Comprehensive Gynaecological History

Comprehensive Gynaecological History

Comprehensive Gynaecological History
• Comprehensive gynaecology history includes a summary of a patient’s information on
o Menstrual, obstetrical, and sexual history
o Contraceptive use (past and current),
o Gynaecologic history
        Pap smears examination,
       Reproductive health problems such as infections and other diseases of the female
       genital tract and endocrine disorders)

Creating Rapport
• Creating rapport is important in order to gain toleration and cooperation from the patient.
• Rapport may include the following aspects:
o Greeting by shaking hands
o Welcoming
o Introduce yourself using same language as client
o Offering a seat
o Have time for client, and do not interrupt
o Say ‘yes’, ‘um-hum’ or use non verbal gestures to show that you care
o Make eye contact
o Do not attend to other clients while busy with another

Systematic Documentation of Gynaecological History

• Introduction,
   age,
    place of residence,
      parity, LNMP
• Chief complaint and duration
• History of presenting illness (refer the contents under the obstetric history)
• Review of other systems (i.e., probe for involvement of other systems).
• Past medical history

o Ask questions with regards to medical, drugs and surgical history which could have influence on the current condition.
• Gynaecological history
o Indicate age at menarche, menstrual cycle and its regularity, periods/amount of blood Loss, previous infections and their treatment, gynaecological surgeries, contraception history.
o Menstruation: The periodical flow of blood from the uterus commences at the age of 13 and ceases at the age of 45years (it may occur earlier or later respectively).
o The flow of blood may vary from three to five days.
   Menstrual cycle: The periodic cycle from day one of menstruation to the onset of the next menstruation.
The duration varies from 21 up to 35 days.
     Dysmenorrhoea: Pain occurring during menses.
     Menopause: Physiological cessation of menstruation (menstrual cycles).
• Family and social history
o Note: for additional information on family/social history,

Summary of History
- Important Positives and Negatives
• Depending on the responses of the patient, identify key findings revealed during history
taking.
• Remember to document both positive and negative findings.
• Make sure you are able to interpret moods and body language of the patient during history taking so that you can probe for more detailed responses as needed.

Posted by
Welfare Jambo