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Discipline

: Obstetrics & Gynaecology

Sub Discipline

: Gynaecology

Document Title

: Gynaecology Clerking Note

PRESENTING PROBLEMS

Complaints / Symptoms

Please Update Method

Comment On Presenting Problems

Current Medication

MENSTRUAL HISTORY

Menstrual History

Duration Of Flows

Day(s)

Amount Of Flow

Comments

Number Of Pads

Per Day

Dysmenorrhoea

YesNo

After menses

Comments

Intermenstrual Bleeding

YesNo

Post Coital Bleeding

YesNo

Period of Amenorrhoea(POA)

Week(s)

Comment

Comment On Menstrual History

GYNAECOLOGICAL HISTORY

Past Gyn Operations

Colposcopy

D&C

ERPOC

EUA

Laparoscopy

Laparotomy

Myomectomy

Ovarian Cystectomy

Sterilisation

TAH

TAHBSO

Others, specify

Known Gyn Condition

Endometriosis

PCOS

Pelvic Inflammatory Disease

Abnormal Uterine Bleeding

Fibroid

Ovarian cyst

Subfertility

Menopause

Others, specify

Date Of Last Pap Smear

Result Of Pap Smear

Comments

Type Of Contraception Used

None

COCP

Progestogen Only Pill

IUCD

Barrier Method

Implants

Injectables

Calendar Method

Coitus Interruptus

Others, specify

Comments

SEXUAL HISTORY

Sexual Frequency

Comment On Sexual History

MEDICAL AND SURGICAL HISTORY

Medical History

None

Diabetes

Hypertension

Heart Disease

Sexualy Transmitted Diseases

HIV

Breast Cancer

Epilepsy

Others, specify

Past Surgical History

Drug History

ALLERGIES AND ALERT

Allergies

OBSTETRICS HISTORY

Other Comments

SOCIAL AND FAMILY HISTORY

Marital Status

Occupation

Habits

Substance abuse

Drug abuse

Alcohol Addiction

Multiple Sexual Partner

Smoking

Others, specify

Family History

Diabetes

Asthma

Hypertension

Heart Disease

Tuberculosis

Multiple Pregnancy

Malignancy

Type of Malignancy

Congenital Abnormalities

Others, specify

GENERAL EXAMINATION

Vital Sign

Pallor

Oedema

Jaundice

Hydration

Hirsutism

Galactorrhoea

Secondary Sexual Characteristic

Umbilicus

Hernia

All intact

Umbilical

Incisional

Inguinal right

Inguinal left

Femoral right

Femoral left

Comments

Other Findings

SYSTEMIC EXAMINATION

Oral Cavity

Comments

Thyroid

NormalAbnormal

Comments

Cardiovascular

NormalAbnormal

Comments

Respiratory

NormalAbnormal

Comments

Neurological

NormalAbnormal

Comments

Breast

Please Update Method

Lymph Nodes

NormalAbnormal

Comments

Peripheral Pulses

NormalAbnormal

Comments

Gastro - Intestinal

NormalAbnormal

Comments

Liver

NormalAbnormal

Comments

Kidney

NormalAbnormal

Comments

Spleen

NormalAbnormal

Comments

Skin

NormalAbnormal

Comments

Eyes

NormalAbnormal

Comments

Ears

NormalAbnormal

Comments

Mental Status

NormalAbnormal

Comments

Others, Specify

General Impression

ABDOMINAL EXAMINATION

Body Image

Comments

GYNAECOLOGICAL EXAMINATION

Vulva

Normal

Atrophic

Warty growth

Varicose veins

Leukoplakia

Bartholin's abscess

Bartholin's cyst

Trauma

Ulcers

Herpetic lesions

Others, specify

Comments

Vagina

Normal

Fresh torn hymen

Abnormal discharge

Inflamed

Atrophic

Stenosis

Cystocoele

Rectocoele

Enterocoele

Vaginal cyst

Tear and laceration

Intact hymen

Old torn hymen

Obliterated

Ulceration

Haematocolpos

Septum

Others, specify

Comments

Urethra

Normal

Urethrocoele

Urethral prolapse

Caruncle

Urge incontinence

Stress incontinence

Trauma

Bullous lesions

Others, specify

Comments

Rectal Exam

Normal

Normal anal tone

Lax anal tone

Haemorrhoids

Bleeding

Mass per rectal

Induration

Growth

Mass felt in POD

Others, specify

Comments

Cervix

Appearance

NormalAbnormal

Comments

Position

AxialAnteriorPosterior

Comments

Consistency

Firm

Comments

Contact Bleeding

PresentAbsent

Comments

Cervical Os

NormalAbnormal

Comments

Tenderness

No

Comments

Prolapse

YesNo

Comments

Uterus

Size

NormalEnlargedAtrophy

Position

Anteverted

Comments

Regularity

YesNo

Mobility

YesNo

Tenderness

YesNo

Adnexae

Normal

Fixed mass left

Fixed mass right

Mobile mass right

Mobile mass left

Tender left

Tender right

Others, specify

Comments

Other Findings

RESULTS REVIEW

Comments On Investigations

Comments On Ultrasound

Comments On Histology

DIAGNOSIS

Diagnosis

Concurrent Illnesses

Co-Morbidities

Associated Problems

Risk

Comments

REFERRAL

Plan

Referral

Outgoing

Others, Specify

Orders

SIGNATURES

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