Case taking proforma in Ca Cervix

I General particulars

Name
Age
Sex
Residence
Occupation
Marital status
GP status
Menopausal status

. . .The patient Ms.__________________ a ______ yr old pre/post menopausal lady,

Married since _____ years, residing at ________________ a
______________________ by occupation presents with the chief complaints of .. . . .
(Mention every chief complaint in chronological order)

1. post coital bleeding, Inter-menstrual spotting

2. Foul smelling vaginal discharge

4. Pelvic pain

II Chief complaints - The patient was apparently alright ______ months back
when . . . (ODP for each complaint)

ODP of each complaint

Bleeding - Onset, duration, post coital, intermenstrual spotting, amount of

bleeding, passage of clots.

Discharge - Onset, duration, quantity, foul smell, associated fever.

Pelvic Pain - SITCAR

Exclude causes other than Ca Cx

- No H/O any prior episode of bleeding PV or intermittent spotting before this

episode. (CIN)

- H/O HRT or tamoxifen use (endometrial CA)

- H/O chronic pelvic pain with associated dysmenorrhoea (Chronic PID,

endometriosis)

- H/O any mass coming out per vaginum (prolapse)

 III H/o aetiology/Risk factors

- H/O multiple sexual partners (HPV)

- H/O prior genital warts (HPV)

- H/O Genital cancer in male spouse (HPV)

- H/O OC pills use (Adenoca)

- H/O smoking or tobacco chewing

- H/O taking any chronic medication (immunosuppressive drugs increased risk)

- H/O any prior pap smears (possibility of prior abnormal pap smear / CIN)

- H/O taking any HPV vaccine

IV H/o Complications/metastasis

- H/O copious purulent discharge PV associated with fever and pelvic pain
(pyometra)
- H/O any groin swelling (inguinal nodes)
- H/O oedema feet or backache (RP nodes)
- H/O flank plain radiating to the groin (hydronephrosis)
- H/O any hematuria / bleeding PR (bladder/rectal involvement)
- H/O any neuropathic pain or sciatica
- H/S/O VVF or RVF
- Chest pain, dyspnoea and haemoptysis (lung metastasis)

V. Menstrual / obstetric history

- Age at menarche / menopause (if applicable)

- Age at marriage (coitus at young age increased risk)

- Age at first child (children at young age increased risk)

- G / P / L / A, interval between pregnancies

- H/O any contraception, sterilization
-H/O breast feeding
 - Cycles regular/irregular, every _____ days, lasts for ______ days,
light/moderate/heavy flow. Any associated pain.
VI H/o of treatment taken

H/O any gynaec procedure e.g. D&C

VII Family history

- H/O any gynaecological or other cancers in the family

VIII Personal history

H/O Diet, addictions

IX Past History
- H/O any illness in the past i.e. hospital admission, surgery etc
- H/O DM/HT

X. General Examination

Patient is conscious, cooperative, averagely built and (?poorly in cachexia)

nourished and well oriented in time place and person.

(TPR BP) The patient is afebrile and the pulse and blood pressure and respiration
are normal.

Pallor

Icterus

No localised bony tenderness

Left supraclavicular node

Signs of prior treatment - pigmented streaks on the arms (CT thrombophlebitis)

(if present), Alopecia

XI. Local Examination (first ask pt to pass urine)

a. On inspection of the external genetalia

- Lesion or warts on the vulva

- Fullness in the groin

- Genital Prolapse

- Discharge - type

PS

- friability, growth ______ in size, involving anterior/posterior lips of the

cervix

- Growth proliferative/ulcerative/ulceroproliferative, bleeds on touch

- only ectocervix or endocervial extension

- Fornices free or not

- Vaginal extension, skip lesion

PV

- Size, friability, consistency, tenderness

- Extent - ectocervix, fornices, vagina

- Mobility / parametrial involvement

- Uterus anteverted / retroverted, size normal/bulky

- Presence or absence of any adnexal mass.

PR

- Parametrial involvement

- lateral pelvic wall involvement

- Rectal mucosa is free or not

Examination of inguinal nodes

XII. Systemic examination

Abdomen: Abdominal distension, mass, free fluid

Chest: Any foreign sounds

CVS: S1S2 normal

XIII. Diagnosis with stage or differential diagnosis

Carcinoma of the cervix stage _______