History Taking
This booklet is intended as a practical guide to patient care for registrars, medical officers, interns and medical students attached to the gynaecology units at the University of the Witwatersrand Academic Hospitals. Anyone can use it.
History of the main complaint - very important
Further gynaecological history
Diagnosis & treatment are based on clinical skills, i.e. history & examination. Investigations, e.g. ultrasound & blood tests, are done to resolve a differential diagnosis, or to confirm or refine a suspected diagnosis. Poor clinical assessment will result in muddled & poorly directed investigations that are expensive & lead to incorrect management.
All relevant clinical findings & management MUST be clearly written in the patient’s file. Include the date & time of assessment.
HISTORY TAKING
The most important thing of all is the PRESENTING COMPLAINT, but ask
The ‘big five’ questions
Always ask:
- Age
- Parity and gravidity
- Last menstrual period
- Current method of contraception, if of that age
- Marital status, occupation of patient and partner
These questions give the background, & may point towards certain diagnoses.
The main complaint
Find out the patient’s reason for coming to hospital. If referred by a clinic or a private doctor, ask for the referral note & READ it. Do not go into detail until you have asked the ‘big five’ questions.
History of the main complaint – very important
Pain: duration, severity, type, localization, association with the menstrual cycle, dyspareunia, associated symptoms (urinary & bowel), aggravating factors (lifting, bending, on rising in the morning), alleviating factors, previous episodes & treatment used so far. Bleeding: amount, duration, clots, with pain or not. With a discharge/ Or not/ what type? A mass? For how long? Symptoms? Ask always if there are important symptoms the patient has that you have not asked.
Menstrual cycle
Ask the last menstrual period, the amount, regularity/irregularity of the cycle length, intermenstrual bleeding, post coital bleeding, menarche. Always consider pregnancy if there is amenorrhoea.
Further gynaecological history
- Vaginal discharge & its characteristics
- Sexual history, dyspareunia, contraception (present, past)
- Previous cervical smears, & when last done
- Other previous gynaecological problems, treatment
- Previous gynaecological surgery
- Timing of menopause, & symptoms, where appropriate
- Previous mammograms in women over 50 years, & when last done
Obstetric history
Note the gestation, mode of delivery & outcome of all previous pregnancies, & problems antenatally, at delivery, in the puerperium
Systematic history
Go through a basic systems review: cardiovascular, respiratory, gastrointestinal, urinary, neurological, musculoskeletal, endocrine, haematological, immune. Ask chest symptoms of all HIV affected.
Past History
Include past surgical history, medical, family & drug history, allergies, & habits including smoking & alcohol. Knowledge of HIV status, CD4 count/viral load, use of ARVs, & when tested (if negative) is essential.
Social history
As well as the type of accommodation, electricity, running water, etc. remember: source of income, employment, dependants including children, all of which may cause anxiety/require arrangement if admission or review is necessary. Consider questions on intimate partner violence if the history is suspicious. Ask where the patient lives. Know the area. It may affect ease/difficulty of review.