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Discipline

: Obstetrics & Gynaecology

Sub Discipline

: Gynaecology

Document Title

: Gynaecology Procedure Note

Type Of Gynae Procedure

Procedure Ordered

Last Menstrual Period (LMP)

COLPOSCOPY

Date Of Last Cervical Smear

Result Of Last Cervical Smear (With Date)

Normal

Inflammatory

Atrophic changes

Suspicious

Suggestive CIN

I

Atypical cells

Dyscaryotic

Grossly abnormal cells-maybe malignant

Suggestive of HPV infection

Adenomatous cells

Cells with features of adenocarcinoma

Others, specify

Indications For Colposcopy

Abnormal cervical smear

Persistent postcoital bleeding

Persistent cervicitis/vaginitis

Repeat colposcopy after treatment

Post radical hysterectomy for cancer cervix

Post surgery for cancer endometrium

Serial Monitoring

Others, specify

Vaginal Examination

Vulva

Normal

Atrophic

Bartholin's abscess

Herpetic lesions

Laceration

Leukoplakia

Ulcers

Varicose veins

Warty growth

Others, specify

Vagina

Discharge present

Inflammed

Atrophic

Stenosis

Cystocoele

Rectocoele

Enterocoele

Vaginal cyst

Injuiry

Intact hymen

Old torn hymen

Fresh torn hymen

Obliterated

Ulcerated

Sign of haematocolpos

Septum

Normal

Others, specify

Cervix

Appearance

NormalAbnormal

Position

Contact Bleeding

YesNo

Cervical Os

Close

Tenderness

YesNo

Prolapse

YesNo

Colposcopic Findings

General Appearance

Normal

Atrophic

Inflamed

Contact bleeding

Polypoidal growth

Fungating growth

Nabothian cyst

Cervical polyp

Pendunclated polyp

Ectopian/erosion

Ulceration

Leukoplakia

Aceto white

Discharge

Features suggestive of malignancy

Features suggestive of infection

Other Findings

Vascular Pattern

Normal

Regular vessels

Neovascularisation

Punctation

Mosaicism

Contact bleeding due to vascular fragility

Irregular avascular characteristic

Appearance suggestive of malignancy

Squamo-Columnar Junction

Identified

Not identified

On everted surface of cervix

Deep in cervical canal

Changes seen

Transformation Zone

Delineated

Not delineated

Deep in cervical canal

On everted surface of cervix

Acetowhite Areas

None

Small area

Extensive circumferentially

Mainly left upper quadrant

Mainly left lower quadrant

Mainly right upper quadrant

Mainly right lower quadrant

Extending into the internal cervical canal

Areas of acetowhite patches in the vagina

Areas of acetowhite patches on the vulva

Leukoplakia

Schillers Test

Not DoneDone

Negative

Colposcopic Investigative Procedure

Colposcopic Biopsy

DoneNot Done

No. Of Sample for HPE

Other Investigative Procedures

Cervical smear for chlamydia

Cervical smear for C&S

Cervical smear for cytology

Cytology for HPV

Endometrial biopsy

Vulval punch biopsy

Vaginal biopsy

Others, specify

Colposcopy-Therapeutic Procedures And Follow Up Plan

Laser Therapy

"Cold" coagulation to cervix

Cryo / cautery to cervix

Diathermy

Diathermy loop excision (LLETZ)

Cone Biopsy

Polypectomy

Regular cervical sreening/smear

Treat cervical/vaginal candidiasis/infection

Hysterectomy

Others, specify

CYTOLOGICAL SMEAR

Screening Summary

Cytological Smear

Conventional smear

Sampling Site

CervixVagina

Screening Type

New

Repeat

Routine

Indicated

Clinical Summary

Hormonal Status

Contraceptive / Hormonal Theraphy

Treatment History

Chemotherapy

Pelvic Radiation Exposure

Gynaecology Surgery

None

Symptoms And Signs

None

Vaginal discharge

Abnormal Bleeding

Cervix

ENDOMETRIAL SAMPLING

Vaginal Examination

Vulva

Normal

Atrophic

Warty growth

Varicose veins

Leukoplakia

Bartholin's abscess

Bartholin's cyst

Laceration

Ulcers

Herpetic lesions

Others, specify

Vagina

Discharge present

Inflammed

Atrophic

Stenosis

Cystocoele

Rectocoele

Enterocoele

Vaginal cyst

Injuiry

Intact hymen

Old torn hymen

Fresh torn hymen

Obliterated

Ulcerated

Sign of haematocolpos

Septum

Others, specify

Cervix

Appearance

Abnormal

Position

Anterior

Contact Bleeding

No

Cervical Os

Close

Tenderness

No

Prolapse

No

Uterus

Size

Uterine Sound

YesNo

Position

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

Outcome

SuccessfulUnsuccessful

Hpe Sent

YesNo

OFFICE HYSTEROSCOPY

Procedures

Diagnostic Hysteroscopy

Division

Ablation

Endoscopic Surgery for Ashermanns synd

Hydrothermal Ablation

Removal of IUD

Removal of Polyps

Endometrial biopsy

Others, specify

Hysteroscope

Size

Type

Resectoscope

YesNo

Biopsy forceps

YesNo

Others, specify

Cervical Dilatation

Distending Media

Normal Saline

CO2

Glycine

Others, specify

Fluid Used

In

LITRE

Out

LITRE

Balance

Ablative Media

Electrodiathermy

CO2 laser

Nd:YAG laser

Hydrothermal

Others, specify

Findings

Normal

Areas of atypical endometrium

Atrophic endometritis

Endometrial polyps

Impacted IUD

Intrauterine adhesions

Pedunclated fibroid

Submucous fibroid

Uterine septum

DUB

Ostium Seen

Right

No

Others, specify

Hysterscopy Diagram

Complications

Bleeding

Failure of procedure

Fluid Overload

Gas embolism

Infection

Others, specify

INSERTION OF CONTRACEPTIVE IMPLANT

Site Of Implant

Right armLeft arm

INSERTION OF IUD

Type Of IUD

Multiload

Copper-T

Progesterone - releasing IUD

Others, specify

Vaginal Examination

Vulva

Normal

Atrophic

Bartholin's abscess

Bartholin's cyst

Herpetic lesions

Laceration

Lax perineum

Leukoplakia

Ulcers

Varicose veins

Warty growth

Others, specify

Vagina

Fresh torn hymen

Discharge present

Inflammed

Atrophic

Tight introitus

Stenosis

Cystocoele

Rectocoele

Enterocoele

Vaginal cyst

Injuiry

Intact hymen

Old torn hymen

Obliterated

Ulcerated

Sign of haematocolpos

Septum

Others, specify

Cervix

Appearance

Abnormal

Position

Anterior

Size

Abnormal

Status

NormalAbnormal

Contact Bleeding

AbsentPresent

Cervical Os

NormalAbnormal

Tenderness

YesNo

Prolapse

No

Uterus

Size

Uterine Sound

YesNo

Position

Anteverted

Comments

Regularity

YesNo

Mobility

No

Tenderness

YesNo

Other Findings

Complications

Bleeding

Comments

INSERTION OF VAGINAL PESSARY

Vaginal Findings

Urethra

Normal

Urethrocoele

Urethral prolapse

Caruncle

Urinary leak

Stress incontinence

Injuiry

Bullous lesions

Others, specify

Comments

Vagina

Cystocoele

Others, specify

Comments

Uterus

Normal Size

Bulky

8 - 10 weeks size

11 - 14 weeks size

15 - 20 weeks size

21 - 24 weeks size

>25 weeks size

Anteverted

Retroverted

Others, specify

Comments

Insertion Of Vaginal Pessary

Indications - Vaginal Pessary

UV prolapse

Urinary Retention

Stress incontinence

Others, specify

Comments

Types Of Pessary

Ring pessary

Hodge pessary

Others, specify

Comments

Size Of Pessary (Mm)

Removal Of Pessary

Weeks

Comments

Other Findings

Comments Insertion Of Vaginal Pessary

REMOVAL OF CONTRACEPTIVE IMPLANT

Site Of Implant

Right armLeft arm

Date Of Insertion

Comments

REMOVAL OF IUD

Type Of IUD

Multiload

Copper-T

Progesterone - releasing IUD

Others, specify

Date Of Insertion

Duration Of IUD Used

IUD Thread Present In Vagina

YesNo

Comments

Complications IUD Removal

Miscarriage

Infections

Preterm labour

Bleeding

None

Others, specify

Comments

URODYNAMICS

Urine Nitrite

PositiveNegative

Antibiotic Prophylaxis

Maximum Urine Flow Rate

mls (n>-15mls/S)

Amount Of Urine

mls (n>-150mls)

Residual Urine

mls (n<-150mls)

Maximum Bladder Capacity

mls (n>-400mls)

Mid Urethral Closure Pressure (Mucp)

Erect Stress Test

G

Ring Pessary

InsertedInsitu

Diagnosis

Comments

LAPAROSCOPY

Date Time

Anaesthesia

Epidural

Operation Finding

Uterus

Left Ovary

Right Ovary

Left Tube

Right Tube

Pelvic Peritonium

MANAGEMENT

OPERATIVE PROCEDURE

Date Time

PERFORMING STAFF

Performing Staff

SIGNATURES

Notes Component

COLPOSCOPY
CYTOLOGICAL SMEAR
ENDOMETRIAL SAMPLING
OFFICE HYSTEROSCOPY
INSERTION OF CONTRACEPTIVE IMPLANT
INSERTION OF IUD
INSERTION OF VAGINAL PESSARY
REMOVAL OF CONTRACEPTIVE IMPLANT
REMOVAL OF IUD
URODYNAMICS
LAPAROSCOPY
MANAGEMENT
OPERATIVE PROCEDURE
PERFORMING STAFF
SIGNATURES

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