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Gynaecological history (PC/HPC (Pain (Character Colicky (ureteric,…
Gynaecological history
PC/HPC
Pain
Character
Colicky (ureteric, primary dysmenorrhoea)
Deep, dull (deep dyspareunia)
Superficial (superficial dyspareunia)
Radiation
Iliac fossa to groin (ovarian)
Onset
Acute
Chronic
Intermittent (dyspareunia)
Associated symptoms
Discharge, incontinence, prolapse,
urinary/bowel symptoms, systemic symptoms
Site
Midline/lower abdo (primary dysmenorrhoea)
Iliac fossa (ovarian)
Pelvis/lower abdo (deep dysparaunia)
Back/lower abdo (secondary dysmenorrhoea)
Sacrum/groin (ureteric)
Vaginal introitus (superficial dysparaunia)
Exacerbating/relieving factors
Exacerbating: intercourse (dyspareunia), menstruation
Relieving: bowel opening, analgesia
Timing
Constant/intermittent
Worsening/stable
Relationship to menstrual cycle (first few days of menses [primary dysmenorrhoea];
pre- and throughout menses [secondary dysmenorrhoea], ovulation [mittelschmirtz])
Relationship to sex (during [superficial dyspareunia], after [deep dyspareunia])
Severity
1-10
Discharge
Amount, colour, smell (malodorus), itch
Urinary symptoms
Incontinence (stress or urge)
Dysuria
Frequency
Nocturia
Prolapse
Bowel symptoms
Incontinence
Bloating
Constipation/diarrhoea
Appetite change
Gynaecological
history
Contraceptive history
Sexually active
Current and previous methods of contraception
Fertility and any problems
Any STIs
Past gynae history
Known disorders (STI, PID, endometriosis, ectopics)
Previous failed pregnancies <24w (miscarriage, ectopics, abortions, molar pregnancies); dates, methods, complications
Past gynae surgery
Smear history
Normal and abnormal smears
Date of last smear
Menstrual history
LMP (or menopause)
Cycles (# days bleed/total length of cycle), regularity
Heavy bleeds (clots, flooding, multiple pads/tampons)
Unscheduled bleeds (inter-menstrual, post-coital, post-menopausal)
Associated pain (pre, during)
Age at menarche
Obstetric history
Parity (P)
Pregnancies reaching viable gestational age (>24w)
Includes live and stillbirths
Twin pregnancy counts as one parous event
Children
Antenatal problems
Gestation
Delivery date
Methods of delivery
Outcome (incl weight)
Complications
Gravidy (G)
Total number of pregnancies experienced
only needed in obstetric history summaries
Abortus (A)
Pregnancies ending <24w
Miscarriages, abortions, ectopics, molar
Abortions
Gestational age
Method
Reason
PMH
Medical history
Surgical history
DH/allergies
FH
Gynae disorders
Fibroids
Endometriosis
Clotting disorders
DVT/PE
Cancers
Cervical/endometrial/ovarian
Breast
SH
Lifestyle (smoking, alcohol)
Occupation
Social support
Demos
Other key
Parity
LMP
Pregnant/not
Contraception/not
Last smear (>25y)
Last mammogram (>50y)
Occupation
Age
Name