Case List Instructions
The candidate must list a minimum of 30 patients, but no more than 40 patients, with conditions that fit into the listed Office Practice categories:
Follow these rules when listing office practice patients:
a. Do not list more than two patients in any one category;
b. It is not necessary to include a patient in every category;
c. Do not include any patient that appears as an admitted patient on the Obstetrics or Gynecology lists; and
d. Do not include any patients that had procedures performed in any location except the office. Specifically, patients who had an outpatient procedure in a surgical center must be listed on the Gynecology case list.
Office Practice Categories
- Preventative care and health maintenance
- Lifestyle counseling (smoking cessation, obesity, diet, exercise, substance abuse, etc.)
- Sexual dysfunction
- Family planning (contraception including IUD placement, etc.)
- Preconception evaluation, prenatal and genetic diagnosis
- Geriatric care
- Disorders of menstruation (amenorrhea, dysmenorrhea, abnormal uterine bleeding, etc.)
- Infertility evaluation and management
- Immunizations
- Endometriosis: diagnosis and office management
- Perimenopausal and menopausal care
- Pediatric and adolescent gynecology
- PCOS
- Evaluation and management of acute and chronic pelvic pain
- Vaginal disease (infections, VAIN, etc.)
- Vulvar disease (infections, dermatoses, VIN, etc.)
- Breast disease, benign and malignant
- Evaluation and office management of urinary and rectal incontinence
- Urinary tract infections
- Sexually transmitted infections
- Uterine myomata
- Office surgery (biopsy, hysteroscopy, sterilization, LEEP, etc.)
- Abnormal cytology, colposcopy and CIN
- Ultrasonography
- Galactorrhea
- Hirsutism
- Benign pelvic masses
- Sexual assault
- Domestic violence
- Office evaluation and management of pelvic floor disorders
- Endocrine diseases (e.g., diabetes mellitus, thyroid, or adrenal disease)
- Major medical diseases (respiratory, gastrointestinal, cardiovascular, hypertension, etc.)
- Minor medical diseases (headache, low back pain, irritable bowel, etc.)
- Medical management of ectopic pregnancy
- Psychiatric illnesses (depression, anorexia, bulimia, etc.)
- Diagnosis and management of hypercholesterolemia and dyslipidemias
- Amniocentesis
- Cancer genetic screening and preventive measures
- Ovarian preservation counseling
- Patients with unique obstetric or gynecologic needs (LGBTQI patients, substance and alcohol abuse)
- Reproductive tract congenital anomalies
- Premenstrual dysphoric disorder
- Structural uterine abnormalities (polyps, hyperplasia, adenomyosis)
- Disorders of puberty
- Sexual development disorders (structural, chromosomal)
- Reproductive tract cancer
- Uncategorized (cases in this category do not count toward the required 40 cases)
List each patient separately and include the problem (one of the categories listed above), diagnostic procedures, treatment, results and number of office visits during the 12-month period.
All hospitalized and short-stay gynecological patients must be entered as follows:
a. List all gynecologic patients managed during the 12-month collection period (or 18- month period, if an extended time case list is submitted and/or patients chosen from the fellowship or senior year of residency).
b. A minimum of 15 gynecologic patients are required. In order to meet the minimum requirement a candidate cannot count more than two patients from any one of the gynecology categories listed below.
Example: A candidate has 5 patients who had a diagnostic laparoscopy. They all must be entered on the case list, but only 2 of the 5 will be counted as meeting the minimum requirement of 15 gynecological cases.
c. A preoperative diagnosis should appear for all major and minor surgical procedures. The size of ovarian cysts and neoplasms must be recorded. For non-surgical conditions, the admission diagnosis should be recorded. Non-surgical admissions will not have a surgical pathological diagnosis. The treatment recorded should include all surgical procedures, as well as primary non-surgical therapy. “Surgical diagnosis” is the final pathology diagnosis. For hysterectomy specimens, the uterine weight in grams must be recorded. In cases without tissue for histologic diagnosis, the final clinical diagnosis should be listed. If the preoperative and postoperative diagnoses are the same and there is no pathology, you do not need to relist the diagnosis.
d. “Days in hospital” is the arithmetic difference between the date of discharge and the date of admission. Specific dates of admission and discharge should not be provided. If a patient had an outpatient procedure and was not admitted, list the number of days in hospital as “0.”
e. List any remaining patients that do not fit into any of the listed categories in the “Uncategorized” category
Gynecology Categories
- Abdominal hysterectomy, any type (e.g., total, subtotal, laparoscopic, robotic)
- Laparotomy
- Vaginal hysterectomy (including laparoscopically assisted)
- Diagnostic laparoscopy
- Operative laparoscopy (other than tubal sterilization and hysterectomy)
- Operative hysteroscopy
- Uterine myomata
- Repair of pelvic floor defects; prolapse
- Endometriosis and adenomyosis: surgical management
- Sterilization procedures
- Invasive carcinoma
- Urinary and fecal incontinence: operative management
- Ectopic pregnancy: surgical management
- Operative management of pelvic pain
- Congenital abnormalities of the reproductive tract
- Pelvic inflammatory disease
- Adnexal problems (excluding ectopic pregnancy and PID)
- Abnormal uterine bleeding
- Surgical management of VIN, CIN, and VAIN
- Postoperative complications (hemorrhage, wound, urinary tract, GI, pain, thrombotic, embolic, neurologic, fever, etc.)
- Management of rectovaginal or urinary tract fistula
- Preoperative evaluation of co-existing conditions (respiratory, cardiac, metabolic diseases)
- Gestational trophoblastic disease
- Incomplete, septic, complete, and other abortion
- Intraoperative complications (e.g., blood loss, hemorrhage, bowel injury, urinary tract injury)
- Dilation and currettage
- Emergency care (e.g., surgical management of ectopic pregnancy, acute bleeding, etc.)
- Laparoscopic hysterectomy (e.g., total, supracervical, robotic)
- Lysis of intrauterine adhesions
- Surgical management of Bartholin gland
- Uncategorized (cases in this category do not count toward the required 15 cases)
If, but only if, a candidate cannot list 15 gynecological cases in the above categories, an 18-month case list and/or an appropriate number of cases from fellowship or senior residency case logs may be included. If senior resident cases are used, only list 15 cases.
A list of a minimum of 15 obstetrical patients must be entered. Separately enter each patient with a complication or abnormality, as well as medical and surgical intervention during pregnancy, labor, delivery and the puerperium. Normal, uncomplicated obstetrical patients should not be listed.
The term "normal obstetrical patient" for this listing implies that the:
a. pregnancy, labor, delivery and the puerperium were uncomplicated; and labor began spontaneously between the 39th and completion of the 41st week of gestation; patients delivering before 39 weeks gestation should be listed in the "preterm," “late preterm” or "early term" categories;
b. membranes ruptured or were ruptured after labor began;
c. presentation was vertex, position was occiput OA, LOA or ROA, and labor was less than 24 hours in duration;
d. delivery was spontaneous with or without episiotomy, from an anterior position;
e. the infant had a five-minute Apgar score of 6 or more and weighed between 2500 and 4500 grams and was healthy, and
f. placental delivery was uncomplicated, and blood loss was less than 500 mL
All deliveries not fulfilling these criteria must be listed individually. Include the gestational age at admission.
A minimum of 15 obstetrical patients is required. In order to meet the minimum, a candidate cannot count more than two patients in any of the categories listed below.
Example: A candidate has 5 obstetrical patients with diabetes mellitus. They all must be entered on the case list, but only 2 of the 5 will be counted as meeting the minimum requirement of 15 obstetrical cases.
List the remaining patients who do not fit into a specific category in the “Uncategorized” category. If the candidate is back-up for a midwifery group, a midwife delivery may not be listed unless the candidate performed the delivery. If the candidate is teaching faculty, all resident cases for which the candidate had responsibility must be included. If the candidate is the responsible staff for a resident for a cesarean delivery, that delivery should be listed individually.
All deliveries not fulfilling these criteria must be listed individually. Include the gestational age at admission.
Obstetrical Categories
- Preconception evaluation, prenatal and genetic diagnosis
- Preterm labor without delivery
- Premature rupture of fetal membranes at term
- Preterm premature rupture of fetal membranes
- Cerclage
- Preterm delivery (before 34 weeks gestation)
- Late preterm delivery (34 weeks 0 days to 36 weeks 6 days gestation)
- Post-term pregnancy and delivery
- Induction and augmentation of labor
- Labor abnormalities (including dystocia)
- Fetal heart rate abnormalities (e.g., variable or late deceleration, absent or poor variability, tachycardia, bradycardia)
- Breech and other fetal malpresentations
- Cord problems (e.g., prolapsed cord, cord entanglement)
- Operative vaginal delivery (e.g., vacuum, forceps)
- Obstetrical hemorrhage (e.g., antepartum, intrapartum, postpartum)
- Obstetrical vaginal lacerations (e.g., 3rd and 4th degree lacerations cervical laceration)
- Vaginal or perineal hematoma
- Primary cesarean delivery
- Repeat cesarean delivery
- Vaginal birth after cesarean delivery
- Cesarean hysterectomy
- Complications of cesarean delivery (e.g., hemorrhage, wound infection, disruption, or hematoma)
- Complications of OB anesthesia (e.g., epidural hypotension, general anesthesia complications)
- Intrapartum or intra-amniotic infection (e.g., amnionitis, chorioamnionitis )
- Puerperal infection (e.g., post cesarean endometriosis)
- Second trimester spontaneous abortion
- Third trimester fetal loss
- Hypertensive disorders of pregnancy (gestational hypertension, preeclampsia, eclampsia)
- Cardiovascular or pulmonary disease complicating pregnancy
- Renal or neurological disease complicating pregnancy
- Hematological or endocrine diseases complicating pregnancy
- Autoimmune disorders of pregnancy
- Infectious diseases (CMV, Group A streptococcus, Zika virus, etc.)
- Psychiatric disease complicating pregnancy
- Pregnancies complicated by human immunodeficiency virus infection (HIV)
- Abnormal fetal growth
- Pregnancies complicated by fetal abnormalities
- Placental abnormalities (e.g., low lying, previa, accreta, abruption)
- Thromboembolic complications
- Trauma in pregnancy (e.g., automobile accidents)
- Multifetal pregnancy
- Diabetes and gestational diabetes
- Shoulder dystocia
- Early term delivery (37 weeks 0 days to 38 weeks 6 days gestation)
- Shoulder dystocia
- Surgical conditions (e.g., acute abdomen, adnexal masses)
- Medical disorders unique to pregnancy (e.g., hyperemesis, cholestasis of pregnancy, acute fatty liver, peripartum cardiomyopathy, PUPPS, herpes gestationis)
- Acute maternal decompensation (e.g. amniotic fluid embolism, septic shock)
- Uncategorized (cases in this category do not count toward the required 15 cases)
If, but only if, a candidate cannot list 15 obstetrical cases in the above categories, an 18-month case list and/or an appropriate number of cases from fellowship or senior residency case logs may be included. If senior resident cases are used, only list 15 cases.