GYNE HISTORY TAKING

GENERAL DATA
Patient Name:
Age/CS:
Address:
Gravida _ Para _ (_ _ _ _)

CHIEF COMPLAINT
Pelvic pain

HISTORY OF PRESENT ILLNESS

Example:

3 years PTA, the patient noted occasional tolerable pelvic pain,

ps 4/10 during menstruation associated with dyspareunia.

2 months PTA the patient noted pelvic pain with increasing

severity, ps 7/10 radiating to the legs occurring daily. No
medication was taken. Consult was done and an ultrasound of
the whole abdomen revealed mild fatty liver. The patient was
then referred to the current attending physician.

1 week PTA. Still with pelvic pain associated with loose bowel
movement. Sought consult with AP. TVS revealed normal-sized
retroverted Uterus, Right adnexal mass, atrophic left ovary, and
minimal cul-de-sac fluid.

PAST MEDICAL HISTORY

Previous operation
RTI’s/STD/HIV: None
( ) Hypertension
( ) Bronchial asthma
( ) DM
( ) Cardiac disease
( ) Thyroid disease
FAMILY MEDICAL HISTORY
( ) Hypertension – maternal and paternal
( ) Multiple births
( ) Birth defects
( ) DM
( ) Heart disease
( ) Pulmonary TB
( ) Malignancy
( ) Thyroid disease

OBSTETRIC HISTORY
Gravida _ Para _ (_ _ _ _)

GYNECOLOGIC HISTORY
Menarche: 15 years old
Interval: Interval
Duration: 7 days
Amount: 7 pads/day, moderately soaked
( ) Dysmenorrhea
Menopause: March 2020

PERSONAL/SOCIAL/SEXUAL HISTORY
Occupation:
Spouse’s Occupation:
( ) Smoking
( ) Alcohol intake
( ) Substance abuse
( ) Physical/Sexual abuse
Coitarche: 29 years old
Number of sexual partner: 2
Desired family size: 3
Contraceptive History: Condom
Pap Smear: May 2022 – Unremarkable findings
REVIEW OF SYSTEMS
( ) Fever
( ) Syncope
( ) Fatigue
( ) Unintentional weight loss
( ) Dyspnea
( ) Dizziness
( ) Dysuria
( ) Pelvic pain

PHYSICAL EXAMINATION
Vital Signs:
BP: mmHg
HR: bpm
RR: cpm
Temp: C
Height: cm
Weight: kg
BMI: ___ (Category)

General Survey: Awake, alert, Comfortable, not in respiratory

distress, ( ) pallor, non-cachectic
HEENT: Anicteric sclerae, pale palpebral conjunctiva
Breast: Symmetrical, ( ) Erythema, ( ) Dimpling
Lungs: Equal chest expansion, CBS, ( ) crackles, ( ) wheeze
Heart: adynamic precordium, distinct heart sounds, ( ) murmur
Abdomen: soft, flabby, non-tender
Extremities: Warm, full radial pulses, ( ) edema
Neurologic: GCS __, ( ) neurologic deficit

Pelvic Exam:
External Genitalia: Grossly normal
Speculum: Cervix pulled, slightly anterior, smooth, pinkish
Internal Examination: Admits 2 fingers with ease, corpus cannot
be appreciated, cervix smooth, no palpable adnexal mass, ( )
bilateral tenderness
Direct Rectal Examination: Good sphincter tone, smooth rectal
mucosa

LABORATORY RESULT
IMPRESSION
Gravida 3 Para 2 (2012) Ovarian New Growth, Right, Probably
Malignant; Hypertension Stage II; Status Post Excision of Breast
Mass, Bilateral (1999, SPMC); Status Post Appendectomy (1988)