Download Medical record – gynecology

Medical record – gynecology
Reason for actual visit
Referral letter, antenatal record
Allergies
Allergies to medicine, latex, contrast etc. Type of allergic reaction.
Family history
Hereditary diseases (e.g. diabetes, cardiac, cancer)
Expositions
Infectious disease, sexually transmitted disease, MRSA (occupation, hospitalization during
foreign travel).
Previous medical history
Sexually transmitted infections.
Neoplasia (cancer): Participation in screening for cervical cancer (smear): Regularly? Date and
result of last smear.
Cervical intraepithelial neoplasia. Gynecological cancer.
Operations Gynecological, abdominal.
Fertility. Actual desire to become pregnant? Fertility problems?
Medical, surgical, psychological diseases.
Obstetric history
Number and outcome of pregnancies. Spontaneous miscarriages, induced abortions, ectopic
pregnancies. Deliveries, vaginal/cesarean section. Outcome for the children.
Sexual history. Sexually active, relations.
Contraception. Type of (e.g. p-pill, intrauterine device, other).
Menstrual history. Age at menarche, menopause. Menstruation, duration, severity and interval.
Chief complaint
History of present illness. Symptoms, onset, development, previous treatment.
General symptoms: Fever, weight loss, nausea, fatigue.
Bleeding: Change in the menstrual bleeding pattern, intermenstrual bleeding, postmenopausal
bleeding. Date of last menstruation.
Pain: Strength (VAS score), localization, aggravating/relieving factors.
Vaginal discharge: Amount, appearance, smell, change.
Current medication: Special attention: hormones therapy, anticoagulants.
Review of systems
Special focus on
Cardiovascular
Respiratory
Gastrointestinal: Bowel habits, stools (frequency, color, changes) abdominal pain, appetite,
weight loss, nausea, vomiting.
Urinary: itching, dysuria, pain, frequency of voiding, hematuria, incontinence, incomplete
emptying of the bladder, vaginal/uterine prolapse.
Tobacco
Present/previous use. Type, amount.
Alcohol
Amount and type.
Drugs
Use of illegal drugs/misuse of prescription drugs. Present/previous use.
Social history
Family, education, job, economy. Social services.
Physical examination
The physical examination in gynecology is focused, which means that you should only do the
examinations relevant for the present problem.
Overview
General appearance: well/bad, acute/chronically ill, dyspnoe
Nutritional status: Height, weight, (BMI).
Neurological/psychiatric: Awareness/orientation/mood
Vital signs: Temperature, blood pressure, pulse, respiration, and saturation.
Eyes
Mouth: Tongue, throat, teeth.
Lymph nodes: Palpable lymph nodes (e.g. submandibular, neck, axilla, groin)
Mammae: Inspection/palpation. Symmetry. Tumor. Skin. Nipple, secretion.
Respiratory: Vesicular/bronchial respiration. Abnormal sounds. Percussion.
Cardiovascular: Heart rate/peripheral pulse. Regular/irregular. Abnormal sounds.
Abdomen: Inspection: Flat/obese/scar. Palpation: Smooth/ tense, pain (localization
direct/indirect/peritoneal reaction), defence. Tumor. Liver/spleen. Hernia. Ascites. Auscultation:
normal, metallic, sparse/absent.
Rectal exploration: Tumor, anal reflex, stools (color, blood).
Spine: Inspection/palpation. Mobility. Pain at palpation/percussion.
Extremities: Inspection/palpation. Mobility.
Skin: Edema. Ulcerations. Varicose veins. Color. Skin temperature.
Neurology: Sensibility, strength, reflexes.
.
Para clinic examinations: ECG, blood tests, urine stick, imaging (ultrasound, x-ray, CT, MR)
Gynecological examination
Inspection of the external genitalia: Skin and mucosa (color, ulceration, warts). Vagina: mucosa
and cervix (erythroplakia, ulceration). Prolapse (anterior/posterior/uterus). Vaginal discharge.
If relevant: Cervical smear, microbiological samples (e.g. Chlamydia.)
Palpation: Bimanual palpation. Pain. Uterus, position, size. Adnexa, cyst, tumor.
Ultrasound examination, transvaginal or abdominal
Uterus: Position, thickness of endometrium, pregnancy, fibroma, adenomyosis.
Ovaries: Cysts/tumor (number, size, appearance).
Fluid in fossa Douglassi.
Conclusion
Most important positive/negative findings. Tentative diagnosis.
Plan
Immediate treatment.
Monitoring
Further examinations.
Medication, infusions.
Medical record - obstetrics
Gestational age, parity
Gestational age: GA XX+X (fulfilled weeks + days).
Parity: PX (P0=nulliparous, P1=has delivered once before, P2=has delivered twice before.) Live
born as well as stillborn are counted.
Reason for actual visit
Referral letter, antenatal record
Allergies
Allergies to medicine, latex, contrast etc. Type of allergic reaction.
Family history
Hereditary diseases (e.g. genetic, diabetes, cardiac, cancer)
Expositions
MRSA (occupation, hospitalization during foreign travel), ESBL, VRE, GBS.
Obstetric history
Number and outcome of pregnancies. Spontaneous miscarriages, induced abortions, ectopic
pregnancies. Deliveries, vaginal/cesarean section. Previous infertility.
For each previous delivery: Year, gestational age. Complications during pregnancy. Mode of
delivery: vaginal, instrumental vaginal, cesarean (acute/elective and reason). Outcome for the
baby: weight, Apgar score, admittance to neonatal intensive care.
Medical history
Nutritional status: Height, weight, (BMI).
Operations: Gynecological, abdominal (e.g. conisatio, removal uterine fibroma).
Sexually transmitted disease: Herpes, condylomata
Medical, surgical, psychological diseases.
Chief complaint/Present pregnancy
Date of the last menstruation (first day), menstrual cycle (regular/irregular, duration of
bleeding/cycle e.g. 7/28 days).
Fertility treatment to achieve this pregnancy
Bleeding during pregnancy. (if yes, then ask for date for the last cervical smear).
Fetal movements (from GA 20, daily from GA 24)
Nausea, vomiting, pelvic pain
Symptoms of preeclampsia (headache, visual disturbances, upper abdominal pain (epigastrium,
liver area), feeling sick, nausea).
Pain (localization, aggravating/relieving factors
Contractions (strength, duration, interval)
Rupture of membranes/”braking the water” (amount, color)
Review of systems
Gastrointestinal: Appetite, weight gain, nausea, vomiting. Bowel habits, stools (frequency,
constipation).
Urinary: itching, dysuria, pain, frequency of voiding (signs of urinary tract infection)
Spine, extremities: Low back pain, pelvic pain, edema
Skin: Itching
Medication: Vitamins, iron therapy, other.
Tobacco
Present/previous use. Type, amount.
Alcohol
Amount and type.
Drugs
Use of illegal drugs/misuse of prescription drugs. Present/previous use.
Social history
Family, partner. Education, job, economy. Social services.
Physical examination
The physical examination in obstetrics is focused, which means that you should only do the
examinations relevant for the present problem.
Blood pressure and urine stick is almost mandatory at all antenatal visits.
Overview
General appearance: well/bad, acute/chronically ill, dyspnea
Nutritional status: Height, weight, (BMI).
Neurological/psychiatric: Awareness/orientation/mood
Vital signs: Temperature, blood pressure, pulse, respiration, and saturation.
Mammae: Inspection/palpation.
Respiratory: Vesicular/bronchial respiration. Abnormal sounds. Percussion.
Cardiovascular: Heart rate/peripheral pulse. Regular/irregular. Abnormal sounds.
Abdomen: (See special obstetric abdominal examination) Inspection: Flat/obese/scar. Palpation:
Smooth/ tense, pain (localization direct/indirect/peritoneal reaction), defence. Tumor.
Liver/spleen. Hernia. Ascites. Auscultation: normal, metallic, sparse/absent.
Rectal exploration: Tumor, anal reflex, stools (color, blood).
Spine: Inspection/palpation. Mobility. Pain at palpation/percussion.
Extremities: Inspection/palpation. Mobility.
Skin: Edema. Ulcerations. Varicose veins. Color. Skin temperature.
Neurology: Sensibility, strength, reflexes.
.
Para clinic examinations: ECG, blood tests, urine stick
Obstetric examination
Uterus: Palpation: Tonus (normal/increased), irritability (palpation provokes contraction),
tenderness.
Fetus: Leopold’s maneuvers (fetal position, presenting part, fetal back, engagement and mobility
of the presenting part)
Measuring the fundal height (from the upper part of the symphysis to the fundus).
Fetal heart rate (auscultation, CTG).
Gynecological examination
Inspection
Antenatal: in case of bleeding or if ruptured membranes are suspected.
Postnatal: in case of bleeding, fever
Vaginal exploration
Suspected/manifest labor
Abdominal ultrasound examination
Fetal position, presenting part, localization of placenta.
Heart rate, fetal movements, amniotic fluid
Fetal size
In early pregnancy: CRL
From mid pregnancy: Estimated fetal weight (head circumference, abdominal circumference,
femoral length).
Blood flow: a. umbilicalis, a. cerebri media.
Transvaginal ultrasound examination
Early pregnancy: localization of pregnancy, number of fetuses, heart rate, CRL
From mid pregnancy: Cervical length (during contraction or fundal pressure)
Conclusion
Most important positive/negative findings. Tentative diagnosis.
Plan
Immediate treatment.
Monitoring
Further examinations.
Medication, infusions.
.