OB/Gyn Templates
From James.Pirruccello.Us
[edit] Triage & Antepartum
- Cardinal questions:
- Leakage of fluid?
- Bleeding?
- Contractions?
- Baby moving?
- Pain in abdomen?
- Fever?
[edit] Mag Note
- S - Elucidate pre-eclampsia symptoms and magnesium toxicity symptoms.
- Pre-eclampsia
- Symptoms - RUQ pain or right shoulder pain, headache, visual disturbance, foamy urine (proteinuria), nausea, vomiting
- Signs - HTN, edema, proteinuria
- Mag toxicity
- Symptoms - dyspnea, muscle weakness, lethargy, drowsiness
- Signs - loss of DTRs, muscle weakness, changes in pulmonary auscultation due to weakened respiration
- Pre-eclampsia
- O
- Vitals
- SVE Deferred
- FHT (baseline FHR; short-term variability; accelerations; decelerations)
- Toco (variability or contractions; MVU if intrauterine (amplitude * freq per 10 min)
- A/P
- Presentation (vtx), GBS (+/-)
- FWB reassuring/not
[edit] Strip Note
- S
- No complaints (or complaints, if any)
- O
- Vitals
- SVE Deferred
- FHT (baseline FHR; short-term variability; accelerations; decelerations)
- Toco (variability or contractions; MVU if intrauterine (amplitude * freq per 10 min)
- A/P
- Presentation (vtx), GBS (+/-)
- FWB reassuring/not
