History taking Flashcards
What are some common presenting complaints in obs and gynae?
- Period abnormalities
- Pelvic pain
- Pain on intervourse
- Urinary incontinence
- Prolapse
- Infertility
- Sterilisation request
- Bleeding/pain in early pregnancy
- Post menopausal bleeding
- Vaginal discharge
What are the period abnormalities?
- Heavy period - menorrhagia
- Painful period - dysmenorrhea
- Irregular period
- Absent period - amenorrhea
Demographic and reproductive identifiers
- Pt name
- Age
- Marital/relationship status
- Parity
- Occupation
What qs do you ask in a menstrual hx?
- First day of last menstrual period
- No of days of bleeding/flow
- Length and regularity of cycle
- Any abnormal bleeding - intermenstrual or post coital bleeding
- Age of first period - menarche
What questions do you ask about contraception?
- Current method of contraception and duration of use
- Previous methods
- Any problems w contraception?
What qs do you ask about obstetric hx?
- Gravidity
- Parity
- Pregnancy outcomes
- Birth weights
- Modes of delivery
Gravidity vs parity
Gravidity - no of times a woman has been pregnant
Parity - no of times a woman has given birth to a fetus >24 weeks
What questions do you ask in a gynaecological hx?
- Past problems? - ix and treatment
- Previous gynaecological operations
- When had last smear and what was the result?
What other non specific qs do you ask?
- PMH
- DH and allergies
- FH
- SH
- Systems review
What are the qs to ask about abnormal vaginal discharge?
- Volume
- Colour - green, yellow, grey, blood stained
- Consistency - thickened or watery
- Smell
What are the 6 Cs of a sexual history?
- Contraception - what using? if any
- Cycle - when did you have ur last period
- Children - have you ever been pregnant
- Cytology - when did you have your last smear
- Chlamydia - STIs risk assessment
- hepatitis C/B/HIV
What qs do you ask someone about their last sexual contact?
- Male or female
- Regular or casual sex?
- How long have you been together
- Did you use a condom
- What country was the partner from
- What type of sex - vaginal, oral, anal
- Any suspected infection or sx in the partner
- How many sexual partners in the last 3 months
What are the hepatitis C + B screening questions?
- Sex w another man
- IVDU?
- Chemsex?
- Paid for sex or been paid for sex?
- Had sex w someone not from the UK
- Medical procedures or blood transfusions
- Tattoos or piercings in a dodgy place
- Sexual assault?
- Hep B vaccine?
What are the key pregnancy details in an obs history?
- Gestational age
- Gravidity - number of times a woman has been pregnant, regardless of the outcome eg. G2
- Parity - number of times a woman has given birth to child w gestational age 24 weeks or more, regardless of if alive or not
What are some key obstetric presenting complaints?
- N+V
- Reduced fetal movements - fetal distress or early fetal demise
- Vaginal bleeding
- Abdo pain
- Vaginal discharge - STI
- Loss of fluid - rupture of amniotic membranes
- Headache, vistual disturb, epigastric pain and oedema - pre eclampsia
- Pruritis - obstetric cholestasis
- Unilat leg swelling - DVT
- Chest pain and SOB - PE
N+V in pregnancy
Starts: 4th-7th week
Peak: 9th-16th week
Resolves: 20th week
Persistent vomiting and severe nausea = hyperemesis gravidarum
Reduced fetal movements
- Start at 16-24 weeks
- Mother knows the usual amount of movements and if they are reduced this should be taken very seriously
- Associated w - stillbirth, fetal growth restriction, placental insufficiency
Vaginal bleeding
- Pain
- Associated trauma - inc domestic violence
- Fever/malaise
- Recent US scan results - position of the placenta
- Cervical screening history, sexual history, PMH
- Fatigue if suspect anaemia
- Symptoms of hypovolaemic shoc
Vaginal discharge
Changes to:
- Volume
- Colour - green, yellow, blood stained = infection
- Consistency
- Smell
Urinary symptoms
UTIs common in pregnancy and need to be treated promptly - untreated = increase risk fetal death, developmental delay and cerebral palsy.
Dysuria, freq, urgency, fever
Pre eclampsia signs and symptoms
Headache - severe and frontal
Swelling of hands, feet and face
Epigastric tenderness
Visual disturb - blurred of flashing lights
Reduced fetal movements
What are the normal extras for obs history?
- ICE
- Systemic enquiry
- Immunisation history - flu, whooping cough, Hep B
- Is pt taking folic acid, mode of delivery, medical illness in pregnancy, single or multiple gestation
- Mental health history
What information are you asking for about scan results in an obs history?
- Growth of fetus - CRL expected for gestation age
- Placental position - embedded in lower third of uterine cavity = increased risk placenta praevia
- Fetal anomalies
What do you screen for in pregnancy?
In obs history need to see if patient has had screening and what the results were:
- Down’s syndrome screening
- Rhesus status and presence of any ab ?
- Hep B, HIV, syphilis
What do you ask in previous obs history?
- Gravidity and parity
- For term pregnancies - gestation at delivery, birth weight, mode of delivery, complications , assisted reproduction, stillbirth?
- <24 week pregnancies - miscarriage and gestation, termination of pregnancy, ectopic pregnancy
What are the different trimesters? What problems are associated with it?
- 1st trimester - 0-13 weeks, nausea, breast tenderness, freq, fatigue
- 2nd trimester - 14-26 weeks, less likely to have sleeping problems and nausea but maybe constipation, heartburn, back pain
- 3rd trimester - 27-40 weeks, sleep problems, incontinence, varicose veins, haemorrhoids
What PMH do you need to know about in an obs history?
- Cervical screening
- Previous gyneacological conditions and treatments
- Any surgical history - abdo/pelvic surgery, C section, LETZ
- Allergies
- DH
What FH medical conditions do you need to ask about?
- Inherited genetic conditions
- T2DM
- Pre eclampsia
What do you need to ask about in SH for obs history?
- General social context
- Smoking
- Alcohol
- Recreational drug use
- Diet and weight
- Occupation
- Domestic abuse
