Dr J. WoodmanDr J. WoodmanDr C.GnanachandranDr C.Gnanachandran

Taking a History in Obstetrics and Gynaecology

History takingHistory takingTaking a good history is an art formTaking a good history is an art form

An intelligent history is focused toward management and patient care

THE BASICSTHE BASICS• Presenting complaintPresenting complaint

• History of presenting complaintHistory of presenting complaint• Gynaecological historyGynaecological history• Obstetric historyObstetric history• Past medical historyPast medical history• Surgical historySurgical history• Family historyFamily history• AllergiesAllergies• Drugs/ medicationsDrugs/ medications• Psychological well-beingPsychological well-being• Social circumstancesSocial circumstances

History taking in GynaecologyHistory taking in Gynaecology• Presenting complaint: Presenting complaint:

► e.g. IMB, PCB, menorrhagiae.g. IMB, PCB, menorrhagia• History of presenting complaintHistory of presenting complaint

► Duration, SeverityDuration, Severity► Impact on quality of life?Impact on quality of life?► Expectations?Expectations?► Associated symptomsAssociated symptoms► Pelvic pain / dyspareuniaPelvic pain / dyspareunia

• Gynaecological historyGynaecological history► Menstrual diary / pattern, LMPMenstrual diary / pattern, LMP► Subfertilty / PID / InfectionsSubfertilty / PID / Infections► Contraception / menopause / HRTContraception / menopause / HRT► Termination of pregnancy/ MiscarriagesTermination of pregnancy/ Miscarriages► Cervical smearCervical smear► Bowel symptomsBowel symptoms► Bladder symptomsBladder symptoms

• Obstetric historyObstetric history Deliveries & complicationsDeliveries & complications

History in Gynaecology (cont)History in Gynaecology (cont)

• Presenting complaintPresenting complaint• History of presenting complaintHistory of presenting complaint• Gynaecological historyGynaecological history• Obstetric historyObstetric history• Past medical historyPast medical history• Surgical historySurgical history• Family historyFamily history• AllergiesAllergies• Drugs/ medicationsDrugs/ medications• Psychological well-beingPsychological well-being• Social Social

History taking in ObstetricsHistory taking in Obstetrics

► Age Age ► Gravidity and Parity (e.g. G3 P1 +1)Gravidity and Parity (e.g. G3 P1 +1)► Current gestation Current gestation ► Blood groupBlood group► Presenting ComplaintPresenting Complaint► History of Presenting ComplaintHistory of Presenting Complaint

Onset, Periodicity, Duration, Recurrence Onset, Periodicity, Duration, Recurrence ► Past Obstetric History -Past Obstetric History -

►Length of pregnancies Length of pregnancies ►Mode of deliveryMode of delivery►Weight of babies Weight of babies ►Complications Complications

► Any antenatal problems so far? Any antenatal problems so far?

History taking in Obstetrics History taking in Obstetrics (cont)(cont)

► Menstrual History including LMPMenstrual History including LMP► Cervical smear history Cervical smear history ► Was this a planned pregnancy? Was this a planned pregnancy? ► Past Medical HistoryPast Medical History

Current or past illnesses Current or past illnesses ► Past surgical history Past surgical history

Especially any surgery in the abdomen, pelvis or vaginaEspecially any surgery in the abdomen, pelvis or vagina► Drug History Drug History

Prescribed medications Prescribed medications Non-prescribed medications / herbal remedies Non-prescribed medications / herbal remedies Recreational drugs Recreational drugs

► Smoking and alcoholSmoking and alcohol Including if an ex-smokerIncluding if an ex-smoker Any attempts at smoking cessationAny attempts at smoking cessation

► Family History DVT/ DM/ HT/ congenital anomaliesFamily History DVT/ DM/ HT/ congenital anomalies► Social History: Occupation, supportive partner / familySocial History: Occupation, supportive partner / family

THE BASICSTHE BASICS

• Presenting complaintPresenting complaint• History of presenting complaintHistory of presenting complaint

• Gynaecological historyGynaecological history Menstrual historyMenstrual history Sexual historySexual history ContraceptionContraception Cervical smearsCervical smears

• Obstetric historyObstetric history GravidityGravidity ParityParity Deliveries & Deliveries &

complicationscomplications

General historyGeneral history• Past medical historyPast medical history• Surgical historySurgical history• Family historyFamily history• AllergiesAllergies• Drugs/ medicationsDrugs/ medications• Psychological well-beingPsychological well-being• SocialSocial

THE END