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Chapter: Medicine Study Notes : Reproductive and Obstetrics

History - Gynaecology

Presenting complaint: recorded as direct quote from the patient. Give them time to tell you. Stop and listen!



·        Introduction Data:

o   Age

o   Gravidity = total number of pregnancies 

o   Parity = # of deliveries (multiple births = 1 delivery – but definitions vary…). E.g. P1(SB) = one stillbirth. P1(twins). Eg: G4P2 (+TOP + SAB). SAB = Spontaneous Abortion. 

o   LMP

o  +/- Martial status 

·        Presenting complaint: recorded as direct quote from the patient. Give them time to tell you. Stop and listen!

·        History of presenting complaint.  Include:

o  Bleeding: 

§  Quantity (eg # of pads per day – but ask why they change – 1 per hour too much), double protection needed (eg tampon and pad), soaking through, etc

§  Duration 

§  Quality.  Bright red Þ fast flow.  Brown Þ slow flow.  Clots

§  Timing: with menses, inter-menstrual, post-coital

§  Always consider anaemia, look for signs, do FBC if indicated

o  Pain:

§  Location (be specific)

§  Radiation 

§  Circumstances (related to menses, meals, activity, time of day). Want to differentiate from bowel and bladder pain

§  Character: sharp, dull, continuous, intermittent, severity

§  Reliving factors: position, medication

o  Vaginal Discharge:

§  Duration

§  Relationship to menses

§  Colour, odour, consistency

§  Associated symptoms: itch, burn, dyspareunia, vulvar irritation

§  Response to treatment, if any

o  Urinary symptoms:

§  Incontinence: stress or urge

§  Frequency, urgency

§  Dysuria

§  Haematuria

·        Past Gynaecological History:

o  Age of menarche – probably not a big deal – were you significantly younger or older than friends 

o  Menses: Frequency (normal 21 – 35 days) and duration (normal 3 – 7 days), regularity (some variation normal). NB:

§  First day of bleeding = 1st day of menstrual cycle. Teenagers will often give their period length as first day without bleeding to first day of bleeding – check understanding 

§  Ovulation is 12 – 16 days before the start of the next period (determined by timing of the following period, not the prior period). Fertile for 5 – 7 days before ovulation

o  If post-menopausal, when did periods stop and are there any symptoms

o  Past gynaecological problems or procedures

o  ? Sexual history, currently sexually active

o  Current/past contraception

o  Past STD‟s, UTIs,

o  Incontinence

o  Smear history: last smear date, any abnormal

·        Past Obstetric History (mainly for obstetric history)

·        Past Medical and Surgical History (and maybe very brief systems review)

·        Medications:

o  Remember vitamins and non-prescription meds – may be bad in pregnancy

o  Allergies

·        Family History: Sister or mother with fertility, pregnancy or gynaecological problems

·        Social History:

o  Marital/relationship status 

o  Sexual activity, sexual orientation („Are you in a relationship with a man or a woman‟), number of partners. To avoid embarrassment, just ask straight

o  Cigarette, alcohol and recreational drug use

o  Occupation 

o   ?Victim of interpersonal violence (but don‟t introduce it in a crisis situation).

·        Gynaecological write-up: [name] is a [age] year old G_P_ LMP (date) who presents complaining of (PC). Then HPC, including all pertinent (+) and (–) and any relevant past medical, surgical or gynaecological information.


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