Obstetrics and Gynecology Intern Handbook 2013-2014
SIGNOUT TIMES & IMPORTANT NUMBERS Mon 0630 and 1830 Tues 0630 and 1730 Gyn Pager 12055 Wed 0630 and 1730 GynOnc Pager 12825 Thurs 0630 and 1830 R1 OB 222-7964, Postpartum Pager 12225 Fri 0630 and 1730 R2/R3 OB 222-7965 Sat 0800 and 1930 Chief 444-9844 Sun 0800 and 1930 TABLE OF CONTENTS Day OB and Nightfloat.... pg 3 Conferences. pg 3 Postpartum. pg 5 OB Floor Calls... pg 6 Gyn Onc. pg 8 US/REI. pg 10 GYN.. pg 10 Continuity Clinic. pg 11 Medical Spanish. pg 13 Dictation 101 pg 17 An important note: Much of the information in the following pages can and will vary depending on your senior residents and attending. Communication with your team is key. 2
Day OB and Night Float Daily Schedule and Events Lectures/ Grand Rounds: Mon 7:30 11:30 am Fetal Strip Rounds: 1 st, 2 nd, and 5 th Wed of each month 7:30 am (7:15 if Dr Druzin) MFM Journal Club: 3 rd Wednesday of each month 7:30 (US or Gyn Clinic presents) GynOnc Journal Club 4 th Wednesday of each month 7:30 (Onc R2 presents) Perinatal conference: Fridays at noon (off-service intern covers this, expect email Wed or Thurs with which cases are being presented) Intern Conferences: Wed AM Teaching 0730 in OB conference room (3 rd floor) All Wednesdays (except 3 rd and 4 th ): Fetal Strip Rounds. Day OB intern prepares and presents an interesting fetal strip. Another intern and students read the strip. Stockpile interesting strips for the future. 3 rd Wednesday: MFM Journal Club. An intern and MFM fellow present an article. Coordinate with fellow interns to make a calendar for the year. Communicate with MFM fellow about which article on your month. 4 th Wednesday: Onc Journal Club: R2 on Onc presents you re off the hook! Perinatal Conference Fridays at noon (1 st floor Packard by elevators) Attended by MFM and NICU faculty and residents. No strips, just prenatal course including interesting maternal diseases or complications. Be brief. Include US findings, +/- betamethasone, APGARs, cord gases (BE SURE TO HAVE THESE!), and weight. Peds resident will present the baby s hospital course. 3
***You are not responsible for presenting babies transferred to LPCH after birth (outborn babies)*** The R1 on US/REI should present at Perinatal Conference and read the strip at Strip Rounds. If there is no R1 on US/REI, the intern on Gyn Clinics is responsible. If there is no resident on Gyn Clinics (on vacation) then perinatal conference becomes the L&D R1 s responsibility and the R1 on Onc will read the strip on Wednesdays, if you are the resident on Gyn clinic and have vacation, be sure to let the other R1 know! Admit Orders Pre-checked order sets available in Powerchart, with these items already checked off - Admit to L&D ADD the attending (SWC vs SMC) - Vitals (per routine) Cycle BPs at least q1hr for pts with ghtn/ PreEclampsia - Activities: bedrest (in active labor) - Nursing: CEFM x 2, strict I/O s if on magnesium - Diet: sips and chips in active labor - IVF: NS or LR See diabetic protocol for IVF Pre-eclampsia and receiving Mg fluid restrict <2400/24 hrs (100cc/hr) this is part of PIH/mag order set - Meds: Fentanyl 100 mcg IV Q1hr PRN x maximum of 3 doses Induction/augmentation agents (cervidil, miso, or pitocin) For Pre-E - Mg 4g loading dose, then 2gm/hr IAL (If Cr 1.0 check with upper level about dose/hr) For DM See protocol for insulin regimen For GBS+ Ampicillin 2g IV loading dose, then 1g q4h until delivery. See section on GBS+ for alternatives 4
Labs: CBC on everyone, T&S per protocol; for Pre-E (CBC, uric acid, AST/ALT, creatinine, UA (straight cath), Urine protein:creatinine ratio this is ordered as urine protein w/creatinine in Powerchart. Laboring Patients Complete OB MD Worksheet Care Form on PowerChart then generate H&P, print discharge prescriptions. Confirm fetal presentation with U/S on ALL new admits. Write progress notes every 2 hours while on Pit, Mag or IAL, every 4 hours if Cervidil or miso and healthy. If doing an exam, tell the nurse before or after. Have someone follow your cervical exams for the first 2 months. 5
Review the fetal central monitors frequently, if there is any concern, SEE the patient and ask another resident or the attending to review the strip with you. For AROM/FSE/IUPC you will always need the nurse present in the room. Update the sign-out on the computer regularly Consent patients for vacuum, forceps, C/S, BTL translators are always available if necessary. Patient signs the pre-printed consent and also write computerized progress note documenting consent Call upper resident and attending for all deliveries. For vacuum, forceps, preterm, twin deliveries upper years get first dibs. Triage/OB Checks 4 key questions: Contractions? Vaginal bleeding? Leakage of fluid/rom? Fetal movement? Confirm dates Date by LMP c/w US? When was US? Review pt s chart! Antepartum issues? Look at BPs. Has the patient had Pre-E labs? Present the case to upper resident. If a continuity patient is to be admitted, notify that resident Common OB check issues and management: LOF/VB: sterile speculum first with water/minimal gel (NO digital exam for previas!) Look for pool, nitrazine swab (or paper), make slide to check for ferning. Decreased FM: Reactive NST, nml AFI, and review kick counts. Arrange for NST/AFI in 3-4 days in PDC. Fax PDC form and give to patient. r/o PreE: cycle BPs, send serum labs and urine. If discharging with 24 hr urine, make sure to add patient to out there, follow up portion of sign out with phone number and MRN. UTI: Remember to send urine for culture and f/u result (put on out there, follow up list). Macrobid 100 mg po bid x 7 days prior to 37 wks Keflex 500 BID x 7 days any GA 6
**what # UTI in preg? Do they need daily suppressive abx after treatment? BV: Clue cells on wet mount, grey discharge with + whiff test. Metronidazole 500mg PO bid for 7 days Yeast: Budding hyphae on KOH. Fluconazole x 1 or Monistat 3 or 7 day course Perinatal Diagnostic Center: Formal ultrasounds, NST/AFI, amniocentesis, CVS, and FLM To schedule: Fill out requisition and FAX to the PDC; include EDC on form. If STAT, call PDC ext. 57030 to let them know about the patient. Give a copy of the requisition to the patient and circle phone #. The patient must call to make the appt. PEARLS 1. GBS + or GBS bacteruria: Ampicillin 2g IV then 1g q4hr until delivery; ideally 2 doses (4 hr) of antibiotics prior to delivery. If PCN allergic: Ask about reaction. If not anaphylactoid, give Kefzol. If anaphylactiod (inc hives), check for sensitivities. Clinda 900mg IV q8h if sensitive, or Vanco 1gm q12h if not clinda sensitive or no sensitivies available. For labor checks, collect a GBS swab if not done already 2. Intrapartum fever VS Chorioamnionitis: Maternal temp >38 WITHOUT fetal or maternal tachycardia. Talk to chief/attg. - One time temp >38ºC in labor without second chorio diagnostic criteria (maternal tachycardia, fetal tachycardia, uterine tenderness, foul smelling AF, or maternal leukocytosis) management options: 1. Treat with Amp and Gent A. May diagnose as either Intrapartum Fever or CHORIO, based on risk factors (ROM status/duration, GBS status, misoprostol, epidural), trajectory of clinical 7
minutes! scenario (maternal temp curve, FHR trend, etc.) B. Inform NICU of final impression at delivery 1. CHORIO- full diagnostic evaluation and empiric antibiotics 2. IP Fever- evaluated clinically: no labs, monitored for infxn signs -- OR -- 2. Repeat the temp in 30 minutes A. NO Tylenol, NO fluid boluses, NO ice packs/cooling blankets!!! B. If still >38ºC, then diagnose CHORIO or IP Fever ; tx w/ Amp & Gent C. If <38.0, may proceed without dx of/tx for chorio CONTINUE to monitor maternal temperature every 30-60 3. Chorioamnionitis treatment: NSVD - Amp 2g IV q6h + Gent daily dosing 5mg/kg x 24h afebrile PP (error msg will pop up in Cerner stating calculated dose too high click OK; pharmacy is used to this dosing in labor) if C/S ADD Clinda 900mg IV q8h to Amp/Gent, x 48h afebrile PP Course begins from first afebrile, not last fever 4. Induction of Labor: Is cervix favorable? Is the patient contracting? If cervical ripening is indicated and contractions LESS than 3 per 10min Cervidil Placed in vagina, left in place x 12h Misoprostol Oral: 50mcg PO, then 100mcg in 4h if still necessary and few contractions If cervix unfavorable and contractions MORE than 3 per 10 min 8
Consider foley bulb filled with 50-60 cc NS. +/- Low-dose Pitocin (max of 10) 5. Augmentation of labor (Induction with favorable cervix and/or frequent contractions) Pitocin Order as Pitocin per protocol, starting dose is 1 milliunit. Low-dose (not to exceed 10 milliunits) is sometimes used for unfavorable cervix with too frequent contractions 6. VBAC: Always consent for C/S and VBAC on admission Review operative note from previous surgery to confirm low transverse uterine incision NO prostaglandins (e.g. NO miso or cervidil). Low-dose pit (generally max of 10 mu) is okay different attgs have different max Pit for VBACs. Most attendings want an FSE placed as soon as feasible. Some will also want an IUPC, so ask. 7. Patients on Magnesium Sulfate: Review BPs, check reflexes, I/O, listen to lungs, follow labs. Ask patient about headaches, blurry vision, scotoma, SOB, RUQ pain. If a Stanford patient, Foley should remain in place x24 hrs PP, even if NSVD (for documentation of I/O). 8. Diabetes: (See Diabetic management protocol in Powerchart) A1GDM: Stanford: FS q4hr in latent labor, q1hr IAL, SMC: Admit FS. No postpartum FS necessary. 2hr GTT at 6wk PP A2GDM: FS q4hr in latent labor, q1hr IAL. Insulin drip if FS > 110. Fasting FS PPD1. Consider FS fasting and AC is suspicion for DM2. 2hr GTT at 6wk PP visit. Type 2 DM: FS q4hr in latent labor, q1hr IAL. Insulin drip if FS > 110. Fasting and AC FS postpartum with sliding scale for FS > 200. Consider 9
restarting pre-pregnancy hypoglycemics, preferable metformin (less risk of hypoglycemia). Type 1 DM: FS q1hr during labor. Insulin drip in labor if FS >70. Postpartum, start insulin at 1/2-1/3 pregnancy dose (ask chief/attg guidance) and check fasting, AC, PC and qhs FS. If pt has insulin pump, usually restart PPD1 or POD1 (when tol reg diet) ***ANY TIME PT IS ON AN INSULIN DRIP, THERE MUST BE D5 RUNNING AS WELL*** 9. Medical Students: Try to get them involved! Easiest to give them specific tasks at first. All notes need to be cosigned. Have them follow and write notes on laboring patients. Multips with epidurals are best for them to deliver. They can see OB checks and write notes. Also remove staples on post-op patients who are going home. L&D progress notes: (use.sigdatetime to date and time all notes) OB R1 Labor PN S: Comfortable/desires pain meds. If pre-eclamptic, any sxs? O: VS (.vitals), If on Mg, also note I/Os, MS, lung exam and DTRs (.io) FHT: baseline, variability, accels/decels Toco: q X minutes; Pitocin @ x SVE: dil / eff / station, position of head if known, +/- caput Labs: If applicable A/P: X yo GxPx @ x weeks by LMP c/w x week US, in active labor/induction for. (.obmaternalid) MWB: AFVSS; if diabetic, fingersticks; if Pre-E, symptoms, etc. Other important maternal issues FWB: Cat X tracing. Other relevant info e.g. fetal anomalies, NICU presence for delivery? Labor: Adequate progress? Meds? Next intervention? Pain: comfortable; epidural/fentanyl 10
GBS: always verify for yourself that they are receiving antibiotics if indicated (.obgbsstatus) Delivery Note: ( make a dotphrase for yourself, amend as necessary!) Pt arrived in active labor/induced/ augmented for. (may include meds used). She progressed to complete rapidly /over x hours, and pushed x hours to deliver. (Note presence of increased BPs, infection, deviations from labor curve, meconium). Infant s head delivered in a controlled fashion/precipitously over IP/MLE, under local/epidural/no anesthesia. Nuchal cord x X (or no nuchal). Anterior shoulder delivered with/without difficulty (if dystocia, note maneuvers used). Posterior shoulder and body followed easily. Cord was clamped and cut, infant to mom/rn/peds. Placenta with 3VC delivered spontaneously and intact/ manually extracted. Describe placental/cord abnormalities, if present. X degree laceration repaired with x-vicryl/monocryl in usual fashion. Describe repair if complicated. If 3 rd or 4 th degree lac, document rectal exam. (If cord gas or placenta sent, document why). Baby to WBN/NICU for Mom to postpartum floor stable. The attending physician, Dr. X, was present and participated directly in the entire procedure. POSTPARTUM OB intern covers the postpartum pages (pager 12225) Transfer this to your pager at start of shift (call page operator at x34000) Ob Intern on Nights: - After midnight print 5 lists for rounding: 1.Yourself, 2. Day intern, 3. SWC attending, 4. SMC attending 5. Kathleen (NP) o Include service, PPD/POD, pertinent complications (chorio/endometritis/gdm/pree). 11
o Assign Kathleen 3-4 Stanford patients who are uncomplicated (A1GDM OK, chorio AFTER abx if have remained afebrile, etc). o CROSS OFF Kathleen s patients from everyone else s lists (attendings do NOT need to see her patients) o Highlight patients to be seen by each recipient of above list (see below who to round on ) - Prep all postpartum notes EXCEPT for those patients to be seen by Kathleen. o Basic note example: 25 yo G2P2002 POD2 s/p PLTCS for arrest of descent 1. RPPC (routine postpartum care) 2. POD1 Hct 28, appropriate given starting Hct and EBL. FeSO4 on discharge. 3. A2GDM: PPD1 FS 96. Pt to have 2h OGTT at 6 wk pp visit. 4. Vaccines: RI, s/p TDap and flu. VNI (varicella nonimmune) varivax ordered postpartum. Postpartum contraception: Mirena at 6 wk visit o o Make sure to advance dates (POD2 POD3). Can start prepping notes before midnight just make sure to advance to the next day s date at 0600. You cannot change the date after submitting the note! o If you make a note with the wrong date, right-click on the body of the note, select Forward click Review in yellow box, To: HIMS, Comment: Created in error, please delete. - Talk to your chief about when to go to PP (F1/F2) to round Who to round on: WEEKDAYS 1. All San Mateo County patients. 12
2. All SWC (Stanford) patients: NP Kathleen will round on uncomplicated NSVD and CS Complicated patient needs to be seen by the intern (In general if patient is on signout they are complicated) 3. Private CS with resident assist (look at CareForm delivery summary in Powerchart). We generally don t write orders on private patients (ask chief or private attending) Simple orders including Tylenol, Motrin, Benadryl, heating pads (KPads) are ok When called about issues (fever, BP, labs): evaluate the patient, run it by upper resident, and usually call the private to discuss plan WEEKENDS: ALL SMC, SWC and private CS - No NP or off-service intern Wound Care Horizontal staples remove on POD4 and place steris o POD3 OK if going home early o Use caution if pt obese, diabetic Vertical staples stay in for 7-10 days post op (i.e. leave in on discharge) o Instruct patient to return to her OB clinic to get staples removed. Include this CLEARLY on discharge summary o Call Deb at clinic (number on signout) to request appointment for patient Prolene (blue permanent suture) remove day of discharge o Make sure long end is free then pull by loop to remove Opsite (placed over subcutaneous sutures) remove prior to discharge 13
o No need to put anything on top POSTPARTUM ISSUES Anemia Anyone with Hct < 30 gets FeSO4 on discharge If Hct<25 consider starting as inpatient once tolerating PO If Hct <20 discuss transfusion with patient Rh Negative RhoGAM PRN pre-selected as part of postpartum orders If indicated (i.e. baby Rh pos) confirm on MAR that RhoGAM given and include on discharge summary Postpartum Contraception safe in breast feeding Micronor ( mini-pill ): Progesterone-only. 1 tab PO QD, start 2 nd Sunday after delivery. 11 refills. Can switch to regular OCPs when no longer breast feeding. No placebo week. Very important to take at same time every day Depo-Provera: 150 mg IM injection Q 3 months. Remind patient that they need to repeat every 3 months. Mirena or Paragard IUD: post-placental or at 6 weeks PP visit Implanon/Nexplanon: PP or at 6 week PP visit Condoms: if patient breastfeeding and refuses all of above encourage at least condoms Vaccinations 1. Rubella non-immune (RNI): MMR prior to d/c. Patients should not become pregnant 1 month after receiving vaccine. 2. Tdap: If no tetanus within 2 years recommended 3. Varicella non-immune: Varivax prior to d/c with booster at 6 week PP visit 14
Document all vaccinations in discharge summary, especially important for SMC patients Postpartum tubal ligations For MediCal must have tubal consent signed 30 days prior to due date If less than 40wks only 3 days prior is okay Consent patient with general surgical consent and document in electronic medical record Postpartum Floor Calls GO see the patient and TALK to your team! 1. Temperature Most everyone treats >38.5 regardless of mode of delivery, for temps 38-38.5 it varies Questions: Mode and time of delivery, was temp repeated, do they have chorio, or did they get miso (this frequently causes a temp)? Patient Evaluation: Does pt look sick? Breast tenderness? Lungs clear? CVAT or suprapubic tenderness? Uterine tenderness? Wound cellulitis? Calf tenderness/swelling (DVTs)? Possibe studies: CBC, Cath UA and C&S, CXR, Tylenol 650-1000mg PO q6 prn fever For presumed endomyometritis (temp with fundal tenderness >24h PP): Gentamicin 5 mg/kg q24h Clindamycin 900mg IV q8 +/- Ampicillin 2 g IV q6hours *** Treat with antibiotics until afebrile (T<38) >48 hours from first time afebrile (not last fever). 2. Low HCT: 15
If <20 need to go see patient to evaluate for transfusion Patient Evaluation: Vitals, orthostatics, urine output, symptoms, ongoing bleeding. Treatment: Consider transfusion (usually if Hct <20 or symptomatic), rechecking Hct, and FeSo4 3. Bleeding Questions: How much blood, mode of delivery, EBL/QBL, vitals, orthostatics, urine output Patient Evaluation: Look at quantity of blood yourself, and if concerning call upper level to do pelvic and remove clots, membranes, and/or administer meds. Treatment: Pitocin, methergine (if normal BPs), hemabate (if not asthmatic), or miso buccal. Consider Keflex 1 g if you perform manual extraction on the floor. 4. UTI Symptoms Cath UA, urine culture (follow up final culture) If positive treat with Keflex 500mg PO QID x 5-7 days 5. Anuria or low UOP Bolus LR or NS 500-1000mL. (Do not bolus pts on Magnesium or with cardiopulm disease), strict I/Os, if low (<30cc/h) may straight cath with Foley to check for urinary retention. 6. Urinary rentention If pt has not voided for 4-6hrs s/p Foley removal: straight cath with Foley if > 250cc urine leave Foley in place for 24 hours of bladder rest. Voiding trial the next day: if pt fails, may need d/c with Foley plus leg bag with teaching and outpatient f/u for removal 6. Magnesium 16
Ask about scotoma, RUQ pain, headache. Check I/Os, DTRs, Lungs Common Mag Calls: Can we decrease frequency of vitals? Question: What have UOP and vitals been like? May go from vitals q1 to q2, etc. Is the patient Mag toxic? The patient is very groggy should we decrease the Mag? Go evaluate patient, do PE and check vitals. What are her UOP and Cr (if > 1.0 need to decrease)? Check Mag level and consider decreasing to 1.5g/hr or 1g/hr 7. Elevated BPs Questions: Any severe range (>160/105)? Trend BPs? New onset or ongoing problem? Does patient have preeclampsia, ghtn, chtn? Treatment: We treat BPs SBP>160 DBP>105. Please note these numbers vary according to attending. If the BP is new we may want to get labs to evaluate for Pre-E. Severe range blood pressure Ask RN to repeat reading in 10 minutes and to prepare to give IV meds at that time. If still > 160/> 105, IV push is necessary: Labetalol OR Hydralazine. We usually start with Labetalol. o Labetalol 20 mg IV 40 mg 80 mg 80 mg. Labetalol should be pushed slowly (over 2 min ideally). o Hydralazine 5 10 mg doses q 15 min After first IVP, ask RN to check vitals q 15 min x 1 hr, then q 30 min for the following 2 hrs. If persistently elevated BPs, continue along algorithm as above. Wait 15-20 minutes after Hydral to allow for BP change before giving another dose. If NO IV access and severe range BPs, can give PO Labetalol 200 mg OR PO Nifedipine 30 mg (short-acting) while RNs get IV access. 17
Discharging NSVDs 1. Discharge home on PPD2, encourage multips to go home PPD1 (at least 24 hours since infant s birth) 2. Discharge prescriptions: Colace 100 mg po bid prn (#60, 3 refills) Motrin 600 mg po q6h prn (#30, no refills) Cont PNV if breastfeeding FeSO4 BID if Hct <30 Micronor if desired PO antihypertensives if on a regimen in-house Discharging C-sections 1. POD3 or 4 after passing flatus and tolerating reg diet. Remove staples (unless vertical or pt obese, diabetic), prolene or opsite. 2. Discharge Rx: As above plus Norco or Percocet 5/325 or Vicodin 5/500 1-2 tabs po q4-6 hours pm pain (#30, no refills) Percocet MUST go on hand written Rx (get from upper level resident) Discharge Summaries 1. Create discharge summary for patients who receive a transfusion, are hospitalized longer than PPD2 or POD4, or received IV BP meds. Use your judgement if a patient has a complex course, it is helpful to outside and future providers to have a clear hospital course. 2. All patients previously on AP who then deliver that admission: copy and paste AP course from signout into CareForm (ask your 2 nd year to edit if needed). You add the postpartum course. 3. If a patient was transferred from OSH be sure to send discharge summary to outside provider. 18
Signing Out Post-Partum Sign out complex patients or those that need follow-up by the oncoming team. No need to go over FYIs. -DO sign out: pree, DM1, DM2, chorio/endometritis, PPH, wound complications -NOT necessary to sign out: FS for A2GDM, SW, or vaccinations; just confirm that the order is in *********************************************** CONSENTING BLOOD TRANSFUSION RISK HIV less than 1/2,000,000 Hepatitis C less than 1/2,000,000 Hepatitis B 1/500,000 SAMPLE C-SECTION CONSENT I discussed with the patient the risks, benefits, and alternatives of a Cesarean section. I explained to the patient there is a risk of infection and damage to internal organs including bladder, bowel, ureters, blood vessels, and nerves. I also explained to the patient there is a risk of bleeding which may require a blood transfusion or in rare cases a hysterectomy. I explained that the risks of a blood transfusion include the risks of the transmission of HIV (<1/2,000,000), Hepatitis C (<1/2,000,000), or Hepatitis B (1/500,000). The patient demonstrated understanding and all questions were answered. Consent signed. SAMPLE BILATERAL TUBAL LIGATION CONSENT 19
I discussed with the patient the risks, benefits, and alternatives of a bilateral tubal ligation. I explained to the patient that this is a method of permanent sterilization but does have a failure rate of 3-5/1000. I explained to the patient that if she does become pregnant after a tubal ligation she is at increased risk of an ectopic pregnancy and should be evaluated by a physician immediately. I explained to the patient there is a risk of infection and damage to internal organs including bladder, bowel, ureters, blood vessels, and nerves. I also explained to the patient there is a risk of bleeding which may require a blood transfusion. I explained that the risks of a blood transfusion include the risks of the transmission of HIV (<1/2,000,000), Hepatitis C (<1/2,000,000), or Hepatitis B (1/500,000). The patient demonstrated understanding and all questions were answered. Consents signed. Gyn-Onc AM To Do: 1. Call R2 NF for sign out 222-7965, always by 6:15am or earlier 2. Call 288 (operator) to transfer pager #12825 to your pager # 3. Print sign-out off secure workspace: obgynresidents.stanford.edu 4. Print Rounding Report from epic 5. Circle abnormal vitals, note pain meds used, note Is and Os by shift 6. Copy Rounding Report for each member of team 7. Prep inpatient progress notes (if time and depending on team) Admissions and D/Cs 1. Admissions must have H&Ps. Use gyn-onc order sets and templates in EPIC for admission 2. For discharges: Use discharge tab in Epic. 20
First do general discharge order set. Include day and night contact numbers for the patient. Day # 498-6000, Night 723-4000 and ask for gynonc doctor on call (.oncfu) Next do discharge summary. You can cut and paste course from sign out into Hospital course but change wording to make it understandable (e.g. spell out abbreviations). (.gyndischarge) All new meds or refills needed. Narcotics will require secure (paper) Rx from upper resident Clinics (M,W,F) 1. Clinic notes can be done in EPIC or dictated. Ask you chief which attendings want new patients dictated. Send note to referring MD. 2. Do as much floor work as possible from clinic. This is the interns 1 st priority. Orders, lab f/u, updates from nurses, etc. 3. For clinic patients: See the patient, get history and brief PE, then present to the attending (they will do pelvic/breast exams with you). 4. Try to finish clinic notes that evening (for Berek this is a must, for other attendings by the end of week is ok) Tumor Board (Fridays at 7:30) 1. Patients are most OR patients from the previous week and some new patients from clinic. Ask your chief or fellow. 2. Each patient is presented with their identifying info (age, type of cancer, stage) and a summary of their tumor history: a. Key events radiology and pathology b. Surgeries c. Chemo/Radiation d. Brief: PMHx, PSHx, ObGHx, Meds, FH, SH **look at previous TBs and the team will help you too** 4. Pathology slides have accession numbers which are listed in the computer. 21
5. For recent pathology, call Surgical Pathology (across from 2 nd floor escalators) and request new accession numbers. If you call the hot seat pathologist for a prelim read, just indicate that the pathology is pending and for review in the Tumor Board document 6.Outside radiology studies need to be submitted to radiology and scanned in. Ultimately your job but frequently clinic RNs Joanne and Cherie will help. 7. Send a copy of tumor board to Helen Wong hswong@stanford.edu by Wed at 4:30pm to distribute Weekly Schedule: Wear scrubs on OR days, clinic attire (business casual) on clinic days. All clinic is on the first floor of Blake Wilbur The intern must go to Multi-Disciplinary Rounds (MDRs) at 11:30 in the am conference room daily (except Monday fellow goes during chairman rounds) and sign-in. This is a meeting with case management, charge RN, SW- keep discharge needs/planning in mind. Monday (Dorigo/MacLaughlan clinic) 1. Grand rounds and lecture 7:30 11:30 am, transfer pager to fellow during this time 2. Chair Rounds 11:30 am 3. Sign-out at 1830 Tuesday (OR Day) 1. Facilitate patients going to the OR 2. Floor work: update discharge summaries, check labs, etc. 3. For urgent patient questions, go to or call into the OR, or ask upper residents 22
4. Post-op checks: Approx. 4h after procedure. Include vitals, fluids (I/Os), meds (esp. pain) 5. Work on Tumor Board. Just do it. Prep new patients for Wed clinic. 6. Signout at 1730 Wednesday (Teng/Berek Clinic) 1. Strip rounds or journal club 7:30 8:30AM 2. Clinic with Dr. Teng/ Berek (1 st floor Blake Wilbur), this clinic often goes late 3. Finalize Tumor Board Email Tumor Board to hswong@stanford.edu by 4:30pm 4. Signout at 1730 Thursday (OR Day) Just like Tuesdays. Prep new patients for Friday clinic. Sign-out at 1830. Friday (TBD) 1. Tumor Board 7:30AM 1. Clinic in Blake Wilbur 1 st floor 2. Signout at 1730 Helpful Hints: 1. Gyn Onc Pager: 12825 2. Chemo patients admitted to FGr or EGr 3. All other patients preferably go to F3 4. Replacing electrolytes Phosphorus: Phos NAK packets Magnesium: Mag Sulfate IV 8 meq is 1g, so order 8 or 16 Potassium: 10 meq IV will raise K by 0.1 replaced K <4.0 (order IV 2% lidocaine too! Potassium repletion stings) Calcium: Calcium gluconate 1g IV 6. Hct <30, consider transfusion discuss with chief (1 units PRBCs should increase Hb by 1 and Hct by 3) 23
7. IVF: D5 1/2NS + 20 meq K@ 125 cc/h (routine fluid orders postop or NPO) Sample Gyn Onc Note EPIC ** Click Notes tab on left, New Note. (.gyn) and chose gyn progress note. This will bring up a template and import all vitals, labs, and meds. Review imports and add interval history and plan. R1 Gyn Onc PN POD#1, HD#2 Interval History: Pain, flatus, nausea, vomiting, diet, SOB, etc. O: Filled in by EPIC. Review, especially I/O and drain output PE: Gen: does the patient look uncomfortable, is she alert, awake, and oriented? Neck: look at the line sites: is there erythema, warmth, bruising? Heart: rate, rhythm, murmurs.. Lungs: listen sitting up or patient rolled to side; crackles? Decreased breath sounds? Abdomen: look for distention, ascites; listen for bowel sounds; check ostomy sites, color of output Wound: check site for erythema, warmth, bruising, etc. if would is being packed remove packing and note granulation tissue, pus, fluid, bleeding, foul smell, etc. (allow extra time for packing wounds!) Extremities: check to see that TEDs/SCDs are placed, look for tenderness, edema Labs: imported by Epic (.rrcbc,.rrbmp, etc) Radiographic Studies: imported by Epic Pathology: Look up any pending pathology 24
A/P: ##yo with [diagnosis] s/p [surgery] etc. Onc: Brief dx, course, intraop findings pathology Pain: note PCA or oral meds Heme: note pt s last Hct, if any transfusions needed, epogen; note if pt has thrombocytopenia ID: note if pt has temperature spike, work-up involved, day of antibiotics; pending micro CV: Treatment of HTN, arrhythmias, chest pain, etc Resp: note saturations and oxygen requirements, and interventions needed for SOB, effusions, etc GI: note the patient s diet, if she is on GI prophylaxis (pepcid), stool softeners, if has NGT, tx for nausea/vomiting FEN: note plan for chem., labs, TPN, IVF, etc Endo: note if diabetic, has thyroid disease, meds PPx: note if pt has TEDs/SCDs, heparin, lovenox Dispo: discharge plan, SW or case manager consult if needed Dr. MacLaughlan has specific laproscopic post-op orders as follows: Post-op orders for minimally invasive hysterectomies +/- staging: (includes robotic and straight stick laparoscopy) Activity: Night of surgery - out of bed to chair OR sit up in bed with legs dangling. Ambulate in am POD1. SCDs while in bed. Nursing: at 6am on POD1 (assuming adequate urine output), backfill bladder and d/c foley. If no void in 30 minutes, notify housestaff. Resist replacing foley. Diet: regular IVF: maintenance fluid as indicated. Heplock patient when tolerating po. If patient is drinking at time of post-op check, has adequate UOP and labs are OK, make sure fluids are stopped. Patients often get a lot of fluid during a 25
long case, but have lower insensible losses. The relative fluid overload can slow down their ability to get out of bed and have return of bowel function. Meds: Toradol 30mg IV scheduled q 6 hours x 24 hours (in most patients) Ibuprofen 600 mg po q 6 hours scheduled starting on POD2 Zofran reglan (no phenergan makes them too sedated) Percocet prn dilaudid/morphine (small doses) prn. No PCA lovenox only if patient not going home on POD1 Labs: post-op labs 6 hours after surgery gives you time to replete/tweak if necessary and still have an am d/c US/REI ROTATION WEEKLY SCHEDULE The PDC is located directly next to F3. Arrive at PDC at 8am, finish by 5pm. The REI clinic is located at 900 Welch Road. Arrive at 8am, finished by 5pm. AM Monday Tuesday Wednesday Thursday Friday Grand Rounds Lectures REI PDC US PDC US REI PM PDC US PDC US PDC US PDC US PDC US OUTPATIENT GYNECOLOGY ROTATION For GYN clinic days (at Stanford), review the clinic schedule made by the chiefs to see what attending you are assigned that day. Check the ambulatory schedule that was emailed out for your exact schedules! 26
In general the GYNC-1 Rotation is similar to the example below, but depending if there are other residents on clinic rotations, some clinic schedules will vary! AM PM Monday Tuesday Wednesday Thursday Friday Grand Gyn Clinic GYN Planned Gyn Clinic Rounds Parenthood Family REI Castro Commons Planned Gyn Clinic Practice* Parenthood GYN-C2 is a little different. You start your continuity clinic and you go to the VA. Again, check the ambulatory schedule. AM PM Monday Tuesday Wednesday Thursday Friday Grand Gyn Clinic GYN Planned Continuity Rounds Parenthood Clinic VA Gyn REI Castro Commons Planned Gyn Clinic Clinic Parenthood GYN clinic: Blake Wilbur Basement REI 900 Welch Road Planned Parenthood: 1691 The Alameda, San Jose, CA Continuity clinic: OB or GYN every other week starting in January OB: 770 Welch Road GYN: Blake Wilber, basement VA: 3801 Miranda Avenue, Palo Alto, CA 94304 - Women s Clinic is in bldg 5, toward the back of the VA complex. Work with Dr. Ed Cohen Castro Commons: 1174 Castro Street, Suite 250 Mountain View, CA 94040 27
*Family Practice *** PLEASE EMAIL DR. TRACY RYDEL at least one week before your rotation starts! 3 rd Floor Blake Wilbur Some Tips for Peds GYN clinic (Castro Commons) from Dr. Hillard: 1. This is NOT PEDIATRICS 2. This is NOT ADULT GYNECOLOGY 3. This is NOT ADOLESCENT MEDICINE It is a (usually) a busy consultative service in which there are specific expectations, based on many, many years of experience in working with adolescent girls, young girls, mothers and families, pediatric residents, gynecology residents, and medical students. I must balance the needs of my patients, their families, and the teaching/ learning environment. This means that I will ask you to do things in some very specific ways that often are different from the style that you may be accustomed to. Please ALWAYS introduce yourself to me at the beginning of the clinic session (Name, rank, serial #--just kidding), but please give me your name first and last, what you prefer to be called, and what type and year resident/student you are. While I may have met you before, I really do work with MANY residents and students ob/gyn, pediatrics, family medicine, internal medicine, plus Stanford medical students from year 1-6/7+, plus undergraduate students. Thus your name or level of study may escape me. Also, I do like to know where you re headed in your career primary care, hospitalist, specific peds subspecialty, etc. I would like very much to tailor my teaching to your needs. I will ask you as well what your objectives for the session are, in an effort to try to meet those objectives. However, some objectives are not realistic or achievable during your limited time with me. If it is your objective to learn how to better perform a pelvic examination, I will tell you that this is a laudable goal, but not one that we can realistically achieve in one 4 hour 28
session of pediatric and adolescent gynecology. This is a more realistic goal for your adult gynecology rotation. Many times in this referral clinic, a gyn exam will not be performed (for a variety of reasons that we can discuss). When it is required, it is more likely to be in association with specific symptoms that require a specific technique, or it is a first gynecologic exam where my bias is that a young woman deserves the MOST EXPERIENCED examiner. It is also my bias that you can learn techniques and tricks of the trade from observing an exam. On the first day of your clinic experience, please arrive about 15 minutes earlier than the first patient is scheduled. We will virtually ALWAYS have 0830 patients (in which case, I need you to arrive at 0815, and we sometimes have 0800 patients, so please check the schedule prior to the first day in clinic. The presentation format is one that is essential to be able to think logically about a gyn patient s complaints. As an identifying sentence, I need to know: NAME, age, G P, LMP, whether currently or ever sexually active, current hormonal therapy/contraception, and reason for the visit. Sometimes I ask staged questions that some may view as pimping ---I hope that you can think about the answers, and view them as an opportunity to learn and consolidate knowledge. I ask you to think, and perhaps the exercise will help you remember. 5 symptoms of early pregnancy 6 descriptors of the uterus on exam Diagnostic criteria for PCOS Causes of hirsutism/hyperandrogenemia other than PCOS OB CONTINUITY CLINIC 29
You will be starting you OB and GYN continuity clinics in January. Each week you will alternate OB and GYN clinics. Check AMION clinic tab to see what clinic you are scheduled to be in Prenatal visit frequency Visits q 4 weeks until 28 weeks, q 2-4 weeks from 28-36 weeks, weekly visits starting at 35-37 weeks More frequent visits for high risk Pregnancy Dating Good dating by ACOG criteria US at less than 20 weeks of gestation supports gestational age of 39 weeks or greater. Fetal heart tones have been documented as present for 30 weeks by Doppler ultrasonography. It has been 36 weeks since a positive serum or urine HCG pregnancy test result. Weight Gain Guidelines (for singletons, no guidelines exist for multiples) Normal-weight (BMI 18.5-24.9): Gain 25-35 pounds Overweight (BMI 25 to 29.9): Gain 15 to 25 pounds Obese (BMI of 30): Gain 11 to 20 pounds Underweight (BMI < 18.5): Gain 28 to 40 pounds. Nutritional Requirements Iron: 27 elemental mg q day. Found in most PNV. Add 65 mg bid for anemia (hematocrit less than 30-32 percent) Folic acid: 600 mcg Calcium: 1000 mg q day. Give supplemental Ca for pt with low dairy intake 30
Labs/Routine tests First trimester labs: CBC, T+S, rubella, varicella, HbsAg, syphillis, HIV, pap, GC/CT and urine culture Tuberculosis screening: PPD not contraindicated in pregnancy; SMC is using quantiferon. Third trimester labs: Repeat CBC 24-28 weeks, GBS swab 35-37 weeks Genetic Screening CF screening on all pts who have not previously been screened; Tay sachs / ashplex panel for Ashkenazi Jewish patients Stepwise Sequential screening 95% detection rate 1 st trimester: Serum testing and Nuchal translucency (now covered for all patients) Serum testing includes Pregnancy associated plasma protein-a (PAPP-A) and free bhcg Serum testing done between 10wk 0 days -13wk 6 days; sono for NT done between 11 wk 2 days and 14 wk 2 days. If positive, diagnostic test offered (CVS / amniocentesis ) If negative, second trimester test offered (Quad Screen ) Dates for first and second trimester serum screening are based on early ultrasound CRL dates even if EDC not revised 2 nd trimester: Quad screen Roughly between 15-20 weeks (exact date range given to pt by genetic counselors after first trimester screen) Includes MSAFP, inhibin A, unconjugated estriol and hcg Screens for T21, T18, neural tube defects and SLOS ( Smith Lemli Opitz Syndrome) Diagnostic Genetic Testing CVS: Between 10-12 weeks. Cannot diagnose NTD. 31
Amnio: Around 16 weeks. Can test for anueploidy, NTD, and blood type. Loss after amnio is quoted as < 1 %. Ensure Rh negative patients have been given Rhogam after CVS or amniocentesis. Vaccines Recommended during pregnancy: Influenza, H1N1 vaccines, Tdap OK in pregnancy, if needed: hepatitis B, pneumococcal (for pts with h/o splenectomy) Contraindicated in pregnancy: any live attenuated vaccines, e.g. MMR, varicella Food restrictions No raw fish, undercooked meats Avoid poorly refrigerated deli products (source of listeria), and unpasteurized dairy products/juices Wash raw vegetables and fruits well Avoid ocean fish with high mercury content: shark, swordfish, king mackerel, tilefish, albacore tuna (light tuna okay) Total fish consumption per week should be < 12 ounces. Exercise in Pregnancy In the absence of complications, 30 minutes of moderate exercise daily is recommended. Avoid supine exercises. Do not initiate high intensity exercise once pregnant Decrease activity in 2 nd -3 rd trimester with h/o preterm labor or IUGR Isoimmunization in Pregnancy All RH negative patients should receive 300 mcg of Rhogam around 28 weeks, and in the following circumstances: Ectopic, Abortion (threatened, spontaneous or induced) CVS or amniocentesis 32
Abruption, abdominal trauma Excessive vaginal bleeding at delivery Infant that is RH+ Antenatal testing (NST, AFI, BPP, umbilical artery dopplers) Indications include Maternal disease: SLE, APLAS, coagulation disorders, heart or renal disease, insulin requiring DM, GHTN, mild Pre-eclampsia, Hemoglobinopathies, poorly controlled asthma, heavy tobacco use, abnormal serum markers on 1 st /2 nd trimester testing, maternal age >40. Fetal indications: Decreased FM, Oligo/polyhydramnios, IUGR, Isoimmunization, Multiple gestations, post dates pregnancy (after 40 weeks) BPP: includes NST, AFI (pocket > 2cm), fetal movement (3 or more discrete body/limb movements within 30 minutes), fetal breathing (1 or more episodes of breathing for 30 seconds in 30 minutes), fetal tone (One or more episodes of fetal extremity extension with return to flexion within 30 minutes). 8-10: reassuring 6-8: proceed with delivery if term or close monitoring if preterm <4 nonreassuring Start around 32-34 weeks for most high risk conditions Repeated weekly, or even twice weekly in higher risk situations Chance of IUFD after normal NST is < 3/1000 and < 0.8/1000 after BPP 8-10. Kick counts: Start at 32 weeks. Perception of 10 fetal movements over 1 hr (or 5 movements in 30 mins) is reassuring. Done once daily; periods of decreased fetal movement normally happen throughout the day and can last up to 4-6 hours. Call L&D if they do not perceive the minimum fetal activity or the baby is not moving as much as usual. 33
Miscellaneous Work: Until delivery if pregnancy is uncomplicated, and disability not covered until at least 36 weeks. Air travel: Restrictions start at about 36 weeks to avoid onset of labor while travelling. Many airlines require a letter once they are visibly pregnant. Ambulate when able in flight or wear SCDs to decrease the risk of DVT. Provide emergency signs and symptoms sheet with L&D contact info once they are 20 weeks. 34
Ob-Gyn Medical Spanish Quickie L&D H&P: How old are you? Cuántos años tiene usted? Gravida? (ie, How many pregnancies have you had?) Cuántos embarazos ha tenido? Para? Cuantos ninos viven? Other pregnancies/miscarriages? Ha tenido malpartos/abortos/ectopicos? When was the first day of your last period? Cuándo fué el primer día de su última regla (menstruación, periodo)? What is your due date? Cuándo será su fecha de parto? Ultrasound? When first? Cuando fue so primer ultrasonido? Why did you come to the hospital? Porque ha venido al hospital? Have you been going to clinic? How many times? Which clinic? How often were they once they became regular? 35
Con que frecuencia se presentaron los dolores una vez que empezaron a venirle regularmente? How often are your pains? Cada cuánto tiempo le dan los dolores? How long do they last? Cuánto le duran? Have you had any bleeding? Ha sangrado? Was it pinkish or bright red? Fué de color rosado o rojo? How much? A cupful? A tablespoonful? A teaspoonful? Cuánta sangre? Una taza? Una cucharada? Una cucharadita? Are you passing clots? Very large? Le salen coágulos? Muy grandes? Did your membranes rupture? Has your bag of waters broken? Se le reventó la bolsa de agua? Se le reventó la fuente? What time did it break? A qué hora se le reventó? How much water did you lose? Down the legs? Cuánta agua perdió? Le mojó las piernas? Your cervix is dilated to 3 centimeters. Su cuello tiene tres centímetros de dilatación. Your cervix is not dilated. Su cuello no está dilatado (abierto). You are in labor. Your membranes have ruptured. Está en trabajo de parto. Su fuente está rota. Obstetric History Have you had any problems with past pregnancies? Ha tenido problemas con sus embarazos pasados? Bleeding? Hypertension? Toxemia? Tuvo sangrado? Tuvo alta presión de sangre? Tuvo toxemia? How many children have you had? Cuántos niños ha tenido? Are they all living? Están todos vivos? What was the cause of death? At what age? Cuál fue la causa de muerte? A qué edad? Were any born early (premature)? Ha tenido usted algun niño prematuro? 36
What year were they born? En que año nacieron? Was s/he born vaginal or by cesarean? El naciemiento fué normal (por la vagina) o por cesárea? How much did they weigh @ birth? Cuánto pesó el bebé al nacer? Have you ever had a miscarriage? Ha tenido usted algún malparto un aborto o perdió algún embarazo? Have you ever had an abortion? Ha tenido un aborto provocado? Have you ever had an ectopic (tubal) pregnancy? Ha tenido un embarazo ectópico (embarazo en la trompa)? Have you ever had a stillborn? Ha tenido un niño qué nació muerto? Have you ever had a cesarean section? Ha tenido usted una operación cesárea? Why? What date? Porqué? En qué fecha? HTN? Bleeding? Too large baby? Alta presión? Sangrado? Bebé demasiado grande? Narrow pelvis? Fatigue? Breech? Pelvis estrecha? Fatiga? Bebé sentado? Your cervix wouldn t open? El cuello de la matriz no se abrió? What was the date of your last pregnancy? En qué fecha fué su último embarazo? What was the weight of your largest (smallest) baby? Cuánto peso su bebé más grande (pequeño) al nacer? After birth, any problems with the children? like birth defects? Mental retardation? Algun niño tuvo defectos de nacimiento? Retraso mental? What was the cause of death? At what age? De qué murió su niño? A qué edad? Past Medical History, Past Surgical History Do you have any medical problems? Tiene usted algún problema médico? Hypertension? Alta presión? Heart disease? Enfermedad del corazón? Asthma/Tuberculosis? Asma/tuberculosis? Problems with your kidneys, urine infections, liver, hepatitis, diabetes, thyroid disease, seizures, or cancer (colon, breast)? 37
Problemas con riñones, infección de orina, hígado, hepatitis, diabetes, enfermedad de la tiroides, convulsiones (ataques) o cáncer (de los intestinos, senos/pechos)? Have you had any operations? Ha tenido alguna operación (cirugía)? Past Gynecologic History What do you use for birth control? Qué typo de anticonceptivo usa? Have you ever had a sexually transmitted infection? Ha tenido alguna venérea enfermedad? Have you ever had an abnormal pap smear? Ha tenido un papanicolao anormal (malo)? When was your last pap? Cuando fué su último papanicolao? Are your periods regular? Are they light, medium, or heavy? Le viene la regla normal cada mes? Leve, normal, o abundante? Do you get cramps with your period? Le da cólico con su regla? On a scale of 1 to 10, 1 being very mild pain and 10 being very strong pain, how bad is your pain? Del uno al diez, el uno siendo muy leve, y el diez muy fuerte, que número le daría a su dolor? When was your last mammogram? Cuándo fue su última mamografía? Social History, Meds, Allergies, Family History Do you smoke, drink or do any drugs? Fuma cigarrillos? Bebe alcool? Usa drogas? With whom do you live? Con quién vive? Is there violence in your home? Hay violencia en su casa? Do you take any medicines? Está tomando medicinas? Do you have any allergies? Tiene usted alguna alergia? Has anyone in your family had? Alguien en su familia ha tenido? See above for conditions. Return OB Visit Have you had any problems with this pregnancy? Ha tenido algún problema con éste embarazo? Have you been vomiting? Ha estado vomitando? 38
Have you had any infections? Of what? Ha tenido alguna infección? De qué? Have you felt the baby move yet? Ha sentido que su niño se mueve? Has the baby been moving normally? Se ha movido bastante su niño? Have you had painful urination? Ha tenido dolor al orinar? Have you had the urge to urinate often? Tiene ganas de orinar muy a menudo? Have you spots/starts in front of your eyes? Ha notado manchas enfrente de los ojos? Have you had severe headaches? Ha tenido dolores de cabeza fuertes? How many times a week? Cuántas veces en una semana? Have you had swelling of both hands, face, legs? Se le han hinchado las manos, la cara, las piernas? Can you use/wear your rings? Puede ponerse sus anillos? Go to L&D if: you have vaginal bleeding; your water breaks; (if preterm)you have >6 contractions per hour; you are have regular contractions every 5 (if full-term); or if the baby isn t moving for >8h even though you ate something. Vaya al hospital se tiene sangrado vaginal, si se rompe su fuente, si tiene más de seis contracciones en una hora, si tiene contracciones regulares cada cinco minutos, si el bebé no se mueve por más de ocho horas, aunque ha ya comido. Instructions You are going to stay in the hospital. Se va a quedar en el hospital. You may go home. Se puede ir a casa. You are in early labor. Está en la primera parte del parto. Stay at the hospital and walk for two hours. Quédese aquí en el hospital y camine por dos horas. The heartrate of the baby is normal. El corazón del niño está normal. Take off your clothes. Quítese la ropa. 39
Take off your panties. Quítese su ropa interior (panteletas). I am going to examine you. Voy a examinarla. Bend your knees. Doble las rodillas. Open your legs. Abra las piernas. Put your feet together. Junte los pies. Relax your body. Descanse (relaje) el cuerpo. Lie down on your back. Acuéstese en su espalda. (Acuéstese boca arriba). Lie down on your right (left) side. Acuéstese de lado derecho (izquierdo). Move down on the table. Bájese. Move. Muévase. Don t push. No empuje. Breath through your mouth. Respire por la boca. Push with your pains. Empuje cuando sienta dolor. Do you understand? Comprende? Congratulations. You have a baby girl (boy). Felicitaciones. Es una niña (un niño). Anatomy Abdomen el abdomen/vientre, la barriga Appendix el apéndice (ruptured) (reventada/roto) Head la cabeza Breasts los senos Nipple el pezón Butt las sentaderas Rectum el recto Bladder la vejiga Vagina la vagina Cervix el cervix, el cuello de la matriz Uterus el útero, la matriz Fallopian tubes las trompas (los tubos) Ovaries los ovarios Cyst el quiste 40
Other Mild Leve Medium Mediando Heavy Abundante Severe Severo/Fuerte Postpartum/Post-Operative: How do you feel? Como se siente? Have you passed gas? Ha pasado gas por detras? Have you had a bowel movement? Ha pasado excremento? Are you dizzy when you stand up? Tiene mareas cuando levanta? Do you feel pain? Nausea? Vomiting? Siente dolor? Tiene nausea? Vomito? Are you having vaginal bleeding? Is it heavy? It s normal to have a bloody vaginal discharge for up to 6 weeks postpartum. Tiene sangre por la vagina? Sangra demasiado? Es normal a tener flujo con sangre por la vagina hasta seis semanas despues el nacimiento. You had the kind of c-section that you can try to have your next baby vaginally. Ha tenido el typo de cesarea despues que puede tener su proximo bebe por la vagina. You had the kind of c-section that you should not try to have vaginal birth again. You need to have c-sections for all your future deliveries. Ha tenido el typo de cesarea despues que is importante que no trata a tener bebes por la vagina. Necesita tener cesareas por todo sus embarazos en el futuro. When the baby delivered, your anal sphincter tore. You must be careful not to strain too much or have constipation so that you don t tear out your stitches. Cuando el bebe salio, a rompado su ano. Necesita cuidarse para no hacer demasiado fuerza o a tener estrenimiento para no romper las puntadas en su ano. Your stitches will dissolve. Sus puntadas van dessolver naturalmente. What do you want to use for birth control? Que quiere usar para anticonceptivo? Condoms? Birth Control Pills? Three-month shot? IUD? Patch? Condones? Pastillas anticonceptivas? La inyecion de tres meses? El dispositivo? El parche? We recommend that you not have sex until after your 6 week checkup. Recommendamos a no tener relaciones por las seis semanas hasta su cita en la clinica. 41
If you use condoms, you must have lubrication by the bedside because it is very common after having a baby to have more vaginal dryness. If you have sex without enough lubrication, you may get vaginal irritation. Si usa condones, necesita tener lubrication al lado de la cama porque es muy commun despues un nacimiento a estar seco en la vagina. Si tiene relaciones sin bastanta lubrication, puede tener irritacion en la vagina. If you use Birth Control Pills or Patch, you should wait until the 3 rd Sunday after you had the baby to start them. Si usa las pastillas anticonceptivas o el parche, necesita esperar hasta el tercer domingo despues el nacimiento para empezarlos. If you have the 3-month shot, you can get it before you leave the hospital. Si quiere la inyeccion, puede receberlo antes de salir el hospital. If you have the IUD, you should not have sex until your doctor can put it in, after your 6 week checkup. Si quiere el dispositivo, es important que no tenga relaciones antes de su cita a seis semanas cuando su doctor puede ponerlo. You can get the 3-month shot once, to cover you until you can get your IUD. Puede receber la inyeccion de tres meses una vez para cubrir usted hasta puede receber el dispositivo. With the patch, 1 patch is for 1 week. Each Sunday, you put on a new patch. You wear it 3 weeks on, 1 week off. You should have your period the week you have it off. You must remember to start it the next Sunday after your patch-free week. Con el parche, un parche es por una semana. Cada domingo, ponga un parche nuevo. Tiene tres semanas con parche, una semana sin parche. Va tener la regla durante la cuarto semana cuando no usa el parche. Necesita recordar a empezar el parche otra vez despues la semana sin parche. If you are breastfeeding and want oral contraceptives, we usually give the progestin-only pill to not decrease your breastmilk. This pill is weaker than the regular pill and you cannot be late in taking it. You must take it the same time everyday or you may get pregnant. If you miss it, you should use condoms. Si el bebe come por el pecho y quiere pastillas anticonceptivas, damos la pastilla con solamente progestin (no estrogen) para no disminuer la leche. Este pastilla es mas leve que la pastilla regular, y no puede tomarlo tarde. Necesita tomarlo al mismo tiempo cada dia o puede embarasarse. Si olvida su pastilla, necesita usar condones por un mes en addicion a las pastillas. The regular birth control pill and the patch may diminish your breastmilk production. The 3-month shot and the IUD should not affect your breastmilk production. You may want to start with the 3-month shot, and switch over at your 6 week checkup when you know your milk supply is well-established. La pastilla anticonceptiva regular y el parche pueden disminuer la leche. La inyeccion de tres meses y el dispositivo no affectan la leche. Puede empazar con la inyeccion, y a su cita de seis semanas, puede cambiar a otro metodo cuando esta segura que su leche viene bien. Breastfeeding is very good for the baby. Breastfeeding is easier and cheaper than bottle-feeding. Breastfed babies have less infections than formula-fed babies. A comer por el pecho es muy bien por el bebe. Comer por el pecho es mas facil y mas barato que toma botella. Bebes quien come por el pecho tienen menos infecciones que bebes quien toma bottella. 42
You have anemia. You must take iron to build your blood supply up. You will feel stronger (less weak) if you do. Tiene anemia. Necesita tomar iero para hacer su sangre mas fuerte. Va sentir mas fuerte (menos debil) si toma su iero. I m writing a prescription for stool softener. It s also important to drink a lot of water and eat fruits & vegetables so you have soft poop (no constipation) that s easy to pass. Escribo una recetta por medicine para hacer su excremento mas blandito. Es importante a tomar much agua y a comer muchas frutas y verduras para tener excremento blandito (no estrenimiento) que es facil a pasar. 43
DICTATION For Stanford ***use for Gyn Onc and Gyn service *** Dial 233 or 650 723 6100. For STAT dictation, dial Medical Transcription Services 650 723 5588. Enter ID (same ID as for Centricity or Carecast). Do not enter leading 00s. For eg, 0012 enter 12. Enter clinical code followed by the # key. Enter code: Description: 1 Inpatient 2 ED 3 Outpatient Surgery Enter Clinical Area Code (To obtain code, call Clinic Visit 3-5588) 263 Gyn Onc 264 Gyn Enter work type followed by the # key. Inpatient/Ops Clinic 2 = H&P 32 = New Patient Visit 3 = Inpatient Progress Note 33 = Clinic Visit 4 = Inpatient Consult 34 = Outpatient Consult 5 = Operative Report 35 = Outpatient Procedure 6 = Inpatient Letter 36 = Outpatient Letter 7 = Discharge Summary 37 = Follow-up Visit 8 = Transfer Off Service 38 = CDMS 39 = Off Site SNF Visit 40 = Radiology Report 41 = Non-Patient Doc. 42 = Non-Patient Letter 44
Enter the patient s 7 digit medical record number followed by the # key. Do not use check digit (which is the last digit of the record- the number followed by the dash) Press 6 any time during the dictation to assign a high priority. Then call Transcription 3-5588 any time to ensure processing. To begin dictation, press 2. To pause, press 2 again. ***Dictate your first and last name and your title (resident physician) Attending physician Patient s first and last name MRN Type of report Date of service 2 Dictate/ Stop 7 Rewind 3 Short rewind and play 8 New report 4 Fast forward 9 Insert 5 Disconnect and get job no. 44 End of job 6 High priority (STAT) 8# New report, same work type 77 Rewind to beginning with auto playback Example of common Stanford dictation: Gyn Onc clinic clinic visit: Dial 233 ID number Clinic code 263 Work type 33 for clinic visit 7 digit MR number 2 to begin then dictate the beginning patient information (refer to number 7) 8 for new report or 5 to disconnect (always write down the job number on the clinic note after the dictation) For LPCH *** use for discharge summaries*** Dial 78278 or 800 4992038 Enter ID number followed by # sign Press 1 to dictate Enter Clinic Code followed by # sign OB clinic code 270; Inpatient clinic code 1 45
Enter work type followed by # sign 2 H& P 10 Clinic Visit 4 Inpatient consultation 11 EEG 5 Operative Report 12 Clinic Procedure 6 Inpatient Letter 13 Outpatient Letter 7 Discharge Summary 14 Outpatient consultation 8 Transfer Summary 15 Clinic Note (not visit related Example of common LPCH dictation: OB discharge summary: Dial 82278 Dial 1 Clinic Code 1 for inpatient Work type 7 for discharge summary Enter FIN number 2 to begin then dictate your name, attending name, the patient information (refer again to number 7 ***) To hang up press 5 or press # and then 8 to start dictating a new report For Stat press 6 at any time during dictation 46