Obs and Gynae pocket doctor template

this is the gynae history from the POCKET DOCTOR booklet:

INTRO

CHECK
Patient name and age

PRESENTING COMPLAINT

HISTORY OF PRESENTING COMPLAINT

1. BLEEDING
menarche
period regularity
heavy? if yes: pad changing per day/flooding/clots/tiredness
LMP
IMB/PCB/PMB
Discharge: if yes: colour, smell

2. FERTILITY
Sexual contacts
STI's
contraception: barrier and birth control
HRT if post-menopause
Pregnancy attempts
Smears: last date and result
Breast screening

3. PAIN
Painful periods? at what part of cycle
Painful sex? On penetration/during

4. UROGYNAE
Prolapse: dragging sensation/something 'coming down'. Back pain.
Urinary: incontinence? relation to coughing/sneezing/straining
Urinary symptoms: freq, noct, dysuria, strangury, hameaturia, unable to interrupt stream.
Bowel habits: esp change in habits.

OBSTETRIC HISTORY
Pregnancies: date delivered, mode, weight, problems.
Miscarriages: gestation?
Termination: gestation, reason?
ectopics

PAST MEDICAL HISTORY
esp gynae operations

DRUG HISTORY

FAMILY HISTORY

SOCIAL HISTORY

summary
address pesky concerns

[Kindly written up by a friend]

'Explanations' Template for OSCE's or in life.

A friend of mine said:

real simple template:
egs are for endoscopy

1. WHAT it is and WHY we do it (camera test to look for ulcers/bleeding)
2. HOW we do it (spray at back of throat, thin camera tube in mouth)
3. SIDE effects and RISKS (sore throat and infection/perforation)
4. RESULTS: when and how you get them
5. PREPARATION and AFTER the procedure (eg starve 6hrs before endoscopy, have a lift home organised)

its quite basic, but covers most things!

In essence its, why what how, side effects, risks, complications, results, preparation, afterwards [immediate, short term, longterm]