GYNAE HISTORY Flashcards
1
Q
Stage 1
(6)
A
Opening the consultation
- *1.** Wash your hands and don PPE if appropriate
- *2.** Introduce yourself to the patient including your name and role
- *3.** Confirm the patient’s name and date of birth
- *4.** Explain that you’d like to take a history from the patient
- *5.** Gain consent to proceed with taking a history
- *6.** Confirm last menstrual period, gravidity and parity early on in the consultation
2
Q
Stage 2
(1)
A
Presenting complaint
1. Use open questioning to explore the patient’s presenting complaint
3
Q
Stage 3
(11)
A
- *History of presenting complaint**
- *1.** Site: ask where the symptom is (if relevant)
- *2.** Onset: clarify when the symptom first started and if the onset was sudden or gradual
- *3.** Character: ask the patient to describe how the symptom feels
- *4.** Radiation: ask if the symptom moves anywhere else
- *5.** Associated symptoms: ask if there are any other associated symptoms
- *6.** Time course: ask how the symptom has changed over time
- *7.** Exacerbating or relieving factors: ask if anything makes the symptom worse or better
- *8.** Severity: ask how severe the symptom is on a scale of 0-10
9 Screen for other key gynaecological symptoms (e.g. abdominal pain, pelvic pain, post-coital
bleeding, intermenstrual bleeding, post-menopausal bleeding, abnormal vaginal discharge,
dyspareunia, vulval skin changes, vulval pruritis, fatigue, fever, weight loss)
10 Explore the patient’s ideas, concerns and expectations
11 Summarise the patient’s presenting complaint
4
Q
Stage 4
(1)
A
- *Systemic enquiry**
- *1**. Screen for relevant symptoms in other body systems
5
Q
Stage 5
(6)
A
- *Menstrual history**
- *1.** Ask about the duration of menstruation
- *2.** Ask about the frequency of menstruation
- *3.** Ask about the volume of menstruation
- *4.** Ask about dysmenorrhoea
- *5.** Ask the patient when the first day of their last menstrual period was (if not done already)
- *6.** Ask the patient how old they were when they started having periods and (if relevant) when they went through the menopause
6
Q
Stage 6
(2)
A
- *Contraception**
- *1**. Clarify the type of contraception currently used
- *2**. Explore the patient’s previous contraception history
7
Q
Stage 7
(1)
A
- *Reproductive plans**
- *1**. Ask if the patient is considering having children in the future
8
Q
Stage 8
(3)
A
- *Past gynaecological history**
- *1**. Ask if the patient has previously had any gynaecological problems
- *2**. Ask the patient if they’ve previously undergone any surgery or procedures in the past
- *3**. Clarify the patient’s cervical screening history
9
Q
Stage 9
(2)
A
- *Past medical history**
- *1.** Ask if the patient has any medical conditions
- *2.** Ask if the patient has any allergies and if so, clarify what kind of reaction they had to the substance
10
Q
Stage 10
(3)
A
- *Obstetric history**
- *1.** Clarify the patient’s gravidity and parity (if not done already)
- *2.** Gather key details about the patient’s current pregnancy (if relevant)
- *3.** Gather key details about the patient’s previous pregnancies (if relevant)
11
Q
Stage 11
(1)
A
Drug history
1. Ask if the patient is currently taking any prescribed medications or over-the-counter
remedies
12
Q
Stage 12
(3)
A
- *Family history**
- *1**. Ask if there is any family history of malignancy
2. bleeding disorders
3. blood clots.
13
Q
Stage 13
(6)
A
- *Social history**
- *1**. Explore the patient’s general social context (accommodation, who the patient lives with, support)
- *2**. Take a smoking history
- *3**. Take an alcohol history
- *4**. Ask about recreational drug use
- *5**. Ask about diet, weight and occupation
- *6**. Ask about domestic abuse
14
Q
Stage 14
(3)
A
- *Closing the consultation**
- *1**. Summarise the salient points of the history back to the patient and ask if they feel anything has been missed
- *2**. Thank the patient for their time
- *3**. Dispose of PPE appropriately and wash your hands
