Chief Complaint ·
Medical History ·
OB-GYN History ·
Menstrual History ·
Pregnancy History ·
Sexual History ·
In obstetrics and gynecology, as in most other specialties, the patient's
history is of extraordinary importance. It not only provides some insight into
what might be troubling the patient, but in about 90% of cases, it will provide the
diagnosis. Some aspects of history-taking are the same as might be found in a
general medicine practice. Others are very specific to OB-GYN complaints.
The reason for the visit. It might be for a routine GYN visit, or to refill birth control pills, or because of a
vaginal discharge. The Chief Complaint can almost always be stated in one
sentence or less.
In writing up your report of a visit, put the "CC" right up at the
top where everyone can read it and you won't forget it.
What led up to the current situation? When did the symptoms
begin? Have they been constant, improving or worsening? Is there anything that
makes this worse or better? Ask how the patient has been since her last examination. This is an opportunity for you to get a current medical status report. You might ask:
For patients not previously seen or for whom you have no medical records, you should
note any previous significant medical or surgical illness, and allergies.
"Have you every been hospitalized for any medical illness?"
"Have you ever had any surgery?
"Are you allergic to any medicine?
Ask her to identify medications she takes regularly. This will provide additional insight into her current health status and may identify
areas of her medical history she has forgotten. Some medications are of
gynecologic or obstetric significance. (hormones, antibiotics).
In many practices,
patients coming into the office are routinely asked to fill out a form
that summarizes their Chief Complaint, Past History, Medications, and a
Review of Systems. This is the form I use in my office. I like it
because it gives the patient an opportunity to explain their situation
in their own words (within the provided structure), and makes sure there
is nothing worrying the patient that I might have overlooked.
Some aspects of the patient's OB and GYN history are very relevant to their
current situation. Among these are:
Number and types of births
Prior gynecologic problems (Pap smear abnormalities, bleeding problems,
STDs, and others).
Record menstrual data. Age of onset of menses (menarche), the regularity (or irregularity) of menses, their
frequency, duration, heaviness and any associated symptoms, such as
headaches. Note the first day of the last menstrual period
Determine the number and nature of pregnancies. Gravida (G) means the total number of pregnancies. Para (P) means the number of
children born. Abortions (AB) means the number of spontaneous or induced abortions.
Note the type of delivery, whether there were any complications, and the
outcome. I always like to know the names of her children. It helps me in asking
questions later, personalizes my service to her, and and provides a
non-threatening topic of conversation at later visits that helps to reduce
Inquire as to the method currently used for contraception. This may provoke an answer that opens the door to a discussion of sexual issues that
may be troubling to her.
If she answers, "none" to this question, I always wonder why that might be.
She is not sexually active.
She is engaged in an alternative lifestyle.
She is seeking a pregnancy.
She would like to avoid a pregnancy but doesn't know how.
She is not on good terms with her significant other.
She or her partner is experiencing a sexual dysfunction.
The depth of your sexual history inquiries will depend on why the patient is
seeing you and the clinical circumstances. For some encounters, sexual history
is irrelevant and omitted. For other encounters, an abbreviated sexual history
is appropriate. For some, a full and detailed sexual history is the needed. In
those cases, questions may include:
Age at first coitus
Current sexual activities (vaginal, oral, anal, manual)
Current frequency of sexual activities
Past sexual activities
Safer sex practices
Number of partners (current and in the past)
Sexual preferences (men only, women only, men or women)
Sexual dysfunctions (problems with arousal, pain, lubrication, orgasm)
Worries or concerns about sexual issues.
For some patients (and some physicians), dealing with these issues may be
stressful. Ask your questions in a direct, honest, and non-threatening way and
you will usually find the patient responds similarly.
Assess her general nutritional status. This can be done visually and with noting her height and weight.
For women with a
normal, balanced diet, nutritional supplements are probably not necessary, but most people
have difficulty maintaining a normal balanced diet. For those women, a daily multivitamin can be
very helpful in making up for any nutritional deficiencies. Additional iron is
particularly helpful for women in maintaining a positive iron balance. Otherwise, the
steady loss of iron through menstruation can lead to some degree of anemia.
For women anticipating a pregnancy, Folic acid 400 mg PO daily is recommended by the
Center for Disease Control to reduce the risk of birth defects related to the spine.
I sometimes will ask:
Regular exercise is important for physical and psychological reasons.
Women who exercise regularly will generally experience less trouble with cardiovascular
disease, bone loss (osteoporosis), weight control, and depression.
To be most effective, the exercise should be strenuous enough to cause sweating, last
at least 20 minutes, and occur several times a week. Lesser amounts of exercise may also
As a group, women are more likely than men to sustain minor athletic
injuries when exposed to the same degree of athletic stressors. Reasons
for these findings
may include level of training or fitness, degree of experience with exercise,
architectural construction of the pelvis and lower limbs, and possibly hormonal effects.
I advise women to try to avoid athletic injuries while continuing to
exercise by not performing the same exercise two days in a row. This
gives their body 48 hours to recover.
Depression is a common clinical problem affecting twice as many women as men. Talking
with the patient will give you a reasonable assessment of her mood.
Depression is diagnosed whenever a depressed mood or loss of interest/pleasure is
associated with at least four other symptoms, consistently over a two-week period.
Depressed mood most of the day, most days
Marked loss of interest in normal activities most of the day, most days
>5% change in body weight in 1 month when not intentionally trying to modify body
Insomnia or too much sleep most nights
Psychomotor agitation or depression most of the time
Marked fatigue nearly every day
Feeling worthless or inappropriately guilty most of the time
Diminished ability to think or make decisions most days
Recurring thoughts of death or suicide
Intimate Partner Abuse
Physical abuse of intimate partners is much more common than most people
believe. 8% of women will report of history of such violence, while 29% will
report such a history, if asked. IPA encompasses child abuse, elder abuse, and
both male and female partner physical abuse.