well woman exam and Pap smear. No complaints.Past OB/GYN Hx: (address H/O STD's, PID, abnormal Paps, problems with contraceptivemethod, etc.)PMH:PSH:Meds:Exam (example):A: Normal gyn examBreast: no masses, no galactorrheaAbd: soft, NT, no massesPelvic:-EFG: without lesion, nl BUS-Vagina: no lesions-Cervix: parous, no lesions-Uterus: NSSC, RV-Adnexa: no palpable masses-RV: confirms, guaiac negP. Pap doneRefill Depo-ProveraCounseling regarding: (address appropriate items: risky behaviors, smoking,immunizations or other age-appropriate screening, etc)F/U one year or prnSignature
Delivery Note:Date: Time:25 year-old G2P1001 progressed to C/C/+1 and pushed for delivery of a viable male infant inthe OA position over a second degree laceration. Infant’s head was delivered atraumatically,bulb suctioned at perineum, and shoulders and body delivered without difficulty. Active cryelicited. 3 vessel cord clamped and cut. Infant passed to awaiting pediatric team w/ activecry and good tone noted. Apgars were 9 and 9. Weight= 3450g. Time of birth = 0515.Normal appearing placenta delivered spontaneously, manual uterine massage provided goodhemostasis. Second degree laceration repaired w/ 2-0 vicryl in standard fashion.SignaturePostpartum Note:PPD # ____:___ y.o. G _ now P______ who delivered by __(method) at ______ weeks.Prenatal/antepartum course complicated by _____________________.Intrapartum course complicated by ____________________.Today the patient notes: (address nay complaints, postpartum events out of the ordinary)Tolerating_______ diet +/- nausea vomiting +/- flatus/BMPain control: (address type, adequacy)Voiding/ Foley:Infant status: (particularly if in the NICU, or if a problem has arisen)Breast/ Bottle feeding:VS: (Tm/Tc): BP: R: P:I/O ( MgSO4 and C-section patients):Heart:Lungs:Abdomen: (address fundal height, consistency and tenderness)Incision: (as applicable)GU: (address lochia, episiotomy/laceration)Extremities: (Homan's sign/ edema/reflexes)Lab results: (Hct, possible chemistries if pre-eclamptic patient)A/P: PPD # _____Meds:Labs:Any additional plansContraceptive plans:Signature
Page 1 and 2: Uniformed Services UniversityObstet
Page 3 and 4: IMPORTANT CONTACT INFORMATION:CLERK
Page 5 and 6: San Antonio Military Medical Center
Page 7 and 8: THIRD YEAR CLINICAL CLERKSHIPDepart
Page 9 and 10: These PBL cases are available in yo
Page 11 and 12: II.Instructional Objectives:The cli
Page 13 and 14: The APGO “Essential Elements” l
Page 15 and 16: The Surgical Experience:1. The stud
Page 17 and 18: III. Assigned Reading:Hacker et al.
Page 19 and 20: Failure of the standard remediation
Page 21 and 22: V. Attendance Policy:You are expect
Page 23 and 24: VII. Suggested Resources:The follow
Page 25 and 26: 3. History of Abortion:• Type of
Page 27 and 28: IX. Obstetric and Gynecologic Exami
Page 29 and 30: X. Survival Tips for Obstetrics and
Page 31 and 32: Note: These people with SROM will b
Page 33: XI.Sample Progress Notes:Brief Op N
Page 37 and 38: Biophysical profile: A physical ass
Page 39 and 40: Dysuria: Painful urination.Eclampsi
Page 41 and 42: Laparoscopic Assisted Vaginal Hyste
Page 43 and 44: Mid pelvis: An imaginary plane that
Page 45 and 46: Uterine: Prolapse of the uterus, us
Page 47 and 48: Virilization: The development of ma
Page 49: GYN AcronymsAF/RF: ante flexed/retr

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