By R.D. Sinelnikov

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Learn the pertinent operative anatomy/pathophysiology prior to each surgery. It’s difficult to impress an attending with your knowledge of anatomy, but not knowing it can look quite bad. Often, asking the resident for an atlas or good description of the operation is helpful. You should know as much as possible about your patient, why they are having surgery, the indications/contraindications, etc. 3. Expect to retract: This is not glamorous, but it will be your job and is essential to getting the surgery done well.

O: VS and UOP: If not in computer, be sure to ask nurse. GEN: A&O. NAD. CV: RRR. no m/r/g LUNGS: CTAB. ABD: Note +/- BS. Soft. ND. Appropriate tenderness. INCISION: c/d/i. No erythema or drainage. ) EXT: Note edema and +/- SCDs/TEDs Labs/Studies: *** 38 A/P: POD # s/p (procedure) for (what reason). List how patient is doing. AFVSS. 1. FEN: IVF, diet 2. GU: d/c foley? 3. CV: Stable? 4. Pain: Change to PO meds? 5. Other medical problems and their tx 6. Path: Pending if not back yet. When back, print a copy for the chart (if at Prentice).

1. MWB: How is the mother doing? Does she need pain meds? Are pain meds helping her? 2. FWB: Reassuring. EFW. 3. Labor: Cont pit or expectant management. Stage of labor. Include any change in labor. 4. GBS status: If positive, then indicate antibiotic given and # doses. Delivery Note: There is a specific ―AdHoc‖ form in PowerChart for this. Procedure: NSVD/LFVD/Primary LTCS/Repeat CS/Classical CS PreOp Dx: # of weeks IUP. # of hours in 2nd stage of labor. If C/S, give reason why. PostOp Dx: Same Attending: *** Assistant(s): Resident and/or student present for delivery Anesthesia: Typically CLE (epidural) or spinal (for C/S) EBL: For C/S, ask anesthesiologist IVF: For C/S, ask anesthesiologist UOP: For C/S, ask anesthesiologist Findings: **Viable M/F infant.

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Atlas of Human Anatomy by R.D. Sinelnikov
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