Gynecology and Obstetrics, 2004 Edition [Paperback]

Paul D. Chan MD (Author), Susan M. Johnson MD (Author)

Book Description

Publication Date: January 24, 2003

Pocket-sized quick-reference guide to the new ACOG guidelines. Updated and revised topics include surgical documentation, general gynecology, gynecologic oncology, obstetrics, and complications of pregnancy. Outline format. Previous edition: c2002. Softcover.

Editorial Reviews

Excerpt. © Reprinted by permission. All rights reserved.

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, laboratory studies, medications, and antibiotics.

Discharge Summary

Patient's Name:
Chart Number:
Date of Admission:
Date of Discharge:
Admitting Diagnosis:
Discharge Diagnosis:
Name of Attending or Ward Service:

Surgical Procedures:
History and Physical Examination and Laboratory Data: Describe the course of the disease up to the time the patient came to the hospital, and describe the physical exam and laboratory data on admission.
Hospital Course: Describe the course of the patient's illness while in the hospital, including evaluation, treatment, outcome of treatment, and medications given.
Discharged Condition: Describe improvement or deterioration in condition.
Disposition: Describe the situation to which the patient will be discharged (home, nursing home).
Discharged Medications: List medications and instructions.
Discharged Instructions and Follow-up Care: Date of return for follow-up care at clinic; diet, exercise instructions.
Problem List: List all active and past problems.
Copies: Send copies to attending physician, clinic, consultants and referring physician.

Product Details

• Paperback: 149 pages
• Publisher: Current Clinical Strategies Pub; 7th edition (January 24, 2003)
• Language: English
• ISBN-10: 1929622325
• ISBN-13: 978-1929622320
• Product Dimensions: 6.5 x 4.1 x 0.4 inches
• Shipping Weight: 4 ounces
• Amazon Best Sellers Rank: #2,381,419 in Books (See Top 100 in Books)