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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. .