Professional Documents
Culture Documents
Patient-Doctor Relationship
o Complete history
o Complete PE
o Labs
New Patient
o Take Time
Perform comprehensive PE
o Establish data base, along with DPR basd on
a good communication
Gynecological changes
Pregnancy history
Overview
o Most important part of gynecological
evaluation
o Provides tentative diagnosis (impression)
before PE
o LEGAL document
Name
Age
Gravidity (G)
o State of being pregnant
Parity (P)
o Outcome of pregnancy
o FPAL (in digits)
A = Abortion
Chief Complaint
Only one
Reason for admission
Common gynecological complaints
o Bleeding (vaginal)
o Pain (specify: use 9 regions of abdomen)
o Mass (abdominal or pelvic)
o Vaginal discharge
o Urinary or GI symptoms
o Protrusion out of the vagina
o Infertility
Menstrual cycle
Voiding
Bowel movements
Age of menarche
Degree of Discomfort
Premenstrual symptoms
Cycle
o Counted from the first day of menstrual flow
of one cycle to the first day of menstrual
flow of the next
Excessive menses
o Need to frequently change saturated
sanitary pads or tampons
o Passage of many or large blood clots
Dysmenorrhea
o Painful menstruation
o Discomfort or pain at the hypogastric area,
often associated with backache
o Common
o Begins just before or soon after the onset of
bleeding
o Subsides by day 2 or 3 of flow
o May be associated with systemic symptoms
Obstetric History
Number of pregnancies
FPAL
Complications of previous pregnancies
o Antepartum, intrapartum or postpartum
Duration of labor
Type of delivery
o Place: hospital, house, hilot, TBA, physician
Anesthesia used
Perinatal status of fetus
o Birthweight
o Early growth and development of children
including feeding habits, growth, overall
well-being, current status
History of Infertility
o Evaluation, diagnosis, treatment, outcome
Medical History
Allergies
Previous hospitalizations
o Reason, date, outcome
Vaccination
o Type, date
Surgical History
Operative procedure
o Outcomes
o Complications
o Surgical diagnosis
o Pathologic diagnosis
Review of Systems (subjective)
Pulmonary
Cardiovascular
Gastrointestinal
Genital
Urinary
o Dont combine, as in GU
Vascular
Neurologic
Endocrinologic
Immunologic
Breast Symptoms
Masses
Galactorrhea
Pain
Family history
Social History
Marital status
o Number of years married
o Period of infertility
Occupational History
o Exposure to radiation
o Infectious agents
Sexual History
o Partners, protection from STDs
General Impression
o Level of consciousness
o Ambulatory
o Nutritional state
o Presence of facial or excessive body hair
o Vital signs
Physical Examination (PE)
(objective)
Heart
Breast
Abdomen
Lower extremities
Pelvic examination
Gynecological Examination
Pelvic Examination
o Most commonly performed medical
procedure
o Performed during the first visit
o Patient should be encouraged to give
feedback during PE to reduce anxiety
o Lithotomy position
Menopausic nulligravid
Inspection of the Vulva
o The vulva should be examined for:
Growth of hair
Discoloration
Labial abnormality
Warning
o The physician should prepare the patient for
any pelvic examination by warning her in
advance and examining fingers and
speculum
Important:
o Not only because the patient cannot see
what is going on
o But also because the area to be examined is
extremely sensitive, both psychologically
and physically
Inspection of the Vagina and Cervix
Graves Speculum
o Employed for visualization of the vagina and
cervix
o Bivalve
Inspection
o The cervix should be inspected for
Color
Erosion
Evidence of trauma
Presence of lesion
*Pap smear is encouraged if not done yet
Pap Smear
Major objectives:
1. sample exfoliated cells from the
endocervical canal
2. Scrape the transitional zone
Hemorrh
After
o Uterosacral ligament
Vagina
o Leukorrhea
o Color
Cervix
o
o
o
Uterus
o
o
o
Adnexa
o
o
o