History taking and examination in obstetrics clinical gate. Taking a history is the initial step in the physicianpatient encounter. The minimum recommended laboratory tests include tests to. Allergies are you allergic to any drug, medication, latex or other substance. Oct 17, 2016 this is a learning in 10 voice annotated presentation vap on how to take gynecological history to learn more about learning in 10 lit, please visit. Free obgyn board exam sample questions boardvitals blog. Obstetrics and gynecologygynecological history taking. Taking a gynaecological history requires asking a lot of questions that are not part of the standard history taking format and therefore its important to. A reproductive health assessment should endeavour to gather information as completely as possible at each visit. Obstetrics and gynecologyobstetric history taking wikiversity. Online history form patient history the patient history form will gather the following information.
A gynaecological history involves asking questions relevant to the female reproductive system. After all, it is the aetiology of a symptom that guides the physicians questioning. 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. The student shall have a physical examination within the 12month period preceding the date of entrance to salem college. Menstrual history menarche, duration, flow and cycle length of menses, imb intermenstrual bleeding, or contact bleeding, dysmenorrheal, pms, climacteric. Assessment of the gynecologic history and the pelvic examination is part of the assessment of female patients in many clinical contexts. Number of days from the start of one period to the start. Obstetric history taking osce guide osce guide geeky medics. History taking forms a cornerstone of medical practice as it helps arrive at a diagnosis. Current surveillance data indicates that overall rates of bacterial sexually transmitted infections stis are increasing rapidly.
For adolescents, the health history is an important tool for identifying health problems and risks. To adequately evaluate the gynecologic patient, it is important to establish a rapport during the history taking. Preparing for your first rotation university of washington. Summary the history should summarized in one or two sentences before proceeding to the exa mination to focus the problem and alert the examiner to silent 16. In gynae the historytakingsequence, essentially itis similar to a case would bea.
To be completed by physician or clinic and must be in english. Unless a patients problems require the services of a psychiatrist or some other specialist, the doctor should be prepared to act as a counselor and work with the patient during a mutually agreeable time when it is possible to listen to her problems without being hurried and to give support, counsel, and other. Taking an obstetric history requires asking a lot of questions that are not part of the standard history taking format and therefore its important to understand. Obstetric history format fill online, printable, fillable, blank. Clinician familiarity with the gynecologic evaluation can help reduce anxiety for both patients and health care professionals. Clinical lecturer in obstetrics and gynaecology, st georges, university of london, uk. A nurse may be perceived as less threatening, and may be able to take the history in a less hurried manner. Please list all medications or treatments you are currently taking.
View this tutorial for guidance on getting started with the health history assignment. Various gynecological problems were evaluated by detailed history taking and thorough clinical examination. Professor geoffrey chamberlain asked me to assist him with the combining of the original wellestablished separate lecture notes on obstetricsand lecture notes on gynaecology by joining him as editor of this textbook aimed at undergraduate medical, midwifery. When taking any history in medicine it is essential to understand what the presenting complaint means if any and what the possible causes differential diagnosis of the presenting complaint may be. A full gynecological history and examination consists of at least a full history regarding general health, gynecological signs and symptoms, breast signs and symptoms and an abdominal, speculum and bimanual examination. Gynecological questionnaire for women general information. Proper history taking leads to a good diagnosis and it helps to avoid. Skip spending hours on manual data entry and scouring through paper forms with this obgyn patient history form template. Obstetric and gynecological history sharinginhealth.
Female health history medications are you taking any medications. While rates of new diagnoses have decreased, the risks of acquiring hiv are still relatively high for some females, specifically blackafricanamerican women. The minimum recommended laboratory tests include tests to screen for anemia and to rule out current pregnancy. This should be placed within the context of a patients education, social, cultural, and emotional state. Yes no any history of constipation difficulty in bowel movement. Patient and provider perspectives on sexual history taking.
The information gained during the physical examination helps the clinician to narrow the list of possible diagnoses to. The patient needs to tell her story to an interested listener who does not allow body language or facial expressions to imply disinterest or boredom. As a physician, you want to make the most out of your time with patients. Patient information medical history surgery hospitalizations current medications social history gynecological history pelvic pain questionnaire obestetrical history urinarybowel history urinary questionnaire family history over 50questionnaire patient registration the patient registration. Include prescribed drugs and overthecounter drugs, such as vitamins and inhalers. High cholesterol stroke blood clots diabetes breast cancer liver cancer heart disease heart attack high blood pressure other do any women in your family have a history of check all that apply.
Registration form pdfdoc this is for new patient who has never been seen at our practice before. We suggest taking out your textbook to remind yourself of what taking a health history entails. Family history do your parents or siblings have any of the following. Some of the questions are highly personal and therefore good communication skills and a respectful manner are absolutely essential. This form allows you to track all your patients data in one convenient place. Gynecological history taking involves a series of methodical questioning. Patient medical history suburban gynecology new lenox. Her prenatal course has been unremarkable, with a normal fetal growth and development ultrasound at. In some settings, it may be appropriate for nursing staff to be involved with history taking. It is essential to appreciate that taking a comprehensive history in obstetrics and gynaecology involves eliciting confidential and often very personal information. Investigations like haemogram, coagulation profile, hormonal assays and ultrasonography. Menstrual history menarche, duration, flow and cycle length of menses, imb intermenstrual bleeding, or. The physician should be concerned about conditions other than purely somatic ones.
Both the medical and family history are important in order to obtain. It contains basic personal and insurance information. Obtaining an accurate history is important to confirm a womans suspicion of pregnancy, make accurate fetal dating, assess general health of the mother and fetus directed toward risk factors known or suspected to diminish the health of either the woman or her developing fetus. Gynaecological history taking osce guide geeky medics. Gynaecological history introduction 1 introduces themselves 2 con.
After all, it is the aetiology of a symptom that guides the physicians questioning basic structure of an obstetric history. Consider opportunistic screening for cervical cancer using. Menstrual history lnmp, lmp age menarche, menopause cycle length, duration, regularity flow associated symptoms pain, pms abnormal menstrual bleeding intermenstrual, postcoital sexual history age when first sexually active number and sex of partners history of sexual assault or abuse contraceptive history. This further treatment may involve examination of the patient. Mar 16, 20 summary the history should summarized in one or two sentences before proceeding to the exa mination to focus the problem and alert the examiner to silent 16. Have you ever been on hormone therapy estrogen progesterone. Hpi first sentence should include age, parity, lmp and present problem details about cc and other relevant information. Please place a check mark if you or your family have ever had any of the following. This provides a basis for emphasizing aspects of the subsequent physical examination, and for initial decisions about diagnostic testing and treatment. Gynecological history taking involves a series of methodical questioning of a gynecological patient with the aim of developing a diagnosis or a differential diagnosis on which further management of the patient can be arranged. A 25 year old g1po woman at 37 weeks gestation with a history of a spinal cord transaction at t8 level presents to the obstetrical office.
This dataset contains information on gynecologic history, such as menstrual periods, menopause, use of hormones, diagnosis of endometriosis, other gynecologic conditions, pelvic pain unrelated to menstrual period, number of pregnancies, removal of uterus or ovaries, other gynecologic surgeries. List all medications you are currently taking including the dosage, frequency, and any nonprescription medications. This medical record is confidential and will not be released to anyone without your written consent except as may be required by law. Gynaecological history 28 previous cervical smears 29 previous gynaecological disease 30 sexually transmitted infections obstetric history 31 gravidity parity 32 details of each pregnancy 33 miscarriages ectopic pregnancies past medical history 34 asks about patients medical conditions 35 asks about patients surgical history drug history. G is a 54yearold hairdresser who reports pressure over her left chest like an. Gynecology notes pdf 54p this note covers the following topics such as approach to the patient, differential diagnosis of common gynecological complaints, pelvic relaxation, prolapse, reproductive endocrinology, urinary incontinence, gynecological oncology, endoscopic surgery in gynecology, endometriosis, adenomyosis and gynecological infections. Have you been vaccinated for human papilloma virus hpv gardasil. Gynaecological history and examination should be handled with sensitivity and. Please print out and complete this form prior to your arrival. Persatuan obstetrik dan ginekologi usm history taking and clinical examination for obstetric and gynaecology patients adibah ibrahim, m. Pdf this book is specifically designed to cover important clinical cases. As for the clinical breast examina tion ultrasound is best done in the first half of the menstrual cycle before ovulation. In the united states us, women face a number of serious issues concerning sexual health.
Taking a history and performing an obstetric examination are different compared. This is a learning in 10 voice annotated presentation vap on how to take gynecological history to learn more about learning in 10 lit, please visit. Students participating in athletics must have the physical exam within the 3month period preceding the date of entrance to salem college. History taking in obgyn free download as powerpoint presentation. A comprehensive guide to gynaecological history taking in an osce setting, including menstrual and contraceptive history taking. Unlike the conversation concept lab, there are no prompts during your interview, so you should prepare prior to entering ms. Foundations of physical examination and history taking. Any history of therapeutic xray treatment or anticancer drugs.
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