Gynaecology Clerking

Name : Age : Race :

MRN : DOA : DOC :
Occupation : Marital : Gravida/ :
Status Para
LMP : LCB : UPT :

Chief Complaint:

HOPI:
A. Abnormal menstrual bleeding

B. Vaginal Discharge

Onset :
Duration :
Amount :
Colour :
Pus/Blood :
Odour :
Itchiness :
Cyclical changes w/ mestruation :

C. Lump at vulva

Onset :
Duration :
Site (Inside/Outside Vagina) :
Reducible/Not :
Assoc. Symptoms :

D. Abdominal pain/Pelvic pain

Site :
Onset :
Character :
Radiation :
Associated Symptoms :
Time :
Exacerbating/Relieving :
Severity :
Relationship to :
menstrual cycle
Presence of period of :
amenorrhoea

(acute pelvic pain assoc w/vaginal bleeding after a period of amenorrhea = ectopic preg)

E. Abdominal distension/ Abdomino-pelvic mass

Onset :
Duration :
Sudden/Gradual Onset :
 F. Pressure Symptoms
Urinary GIT
1) dysuria 6) incontinence 1) constipation
2) hematuria 7) incomplete 2) diarrhea
3) colour voiding 3) early satiety
4) frequency 8) dribbling 4) flatulence
5) urgency 9) enueresis
10) oligouria
11) polyuria

G. Constitutional Symptoms

LOA :
LOW :
Lethargy :
Fever :
Nausea :
Vomit :
SOB (Pleural Eff) :

H. Climacteric Symptoms

Hot Flash :
Night Sweats :
Depression :
Insomnia :
Dyspareunia :
Headache :

REVIEW OF SYSTEMS
Menstrual History
 LMP:
 __th day of period
 Menopause:
Menarche:
Days of cycle:
Lasted for ___ days (if irregular determine shortest and longest interval/cycle)
Regular/irregular
Flow : Normal/heavy/minimal :
Flooding :
Colour of blood :
Blood clot (size/frequency) :

Pads No of pads :
Type of pads :
Fully soaked :

Dysmenorrhoea: Treatment :
Severity :
Onset/timing :
Before/After Marriage :
Primary/Secondary :

Other abnormal Amenorrhoea :

menstrual Intermenstrual :
bleeding bleeding
Irregular menses :
Postcoital bleeding :
Postmenopausal :
bleeding

Anaemic Symptoms : lethargy ( ), reduced effort tolerance ( ), headache ( ), syncope ( ),

breathlessness ( ), palpitations ( ), Hb level ( ), Bleeding tendency ( )

Admission for blood transfusion

Effect to her quality of life

What has been done? Any investigations?

What treatment taken so far? Response?

Antenatal History
1) 1st Trimester (1-13w)
a. Wt/Ht/BMI (Pre-pregnancy and current):
b. Planned ( ), Wanted ( ), Spontaneous ( )
c. Urine Pregnancy Test:
I. Why:
II. When:
III. Result:
d. How pregnancy confirmed:
I. Why:
II. When:
III. Where:
IV. What test:
e. Early scan:
f. Total scans:
g. Latest scans:
h. Booking:
I. When:
II. Frequency:
III. Where:
IV. Sugar:
V. Proteinuria:
VI. Glycosuria:
VII. BP:
VIII. Hb:
IX. Blood Group and Rhesus:
X. Infective screening: HIV/VDRL/HepB/Rubella/BCG
XI. Symptoms: PV bleed ( ), Hyperemesis ( ), Anaemia ( ), UTI ( ),
Constipation ( ).
XII. Supplements:

2) 2nd Trimester (14-27w)

a. MGTT:
I. When:
II. Result:
III. Result:
IV. Why:
b. Prenatal screening:
c. Quickening/Fetal movement:
I. First start:
II. Kicks per day:
d. Regular antenatal check-up:
e. Ultrasound results:
I. No of fetus:
II. Placenta:
III. Liquor:
IV. Uterus:
V. Ovaries:
 3) 3rd Trimester (28-40w)
a. Doppler/CTG:
b. Hospital admission:
c. Signs of labor: show, leaking liquor, contraction pain
d. Fetal movement:
i. Trend: Increase/Decrease as pregnancy progress
ii. Fetal kick chart:

Past Obstetrics History

Details of each pregnancy:
Pregnancy :
Year :
Age :
Gender :
Mode of Delivery :
Where :
Term (weeks) :
Birth Weight :
Breast Feeding :
Vaccination :
Child’s Outcome :
Complication
Antenatal :
Intrapartum :
Postpartum :

a. Miscarriages (<22w/<500g)
 Why:
 Induced/Spontaneous:
 Scan to confirm pregnancy:
 D&C/Products of conception for HPE:
b. Ectopic
 Which side affected:
 Scope or open (laparotomy/laparoscopy):
 Salphingectomy/Salphingotomy:
c. Stillbirth
d. Neonatal death
 Year:
 Assoc. Problems:

Past Gynaecological History

  Contraception:
 Urine pregnancy test:
 Pap smear:
o Last done:
o Where:
o Result:
 Breast:
o Self-Examination:
o Last done:
o Where:
o Result:
 Other gynae problems:
o Fibroid/Ovarian cyst/Endometriosis/Subfertility
o When:
o Treatment:
 Previous Gynae operation
o Myomectomy:
o Cystectomy:
o Dye insufflations:
o Salphingectomy:
o D&C:

Sexual History
 Age of 1st coitus:
 No of marriage:
 Duration of marriage:
 Consanguinous marriage:
 Dyspareunia:
 Postcoital bleeding:
 Frequency of intercourse:
 Number of partners:
 Awareness of safe sex:
 STD: if any, get history in detail

Medical History/Drug History

Any illness :
When diagnosed :
Where :

Medications :
Med Supplier :
Compliance :
Gram/Dose/Times :
per day
Medical check up :

Allergy History
Family History

Social History
 Where live:
 House type:
 Basic amenities:
 Smoke/Alcohol/Drugs:
 Occupation:
 Husband:
o Age:
o Occupation:
o Smoke/Alcohol/Drugs:
 Household income:

PHYSICAL EXAMINATION

GENERAL
1) surroundings
 2) vital signs
3) hands
4) face
5) lymph node
6) legs-oedema

EXPOSURE
xiphisternum → sym pubis

INSPECTION
1) abd distension
2) abd moves w/ inspiration(✘inflamed)
3) umbilicus (N=centrally located, inverted)
4) dilated veins
5) linea nigra
6) linea albicans
7) scars:
i- name
ii- length
iii- longitudinal/transverse
iv- site
v- well healed
vi- hypertrophy/keloid
vii- cough impulse

PALPATION
(a) Superficial
̵̵ soft
̵̵ tender

(b) SFH
prepare tape
palpate; xip → mass
finger breadth (correspond to xiphisternum/umbilicus)
measure; border of mass →symp pubis

clinically,
uterus at ___weeks
measuring ____cm correspond to ___weeks of gestational age

xiphisternu 40w (✔fullness of

m subcostal) 1 finger= 2cm
36w (✘fullness of 1 week= 1cm ±
subcostal) 2cm
umbilicus 22w
suprapubic 12w

(c) Mass
i- site
ii- border; percuss→palpate
iii- regular/irregular
 iv- size
v- shape
vi- consistency; compare
vii- firm/hard/soft
viii- surface; smooth/lobulated
ix- tenderness
x- mobility; horizontal/vertical
xi- get below

(d) Liver
(e) Spleen
(f) Renal
(g) Ascites

AUSCULTATION
1) Mass; bruit=vascularize
2) Bowel sound (N=3x/min)
3) Renal Bruit

MALIGNANCY
1) Bone pain
2) Pleural effusion

HEART
anemic →cardiac failure