GYN: History Taking

GYN: History taking

Name:

Husband’s name:

Age:

Time since marriage:

Address:

LMP:

Parity:

Presenting Complaint:

Examples

- Amenorrhea: secondary amenorrhea is when the patient hasn’t had her periods for more than 6 months.

- Menorrhagia: Heavy menstrual flow but normal duration.

- Dysmenorrhea: painful periods.

- Oligomenorrhea: cycle is prolonged (more than 35 days)

- Polymenorrhea: the cycle is less than 21 days and so the patient has periods more than once in one month.

Normal Menstrual Cycle is approx: 21-35 days long

Normal amount of blood loss: 5-80 ml

Length of periods: 1-8 days

HOPC:

- onset

- duration

- associated symptoms

- aggravating and relieving factors

Menstrual History:

- Age at menarche

- Cycle

- Flow

- Dysmenorrheal?

- Intermenstrual bleeding?

- Post-coital bleeding?

- Contraceptive use?

- Has she ever had a PAP Smear taken?

- LMP

Obstetrics History:

- Ask about each pregnany: Duration of pregnancy? Complications? Outcome?

- Ask about each delivery: Mode of delivery? Place of delivery? Complications at the time of delivery?

- Ask about each baby: Birth weight of baby? Was the baby breast fed?

Past History:

- Past medical: HTN, Diabetes, TB, Seizures, Asthma etc..

- Past Surgical

- Blood Transfusions

- Is her vaccination up-to-date?

Personal History:

- Appetite

- Sleep

- Bowel

- Micturition

- Recent weight gain/weight loss

- History of any addictions (such as smoking, naswaar, hooka etc..)

- History of any allergies to foods or medicines?

Family History:

- Is the marriage consanguineous?

- History of breast cancer, ovarion cancer, uterine cancer etc..

- History of HTN, Diabetes etc..

Social History:

- # of family members

- # of earning members

- Approximate income?

- Use of boiled water at home?