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How do you write OB history?

Obstetric history: 4-2-2-4. Alternatively, spell out the terms as follows: 4 term infants, 2 premature infants, 2 abortions, 4 living children.

What is G3P1011 in pregnancy?

® G3P1011-a woman who is currently pregnant, had one full term delivery and one abortion or. miscarriage and one living child. ® G2P1002- a woman who is currently pregnant. and had twins in her first pregnancy.

How do I access my OBS history?

First, ask about the gestational age of the pregnancy. Gestation is described as weeks+days (e.g. 8+4; 30+7; 40+12 \u2013 post-dates). The last menstrual period date (LMP) can be used to estimate gestation, with Naegele's rule the most common method (to the first day of the LMP add 1 year, subtract 3 months, add 7 days).

What is obstetrical history?

An obstetric history involves asking questions relevant to a patient's current and previous pregnancies. Some of the questions are highly personal, therefore good communication skills and a respectful manner are absolutely essential.

What should an OB GYN history include?

Obstetric history. Patients should be asked to list all pregnancies and the outcome of each, with attention to whether the pregnancy was intrauterine or ectopic....Menstrual History. Age at menarche. ... Last menstrual period (LMP). ... Menstrual pattern and associated symptoms. ... Perimenopause/menopause.

gyn history template

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What is OB physical assessment?

Obstetric examination focuses on uterine size, fundal height (in cm above the symphysis pubis), fetal heart rate and activity, and maternal diet, weight gain, and overall well-being. Speculum and bimanual examination is usually not needed unless vaginal discharge or bleeding, leakage of fluid, or pain is present.

What are the physical assessment of pregnant woman include?

Antenatal Care Module: 9. General Assessment of the Pregnant Woman 9.1 Checking for symptoms of poor nutrition or lack of iodine. ... 9.2 Checking her weight. ... 9.3 Checking her temperature. ... 9.4 Checking her pulse. ... 9.5 Checking for signs of anaemia. ... 9.6 Checking for shortness of breath. ... 9.7 Checking her blood pressure.

How do you write gynae history?

Presenting complaint Last menstrual period (LMP) - date of first day of bleeding. Cycle length and frequency - eg, 5/28, five days of bleeding every 28 days. Heaviness of bleeding. ... Presence or absence of intermenstrual bleeding (IMB). Presence or absence of postcoital bleeding (PCB). Age of menarche/menopause.

What should an obstetric history include?

Obstetric History Gravidity. Number of times pregnant. Parity. Number of live births. Miscarriages. Terminations. Previous Pregnancies. Length, mode of delivery. Length of Pregnancy. Gestational age at delivery. Induction. Spontaneous / induced. Mode of Delivery. Vaginal, forceps, suction, elective / emergency caesarean.

What is the importance of reviewing gynecological history?

A detailed review of a patient's health status, previous medical conditions, and gynecologic history provides pertinent and important information that guides the physical and pelvic examination , furnishes the indications for screening, and directs the selection of diagnostic testing and imaging studies needed to ...

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