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37 Cards in this Set

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Components of a Full OB History:
Patient Information, Pregnancy Dating, Present Pregnancy History, Past OB Hx, Past Medical Hx, Past Gyn History, Family History, Social History, Future Contraceptive Plans
Components of a Physical:
Abdominal Exam, Pelvic Exam
What are the included in Patient Information?
Patients age, ethnic background, Gravidity, Parity, SAB, TAB, SB, LC
What does G stand for?
G= gravidity = # of times pregnant
What does P stand for?
P= Parity= # of pregnancies caried to viability (20 weeks or more)
What does viable stand for?
cabable of growing or living
WQhat does SAB stand for?
SAB= # of spontaneous abortions, <20 weeks or <500 grams
What does TAB stand for?
TAB= # of therapeutic abortions
What does SB stand for?
#of stilbirths
What does LC stand for?
# of Living Children
What equals Gravidity?
Parity + SAB+TAB = Gravity
What equals Parity?
SB + LC= Parity
Exceptions: If child died at early age, or lady with a set of twins, she would be, G1, P1, LC2
What does G,P,SAB,TAB,SB,LC stand for?
G= gravidity
P= Parity
SAB= Spontaneous abortions
TAB= therapeutic abortions
SB= still births
LC= living Children
How would one denote twins?
G1, P1, LC2
What are the components to dating a pregnancy?
LNMP, LMP, Menstrual EDC, Last use of contraceptive pills? or "never used",First Documented positive pregnancy test, date of first dumented pelvic exam for uterine sizing, ultrasound, fetal heart tones, estimagted gestational age
What does LNMP stand for?
last normal menstrul period
What does LMP tand for?
the first day of the last mentrual period
What is included in a statement about LMP?
last mentrual period includes a statement as to whether the patient is sure or unsure of this LMP date, usual cycle length in days, whethere the patient is regulare or not
What does menstrual EDC stand for?
estimated date of confinement, or delivery of the baby
How is menstrual EDC determined?
By wheel given at orientation
What most you notate for the first documented positive pregnancy test?
whether it was serum or urine test, and the date of the test
What must you document in a pelvic exam?
uterine sizing (excellent correlation with dates in first trimester), # weeks by dates, # weeks by exam
When is an ultrasound measuring crown-rump length accurate for pregnancy dating?
accurate to about 14 weeks
When is an ultrasound measuring biparietal diameter accurate for pregnancy dating?
14-22 weeks of gestation
What happens when an ultrasound uptill the gestational age of 22 weeks disagrees with the dating by LMP?
The patients EDC maybe officially changed
What happens after 22 weeks if pregnancy dating from the LMP and ultrasound disagree?
After 22 weeks, the ultrasound is less reliable, and unless it disgrees with the LMP by >4 weeks, you would go with the LMP
When are fetal heart tones first heard?
FHT can be heard by doptones beginning at 10-12 weeks gestation and by fetoscopes at 18-20 weeks
How is estimated gestational age calculated and what is included in a statement of EGA?
estimated gestational age is determined from the LMP, Menustrual EDC, first documented positive pregnany test, pelvic exam, ultrasounds, and Fetal Heart Sounds.
Included in EGA is a statement as to whether you feel the dating is poor, fair, good, or excellent based on all of the above information
What is included in Present Pregnancy History?
Any prenatal care recieved so far (place, and # of visits), any problems in the pregnancy (bleeding, infections, durg exposure, hypertension), all medications (including over the counter) used during pregnancy
What is included in the past OB Hx?
Birth Hs of other children, and any past C-sections with operative report to determine whether the patient requires a repeat C-section
What in included in the birth hs of other children?
year, place, weeks gestation, weight, sex, delivery mode, and any complications
What is included in past medical Hx?
allergies, transfusions, operations, hospitilizations, trauma, medical illnesses, seizures, hypertension, diabetes, heart diseases, kidney diseases, migraines, thyroid disorders, asthma, tuerculosis (PPD results), hepatitis, recurrent UTI's, blood disorder, psychiatric problems, any other medical illness, childhood disease, rhematic fever, chicken pox
What is included in past Gyn Hx?
Age of start of menses, how regular, how many days of flow, heavy or light flow, birth control method, hs of IUD use, DES exposure, history of STDs (HSV, GC, chlamydia, HPV) last pap and results, last mammogram if >35 y.o
What must you include in family history?
heart diseases, HTN, diabetes, TB, bleeding disorders, twins or other multiple pregnancy (identical or fraternal), birth defects or congenital anomalies, mental retardation, neonatal deaths,, cancer, or any other diseases
What is included in social history?
Tobacco (# of packes per day, for how many years, during pregnancy?), alcohol (how much, what type-beer, whiskey, wine, for how long, when), drugs including IV drug abuse (type of drug, how often, for how long), marital status, occupation, father of baby involved? planned pregnancy? does the patient have social support? is the patient happy about pregnancy?
What do you write if the patient does not use any tobacco, ETOH, durgs?
No T/E/D
What must one ask in consideration of future contraceptive plans?
permanent sterilization desired, birth control pills (BCP's), foam and condoms, IUD, diaphragm, etc