OB Case Format
“(initials) is a (age) y/o G (gravity) P (parity) female who presents @ (EGA) weeks with (main presenting symptom explained as pertinent positives as well as negatives; typically ‘painful contractions’ or ‘leakage of fluid’ or ‘decreased fetal movement’ or ‘bleeding’ or any combination of these) x (duration of presenting symptom)”
“Her antepartum course has been significant for (normal vs. abnormal prenatal labs, any additional tests, procedures or hospitalizations during the pregnancy)”
“Her past OB history is significant for (all pregnancies and their outcomes are summarized here): xx/xx/xxx (date), M or F, weight, type of delivery (vaginal, forceps, vacuum), any complications”
“Her Gyn history: menarche age __, frequency of menses, # of days of menses, any h/o intermenstrual spotting. STD’s, abnormal pap smears? Last pap ___.”
“Her past medical history is significant for...”
“Her past surgical history...”
“Her medications include...”
“She has (no known) drug allergies...”
“Her family history is significant for... (any breast, colon, uterine, ovarian cancer)”
“Her social history is significant for...”
“Her review of systems is significant for...”
“On physical exam, she is alert, gravid, (‘lying comfortably in a stretcher’; ‘writhing in pain with contractions’); list VS; (HEENT, CV, and lungs are examined, but only positive findings are mentioned; if these are all WNL, go directly from vital signs to the abdominal exam); abdomen is soft, gravid and nontender (or otherwise); vaginal exam (or sterile speculum exam) is significant for (dilatation, effacement per ___(person performing), station); fetal heart rate is... Extremities have no edema or calf tenderness (or otherwise)”
“Labs at admission are significant for... (typically CBC only)”
“In summary, this is a (age) y/o (primip, multip) who presents (preterm, at term) weeks with (main presenting symptom); the plan is...”
“ Her interval course ... (explain in a brief but detailed manner her labor course; use terms like ‘2 hours later...’ and ‘4 hours after that...’ rather than times; for births, include weight, gender, Apgars and gasses if obtained)”
OB Case Example
MS is a 36 y/o G3P1011 female who presents @ 38 4/7 weeks with painful contractions for four hours and leakage of fluid for two hours; she has no bleeding and feels the baby moving; her antepartum course has been significant for prenatal labs with an elevated glucose challenge test followed by a normal glucose tolerance test and a brief hospitalization @ 22 weeks for dehydration due to gastroenteritis; her past OB history is significant for a full term normal spontaneous vaginal delivery @ term in 1998, and a spontaneous abortion with a dilatation and curettage at 8 weeks in 2000; her Gyn history is significant for a triad of 31 x 4-5 x 14; she was diagnosed with HPV in 1994, and has no fibroids or ovarian cysts; her past medical history is significant for hypothyroidism, and her medications include Synthroid 88 mcg as well as prenatal vitamins; she gets a rash from sulfa containing medications, and a family history is significant for a maternal grandfather with CHF and a paternal aunt with post-menopausal breast cancer; her social history is significant for a 15 pack-year history of cigarettes ending prior to her first pregnancy; no alcohol or drugs; her review of systems is significant for generalized fatigue and constipation; on physical exam, she is alert, gravid, and in moderate discomfort with contractions; vital signs are stable; there is a four over six systolic ejection murmur loudest over the left lower sternal border; her abdomen is soft, gravid and nontender; vaginal exam is significant for a cervix that is 4-5 cm, 80% effaced and at minus three station; the fetal heart rate has a baseline of 140’s with accelerations and occasional mild decelerations; there are 60 second contractions every four to six minutes; extremities have no edema or calf tenderness to the mid-shin;; labs at admission are significant for a hematocrit of 30.1%; in summary, this is a 36 y/o multipara at term who presents in active labor; the plan is to admit her, offer epidural, monitor continuously and anticipate spontaneous vaginal delivery; her interval course: She received an epidural, and two hours later her vaginal exam was 7 cm, 80% effaced and minus two station; the heart remained reassuring, and she was fully dilated three hours later; she pushed effectively for 45 minutes, and had a normal spontaneous vaginal delivery of a 3840 gram female, Apgars 8 @ 1 minute and 9 @ 5 minutes over a first degree laceration; the placenta delivered spontaneously and intact, and the laceration was repaired; mother and newborn were brought to post-partum in stable condition
Surgery Case Format
“(initials) is a (age) y/o G (gravity) P (parity) female who presents for surgical management of (presenting symptom)”
“She initially presented (number of days, weeks, months or years) prior to admission with (initial complaint); studies performed include...”
“She is (not) sexually active (monogamous, discomfort, etc.; premenopausal contraception)"
“Her past OB history is significant for (all pregnancies and their outcomes are summarized here): xx/xx/xxx (date), M or F, weight, type of delivery (vaginal, forceps, vacuum), any complications”
“Her Gyn history: menarche age __, frequency of menses, # of days of menses, any h/o intermenstrual spotting. STD’s, abnormal pap smears? Last pap ___.”
“Her past medical history is significant for...”
“Her past surgical history...”
“Her medications include...”
“She has (no known) drug allergies...”
“Her family history is significant for...(any breast, colon, uterine, ovarian cancer)”
“Her social history is significant for...”
“Her review of systems is significant for...”
“On physical exam, she is alert, gravid, (‘lying comfortably in a stretcher’; ‘writhing in pain’, etc); list VS; (HEENT, CV, lungs and breasts are examined, but only positive findings are mentioned; if these are all WNL, go directly from vital signs to the abdominal exam); abdomen is soft and nontender (or otherwise); pelvic exam (or exam under anesthesia) is significant for (assessment of uterus & adnexa; rectovaginal exam, etc)... Extremities have no edema or calf tenderness (or otherwise)”
“Labs at admission are significant for..."
“In summary, this is a (age) y/o who presents for surgical management of...”
“Her interval course ... (explain in a brief but detailed manner her operative and post-operative course; use terms like ‘2 hours PO...’ and ‘4 hours later...’ and ‘on the second postoperative day...’ rather than times; include pathology if available)
Surgery Case Example
JL is a 63 y/o G2P2 female who presents for surgical management of an adnexal mass; she initially presented six weeks prior to admission with bloating and weight loss; studies include pelvic ultrasound documenting a 5 cm multiloculated mass replacing the left ovary as well as a CT scan demonstrating no adenopathy; she is sexually active, monogamous, and has mild insertional dyspareunia ameliorated with K-Y Jelly; her past OB history is significant for two vaginal deliveries at term; her Gyn history is significant for symptomatic menopause at 52, treated for three years with combination hormone replacement therapy; she has no history of STD’s, fibroids or previous ovarian cysts; her past medical history is significant for an appendectomy at 14 y/o and chronic hypertension; her medications include Norvasc 2.5 mg daily; she has no known drug allergies; her family history is significant for a sister with NIDDM and a maternal aunt with chronic hypertension; her social history is significant for no cigarettes, social alcohol and no drugs; her review of systems is significant for vaginal dryness;; on physical exam, she is alert, anxious and in no apparent distress; her vital signs significant for a blood pressure of 144 / 90; her abdomen is soft and nontender; exam under anesthesia is significant for a mobile mass on the left and a small uterus; rectovaginal exam confirms parametria are free; extremities have no cyanosis, clubbing or edema; labs at admission are all WNL; in summary, this is a 63 y/o who presents for surgical management of an adnexal mass; she underwent an operative laparoscopy with a left salpingo-oophorectomy, with frozen section revealing a benign serous cystadenoa; she had an uncomplicated postoperative course and was discharged home with a stable hematocrit on the first post-operative day
Clinic Case Format
“(initials) is a (age) y/o G (gravity) P (parity) female who presents to clinic for (chief complaint or routine gyn care)“
“She is (not) sexually active (monogamous, discomfort, etc.; premenopausal contraception)"
“Her past OB history is significant for (all pregnancies and their outcomes are summarized here): xx/xx/xxx (date), M or F, weight, type of delivery (vaginal, forceps, vacuum), any complications”
“Her Gyn history: menarche age __, frequency of menses, # of days of menses, any h/o intermenstrual spotting. STD’s, abnormal pap smears? Last pap ___.”
“Her past medical history is significant for...”
“Her past surgical history...”
“Her medications include...”
“She has (no known) drug allergies...”
“Her family history is significant for... (any breast, colon, uterine, ovarian cancer)”
“Her social history is significant for...”
“Her review of systems is significant for...”
“On physical exam, she is alert (‘lying comfortably in a stretcher’; ‘writhing in pain’, etc); list VS; (HEENT, CV, lungs and breasts are examined, but only positive findings are mentioned; if these are all WNL, go directly from vital signs to the abdominal exam); abdomen is soft and nontender (or otherwise); pelvic exam (or exam under anesthesia) is significant for (assessment of uterus & adnexa; rectovaginal exam, etc)... Extremities have no edema or calf tenderness (or otherwise)”
“In summary, this is a (age) y/o who presents to clinic for ...”
“Her interval course ... (explain in a brief but detailed manner her clinic visit and care plan)”
Clinic Case Example
MA is a 44 y/o G0P0 female who presents to clinic for evaluation of a malodorous vaginal discharge; she is sexually active, monogamous, has no discomfort and uses OCP’s for contraception; she has no past OB history; her Gyn history is significant for menarche age 11, menses q28 days, lasting 2-3 days with no intermenstrual spotting. denies history of STD’s; last pap smear 1 year ago with hx of 1 abnormal papin 1997-fw within normal limits; she has no past medical history and is on no prescription medications; she has no known drug allergies; her family history is significant for a cousin with mental retardation; her social history is significant for social alcohol and occasional grass; her review of systems is significant for a persistent dusky malodorous vaginal discharge she has noted for the past 5 days; on physical exam, she is alert and in no apparent distress; vital signs are stable; abdomen is soft and nontender; pelvic exam is significant for a dusky discharge found to have an elevated pH as well as WBC’s and clue cells on white mount; her uterus & adnexa are WNL; extremities have no cyanosis, clubbing or edema; in summary, this is a 44 y/o G0P0 who presents to clinic for evaluation of vaginal discharge found to be bacterial vaginosis; the plan is to treat with metronidazole vaginal cream for five nights and follow up as needed for routine gyn care
