OB 101
Obstetrical History General Data: Initial, Age, Gravity, Parity, LNMP, If pregnant include EDC (-3, (-3, +7), +7), AOG, Date, Time of Admission. st
nd
Chief complaint: (If for prenatal check up- State its order of chronology eg. If it is 1 or 2 & so on) -bleeding, pain (specific site), Mass, Vaginal discharge, Urinary & vaginal symptoms, Infertility, protrusion of vagina. HPI: PQRST for Pain (Provoking, Palliating, Quality, Radiation, Region, Severity, Timing- constant or intermittent). -Unusual Correlations (Associated symptoms) -other symptoms CODIERS: CODIERS:
1. Chronology of complaints- sequence of events lead up to the c urrent problem? 2. Onset: When did the problem begin? 3. Description/duration: where, like/how long/constant or sporadic 4. Intensity: how severe, getting better or worse? 5. Exacerbation: what enacts or m akes it worse? 6. Remission: what relieves or makes it go away? 7. Social: how affected work, family, self image, activities? ANDREA MANKOSKI¶S PAIN SCALE (for pain Severity) o 1
Pain free Very minor annoyance Occasional minor twinges Minor annoyance - occasional strong twinges.
No med No med
3
Annoying enough to be distracting.
4
Can be ignored if you are really involved in your work, but still distracting.
Mild pain killer effective effective (i.e., aspirin, ibuprofen). Mild painkillers relieve pain for 3-4 hours.
5
Can't be ignored for more than 30 minutes
Mild painkillers reduce pain for 3-4 hours.
6
Can't be ignored for any length of time, but you can still go to work and participate in social activities.
Stronger painkillers (Codeine, Vicodin) reduce pain for 3-4 hours.
2
No med
1 Prepared by ACLB
OB 101
7
Makes it difficult to concentrate, interferes with sleep You can still function with effort. Stronger painkillers are only partially effective.
Strongest painkillers relieve pain (Oxycontin, Morphine).
8
Physical activity severely limited. You can read and converse with effort. Nausea and dizziness set in as factors of pain.
Stronger painkillers are minimally effective. Strongest painkillers reduce pain for 3-4 hours.
9
Unable to speak ² crying out or moaning uncontrollably ² near delirium.
Strongest painkillers are only partially effective
10
Unconscious. Pain makes you pass out.
Strongest painkillers are only partially effective.
Most Common chief complaints: Complaint
onset
Provoking
palliating
Quality
Radiation/ region
Severity/ intensity
Timing/ duration
Pain
When?
Physical activities
Relieved by what?
Sharp dull
Lumbo Sacral?
Pain scale
Bleeding
When?
Exacerbated By coitus? Phy act? Terminate preg?
Meds? Bed rest?
Profuse to Mild? Mild becoming profuse
How long Intermittent? Constant? Days? Days?
Post partum bleed
When?
Mild 1 pad Mod 2-4 soak Profuse 5 or > Well soak Blood clots?
meds
Days?
Relations
descrip tion
Type of delivery
Describ e deliver Manage ment of labor Descrie d dischar ge
Lacerations ? Vaginal discharge
When?
Follicular phase?
Amenorrhe a
When? LNMP?
Meds? Hormones?
Vulvar pruritus
When?
infertility
When?
During urination? Food or drug intake? Undies? Drugs? Contraceptives ?
Scanty?
Amount?
Days?
Days, weeks, months, years
Remission ?
Sudden?
Intense?
How long?
Sex? Social effect Fever? Breast changes Nausea & vomiting Weight gain Spotting pain Weight gain?
describ e
How long?
2 Prepared by ACLB
OB 101
Systems review: (for non-pregnant patients)
General Fever, chills, usual weight, usual state of health, wt changes, weakness, fatigue, sweats, heat/cold intolerance, anemia, bleeding tendencies, blood transfusion, rxns, exposure to radiation? Skin Rashes, itching, hives, easy bruising, hx of eczema, dryness, changes in skin color, hair changes, texture, nail changes, Hx of skin disorders, lumps, hair dyes
Head Dizziness Headaches Pain Fainting Hx. Of head injury Stroke hx Eyes Eyeglasses Current vision Change in vision Double vision Excessive tearing Pain, eye exams?, unusual sensations, redness, discharges, hx of glaucoma, cataracts, injuries Ears Hearing impairment? Hearing aid Discharges Dizziness, pain, ringing infections
Neck Lumps, goiter, pain on movement, hx. Of swollen neck, thyroid mass, thyroid surgery, tenderness
GIT Musculoskeletal Appetite Weakness, Paralysis, Excessive hunger or thirst? Muscle stiffness, limitation Nausea, vomiting, of movement, joint pain, swallowing?, constipation, joint stiffness, arthritis, Diarrhea, Heartburn, gout, back problems, Abdominal pain, changes in muscle cramps, deformities stool color, caliber, consistency, frequency of bowel movement, blood Chest vomiting, rectal bleeding, Cough, pain, shortness of black tarry stools, laxative breath, sputum (quantity, or antacids? appearance), TB, Asthma, Excessive belching, food pleurisy, bronchitis, intolerance, change in coughing out of blood, abdominal size, wheezing, x-ray, BCG? hemorrhoids, infections, jaundice, rectal pain, Xrays, hepa, liver dis, gallbladder dis. Heart Urinary Pain, BP, palpitations, Frequency, urgency, Shortness of breath during difficulty in starting the exertion or lying flat, while stream, incontinence, sleeping, hx of heart attack, excessive urination, Rheumatic fever, ECG burning, blood, infections, findings others stones, bed-wetting, flank pain. Awakening to urinate, Vascular Female Genitalia Pain in legs, calves, thigh, Lesions, itching, discharge, retention, urine color, odor or hips, pain while walking, pap smear result, pain in varicose veins, sex, frequency of sex, thrombophlebitis, coolness contraceptives, fertility of extremity, loss of hair on problems, happy with sex?, legs, discoloration of hernias, STD hx and extremities, ulcers treatment, menarche, intervals, duration, amount, LMP, bleeding between periods, number of pregnancies, abortions, Breasts Neurologic term pregnancies, Lumps, discharges, pain, Fainting complications in preg, tenderness, self-exam Dizziness describe labor, number of findings? Blackout living children, menstrual Paralysis, strokes, pain, age of menopause, Numbness, tingling, menopausal symptoms, burning, tremors, loss of postmenopausal bleeding
3 Prepared by ACLB
OB 101
Nose Bleeds Infection Discharges Frequency of colds Nasal obstruction Hx. Of injury Sinus infection, hay fever
Mouth & throat Teeth condition Gums, frequent sore throats, burning of tongue, hoarseness, voice changes, postnasal drip
Male genitalia Lesions of the penis Discharges, impotence, pain, scrotal masses, hernias, frequency of intercourse, happy with sex?, Fertility, prostate, STD & treatment
memory, Psychiatric disorders, mood changes, nervousness, speech disorders, unsteadiness of gait, general behavioral change, loss of consciousness, hallucinations, disorientation
Antenatal course for pregnant patients: First trimester (0 ±13 completed weeks) Weight prior to pregnancy Was preg. test done? Signs & symptoms like Fatigue, vomiting, nausea, weight gain or loss, fever, spotting, amenorrhea, urination, areola, nipple changes, breast changes (when?) Date of first prenatal check up? AOG at prenatal check up? Place& who did the prenatal? Baseline BP Subsequent prenatal visits? Findings? BP ranges Medications/ vitamins/ dosage Vaccines? Number of injections? Illnesses incurred/ operations/ accidents? Hypertension? Diabetes? Lab result? Management? Diet modification Ultrasound? Danger signs of pregnancy?
Third trimester (29- 40 completed weeks) Symptoms gone? Latest symptoms? Notice an Enlarging Abdomen? Weight gain? Place& who did the prenatal? Subsequent prenatal visits? Findings? BP ranges Medications/ vitamins/ dosage Illnesses incurred Hypertension? Diabetes? Lab result? Management? Diet modification Ultrasound result? -Fetal age, significant findings Enlarging abdomen Danger signs of pregnancy? Active Fetal movement? Braxton hicks (Duration, interval, regular or irregular) Illnesses incurred Operations/ accidents? Leopold¶s maneuver? Findings?
Second trimester ( 14 ± 28 completed completed weeks) Signs & symptoms like Fatigue, vomiting, nausea, weight gain or loss, spotting, bleeding, breast changes or latest symptoms? Notice an Enlarging Abdomen? Place& who did the prenatal? Subsequent prenatal visits? Findings? BP ranges Medications/ vitamins/ dosage Vaccines? Number of injections? Illnesses incurred Hypertension? Diabetes? Lab result? Management? Diet modification Quickening (Date) Ultrasound result? -Fetal age, significant findings Enlarging abdomen Fetal movement? Irregular or Regular Danger signs of pregnancy? Illnesses incurred Operations/ accidents?
SUMMARY Total weight gain? Latest weight- prior pregnancy weight= weight gain Total number of pregnancy visits? Danger signs all throughout pregnancy? Treatment? Maintenance?
Danger signs of Pregnancy: 1.Vaginal bleeding- amount, color, intensity (profuse?), associated pain (PQRST)- in abortions
4 Prepared by ACLB
OB 101
2. Severe Nausea & Vomiting 3. Fever & chills ±indicate infection 4.Escape of Clear Fluid (Bag of Water)- in PROM, Preterm labor 5.Severe Headache- may be pre-ecclampsia/ ecclampsia 6.Edema/ swelling of face or fingers 7.Pelvic or Abdominal pain- in abortions, ectopic preg, placental abruption, preterm labor 8.Elevated BP 9.Absence of fetal movementmovement- in fetal demise, fetal distress
Diagnosis of pregnancy:
Presumptive symptomssymptoms- nausea w/o vomiting, disturbances in urination, fatigue, perception of fetal movement, breast symptoms Probable evidenceevidence- abdominal enlargement, changes in uterine size, shape, consistency, cervix changes, Braxton- hicks, ballotment, outlining of fetus Positive signssigns- FHT, fetal movement movement perceived by examiner, Ultrasound Ultrasound fetal recognition.
MENSTRUAL HISTORY: HISTORY : menarche X Interval X Duration, Duration , LMP, PMP Gyne patients: patients: (detailed) number of pads, intensity or amount, color of blood, odor, interval (shortest to longest), irregular (> 7 days) blood clots, dysmenorrhea (onset, occurred before, during or after menarche? day in cycle, radiation, location, location, duration, pain scale, progressive or intermittent or constant), LMP, PMP, infertility problem, dysparenuria.
OB HISTORY: if more than 1 pregnancy tabulate. All Deliveries done in the hospital are placed in the Postpartum note! Deliveries done outside the hospital like birth centers or home deliveries are place here in Tabulated form .
No of pregnan cy G1
Year Wgt Sex
Duration
Type of delivery
Place of delivery
Who delivered
Condition At birth
Maternal complication
Fetal complications
C/S NSVD, Forceps Vacuum Breech extractio n
Clinic hospital
OB Physician Traditional Birth attendant
Dead Alive Needed resuscitation
Ecclampsia bleeding
Congenital anomalies
-Number of pregnancies, full term? Complications, Complications, abortions, and congenital anomalies what age of gestation, D &C (why & where is it done?) CONTRACEPTIVE HISTORY Pills or any contraceptive? When started using, duration, and side effect? If not discontinued, did she know how to use? Describe the technique If discontinued, why discontinued, when discontinued? IUD? Why removed? SEXUAL HISTORY Asked only if suspecting the ff: has STD, PID, Ca of the cervix, abnormal vaginal discharges, pruritus, infertility
5 Prepared by ACLB
OB 101 st
-Age of 1 coitus, number of sex partners, single, post coital bleeding, dysparenuria, Last sexual contact, frequency. PAST MEDICAL ILLNESS/ OPERATIONS Medical condition Medications Allergies Surgical procedures Hospitalizations
FAMILY HISTORY Heredofamilial diseases: diseases: Ca, DM, Myoma, Relevant kidney dis. Who in the Family? Mother, Father, grandpa, etc Difficulty of labor, twins, congenital malformation SOCIAL/PERSONAL HISTORY A. Birth day, birth place, Nationality, Religion, occupations B. Year of m arriages, duration of infertility, --separated? C husband¶s age, occupation, religion, state of health D. Home condition- maternal or paternal side -Medication, years, dosage -Diabetic, Asthmatic -Food or drug allergies, which one? -Family members with diabetes or asthmatic, drug m aintenance, allergies (which side) E Stress level- related to recent life event, or occupation or finances F Habits: smoking, years, packs or sticks/day; coffee G. Educational attainment .
.
.
NUTRITIONAL HISTORY A. Description and amount ( 3 meals/day) meals/day) of Previous meal. B. Appetite & regularity of meals C. Dentition, false teeth, chewing D. Food likes & dislikes E. Food allergies F. Snacks G. Budget for food/day BMI (Kg/m2) = wt in kg Ht in m2 Calorie index= Ideal Body weight: Women: Ideal Body Weight (kilograms) = [Height (cm) - 100] + ([Height (cm) - 100] x 15%) Men: Ideal Body Weight (kilograms) = [Height (cm) - 100] - ([Height (cm) - 100] x 10%)
Total Energy Requirement (TER): BER= Weight in Kilograms X (24 (hrs.) x Calorie requirement/hr) NB: For every Kg of Body weight 1.2 ± 1.3 kilo Calorie is required/ hour
Sedentary - none or or very little little exercise exercise = BMR X 1.2 (others (others 1.3) Light activity activity for average of 2 days/week = BMR X 1.375 Moderate activity level exercising 4 days/week = BMR X 1.5 High activity activity levels exercise exercise & sports more than 6 days/week days/week = BMR X 1.7
6 Prepared by ACLB
OB 101
Higher activity levels = up to 2 x BMR
Calorie requirement for sedentary Patients: 1.2 -1.3; average 1.25 BER= 44.87 x (24hrs x1.25) = 1346.1 TER= 1076.88 + 300 = 1646.1 calories NB: 300 calories additional requirement for pregnant women. TER= (IBD in Kg X 30) + 300 POSTPARTUM NOTE (History of postpartum) -date of admission -Date & time of delivery -type of delivery -condition of baby, sex, weight GYNECOLOGICAL NOTE (post operative note) -Date & time of surgery -type of surgery -indications PHYSICAL EXAM (Do complete PE but with emphasis on the Breast, Abdomen, pelvis) Vital signs BREAST: Inspection- Symmetry, Engorgement, prominent veins, Nipple & Areola- inversion, pigmentation, discharges, inflammatory lesions PALPATION:
Masses- multiple or solitary, Tenderness, Tenderness, Lymphadenopathy
ABDOMEN: ABDOMEN: OB PE methods -I nspection nspection ± Shape: Globular, flabby, fl at? Symmetrical? Scars, striae, linea Alba, fundal height, height , n nterval) -Palpation- Masses, Leopold¶s maneuver, contractions if present ( I Intensity, tensity, Duration, I nterval) Leopold¶s: LM 1
Report Breech Cephalic
Interpretation Interpretat ion fetal buttocks fetal head
LM 2
Fetal back directed to L or R
Hard, resistant convex structure
LM 3
Cephalic, unengaged, floating Or Breech
Fetus fixed into cervix or not
LM4
Cephalic prominence on L or R Engage= Negative; Not engaged= cephalic prominence is palpated
TAL ATT I ITUD T FE TAL UDE: Lie ± Lie ± Longitudinal, transverse, oblique Position ± LOP, LOT, LOA, ROA, ROT, ROP Presentation- Vertex, Sinciput, Brow, Face Contractions- Duration, Interval, Intensity -Percussion-
Dullness?
Auscultation- Auscultation
bowel sound, FH T? T? Location of FH T (by quadrant)
7 Prepared by ACLB
