Gynaecology history-taking

Published on 09/03/2015 by admin

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Last modified 09/03/2015

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1 Gynaecology history-taking

The importance of taking an accurate and detailed history cannot be overemphasized, particularly in gynaecology where the symptoms are often embarrassing and patients may not wish to discuss them unless specifically asked. The very nature of the specialty requires the history-taker to be respectful, sensitive and on the alert for both verbal and non-verbal cues. It is essential that during the consultation one tries to put the patient at ease so that she feels as comfortable as she can discussing her symptoms.

The consultation

The consultation should commence with a professional introduction assuming one has looked at the referral letter or the notes beforehand so that the woman can be addressed appropriately. As with all histories, it is easiest to start with the presenting complaint. When did the problem first begin, how long has it been present and how frequently does it occur? How much does it affect her quality of life? If the problem is pain, then one must elicit what exacerbates the pain and what alleviates it. The site and nature of the pain must be determined. As with all history-taking it is important to ask open questions rather than direct questions initially. Enquire whether she has ever consulted anyone else about this problem, and if so, what was the management?

Presenting complaint

Abnormal bleeding

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