History taking sample in Gynecology

1. Gynecological clinical interview
1. Introduction
- Name
- Age
- Married/unmarried
- If married, married duration and
how many children?
- Occupation
- Address
- Date of admission
2. Presenting complaint
- Brief statement of the general
nature and duration of the main
complaint
- (ex- complains of bleeding per
vaginal for 18 days duration)
3. Subsidiary complaints
a. Ex fever for 5 days
4. History of the presenting complaint
- Describe the presenting complaint
in chronological order
- Eg – abnormal menstrual bleeding
 LRMP
 Pattern of bleeding –
regular/irregular
 Amount
 Fresh or altered blood
 Passage of clots or flooding
 No of sanitary towels used
per day
 Intermenstrual bleeding
 Associated symptoms
 Abdominal pain
 Backache
 Dyspareunia(
deep/superficial)
 Features of anemia-
faintishness
 Effects on day today
activities
5. History of subsidiary complaints
- Describe the subsidiary complaint
in chronological order
6. System inquiry
- Appetite,LOW,LOA
- Urinary symptoms
 Frequency –day and night
 Urgency
 Hesitancy
 urge incontinence
 stressincontinence
 retention
- bowel habits
 frequency
 constipation/loose stools
 bloodstained
- CVS
 Shortnessof breath
 Palpitations
- Respiratory symptoms
 Cough
 Haemoptysis
- CNS
 Numbness
 Fits
- Menopausal symptoms
7. Menstrual History
- Age of menarche
- LRMP
- Length and duration of the cycle
- Premenstrual symptoms

2. - Dysmenorrhea
8. Past Gynaecological History
- Symptoms
- Abortions
- Surgery – D&C, PAP smear
- Drug treatment
9. Past Obstetrics History
- No of children with age and birth
weights
- Any abnormalities with pregnancy,
labor, puerperium
- No of miscarriages and gestation,
which they occurred
- (if the blood group is negative
whether the rhogum given or not)
10. Coital History
- Frequency
- Dyspareunia – superficial/deep
- Post coital bleeding – amount – for
how long, fresh/altered
11. Contraceptive History
- Using or not
- Method ( OCP, condoms )
- Duration
- Complications
12. Past Medical History
- HT, DM, BA, IHD
13. Past surgical History
- Operations ( under GA is
important )
14. Dietary History
- Dietary iron intake
- Fat content of a diet
- Amount of food intake
15. Family History
- HT, DM, IHD, carcinomas
associated with genital tract)
- Carcinoma/ polyps in GIT
- Carcinoma of breast
16. Social History
- Occupation of the patient, income
- Occupation of the husband/
income
- Family support
- Is any family member will get
affected due to Pt’s illness?
- Smoking
- Alcohol
Examination
1. General examination
- Comfortable or not
- Well/ ill
- Dyspneoic
- Pale
- Icterus
- Thyroid enlargement
- LN enlargement – inguinal
- Bleeding patches over the skin
- Varicose veins
- Ankle oedema

3. 2. CVS
- Pulse rate
- Blood pressure
- Ht Dr/murmurs
3. Respiratory system
- Respiratory rate
- Breath sounds
- Added sounds ( ronchi,
crepitations )
4. CNS
- Conscious, rational
- Cranial nerves
- Motor system
- Sensory system
5. Abdomen
- Distened/ non distended
- Surgical scars
- Dilated vessels
- Umbilicus
- Hernia
- Diverticulation of recti
- Lump
 Site, size(ex. Compatible
with 16 wks of POA) shape
 Consistency
 Surface
 Margins
 Tenderness
 Moves horizontally and/
vertically
 Can/ can’t get below the
lump
- Liver, spleen
- Free fluid
- Bowel sounds
6. Vaginal examination
Inspection
- Vulva- swelling, soreness, scratch
marks, warts
- Discharge
- Ask to strain and look for lumps
arising at vulva
- Ask to cough and look for
incontinence
Speculum
Vagina
- Lumps, ulceration
- Purulent/ whitish discharge
Cervix
- Size, color
- Surface
- Nodules, growths
- Os
 Nulli/ multiparous
 Discharge, bleeding,
products of conceptus
 Contact bleeding
 Open/close
 Descent

4. Palpation
- Cervix
o Tenderness
o Consistency
o Size
o Growth,nodules
- Os
o Nulli/multiparous
o Discharge,bleeding,products
of conceptus
o Contact bleeding
o Open/close
o Descent
- Uterus
o Size
o Position- ante/retro
o Mobility
o Ante.Surface
o Post.Surface
o Utero sacral ligament
- Adnexiae
o Tenderness
o Tethering
o Lumps
- Pouchof douglas
o deposits
Presentingfindings
There is female typehair distribution. (nothing
called“ normal”hairdistribution.Male type
(inPCOS) or shaven.
Externalgenitalia looksnormal.Vagina is
atrophied.No visible lumps.
Separate the labiabykeepingthe fingersat
upper2/3 & lower1/3 junction.
Urethral& vaginalopeningsarenormal.
Askto cough.
There is no stress incontinence.
Askto strain.
There is cystocele/ rectocele etc.
InsertCusco’sspeculum.
Cervix is nulliparous/multiparous.
Os is closed.
Ant& postlips (in multipara) arenormal/
ulcerated/ectropian.
There is purulentdischarge.
PVE
Os is closed
Cervix is firm.No cervical excitation (optional)
–in PID.
Uterusis ante/retroverted &normal/16
weekssize.
No adenexialmasses.