Gynecology History Taking

- Ankit Suniyal

1. Patient Details
• Name –
• Age –
• Menstrual status – perimenopausal /postmenopausal
• With Para ____ & live birth ____
• Hailing from (Address)_____
• Educated up to ___
• Working as (Occupation)- ______
• Family’s Monthly income / Socio-economic status –
• Marital status – unmarried/married/widow/divorced/separated

2. Chief complain
• Vaginal discharge with/out pruritus
• Bleeding per vagina
• Mass per abdomen
• Pain in abdomen/pelvis
• Mass descending per vagina
• Referred from _____ hospital as a ____ by ____ findings

3. History of presenting illness (HOPI)

• Patient was apparently normal ___ months back , when she noticed ___
• Elaborate symptoms – duration, chronological order
• Etiology/ cause/ risk factors –
• Complications -
• h/o DM/HTN –
• h/o Fever –

GYNE HISTORY | Ankit Suniyal

 • UTI –

A) History in Discharge per vaginum

• Onset & duration –
• Amount(Quantity) – scanty/moderate/excessive
• Type of discharge/consistency – thick /thin/frothy / watery /pus
• Color – white /greenish /gray /yellowish
• Odour –
• Periodical discharge / continuous /intermittent ?
• Blood stained or not ? Relation to cycles ?
• Associated with Pruritus & irritation ?

B) History in Bleeding per vaginum

• Pattern of bleeding – poly/oligo/metrorrhagia (*menstrual history) *Rhythm of cycle

• Amount/ Quantity of flow –
• Associated with clots /pain?
• Duration of bleeding –
• Interval between 2 bleedings - continuous/intermittent
• Onset – post coital bleed/ intermenstrual bleed
• H/o of STDs/TB/ OCP/IUCD

C) History of a Mass per Abdomen

• Onset – sudden/insidious
• Duration –
• Site -
• Size & growth rate –
• Associated with pain ?

GYNE HISTORY | Ankit Suniyal

 • Pressure Symptoms (*for ovarian mass )– dyspepsia ,abdominal distention , sense
of bloating after meals & loss of appetite , weight loss , dull abdomen pain , dyspnea,
nausea , vomiting
• H/o pedal odema

D) History of Pain
• Onset – sudden / insidious
• Site –
• Duration & Nature of pain –
• Relation to cycle -
• Radiation -
• Aggravating & Relieving Factor -
• Associated with vomiting / fever?

E) History in Mass descending per Vaginum

• Duration -
• Onset – gradual/abrupt
• Mass is continuously present/present at the time of straining
• Aggravates by cough/defecation/straining/exercise/lifting weight?
• Relieves by lying down
• Reducible/irreducible?
• Inconvenience caused by the mass – unable to walk/carryout daily activities

F) History in Prolapse (Mass PV)

• Fullness of vagina
• Mass descending per vagina – onset , duration
• Reducible or non- reducible mass ?
• Low back pain
• Urinary symptoms *cystocele (inc. frequency, difficulty in initiation, *empty the
bladder after reducing the mass , incomplete voiding, UTI, stress incontinence)
• H/o increased abdominal pressure– constipation, chronic cough/lung disease,
ascites , abdominal tumors

GYNE HISTORY | Ankit Suniyal

 • Constipation
• White discharge/bleeding
• Sexual dissatisfaction

4. Bowel & bladder history

Ureter obstruction , hydro nephrosis , Abdomen mass, fibroid
• Pressure symptoms - increase frequency of urine , Urine retention & difficulty in
urine
(Staging)-
• h/o inc. frequency of micturition , dysuria , hematuria, incontinence , fistula formation
• h/o of rectal involvement – diarrhea/constipation, rectal pain , bleeding per rectum ,
fistula formation

5. Menstrual History
• Age at Menarche
• Attained Menopause at __
• Cycles – regular/irregular , frequency, days of flow , volume , associated with
clot/pain , h/o - intermenstrual/post menopausal bleed ,
• Last LMP –

6. Marital history
• Married since –
• No. of children ? / last child birth __
• Contraception use ? – OCP / IUCD

7. Obstetric history
• H/o infertility / null parity
• H/o recurrent abortions
• Age at the time of marriage –
• Age at the time of 1st child , 2nd child, nth… -

GYNE HISTORY | Ankit Suniyal

 • H/o breastfeeding
Obstetric history in case prolapse
• H/o large fetus –
• Mode of deliveries – vaginal /LSCS
• h/o abortion ?
• Delivery by untrained dai/person ?
• h/o fundal pressure ? h/o prolonged second stage ? h/o premature bearing down ?
• Interval /spacing between pregnancy (multiparity with short interval )
• h/o any operative procedure – forceps/Vacuum/etc.

8. Past history
• Surgery – Prolapse /rectum /fibroid Sx
• h/o hysterectomy/salpigectomy/tubal ligation
• Past history of TB/ PID
• Cardiac / DM /Endocrine /Thyroid disorder
• History of –colon/endometrial Ca./ovarian/breast

9. Personal History
• allergy to any medication ?
• h/ o drug intake
• Sleep , loss of Appetite & weight loss
• Addictions – alcohol & tobacco/ smoking
• Diet – high fat diet & obesity
• High of high risk behavior/multiple sex partners/STDs -
• H/o of dyspareunia –

10. Family history

• Family/personal history of Ca of colon/endometrium/ovary/breast ca
• Family H/O -DM,HTN, TB, Bleeding disorders / fibroid
• *family history is non significant in cervical Ca./Prolapse patient

GYNE HISTORY | Ankit Suniyal

 11. Summary of history
• ____ year old ,perimenopausal/post menopausal woman (*sterilized/unsterilized)
with para____ live ____has come with C/C___ With comorbidities – HTN/DM with
symptoms likes______
• Suspecting benign/malignant lesion of _____ with risk factors like ___
• Probably due to ____
• My provisional/Differential diagnosis is _____

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GYNE HISTORY | Ankit Suniyal