GYNE FORMAT

Presenting a case of ___________, ____ year old Gravida __Para ___(__-__-__-__) (single/married), Filipino,
(religion) _______________ from _____________________ admitted for the __________ in NMMC due to
__________.

For the past medical history, patient has (no history of medical hospitalizations or surgical admissions)/
(history of __________________________________________ No known food and drug allergies.

For the family history, patient has (no history of heredofamilial disease)/ (history of hypertension, diabetes
mellitus, asthma, cancer) on her [maternal/paternal] [paternal] [maternal] side.

For the personal and social history, patient is a ____________________ graduate, works as a
____________________ married for __________years to ____year old ____________
Patient is a non-smoker, non-alcoholic beverage drinker and denies use of illicit drugs.

For the gynaecologic history, she had her menarche at _____ years old with subsequent menses at
[regular/irregular] intervals, _____ days in duration and consumes _____ pads per day, [moderately/fully]
soaked, [scanty/moderate/profuse] flow [associated/not associated] with dysmenorrhea. She had her coitarche
at _____ years old with _____ sexual partner. Family planning used was/were
___________________________________________________________________

For the obstetrical history, patient is a Gravida__ Para ___ (__-__-__-__)

Type of Delivered
Gravida Year Term BW Where Complications
delivery by

For the History of Present Illness,

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For the patient’s physical examination,

Patient was examined conscious, coherent, ambulatory, and not in respiratory distress with the following vital
signs: BP _____ mmHg; heart rate _____ beats per minute; respiratory rate _____ cycles per minute;
temperature _____ afebrile with a weight of _____ kg and height of _____ cm. BMI______.

Skin of patient is warm and of good turgor.

HEENT: [pink/pale] palpebral conjunctivae; anicteric sclera; moist lips and tongue
C/L: no retractions, equal chest expansion, clear breath sounds
CVS: adynamic precordium, distinct heart sounds, no murmur
Abdomen was examined _________________________________________________
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Speculum Exam: ___________________________________________________________
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Bimanual Pelvic Exam:
I:
C:
U:
A:
D:
Extremities: absence of edema with good peripheral pulses

Admitting
Impression:______________________________________________________________________________
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Plan:
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