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Gynaecology Clerking Note

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PRESENTING PROBLEMS

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MENSTRUAL HISTORY

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Menstrual History

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Duration Of Flows

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Amount Of Flow

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Number Of Pads

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Dysmenorrhoea

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Comments

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Intermenstrual Bleeding

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Post Coital Bleeding

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Period of Amenorrhoea(POA)

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Comment

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Comment On Menstrual History

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GYNAECOLOGICAL HISTORY

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Past Gyn Operations

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Known Gyn Condition

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Date Of Last Pap Smear

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Result Of Pap Smear

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Comments

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Type Of Contraception Used

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Comments

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SEXUAL HISTORY

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MEDICAL AND SURGICAL HISTORY

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ALLERGIES AND ALERT

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OBSTETRICS HISTORY

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SOCIAL AND FAMILY HISTORY

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GENERAL EXAMINATION

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Vital Sign

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Pallor

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Oedema

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Jaundice

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Hydration

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Hirsutism

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Galactorrhoea

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Secondary Sexual Characteristic

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Umbilicus

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Hernia

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Comments

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Other Findings

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SYSTEMIC EXAMINATION

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Oral Cavity

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Comments

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Thyroid

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Comments

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Cardiovascular

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Comments

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Respiratory

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Comments

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Neurological

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Comments

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Breast

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Lymph Nodes

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Comments

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Peripheral Pulses

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Comments

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Gastro - Intestinal

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Comments

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Liver

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Comments

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Kidney

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Comments

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Spleen

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Comments

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Skin

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Comments

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Eyes

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Comments

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Ears

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Comments

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Mental Status

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Comments

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Others, Specify

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General Impression

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ABDOMINAL EXAMINATION

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GYNAECOLOGICAL EXAMINATION

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Vulva

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Comments

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Vagina

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Comments

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Urethra

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Comments

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Rectal Exam

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Comments

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Cervix

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Appearance

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Comments

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Position

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Comments

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Consistency

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Comments

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Contact Bleeding

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Comments

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Cervical Os

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Comments

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Tenderness

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Comments

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Prolapse

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Comments

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Uterus

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Size

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Position

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Comments

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Regularity

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Mobility

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Tenderness

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Adnexae

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Comments

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Other Findings

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RESULTS REVIEW

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DIAGNOSIS

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REFERRAL

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Plan

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Referral

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Outgoing

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Others, Specify

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Orders

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SIGNATURES

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