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GYNECOLOGIC HISTORY AND EXAMINATION

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It is common practice to obtain much of the history by paramedical personnel, interactive computer activities, or a patient questionnaire completed before seeing the physician. Hence, the patient–physician interaction can be focused with emphasis on the patient’s concerns. Additionally, important positive and negative findings may be reviewed with the patient before the physical examination. | GYNECOLOGIC HISTORY AND EXAMINATION HISTORY It is common practice to obtain much of the history by paramedical personnel interactive computer activities or a patient questionnaire completed before seeing the physician. Hence the patient-physician interaction can be focused with emphasis on the patient s concerns. Additionally important positive and negative findings may be reviewed with the patient before the physical examination. AGE MARITAL STATUS GRAVIDITY AND PARITY CHIEF COMPLAINT The patient s main problem s in her own words listed in her order of seriousness comprise the chief complaint. PRESENT ILLNESS The patient s health at the onset of illness and the symptoms in sequence of development form the present illness. As much detail e.g. facts dates as is possible is included documenting what where when why how and to what degree each complaint affects her. PAST HISTORY MENSTRUAL HISTORY The age and character of the menarche or menopause should be described. The last menstrual period LMP previous menstrual 505 Copyright 2001 The McGraw-Hill Companies. Click Here for Terms ofUse. 506 BENSON PERNOLL S HANDBOOK OF OBSTETRICS AND GYNECOLOGY period PMP and last normal menstrual period LNMP if relevant should be recorded. Also the regularity duration amount of bleeding number of perineal pads or tampons pain mucous discharge and intermenstrual or postcoital spotting should be recorded. GYNECOLOGIC HISTORY Record the following. Gravida G the number of previous pregnancies para P the number of previous term pregnancies abortions Ab the number of pregnancies terminated spontaneously or electively before 20 weeks gestation or 500 g premature deliveries Pre the number of pregnancies terminated between 21-35 weeks gestation or 500-2499 g living children LC the number of children currently living with twins noted in parenthesis at the end of the sequence. Often this is recorded in a summary with just the numbers in the sequence noted e.g. 4 2 1 2 4 Twins 1 pr. would mean .