Common smart phrases/clinic templates for general ob/gyn



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Common smart phrases/clinic templates for general ob/gyn (created by faculty physicians)
Topic Page No.
Annual Exam 2-8

Colposcopy 9-11


Cryotherapy 12-13


Endometrial Biopsy 14-15
Implanon/Nexplanon placement 16-19

Implanon Removal 20-21


IUD placement 22-23
IUD Check 24-25
LEEP 26-29

LEEP POSTOP 30


Pap/cervical dysplasia f/u 31
Pre op for C-section 32-34
2 week c-section check 35

Post op general 36-37

Postpartum 38-40

Pre op H&P 42-44

Vaginitis 45

Annual Exam


Dumermuth

CC: Annual Gynecologic Examination

HPI: @NAME@ is a @AGE@ G***P*** who presents for annual gynecologic examination. She has the following concerns: ***
Health Maintenance: She exercises ***days per week with ***. She wears her seatbelt routinely. She *** perform*** monthly self breast exams. She *** had her cholesterol checked ***. Her @PAPDATE@ She feels safe at home.
@MEDICALHX@

@SURGICALHX@



Past OB/Gyn History:

@OB@, menstrual cycles every *** days, with *** days of *** bleeding. Denies any history of sexually transmitted infection. No history of abnormal pap smears, her last pap smear was ***.

@FAMHX@

Social History:

@SOC@


@ALLERGY@

@MEDSCURRENT@


Review of Systems:

A complete review of systems was performed and was negative, except as listed.

***
Physical Exam:

@VS@


GEN: The patient was alert and oriented x3, pleasant well-appearing female in no acute distress.

HEENT: Unremarkable, no anterior or posterior lymphadenopathy, no thyromegaly

CV: RRR, no murmurs

RESP: Clear to auscultation bilaterally

BREAST: Symmetric breasts with no palpable breast masses or obvious breast lesions. She has no retractions or nipple discharge. She has no axillary abnormalities or palpable masses. Self breast exam is taught.

ABD: Soft, nontender, nondistended, normoactive bowel sounds, ***

EXT: WWP, nontender, no edema

BACK: No CVA tenderness, no tenderness to palpation along spine

PELVIC: Normal appearing external female genitalia, normal vaginal epithelium, no abnormal discharge. Normal appearing cervix. Bimanual: No CMT, *** week uterus, nontender. No palpable adnexal masses. Rectovaginal exam was ***.
Assessment & Plan: @NAME@ is a @AGE@ @GP@ with ***.
1. Pap: The patient's @PAPDATE@ She is due for a repeat pap ***.

2. I discussed regular exercise, self breast exams, routine seat belt use. She is due for ***.




Anderson

CHIEF COMPLAINT:

  1. Annual examination.

  2. ***


HISTORY OF PRESENT ILLNESS:

@FNAME@ is a @AGE@ female who presents today for a routine annual examination and discussion of the above. @GP@ ***


PAST MEDICAL HISTORY:

Current Health Link data were reviewed with the patient/updated as necessary.


PAST SURGICAL HISTORY:

Current Health Link data were reviewed with the patient/updated as necessary.


FAMILY HISTORY:

Current Health Link data were reviewed with the patient/updated as necessary.

Breast cancer: {Yes/No:60}. Ovarian cancer: {Yes/No:60}. Uterine cancer: {Yes/No:60}. Colon cancer: {Yes/No:60}. Osteoporosis: { Yes/No:60}.
OB/GYN HISTORY:

@OB@


@LMP@.

Last Pap: @LPAP@

History of abnormal Paps, sexually transmitted infections, or pelvic inflammatory disease: {Yes/No:60}.
SOCIAL HISTORY:

She is {marital status:62} and works ***.

Exercise regularly: {Yes/No:60}.

Tobacco: {TOBACCO USE:13621}

Alcohol: {ALCOHOL USE:13625}

Caffeine: {CAFFEINE USE:13623}

Wears seat belt on a regular basis: {Yes/No:60}.

Feels safe in her current environment: {Yes/No:60}.

***
MEDICATIONS:

@cmeds@
ALLERGIES:

Current Health Link data were reviewed with the patient/updated as necessary.
SCREENING:

Last Papanicolaou test: @LPAP@.

Last cholesterol: @LCHOL@.

Last tetanus: @LTETANUS@.

Last mammogram: @LMAMMO@.

Regular self-breast exam: {Yes/No:60}.

Calcium intake: {Yes/No:60}.

***
REVIEW OF SYSTEMS:

Please see history of the present illness for pertinent positives.

{NEGATIVE ROS COMPLETE FEMALE:10171}


PHYSICAL EXAMINATION:

VITAL SIGNS: @VS@

GENERAL: She is {GENERAL APPEARANCE:5021}.

HEENT: Pupils are equal, round, and reactive to light. Sclerae are anicteric. Mucous membranes are moist. Oropharynx is clear without erythema.

NECK: No preauricular, submandibular, or supraclavicular lymphadenopathy. No thyromegaly.

SPINE: Straight. There is no costovertebral angle tenderness.

SKIN: No atypical nevi or rash.

EXTREMITIES: Without cords, edema, or rash.

CARDIOVASCULAR EXAM: Regular rate and rhythm, normal S1 and S2, and no murmurs, rubs, or gallops.

LUNGS: Clear to auscultation bilaterally.

ABDOMEN: Soft, {FLAT/OBESE:602}, nontender, and nondistended. No hepatosplenomegaly. No rebound or guarding. Groin is without lymphadenopathy.

NEUROLOGIC EXAM: Alert and oriented times 3. No focal deficits.

BREAST EXAMINATION: Bilaterally symmetrical breasts. There is no axillary lymphadenopathy. No mass, discharge, or dimpling.

GYNECOLOGIC EXAM: {PELVIC EXAM:709} {*** Insert your normal pelvic exam}

Stool today is Hemoccult negative.
ASSESSMENT:

Normal gynecologic exam.

Routine GYN exam per the Wisconsin Well-Women Program.

See Health Link diagnoses.


PLAN:

  1. She was counseled regarding her findings.

  2. She will be notified with the results of her Pap smear.

  3. STD testing was offered and {DONE:12093}.

  4. Screening: We discussed breast self-examination, and a shower card was given. We discussed calcium and vitamin D intake, and a handout was given. She will have a fasting cholesterol panel for screening. {HEALTH MAINTENANCE:5237} {SCREENING MEDICARE:11683}

  5. Followup: I have recommended annual examinations or sooner with concerns. Her questions were answered.

Bennett


CHIEF COMPLAINT:

  1. Annual examination.

  2. ***


HISTORY OF PRESENT ILLNESS:

@FNAME@ is a @AGE@ female who presents today for a routine annual examination and discussion of the above. @GP@ ***


OB/GYN HISTORY:

@OB@


@LMP@.

History of abnormal Paps:{Yes/No:60}

Sexually transmitted infections, or pelvic inflammatory disease: {Yes/No:60}.

Sexually Active:{YES/CAP NO:18859}

Contraception:{contraception:11438}
SCREENING:

Last Papanicolaou test: @PAPDATE@


Last cholesterol: @RESULAST(chol:1,trig:1,hdl:1,ldl:1)@

Last tetanus: Tetanus vaccination status reviewed: {TETANUS STATUS:5746::"Tetanus re-vaccination not indicated"}.

Last mammogram: @MAMDATE@
Regular self-breast exam: {Yes/No:60}.
Calcium/Vitamin D intake: {Yes/No:60}.
Last Colonoscopy: @COLODATE@
Last Bone Density scan: @BONEDATE@


Past Medical, Surgical and Family History:

Current Health Link data were reviewed with the patient/updated as necessary.


Family hx of breast cancer, ovarian cancer, colon cancer? {Yes/No:60}

Family hx of thromboembolic event, clotting disorder? {Yes/No:60}

Family hx of CVD? {Yes/No:60}

Family hx of diabetes? {Yes/No:60}


SOCIAL HISTORY:

She is {marital status:62} and works ***.

Exercise regularly: {Yes/No:60}.

Tobacco: {TOBACCO USE:13621}

Alcohol: {ALCOHOL USE:13625}

Wears seat belt on a regular basis: {Yes/No:60}.

Bike Helmet: {YES/CAP NO:18859}

Feels safe in her current environment: {Yes/No:60}.


MEDICATIONS:

@cmeds@
ALLERGIES:

Current Health Link data were reviewed with the patient/updated as necessary.
REVIEW OF SYSTEMS:

Please see history of the present illness for pertinent positives.

{NEGATIVE ROS COMPLETE FEMALE:10171}
PHYSICAL EXAMINATION:

VITAL SIGNS: @VS@


GENERAL: She is {GENERAL APPEARANCE:5021}.

HEENT: Sclerae are anicteric. Mucous membranes are moist. Oropharynx is clear without erythema.

NECK: No preauricular, submandibular, or supraclavicular lymphadenopathy. No thyromegaly.

SKIN: No atypical nevi or rash.

EXTREMITIES: Without edema, or rash.

CARDIOVASCULAR EXAM: Regular rate and rhythm, normal S1 and S2,

LUNGS: Clear to auscultation bilaterally.

ABDOMEN: Soft, {FLAT/OBESE:602}, nontender, and nondistended. No hepatosplenomegaly. No rebound or guarding. Groin is without lymphadenopathy.

NEUROLOGIC EXAM: Alert and oriented times 3. No focal deficits.

BREAST EXAMINATION: Bilaterally symmetrical breasts. There is no axillary lymphadenopathy. No mass, discharge, or dimpling.

GYNECOLOGIC EXAM: {PELVIC EXAM:709}

***Stool today is Hemoccult negative. ***


ASSESSMENT:

Normal gynecologic exam.

***
PLAN:


  1. She will be notified with the results of her Pap smear.

  2. STD testing was offered and {DONE:12093}.

  3. Screening: We discussed calcium and vitamin D intake. ***Screening mammogram ordered *** She will have a fasting cholesterol panel for screening. ***Immunizations given*** {HEALTH MAINTENANCE:5237} {SCREENING MEDICARE:11683}

  4. Followup: I have recommended ***annual examinations or sooner with concerns. Her questions were answered.

Bradley

CC: Annual exam
HPI: @NAME@ is a @AGE@ G***P*** who presents for ***
Past Medical History:

@MEDICALHX@


Past Surgical History:

@SURGICALHX@


Past OB/Gyn History:

@OB@, menstrual cycles every *** days, with *** days of *** bleeding. Denies any history of sexually transmitted infection. No history of abnormal pap smears. Her last pap smear was ***.


Family History:

@FAMHX@
Social History:

@SOC@

Review of Systems:

Skin: No rashes or discolorations of any concern.

RESP: Denies SOB, no cough.

CV: Denies chest pain or palpitations.

Breasts: Denies masses, pain and nipple discharge.

GI: Denies abdominal pain. Denies changes in bowel habits.

GU: Denies dysuria, frequency, incontinence and hematuria.

Genitalia: Denies abnormal vaginal discharge.
Physical Exam:

@VS@


GEN: The patient was alert and oriented x3, pleasant well-appearing female in no acute distress.

HEENT: Unremarkable, no anterior or posterior lymphadenopathy, no thyromegaly

CV: RRR, no murmurs

BREASTS: Breasts: Symmetric. No dominant, discrete, fixed or suspicious masses are noted. No skin or nipple changes. No palpable axillary nodes.

RESP: Clear to auscultation bilaterally

ABD: Soft, nontender, nondistended, no masses or organomegaly

BACK: No CVA tenderness, no tenderness to palpation along spine

PELVIC: Normal appearing external female genitalia, normal vaginal epithelium, no abnormal discharge. Normal appearing cervix. Uterus is smooth, mobile and, nontender. No palpable adnexal masses. No anoperineal lesions. Rectovaginal exam was ***. A thin prep pap smear was obtained.

SKIN: No concerning lesions

EXTREMITIES: No edema



Assessment & Plan:

1. Routine annual exam.

We discussed ACOG guidelines for pap smear screening frequency. ***

We discussed healthy diet, exercise, self breast awareness.

RTC one year or earlier PRN.
2.

COLPOSCOPY

Anderson


Colposcopy Exam
CHIEF COMPLAINT: @CHIEFCOMPLAINTN@
HISTORY OF PRESENT ILLNESS: The patient is a @AGE@ female who ***
@@CMED@
@ALGENC@
PHYSICAL EXAMINATION:

Vital Signs: @V@

General: Well-developed, well-nourished, @AGE@ female in no acute distress.

Pelvic Exam: External genitalia reveal normal BUS and vulva. No lesions, whitened epithelium, or erythema. Vagina is pink, moist, and rugous without lesions. No abnormal discharge. No blood. Cervix is {CERVIX EXAM:11354}. Parametrium is clear. Gross naked eye description: ***.


IMPRESSION:

@DIAG@
PLAN:



  1. We discussed abnormal Pap smears, commonality of HPV and possible role in cervical dysplasia and cervical cancer. We discussed HPV vaccine options currently FDA indicated for ages 11-25.

  2. We discussed colposcopic exam for assessment, procedure, risks, and benefits. Patient was given handouts. The patient desires to proceed with colposcopy.

PROCEDURE NOTE: Colposcopic examination of the vulva, vagina, and cervix was performed, including application of acetic acid, and is diagramed on the colposcopy form in chart. Findings: ***. Biopsy/ies done: {YES/NO:12193}. Pap done: {YES/NO:12193}

  1. Disposition will be pending pathology, but we discussed probable observation if mild dysplasia versus age-specific observation or treatment if moderate or severe dysplasia.

  2. ***

Dumermuth

@AGE@ year old female presents for colposcopy referred by ***.

Indications:

Pap smear *** showed: {PAP SMEAR DIAGNOSES:726::"normal"}. Prior pap(s) showed {PAP SMEAR DIAGNOSES:726::"normal"}.

@LMP@.

Contraception: {contraception:11438}



Number current sexual partners: ***

Number of partners in lifetime: ***

High risk partner: {Yes/No:10029::"No."}

History of STD: {Yes/No:10029::"No."}

Future fertility desired: {Yes/No:10029::"No."}

Prior cervical/vaginal findings: {COLPOSCOPY ASSESSMENT:733}.

Prior cervical treatment: {COLPOSCOPY TREATMENT RECOMMENDATIONS:727}.
Symptoms/History:

Abnormal vaginal discharge: {Yes/No:10029::"No."}

HIV: {Yes/No:10029::"No."}

Pregnant: {Yes/No:10029::"No."}

Postmenopausal: {Yes/No:10029::"No."}

DES Exposure: {Yes/No:10029::"No."}

Intermenstrual bleeding: {Yes/No:10029::"No."}

Postcoital bleeding: {Yes/No:10029::"No."}

Immunosuppressed: {Yes/No:10029::"No."}

Bleeding Problems (non-gynecological): {Yes/No:10029::"No."}

Smoking: {YES/NO:64}

NSAID current use: ***

Other serious chronic illnesses: ***
Procedure for colposcopy and biopsy has been explained to the patient including indication for colposcopy and alternatives as well as risks and potential complications. {CONSENT TYPE:10035::"Verbal"} informed consent was obtained.
PROCEDURE:

The speculum was placed in vagina and excellent visualization of cervix was achieved. The greenfield filter was used. *** atypical vasculature was noted. Cervix was swabbed x3 with acetic acid solution.


FINDINGS:

Cervix: {COLPOSCOPY CERVIX FINDINGS:728}; {COLPOSCOPY CERVIX PROCEDURE:729}.


Vaginal inspection: {COLPOSCOPY VAGINAL EXAM:730}.
Vulvar colposcopy: {COLPOSCOPY VULVAR EXAM:731}.
Procedure Summary: {COLPOSCOPY SUMMARY:732}.
ASSESSMENT:

{COLPOSCOPY ASSESSMENT:733}.


PLAN:

1. All specimens were labeled and sent to Pathology, we will base further treatment on pathology findings. We will call patient with biopsy results.

2. Treatment options briefly discussed with patient. All questions answered.

3. Postbiopsy instructions were given to patient. The patient was asked to call with any questions or concerns.

Miller

REFERRING PROVIDER: @pcp@


HISTORY OF PRESENT ILLNESS: A @age@, {RACE:8101} is here for colposcopy for a Pap smear showing {reason for colposcopy:15840}.
Prior history of abnormal Pap: {Yes/No:60}.

Prior colposcopy: {Yes/No:60}.

Contraception: {contraception:15149}.
Nursing note is reviewed.
Discussed with patient continuum of abnormalities of the cervix, including atypical squamous cells of undetermined significance, low-grade dysplasia, and high-grade dysplasia. Discussed that in general either atypical squamous cells of undetermined significance or low-grade dysplasia is followed closely. Discussed that some patients with low-grade dysplasia progress, but some patients with low-grade dysplasia regress to normal, and that we usually do give patients time to see if they will revert to normal with observation. Discussed that if low grade is confirmed, I would recommend a repeat Pap smear in 4 months and a repeat colposcopy if abnormal Pap persists at 1 year.
I did discuss that high-grade dysplasia is treated, and treatment would consist of either cryocautery of the cervix or loop electrical excision procedure (LEEP) cervical cone biopsy. The idea behind both treatments is that they get rid of the abnormal surface cells on the cervix, and that the surface cells are replaced with healthy normal cells. Discussed that the purpose of the colposcopy is to ascertain the exact level of her dysplasia. Discussed that in all likelihood we will be recommending a cervical biopsy. Patient was in agreement. Consent was obtained. Patient was given brochures outlining both of these procedures.
PROCEDURE NOTE: Acetic acid was applied. On colposcopic examination, there was white epithelium {with/without:10391} mosaicism at ***. There {WAS/WAS NOT:9033} punctation. Biopsy was taken at the *** o'clock area. Monsel solution was applied to the base of the biopsy site for hemostasis. {COLPOSCOPY SUMMARY:11499}
IMPRESSION: Abnormal Pap.
PLAN: We will plan to notify the patient of biopsy results when available. ***

Cryotherapy

Dumermuth

@AGE@ female present for cryotherapy. Her colposcopy on *** had a biopsy showing *** with negative ECC. Based on her biopsy results I recommended proceeding with either an excisional procedure in the form of a LEEP or cryotherapy. Both options were discussed in detail. Since her last visit, she has no new complaints or concerns and no changes in her medical history. The patient desires cryotherapy.

The cryotherapy procedure was discussed with the patient in detail. The risks, benefits, alternatives and indications for the procedure were reviewed in detail. The patient understands the implications of cryotherapy procedure on future fertility and pregnancy. She understands that she could have some cervical stenosis making obtaining pregnancy difficulty in the future. She could also develop pyometria with associated PID. She also understands the small risk of preterm delivery after cryotherapy. The patient understands the risk of infection, the risk of bleeding and the risk of injury to other organs during this procedure. All the patient's questions were answered regarding the procedure prior to proceeding. Verbal and written consent was obtained.

The patient was placed in dorsal lithotomy. Her external female genitalia appeared within normal limits. An insulated speculum was inserted. The vaginal epithelium was visualized and appeared to be within normal limits. Her cervix is easily visualized. A colposcope was used to further visualize her cervix. The entire extent of the lesion was identified. A paracervical block was then performed with 1% lidocaine at the 4 and 8 o'clock positions around the cervix. Cryotherapy was then performed with *** minute freeze, *** minute thraw and *** minute freeze, covering the entire transformation zone. This was done in an uncomplicated fashion. Excellent hemostasis was noted.

The patient tolerated the procedure well. There were no complications with the procedure. The patient was doing well post procedure. She was not lightheaded or dizzy and was asymptomatic. Her cervix was hemostatic.

ASSESSMENT AND PLAN: Ms @NAME@ is a @AGE@ female with CIN-*** now status post cryotherapy procedure performed today. The patient will return to the clinic in 2 weeks' time to evaluate her cervix status post her cryotherapy. All the patient's questions were answered in detail in the clinic today. Her followup plan and further treatment will be discussed when she returns for her post procedure visit.

Bennett


Cryotherapy Procedure Note
Diagnosis: ***
@NAME@ @AGE@ @GP@ who presents for cryotherapy of her cervix for *** cervical dysplasia. Risks, benefits and alternatives were discussed including persistent disease and need for retreatment, cervical stenosis, injury to vaginal tissues. She consented to procedure. A plastic speculum was placed in the vaginal and the cervix was visualized, appropriate probe selected. The probe was applied to the cervix and freezing employed for 3 minutes, defrost for 1 minute, then another 3 minutes of freezing. She tolerated the procedure well.
Follow up care and expectations reviewed, including refraining from intercourse and using only tampons for the next 2 weeks.
She will return for a follow up pap at 6 month intervals for the next year, then yearly for the next 20 years.

Endometrial biopsy

Anderson


We discussed possible causes of bleeding, as above. We discussed possible sonohysterogram. We discussed role of endometrial biopsy for diagnostic purposes and reviewed procedure, risks, and benefits. The patient desired to proceed with endometrial biopsy. Pap smear was {DONE:12093}.
PROCEDURE NOTE: Vacurette endometrial biopsy was performed using aseptic technique with iodine preparation. {***Document if procedure required single-tooth tenaculum, os finders, was without difficulty}
The uterus was sounded to a length of *** cm. Adequate sampling was obtained with minimal blood loss. The patient tolerated the procedure well. Disposition will be pending pathology.

Dumermuth

After discussion with the patient regarding her abnormal uterine bleeding I recommended that the patient proceed with an endometrial biopsy for further diagnosis. The risks, benefits, alternatives, and indications for an endometrial biopsy were discussed with the patient in detail. She understood the risks including infection, bleeding, cervical laceration and uterine perforation with injury to other organs like her bowel and bladder. The patient was agreeable to proceed with an endometrial biopsy and verbal consent was obtained. At this point a bimanual exam was performed, which revealed an approximately ***-week size uterus that was *** position with no palpable adnexal masses, cervical motion tenderness, or abnormalities. On speculum exam, the patient no abnormalities in her vaginal epithelium. Her cervix was easily visualized and thought to be within normal limits. The cervix and vagina was then cleansed with Betadine x 3. A single-tooth tenaculum was placed on the anterior lip of the cervix and an endometrial biopsy was performed without difficulty. Her uterus sounded to *** cm. Adequate tissue appeared to be obtained. The patient tolerated the biopsy without difficulty. No complications occurred during the biopsy. The tenaculum was removed from the anterior lip of the cervix. Hemostasis was noted.
Bradley

Procedure Note: Endometrial biopsy

After discussion with the patient regarding her abnormal uterine bleeding I recommended that she proceed with an endometrial biopsy for further diagnosis. The risks, benefits, alternatives, and indications for an endometrial biopsy were discussed with the patient in detail. She understood the risks including infection, bleeding, cervical laceration and uterine perforation. Verbal consent was obtained.


A bimanual exam was performed, which revealed an approximately ***-week size *** anteverted uterus with no palpable adnexal masses, cervical motion tenderness, or abnormalities. On speculum exam, there were no abnormalities in her vaginal epithelium. Her cervix was easily visualized and thought to be within normal limits. The cervix and vagina was then cleansed with Betadine x 3. A single-tooth tenaculum was placed on the anterior lip of the cervix. Her uterus sounded to *** cm. The biopsy pipelle was advanced and the specimen obtained in the usual fashion. An adequate amount tissue appeared to be obtained. The patient tolerated the procedure well without difficulty. No complications occurred. The tenaculum was removed from the anterior lip of the cervix. Good hemostasis was noted.


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