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: __________________________________________________________________________

__________________________________________________________________________

__________________________________________________________________________

History of Presenting Complaint

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

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: ____________________________

__________________________________________________________________________________________

Family History

DM, HTN, MI, stroke, TB, hepatitis, asthma, cancer, twins, congenital anomalies, infertility, prolapse

__________________________________________________________________________________________

Medication History

__________________________________________________________________________________________

Allergies

__________________________________________________________________________________________

Social History

Smoking, hukka, niswaar, alcohol Housing: _____________________________________________

Monthly income: _____________________________ Social class: ___________________________________________

______________________________________________________________________________________________________________

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: ________________________________

___________________________________________________________________________________________________________

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 ____________ 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

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Differential Diagnosis

_________________________ _________________________ _________________________ _________________________

Investigations

_____________________ _____________________ ___________________ _____________________ _____________________

Plan/Treatment

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

______________________________________________________________________________________________________________

Arslan Gujjar is a retard :p