Gynecological Conditions and Disorders of the Breast

Name:	SSN:
Date of Exam:	C-number:
Place of Exam:

A. Review of Medical Records:

B. Medical History (Subjective Complaints):

Provide:

1. Date of onset of symptoms.
2. Describe symptoms, e.g., abnormal bleeding, vaginal discharge, fever, pain, bowel or bladder symptoms, etc.
3. Treatments:

1. Detail all breast and pelvic surgery.
2. If a malignant process has been identified, provide:

1. Date of confirmed diagnosis.
2. Date of the last surgical, X-ray, antineoplastic chemotherapy, radiation, or other therapeutic procedure.
3. Expected date treatment regimen is to be completed.
4. If already completed, provide date.
5. Fully describe residuals.

c. Detail hormonal and other medications and whether continuous medication is required, response, and side effects.

4. Include complete menstrual history, pregnancy history, and urinary tract history.

C. Physical Examination (Objective Findings): Provide a full gynecological and breast examination (unless only a particular condition or portion of the examination is requested).

Address each of the following and fully describe current findings:

1. Uterus.

1. If post operative, state extent of surgery.
2. If prolapse is present, is it through the introitus?
3. If displaced, are there adhesions and/or menstrual disturbances.

2. If rectovaginal fistula is present, describe extent and frequency of leakage and whether a pad is required.
3. If urethrovaginal fistula is present, describe whether absorbent material is required and how often it must be changed.
4. If rectocele, cystocele, or perineal relaxation is present, is it due to pregnancy?
5. Breasts.

If post-operative, Identify the type of surgery using the following definitions:

1. Radical mastectomy - removal of the entire breast, underlying pectoral muscles, and regional lymph nodes up to the coracoclavicular ligament.
2. Modified radical mastectomy - removal of the entire breast and axillary lymph nodes (in continuity with the breast). Pectoral muscles are left intact.
3. Simple (or total) mastectomy - removal of all the breast tissue, nipple, and a small portion of the overlying skin, but lymph nodes and muscles are left intact.
4. Wide local incision - includes partial mastectomy, lumpectomy, tylectomy, segmentectomy, and quadrantectomy. This means removal of a portion of the breast tissue.
5. Describe any alteration of size and form.

D. Diagnostic and Clinical Tests:

1. CBC.
2. Urinalysis.
3. Laparoscopy is required to establish diagnosis of endometriosis and to confirm bowel or bladder involvement.
4. Ultrasound, mammography, if indicated.
5. Pap smear (if none within past year).
6. Include results of all diagnostic and clinical tests conducted in the examination report.

E. Diagnosis:

Signature:

Date: