Gynecological History

Patients Profile

MR#: ________________________

Name:

Husbands/Fathers Name:

_____________________________________
_____________________________

Age:

_____________________________________

Husbands Age:

_____________________________

Education:

_____________________________________

Husbands Education:

Occupation:

_____________________________________

Husbands Occupation: _____________________________

Blood Group:

_____________________________________

Husbands Blood Group:

_____________________________

_____________________________
Married for (Yrs):

_____________________________________

L.M.P:

_____________________________________

Parity:

_____________________________________

PRESENTING

Consanguinity: Yes/No

Phone:

_____________________________________

Residence:

_____________________________________

COMPLAINT :

__________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

History of Presenting Complaint

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Review of System
G ENERAL : 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
R ESP : 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:

_____________________________________

Husbands History (Specific to Infertility)

Surgical Illness: _________________________________

Medical illness:

______________________________________
History of prolonged illness:

_________________________

Any other:

______________________________________
History of prolonged medication:
__________________________________________________________________________________

Past Obstetrics History

Year

Place of

of

Birth

Duration

Complication

Mode of

Se

Birth

Breastf

Current

Delivery

Weigh

ed

Health

Birth

Status

Past Medical History

Medical: DM, HTN, MI, stroke, TB, hepatitis, asthma, cancer, DVT, anemia
Surgical: trauma, transfusions, anesthesia complications, previous surgery: ____________________________
__________________________________________________________________________________________

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:

___________________________________________
_____________________________________________________________________________________________________________
_

Examination
GENERAL AND PHYSICAL EXAMINATION
Appearance:
___________________________________________________________________________________________________
Height:

________________________

Pulse:

________________________/min

Temperature:

________________________

Weight:
Blood pressure:

___________________kg
_______ / _______mmHg

Respiratory rate:

___________________/min

H ANDS: leukonychia, koilonychia, thenar or hypothenar atrophy, sweatiness, splinter hemorrhages, clubbing
S KIN : 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 ______________
N ECK : normal carotid pulses, tracheal deviation, goiter, engorged neck veins
LYMPH NODES:
__________________________________________________________________________________________________
LUNG :
________________________________________________________________________________________________________
H EART :
_______________________________________________________________________________________________________
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

Umbilicus: ________________________________

distension, visible veins

___________________________________________________________________________________________________________
Palpation

Hepatomegaly, splenomegaly, kidneys palpable, guarding, abdominal rigidity

Tenderness:
___________________________________________________________________________________________

Percussion

Liver span: ______________

Shifting dullness: ______________

___________________________________________________________________________________________________________
Auscultation

Bowel sounds: increased/decreased/normal

Renal bruit, splenic rub, aortic bruit

PELVIC EXAMINATION
Vulva/Perineum
Hair distribution: ________________________________________
Discharge: Color ___________

Amount ____________

Bleeding:

Amount ____________

Color ___________

Smell _____________

Labia Minora: ________________________________________ Labia Majora:

Clitoris:

________________________________________

_____________________________________

Introitus:

______________________________________
Perineum

: ________________________________________

Speculum Examination
Discharge: Color ___________

Amount ____________

Bleeding:

Amount ____________

Color ___________

Smell _____________

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
_________________________

_________________________

_________________________

_________________________

Investigations
_____________________

_____________________

___________________

_____________________

_____________________

Plan/Treatment
_____________________________________________________________________________________________________________
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Arslan Gujjar is a retard :p