APPROACH TO THE PATIENT
includes ID, CC, HPI, PMH, Meds, Allergies, etc...
Obstetrical History Gravida__ Para__ SAB__ TAB__ L__ year, hospital, outcome, mode of delivery, sex, gestational age, weight, complications
Menstrual History LNMP, LMP age menarche, menopause cycle length, duration, regularity flow associated symptoms • pain, PMS abnormal menstrual bleeding • intermenstrual, post-coital
Sexual History age when first sexually active number and sex of partners history of sexual assault or abuse
Contraceptive History present and past contraception modalities reasons for discontinuing compliance complications/failure/side-effects
Gynecological Infections STDs, PID (herpes, chlamydia, gonorrhea, etc...) vaginitis, vulvitis lesions include treatments, complications, etc...
Gynecological Procedures last Pap smear • history of abnormal Pap • follow-up and treatments gynecological or abdominal surgery previous ectopic pregnancies
height, weight, BP breast exam abdominal exam pelvic exam including • observation of external genitalia • speculum exam +/– smears and swabs • bimanual exam • cervix size, consistency, os, and tenderness • uterus size, consistency, contour, position, shape, mobility, and other masses • adnexal mass, tenderness • rectovaginal exam • rectal exam
ßhCG• evaluation of abnormal uterine bleeding, preoperative investigation • investigation of possible pregnancy or ectopic pregnancy, work-up for GTN • monitored after the medical management of ectopic and in GTN to assess for cure and recurrences LH, FSH, TSH, PRL • amenorrhea, menstrual irregularities, menopause, infertility, etc...
MCCQE 2000 Review Notes and Lecture Series