1. Gynaecological History

2. Personal Data
• Name of the patient. • Husband’s name.
• Age . • Husband’s age.
• Occupation. • Occupation.
• Residence. • Level of education.
• Level of education. • Blood grouping.
• Tribe. • Consanguinity.
• Marital status. Single or
married
• Duration of marriage.

3. • Presenting problem : C/O
Allow the patient to describe this in her own
words as it is important to understand what it is
that the patient perceives to be the problem.
History of presenting illness :
HPI : should be focus on the presenting problem
or complaint , e.g. menstrual problems,
pain,subfertility, urinary incontenence, …….. , etc.

4. • Menstrual History :
Age of menarche .
KATA 5/28
LMP
Pattern of bleeding : regular or irregular and length
of cycle .
Amount of blood loss : more or less than usual,
number of sanitary towels or tampons used,
passage of clots or flooding

5. • Menstrual History :
Any intermenstrual or post-coital bleeding .
Any pain relating to the period, its severity
and timing of onset .
Any medication taken during the period .

6. Pelvic pain :
Site of pain, its nature and severity .
Anything that aggravates or relieves the pain-
specifically enquire about relationship to
menstrual cycle and intercourse .

7. Vaginal discharge :
• Amount, colour, odour, presence of blood
• Relationship to the menstrual cycle
• Any history of sexually transmitted diseases (STDs)
or recent tests
• Any vaginal dryness (post-menopausal).
Cervical screening :
Date of the last smear and any previous
abnormalities.

8. • Sexual history (if applicable)
• Coitus
pain, bleeding
• frequency (if appropriate).
• Contraceptive history
Contraception currently used and previously ,
and any problems with it .

9. Menopause (where relevant) :
• Date of last period
• Any post-menopausal bleeding
• Any menopausal symptoms.
Past gynaecological history :
This should include any previous gyneacological
problem and its treatments , gynaecological
operation (D&C , myomectomy… etc), date and
complication(s).
- Type of anesthesia used and complication(s).

10. • PAST obstetrical history :
• Number of childrens with ages and birth wt.
Any complications during pregnancy ,
delivery or puerperium .
• Number of miscarriages and gestation at
which they occurred , their management and
any complication.

11. Past medical and surgical history
- Hypertension.
- Diabetes.
- Asthma.
- Hospitalization.
- Blood transfusion
- Any surgical operation, date and
complication(s).
- Type of anesthesia used and complication(s).

12. - Family history
Hypertension, diabetes, asthma, cardiac
disease , thyroid disease or any disease.
Family history of gynaecological cancers
( ovaries , uterus , cervix ) , or any other
cancer especially breast cancer

13. Drug history:
• Regular use of medication (chronic use).
• Allergy to any drug specially penicillin.
• Current use of medication.
Social history:
• Housing condition.
• Abnormal habit e,g smoking

14. Systemic review :
A systemic review 0f all other organs especially :
Urinary system :
• frequency - number of times per day
• nocturia - need to pass urine during the night
• dysuria - discomfort on passing urine
• urgency - strong desire to pass urine which can not be
ignored
• incontinence - involuntary leaking of urine
• provocation factors e.g. coughing, laughing, running.

15. 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. Examination
• General examination: General appearance of the
patient: Gait , BMI , Vital signs, Face, Hands
 Head and neck. (examine the thyroid gland)
 Cardiovascular system.
 Respiratory system.
 breast examination
 Lower limp for oedema and varicose veins

17. Abdominal examination
 . Inspection:
Abdominal distention , shape, asymmetry , masses, scars, hernia,
dilated veins.
Palpation:
 Superficial palpation for: tenderness ,rigidity , guarding.
 Deep palpation for: organomegaly. (liver, spleen, kidneys),deep
palpation for any masses and if present determine if arising from
the pelvis “(can I get below the mass?”).
 Percussion: dull if the mass is solid, tympanitic if distended
bowel, shifting dullness and fluid thrill in case of ascites.
 Auscultation: usually used postoperatively to detect bowel
sounds.

18. Con.
 Pelvic examination.
 Bimanual vaginal examination.
 Rectal examination
 Provisional diagnosis
 Investigation
 Final diagnosis
 Management