History Taking And Physical Examination

Question 1

1. Gynecological history taking procedures

Answer 1

1. A. Established raport: Always introduce yourself fully and explain what you are going to do; patients are often very apprehensive and nervous.

B. Demographics:NASMORAN
Name
Age
Sex
Marital status 
Occupation
Religion
Address 
NHIS

C. Presenting complain
Let patient describe their problems

D. History of presenting complaint
In case of pain use SOCRATES
Patient should give extra and more detailed information of their complaint

E. Menstrual history

• Date of first day of LMP.
• Age at menarche/menopause.
• Menstrual pattern (number of days bleeding/length of cycle).
• Amount/character of bleeding (flooding, clots, double protection).
1 Always ask about intermenstrual (IMB) + postcoital bleeding (PCB). 1 Always ask about any postmenopausal bleeding (PMB).
• Any associated pain + pattern (dysmenorrhoea). Has this changed?
• Ask about pain at other times including dyspareunia.
• Current and recent contraception (or not!) and details.
• Current/future pregnancy plans—this may alter/limit therapeutic
options, as many treatments are contraceptive.

F. Past obstetrics history

All pregnancies must be recorded, including successful ones, miscarriages, ectopic pregnancies, TOPs, and molar pregnancies. Outcomes, gestation and mode of delivery, complications, birth weight, and current health of child(ren) should all be documented (see b Obstetric history: current pregnancy, p. 2)

G. Past gynecology history

• History of any other gynaecological problems especially endometriosis, fibroids, polycystic ovaries, and subfertility.
• All previous gynaecological surgery.
• Date of last cervical smear and result. Were they always normal?

H. Sexual history

• Dyspareunia: superficial on penetration or deep pain.
• Sexually transmitted infections or pelvic inflammatory disease (PID). • Any abnormal vaginal discharge.

I. Medical and surgical history
• All medical conditions, especially diabetes, hypertension, asthma, thrombo-embolism. Major effect if surgery is being considered.
• All previous abdominal surgery is important also.

J. Drug history/ Allergies

• Details of all medication (doses and duration of use).
• Allergies to medications and severity (anaphylaxis or rash?). • Use of folic acid in early pregnancy.

K. Family history
• Especially diabetes, i BP, and thrombo-embolism.
• Familial cancers should always be considered, as well as others with a
genetic association including: • breast
• ovarian
• endometrial
• bowel.

L. Social history

• Home conditions and relationships.
• Occupation.
• Smoking and alcohol intake.
• Lifestyle issues such as use of recreational drugs.

Question 2

Gynaecological physical examination

Question 3

Obstetrics history taking procedure

Question 4

Obstetrics physical examination