Medical History

Chief Complaint    Medical History    Medications    OB-GYN History    Menstrual History    Pregnancy History    Contraception    Sexual History    Nutrition    Exercise    Mood    Patient Questionnaire

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.

Chief Complaint
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.

  • "What brings you to see me today?

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.

Past History
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:

  • "Have you had any problems since I last saw you?"

  • "How are you feeling today?"

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?

Medications
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).

  • "Are you taking any medication on a regular basis?"


Patient Questionnaire

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.

OB-GYN History
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

  • Menstrual history

  • Sexual history

  • Prior gynecologic problems (Pap smear abnormalities, bleeding problems, STDs, and others).

Menstrual History
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 cramps, bloating or headaches. Note the first day of the last menstrual period

  • LMP_________   

  • Menarche age______   

  • Menses are regular/irregular  

  • Menses Q_____ days x ______ days.

Pregnancy History
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 patient anxiety.

  • G_______

  • P_______

  • AB_____

Contraception
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. Perhaps:

  1. She is not sexually active.

  2. She is engaged in an alternative lifestyle.

  3. She is seeking a pregnancy.

  4. She would like to avoid a pregnancy but doesn't know how.

  5. She is not on good terms with her significant other.

  6. She or her partner is experiencing a sexual dysfunction.

Sexual History
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.

Nutrition
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:

  • "Are you eating a normal, balanced diet ?"

  • "Do you normally take a vitamin pill?"

Exercise
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 be beneficial.

  • "Do you get a chance to exercise regularly?"

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.

Mood
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. (DSM-IV)

  • 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 weight

  • 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.

The Gynecologic Exam

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Military Obstetrics & Gynecology

This information is provided by The Brookside Associates Medical Education Division.  The Brookside Associates, Ltd. is a private organization, not affiliated with any governmental agency. The opinions presented here are those of the author and do not necessarily represent the opinions of the Brookside Associates or the Department of Defense. The presence of any advertising on these pages does not constitute an endorsement of that product or service by either the US Department of Defense or the Brookside Associates. All material presented here is unclassified.

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