Medical history taking in pregnant women. Proper history taking leads to a good diagnosis and it helps to avoid many complications.

1. Gynaecological
HistoryTaking
Kavya Liyanage

2. Components
of
HistoryTaking
 General information
 Presenting complaint
 History of presenting complaint
 Menstrual history
 Pelvic pain
 Vaginal discharge
 Cervical screening
 Sexual and contraceptive history
 Menopause (if relevant)
 Previous gynaecological history
 Previous obstetric history
 Previous medical history
 Systemic inquiry
 Family history
 Social history

3. General
Information
 Name
 Age
 Occupation
 Home town

4. Presenting
Complaint
 Main complaints
 Duration of main complaints
 Eg- menstrual problems
Urinary incontinence
Subfertility
Pain
Lump in vulva

5. History of
Presenting
Complaint
 Detailed information about the presenting
complaint

6. Menstrual
History
 Age of menarche
 Usual duration of each period (eg- 5/28)
 Length of cycle
 First day of last period
 Pattern of bleeding : regular or irregular and length
of cycle
 Amount of blood loss:
 more or less than usual
 Number of sanitary towels or tampons used
 Passage of clots or flooding
 Any inter-menstrual or post coital bleeding
 Any pain related to period, its severity and time of
onset
 Any medication taken during the period

7. Pelvic Pain
 Site of pain
 Its nature
 Severity
 On set of pain
 Duration or timing
 Radiation
 Relieving factors
 Exacerbating factors
 Any associated symptoms

8. Vaginal
Discharge
 Amount
 Colour
 Odour
 Presence of blood
 Relationship to menstrual cycle
 Any history of sexually transmitted disease (STD) or
recent tests
 Any vaginal dryness (post menopausal)

9. Cervical
Screening
 Date of last smear
 Any previous abnormalities

10. Sexual
and
Contraceptive
History
 Type of contraceptive used
 Duration
 Any problems regarding it
 Sexual active?
 Any pain during intercourse

11. Menopause
(if relevant)
 Date of last period
 Any post menopausal bleeding
 Any menopausal symptoms

12. Previous
Gynaecologica
l History
 Any previous gynaecological treatments or surgery

13. Previous
Obstetric
History
 Number of children and birth weights
 Any abnormalities with pregnancy, labour or the
puerperium
 Number of miscarriages and gestation at which they
occurred
 Any terminations of pregnancy with record of
gestational age and any complications

14. Previous
Medical
History
 Any serious illness and operations with dates

15. Systemic
Inquiry
 Appetite, weight loss, weight gain
 Bowel functions
 Bladder function
 Enquiry about other symptoms

16. Family History  Any genetical disease

17. Social History
 Social situation
 Occupation and its environment
 With whom does she live with?
 Housing
 Relationships
 Smoking and alcohol intake
 Support at home

18. ThankYou!