The Gynecologic History

1. Chief complaint
2. History of present illness
3. Menstrual history
1. Age at menarche
2. Last menstrual period
3. Menstrual pattern
1. Cycle length
2. Duration of flow
3. Amount of flow
4. Moliminal symptoms?
5. Associated pain (dysmenorrhea, mittelschmerz)
6. Intermenstrual bleeding
4. Perimenopause/menopause
1. Bleeding pattern
2. Vasomotor symptoms
3. Hormone replacement therapy
4. Contraception
1. Current method; satisfied with method?
2. Previous methods, including complications, reasons discontinued
5. Cervical and vaginal cytology
1. Most recent Pap smear result
2. History of abnormal Pap smears? If so, nature of diagnosis, treatment, and follow-up
6. Infection
1. History of sexually transmitted infections
2. History of vaginitis, including types, frequency, and treatment
3. History of pelvic inflammatory disease
7. Fertility/infertility
1. Desire for future fertility
2. Any difficulty conceiving in past? If so, prior evaluation and treatments
8. Sexual history
1. Type
2. Concerns about libido, dyspareunia, or orgasm?
3. History of sexual abuse or sexual assault?
9. Obstetric history
1. Describe each pregnancy and the outcome.
2. Describe any maternal, fetal, or neonatal complications
10. Past medical history
1. Current or past illnesses
2. Hospitalizations
11. Past surgical history
1. Past gynecologic surgeries
2. Past nongynecologic surgeries
12. Medications and allergies
1. Prescribed medications
2. Over-the-counter medications
3. Herbal preparations
4. Allergies to medications and nature of reactions
13. Family history
1. Significant illnesses of family members
2. Known hereditary conditions in family
14. Social history
1. Marital or relationship status
2. Level of education
3. Occupation
15. Review of systems
 1. Abdomino-pelvic
1. Gynecologic
2. Urinary
3. Gastrointestinal
2. Breast
3. Other
16. Health maintenance
1. Tobacco, alcohol, illicit drug use
2. Diet
3. Calcium and folate intake
4. Exercise
5. Use of seatbelts, helmets, sunscreen, smoke detectors
6. Firearms in the home?
7. Dates and results of screening tests such as mammography, sigmoidoscopy or colonoscopy, bone
densitometry, lipid analysis, glucose and thyroid testing
8. Immunizations and dates administered
1. Chief complaint (CC).
2. History of present illness (HPI):
1. The circumstances at the time the problem began, including activities that the patient was
engaged in, medical problems that she was experiencing at the time, and any medications that
she was taking around that time. Ano po ba ang ginagawa niyo kapag ito ay nararanasan ninyo?
May iba pa po ba kayong karamdaman noong naranasan ninyo ito? May gamut po ba kayoing
iniinom noong naranasan ninyo ito?
2. The time course of the problem. Was this a transient problem, or has this been chronic,
recurrent, or persistent? Are the symptoms temporally related to the menstrual cycle? Kailan po
ba ito nagsimula? Pabalik-balik ba ito, minsan meron, minsan nawawala o tuloy-tuloy?
Nararanasan po ba ninyo ito tuwing may regla o nakikisabay sa pagreregla?
3. Is this a new problem, or has the patient experienced similar symptoms in the past? If the
problem involves disruption of an otherwise normal function (such as amenorrhea), did the
patient have normal function at some point in the past? Bago lang po ba ang iyong problema? Or
meron na noon pero nagnormal then bumalik ulit?
4. Characteristics of the problem, and associated symptoms. In the case of pain, this would include
questions about the location, severity, nature (e.g., sharp, dull, cramp-like), exacerbating factors,
relieving factors, and whether the pain radiates to another location. With respect to bleeding, this
would include the frequency, amount, and duration of flow, and whether the patient is
experiencing fatigue or lightheadedness. Ano pa po ba ang mga nararamdaman ninyo na feeling
ninyo sumasabay sa pangunahin ninyong suliranin? May masakit po bang parte ng inyong
katawan? May pagdurugo po ba?
5. To what extent is the problem interfering with the patient’s usual activities? Sa inyong palagay
paano po ba naaapektuhan ang inyong pang araw-araw na gawain ng inyong suliranin?
6. Has the patient undergone any previous evaluation or treatment for the problem? If so, it is
helpful to obtain the patient’s permission to request these medical records. Naikonsulta niyo na
po ba ito sa ibang duktor? At nabigyan po ba kayo ng gamot?
7. Why did the patient seek evaluation of the problem at this point? Have the symptoms changed or
increased in severity? Bakit ngayon lang po ninyo naikonsulta ang inyong suliranin?
3. Menstrual History.
1. Age at menarche. Kailan po ang una ninyong regla noong bata pa kayo? The average age at
menarche is 12–13 years, with a range from 9 to 17 years. Initially, menstrual cycles are typically
anovulatory and menses occur at irregular intervals.
2. Last menstrual period (LMP). Kailan po ba ang unang araw ng inyong huling pagreregla bago
nag-irregular ang inyong pagreregla… at kailang po ba ang huli ninyong pagreregla. By
convention, the first day of the last menstrual period is recorded.
3. Menstrual pattern and associated symptoms.
1. Cycle length. The cycle length is the interval from the first day of one menstrual period to
the first day of the next menstrual period. The median cycle length is 28 days, but
ovulatory cycles have been noted to occur at intervals of 23–39 days. There is often a
gradual decrease in cycle length in the later reproductive years. A change from a patient’s
previous pattern is often a more reliable sign of a problem than a particular interval. Ano
po ba ang inyong cycle… kada anong araw?
2. Duration of flow. Menses commonly last for 3–5 days, with a range of 1–7 days. Gaano po
ba katagal ang inyonhg pagreregla?
3. Amount of flow. The average blood loss during a menstrual period is 30 mL, with a range
of 10 to 80 mL. Gaano po kadaming pads ng napkin ang nakokunsumo ninyo sa isang
araw? Sa nakaraan po, dumami po ba o kumaunti ang dugo?
4. Presence of moliminal symptoms. Many women experience predictable physical and
emotional symptoms during the late luteal (premenstrual) phase of ovulatory menstrual
cycles. Symptoms typically begin a few days before menses and resolve with the onset of
 bleeding. Commonly reported symptoms include breast tenderness, abdominal
distension, weight gain, food cravings or increased appetite, irritability, and lability of
mood. Severe or prolonged symptoms that interfere with a patient’s usual activities
warrant further evaluation.
5. Associated pain. Nagdydysmenorrhea po ba kayo tuwing kayoy dinadatnan? Kelan ito
nagsisimula at kalian nawawala? Nagkakaroon pa po ba kayo ng iba pang nararamdaman
tuwing rineregla gaya ng diarrhea, nausea, or headache. Nawawala po ba ang mga ito
kapag natatapos ang pagreregla? Some women experience unilateral pelvic pain at
midcycle associated with ovulation (mittelschmerz).
6. Intermenstrual bleeding. Some women note a small amount of bleeding (spotting) at
midcycle. Nagkakaroon po ba kayo ng pagdurugo sa kalagitnaan ng cycle?
4. Perimenopause/menopause.
1. Bleeding pattern. In the late reproductive years, the intermenstrual interval typically
becomes less predictable. Often the interval shortens and then becomes variable.
Menopause is defined as the absence of menses for 1 year. While women rarely will have a
subsequent menstrual period with typical associated symptoms, bleeding after this time
is considered abnormal (postmenopausal bleeding) and warrants evaluation. The average
age at the cessation of menses is 51 years, with a range from 40 years to the late 50s.
2. Associated symptoms. Sa ngayon po nagkakaroon po ba kayo ng hot flushes and sweats at
night; pagpurol ng memorya; hindi maayos na pagtulog; masakit na batok, balikat, at
likod? Pagtutuyo po ng puwerta; sumasakit po ba tuwing nagtatalik kayo ni mister? Ang
gana po ninyo sa pakikipagtalik bumaba po ba o lumakas?
3. Hormone replacement therapy. May mga gamut po ba kayong iniinom para sa inyong
narrarmdaman ngayon? Mahilig po ba kayong uminom o kumain ng mga pagkain na
mataas ang soya? Halamang gamut po?
4. Contraception.
1. Past methods of contraception. Noong kalakas pa po ninyo nin mister na magtalik, gumagamit po
ba kay ng contrceptives? Ano-ano po ang mga ito? At kalian ninyo ginamit? May kumplikasyon
po ba ayong naramdaman noon? At bakit po ninyo itinigil ang paggamit?
5. Cervical and vaginal cytology. Nagpapap-smear nap o ba kayo noon? Gaano po kadalas?
6. Infection.
1. History of sexually transmitted infections. Currently, approximately 20 infections are known to
be transmitted by sexual contact. Naranasan niyo nap o bang nagkaroon ng impeksyon sa
puwerta?
2. History of monilial vulvo-vaginitis or bacterial vaginosis.
3. History of salpingo-oophoritis (pelvic inflammatory disease).
7. Fertility/infertility. Sa pagbubuntis po ninyo noon, hindi po ba kayo nahirapang gumawa ng bata?
8. Sexual history. Kumusta naman po ang situasyon ninyo ni mister, ang inyong pagtatali? Ok pa po ba?
May mga bagay po ba kayong gustong itanong? May sumasakit po ba sa inyo pag kayo ay nagtatalik? Sa
kagustuhang gawin ang pagtatalik po, may problem aba doon?
9. Obstetric history. Ilang beses nap o ba kayo nagbuntis? Ilang bese po kayong nanganak? Buhay po ba
lahat ng anak ninyo? Nakunan po ba ayo noon? Ipinagbuntis niyo po ba sila ng siyam na buwan? Normal
po ba ang inyong panganganak? Kumplikasyon po?
10. Past medical history. Naospital na po ba kayo maliban sa inyong panganganak? Ano pong dahilan? Ano-
ano po ang mga nakaraang karamdaman ninyo?
11. Past surgical history. Naopera na po ba kayo? Saan at anong operasyon ito? Kailan po? May
kumplikasyon po ba?
12. Medications and allergies. Ano-ano po ba ang mga gamut na iniinum ninyo sa ngayon? OTC? Herbal?
Bitamina? May allergy po ba kayo sa mga gamut; sa pagkain po?
13. Family history. Ano-ano po ang mga sakit sa pamilya ninyo? Magsimula po tayo sa mga magulang ninyo
at ng inyong asawa. May cancer, diabetes mellitus, cardiovascular diseases, hyperlipidemia, osteoporosis,
 and other hereditary disorders po bas a pamilya ninyo? Sino-sinu po ang may karamdaman sa kanila at
kalian ito nalaman o natuklasan ng duktor?
14. Social history. Pertinent aspects of a patient’s social history include her marital or relationship status,
level of education, and occupation. Kumusta naman po ang relasyon ninyo ng inyong asawa? Ano po ang
natapos ninyo at trabaho?
15. Review of systems.
1. Abdomino-pelvic.
1. Gynecologic.
1. Abnormalities of uterine bleeding. The postmenopausal patient should be asked
about the presence of any bleeding (postmenopausal bleeding). All women should
be asked about postcoital bleeding.
2. Pelvic pain. Pelvic pain should be characterized as cyclic (predictably occurring at
certain times of the menstrual cycle such as with ovulation or with menses), or
noncyclic. The mode of onset, character, location, radiation, severity, duration,
exacerbating and relieving factors, whether there is pain with intercourse
(dyspareunia), and any associated symptoms should be recorded. Given that the
reproductive organs are in close proximity to the urinary tract and the
gastrointestinal tract, pain that is perceived in the pelvis may be related to one of
these organ systems. Pain associated with the abdominal wall musculature, fascia,
or nerves often increases with activities such as lifting.
3. Symptoms of uterine or vaginal prolapse. Patients with genital tract prolapse
(uterine prolapse, cystocele or cystourethrocele, or rectocele) may be aware of a
sense of pelvic pressure or the presence of tissue at or protruding through the
introitus. Patients with a cystocele or cystourethrocele may note urinary
incontinence with activities that increase intra-abdominal pressure such as
coughing and sneezing, or with athletic activities such as running. Patients with a
rectocele may note constipation and may need to splint (place pressure on the
perineum or on the posterior vaginal wall) in order to defecate.
4. Vaginal discharge. The patient should be asked about a change or increase in
vaginal discharge, and if present, whether there are any associated symptoms
such as vulvo-vaginal pruritus or burning, and malodor.
5. Vaginal dryness. Dryness or decreased vaginal lubrication may be noted when
estrogen levels are low postpartum or at the time of menopause, or may be
associated with disorders such as Sjögren’s syndrome.
6. Vulvar lesions. Inquiries should be made about the presence of raised or
ulcerative vulvar lesions. The patient should be asked about any changes in the
appearance of lesions that have been present for a period of time.
7. Vulvar pruritus or burning. The patient should be asked about symptoms of
vulvar pruritus and burning, which may be symptoms of vulvo-vaginitis, a contact
dermatitis, or vestibulitis. These symptoms may also be noted with conditions
such as lichen simplex, lichen sclerosus et atrophicus, vulvar intraepithelial
neoplasia, and carcinoma of the vulva.
8. Sexual dysfunction. Symptoms of sexual dysfunction fall into several categories
and include abnormalities of arousal (decreased libido), pain with intercourse
(dyspareunia), and inability to achieve orgasm (anorgasmia).
2. Urinary symptoms.
1. Symptoms of urinary tract infection include dysuria, urinary frequency, urinary
urgency, and hematuria.
2. Symptoms of urolithiasis include flank pain and hematuria.
3. Urinary incontinence. Urinary incontinence may be experienced with a variety of
conditions including urinary tract infections, congenital anomalies, vesico- or
 uretero-vaginal fistulae, cystocele or cystourethrocele, detrusor instability, and
various neurologic conditions. It is helpful to know when the incontinence
characteristically occurs (continuously, with activities such as coughing, sneezing,
or running, on the way to the bathroom, or with stimuli such as running water or
jingling keys).
4. Urinary retention. Inability to void may caused by compression of the urethra
(e.g., by a leiomyoma or periurethral edema) or occur after pelvic surgical
procedures. Incomplete emptying of the bladder may occur in patients with a
cystocele.
3. Gastrointestinal symptoms. Patients should be asked about symptoms of nausea,
vomiting, constipation, diarrhea, blood with the stools, pain with defecation, the need to
splint to defecate, and incontinence of stool or flatus. Patients with the irritable bowel
syndrome often report alternating symptoms of constipation and diarrhea, associated
with crampy abdominal pain. Incontinence of stool or flatus may be noted after injuries
to the anal sphincter during childbirth, or in association with anal or rectovaginal fistulae.
2. Breast. Patients should be asked about the presence of breast masses, discharge, pain, and a prior
history of breast biopsy. When a mass is noted, it is helpful to know how long this has been
present, and whether it varies in size with the menstrual cycle. Breast discharge should be
characterized as unilateral or bilateral, and the color noted. Galactorrhea (a milky discharge) may
be unilateral or bilateral, and can be seen with hyperprolactinemia, hypothyroidism, and with the
use of certain medications, including oral contraceptives. A unilateral bloody discharge is
typically seen with an intraductal papilloma. A unilateral greenish discharge may be seen with
ductal ectasia. Mild cyclic pain is common, related to the hormonal changes of the menstrual
cycle. More prolonged or severe pain may be associated with fibrocystic changes.
3. Other. A review of symptoms related to other organ systems should be undertaken in order to
assess for nongynecologic conditions that warrant evaluation and treatment, and because many
nongynecologic conditions have associated gynecologic symptoms. Symptoms that are
particularly likely to be associated with gynecologic conditions include a history of significant
weight loss or weight gain, excess hair growth (hirsutism), and symptoms of depression.
16. Health maintenance. A history of general health habits should be elicited, including an assessment of
tobacco use, alcohol intake, and the use of illicit substances. It is important to ask about the patient’s
diet, including calcium intake, folic acid intake, and whether she exercises regularly. A preventive care
history includes questions about habits such as seatbelt use, helmet use for sports activities, the use of
sunscreen, whether there are working smoke detectors in the home, and whether there are firearms in
the home. History of immunity to infectious diseases such as rubella and varicella, and whether vaccines
have been administered for high risk human papillomavirus (HPV,) hepatitis B, tetanus and diphtheria,
pertussis, the pneumococcus, and influenza.
PHYSICAL EXAMINATION
General Survey:
The patient is conscious, coherent, ectomorph, not in cardiorespiratory distress, not in pain, on sitting
position.

Patient’s Vital Signs:

BP: Ht:
CR: Wt:
RR:
Body Temp:

Skin:
Hair:
Face:
HEENT:
Thorax:
Heart:
Breast:
inspection for skin changes, symmetry, contours, and retraction in four
views—arms at sides, arms over head, arms pressed against hips, and leaning forward.
Palpate and note for:
Consistency
Tenderness
Nodules (location, size, shape, consistency,delimitation, tenderness, mobility).
Palpate the nipple for discharge
.
Abdomen:
Pelvic Exam:
EXAMINATION OF THE ABDOMEN.

Inspection, auscultation, percussion, and palpation.

 Inspection: contour of the abdomen, appearance of the skin

 Auscultation aids in the assessment of intestinal peristalsis (bowel sounds) and in the detection of
abdominal bruits.
 Percussion is utilized to determine the size of abdominal and pelvic structures such as the liver and
masses, as well as any abdominal fluid collection such as ascites. Percussion is also useful for assessing
abdominal and pelvic tenderness.
 Palpation is performed to assess for tenderness, organ enlargement, and masses.

PELVIC EXAMINATION.

External genitalia.

 external genitalia first for normalcy of appearance and hair distribution.

 Any lesions or developmental abnormalities are noted.
 The skin should be inspected and palpated for superficial and subcutaneous lesions.
 Bartholin’s (greater vestibular) gland openings are located at approximately the 5 and 7 o’clock positions,
just lateral and posterior to the vaginal orifice. The urethra is inspected for the presence of caruncle and
other findings.

Vagina and cervix.

The vagina and cervix

 inspected for lesions

  presence or absence of rugae to assess the level of estrogen present.
 assesses any vaginal discharge that is present for normalcy in appearance, color, consistency, and
odor. Physiologic vaginal discharge is scant in amount, flocculent, and white. The pH of the
normal vagina is less than 4.2. Normal cervical mucus is clear.

Cervical cytology

Bimanual examination. Tenderness with lateral movement of the cervix (cervical motion tenderness) is
assessed, as well as the size, mobility, position and contour of the uterus. The adnexa are palpated. Any masses
that are appreciated are assessed for size, location, mobility, tenderness, and contour. The posterior cul-de-sac
and utero-sacral ligaments are checked for nodularity and masses.