How do you take case history in obstetrics and Gynaecology?
- Opening the consultation.
- Presenting complaint.
- History of presenting complaint.
- Systemic enquiry.
- Current pregnancy.
- Previous obstetric history.
- Gynaecological history.
- Past medical history.
What should a gynecological history include?
For the gynecologic history, doctors ask about the problem prompting the visit, past and present menstrual periods, past pregnancies, sexual activities, and gynecologic symptoms, disorders, and treatments that the woman has had in the past.
How do you document OB history?
Accompanied by Arabic numbers, G, P, and A (or Ab) describe the patient’s obstetric history. Roman numerals are not used. Separate GPA sections by commas. Alternatively, spell out the terms in lower case.
How do I present an OBS exam?
Lie
- Facing the patient’s head, place hands on either side of the top of the uterus and gently apply pressure.
- Move the hands and palpate down the abdomen.
- One side will feel fuller and firmer – this is the back. Fetal limbs may be palpable on the opposing side.
What is gynecologic history?
A gynaecological history is an assessment of the female reproductive system. It can be a delicate subject for some women, and it is important to treat any information divulged with sensitivity and respect. However, the clinician cannot shy away from asking clinically relevant questions.
Why is past obstetric history important?
Abstract. A carefully obtained obstetric history can provide the family physician with useful clues to his patients’ health risks. A previous infant’s birth weight and certain congenital malformations may indicate a predisposition to vascular hypertensive or diabetic illness.
What is a Gynaecology examination?
gynecological examination, procedures aimed at assessing the health of a woman’s reproductive system. The general examination usually makes use of a speculum for a view of the vagina and cervix. More specialized procedures include the Pap smear for the detection of cancer of the cervix.
What is OB assessment?
Obstetric risk assessment is an important component of comprehensive obstetric care. It is a tool used to evaluate the medical, psychosocial, familial, and environmental factors that increase the chance of an adverse outcome. Such outcomes may involve the mother, the infant, or both.
What does OB HX mean?
Obstetrical History – Pregnancy Checkup or Complication During Pregancny.
What is a gynaecology assessment?
A gynaecological examination is done to assess the overall health of the female reproductive system. During the exam, the gynaecologist will look at the external and internal reproductive organs, as well as at the breasts, to determine whether there are any problems or conditions present.
What is bad obstetric history?
Bad obstetric history (BOH) implies previous unfavorable fetal outcome in terms of two or more consecutive spontaneous abortions, early neonatal deaths, stillbirths, intrauterine fetal deaths, intrauterine growth retardation and congenital anomalies.
What is the purpose of gynecologic examination?
What history should nurses take during antenatal assessment?
The woman must also understand your role in the assessment, because if she views you only as the interviewer you would only get superficial information from her.
- Health History.
- Demographic Data.
- Chief Concern.
- History of Past Illnesses.
- History of Family Illnesses.
- Social Profile.
- Papanicolaou Smear (Pap smear)
- Blood Studies.
What are the four components of antenatal?
Women who attended ANC were asked if they received the following seven components of ANC at least once: 1) blood pressure measurement, 2) provision of a blood sample, 3) provision of a urine sample, 4) tetanus vaccination, 5) IPTp including number of times, 6) deworming treatment, and 7) iron-folic acid supplements.
What is HX used for?
A record of the state of health and medical history of members of the patient’s immediate family, which may be of interest to the physician or other health care provider because of genetic or familial tendencies noted.
Why does HX mean history?
What is the full form of HX? The Full form of HX is Medical History, or HX stands for Medical History, or the full name of given abbreviation is Medical History.
When should I take my obstetric history?
It’s also worth noting that before 18 weeks gestation, most obstetric conditions are unlikely, therefore your history should be gynaecology focussed (e.g. abdominal pain at 8 weeks gestation could be an ectopic pregnancy). Download the obstetric history taking PDF OSCE checklist, or use our interactive OSCE checklist.
Why is obstetric history important in a gynaecological assessment?
It is important to take a brief obstetric history as part of a gynaecological assessment, as it may be relevant to the patient’s presentation. This is less detailed than a focused obstetric history. Gravidity is the number of times a woman has been pregnant, regardless of the outcome.
How do I take a gynaecological history?
A gynaecological history involves asking questions relevant to the female reproductive system. Some of the questions are highly personal and therefore good communication skills and a respectful manner are absolutely essential. Taking a gynaecological history requires asking a lot of questions that are not part…
What questions should I ask during a gynaecological consultation?
Ask if the patient has previously had any gynaecological problems: Ask the patient if they’ve previously undergone any surgery or procedures in the past such as: Clarify the patient’s cervical screening history: Confirm the date and result of the last cervical screening test.