22 Questions
What does 'Para' refer to in obstetric notation?
Number of pregnancies a woman has completed beyond 20 weeks gestation
How would a woman who has been pregnant 3 times (with one set of triplets) be described in obstetric notation?
G 3, P 2
What does 'G' stand for in expanded obstetric notation?
Gravida
How would a woman who has been pregnant 3 times (with one set of triplets) be described in expanded obstetric notation?
G 3, T1, P1, A1, L4
What does 'A' stand for in expanded obstetric notation?
Abortions/Miscarriages
What is an alternative way to write the expanded notation 'G 3, T1, P1, A1, L4'?
G 3, 1-1-1-4
What is included in the Past Medical History?
Allergies, accidents or injuries, illnesses, immunizations, and screening procedures
What is the significance of clarifying symptoms in the Past Medical History?
To provide accurate information about the patient's allergies
What is the purpose of inquiring about the patient's past surgical procedures?
To identify potential surgical complications
What is included in the gynecological history?
Age at menarche, last menstrual period, menstrual pattern, and pain
What is the purpose of inquiring about the patient's immunizations?
To ensure the patient is up to date on all recommended vaccinations
What is included in the screening procedures?
Colonoscopy, mammogram, and pap smear results
Why is it essential to inquire about the patient's past accidents or injuries?
To understand the patient's medical history and potential complications
What is the significance of documenting the patient's current medications?
To identify potential medication interactions
What is the main purpose of eliciting other active problems (OAPs) in a patient's medical history?
To differentiate between current and past medical problems
What is the key to acquiring an accurate past medical history?
Emphasizing the relevant features of past health and medical care experiences
What is the primary difference between traditional past medical history and other active problems (OAPs)?
Relevance to the current syndrome
Why is it essential to differentiate between other active problems (OAPs) and traditional past medical history?
To identify potential contributing factors to the current syndrome
What is the primary goal of eliciting a patient's past medical history?
To emphasize the relevant features of past health and medical care experiences
What is the main challenge in eliciting a patient's past medical history?
Getting too overwhelmed with details about unimportant events
How can clinicians effectively elicit other active problems (OAPs) from a patient?
By inquiring about other symptoms or problems the patient has recently had
Why is it important to keep an inquiry open-minded when eliciting a patient's past medical history?
To avoid missing important events
Study Notes
Past Medical History (PMH)
- A PMH is a bridge between the HPI (History of Present Illness) and other active problems (OAPs)
- It deals with structured data and specific questions about predetermined topics
Components of PMH
- Allergies (clarify symptoms)
- Accidents or Injuries (e.g., appendectomy, MVA)
- Immunizations (e.g., varicella, pap, mammogram, colonoscopy)
- Illnesses (beginning in childhood, e.g., GERD, hyperlipidemia, pneumonia)
- Current Medications (e.g., ranitidine, atorvastatin)
- Hospitalizations (e.g., left arm surgical repair, gallbladder removal)
- Surgical Procedures (e.g., left arm fracture, gallbladder removal)
- Gynecologic and Obstetric History
- Gynecologic: age at menarche, last menstrual period, menstrual pattern
- Obstetric: number of pregnancies, term births, preterm births, abortions/miscarriages, living children
Other Active Problems (OAPs)
- OAPs are medical problems that may contribute to the current syndrome or must be considered in responding to it
- Differentiate OAPs from traditional items in the PMH
- Examples: diabetes, hypertension, coronary artery disease, osteoporosis
Eliciting an OAP
- Ask open-ended questions to avoid missing important events
- Examples: "Has anything else been bothering you?", "Aside from your chest pain, can you think of other symptoms or problems that you've recently had?", "In addition to your diabetes, do you have any other illnesses that have been acting up lately?"
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