Ob gyn history and physical sample 2025

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The HP: History and Physical is the most formal and complete assessment of the patient and the problem. HP is shorthand for the formal document that physicians produce through the interview with the patient, the physical exam, and the summary of the testing either obtained or pending.
The gynecologic exam typically includes an inspection of the external genitalia, a speculum exam to inspect the and , and a bimanual exam to assess the and adnexa by palpation. In some situations, a rectovaginal exam may also be appropriate; however, this step is often omitted.
This includes reviewing any pre-existing conditions, past hospitalizations and surgeries, allergies, medications being taken, and family medical history.
Past gynaecological history Infection: Any past history of pelvic inflammatory disease (PID). Whether it was adequately treated, including contact tracing. Any known contact with sexually transmitted infections. Gynaecological operations. Smear history - date and result of last cervical smear, previous abnormalities.
A physical exam may include a pelvic exam, cervical cancer screening, or a exam: In a pelvic exam, your ob-gyn may look at your , , and to check for any signs of problems. And your ob-gyn may check your internal organs with a gloved hand.
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The Two Parts of the HP Chronic and acute conditions, both past and present. Surgeries or procedures the patient has had. Major illnesses or injuries. All allergies, including those caused by medications, foods, and environmental factors.

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