GYNECOLOGIC HISTORY AND EXAMINATION doc

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HISTORY

It is common practice to obtain much of the history by paramed￾ical personnel, interactive computer activities, or a patient ques￾tionnaire completed before seeing the physician. Hence, the

patient–physician interaction can be focused with emphasis on the

patient’s concerns. Additionally, important positive and negative

findings may be reviewed with the patient before the physical ex￾amination.

AGE, MARITAL STATUS, GRAVIDITY,

AND PARITY CHIEF COMPLAINT

The patient’s main problem(s) in her own words listed in her order

of seriousness comprise the chief complaint.

PRESENT ILLNESS

The patient’s health at the onset of illness and the symptoms in se￾quence of development form the present illness.As much detail (e.g.,

facts, dates) as is possible is included, documenting what, where,

when, why, how, and to what degree each complaint affects her.

PAST HISTORY

MENSTRUAL HISTORY

The age and character of the menarche (or menopause) should be

described. The last menstrual period (LMP), previous menstrual

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GYNECOLOGIC HISTORY

AND EXAMINATION

CHAPTER

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BENSON & PERNOLL’S

506 HANDBOOK OF OBSTETRICS AND GYNECOLOGY

period (PMP), and last normal menstrual period (LNMP), if

relevant, should be recorded. Also, the regularity, duration, amount

of bleeding (number of perineal pads or tampons), pain, mucous

discharge, and intermenstrual or postcoital spotting should be

recorded.

GYNECOLOGIC HISTORY

Record the following. Gravida (G), the number of previous preg￾nancies; para (P), the number of previous term pregnancies; abor￾tions (Ab), the number of pregnancies terminated (spontaneously

or electively) before 20 weeks gestation or 500 g; premature deliv￾eries (Pre), the number of pregnancies terminated between 21–35

weeks gestation or 500–2499 g; living children (LC), the number

of children currently living, with twins noted in parenthesis at the

end of the sequence. Often, this is recorded in a summary with just

the numbers in the sequence noted; [e.g., 4,2,1,2,4 (Twins 1 pr.)

would mean the woman had been pregnant 4 times, had 2 term preg￾nancies, had 1 abortion, had 2 premature births, and has 4 living

children (here, the twins were premature but survived)].

In some patients, a more detailed obstetric history is indicated,

including dates of all pregnancies; their duration, character, and du￾ration of labor; and method of delivery (with type of uterine inci￾sion if cesarean birth). Complications, weight and gender of in￾fant(s), stillbirths, abortions, neonatal complications, and current

status of living children should be noted also.

MEDICAL AND SURGICAL

HISTORY

Record medical allergies (e.g., penicillin, iodine, horse serum) as

well as important nonmedical allergies (e.g., shrimp). Record any

excessive bleeding potentially indicative of a coagulopathy. A sum￾mary of the patient’s childhood and later illnesses in chronologic

order together with complications and the treatment prescribed for

each is important. Record operations and injuries, with dates and

outcome. Record all medications (prescription, proprietary) as well

as alternative health care (medications, acupuncture, etc.).

FAMILY HISTORY

Age, health, and cause and date of death of first- through third￾degree relatives (often a brief pedigree is the best demonstration of

this material) should be recorded. Also note familial or hereditary

abnormalities, diseases, bleeding tendencies, occurrence of cancer,