Gynaecology and Obstetrics Assessment

GYNAECOLOGY ASSESMENT
DEMOGRAPHIC DATA
• Name of patient:
• Name of attender:
• Age:
• Occupation:
• Religion:
• Date of admission:
• Date of examination:
CHEIF COMPLAINS:
HISTORY OF PRESENT ILLNESS:
MESTRUAL HISTORY:
• Age when attained puberty (menarche):

• Cycles (regular/ irregular):
• Flow (heavy/ normal/ less):
• Pain:
OBSTETRIC HISTORY:
• Number of pregnancies: GPLA

• H/O abortions/ miscarriages:
• H/O ectopic pregnancy:
• Live births:
• H/O still birth:
• Previous delivery (FTNVD/ LSCS):
PAIN ASSESMENT (OPQRST)
• Onset of pain:
• Precipitating factor:
• Quality of pain:
• Relieving factor:
• Site of pain:
• Temporal variation:
VAS (visual/ verbal):
Rest
|------------------------------------------------------------------------|
score:_______
0 10
Activity
|------------------------------------------------------------------------|
score:______
0 10
MEDICAL HISTORY
• H/O DM, TB, HTN, OTHERS

• H/O TORCH infections:
T-Toxoplasmosis
O- others(syphilis,hepatitis B
R- Rubella
C- Cytomegalo virus
H- Herpes simplex
• H/O blood transfusion:
• H/O and treatment of infertility:
SURGICAL HISTORY:
FAMILY HISTORY:
SOCIAL HISTORY:
FUNCTIONAL HISTORY:
• Diet:
• Appetite:
• Sleep:
• Bowel and bladder:
Bladder (urological) functions:

• Frequency of micturation:
• Volume of micturation:
• Urge of micturation:
• Urine leakage:
GENERAL PHYSICAL EXAMINATION:
VITALS
• PR:
• RR:
• BP:
• Temperature:
• PICCLE:
P- Pallor
I- Icterus
C-Cyanosis
C-Clubbing
L-Lymphadenopathy
E-Edema
POSTURE:
ANTERIOR POSTERIOR LATERAL

Sitting
Standing
GAIT:
• Phases of gait:
• Cadence:
• Deviations in gait pattern:
ABDOMINAL EXAMINATION
• Swelling:
• Tenderness:
• Spasm:
• Incision:
• Scar:
BREAST EXAMINATION
• Swelling:
• Discharge:
• Edema:
• Redness:
• Lump:
• Fungal infections:
PELVIC EXAMINATION
• Inspection of vulva:
• Pelvic tenderness:
• Pelvic mass:
• Vaginal walls:
• Fungal infections:
➢ Rectal examination:
MUSCULOSKELETAL EXAMINATION:
• Palpation- tenderness:
-Spasm:
-warmth:
• Movements - lumbar:
-SI:
• Manual muscle testing
• Abdominals:
• Back extensors:
• Pelvic floor muscles:
SPECIAL TESTS
• Pad test:
• Cone test:
• Stress test:
• Tests for joint dysfunction:
INVESTIGATIONS:
DIAGNOSIS:
PROBLEM LIST:
SHORT TERM GOALS:
LONG TERM GOALS:
PHYSIOTHERAPY TREATMENT PLAN:
FOLLOW UP:
OBSTETRICS ASSESMENT
DEMOGRAPHIC DATA
• Name of patient:
• Name of attender:
• Age:
• Occupation:
• Religion:
• Date of admission:
• Date of examination:
CHEIF COMPLAINS:
HISTORY OF PRESENT ILLNESS:
MENSTRUAL HISTORY:
• Age when attained puberty (menarche):
• Cycles (regular/ irregular):
• Flow (heavy/ normal/ less):
• Pain:
OBSTETRIC HISTORY
Current pregnancy-
• Age at the time of conception:
• Mode of conception (spontaneous/ assisted/ hormonal):
• Last menstrual period:
• Expected date of delivery:
• Antenatal checkups:
• History of immunization:
Previous pregnancy-
• GPLA:
G- Gravida (number of times you are pregnant
P-parity (number of fetus crossing period of
viability)
L-live birth (number of live birth)
A-Abortion (number of abortions)
• Type of delivery (previous):
• H/O abortion/ miscarriage:
• H/O ectopic pregnancy:
• Live births:
• H/O still birth:
PAIN ASSESMENT: OPQRST
• Onset of pain:
• Precipitating factor:
• Quality of pain:
• Relieving factor:
• Site of pain:
• Temporal variations:
VAS (visual/ verbal):
Rest
|-----------------------------------------------------------------|
score: _______
0 10
Activity
|-----------------------------------------------------------------|
score:______
0 10
MEDICAL HISTORY
• H/O DM, TB, HTN, OTHERS
• H/O TORCH infections-toxoplasmosis, others(syphilis,
hepatitis ), rubella, cytomegalovirus, herpes simplex.
• H/O blood transfusion:
• H/O and treatment of infertility:
SURGICAL HISTORY:
FAMILY HISTORY:
SOCIAL HISTORY:
FUNCTIONAL HISTORY:
• Diet:
• Appetite:
• Sleep:
• Bowel and bladder:
Bladder (urological) functions:
• Frequency of micturation:
• Volume of micturation:
• Urge of micturation:
• Urine leakage:
GENERAL PHYSICAL EXAMINATION:
VITALS
• PR:
• RR:
• BP:
• Temperature:
POSTURE:
ANTERIOR POSTERIOR LATERAL
Sitting
Standing
GAIT:
• Phases of gait:
• Cadence:
• Deviations in gait pattern:
ANTENATAL EXAMINATION
ABDOMINAL EXAMINATION
ON INSPECTION-
• Skin condition:
• Linea nigra(hyperpigmentation):
• Striae:stretch marks
• Foetal movements:
ON PALPATION-
• Uterus shape and size:
• Presentation:
• Fetal poles and lie:
• Fundal height:
• Level of presenting part:
• Engagement:
ON AUSCULTATION-
• Fetal heart rate:
POSTNATAL EXAMINATION
ON OBSERVATION-
• Pedal edema:
ON EXAMINATION-
Breast examination
• Contour:
• Tenderness:
• Engorgement (filled with too much milk):
Abdominal examination
➢ DRAM (Diastasis recti abdominus)-
• Supra-umbilical:
• Umbilical:
• Infra-umbilical:
➢ Abdominal girth measurement:

Musculoskeletal examination:
• Palpation- tenderness:
-Spasm:
-warmth:
• Movements - lumbar:
-SI:
• Manual muscle testing
• Abdominals:
• Back extensors:
SPECIAL TESTS:
• SLR:
• Fabers test:
• Neural gapping:
• Others:
INVESTIGATIONS:
DIAGNOSIS:
PROBLEM LIST:
AIMS FOR PT MANAGEMENT:
SHORT TERM GOALS:
LONG TERM GOALS:
PHYSIOTHERAPY TREATMENT PLAN:
FOLLOW UP:

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GYNAECOLOGY ASSESMENT

HISTORY OF PRESENT ILLNESS:

• Age when attained puberty (menarche):

• Number of pregnancies: GPLA

PAIN ASSESMENT (OPQRST)

VAS (visual/ verbal):

• H/O DM, TB, HTN, OTHERS

Bladder (urological) functions:

GENERAL PHYSICAL EXAMINATION:

ANTERIOR POSTERIOR LATERAL

SHORT TERM GOALS:

LONG TERM GOALS:

PHYSIOTHERAPY TREATMENT PLAN:

HISTORY OF PRESENT ILLNESS:

Bladder (urological) functions:

➢ Abdominal girth measurement:

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