Dr J. Woodman Dr C.Gnanachandran

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Presentation transcript:

Dr J. Woodman Dr C.Gnanachandran Taking a History in Obstetrics and Gynaecology Dr J. Woodman Dr C.Gnanachandran

History taking Taking a good history is an art form An intelligent history is focused toward management and patient care

THE BASICS Presenting complaint History of presenting complaint Gynaecological history Obstetric history Past medical history Surgical history Family history Allergies Drugs/ medications Psychological well-being Social circumstances

History taking in Gynaecology Presenting complaint: e.g. IMB, PCB, menorrhagia History of presenting complaint Duration, Severity Impact on quality of life? Expectations? Associated symptoms Pelvic pain / dyspareunia Gynaecological history Menstrual diary / pattern, LMP Subfertilty / PID / Infections Contraception / menopause / HRT Termination of pregnancy/ Miscarriages Cervical smear Bowel symptoms Bladder symptoms Obstetric history Deliveries & complications 4

History in Gynaecology (cont) Presenting complaint History of presenting complaint Gynaecological history Obstetric history Past medical history Surgical history Family history Allergies Drugs/ medications Psychological well-being Social

History taking in Obstetrics Age Gravidity and Parity (e.g. G3 P1 +1) Current gestation Blood group Presenting Complaint History of Presenting Complaint Onset, Periodicity, Duration, Recurrence Past Obstetric History - Length of pregnancies Mode of delivery Weight of babies Complications Any antenatal problems so far?

History taking in Obstetrics (cont) Menstrual History including LMP Cervical smear history Was this a planned pregnancy? Past Medical History Current or past illnesses Past surgical history Especially any surgery in the abdomen, pelvis or vagina Drug History Prescribed medications Non-prescribed medications / herbal remedies Recreational drugs Smoking and alcohol Including if an ex-smoker Any attempts at smoking cessation Family History DVT/ DM/ HT/ congenital anomalies Social History: Occupation, supportive partner / family

THE BASICS Presenting complaint General history History of presenting complaint Gynaecological history Menstrual history Sexual history Contraception Cervical smears Obstetric history Gravidity Parity Deliveries & complications General history Past medical history Surgical history Family history Allergies Drugs/ medications Psychological well-being Social

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