5 of 5 Revised GYNECOLOGIC EXAM (FEMALE) Bimanual examination report format Genitalia labia, clitoris, urethral orifice& introitus all nl Inspection of Cervix and Vagina bulging with straining, nl vaginal mucosa, cervix pink discharge. A pelvic examination is the physical examination of the external and internal female pelvic organs.
It is called" bimanual exam" when two hands are used and" manual uterine palpation" ( palpation meaning an examination by touch). Medical History And Physical Examination. Technical Medical History and Physical Examination The results of required tests for tuberculosis and syphilis must be entered in the appropriate spaces on the medical report form. FGGT and the pelvic exam case report forms y When the term from the case report form is more specific than the term from the FGGT, use the term from the case report form y Use routine QCQA opportunities to help PHYSICAL EXAMINATION: VITAL SIGNS: Blood pressure, weight 146, temperature 98.
6, pulse 74, height 6634 inches. GENERAL: Alert and oriented x3. GENERAL: Alert and oriented x3. No acute distress. Assessment of the gynecologic history and the pelvic examination is part of the assessment of female patients in many clinical contexts.
Clinician familiarity with the gynecologic evaluation can help reduce anxiety for both patients and healthcare professionals. The gynecologic history and physical examination in adult women are said reviews), and continuing provide documentation in section 6 of the record. (17) Bimanual pelvic exam. Patient perceptions of the need for chaperones during pelvic exams. Speculum examination, Bimanual examination, Rectovaginal examination, SPECIAL after hysterectomy, DOCUMENTATION, SUMMARY AND Bimanual examination revealed no organomegaly.
She has a history of fibroid of her uterus. Long discussion was held about fibroids and their atrophy in the menopause upon estrogen withdrawal. The bimanual examination (also known as a pelvic examination) is an examination of the female genital organs. In this article, we shall look at how to perform a bimanual examination in an OSCEstyle setting. Introduction. Introduce yourself to the patient Clinical ReportGynecologic Examination for Adolescents in the Pediatric Ofce Setting abstract an adequate sample for diagnosing these infections.
Visualizing the cervix ing the bimanual examination. The pelvic examination should be per Bimanual Vaginal (PV) Examination Foreword Bimanual or PV examinations are performed for a number of clinical reasons, for example with problems relating to menstruation, irregular bleeding, dyspareunia, abnormal vaginal discharge or pelvic pain.
Sample Written History and Physical Examination History and Physical Examination Comments Patient Name: Rogers, Pamela Date: 6204 Referral Source: Emergency Department Data Source: Patient Chief Complaint& ID: Ms. Rogers is a 56 yo WF Define the reason for the patients visit as who has been having chest pains for the