history taking and PE, office gynecology Flashcards
(38 cards)
General data
name, age, marital status, religion, OB INDEX address, naem of hospital, number of admission, date of admission
OB INDEX
GP TPAL
G
GRAVIDITY, number of pregnancies, irregrdless of outcome
P
parity, number of pregnancies wc reached the age of viabilty >=28wks
T
term >=37 wks
P
preterm, less than 37 wks aog
A
abortion
L
number of children alive
chief complaint
primary symptom prompting the patient to seek medical attention
OBSTETRIC/GYNECOLOGIC HX
age of meanrche, subsequent menses, age of coitus, number of sexual partners, hx of post coital bleeding, infections, dyspareunia, method of contraception, legth of time used, complications, lmp and pmp
mean duration of regular menstrual cycle
28 plus minus 7 days
timing of bse
7-10 days after onset pf menstruation in regular menstruating women, same calendar day for post menopausal and post hysterctomy px
different positions for bse
arms at the side, arms overhead, hand on hips, bending forward
palpation
standing or lying method
wet technique
standing position, done while in the shower to increase tactile sensitivity
flat pads of what fingers for palpation
2nd 3rd 4th
3 methods of bse
rotatary, circular, vertical, wedge palpation
pelvic exam
dorsal lithotomy position *drape the px, tell px to relax
HOW TO DO SPECULUM EXAM
insert spec in a vertical position direct downward (if up, SP na kasi so ouchy) gently twist open and look for cervix screw and stabilize, get sample
BIMANUAL EXAM indications
both pregnant and nonpregnant patients
in IE palpating the ant fornix is for
locating the uterus
in IE, palpating the lat fornix
to assess the adnexa
in IE, the dominant hand (index and mid fing) is
inserted to the vagina
in IE, the nondom hand
used to palpate the fundus of the uterus