history taking in obstetric and gynecology

History Taking in Obstetric and Gynecology. For 4th year medical students

Hashem Yaseen MBBS, MSc (O&G), JBOG, Arab.BOG, MRCOG

Obstetric and Gynecology Department

The time in life when a girl becomes sexually mature. It is a process that usually happens between ages 10 and 14 for girls

Permanent cessation of menstrual cycles. 12 months without a menstrual period. At age of 45 to 55 ,

What is special about OBGYN History

taking?● Obstetric History

● Past obstetric surgical history

● Fertility and sexual history

● Partner notification

● Correlate S&S with menstrual cycle

● Add gynecological causes to non-gyne CC

● Contraception to drug history

● Cervical smear history

Overview MENSTRUAL HISTORY

Pelvic Pain

Common presenting symptoms

Obstetric History

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● Donec risus dolor porta venenatis ● Pharetra luctus felis● Proin in tellus felis volutpat





Past obstetric Hx 05● Date of marriage, marriage

conception period, ● Full Hx of each pregnancy.

Review of systems

04 ● Review all systems in relation to Hx of present illness.

Hx of presenting complaint03

● Telling your story● Analysis CC● Associated symptoms● Important negative symptoms - DDx● Management history

Presenting complaint02

● It’s duration● From ER or referal● Booking visit (Pregnancy)

Patient profile01● Name, Age, occupation, address● Name & occupation of husband● Gravida , para● LMP







Family history10● Chronic disease● Cancers● Genetic diseases● consanguinity

Drug history09● Types, Dose● Compliance● OTC ● Contraception

Past surgical history08

● Any surgical procedures● When● Complications● Outcome

Past medical history07

● Any significant diseases and its duration● Complications● Disease control

Gynaecological Hx 06

● Menstrual Hx● Contraceptive Hx● Cervical smear history







Spouse history13● STI - reinfection● Infertility● Confidentiality

Sexual history12● Use a simple pattern of questioning, and be

straightforward and unambiguous .● explain why you need to ask these types of

question.●

Social history11● Smoking● Alcohol● Insurance


Pelvic Pain


Obstetric History

last menstrual period

The first menstrual period, (average age 12)

Primary amenorrhoea: periods have not started by age 16.Secondary amenorrhoea: there have been no periods for ≥6 months but there was previous menstruation.between periods (intermenstrual, IMB)

• after intercourse (postcoital, PCB)• more than 1 year after the menopause(postmenopausal, PMB).



Primary dysmenorrhoea is pain arising from uterine contraction that is most intense just before and during peak menstruation.

Secondary or progressive dysmenorrhoea, due to underlying pathology such as endometriosis or chronic infection, often manifests as pain that lasts beyond the normal menstrual cycle. Infection, pelvic adhesions and endometriosis can cause generalised pain


Pelvic Pain


Obstetric History

Dyspareunia Dyspareunia is pain during intercourse:

1. felt around the vaginal entrance (superficial) 2. within the pelvis (deep).

Vaginismus: Pain due to involuntary spasm of muscles at the vaginal entrance

Persistent deep dyspareunia suggests underlying pelvic pathology.

Dyspareunia can be due to vaginal dryness following the menopause.

Vaginal discharge

STI.

Partner

Recurrence

Previous treatment

Pelvic masses

Abdominal distension and bloating

Pressure symptoms

Ovarian, uterine, tubal, cervical, and non-gyne .

Incontinence (urinary, fecal)

-Involuntary voiding or leakage of urine or faeces .

- is most frequent in women who have born children.

- stress incontinence with urinary leakage on coughing, sneezing or sudden exertion. - a strong desire to pass urine even when the bladder is not full (urgency) and leakage (urge incontinence)

Prolapse

'something coming down’Weakness in the pelvic floor muscles

● The anterior and posterior vaginal walls

● Cervix● The entire uterus


Pelvic Pain


Obstetric History

Obstetric History

● Age

● Gravidity

● Parity ( G __ P__ + __ )

● Abortions

● last menstrual cycle (LMP)

● Expected date of confinement (EDC) or Expected date of delivery (EDD)

● gestational age (GA) in weeks, Term , preterm, post date

● Any significant medical illness

Q1. A 56-year-old multiparous woman presents with 2 episodes of mild vaginal bleeding. On questioning; last cycle was 18 months ago, and she describes painless bleeding, without clots and changed one pad only. Choose the single best answer from the list below to describe her symptom:

(a) Normal menstrual bleeding

(b) Newly onset menstrual cycle

(c) Intermenstrual bleeding

(d) Postcoital bleeding

(e) Postmenopausal bleeding

Q2. A 36-year-old nulliparous woman presents with abnormal uterine bleeding of 2 years duration. On questioning her cycle is regular, 9/30 days, and she describes passing large clots and flooding through onto her clothes. Choose the single best answer from the list below to describe her symptoms:

(a) Heavy menstrual bleeding

(b) Menorrhagia

(c) Prolonged, heavy menstrual bleeding

(d) Prolonged menstrual bleeding

(e) Irregular heavy menstrual bleeding

Q3. A 24-year-old newly married woman presents with acute lower abdominal pain, it is associated with vaginal bleeding. She has missed period of 2 weeks duration. She denies nausea or vomiting. The most serious diagnosis that should be excluded initially is:

(a) Ectopic pregnancy

(b) Miscarriage

(c) Ovarian torsion

(d) Ruptured ovarian cyst

(e) Uterine cancer

Q4. The first menstrual period experienced by the female is called:

(a) Puberty

(b) Menarche

(c) Menopause

(d) Thelarche

(e) Menorrhagia

Q5. A woman currently pregnant who has had a previous term delivery and one early miscarriage. Regarding Gravidity and Parity:

(a) G2P3A1

(b) G3P1A2

(c) G3P2A1

(d) G1P2A3

(e) G2P2A1

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history taking in obstetric and gynecology

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