OPD ORIENTATION NOTES

GYNE Forms:

OB Forms:
 GYNECOLOGY FORM

General Data ● Registration number should also be placed (we can get this from the receipt
of the patient) - done by Ma’am Glenda
● Date
● Demographics - complete name, age, birthdate
● Don’t forget to get the contact number of the patient especially for pre-op
patients (for follow-up)
● Number of years married, civil status

OB History ● Even if it is a gynecologic case, OB history (GP) should still be placed

○ OB Scoring G_P_ (TPAL)
● Total of Past Pregnancies
● Example: G2P2 (2002)
○ G1 (2019) - delivered to a live term baby boy/girl (BW:___/BW
unrecalled) via NSD or via CS at a lying in clinic/hospital in
Zambales/USTH, (+) complications like Pre-eclampsia
■ If via CS, what is the indication?
● Arrest in cervical dilatation
● Arrest in descent

Menstrual History Menarche

Interval
● If patient presented with missed menses, always ask the longest interval that
she did not have menses
○ Example: longest was 3 months, then followed by 1 month = Interval
will be 28 - 90 days
Duration
Amount
● Pads/day
● Moderately soaked? Fully soaked?
● Is there any presence of blood clots?
Symptoms
● Dysmenorrhea - no / occasional
○ Medications taken
○ What day of the cycle

LMP = “kailan po ang huling araw ng regla?”

Chief Complaint What is the reason for consulting?

● Subjective complaint of the patient

HPI (Onset and Focus on gynecologic diseases first before other systems
Progress) ● Presence of mass
○ Onset, associated pain, associated bleeding, vaginal discharge, fever

Personal Social Not part of the form but important!

History / Sexual Can be placed on the box labeled as “Abnormalities”
History
PERSONAL SOCIAL HISTORY
Ask for:
● Vices
● Alcohol consumption
● Illicit Drugs

SEXUAL HISTORY
● Always be respectful
○ “Maam, sorry, pero medyo sensitive po ang next question ko pero
kailangan po siya sa history taking.”
 ● Coitarche - age of first sexual contact
● # of Sexual Partners
● No post-coital bleeding
● Dyspareunia
● Ask planning method if condom or withdrawal

Physical Exam Vital Signs

● Get the vital signs right away once the patient is in the OPD
○ Reason: if you see a patient that is not stable, you should refer her to
the ER for consult
○ BP, HR, RR, Temperature
○ HR
■ If you got this via pulse oximeter and patient is tachycardic,

● ❗ you have to repeat it manually

Present weight: always put in kilograms (kg)
● Height should always be in centimeters (cm)
○ Compute for the BMI of the patient (kg/m2)

Chest: symmetrical chest expansion

Head: pink palpebral conjunctiva or pale (but if there are other pertinent information,
you should place it)
Heart: adynamic precordium, no murmurs (if there’s a pathologic finding, put it also)
Pulmo: Clear breath sounds, wheezes, ronchi, crackles
Abdomen: (done together with the resident; note the information)
Skin: lesions, deformities
Extremities: pulses (full equal or bounding)

❗ NEVER PUT UNREMARKABLE ON PE FINDINGS. YOU HAVE TO KNOW THE

NORMAL PE FINDINGS PER SYSTEM

Not found in the form but include BREAST EXAMINATION

● For respect and courtesy, always make it a point that you are with a girl clerk
(whether breast or abdominal exam)
● Drape patient and ask politely to unhook bra

❕
● Examine one breast at a time
● Normal findings: No retractions, no skin dimpling, no masses, no
tenderness, no lymphadenopathies (supraclavicular, axillary etc)

PELVIC EXAMINATION (Always have a resident accompanying you)

● Before doing a pelvic examination, ask the patient to urinate first! Full
bladder may obscure examination)
● External Genitalia: hair distribution in inverted triangle with no gross lesions
● Speculum Exam: cervix is pink, smooth, with minimal mucoid, whitish,
non-foul discharge
● Internal Exam: cervix is firm, long/short, closed; uterus - normal size (if
enlarged, up to how many months?), anteverted/retroverted, movable,
non-tender; no adnexal masses or tenderness
● Rectal Exam: tight sphincteric tone, smooth rectal mucosa (write all findings)
○ If warranted, do a rectal examination (endometriosis or masses to
check for the borders of the mass)

❗ As a clerk, need to master S&O (subjective and objective findings)

❗ Write a tentative diagnosis; even if she is a gynecologic patient, write the OB
score
● Example: G_P_ (TPAL) AUB
 Question:
● What if the patient does not remember LMP?
○ Always probe for the answer
○ Give a pivot point (months, year)
● If multiple partners, do we put all the contraceptives used per partner?
○ No, that’s awkward
○ Just ask what they currently use for family planning
● Do we note why we do rectal exam?
○ No, but you have to know personally why it was done to a certain
patient
● Where do we put the OB history?
○ Does not matter if you skip columns
○ Make sure that it is complete

⭐If you present a patient, example: (make sure that it is systematic)

● We have a 24 year old G2P2 (2002) on day __ of the cycle
● Single, roman catholic, housewife from manila
● Chief complaint is ____
● HPI
● Physical examination - vital signs normal, etc.

Be prepared to be asked questions!

OB FORM

General Data Same as gynecology

Previous Medical / Hypertension, Diabetes, Asthma, Thyroid disease

Surgical History Previous surgery
Blood transfusion
Allergies

Menstrual History MIDAS

LMP is very important

Estimated Date of If based on LMP: Naegele’s Rule

Delivery /
Confinement Q: When will you appreciate quickening?
● Primigravid: 18-20 weeks
● Multigravid: 16-18 weeks

Date Write the date + how many weeks AOG

Weight Should always get the weight in pounds (lbs)

How much was the gain per trimester?

10 Danger Signs of ● If there’s none, don’t write it as “(-)”; write the whole word “NONE”
Pregnancy and
Implication

Urinary Output Regular / Frequent

Bowels Regular / Constipated

Presentation
 Engagement Usually not answered

Position

Fetal Heart Tone ● Doppler - 10 weeks AOG

● UTZ - 5-6 weeks AOG
● Stethoscope - 16-18 weeks AOG

External factors: obesity (give leeway - 12 weeks)

If there’s a patient with abdominal enlargement, try to auscultate

Height of Fundus ● Can start to check for fundic height at 16 weeks (earliest)
○ Kung ilan ang AOG, will coincide with the fundic height
● Landmark: From most superior portion of symphysis pubis to fundus

Leopold’s Maneuver ● Started at 28 weeks

● LM1: fundal - if cephalic in presentation
○ LM1: Breech
● LM2: fetal back - for the purpose of hearing the fetal heart tone (can be
appreciated at the back)
○ LM2: Fetal back right / fetal back left
● LM3: presentation
○ LM3: cephalic
● LM4: not usually done

Then write the FHT:

● Make sure that you allow the patient to hear that there are heart tones

Format should be:

● LM1: breech
● LM2: fetal back right/ fetal back left
● LM3: cephalic
● LM:
● FHT: 145 bpm

Chief Complaint Usually patients seek consult for prenatal check-up

CC: Prenatal Check-Up

Onset and Progress ● You should establish presence of pregnancy

● Put the probable, presumptive and positive signs
○ Missed menses for 2 months, accompanied by breast tenderness,
nausea and vomiting
○ She did a pregnancy test which turns out positive; hence, consult
● Height and weight of the patient
○ Get the pre-pregnancy weight in kg
○ But if present weight, get in lbs

Physical Same as gynecology

Examination
Vital Signs:
● BP of 140/90 and above = refer to a resident

Abdomen: will depend on the age of gestation (indicate)

Pelvic Exam:
● External Genitalia - indicate if there are scars (RMLE, LMLE, Median
episiotomy)
● Speculum Examination

○ ⭐
● Internal Examination (if pregnant)
REMEMBER Hey (U) , Good (C), Chad (V)
 ■ Vagina = violaceous (Chadwick’s)
■ Cervix = soft (Goodell’s)
■ Uterus = softening of the uterine isthmus (Hegar’s)

Tentative Diagnosis
⭐
Example:
Case 1
1st pregnancy = 37-38 weeks
2nd pregnancy = 14-15 weeks
Write is as: G2P1 (1001) pregnancy, uterine at 14-15 weeks

⭐ Case 2
If not sure, then 1st pregnancy at 6-7 weeks
(No TVS done yet)
Write is as: G1P0 consider early pregnancy at 6-7 weeks

Laboratories to ● CBC
Request for First ○ Hemoglobin cut-off:
Prenatal Check-Up ■ 1st trimester = 11 g/dL
■ 2nd trimester = 10.5 g/dL
■ 3rd trimester = 11 g/dL
● Blood typing
● Urinalysis
○ Example: ASYMPTOMATIC BACTERIURIA
■ Pus cells = 5-10/hpf
■ Squamous cells = few
■ No symptoms
■ Will you treat? YES, ALWAYS in pregnant patients
● Drugs that I CAN give:
○ C = Cefuroxime
○ A = Ampicillin
○ N = Nitrofurantoin
● FBS
○ Normal: <92 mg/dL
○ GDM cut-off: >92 mg/dL
○ Overt DM cut-off: 126 mg/dL
○ Example 1:
■ Prenatal is 88 mg/dL = normal
■ Repeat at 24-28 weeks due to human placental lactogen
(HPL) → anti-insulinemic
■ If tested again and still 88 mg/dL (normal), repeat at 32
weeks
○ Example 2:
■ FBS: 100 mg/dL → Gestational DM
■ When to repeat? No need to repeat since diagnosed already
■ Treatment: GDM diet (first line); do the computation then put
on diet for 2 weeks then consider insulin if not controlled
● HBsAg
● HIV
● RPR/VDRL

Prenatal FIRST TRIMESTER: 9-10 weeks

Supplements ● Folic acid 4 mg/tab if with history
○ If no history, 0.4 mg/tab
○ Can give 1 month prior to pregnancy
○ Given up to 14 weeks only
● Multivitamins 1 tablet OD
● Do not give magnesium or else patient will hve diarrhea

SECOND TRIMESTER: 14 weeks

● Ferrous sulfate
 ● Multivitamins
● Calcium - not usually given if patient can drink milk and doesn’t have GDM
○ If with GDM, shift to tablets because milk has simple sugar

Question: If patient brought with her laboratory results, where should we put?
● Put it in this history as: “laboratory is done . . . “, and what AOG it was done

Question: If follow-up cases, what do we write in the history?

● Know 10 danger signs of pregnancy
● Implications
● Example: follow-up at 28 weeks
○ Asymptomatic - can be detailed (no hypogastric pain, no vaginal
bleeding)
○ No danger signs of pregnancy
○ Good fetal movement

Always follow S-O-A-P

(Subjective, Objective, Assessment, Plans)

Question: If a patient had CS, do we put the type of CS (skin)?

● Yes, if possible. You can write it on the scar.
● Important to write also the type of uterine incision/scar = if can patient can
undergo labor
○ If classical - patient can’t go to vaginal delivery
○ If LTCS - patient can depending on the condition (conditional)

Question: What if you made a correction?

● Do not put white out, instead do this (line mark)