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• Christine Serrano

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GYNE CLINICAL HISTORY TEMPLATE CLINICAL HISTORY DATE:

INFORMANT: % RELIABILITY:

GENERAL DATA Name ______________ (first name, middle name, surname), age _____, Gravida: ______ Para: _______ (T_ P_ A__ L _) __________________________________________________________________ Admitted for the ____ time at FEU-NRMF Medical Center on ____________________ PATIENT’S PROFILE Date of Birth: _________________ Occupation: ___________________ Birthplace: ____________________ Habits: ()smoker () alcohol beverage drinker

presently

residing

at

Status:____________________ Attitude: _________________ Religion: _________________ Availability of Relatives: ____

REASON FOR ADMISSION: __________________________

B. OBSTETRICAL HISTORY The patient is a ()primigravid/()multigravida with an obstetrical score of (Gravida___ Para____ (T_P_A_L_). The first pregnancy was delivered on _________(month year) to a ()term/()preterm, ()living/()still birth, ()boy/()girl with a birthweight of ____kgs (____lbs), delivered via ()normal spontaneous deliver/()forceps assisted vaginal delivery/()transverse LSCS due to ____________________(indications) at ()home/()hospital/()lying-in clinic assisted by a ()midwife/()traditional birth attendant/()obstetrician. No fetomaternal complications were noted. He/She is now _______ years old and is apparently healthy. The second pregnancy was delivered (use same formal as above) …// (note: if with abortion: THE _____(number) pregnancy was terminated by ()spontaneous/()induced abortion on ___________ (month, year) at ________ age of gestation. Dilatation and curettage was done at _________ hospital on ________(date).) C. METHOD OF CONTRACEPTION The method of contraception use is ()coitusinterruptus/()oral contraceptive pills/()barrier method/()IUD from ______ (month,year) to ________ (month,year). D. SEXUAL HISTORY The patient had her coitarche at ______(age) with ______ sexual partners. Her partner had _______ sexual partners. She is currently in a ()monogamous, ()hetero, ()homo relationship.

HISTORY OF PRESENT ILLNESS |-----------------|-----------------|-----------------|-----------------|-----------------|-----------------| The patient had her menarche at __________ years old. She has been ()regular/()irregularly menstruating since ______ (year) with an interval of _________ days, lasting for ________ days, __________(amount) in flow, consumed _________ pads per day, ()associated/()not associated with dysmenorrhea. LMP: _______________________ PMP: _______________________ The present condition started ________ hours/days/weeks/month prior to admission, when the patient experienced ______________________________________________________________________________________________________ was subsequently admitted. PAST MEDICAL HISTORY The patient had the usual diseases such as measles, mumps and chicken pox. She denies any history of major illnesses, trauma, accidents, previous hospitalizations or major operations. FAMILY HISTORY Father: ____ age_____ health status Mother: ____ age_____ health status Siblings: ____ age_____ health status She denies other heredofamilial diseases such as diabetes mellitus, heart, liver, kidney, lungs, tuberculosis, nor allergies to food or drugs. PERSONAL AND SOCIAL HISTORY: The patient is ____ (rank) among _____ siblings with ___ sister and _____ brother. She is a/an()elementary, ()highschool, ()college graduate with a degree of __________________________________ and presently works as a ______________________. She is married for ______ years to ______________ (name of patient), ________ years old, who works as a ______________________. She is a _____________ pack year smoker and () an/()non alcohol beverage drinker. She has no food preference and denies any history of food and drug intake.

REVIEW OF SYSTEMS Constitutional:() fever and chills, () malaise,() weight loss Hematology:() easy fatigability, () easy bruisability CNS: () headache, () seizure, and () loss of consciousness HEENT: () blurring of vision, () hearing loss, () tinnitus Respiratory: () dyspnea, () cough, () colds, () apnea CVS: () orthopnea, () palpitations GIT: () diarrhea, () constipation GUT: () dysuria, () frequency, () urgency NMS: () malaise, () arthralgia, () myalgia, () numbness PHYSICAL EXAMINATION General Survey: the patient is ()conscious, ()coherent, () cardiorespiratory distress, with the following vital signs. BP: _______ PR:_____bpm RR:_____cpmTemperature: _______ C HEENT:()Anicteric sclera, ______ palpebral conjunctivae, () nasoaural discharge, () tonsillopharyngeal congestion Neck: Supple neck, () neck vein engorgement, () cervical lymphadenopathy. Chest:()Symmetrical chest expansion, () retractions, ()lagging Lungs:() Vesicular breath sounds, () crackles, () wheezes. Heart:()Adynamic precordium, ()normal rate, ()regular rhythm, ()murmur Breast:() Symmetrical contour, () dimpling, ()papable mass, () tenderness, ()abnormal nipple discharge Abdomen:()Flabby, ()soft/()rigid, ()normo/()hyper/()hypo active bowel sounds, () mass, ()tender/()nontender, ()Globularly enlarged with fundic height of ______cms, fundus occupied by ________, fetal back on the ()right/()left, fetal small parts on the ()right/()left, ()cephalic/()transverse/()breech presentation, engaged with fetal heart tone of 150 beats per minute, best heard on the right lower quadrant and estimated fetal weight of 3410 grams. Speculum exam:() clean looking cervix with _______ (amount), ________ (color) _________ (characteristic), ()foulsmelling discharge. Internal exam: Normal looking genitalia, ()nulliparous/()parousintroitus, vagina admits 2 fingers with ease, cervix is firm and closed, uterus enlarged to ______ months size, no adnexal mass or tenderness Extremeties:() gross deformities, ()full and equal pulses, () edema, () cyanosis Skin:()activedermatoses

REPRODUCTIVE HISTORY ASSESSMENT: A. GYNECOLOGIC HISTORY The patient had her menarche at __________ years old, with an interval of _________ days, lasting for ________ days, __________(amount) in flow, consumed _________ pads per day, ()associated/()not associated with dysmenorrhea. Subsequent menses were ()regular/()irregular, lasts for _______ days with interval of ________ days, ________(amount) in flow, consuming __________ pads per day ()associated/() not assocated with dysmenorrhea. She denies any history of ()dyspareunia, ()post-coital bleeding, ()leucorrhea, and ()exposure to sexually transmitted disease. Pap smear was done last ______month _______year and revealed () normal/() abnormal result (if abnormal, please indicate). Reason for pap smear is ___________________________________________________________________________

PLAN: HISTORY TAKEN BY: JIIC _______________________________