OB Hx Taking Flashcards
(36 cards)
What are variables that influence the status of the px?
Patient: age, hpi, attitude and perception, sex orientation, habits
Fam: px status, caregiving, siblings, hx
Environment: social, economic status, religion, culture and ethnic bg, career
In communication, foundation is based on what 4 key skills?
Empathy
Attentive listening
Expert knowledge
Ability to est rapport
What is the number of times the woman has been or is pregnant?
Gravidity
What is the number of times the woman has delivered a fetus 20 weeks and above, dead or alive?
Parity
For multifetal pregnancy, delivery counts as how many in the parity score?
One
How do you get the OB score?
GP (- - - -)
G - preggy (dead or alive
P - preggy but >20wks (dead or alive)
Full term, pre term, abort, living)
In the AOG based on quickening, how many weeks will be added if primigravidas?
20 weeks
In the AOG based on quickening, how many weeks will be added if multigravidas?
16 weeks
How do you calculate the EDC using Naegele’s rule?
Add 7 days to first day LMP
Subtract 3 months
Add 1 year
EDC responds to what week of gestation?
40th week
How many weeks is considered as full-term?
37-42 weeks
How do you assess previous pregnancies in successful deliveries?
Date Length of gestation Duration of labor Mtd of delivery and where BW Sex of infant Cx
How do you assess previous pregnancies in abortion?
Date
AOG
Date of D&C (if done)
Spontaneous or induced
OB hx, what will you add in present pregnancy?
LMP
AOG
EDC
Usual chief complaint
Labor pains Vaginal bleeding Painless vaginal bleeding Rupture of membranes (watery discharge) Abdominal pain Absence of fetal movements
HPI: Labor pains
Hypogastric pain Crampy Uterine contractions onset Severity (PS) Frequency Interval Duration Ass s/s
HPI: Vag bleeding
Onset Associated pain and/or contractions Est amt Consistency Odor Color
Painless vaginal bleeding characterizes what?
Placenta previa
HPI: rupture membranes
Onset in hrs/days prior to examination Amt Character of fluid Associated contractions Bleeding
HPI: Abd pain (OB)
Ectopic pregnancies Uterine rupture Abruption of placenta Ass loss of consciousness Pallor Bleeding
Gyne px
Menstrual hx
Common: irregular menses
PCOS (food, stress)
HPI for gyne: abdominal pain
Onset Char Loc Duration and freq Radiation Aggravating Relieving Meds Ass s/s
HPI for gyne: abdominal mass
Onset Loc Initial size to present Char/description Mobility of mass (will it elicit pain) Ass s/s (e.g early satiety, urination)
HPI for gyne: abnormal uterine bleeding
- heavy mens
- intermenstrual bleed
- postcoital bleed
- postmenopausal bleed
Onset Char Amnt Interval Duration Ass s/s Aggravating Relieving Meds (eg hormones) - compliance - example progestin irreg, amenorrhea, spotting
