Gynecological History Taking

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TAKING A

GYNECOLOGICAL

HISTORY

eCampus Ontario

Purpose

■

To determine the underlying history related to a gynecological

presentation

■

To identify ways a gynecological history taking differs from a

general history. For example, the focus of this interaction will

include specific questions not necessarily covered in a

general history.

*This educational tool will be discussing gynecology related

information without the inclusion of  breast health/pathology

Process

Question

■

STOP

–

Pause for a moment

■

CONSIDER

–

What is the first step when initiating a history taking

encounter?

■

CONTINUE

–

After considering the question above, continue to the

next slide

ID

General Overview

Question

■

STOP

–

Pause for a moment

■

CONSIDER

–

What requirement must you fulfill before continuing the

history taking?

■

CONTINUE

–

After considering the question above, continue to the

next slide

Permission

■

The client must give permission to

complete both a history and a

physical examination. This can be

done as a verbal consent in Canada.

■

Note that in circumstances where a

second health care related person

will be invited into the room,

permission must also be given for

that person to be present

CMPA 2006

Reason for Visit

■

Historically known as Current Complaint (CC)

■

Short description of reason for presenting to the health care

provider

■

Documented in the patient’s own words if possible

History of Present Illness

■

This is a line of questioning that serves to determine the who

why what where and when of the reason for presentation

■

A systematic approach

■

Helps to use a mneumonic

■

We use BOLDCARTS

Past Medical History

■

Also systematic

■

A line of questioning that seeks to uncover all of the client’s

prior medical history that may be important in the context of

the presentation and the management of the health care for

this client

Question

■

STOP

–

Pause for a moment

■

CONSIDER

–

Some instructors include Allergies and Medications in

the Past Medical History Section of the documentation

for history. Why would you keep these two categories

separate?

■

CONTINUE

–

After considering the question above, continue to the

next slide

Allergies

■

Include questions related to all allergies including:

–

Medication

■

If affirmative be sure to elicit a description of the reaction

experienced

–

Food

–

Environmental

Medications

■

A full list of all medications including OTC and supplements is

required.

■

Include start date, route, dose, schedule and recent

adjustments

■

Also ask about meds recently used for any indication

–

Special attention to recent antibiotic use in the case of

possible STI or other infectious process

Review of Systems (ROS)

■

A systematic approach to ask about any findings in any bodily

system.

■

For gynecological examination this can be a more focused

approach and may change depending on the reason for

presentation

–

Include questions related to menstrual cycle such as

■

DLNMP, normal cycle characteristics, reproductive history,

birth control

■

Any positive findings should be further examined by using

BOLDCARTS to determine any characteristics of the finding

Question

■

STOP

–

Pause for a moment

■

CONSIDER

–

Which aspects of the history are included in the ROS

■

CONTINUE

–

Review the voice over for this slide for further discussion

of what to include in the ROS

Family Health

■

Includes a history of family illness

■

Special attention to findings related to cancer, genetic

disorders and gynecologic pathologies

■

Can ask about family structure here as well

Physical Examination (PE)

■

You are now ready to proceed to the physical examination.

■

Please see module 2 for further information related to PE

Slide Note

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This guide explores the process of taking a gynecological history, emphasizing the importance of thoroughness and patient permission. From introductions to obtaining consent, the steps involved in gynecological history taking are outlined. Attention is given to the nuances of gynecological versus general history taking. Key considerations such as confirming patient identity, conducting a general overview, and seeking consent for both history and physical examination are highlighted.

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Presentation Transcript

TAKING A GYNECOLOGICAL HISTORY eCampus Ontario

Purpose To determine the underlying history related to a gynecological presentation To identify ways a gynecological history taking differs from a general history. For example, the focus of this interaction will include specific questions not necessarily covered in a general history. *This educational tool will be discussing gynecology related information without the inclusion of breast health/pathology

Process ID (yours and theirs) General Overview Permission Reason for visit (AKA CC) HPI PMH Allergies Meds ROS FH

Question STOP Pause for a moment CONSIDER What is the first step when initiating a history taking encounter? CONTINUE After considering the question above, continue to the next slide

ID 1 2 Introduce yourself Provide your name (including preferred pronouns) profession and purpose Determine the ID of your patient ASK the patient what their name is. Asking them to state their name ensures you have the correct person Confirm DoB and address Pay attention to their identified pronouns if given

General Overview Taking a thorough history Taking a thorough history can take time can take time Be sure to complete a Be sure to complete a general overview to make general overview to make sure it is safe to take the sure it is safe to take the time to proceed time to proceed Determine AB Determine AB2 2CT before continuing your history continuing your history CT before Airway Breathing and Bleeding Circulation Trauma

Question STOP Pause for a moment CONSIDER What requirement must you fulfill before continuing the history taking? CONTINUE After considering the question above, continue to the next slide

Permission The client must give permission to complete both a history and a physical examination. This can be done as a verbal consent in Canada. Note that in circumstances where a second health care related person will be invited into the room, permission must also be given for that person to be present CMPA 2006

Reason for Visit Historically known as Current Complaint (CC) Short description of reason for presenting to the health care provider Documented in the patient s own words if possible

History of Present Illness This is a line of questioning that serves to determine the who why what where and when of the reason for presentation A systematic approach Helps to use a mneumonic We use BOLDCARTS

Past Medical History Also systematic A line of questioning that seeks to uncover all of the client s prior medical history that may be important in the context of the presentation and the management of the health care for this client

Question STOP Pause for a moment CONSIDER Some instructors include Allergies and Medications in the Past Medical History Section of the documentation for history. Why would you keep these two categories separate? CONTINUE After considering the question above, continue to the next slide

Allergies Include questions related to all allergies including: Medication If affirmative be sure to elicit a description of the reaction experienced Food Environmental

Medications A full list of all medications including OTC and supplements is required. Include start date, route, dose, schedule and recent adjustments Also ask about meds recently used for any indication Special attention to recent antibiotic use in the case of possible STI or other infectious process

Review of Systems (ROS) A systematic approach to ask about any findings in any bodily system. For gynecological examination this can be a more focused approach and may change depending on the reason for presentation Include questions related to menstrual cycle such as DLNMP, normal cycle characteristics, reproductive history, birth control Any positive findings should be further examined by using BOLDCARTS to determine any characteristics of the finding

Question STOP Pause for a moment CONSIDER Which aspects of the history are included in the ROS CONTINUE Review the voice over for this slide for further discussion of what to include in the ROS

Family Health Includes a history of family illness Special attention to findings related to cancer, genetic disorders and gynecologic pathologies Can ask about family structure here as well