File Name: history taking in obstetrics and gynaecology file.zip
Taking a history is the initial step in the physician—patient encounter. This provides a basis for emphasizing aspects of the subsequent physical examination, and for initial decisions about diagnostic testing and treatment.
This chapter outlines the components of a basic gynecologic history and gynecologic examination. Because a discussion of reproductive issues may be difficult for some women, it is important to obtain the history in a relaxed and private setting.
The patient should be clothed, particularly if she is meeting the provider for the first time. Ordinarily, the patient should be interviewed alone.
Exceptions may be made for children, adolescents, and mentally impaired women, or if the patient specifically requests the presence of a caretaker, friend, or family member. However, even in these circumstances, it is desirable for the patient to have some time to speak with the clinician privately. The manner of address should be formal using the title Mrs.
In some settings, it may be appropriate for nursing staff to be involved with history taking. A nurse may be perceived as less threatening, and may be able to take the history in a less hurried manner.
Alternatively, it may be helpful to ask the patient to complete a self-history form on paper or by computer prior to speaking with the provider. This allows the provider to devote time to addressing positive responses, and ensures that important questions are not missed. At the conclusion of the interview, patients should be asked whether there are concerns that they would like to discuss that were not addressed previously in the interview.
An outline of a comprehensive gynecologic screening history is shown in Table 1. Aspects of the comprehensive history include:. Chief complaint History of present illness Menstrual history Age at menarche Last menstrual period Menstrual pattern Cycle length Duration of flow Amount of flow Moliminal symptoms?
Previous methods, including complications, reasons discontinued Cervical and vaginal cytology Most recent Pap smear result History of abnormal Pap smears?
History of vaginitis, including types, frequency, and treatment. History of pelvic inflammatory disease. Chief complaint CC. Even if the patient is being seen for an annual gynecologic examination, it is helpful to begin the interview by asking whether the patient is experiencing any problems.
History of present illness HPI. The patient is asked to describe any symptoms in her own words. Additional information about the nature of the problem can then be obtained by asking specific questions. It is helpful to know: The circumstances at the time the problem began, including activities that the patient was engaged in, medical problems that she was experiencing at the time, and any medications that she was taking around that time.
The time course of the problem. Was this a transient problem, or has this been chronic, recurrent, or persistent? Are the symptoms temporally related to the menstrual cycle? Is this a new problem, or has the patient experienced similar symptoms in the past? If the problem involves disruption of an otherwise normal function such as amenorrhea , did the patient have normal function at some point in the past? Characteristics of the problem, and associated symptoms. In the case of pain, this would include questions about the location, severity, nature e.
With respect to bleeding, this would include the frequency, amount, and duration of flow, and whether the patient is experiencing fatigue or lightheadedness. Has the patient undergone any previous evaluation or treatment for the problem? Why did the patient seek evaluation of the problem at this point?
Have the symptoms changed or increased in severity? Menstrual History. Age at menarche. Puberty marks the beginning of the reproductive years and includes a series of events that occur over 2—4 years including an increase in height, breast development thelarche , pubic hair growth pubarche or adrenarche , and the onset of menses menarche. The average age at menarche is 12—13 years, with a range from 9 to 17 years.
Initially, menstrual cycles are typically anovulatory and menses occur at irregular intervals. Last menstrual period LMP. By convention, the first day of the last menstrual period is recorded. Menstrual pattern and associated symptoms. Cycle length. The cycle length is the interval from the first day of one menstrual period to the first day of the next menstrual period.
The median cycle length is 28 days, but ovulatory cycles have been noted to occur at intervals of 23—39 days. There is often a gradual decrease in cycle length in the later reproductive years. Duration of flow. Menses commonly last for 3—5 days, with a range of 1—7 days. The withdrawal bleeds experienced by women who take oral contraceptives are often shorter than spontaneous menstrual periods. Amount of flow. The average blood loss during a menstrual period is 30 mL, with a range of 10 to 80 mL.
An objective measure blood loss can be obtained by weighing used menstrual pads or tampons. However, estimates of blood loss based simply on the number of pads or tampons used are quite inaccurate, given that there is significant variation in the absorbency of different sanitary products and even between sanitary pads or tampons in the same package.
Contraceptive method can affect the amount of flow; withdrawal bleeds associated with oral contraceptive use are typically lighter than spontaneous menses, whereas menses of women who use an intrauterine contraceptive device are often heavier.
Presence of moliminal symptoms. Many women experience predictable physical and emotional symptoms during the late luteal premenstrual phase of ovulatory menstrual cycles. Symptoms typically begin a few days before menses and resolve with the onset of bleeding. Commonly reported symptoms include breast tenderness, abdominal distension, weight gain, food cravings or increased appetite, irritability, and lability of mood. Associated pain. Midline cramp-like lower abdominal or back pain at the time of menses dysmenorrhea is common.
The pain generally begins within a few hours of the onset of menses and subsides by the second day of flow. Some women experience associated symptoms such as diarrhea, nausea, or headache.
Severe or prolonged symptoms may occur with pathologic conditions such as endometriosis or adenomyosis, and require further evaluation.
Some women experience unilateral pelvic pain at midcycle associated with ovulation mittelschmerz. This is usually mild, and rarely lasts for more than 24 hours. It may be accompanied by an increase in clear vaginal discharge, related to estrogen stimulation of cervical mucus production.
Intermenstrual bleeding. Some women note a small amount of bleeding spotting at midcycle. Intermenstrual bleeding at other times that occurs spontaneously or after intercourse is considered abnormal. Bleeding pattern. In the late reproductive years, the intermenstrual interval typically becomes less predictable. Often the interval shortens and then becomes variable.
Menopause is defined as the absence of menses for 1 year. While women rarely will have a subsequent menstrual period with typical associated symptoms, bleeding after this time is considered abnormal postmenopausal bleeding and warrants evaluation. The average age at the cessation of menses is 51 years, with a range from 40 years to the late 50s. Associated symptoms. Several symptoms have been associated with the hormonal changes that occur around the time of menopause.
Vasomotor symptoms, including hot flushes and sweats at night, are commonly reported. Poor memory, disturbances of sleep, and aches in the neck, shoulders, and back have a similar prevalence. Vaginal dryness and difficulties with sexual arousal are reported less commonly. It is also helpful to know whether she is consuming soy products in her diet or in tablet form, and whether she is taking herbal preparations.
Current method of contraception. If the patient is premenopausal and sexually active with men, it is important to ask about her current method of contraception and whether she is satisfied with this method or desires a change. Past methods of contraception. A list of past methods of contraception should be obtained, including when they were used, any complications associated with their use, and why the patient discontinued their use.
Cervical and vaginal cytology. It is important to ask whether the patient has had a history of abnormal cervical smears, and if so, what was undertaken in the way of evaluation and treatment.
It is helpful to know at what frequency the patient has undergone cytologic screening in the past. History of sexually transmitted infections. Currently, approximately 20 infections are known to be transmitted by sexual contact. These include bacterial infections caused by Neisseria gonorrhea, Chlamydia trachomatis, Treponema pallidum syphilis , Hemophilus ducreyii chancroid , and Calymmatobacterium granulomatis donovanosis , viral infections caused by herpes simplex, the human papillomavirus virus HPV , the hepatitis B and hepatitis C viruses, and the human immunodeficiency virus, as well as parasites such as Trichomonas vaginalis.
Patients should be asked about whether they have had any of these infections and if so, the treatment that was rendered. History of monilial vulvo-vaginitis or bacterial vaginosis. History of salpingo-oophoritis pelvic inflammatory disease. It is important to assess whether patients have a desire for future fertility, and if so, whether they have had any difficulty conceiving in the past.
Any prior evaluation or treatment for infertility should be described.
Professional Reference articles are designed for health professionals to use. You may find one of our health articles more useful. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Assessment of gynaecological problems should be handled with sensitivity and preservation of dignity for the patient. Allow the patient to tell you her problem.
Pregnancy can be a time of great excitement to the patient, but it can also be a time of danger, and there are certain serious illnesses of pregnancy to be aware of. Much of the history is covered here and documented in notes that the patient is advised to carry at all times. An example can be viewed on the Perinatal Institute website. A good starting point is to ask about number of children the patient has given birth to. Next, sensitively ask about miscarriages, stillbirths, ectopics and terminations.
make an essential Obstetrics and Gynecology framework of the general Take focused history in a patient complaining of an obstetric and.
Gynecological history taking involves a series of methodical questioning of a gynecological patient with the aim of developing a diagnosis or a differential diagnosis on which further management of the patient can be arranged. This further treatment may involve examination of the patient, further investigative testing or treatment of a diagnosed condition. There is a basic structure for all gynecological histories but this can differ slightly depending on the presenting complaint.
Taking a history is the initial step in the physician—patient encounter. This provides a basis for emphasizing aspects of the subsequent physical examination, and for initial decisions about diagnostic testing and treatment. This chapter outlines the components of a basic gynecologic history and gynecologic examination.
A comprehensive collection of clinical examination OSCE guides that include step-by-step images of key steps, video demonstrations and PDF mark schemes. A comprehensive collection of OSCE guides to common clinical procedures, including step-by-step images of key steps, video demonstrations and PDF mark schemes. A collection of communication skills guides, for common OSCE scenarios, including history taking and information giving.
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Gynaecology or gynecology see spelling differences is the medical practice dealing with the health of the female reproductive system. Almost all modern gynaecologists are also obstetricians see obstetrics and gynaecology. In many areas, the specialities of gynaecology and obstetrics overlap. The term means "the science of women ". The Kahun Gynaecological Papyrus , dated to about BC, deals with women's health —gynaecological diseases, fertility, pregnancy, contraception, etc.
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