History Taking In Gynaecology

History Taking in Gynaecology

History Taking in Gynaecology

History taking in gynaecology is somewhat different from history in medicine, because we talk about the health of the mother and her reproductive life.

Personal Data

Name: Mrs. __________________ W/O: Mr. ____________________ Age: ________

Married for: _______ Education: ______ Occupation: _________ Resident of: ______________

Parity: _______ Last Child Born: ______________ LMP: _________________

Mode of Admittance: ____________   Date of Admittance: ____________

Presenting Complaint


History of Presenting Illness (HOPI)

Mrs. __________ was alright _________ weeks/months back when she was presented with symptoms of __________________________________________________________________

Infertility

For ruling out fertility issues, ask following questions,

  • Living together
  • Frequency of coitus
  • Any contraceptive method used
  • Any 1st or 2nd trimester miscarriages

Pelvic pain

For pelvic pain ask follow questions about pain and related symptoms

  • Site
  • Onset
  • Duration
  • Intensity
  • Radiation
  • Character
  • Aggravating factors
  • Relieving factors
  • Associated symptoms

Vaginal Discharge

  • Colour
  • Amount
  • Presence of blood
  • Consistency
  • Odour
  • Relation to periods
  • Associated itching or any irritation
  • Associated with fever
  • H/O of previous PID
  • Treatment?

Abnormal Menstrual Loss

  • Periods regular/irregular
  • Amount of blood loss
  • Number of pads soaked
  • Blood clots present/absent
  • Associated with pain/not
  • Weakness
  • Dyspareunia

Pelvic Mass

  • For how long?
  • Size
  • Progression
  • Vaginal discharge
  • Pressure symptoms
  • Urinary symptoms
  • GIT symptoms
  • Weight loss/gain
  • Association with fever
  • Any association with abnormal periods

Ovarian Cancer

  • Back pain
  • Pelvic pain
  • Loss of appetite
  • Indigestion
  • Weight gain/loss
  • Irregular periods
  • Diarrhea
  • Constipation

Obstetrical History

Gravida: ______ Para: ______ Abortions: _______ Alive: _______ M: ______ F: ______

Sr. No. Date of Deliver DOP, Term, pre or post-term Place of Delivery Sex Birth Weight Status Complications

(APH, PIH, PPH)

Breast feed or not Vaccinated according to EPI schedule or not
 
 
 
 
 
 
 

Gynecological History

  • Age of menarche
  • M/C previous (regular or irregular)
  • M/C present
  • Duration of menses
  • Soaked pads per day
  • Bleeding: Scanty, moderate or severe
  • H/O Dysmenorrhea
  • H/O Dyspareunia
  • H/O intermenstrual bleeding
  • Pap smear
  • Contraceptive method used
  • Its side effects if used

Past Medical & Surgical History

  • Diabetes
  • Hypertension
  • Ischemic Heart Disease
  • Tuberculosis
  • Asthma
  • Hepatitis
  • H/O previous surgery

Family History

1st cousin marriage

Joint family system or not

Family H/O

  • Diabetes
  • Hypertension (HTN)
  • Ischemic Heart Disease (IHD)
  • Breast cancer
  • Ovarian cancer
  • Endometrial cancer
  • Abnormal children

Socioeconomic History

Her husband is a ____________ and she belongs to a lower/middle/upper class of socioeconomic status. They live in joint family system/separately and her diet does/does not contain/s fresh fruits and meat.

Personal History

  • Appetite
  • Sleep
  • Bowel
  • Burning micturition
  • Smoking
  • Weight gain/loss
  • Allergy to drugs

General Physical Examination

A young/old/middle aged lady lying comfortably on bed, is well oriented in time, space and person having vitals of;

  • Blood pressure: ____ mmHg
  • Pulse: ________ Beats/minute
  • Temperature: ___oF
  • Respiratory rate: per minute
  • Pallor
  • Jaundice
  • Orodental hygiene
  • Thyroid
  • Lymph nodes
  • Breast
  • Edema
  • JVP raised or not
  • Others;

Systemic Examination

  1. CVS
  2. Respiratory
  3. GIT
  4. CNS

Abdominal Examination

Inspection

  • Size of abdomen
  • Shape of abdomen
  • Pigmentation
  • Striae gravidarum
  • Scar (Pfennansteil incision)
  • Prominent veins
  • Any mass prominent
  • Shape of umbilicus
  • Cutaneous signs of pregnancy (Linea nigra)

Palpation

  1. Superficial tenderness
  2. Deep tenderness
  3. Palate the mass
  • Site
  • Size
  • Shape
  • Consistency
  • Margins
  • Texture
  • Attachment to underlying skin
  • Attachment to muscles
  1. Visceral palpation
  2. Check ascites if present
  • Shifting dullness
  • Fluid thrill

Auscultation

  1. Auscultate the abdomen for bowel sounds.
  2. Aortic and renal bruits auscultation

Investigations

  1. Baseline investigations
  • CBC
  • Blood grouping & Rh factor
  • Blood sugar
  • Hepatitis B & C screening
  • Urine complete
  • USG
  1. Specific investigations
  • Coagulation profile
  • Gynecologic ultrasound
  • Biopsy
  • CT scan
  • MRI
  • Laparoscopy

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History Taking In Gynaecology

History Taking In Gynaecology