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Gynecology and Obstetrics

Gynecology and Obstetrics

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Published by: api-3712326 on Oct 14, 2008
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03/18/2014

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Current Clinical Strategies 
Gynecology and Obstetrics2004 Edition
New ACOG Treatment Guidelines 
Paul D. Chan, M.D.Susan M. Johnson, M.D.
Current Clinical Strategies Publishing 
www.ccspublishing.com/ccs 
 
Digital Book and Updates
Purchasers of this book may download the digital bookand updates for Palm, Pocket PC, Windows andMacintosh. The digital book can be downloaded at theCurrent Clinical Strategies Publishing Internet site:
www.ccspublishing.com/ccs 
Copyright © 2004 Current Clinical Strategies Publishing.All rights reserved. This book, or any parts thereof, maynot be reproduced or stored in an information retrievalnetwork without the permission of the publisher. Thereader is advised to consult the package insert and otherreferences before using any therapeutic agent. The publisher disclaims any liability, loss, injury, or damage incurred as a consequence, directly or indirectly, of the useand application of any of the contents of this text. CurrentClinical Strategies is a trademark of Current Clinical Strategies Publishing Inc.Current Clinical Strategies Publishing27071 Cabot RoadLaguna Hills, California 92653Phone: 800-331-8227Fax: 800-965-9420Internet: www.ccspublishing.com/ccsE-mail: info@ccspublishing.comPrinted in USA ISBN 1929622-32-5
 
Surgical Documentation for Gynecology 
Gynecologic Surgical History
Identifying Data.
Age, gravida (number of pregnancies),para (number of deliveries).
Chief Compliant.
Reason given by patient for seekingsurgical care.
History of Present Illness (HPI).
Describe the course ofthe patient's illness, including when it began, character ofthe symptoms; pain onset (gradual or rapid), character ofpain (constant, intermittent, cramping, radiating); otherfactors associated with pain (urination, eating, strenuousactivities); aggravating or relieving factors. Other relateddiseases; past diagnostic testing. 
Obstetrical History.
Past pregnancies, durations andoutcomes, preterm deliveries, operative deliveries.
Gynecologic History:
Last menstrual period, length ofregular cycle.
Past Medical History (PMH).
Past medical problems,previous surgeries, hospitalizations, diabetes, hypertension, asthma, heart disease. 
Medications.
Cardiac medications, oral contraceptives,estrogen.
Allergies.
Penicillin, codeine.
Family History.
Medical problems in relatives.
Social History.
Alcohol, smoking, drug usage, occupation.
Review of Systems (ROS):General:
Fever, fatigue, night sweats.
HEENT:
Headaches, masses, dizziness.
Respiratory:
Cough, sputum, dyspnea.
Cardiovascular:
Chest pain, extremity edema. 
Gastrointestinal:
Vomiting, abdominal pain, melena(black tarry stools), hematochezia (bright red blood perrectum).
Genitourinary:
Dysuria, hematuria, discharge.
Skin:
Easy bruising, bleeding tendencies.
Gynecologic Physical Examination
General:Vital Signs:
Temperature, respirations, heart rate, bloodpressure.
Eyes:
Pupils equally round and react to light and accommodation (PERRLA); extraocular movements intact(EOMI).
Neck:
Jugular venous distention (JVD), thyromegaly,masses, lymphadenopathy.
Chest:
Equal expansion, rales, breath sounds.
Heart:
Regular rate and rhythm (RRR), first and secondheart sounds, murmurs.
Breast:
Skin retractions, masses (mobile, fixed), erythema, axillary or supraclavicular node enlargement.
Abdomen:
Scars, bowel sounds, masses,hepatosplenomegaly, guarding, rebound, costovertebralangle tenderness, hernias.
Genitourinary:
Urethral discharge, uterus, adnexa, ovaries, cervix.
Extremities:
Cyanosis, clubbing, edema.
Neurological:
Mental status, strength, tendon reflexes,sensory testing.
Laboratory Evaluation:
Electrolytes, glucose, liver function tests, INR/PTT, CBC with differential; X-rays, ECG (if>35 yrs or cardiovascular disease), urinalysis.
Assessment and Plan:
Assign a number to each problem. Discuss each problem, and describe surgical plans foreach numbered problem, including preoperative testing,

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