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GYNECOLOGY HISTORY AND EXAMINATION

 GYNECOLOGY HISTORY AND EXAMINATION

HISTORY

includes Medical Hx (ID, CC, HPI, PMH, Meds, Allergies, etc... ) and …

Menstrual History

  1. LNMP
  2. LMP
  3. age of menarche, menopause
  4. cycle length, duration,
  5. regularity
  6. flow
  7. associated symptoms : pain, PMS
  8. abnormal menstrual bleeding :  intermenstrual, post-coital

Obstetrical History

  1. GTPAL ( G-Gravidity, other )
  2. hospital
  3. outcome
  4. mode of delivery
  5. sex
  6. gestational age
  7. weight
  8. complications

Sexual History

  1. age when first sexually active
  2. number and sex of partners
  3. history of sexual assault or abuse
Contraceptive History

  1. present and past contraception modalities
  2. reasons for discontinuing 
  3. compliance
  4. complications/failure/side-effects

Gynecological Infections

  1. STDs,
  2. PID (herpes, chlamydia, gonorrhea, etc...)
  3. vaginitis, vulvitis
  4. lesions
  5. include treatments, complications, etc...

Gynecological Procedures 

  1. last Pap smear
    • history of abnormal Pap
    • follow-up and treatments
  2. gynecological or abdominal surgery
  3. previous ectopic pregnancies
PHYSICAL EXAMINATION

  1. height, weight, BP ,PR
  2. breast exam
  3. abdominal exam
  4. pelvic exam including
    • observation of external genitalia
    • speculum exam +/-smears and swabs
    • bimanual exam
      • cervix size, consistency, os, and tenderness
      • uterus size, consistency, contour, position, shape, mobility, and other masses
      • adnexal mass, tenderness
    • rectovaginal exam
    • rectal exam
GYNECOLOGY HISTORY AND EXAMINATION GYNECOLOGY HISTORY AND EXAMINATION Reviewed by Radiology Madeeasy on September 07, 2010 Rating: 5
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