OG35.{1-14,19},OG36.1-2,OG38.4 | Core Clinical Skills — Assignment

CLINICAL SCENARIO

You will write a complete structured case record for a real or simulated obstetric or gynaecological patient, demonstrating competency in history-taking, clinical examination findings, provisional diagnosis, management plan, and discharge documentation. This assignment assesses your ability to integrate clinical reasoning with professional documentation skills — the foundation of safe, continuous, and legally defensible patient care.

Section 1: Patient Identification and Presenting Complaint

Guidance: State age, parity (obstetric formula: G/P/L/A), and the chief complaint with duration. For an ANC patient, include the LMP, EDD calculated by Naegele's rule (adjusted for cycle length), and gestational age in weeks. For a gynaecology patient, describe the presenting complaint in the patient's own words followed by your clinical paraphrase.

Section 2: History of Present Illness

Guidance: Narrate the presenting complaint in chronological order. For an obstetric case, cover: onset and character of any symptoms, relevant antenatal history (fetal movements, bleeding, discharge, swelling), and pertinent systems review (headache, visual disturbance, epigastric pain, dysuria). For a gynaecological case, cover: menstrual history (LMP, cycle regularity, duration, flow, intermenstrual or postcoital bleeding), associated symptoms (pain character, bowel/bladder involvement), and sexual history where relevant and appropriate.

Section 3: Obstetric and Gynaecological History

Guidance: For obstetric cases: list all previous pregnancies in chronological order with outcomes (term/preterm, mode of delivery, birth weight, maternal/fetal complications). For gynaecological cases: list previous gynaecological problems, surgeries, and results. Include contraceptive history and any history of STIs or pelvic inflammatory disease.

Section 4: Clinical Examination Findings

Guidance: Record general examination (built, nourishment, pallor, icterus, oedema, lymphadenopathy), vital signs (BP, pulse, temperature, respiratory rate), and obstetric/gynaecological examination findings. For obstetric patients: symphysis-fundal height, lie, presentation, position, engagement, fetal heart sounds. For gynaecological patients: abdominal examination findings (site, size, surface, consistency, mobility, tenderness of any mass). You need NOT include internal (per-vaginal/per-rectal) examination in this write-up.

Section 5: Provisional Diagnosis and Differential Diagnoses

Guidance: State your provisional (most likely) diagnosis and the reasoning behind it, citing specific positive findings from history and examination. Then list 2–3 differential diagnoses in order of likelihood with a brief clinical justification for each. For an obstetric case, include the obstetric formula, gestational age, and any complication diagnosis (e.g., G2P1L1 at 20 weeks with iron-deficiency anaemia).

Section 6: Proposed Investigation Plan

Guidance: List investigations appropriate to your provisional diagnosis and to routine antenatal or gynaecological care. Specify the clinical question each investigation answers. For an ANC patient, include the minimum investigations mandated by NRHM ANC protocol (haemoglobin, blood group, Rh type, urine albumin/sugar, VDRL, HIV, HBsAg, blood glucose, ultrasound). For a gynaecological patient with a pelvic mass, include the reasoning for ultrasound, tumour markers, or other tests.

Section 7: Draft Discharge Summary

Guidance: Write a discharge summary as if the patient is being discharged after a 48-hour admission. Include: patient details and admission date, reason for admission, significant findings, investigations performed and results (you may use plausible simulated values), treatment given (with specific doses and duration), condition at discharge, follow-up instructions, and medications on discharge with doses. The discharge summary must include at least one actionable follow-up instruction specific to the patient's diagnosis.

Section 8: Reflection — Communication and Ethical Considerations

Guidance: In 150–200 words, reflect on: (a) one communication challenge you would anticipate in managing this patient (e.g., explaining an unfavourable diagnosis, obtaining consent for a procedure) and how you would address it using a structured approach; and (b) one ethical dimension relevant to the case (e.g., confidentiality, patient autonomy, resource allocation) and how you would reason through it.

PEER REVIEW

You will review ONE peer's case write-up using the rubric criteria above. For each criterion, assign a score from the rating scale and write 2–3 sentences of specific feedback explaining your score. In your overall comment (100–150 words), identify: (1) the strongest element of the write-up, (2) the most significant gap you identified, and (3) one specific suggestion your peer can implement to improve their clinical documentation skills. Peer review must be respectful, constructive, and evidence-based — cite specific elements of the write-up to support your assessment.