GYNECOLOGY HISTORY AND EXAMINATION

  HISTORY includes Medical Hx (ID, CC, HPI, PMH, Meds, Allergies, etc... ) and … Menstrual History LNMP LMP age of menarche, ...

 

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