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Obstetrics and Gynecology

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GP TPAL System
G=Gravidity = number of pregnancies.
P=Parity = number of “acts of delivery”
TPAL stands for Term, Pre-term, Abortions, Living children
Example: G3P1011. G3 = She has been pregnant three times, including current pregnancy.
P1011 = 1 full term pregnancies, 0 pre-term pregnancies, 1 abortion or miscarriage or ectopic or molar pregnancy, 1 living child.

Specifics for History and Presentation

Include this info in oral presentations

Include gravidity and parity (expanded Term, Preterm, Abortions, and Living Children)
For OB: include estimated date of confinement and gestational age
For GYN: include LMP
PSH: include C-section and indications for C-Section

Past OB hx:

If any delivery, year, type of delivery, gestational age, any complications, weight of baby.
If any termination, year, spontaneous/ therapeutic, gestational age, any complications.
Ask these questions at all prenatal visits:
- Are you having bleeding per vagina?
- Fluid per vagina?
- Abnormal discharge?
- Contractions/cramps?
- Are you feeling fetal movement? (Ask this only in 2nd and 3rd trimester)

Past GYN hx:

Menstrual history–age of onset/duration/ interval/dysmenorrhea?
Contraception?
Abnormal pelvic structures--ovarian cysts/fibroids
Infections—STI, PID?
Cervical dysplasia screening–last pap, any abnormal pap smears
Sexual history

Assessment

OB Assessment, example: 24yo G3P1011 @ 39.2 wks with history of 1 previous c-section undergoing vaginal trial of labor. Presented with contractions, found to be 4/80/0 and was admitted. Previous low-transverse c-section, counseled on options and desires VBAC. Otherwise uncomplicated prenatal care. Has epidural anesthesia. Made cervical change to 6/80/0. Plan to re-examine in 2 hours.

Always include: Parity, gestational age of pregnancy, reason for admission, labor course. Post partum: parity, delivery type and complications, breast or bottle feeding, contraception, circumcision (if male)

GYN Assessment, example: 48yo G2P2 with history of menorrhagia s/p supracervical hysterectomy, POD#2. Fever today 101.0, non-focal exam. UCx sent, CXR sent, need to follow up on results. If respikes would re-examine, send blood culture and start Kefzol for empiric treatment of intra-abdominal infection.

Always include type of surgery (if any), post op day/complications

Post-partum Note

Date/TimePP#M/F / blood type/ rubella status/ PPD

S: no complaints, tol PO, voiding freely, flatus?, BM?

O: Tm Tc BP P R

Breast vs. bottle feedingBreast: soft, NE (non-engorged), NTCV: RRRLungs: CTA BAbd: FF (fundus firm), nontenderPelv: Mod lochiaExt: no c/c/e

A/P: 18 y/o P1001 PP#1 s/p NSVD/VAD/LF/VBAC with ___ epis/lac stable, afebrile doing well.

PPD#1

routine PP carecheck CBC (Elmhurst)

PPD#2

d/c home___ for contraceptionpelvic rest 6 weeksPP check 6 weeks

If Cesarean:

O: UOP for CS#1

Abd: assess wound, +BS

A/P: 18y/o P1001 s/p 1° LFT C/S for _, POD# doing well. Afebrile.

POD#1

check CBCd/c foleyOOBAdvance diet as tolPlan per PMD (for private patients at Sinai)

POD#2/3

reg dietmedlock IV/d/c IVambulation

POD#3/4

d/c home or staple removal in 1-2 days if POD#3post-op check 2 weeks___ for contraceptiond/c plans per PMD for private patients at Sinai (do not d/c staples or d/c homefor private patients!!!)

Mag Sulfate Note

Mg __ g/hr

S: N/V, dizziness, visual changes, pre-eclampsia symptoms (ie: HA, blurry vision, RUQ pain), if still pregnant - fetal movement, CTXs, LOF, VB

O: T BP ranges (for pre-eclampsia) P R

I/O (for pre-eclampsia)Gen: NAD, awake, alert or easily arousableCV: RRRLungs: CTA BAbd: gravid, NT or FF if postpartumPelv: deferred or last pelvic exam in labor; mod lochia if postpartumExt: DTRs, edemaEFM/Toco if still pregnantLabs: any recent PIH labs or Mg levels that have been done

A/P: 18 y/o P1001 at _ weeks on Mg at gm/hr for pre-eclampsia or PTL. No signs/symptoms of Mg toxicity. Adequate UOP. BPs stable (pre-eclampsia). Adequate tocolysis (PTL).

continue Mg at ___ gm/hrcontinue close monitoringcontinue or s/p dex, amp, erythro for PTLcontinue Mg 24hrs postpartumcheck Mg level and hold mg if suspicious for toxicity

Brief Op Note

Pre-op Dx: Fibroids, menorrhagiaPost-op Dx: sameProcedure: TAH/BSOSurgeons: Attending: Ditchik, PGY-3: Jones, PGY-1: Smith, MS3: (Your name)Anesthesia: GETA (or MAC)Findings: Uterus ~16 wk size, fundal pedunculated fibroid ~5cm, posterior intramural fibroid ~4cm. Bilateral tubes and ovaries grossly normal.Specimens: Uterus, bilateral tubes and ovariesDrains: foleyFluids: IVF – 1500cc, EBL 200cc, UOP 200ccDispo: Pt. to recovery room in good condition.Dr. (name of attending) was present and participated throughout the procedure).

Gynecology Daily Progress Note

Date/Time:POD # HD #

S: +ambulating, +voiding, +tolerating regular diet, +flatus.

Pain controlled w/Percocet.

O: VS – Temp BP P RR O2 sat

I/O – I: 2200cc/24h O: UOP: 800cc/24h Foley other drains bagsChest – RRR, CTAAbd – soft, mildly tender, not distended, +BS, incision c/d/i (stands for clean, dry, intact)Ext – trace edema, no calf tendernessMedsIf on Abx, day of therapy, e.g. (Zosyn d3)Labs: UCx, BCx if appropriate

A/P: Age s/p (name of procedure) (with past medical history to include if pertinent to post op care)

incentive spirometerGI prophylaxisDVT prophylaxisother things to think about when creating a plandiettubes what can be removed,medications converted to PO, d/c if unnecessary, continueIVF rate, type, HLIVDISPO (things to think about)Visiting nurseRehabPT consult

Rotation Requirements

Choose evaluators (residents, attendings, preceptor)Clinical skills certification card

Oral case presentation (20 min max)

H, P, +/-, Labs, RadiologyDifferential, Dx, ManagementHospital or Outpatient courseReview of relevant clinical problem or topic (2 recent journal articles)Commentary on management

Written case presentation (Similar format as above)