PATH WEEK: OBS AND GYN HISTORY TAKING

PERSONAL DETAILS:
Name, age, occupation Ethnicity LMP (last menstrual period) EDD (expected delivery date) Physical signs Histology/blood tests (Need LMP and EDD to interpret the tests)

GENERAL FORMAT :
Presenting complaint History of presenting complaint Past Obstetric and Gynaecological History o Gravidity: number of times that a woman has been pregnant o Parity: number of times that she has given birth to a fetus with a gestational age of 24 weeks or more, regardless of whether the child was born alive or was stillborn. "gravida 2, para 2" (sometimes abbreviated to G2 P2) has had two pregnancies and two deliveries after 24 weeks gravida 2, para 0 " (G2 P0) has had two pregnancies, neither of which survived to a gestational age of 24 weeks. If they are both currently pregnant again, these women would have the obstetric resum of G3 P2 and G3 P0 respectively. Sometimes a suffix is added to indicate the number of miscarriages or terminations a woman has had. So if the second woman had had two miscarriages, it could be annotated G3 P0+2. "lost or ended pregnancy" o Mode of delivery Weights of baby o Birth complications? Haemorrhage Severe tear Going back to theatre Sequela such as urinary Incontinent after large baby o Cervical smears Women after age of 25 Had one before? Normal? Ever had an abnormal one? o Scrapes? Past Medical and Surgical History o Past surgeries? o Past appendicectomy? Did it burst? Adhesions?

GYNAECOLOGY QUESTIONS:
Bleeding Pain Discharge Infertility Pressure/mass Incontinence Duration Timing in cycle Amount/severity Precipitating factors Relieving factors Additional problems

LEFT = SYMPTOMS RIGHT: WHAT YOU NEED TO KNOW ABOUT Relationship to sex? Relationship to urination? Relationship to defecation?

COMMON TERMS:
Dysmenorrhoea - Painful periods o Primary: ever since menarche due to prostaglandins o Secondary: Did not always have it Dyspareunia - Painful intercourse o Superficial: vulva and vagina are sore (can be thrush) - Pain on penetration o Dysuria: Painful urination o Can be superficial o Terminal dysuria: urethritis: painful at the end of urination Stress incontinence: Coughing, laughing, lifting Urge incontinence: Detrusor instability - when you need to go, it is URGENT Strangury : Feeling like you need urination, but nothing Tenesmus : Same but with faeces (incomplete defecation) Oligomenorrhoea: Infrequent periods (normal cycles last around 22-35 days) but if greater than 42 days then it is oligomenorrhoea. Amenorrhoea: Absence of periods: o Primary: Never had a period o Secondary: Pregnancy is most common Menorrhagia : Heavy regular cycles o 4 day period ever 28 days. ( K 4/28 ) Metrorrhagia: Heavy irregular bleeding Mastalgia: Breast pain: Can be normal or be due to HRT etc. (not common cancer) Pruritus vulvae: Itchy bits e.g. thrush, although may be vulva dystrophy or malignancy

OBSTETRIC QUESTIONING
Pain/contractions Bleeding Discharge/fluid leak Urinary symptoms Headache/vision Fetal movements N.B. Gestation Onset Timing Duration Amount Associated factors

LEFT = Symptoms After 37 weeks it is no longer premature 1st trimester = 12 weeks Mid trimester = 12-26 weeks