gynecological history + examination
DESCRIPTION
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Gynecological History
Patient’s Profile MR#: ________________________
Name: _____________________________________ Husband’s/Father’s Name: _____________________________
Age: _____________________________________ Husband’s Age: _____________________________
Education: _____________________________________ Husband’s Education: _____________________________
Occupation: _____________________________________ Husband’s Occupation: _____________________________
Blood Group: _____________________________________ Husband’s Blood Group: _____________________________
Married for (Yrs): _____________________________________ Consanguinity: Yes/No
L.M.P: _____________________________________
Parity: _____________________________________ Phone: _____________________________________
Residence: _____________________________________
PRESENTING COMPLAINT: __________________________________________________________________________
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History of Presenting Complaint
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Review of System
GENERAL: weakness, fatigue, fever
GIT: loss of appetite, nausea, dysphagia, regurgitation, flatulence, heartburn, vomiting, hematemasis, abdominal pain, abdominal
distention, abnormal bowel habit, constipation, diarrhea, abnormal stool, rectal bleeding, incontinence
RESP: hemoptysis, dyspnea, orthopnea, hoarseness, wheezing, chest pain
CVS: dyspnea, paroxysmal nocturnal dyspnea, chest pain, palpitations, dizziness, ankle swelling, limb pain
ENDOCRINE: acne, weight gain, hirsuitism, galactorrhea, hot flushes, night sweats, heat or cold intolerance
UGS: loin pain, poor stream, dribbling, hesitancy, dysuria, urgency, hematuria, polyuria, incontinence, nocturia
CNS: behavioral changes, depression, memory loss, anxiety, tremor, syncopal attacks, loss of consciousness, fits, muscle weakness,
sensory disturbances, parasthesias, dizziness, change of smell, vision or hearing, headaches
MSS: muscle aches, bone pain, joint swelling, limitation of joint movement, disturbance of gait, back pain, muscle wasting
Menstrual History
Menarche: ________ years Cycle: _____/______
Flow and regularity: ____________________________________ Pap smear done: yes/no
Contraceptions used by husband/patient: ___________________________________________________________________________
Dysmenorrhea, postcoital bleeding, dyspareunia, intermenstrual bleeding, _________________________________________________
Coital History (Specific to Infertility)
Frequency of coitus: ____________________________ Erection problems: _____________________________________
Ejaculation problems: ____________________________ Any other: _____________________________________
Husband’s History (Specific to Infertility)
Surgical Illness: _________________________________ Medical illness: ______________________________________
History of prolonged illness: _________________________ Any other: ______________________________________
History of prolonged medication: __________________________________________________________________________________
Past Obstetrics History
Year of
Birth
Place of
Birth
Duration Complication Mode of
Delivery
Sex Birth
Weight
Breastfed Current
Health Status
Past Medical History
Medical: DM, HTN, MI, stroke, TB, hepatitis, asthma, cancer, DVT, anemia
Surgical: trauma, transfusions, anesthesia complications, previous surgery: ____________________________
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Family History
DM, HTN, MI, stroke, TB, hepatitis, asthma, cancer, twins, congenital anomalies, infertility, prolapse
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Medication History
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Allergies
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Social History
Smoking, hukka, niswaar, alcohol Housing: _____________________________________________
Monthly income: _____________________________ Social class: ___________________________________________
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Examination
GENERAL AND PHYSICAL EXAMINATION
Appearance: ___________________________________________________________________________________________________
Height: ________________________ Weight: ___________________kg
Pulse: ________________________/min Blood pressure: _______ / _______mmHg
Temperature: ________________________ Respiratory rate: ___________________/min
HANDS: leukonychia, koilonychia, thenar or hypothenar atrophy, sweatiness, splinter hemorrhages, clubbing
SKIN: spider angiomata, pallor, rash, petechiae, bruises, capillary refill _________, skin turgor ________
EYES: both pupils round, regular and reactive, pallor, jaundice
FACE: chloasma, jaundice, periorbital edema, proptosis, oral hygiene ______________
NECK: normal carotid pulses, tracheal deviation, goiter, engorged neck veins
LYMPH NODES: __________________________________________________________________________________________________
LUNG: ________________________________________________________________________________________________________
HEART: _______________________________________________________________________________________________________
GU: non-palpable kidneys, distended bladder, renal punch
EXTREMITIES: ankle edema, cyanosis, erythema, varicose veins, peripheral pulses normal, calf tenderness
CNS: cranial nerves _________, sensory or motor loss, tone _________, reflexes __________, neck rigidity
BREAST EXAMINATION
Inspection: ____________________________________________________________________________________________________
Palpation: _____________________________________________________________________________________________________
Lymph nodes: _________________________________________________________________________________________________
Any other: ____________________________________________________________________________________________________
ABDOMINAL EXAMINATION
Inspection
Scar marks pigmentation, abdominal distension, visible
veins
Umbilicus: ________________________________
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Palpation
Hepatomegaly, splenomegaly, kidneys palpable, guarding, abdominal rigidity
Tenderness: ___________________________________________________________________________________________
Percussion
Liver span: ______________ Shifting dullness: ______________
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Auscultation
Bowel sounds: increased/decreased/normal Renal bruit, splenic rub, aortic bruit
PELVIC EXAMINATION
Vulva/Perineum
Hair distribution: ________________________________________
Discharge: Color ___________ Amount ____________ Smell _____________
Bleeding: Color ___________ Amount ____________
Labia Minora: ________________________________________ Labia Majora: _____________________________________
Clitoris: ________________________________________ Introitus: ______________________________________
Perineum: ________________________________________
Speculum Examination
Discharge: Color ___________ Amount ____________ Smell _____________
Bleeding: Color ___________ Amount ____________
Cervix: Position ____________________ Size ____________________ Mass ____________________ Ectopy____________________
Bimanual Abdominopelvic Examination
Uterus
Position: ________________________________________ Size: ____________________________________________
Margins: ________________________________________ Mobility: ____________________________________________
Tenderness: ________________________________________
Posterior Fornix
Tenderness: ________________________________________ Mass: ___________________________________________
Fullness: ________________________________________ Nodularity: ___________________________________________
Left Fornix
Fullness: ________________________________________
Mass: Size_________________ Margins _________________ Mobility _________________ Relation to uterus _________________
Right Fornix
Fullness: ________________________________________
Mass: Size_________________ Margins _________________ Mobility _________________ Relation to uterus _________________
If Prolapse Cystocele/Rectocele/Enterocele 1st/2nd/3rd degree ______________________________________
Rectal Examination
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Differential Diagnosis
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Investigations
_____________________ _____________________ ___________________ _____________________ _____________________
Plan/Treatment
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Arslan Gujjar is a retard :p