Makindo Medical Notes

Related Subjects: | Causes of Abnormal Vaginal Bleeding | Vaginal Carcinoma | Cervical Cancer | Endometrial (Uterine) Cancer | Post Menopausal Bleeding | Anatomy of the Uterus | Anatomy of the Ovary | Gynaecological History Taking | Colposcopy | Premature Menopause | Polycystic Ovary Syndrome

Roles in Gynaecological History Taking

• Introduction and Role Explanation: Begin by introducing yourself and clarifying your role as a healthcare provider.
• Verbal Consent: Obtain explicit verbal consent from the patient before starting the history-taking process.
• Establishing Rapport: Create a supportive, confidential, and respectful environment that encourages the patient to be open.

Opening Questions

• Menstrual History:
  • “When was your last menstrual period (LMP)?”
  • “How regular are your periods, and is the current pattern normal for you?”
• Sexual and Contraceptive History:
  • “Are you currently sexually active?”
  • “What type of contraception do you use, and do you use it consistently? Have you ever missed a dose if you’re on the pill?”
• Pregnancy Risk: “Is there any possibility you could be pregnant?”
• STI History: “Have you ever been diagnosed with a sexually transmitted infection or had an STI screening?”
• Obstetric History: “Have you ever been pregnant, had a miscarriage, or experienced complications during pregnancy?”

Background Information

• Demographics: Record the patient’s name, age, and date of birth.
• Marital Status: Clarify if the patient is married, single, widowed, divorced, or separated.

Social Information

• Occupational History: Document the patient’s current and past occupations, as well as the occupation of their partner.
• Living Conditions: Ask about the housing type and home environment.
• Work Environment: Inquire about working conditions and potential exposures or stressors.
• Substance Use: Assess smoking habits, alcohol consumption, and use of other drugs.

Chief Complaints and Symptom Assessment

• Pain and Discomfort:
  • Ask about the duration, severity, location, and periodicity of any pain.
  • Explore factors that exacerbate or relieve the pain.
• Abnormal Bleeding:
  • Determine if there is any abnormal vaginal or intermenstrual bleeding.
  • Clarify the amount, frequency, timing relative to the menstrual cycle, and whether the bleeding is heavy or accompanied by clots.
• Infection Symptoms:
  • Ask about symptoms of infection, such as fever, chills, or pelvic pain.
  • Inquire about any history of recurrent urinary tract or vaginal infections.
• Discharge:
  • Discuss any vaginal discharge, noting its color, consistency (mucoid, purulent), odor, and quantity.
  • Determine if the discharge is associated with irritation, soreness, or other symptoms.

Past Medical History

• Medication History: Inquire about current and past medications, including tranquilizers, oral contraceptives, hormone therapies, anticoagulants, and antibiotics.
• Medical and Surgical History:
  • Document any major illnesses, surgeries, and hospital admissions with approximate dates.
  • Review previous investigations and their outcomes.
• Family History: Ask about hereditary or familial conditions relevant to gynecological health.

Specific Questions

• Sexual History:
  • Assess for painful intercourse (dyspareunia) and any difficulties with sexual activity.
  • Discuss contraception methods and history of STIs.
• Obstetric History:
  • Record the number of pregnancies, outcomes (full-term, premature, miscarriage, ectopic), and any complications during pregnancy, labor, or the postpartum period.
  • Include details such as birth weights and current health status of children.
• Menstrual History:
  • Ask about age at menarche, cycle regularity, and typical duration and flow of menstruation.
  • Determine any recent changes in menstrual flow (increase, decrease, presence of clots or flooding) and any associated dysmenorrhea (pain during menstruation).
  • Record the date of the last menstrual period and any prior cervical smear results.
• Vaginal Discharge and Infection:
  • Detail the character of any discharge: color, consistency, odor, and quantity.
  • Ask if the discharge is accompanied by symptoms such as itching, burning, or irritation, which may indicate an infection.
• Urinary and Bowel Function:
  • Enquire about urinary frequency, dysuria, or incontinence (stress or urge types).
  • Review bowel habits, including any history of constipation, use of laxatives, pain on defecation, or rectal bleeding.

Conclusion

A comprehensive gynaecological history is critical for accurate diagnosis and effective management. By addressing key areas—from menstrual and sexual history to symptoms such as abnormal bleeding, infection, and discharge—clinicians can form a complete clinical picture and tailor their diagnostic and therapeutic strategies to each patient’s unique needs.