OB-GYN Hx Flashcards
Pt profile
A. Gen data B. Menstrual Hx C. Obstetric Hx D. Prenatal Hx E. Contraceptive Hx F. Sexual Hx G. Past Hx H. Personal or Social Hx I. Fam Hx J. CC K. HPI
Gen Data
NAPARROC BBAD PN
NAPARROC BBAD PN
NAPARROC BBAD PN
name, age, parity, aog, religion, race, occup, civil status
birthdate, birthplace, address, date of admission
place of admiss, number of times admitted
Menstrual Hx (8)
SLIMR PH
a. Menarche (age, flow char)
b. Subsequent menses (duration, amt, ass symp - dysme)
c. Intermenstrual bleeding/other abn
d. Relation to oral contraceptives
e. LMP & PMP
f. Menopause (age, meno symptoms)
g. Post-meno bleed
h. Hormone replacement therapy
Obstetric Hx
a. OB score
b. Previous pregnancy
- deliveries (date, length of gest, labor duration, compli, mtd of delivery, wt, sex)
- abortion (date, AOG, date D&C, spont or induced)
- abn preg (ectopic, gestational trophoblastic; dat & mgmt)
c. Present pregnancy (LMP, EDC, AOG)
Prenatal Hx
DDD I LUV U PR MWa
Date of first prenatal CU
Date of last prenatal CU
Date of quickening
Illness
Labs
Ultrasound
Vaccines
Usual BP range
Prenatal caregiver
Regulatory prenatal care
Meds
Wt gain
Past Hx
Childhood illness, immu, serious illnesses, injuries, surgery
Personal social hx
Marital status, habits, allergies, occupation, children, income & sources, hx of travel
Communication foundation is based on what 4 key skills?
EA EA
Empathy
Attentive listening
Expert knowledge
Ability to est rapport
The physician is
Good listener
Genuine
Fair
Facilitative
Honest
Empathetic
Compassionate
Respectful
The number if times the woman has delivered a fetus 20 wks and above (dead or alive)
Parity
Based on quickening
Primigravidas
Multigravidas
Primigravidas - 20 wks AOG
Multigravidas - 16 wks AOG
Naegele’s rule
-3 +7 +1
Full term
37-42
Preterm
Before 37 weeks
Post term pregnancy is defined as pregnancy that has
extended to or beyond 42 weeks of gestation
