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Name of Patient:
Informant:
Reliability:
Historian:
Section and Group:

Hospital:
Department: Obstetrics and Gynecology
Preceptor:
Date taken:
Date submitted:
GYNECOLOGICAL HISTORY

GENERAL DATA: Patients initials, age, G_P_ ( - - - ), civil status, nationality, religion, place of
birth, current residence, consulted the DLSUMC-OPD for the ____ time on _____(date) at _____
(time) . GENDER is not necessary because it is already implied that the patient is a female.
CHIEF COMPLAINT:
PAST MEDICAL/SURGICAL HISTORY: positives then pertinent negatives; do not include
previous hospitalization due to deliveries (VSD, CS, ectopic pregnancy, etc.) which should be
included instead in the OB history.
FAMILY HISTORY: positives and pertinent negatives, always try to elicit the following: (indicate
relationship/consanguinity to patient)
Heredofamilial illness - hypertension, diabetes mellitus, cancers etc.
Communicable diseases PTB, hepatitis etc
History of multifetal pregnancies, congenital anomalies
PERSONAL AND SOCIAL HISTORY: patients educational attainment, employment, source of
income if unemployed, smoking (# of sticks per day for how many years, if already stopped,
indicate when), alcohol intake (if already stopped, indicate when); husband/partners educational
attainment, employment and smoking (# of sticks per day)/alcohol intake; if already stopped,
indicate when); household water source, recreation.
MENSTRUAL HISTORY: Menarche. Describe subsequent menses based on regularity, duration,
amount of flow by napkin count, associated signs and symptoms, medications taken and effect of
medication. Indicate history of menstrual aberrations. LNMP =
PMP=
OBSTETRICAL HISTORY: G_P_ (__-__-__-__)
If multigravid, insert table detailing data of past pregnancies excluding present pregnancy
but to include: date, manner, place, attendant, gender, BW, complications). Under complications,
specify if fetal or maternal (antepartum, intrapartum, postpartum). If (+) CS delivery, indicate: 1nominal order (primary, repeat), 2-type of incision (Low Transverse, Classical), 3-indications
(specify).
GYNECOLOGICAL HISTORY: infections, diseases and surgery pertaining to the female
reproductive tract including breast; Pap smears with dates and results
SEXUAL HISTORY: Coitarche, number of lifetime sexual partners, regularity, satisfaction,
associated signs and symptoms (always ask for history of post coital bleeding, if any), date of last
sexual contact
CONTRACEPTIVE HISTORY: types, generic name (brand name), duration of use, associated
side effects; if already stopped, specify date & reasons for stopping.
HISTORY OF PRESENT ILLNESS:
LNMP
PMP

Include onset of complaint, pertinent signs and symptoms, consultations done, diagnostic test
requested and results, management done, effect of treatment until patient comes for present
consultation.
REVIEW OF SYSTEMS: careful to include symptoms only, entries which consist of PE finding
should not be placed here!
PHYSICAL EXAMINATION
GENERAL SURVEY:
VITAL SIGNS:
BP =
HR =
PR =
Temp =

Present weight =
Height =
BMI =

HEENT:
CHEST AND LUNGS:
BREASTS:
HEART:
ABDOMEN:
GENITALIA:
EXTERNAL GENITALIA: External: look for scars & lesions such as ulcers, varicosities,
discharges
SPECULUM EXAMINATION: Describe shape of cervical os, look for lesions in the
transformation zone such as Nabothian cysts, ulcers, tumors, discharges; result of
VIA if done.
INTERNAL EXAMINATION: Consistency, orientation, presence or absence of motion
tenderness, corpus size and position, presence of adnexal mass, size, mobility if present,
presence or absence of blood per examining finger.
EXTREMITIES: look for & describe varicosities, edema, congenital anomalies, if any.
NEUROLOGIC: if warranted

AS MUCH AS POSSIBLE COMPLETE THE PHYSICAL EXAMINATION.

Indicate if NOT DONE and GIVE THE REASON WHY.

IMPRESSION: AGE, G_P_ (_-_-_-_)

CASE DISCUSSION

Basis for the diagnosis.

Differential diagnoses:

IN YOUR OWN WORDS:

DISCUSS THE PATIENT and FINDINGS IN THE HISTORY AND PHYSICAL EXAMINATION in
terms of:
o Correlation of signs and symptoms with PE findings, pathophysiology, explanation of
diagnostic exams and results, management option and definitive management.
REFERENCES

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NOTE:
o DO NOT COPY / PASTE DISCUSSION FROM YOUR SOURCES OR FROM YOUR
CLASSMATES.
o Submit your individual type written reports in an envelope as a group at least a day prior
to your discussion date to Ms. Haidee Naty-Ramos, department secretary at the OBGyne Office, Rm 2219 of the De la Salle University Medical Center (before 12 noon).
o Make sure you fill up completely the attendance slip, signed by the OB Resident who
assisted you and by the OB Consultant. Submit the attendance slip with your reports.
o Study for the wardwork discussion. You will be graded both for the written report
submitted and participation in the discussion. Wardwork grade comprises 10% of your
final grade.

//mrdo/stc/oct2013