Gynecology history taking and physical examination

Gynecology history taking and physical examinationCreated OnApril 19, 2020Last Updated OnOctober 28, 2020byadmin You are here: Main Clinical Examination Gynecology history taking and physical examination < All Topics Table of Contents Chronology of a patient in Obstetrics & Gynaecology Department: Whenever we see a patient, it comprises certain steps like History taking Physical examination Relevant investigations Diagnosis Definitive treatment (Surgical/ Conservative) Observation during post-operative period/treatment Follow-up Discharge HISTORY TAKING History must be taken in a non-judgmental, sensitive and thorough manner. PERSONAL IDENTIFICATION Name Age Address Occupation Marital Status and no of children with the age of first and last child PRESENTING COMPLAIN (Chief Complaint) – Done in patient’s own words It must be written in chronological order of durations and if all symptoms started at the same time then according to the severity of the symptoms. Common Complaints Pain in the abdomen Vaginal discharge Mass in the abdomen Bleeding per vagina Heavy menses Irregular bleeding Post- menopausal bleeding Post coital bleeding Amenorrhea Unable to conceive Sensation of ‘something coming down’ through the vagina (prolapse) HISTORY OF PRESENTING ILLNESS Here all the chief complaints are explained in detail such as The mode of onset of each symptoms Progression of the diseases Any treatment taken during this period for the same disease Pain in the abdomen- SOCRATES, relationship to menses, micturition, bowel movement, coitus Vaginal discharge Duration Odour Relation to menses and coitus Amount, consistency, colour Associated symptoms- itchiness, pain, swelling, redness, dyspareunia Mass in the abdomen Size Duration Change in size Mode of onset Any accompanying constitutional symptoms Features of pressure effects Bleeding per vagina Onset Duration Menorrhagia (loss of >80ml per cycle) Associated symptoms : pain, itchiness, vaginal discharge Post coital bleeding- spotting after intercourse Amenorrhea Primary amenorrhea Presence of secondary sexual characteristics- axillary, pubic and breast development Chronic debilitating disease leads to anovulation Cyclical abdominal pain- this symptom may attribute to imperforate hymen Eating disorder- anorexia nervosa Hirsutism- indicate androgen excess Secondary amenorrhea Duration, length of cycle Contraception use after delivery History of pelvic inflammatory disease- infections causes adhesion and endometrial destruction History of severe blood loss postpartum – causing pituitary necrosis (Sheehan’s syndrome) Exclusive breastfeeding causes lactational amenorrhea for 6 months by suppressing LH and FSH by high levels of prolactin Surgical procedures such as C-section and dilatation and curettage cause intrauterine adhesion and cervical stenosis Unable to conceive Duration of marriage Frequency of intercourse Menstrual history Contraceptive history Personal history- smoking, excessive indulgence in alcohol Sexual history Partner’s health condition Prolapse Incontinence: stress, urge Bowel symptoms: constipation SYSTEMIC REVIEW Genitourinary system- painful, bleeding during micturition, frequency, nocturia, dysuria, urgency, stream, incomplete emptying Gastrointestinal system- constipation, diarrhea, bleeding per rectum, nausea vomiting Nervous system- symptoms of metastases, stress of a situation PAST GYNAECOLOGY HISTORY Menstrual History Age of first menses Any premenstrual symptoms Duration and flow Regular/ irregular cycle Intermenstrual, postcoital bleeding, dysmenorrhea Coitus Any pain during coitus Difficulty in coitus Frequency (for infertile couple) Any psychosexual problem Contraception Method- efficiency of the method Problem and side effects of the contraception Any plan to change the contraception Menopausal status, result of last pap smear, history of sexually transmitted infection (STI), and Pelvic inflammatory disease Any gynecology procedure done before PAST OBSTETRICAL HISTORY Antepartum, intrapartum, postpartum complications Use of assisted vaginal delivery- forceps or vacuum extraction History of ectopic pregnancy, miscarriage and procedures done PAST MEDICAL HISTORY/ PAST SURGICAL HISTORY Associated diseases that need optimization (diabetes, hypertension, anemia) DRUG HISTORY Explore on all the medications the patient is on especially chronic medication Elicit any history of drug allergy FAMILY HISTORY Similar history in family Any history of malignancies – gynecological, breast or colorectal Other diseases that run in the family SOCIAL HISTORY Smoking, alcohol, drug history Occupational history and socioeconomic status should also be included History of immunization is another important fact to be noted Allergies history should be documented in detail including...

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