Professional Documents
Culture Documents
History and PE
History and PE
4.
5.
6.
Urologic History
Pelvic pain
Location, timing, quality, intensity, duration,
radiation
Precipitating & alleviating factors
Vaginal bleeding
Sexual status and Contraceptive use
Age of first sexual contact
No. of sexual partners
Types of relationships
Dyspareunia (pain or discomfort during coitus),
sexual dysfunction (including the partner)
A. GENERAL DATA
Name, age, occupation, marital status, religion
Gravidity no. of pregnancies carried out
Parity no. of pregnancies that have reached the
age of viability (20wks AOG)
B. CHIEF COMPLAINT
Reason for consult
Must be in the patients vernacular
C. HISTORY OF PRESENT ILLNESS/GYNECOLOGIC
PROBLEM
Allow patient to present problem as she sees it
Presented as a chronologic history of the current
problem
Onset, amount, duration, characteristics
Associated signs & symptoms, pain, anemia (due
to profuse bleeding)
o Vaginal discharge
o Dyspareunia (ask if pain is felt on deep
or shallow penetration)
o Abdominal pain
o Abdominal masses location, size,
consistency, mobility, tenderness
1.
2.
3.
Menstrual History
Age of menarche
Duration of each monthly cycle
No. of days during which menses occur
Regularity of menstruation
LMP and PMP
Characteristics of menstrual flow
o Color
o Amount of flow
o Accompanying sx
o Generally, menstruation occurs monthly
(21 40 days), for 4 7 days, bright
red, with cramping on the day preceding
& the 1st day of the period
o Irregular, dark in color, painless, and
frequently
short
or
very
long
menstruation may indicate lack of
ovulation
o Anovulatory cycles: usually seen in first
few
cycles
of
teens
and
in
premenopausal women
Note any vaginal bleeding not related to menses
If postmenopausal, ask the ff: age at last
menses, menopausal sx, postmenopausal
bleeding
Pregnancy History
Year of pregnancy, duration
Type of delivery
Size, sex, current condition of baby
Complications
Breastfed and how long
Elective terminations and spontaneous abortions,
ectopic/molar pregnancies
Father of each pregnancy (to to estimate no. of
sexual partners)
Vaginal and Pelvic Infections
Infection, treatment, complications
7.
8.
D. SIGNIFICANT
HEALTH
PROBLEMS/GENERAL
HEALTH HISTORY/PAST MEDICAL HISTORY
1. Systemic illnesses
2. Medications taken and indications
3. Allergies
4. Evidence of bleeding or clotting problems
5. Smoking amount, length of time she smoked,
attempts at quitting
6. Use of illicit drugs length of time used, types, side
effects
7. Alcohol intake
E.
FAMILY HISTORY
Detailed FH of 1st order relatives -> construct
family tree
Ask about congenital malformations, MR,
pregnancy loss
F.
G. SAFETY ISSUES
Use of seatbelts, helmets, appropriate footwear
Intimate partner violence
H. REVIEW OF SYSTEMS
PHYSICAL EXAMINATION
-
LALALA-LALA
o
o
Evaluation
for
axillary
&
supraclavicular lymphadenopathy
Abdominal Examination
A.
B.
Inspection
o Symmetry, scars, discoloration, striations
(suggest previous pregnancies or adrenal
gland hyperactivity)
o Note female eschucheon
o If diamond shape (similar to males)
indicates excessive androgen
activity
Palpation
o Note for organomegaly and masses
o Fluid wave
o Rigid abdomen (spasm in rectus muscles
secondary to intraabdominal irritation)
o Elicit
rebound
phenomenon
/tenderness
o Gently press on abdomen and
release -> pain under the spot
(direct rebound) or in a different
portion of the abdomen (referred
rebound)
C. Percussion
o Fluid wave vs solid organs & masses
D. Abdominal Auscultation
o Hypoactive or absent bowel sounds: ileus
due to peritoneal irritation of the bowel
o Hyperactive bowel sounds: partial
complete bowel obstruction
Pelvic Examination
Palpation
nd
th
3
types
of
Graves
speculum:
o Small:
children,
women
who
underwent
tight
perineal repair, aged patient who has
undergone severe involution
o Medium: most women
o Large: obese or grand multiparas
Pederson speculum
o Length of Graves but narrower
o For those not sexually active, never been
pregnant, have not used tampons
LALALA-LALA
Papanicolaou Smear
Basis for Pap smear: exfoliative cytology
Contributed to the decrease in incidence of cervical
CA
Done every 3 years if:
o Low risk individual
o After age 30
o With 3 consecutive negative Pap smears
Do every year if high risk:
o HIV seropositive women
o Immunosuppresed
o (+) DES exposure
o Previously treated for dysplasia or cervical
CA
Pap smear screening may stop at 65 70 y/o
Goal of pap smear: sample exfoliated cells from
endocervical canal & scrape the transitional zone
-
Procedure:
o May use a cotton tipped applicator or Cyto
brush (cyto brush gives more accurate
results & higher yield)
Cytobrush: endocervix
Bimanual Examination
Procedure:
o Uterus pushed up
by pressing on
cervix -> deliver to
abdominal hand
o Identify position,
size,
shape,
consistency,
mobility
Firm
2/3 of women: anteflexed uterus (posterior
wall of uterus is palpated by the abdominal
hand)
2
degree:
uterus
backward in the cul de
sac
Rectovaginal Exam
Thickening or beadiness of
any
of
the
structures:
inflammatory or endometriosis