GYNHistory and Physical Template
ChiefComplaint:
HPI – First sentence should include age, parity, LMP and present problem (details about cc andotherrelevant information).
MenstrualHistory |
Menarche,duration,flowandcyclelengthofmenses,IMB(intermenstrual bleeding), or contact bleeding, dysmenorrheal, PMS,climacteric |
GynecologicHistory |
Breasthistory–historyofbreastdisease,breastfeeding,theuseofSBE(Self Breast Exam),last mammogram(if applicable) |
| Previousgynsurgery(caninclude insurgical history) | |
| Historyofinfertility | |
| HistoryofDES(diethylstilbestrol)usebypatient’smother | |
| Lastpap smear– historyof abnormal pap | |
Contraceptive/SexualHistory |
Currentmethod/patients’satisfactionwithcurrentmethod |
| PastMethods | |
| Currentsexuallyactivity | |
| Numberof Partners | |
| Newpartner in last 3 months | |
| Condomuse | |
| Historyofsexualabuse
History of Domestic Violence |
|
PMH |
Operations/transfusions |
| Allergies | |
| Medications | |
| Habits(smoking, alcohol use,drug use, etc.) | |
| Infectiousdiseases(gonorrhea,Chlamydia,syphilis,herpes,genital
warts,trichomonas, HIV, TB, rheumatic fever, hepatitis) |
|
| Medicalillness | |
SocialHistory |
Maritalstatus |
| Employment | |
| Age andhealth of children | |
| Socialsupports
|
FamilyHistoryCardiovascular, Diabetes, HTN, etc. (same questions as on your typhon documentation)
ROS |
ConcentrateofGY/GI;pertinentnegativesmayinclude,abnormaldischarge,abnormalbleeding,dyspareunia,abdominal/pelvicpain,dysuria,hesitancy,urgency,incontinence,changeinbowel habits,
rectal bleeding |
| Forpost/perimenopausalwoman–hotflashes/nightsweats,vaginal
dryness,abnormalbleeding,irritability,depression,moodchanges |
|
PE |
VitalSigns |
| Thyroid | |
| Breasts | |
| Lungs | |
| Heart | |
| Abdomen | |
| Extremities | |
Pelvic Exam |
Externalgenitalia |
| Vagina | |
| Cervix | |
| Uterus | |
| Abdomen | |
| Recto-vaginal |
PELVIC: Normal appearing external female genitalia, normal vaginal epithelium, no abnormal discharge.
- Normal appearing cervix. No cervical motion tenderness
- Uterus is smooth, mobile and, nontender. Describe the position of the uterus Anteverted, retroverted, or military position
- No palpable adnexal masses.
- No anoperineal lesions. Rectovaginal exam was normal.
- A thin prep pap smear was obtained.
SKIN: No concerning lesions
The image demonstrates various types of cervices you may wish to compare with your patients in GYN clinical.
