Gynaecology & Obstetric (History Taking)
Wash hands, Introduce self, Gain consent. Ask Name & Age
Indications
Vaginal Discharge
Inter-menstrual bleeding
Post coital bleeding
Post menopausal bleeding
PC (Presenting Complaint)
Recording Examination Results
V
Vulva/vagina
V
C – Cervix
Ectropium, ectopy or polyps
Bi Lat Palp
A/V - Anterverted
A/F - Anteflexed
Size, shape, regular and mobile?
Adnexae
Ovaries, US ligaments & paramethium
HPC (History Presenting Complaint)
At this stage, a GI and Genito-Urinary history screen needs to be done on the patient. This is then
followed by a more thorough gynaecological & obstetric history screen
Menstrual History
Age at menarche
Duration and frequency of periods
Amount of bleeding on periods
Any abnormal bleeding (intra, pre or post
menstrual or post coital bleeding)
Contraceptive history or HRT
Last menstrual period
Age of cessation of menstruation
Fibroids
Muscular or fibrous tissue that increase the uterine
surface area and size so that bleeding is more painful
and severe. They nay be submucosal or submural. They
can also mobilise free and present like large polyps.
They are detected by hysteroscopy. Treatment in those
who have had children is usually hysterectomy
Ovarian Pain
Usually in iliac fossa and may be episodic and cyclical
as in endometriosis or constant as in malignancy
Uterine Pain
Centrally in hypogastrium and may radiate to lumbo
sacral
Obstetric History
When (by choice or not?)
No. of full term, miscarriage or terminations
Duration of the pregnancies
How were the children delivered?
What was the weight of the children? & What was the outcome of each pregnancy?
Any problems (thyroid, diabetes, anaemia, BP or UTI from the pregnancy – any current?)
G4 – P3+1 - Gravidity. Parity, P3 being no. of live births)
POH:
- Previous obst history
Sexual History
1 c/s
- Caesarean section
How many sexual partners in last 12 months?
1 ftnd
- Full term normal delivery
1hffd
- Forceps delivery
How many male/how many female?
A&W
- Alive & Well
How many have been casual?
Menarche 12 – Start of Periods
Has any protection been used some, most or not at all? Dysmen D – 2 +2 - Pain start s2 days before and after
Dyspar
- Pain during intercourse
Have you ever had a STD?
IMP/PCB
- Intran Menstr/Post coital bleeding
Male
Problems with sexual drive, erections, penetration, ejaculation or orgasm?
Female
Any problems with sexual drive, pain during intercourse or orgasm?
PMH (Any other previous illnesses)
DH & Allergies (Some can affect or be affected by pregnancy)
RF (Smoking & Alcohol. Travel)
FH (Obstetric problems)
SH (Effects of symptoms on ADL, work, relationship and finances)
Ideas, Concerns & Expectations
Pregnancy Norm Values
Blood & red cell volume >
HP < due to volume >
WCC >
Cardiac Ouput >
GFR > (due to CO)
Urea & Creat< (Due to >GFR)