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The Gynaecological History - Coggle Diagram
The Gynaecological History
Summary Sheet
Part 1
Personal detailss
Part 2
Presenting complaint
Part 3
Background hx
PMhx
Mhx
Fhx
Shx
Part 4
Systems review
Part 5
Sensitive hx
Drug use
Reproductive hx
Pregnancy hx
Menstrual hx
Contraceptive & fertility hx
Cervical / otehr screening hx
Introdution
Introduction Aims
Establish the presence and details of
gynaecological complaints
and its
causes and effects
particularly on her
quality of life
Example
Complaint
Heavy menstrual bleeding
Causes
Uterine fibroids
Effects
Anaemia
Missing work
Establish her
general health
as it may influence the
mangement
of the gynaecological compaints or conditions particularly if an
anaesthetic
is required
Example
BMI 56kg/m2 -> Class III obesity
Afib on warfarin
Some complaints presenting to a gynae service may be non-gynaecological in origin
To establish the presence of a new
non-gynaecological complaint(s) and / or condition
as 1) it may influence
management
of the gynaecological complaints or conditions and / or 2) she may need onward referal
Example
Von Willebrand's disese in a woman presenting with heavy menstrual bleeding
Rectal bleeding in a woman with suspected postmenopausal vaginal bleeding
Structure
Same structure as any hx
Important point is that essential information is obtained in a structured manner
Set up
PCBR
Private area
Chaperone
Background - respect cultural and religious background
Rapport
Non-Gynaecological histories
A reproductive hx should in general from a part of
any woma presenting to any specialy
Some gynae complaints and conditions may present as non-gynaecological initial
Some non-gynaecological conditions may impact her reproductive health
(1) Personal Details
Name and surname
Date of brith and age
Address
First language and language if relevenet
(2) Presenting Complaint details
Medical Prespective - SP-OPD-CS-PAR-A
Site
Site
Radiation
Timing
Onset - relative to cycle
Periodicity
Duration
Nature
Character
Severity - QOL
Factors
Precipitating and aggrevating
Relieveing factors
Other
Assocated gynae or other relevant symptoms / systems
Patient Perspective ICE
Ideas
Cocnerns
Expectations
Preferences and Priorities
Main Gynaecological Presentations
Category 1: Gynaecological Symptoms
Abnormal vaginal bleednig
Lower abdomen / pelvic pain
Abnormal vaginal discharge
Abdominal distension or mass
Prolapse symptoms
Urinary symptoms
Bowel symptoms
Vulval symptoms
Systemic hormonal symptoms eg PMS, PCOS, menopause
Early pregnancy symptoms eg pain, bleeding, vomiting
Category 2: Gynaecological Requests
Cervical screening request
Contraception request
Fertility assessment request
HRT request
TOP request
Category 3: Gynaecological prodecures - Perioperative
Preoperative assessment
Psotoperative assessment
Subsets
Eg Urinary symptoms
Frequency
Dysuria
Haematuria
Incontinence
Approach
Ensure hx is up to date
Include investigations and treatments since presentation / admission
If multiple symptoms - prioritise each
Consider quoting her own words
(3) Background Hx
Past Reproductive History
Pregnancy hx
Establish details of pregnancies
Do you have children
How many children
Have you had anay other pregnancies
Have you ever been pregnant
Express as Gravidity and Parity
Gravidity
Number of pregnancies including current pregnancy if pregnant
Parity
Number of deliveries (live and still)
Details
Mother
Year and location (hospital)
Gestational age
3. Mode of delivery vaginal / caesarean
Vaginal
Onset: Spontaneous or induced + reason
Delivery: Spontaneous or intrumental + reason
C Section
Urgency: Elective or emergency + reason
Analgesia / anaesthesia
Complications
Ante / Intra / Post partum
For
Each
Early Pregnancy Loss
Gestational age - age and size
Managment
Expectant / medical / surgical
Complications
Baby
Gender, age and Name
Birth wight
Birth details
Condition
At birth
Now
Feeding
Breast
Bottle
Menstrual hx
Menstrual Milestones
Menarche / Menopause
Lifetime menstual activity
Pre puberty : No periods
Puberty: Periods start often irregular
Reproductive : Periods are regular each month
Perimenopausal: Periods become irregular and then stop
Post Menopause: No periods
Peri-menopause (Climateric)
Pre-menopause + 1 year post-menopause
Establish details of Menstrual Milestones
Menarche
Normal 10-15 yrs
Average 12-13yrs
Precocoius <10 yrs
Delayed >16 years
Menopause
Normal > 40 years
Average 51 years
Preamture <40 years
Menstrual Cycles / Non menstrual bleeding
Regularity
Interval
pattern
:question:Are your periods regular?
Do your periods come at the same time each month?
Frequency
Interval
length
:question:How many days are there between the first day of your period and the first day of your next period?
Duration
Period
duration
:question: How many days do your periods last?
Volume
Period
volume
:question: Are your periods heavy for you?
CPAAQ
Clots / flooding
Prection - multiple pads
Accidents - particularly at night
Anaemia symptoms
QOL
LMP
First day of the most recent period
Non Menstrual bleeding
IMB - Intermenstrual bleeding
Bleeding between periods
:question: Do you bleed between periods?
Does it always occur at the same time in the cycle?
When in the cycle does the bleeding occur? 1st half / middle / 2nd half
PCB - Post Coital bleeding
Non-mentrual vaginal bleeding in association with sexual intercoure
:question: Do you bleed during or after sex?
Pain
Dysmenorrhoea
Pain associated with menstruation
:question: Are your periods or the days leading up to them painful?
Systemic Symptomes
PMS
PCOS
Menopausal
:question: Do you have any hot flushes or sweats?
Last mentrual period (LMP)
Date
1st day of bleeding during most recent period
:question: When was the first day of your most recent period
Normality
:question: Did it come when you were expecting it
Was it normal?
Importance in
All women of reproductive age
Can alert to possible
pregnancy
Relationship
between cycle day and gynaecomplaint may be important
Certain
investigations and procedures
must be carried out at specific times in the cycle
Approach
Open ended questions
:question: Tell me about your periods
Not easily defined period
Describe the shortest / longests / average interval
Ask if she record her periods - review
Include prior normal menstraul hx in PChx
Women on Hormonal Contraception
Withdrawal bleeding
Articial periods are not natural periods
Breakthrough bleeding
Unscheduled vaginal bleedin on hormonal contraception and is abnormal
Documentation
Periods (k)
Documented as a fraction in medical notes
Eg k = 4/28 means periods last 4 days and occur every 28 days
Irregular periods - Range
Document shortes time interval to the longest tim interval and the average time interval
eg k=7-10/20-35
Terms not to use
Considered
Obsolete
Menorrhagia
Metorrhagia
Oligomenorrhea
Dysfunctional uterine bleedining
Contraception and Fertility hx
Contraceptive Use
Establish Current and Past Use
:question: Are you using any form of contraceptive at the moment?
What contraceptives have you used in the past?
:warning: Some patients may not think of barrier methods and need to be prompte
Establish Problems / Stopping / Changing
:question: Are you / have you had any probelms with any contraceptives?
Why did you stop / change?
Contraceptive Needs
Sexual activity
:question: Are you in a relationship?
Are you sexually active?
Is you partner male or female?
May be on contraception but not sexually active
May be sexually active but not require contraception
If unprotective discuss risks of pregnancy and STIs if relevent
Plans to concieve
:question: Are you hoping to get pregnant either now at some point in the future?
Do you have any plans to get pregnant?
Difficulties concieving
Establish
duration
and results of
investigations
:question: Have you ever tried to get pregnant?
You have not have any children - that by choice?
Cervical / Gynae screening hx
Establish Details of Cervical Screening hx
Date and outcome of last screening
Has routine screen? Ever missed a screen?
Ever had abnormal screen
Outcome (repeat / colposcopy / tx)
HPV vaccine status
:question: Say screen not smear
Cervical Screening Programme
Previous Programm ( 2009-2020)
Cervical
Smear
( cervical cytology)
25 -
60
yrs
Every 3 years (25-44)
Every 5 years (
45
-60)
Current Programme (March 2020)
Cervical
Screening
(
HPV
test + cervical cytology)
25-
65
Every 3 years (25-29)
Every 5 years (
30
- 65)
HPV Vaccinatino Programme
Garasil 9 protection:
HPV 16 / 18 / 6 / 11+31 / 33 / 45 / 52 / 58
90% of cervical cancers
Women age approx
25
or less should have been vaccinated
Establish Details of Breast screening hx
If > 50 yrs
Establish Details of STI screening hx
If appropriate
Opportunistic screens
(3) Background Hx
Past Medical Hx
Illness
Establish details of each
Establish fitness for anaethesia
Excessive weght
CVS / resp conditions
Past Thromboembolic disease
Surgical risk
Operations
Establish past operations
Establish anaesthsia used
Abdo operations: Establish type of entry
Laparoscpoic
Open - increased risk of intra-abdominal adhesions
Establish complications
Hospitalisations
Establish admissions
Reason for admission
Duration of admission
Current or past gynae illnessess. operations or hospitalisaitons
(3) Background History
Medication History
Establish details of Medications
Prescribed
Over the conter
Complementary / alternative medications
Allergies
:question: Are you allergic to any meds? What happens?
Latex if surgery
Iodine if colposcopy
Penicillin if requires abx
(3) Background History
Family History
Gynaecological and related cancers
Breast
Ovarian
Endometrial
Colorectal
Cancer Syndromes
BRCA
Lynch syndrome HNPCC)
Thromboembolic diseasse and Thrombophilia
(3) Background History
Social History
Home
Type of accomodation
Occupation
Relationships
Support at home
Foreign travel
If appropriate
Lifestyle
Smoking
Alcohol
Diet
Exercise
Recreational drug use if appropriate
(4) Systems Review
Establish any other symptoms / problems
:question: Is there something else you think I should know>