Saturday, June 19, 2010

OB-GYN part 1

It seems fitting that a specialty which refers to itself with a five letter abbreviation is one that is chock full of abbreviations, to the point that our syllabus was annotated with a glossary. I imagine this is some subconcious throw-back to the days when physicians spoke in latin both to impress their patients and to conceal their thoughts. Here's a sample:

CC: VB for 2hr
HPI: HC is a 38 yo G4P3103 at 37w5d c/o spontaneous VB this afternoon after waking from a nap. She denies any LOF, d/c, and has postive FM. Pt denies pain, no h/a, dizziness, RUQ pain, or VC. Pt only c/o BRB with dime sized clots. Denies any dysuria, pyuria, hematuria, no n/v/d.

Gyn Hx:
Pap-no hx of abnl pap
STI: neg trich, GC, CT, HIV.
Sx: LTCS for FTP

G1: 2001 IOL for dates at 41, F 6#7
G2: 2003 SVD at 33 F 4#1
G3: 2005 LTCS a 38 for FTP F 6#9
G4: current, pt desires TOLAC.

Med Hx: none
Rx: PNV and Fe
Allergies: NKDA
BrCA: mother, maternal aunt, MGM,
DM: mother, MGF

Pt is 38 G4P3103 c/o VB.
1. U/S
2. FFN, CBC,
3. consider MFM consult.

For the medical purists out there, I know that this is an incomplete H &P and that the assessment and plan are incomplete, but I'm illustrating a point. Here is a prose version:

HC is a 38 year old female with a history of 4 pregnancies, 3 deliveries, 2 term and one premature. She has a complaint of vaginal bleeding. She denies any loss of fluid, vaginal discharge (i.e. purulent discharge), and has felt fetal movement. Patient does not complain of a headache, right upper quadrant abdominal tenderness or vision changes.

Gynecological history:
patient has never had an abnormal pap smear
-no sexually transmitted infections like gonorrhea, chlamydia, trichomonas, or human immunodeficiency virus.
-Her only procedure was a low transverse cesarean section
Obstetrical history:
-G= pregnancy
SVD= spontaneous vaginal delivery
IOL = induction of labor
x#y= lbs and oz
TOLAC= trial of labor after c-section

Family history:
MGM= maternal grandmother
CAD: coronary artery disease
DM: diabetes mellitus.
BrCa: breast cancer

NKDA: no known drug allergies
FFN: fetal fibronectin a test than can help predict the probablility of labor or rupture of fetal membranes.
MFM: maternal fetal medicine: high risk OB doctors.
U/S: ultrasound.

A lot of these abbreviations are very standard, but the OB specific ones can be challenging, especially since they can be interpreted multiple ways i.e. VB could mean vaginal birth, or vaginal bleeding. Mostly there has been a movement towards the standardization of abbreviations in medicine as well as a decrease in their use overall, but OB is a lone holdout.


Maggie said...

wow, there's no way I could ever have understood most of that.

Mike said...

Well in reading that it's actually interesting to see how many abbreviations I learned over the last 6 weeks, I however managed to not learn "TOLAC". OB/GYN has wtma (way too many abbreviations). That being said, I find myself using them liberally without thinking about it just for the sake of convenience.