4fb9d08492 When taking any history in medicine it is essential to understand what the presenting complaint means and what the possible causes (differential diagnosis) of the presenting complaint may be. Endometrial Fibroids. Clinical Features. Cardiovascular Chest pain /Palpitations /Dyspnoea/ Syncope /Orthopnoea / Peripheral oedema Respiratory Dyspnoea /Cough / Sputum / Wheeze / Haemoptysis /Chest pain GIAppetite / Nausea / Vomiting / Indigestion / Dysphagia / Weight loss / Abdominal pain / Bowel habit Urinary Volume of urine passed /Frequency / Dysuria / Urgency / Incontinence CNSVision / Headache / Motor or sensory disturbance/ Loss ofconsciousness/ Confusion Musculoskeletal Bone and joint pain / Muscular pain Dermatology Rashes / Skin breaks / Ulcers Comments GynaeHistoryAbout The AuthorLewis PotterFounder Junior doctor. Potential contra-indications to different methods, eg combined pill. endometrial Ca Younger females may have unexplained irregular periods Poor compliance with oral contraceptives can result in intermenstrual bleeding Gynaecological history Previous cervical smears when? / results? / treatment (e.g. Contents 1 Basic Structure of a Gynecological History 1.1 Introduction 1.2 Presenting Complaint 1.3 History of Presenting Complaint 1.4 Menstrual History 1.5 Past Gynecological History 1.6 Past Obstetric History 1.7 Past Medical History 1.8 Drug History 1.9 Personal History 1.10 Family History 1.11 Social History 2 Diagnosis 2.1 Postcoital Bleeding 2.2 Intermenstrual Bleeding 2.3 Post-menopausal Bleeding 2.4 Menorrhagia 2.5 Oligomenorrhea and Amenorrhea 2.6 Dysmenorrhea 2.7 Dyspareunia in females 3 The Complete History 3.1 Cervical Carcinoma 3.2 Endometrial Carcinoma 3.3 Endometrial Fibroids 3.4 Endometriosis 3.5 Pelvic Inflammatory Disease 3.6 Polycystic Ovary Syndrome 4 References . 403 Forbidden . This is vaginal bleeding more than 6 months after the menopause.
McCarthy, A & Hunter, B (2003) Master Medicine: Obstetrics and Gynaecology (2nd ed.) Philadelphia: Elsevier Saunder . Current or past illnesses Hospital admissions Past surgeries . There is a basic structure for all gynecological histories but this can differ slightly depending on the presenting complaint. Causes include:. Superficial Infection Vaginal atrophy Inadequate episiotomy repair Vaginal/rectal tumor Deep Pelvic inflammatory disease Endometriosis Adenomyosis Cervicitis . Past Medical History. LETZ ) Previous gynecological problems & treatments STDs / PID Current contraception COCP / POP / Depot / Implant /Implanted uterine device Obstetrics history Gravidity number of times a woman has been pregnant, regardless of the outcome Parity X = (any live or stillbirth after 24 weeks) Y = (number lost before 24 weeks) Each pregnancy: Current age of child Birth weight Complications antenatal / perinatal / postnatal Ask sensitively regarding miscarriages / terminations / ectopic pregnancies Past medical history Gynaecological conditions STDs / cervical dysplasia / malignancy Other medical conditions? Surgical history c-section / LETZ / prolapse repair / hysterectomy Any recent hospital admissions?when and why? Drug history Gynaecological medications: COCP / POP / Implant / Depot Transexamic acid Hormone replacement therapy Antifungals Other regular medication Antibiotics Over the counter drugs ALLERGIES Family history Uterine / Ovarian / Genital tract cancers Breast cancer Social history SmokingHow many cigarettes a day? How longhave they smoked for? AlcoholHow many units a week? be specific about type / volume / strength of alcohol Recreational drug use Living situation: House / Flat stairs / adaptations Who lives with the patient? important when considering discharging home from hospital Any carer input? what level of care do theyreceive? Activities of daily living: Is the patient independent / able to fully care for themselves? Can they manage self hygiene / housework / food shopping? Is the illness interfering with these daily activities? Occupation Systemic enquiry Systemic enquiryinvolves performing a brief screen for symptoms in other body systems. It also allows the patient tocorrectanyinaccurate information&expandfurther on certain aspects. Risk Factors. Amenorrhoea is absent menstruation for at least 6 months.