Gynecology and Obstetrics

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, hypertension, 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 accommodation (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 second heart sounds, murmurs.
Breast: Skin retractions, masses (mobile, fixed), erythema, axillary or supraclavicular node enlargement. Abdomen: Scars, bowel sounds, masses, hepatosplenomegaly, guarding, rebound, costovertebral angle tenderness, hernias. Genitourinary: Urethral discharge, uterus, adnexa, ovaries, cervix. Extremities: Cyanosis, clubbing, edema. Neurological: Mental status, strength, tendon reflexes,
sensory testing. Laboratory Evaluation: Electrolytes, glucose, liver function tests, INR/PTT, CBC with differential; X-rays, ECG (if >35 yrs or cardiovascular disease), urinalysis. Assessment and Plan: Assign a number to each problem. Discuss each problem, and describe surgical plans for each numbered problem, including preoperative testing,
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