Ob Gyn Sample #1
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old gravida 2, para 0-0-2-0 female with history of increasing uterine mass, questionable fibroid in the postmenopausal state. She was admitted for exploratory laparotomy and definitive surgery.
OBSTETRIC HISTORY: One termination, one ectopic.
MEDICAL HISTORY: Schizophrenia and breast CA.
MEDICATIONS ON ADMISSION: Ativan, Thorazine, Depakote, Cogentin, and Arimidex.
ALLERGIES: Penicillin and vitamin C.
PREVIOUS SURGERIES: Salpingectomy, right mastectomy, and a cyst removal from her back.
SOCIAL HISTORY: Smoker, reported to have quit last year.
LABORATORY DATA: Admission labs were stable. H&H by staff, 12 and 36.
PHYSICAL EXAMINATION: VITAL SIGNS: Stable. ABDOMEN: Abdominal examination was significant for approximately 25 cm midline pelvic abdominal mass that was nontender.
HOSPITAL COURSE: The patient was admitted for exploratory laparotomy and definitive surgery. Approximately 25 cm left ovarian mass was identified and removed and sent for frozen section. The surgery was performed via midline incision. An abdominal hysterectomy, bilateral salpingo-oophorectomy, pelvic washings, and right hypogastric lymph node dissection were performed while awaiting frozen section from pathology. The surgery was done without complications, and the final pathology report was benign mucinous cystadenoma. No additional procedures were required. The patient’s postoperative course was uncomplicated aside from her anxiety and psychiatric history. The patient was then discharged to home on postoperative day 4 in stable and satisfactory condition.
FINAL DIAGNOSIS: A 25 cm benign mucinous cystadenoma of the left adnexa, status post total abdominal hysterectomy and bilateral salpingo-oophorectomy via midline incision.
DIET: As tolerated.
PHYSICAL ACTIVITY: No heavy lifting, pelvic rest.
MEDICATIONS AND FOLLOWUP: As per Dr. John Doe.
Ob Gyn Sample #2
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old gravida 2, para 1 female at 38 weeks estimated gestational age who presented with complaint of leakage of fluid at 4 a.m. that morning as well as contractions and vaginal spotting beginning yesterday.
PRENATAL HISTORY: Uncomplicated.
PRENATAL LABORATORY VALUES: Blood type O negative. GBS status is positive. Hepatitis B and VDRL were both negative.
OBSTETRIC HISTORY: One full-term cesarean section secondary to breech presentation.
GYNECOLOGIC HISTORY: An abnormal Pap smear that resolved, then demonstrated by colposcopy.
MEDICAL HISTORY: Denies.
SURGICAL HISTORY: C-section.
All other history is noncontributory.
HOSPITAL COURSE: On admission, the patient was found to be grossly ruptured and 1-2 cm dilated, 70% effaced, -3 station contracting every 4-5 minutes with a reassuring fetal heart tracing. The patient was admitted for repeat cesarean section by which she delivered a viable female infant with Apgars of 9 at one minute and 9 at five minutes, weighing 6 pounds 12 ounces. At the time of cesarean section, the patient had previously consented to tubal ligation, which was performed without difficulty. The postoperative course was uncomplicated, and the patient was discharged to home on postoperative day 3 in stable and satisfactory condition.
Ob Gyn Sample #3
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old gravida 0, para 0 female in for abdominal myomectomy secondary to fibroids. The patient denied any pelvic pain or menorrhagia.
GYNECOLOGIC HISTORY: As mentioned, fibroids. No endometriosis or ovarian cysts. No history of pelvic infections. Last menstrual period was MM/DD/YYYY with a regular 32-day cycle and no use of oral contraceptive pills.
PREVIOUS MEDICAL HISTORY: Denies.
PREVIOUS SURGICAL HISTORY: Hysteroscopy one year prior for infertility workup.
MEDICATIONS ON ADMISSION: Multivitamin and Advil p.r.n.
REVIEW OF SYSTEMS: Denied any headaches, blurry vision, nausea, vomiting, dyspnea or any other constitutional symptoms.
All other history is noncontributory.
PHYSICAL EXAMINATION: VITAL SIGNS: The patient on admission had temperature 97.8, pulse 70, and blood pressure 112/62.
LABORATORY VALUES: Hemoglobin 10.4, hematocrit 30.8, white count 4800, and platelets 290,000. Blood type B positive.
HOSPITAL COURSE: The patient was admitted for abdominal myomectomy. The patient underwent abdominal myomectomy and placement of intrauterine balloon and stent. The procedure was uncomplicated. Further details of the surgery can be found in the operative note. The postoperative course, postoperative day 1, was significant for decreased urine output due to volume contraction. The patient responded well to fluid challenge. Vital signs were stable. Postoperative hemoglobin and hematocrit were 8.4 and 25.2, which was appropriate for the surgery that the patient underwent. Other labs were also found to be normal. The remaining postoperative course was uncomplicated and unremarkable, and the patient was discharged to home on postoperative day 2 with prescription for oral Premarin and cream and antibiotics. She was discharged to home in stable and satisfactory condition.
FINAL DIAGNOSIS: Fibroid uterus, status post abdominal myomectomy.
DIET: As tolerated.
PHYSICAL ACTIVITY: No heavy lifting, pelvic rest.
MEDICATIONS AND FOLLOWUP: As per Dr. John Doe.
Ob Gyn Sample #4
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old gravida 4, para 3-0-0-3 female at 38 weeks’ estimated gestational age with history of class B diabetes and chronic hypertension in for scheduled repeat cesarean section.
PRENATAL HISTORY: The patient has been managed by Maternal-Fetal Medicine here for her comorbidities. Blood type B positive. No other pertinent positives.
OBSTETRIC HISTORY: Three term vaginal deliveries.
MEDICAL HISTORY: As mentioned, hypertension and diabetes.
ALLERGIES: No known allergies.
MEDICATIONS ON ADMISSION: Regular insulin 50 units in the a.m. and 50 units in the p.m. and NPH insulin 60 units in the a.m. and 60 units in the p.m., also including Aldomet 250 mg twice daily.
HOSPITAL COURSE: The patient was admitted. On admission, reassuring fetal heart tracing and Accu-Chek of 156. In for repeat cesarean section and tubal ligation. A repeat low transverse C-section and tubal ligation was performed on the patient delivering a viable male infant with Apgars 9 at one minute and 9 at five minutes weighing 8 pounds 6 ounces. The postoperative course was unremarkable. On postoperative day 4 in stable and satisfactory condition with good blood pressure and sugar and glucose control. Endocrinology was consulted after delivery for assistance with controlling her blood sugars.
FINAL DIAGNOSIS: Full-term intrauterine pregnancy complicated by chronic hypertension and diabetes for scheduled repeat cesarean section, status post repeat low transverse cesarean section.
DIET: As tolerated.
PHYSICAL ACTIVITY: No heavy lifting, pelvic rest.
MEDICATIONS AND FOLLOWUP: As per Dr. John Doe.
Ob Gyn Sample #5
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old gravida 5, para 4-0-1-4 female with 18-year history of fibroid uterus and menometrorrhagia for the last 2 years, increasing in severity over the past few months as well as increasing size of fibroids. The patient presents for definitive surgery.
PREVIOUS HISTORY: Last menstrual period of MM/DD/YYYY. Denying any medical history. No hypertension, diabetes or heart murmurs.
SURGICAL HISTORY: Gastric bypass, also a parotid tumor that was benign, tubal ligation, and tonsillectomy and adenoidectomy.
OBSTETRIC HISTORY: Four vaginal deliveries and one miscarriage.
GYNECOLOGIC HISTORY: As mentioned above.
All other history is noncontributory.
HOSPITAL COURSE: The patient on admission had hemoglobin of 11.8 and hematocrit of 36.8. She was hemodynamically stable with a negative urine pregnancy test and coagulation profile within normal range. The patient was admitted for definitive surgery where she underwent a total abdominal hysterectomy and right salpingo-oophorectomy without difficulties. The postoperative course was uncomplicated, and the patient was discharged home on postoperative day 2 in stable and satisfactory condition.
FINAL DIAGNOSIS: Symptomatic fibroid uterus, status post total abdominal hysterectomy and right salpingo-oophorectomy.
DIET: As tolerated.
PHYSICAL ACTIVITY: No heavy lifting, pelvic rest.
MEDICATIONS AND FOLLOWUP: As per Dr. John Doe.
Ob Gyn Sample #6
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old gravida 1, para 0 female at 25 weeks and 2 days, sent by Maternal-Fetal Medicine at an outside facility with history of IUGR and oligohydramnios with absent end-diastolic flow noted on uterine artery Doppler. The patient was now noted to have reverse end-diastolic flow with IUGR and oligohydramnios for evaluation and possible delivery.
PRENATAL HISTORY: Type A2 gestational diabetes, vaginal bleeding, first trimester, normal level 2 ultrasound, and history of IVF pregnancy.
PRENATAL LABORATORY VALUES: Hemoglobin 9.4. Blood type O positive.
OBSTETRICAL HISTORY: No prior obstetrical history.
GYNECOLOGIC HISTORY: No gynecologic history.
PAST MEDICAL HISTORY: Only medical history reported is ulcerative colitis.
MEDICATIONS: On admission, a.m. insulin regimen of 3 units of subcutaneous regular, 3 units regular at lunch, 3 units regular at dinner, and 6 units NPH before bedtime. Additional medications include prednisone 50 mg orally every morning as well as Asacol 800 mg every 8 hours.
PHYSICAL EXAMINATION: On admission, blood pressure 146/80, heart rate 80, respiratory rate 18, and temperature 98.8 degrees. Accu-Chek of 82. The patient had fetal heart tracing in the 140s that was nonreactive, decreased long-term variability and occasional variables. No contractions were noted on the monitor. Ultrasound findings by MFM, 395 grams, weighing at less than the 10th percentile on MM/DD/YYYY and on MM/DD/YYYY 438 grams, less than the 3rd percentile.
Biophysical on admission, 4/10, -2 for NST, -2 for breathing, -2 for AFI.
HOSPITAL COURSE: The patient was admitted to Labor and Delivery for MFM consultation for which recommendations were to administer corticosteroids for fetal lung maturity with the hopes of getting through the steroid protocol and to deliver if fetal heart rate tracing deteriorates. Decision was made due to nonreassuring fetal heart tracing and poor biophysical to proceed with primary classical cesarean section via Pfannenstiel skin incision through which a viable female infant with Apgars of 3 at one minute, 6 at five minutes, and 7 at ten minutes was delivered atraumatically. Placenta, amniotic sac, and fetus were delivered in its entirety and handed immediately to the awaiting pediatrician. The patient’s postpartum course was uncomplicated and unremarkable and discharged home in stable satisfactory condition on postoperative day #3.
FINAL DIAGNOSES: A 25-week with severe intrauterine growth retardation, reverse end-diastolic flow, and nonreassuring fetal heart tracing, status post primary classical cesarean section.
DIET: As tolerated.
PHYSICAL ACTIVITY: No heavy lifting, pelvic rest.
MEDICATIONS AND FOLLOWUP: As per Dr. John Doe.
Ob Gyn Sample #7
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old gravida 2, para 0-0-1-0 female at 41 weeks and 1 day estimated gestational age who presents complaining of contractions.
PRENATAL HISTORY: First trimester vaginal bleeding that resolved.
PRENATAL LABORATORIES: Positive group A strep.
One prior termination, history of fibroids. All other history is noncontributory.
HOSPITAL COURSE: The patient on admission was found to be 3 cm, 90% effaced, -3 station with a reactive fetal heart tracing and admitted for induction of labor secondary to postdates. Following amniotomy and augmentation of labor with Pitocin, the patient began to have recurrent mild to moderate variable decels that would resolve initially with repositioning after several hours, without any significant progress and worsening of variable decels. An IUPC was placed and internal electrode for improved monitoring of labor pattern and fetal well being as well as amnioinfusion via the IUPC, shortly after which continued severe decels despite the amnioinfusion without any resolution, decision was made to proceed with primary low transverse C-section delivering a viable male infant with Apgars of 8 at one minute and 9 at five minutes, weighing 8 pounds 6 ounces. The postoperative course was uncomplicated. The patient was discharged to home on postoperative day 4 in stable and satisfactory condition.
FINAL DIAGNOSIS: Full-term intrauterine pregnancy at 41 weeks estimated gestational age for postdates, status post primary low transverse cesarean section for nonreassuring fetal heart tracing.
DIET: As tolerated.
PHYSICAL ACTIVITY: No heavy lifting, pelvic rest.
MEDICATIONS AND FOLLOWUP: As per Dr. John Doe.
