History
·
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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