Gynaecology - History Taking Flashcards

1
Q

Opening the consultation

Gynaecological history taking has a number of questions that are not part of the standard history taking format and therefore it’s important to understand what information you are expected to gain when taking a gynaecological history.

A
  • Introduce yourself – name/role
  • Confirm patient details – name/DOB
  • Explain the need to take a history
  • Gain consent
  • Ensure the patient is comfortable
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2
Q

Presenting Complaint?

A

It’s important to use open questioning to elicit the patient’s presenting complaint

So what’s brought you in today?” or “Tell me about your symptoms

Allow the patient time to answer, trying not to interrupt or direct the conversation.

Facilitate the patient to expand on their presenting complaint if required

Ok, so tell me more about that” “Can you explain what that pain was like?”

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3
Q

History of Presenting Complaint?​

(1)

A

Onsetwhen did the symptom start? / was the onset acute or gradual?

Durationminutes / hours / days / weeks / months / years

Severitye.g. if symptom is vaginal bleeding – how many sanitary pads are they using?

Courseis the symptom worsening, improving, or continuing to fluctuate?

Cyclicaldo symptoms have any relationship to the menstrual cycle?

Intermittent or continuous?is the symptom always present or does it come and go?

Precipitating factorsare there any obvious triggers for the symptom?

Relieving factorsdoes anything appear to improve the symptoms e.g. an inhaler/?

Associated featuresare there other symptoms that appear associated e.g. fever/malaise?

Previous episodeshas the patient experienced this symptom previously?

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4
Q

History of Presenting Complaint?

(2)

A

Key gynaecological symptoms:

Abnormal vaginal discharge – suggestive of infection

Vaginal bleeding – menorrhagia / intermenstrual/ post-coital / post-menopausal

Vulval itching / discomfort / skin changes

Abdominal / pelvic pain – dysmenorrhea / dyspareunia

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5
Q

History of Presenting Complaint?

(3)

A

Other relevant symptoms:

Urinary symptoms – frequency / urgency / dysuria

Bowel symptoms – change in bowel habit / pain on defecation

Fever – pelvic inflammatory disease – e.g. chlamydia

Tiredness/fatigue – anaemia – often occurs alongside menorrhagia

Weight loss – may suggest malignancy

Abdominal distension – uterine / ovarian malignancy

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6
Q

History of Presenting Complaint?

(4)

A

Pain – if pain is a symptom, clarify the details of the pain using SOCRATES

  • Site – where is the pain
  • Onset – when did it start? / sudden vs gradual?
  • Character – sharp/dull ache
  • Radiation – does the pain move anywhere else?
  • Associations – other symptoms associated with the pain
  • Time course – worsening / improving / fluctuating / time of day dependent
  • Exacerbating / Relieving factors – does anything make the pain worse or better?
  • Severity – on a scale of 0-10, how severe is the pain?
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7
Q

Ideas, Concerns and Expectations?

A

Ideaswhat are the patient’s thoughts regarding their symptoms?

Concernsexplore any worries the patient may have regarding their symptoms

Expectationsgain an understanding of what the patient is hoping to achieve from the consultation

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8
Q

Summarising?

A
  • Summarise what the patient has told you about their presenting complaint.
  • This allows you to check your understanding regarding everything the patient has told you.
  • It also allows the patient to correct any inaccurate information and expand further on certain aspects.
  • Once you have summarised, ask the patient if there’s anything else that you’ve overlooked.
  • Continue to periodically summarise as you move through the rest of the history.
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9
Q

Signposting?

A

Signposting involves explaining to the patient:

  • What you have covered – “Ok, so we’ve talked about your symptoms”
  • What you plan to cover next – “Now I’d like to discuss your past medical history”
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10
Q

Menstrual history?

(1)

A

Age at menarchethe earlier, the greater exposure to oestrogen – ↑ risk of breast cancer

Last menstrual period (LMP)defined as the first day of the LMP

Duration and regularitye.g. 5 day period occurring regularly every 28 days

Flowheavy/light – number of sanitary towels/tampons can be useful to estimate loss

Menstrual painuse the SOCRATES method shown above to assess menstrual pain

Menopausal symptomshot flushes / vaginal dryness / infrequent periods

Hormonal contraceptivescombined oral contraceptive pill (COCP) / progesterone only pill (POP) / depot / implant

If postmenopausalwhat age did they go through the menopause?

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11
Q

Menstrual history?

(2)

A

Irregular bleeding:

Post-coital bleeding – e.g. cervical ectropion / STDs/ vaginitis

Intermenstrual bleeding:

  • Consider malignancy in older females – e.g. endometrial cancer
  • Younger females may have unexplained irregular periods
  • Poor compliance with oral contraceptives can result in intermenstrual bleeding
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12
Q

Gynaecological history?

A

Previous cervical smears – when? / results? / treatment (e.g. LETZ )

Previous gynecological problems and treatments – STDs / PID

Current contraception – COCP / POP / Depot / Implant / Implanted uterine device

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13
Q

Obstetrics history?

A

Current pregnancyhow many weeks? / recent scans?

Graviditynumber of times a woman has been pregnant, regardless of the outcome

ParityX = (any live or stillbirth after 24 weeks) | Y = (number lost before 24 weeks)

Each pregnancy:

  • Current age of child
  • Birth weight
  • Complications – antenatal / perinatal / postnatal

Ask sensitively regarding miscarriages, terminations and ectopic pregnancies

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14
Q

Past medical history?

Drug history?

A

Gynaecological conditions – STDs / cervical dysplasia / malignancy

Other medical conditions

Surgical history – C-section / LETZ / prolapse repair / hysterectomy

Any recent hospital admissions? – when and why?

Gynaecological medications:

  • COCP / POP / Implant / Depot
  • Tranexamic acid
  • Hormone replacement therapy
  • Antifungals

Other regular medication

  • Antibiotics
  • Over the counter drugs

ALERGIES

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15
Q

Family history?

Social history?

A

SmokingHow many cigarettes a day? How long have they smoked for?

AlcoholHow many units a week? – be specific about type / volume / strength of alcohol

Recreational drug use

Living situation:

  • House / flat – stairs / adaptations
  • Who lives with the patient? – important when considering discharging home from the hospital
  • Any carer input? – what level of care do they receive?

Activities of daily living:

  • Is the patient independent and able to fully care for themselves?
  • Can they manage self-hygiene/housework/food shopping?
  • Is the illness interfering with these daily activities?

Occupation

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16
Q

Systemic enquiry?

A

Systemic enquiry involves performing a brief screen for symptoms in other body systems.

This may pick up on symptoms the patient failed to mention in the presenting complaint.

Some of these symptoms may be relevant to the diagnosis (e.g. reduced urine output in dehydration).

Choosing which symptoms to ask about depends on the presenting complaint and your level of experience.

Cardiovascular – Chest pain / Palpitations / Dyspnoea / Syncope / Orthopnoea / Peripheral oedema

Respiratory – Dyspnoea / Cough / Sputum / Wheeze / Haemoptysis / Chest pain

GI – Appetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit

Urinary – Volume of urine passed / Frequency / Dysuria / Urgency / Incontinence

CNS – Vision / Headache / Motor or sensory disturbance/ Loss of consciousness / Confusion

Musculoskeletal – Bone and joint pain / Muscular pain

Dermatology – Rashes / Skin breaks / Ulcers / Lesions

17
Q

Closing the consultation?

A

Thank patient

Summarise the history