OnExam

Identifying Information

  • Gather the patient's general identifying data. As part of the complete obstetrics history, you should also gather:
  • Address the sensitive nature of the interview
    • “I would like to ask you some questions about your sexual health. I understand that this is a sensitive subject, but I need to ask you these questions in order to see whether there are any problems and how I can help you. Is this okay with you?”
    • If patient looks uncomfortable during the interview: “I can see that my questions are making you feel uncomfortable. I understand that this is a sensitive topic. I am asking you these questions to see how I can help you. Everything that we talk about today will remain confidential unless I fear for your safety or safety of others. Is it okay if I ask you a few more questions to complete my assessment?”
  • Gravidity and parity (e.g. G4T1P1A1L2)
    • Gravidity = total number of pregnancies, regardless of outcome (includes current pregnancy, spontaneous & therapeutic abortions, ectopic pregnancy, hydatidiform moles, stillbirths, live births)
    • Parity = number of various pregnancy outcomes
      • T = number of term deliveries (≥37 weeks)
      • P = number of premature deliveries (<37 weeks)
      • A = number of abortions (both spontaneous and therapeutic)(<20 weeks and/or 500g fetal weight)
      • L = number of living children
    • Note: Twins count as 1 instead of 2 for gravidity (e.g. a female who is currently not pregnant, but has 2 living twins carried to term would be considered G1T2P0A0L2)
    • Definitions
      • Nulligravida: a woman who is currently not pregnant and has never been pregnant
      • Nullipara: a woman who has never completed a pregnancy that lasted for more than 20 weeks
      • Primipara: a woman who has had 1 live birth or stillbirth (estimated gestation >20 weeks)
        • Note: Twins count as 1 live birth or stillbirth
      • Multipara: a woman who has had ≥2 live births or still births (estimated gestation >20 weeks)

Chief Complaint

  • Elicit the patient's chief complaint
  • Are there any other complaints

History of Presenting Illness

  • Characterize each of the patient's principal symptoms
  • FIFE: Feelings, ideas, impact on function, expectations

Past History

Menstrual History

  • Age at menarche
  • Last menstrual period (LMP), period before that
  • Regular/irregular, spotting between periods
  • Cycle length (e.g. q28days), duration of bleeding (e.g. 7 days)
  • How heavy= # of pads/tampons per day, spotting lights vs soaking the pad
    • Impact of daily function, missed school/work
  • Presence of blood clots
  • Dysmenorrhea (pain before or during periods)
    • Characterize patient’s pain (link: HPI - OPQRST/OLD CARTS)
    • Impact on daily function, missed school/work
  • Emotional/behavioural changes 5 days before period (PMS)
    • Irritability, anxiety, depression, confusion, crying, poor sleep and concentration, weight gain, pedal edema
  • Associated symptoms including diarrhea, nausea and vomiting, fatigue, dizziness
  • Any recent changes in menstrual cycle
  • If patient has amenorrhea, ask about early symptoms of pregnancy and symptoms of menopause
    • Early symptoms of pregnancy
      • Breast:tenderness, tingling, increased size
      • Urinary frequency
      • Nausea, vomiting, anorexia
      • Easy fatigability
    • Symptoms of menopause
      • Hot flashes
      • Flushing
      • Night sweats
      • Sleep disturbances
  • Definitions
    • Amenorrhea- absence of menses
      • Primary amenorrhea - never had menses
      • Secondary amenorrhea - had menses in the past, but no longer have menses
    • Menorrhagia - prolonged duration of menses (>7d) or large amount (>80cc per cycle) of bleeding during menses
    • Metrorrhagia - bleeding at irregular intervals
    • Oligomenorrhea - infrequent/irregular menses with cycle interval >35 days
    • Polymenorrhea - cycle interval <21 days
    • Menometrorrhagia - both menorrhagia and metrorrhagia
    • Hypomenorrhe a- light menstrual flow

Menstrual History (if patient is post-menopausal)

  • Age at menopause
    • Menopause - absence of periods for 12 consecutive months
  • Postmenopausal bleeding? (Assume endometrial cancer until proven otherwise)
  • Associated symptoms- hot flashes, flushing, night sweats, sleep disturbances
  • Feelings about menopause
  • Impact on daily function
  • Use of Hormone Replacement Theraphy

Obstetrical History

  • GTPAL
  • Type of delivery- vaginal vs C section
  • Problems/complications with pregnancy and delivery

Sexual History

  • Single or have a partner
  • Sexual activity and orientation
    • “Have you ever been sexually active?”
    • “Are you currently sexually active?”
    • “Have you been sexually active with men, women, or both?”
    • Oral sex, vaginal sex, anal sex
    • # of sexual partners
    • Name of current partner, relationship
  • Problems/concerns with your sexual life
    • Feel satisfied with sex life, patient’s partner feel satisfied with sex life
  • Pain during intercourse (dyspareunia)
    • Characterize patient's pain
    • Certain positions that cause pain vs all positions cause pain
    • FIFE
    • Alcohol
    • Experienced any unwelcome sexual advances, perhaps long time ago in childhood
  • Bleeding during or after intercourse (postcoital bleeding)
  • If patient is post-menopausal: vaginal dryness

Contraception

  • Current method of birth control
    • How often patient uses birth control
    • Satisfaction with current method
  • Past methods of birth control
  • Questions/concerns about birth control methods
    • Counsel about options if applicable

Sexually Transmitted Infections (STI)

  • “Have you ever had unprotected intercourse?”
    • When, how often
  • History of STI (e.g. chlamydia, gonorrhea, herpes, syphilis, pelvic inflammatory disease)
    • Treatment done
  • Current partner or previous sexual partner(s) had STI (oral sex, vaginal sex, and anal sex)
  • Concerns about STI, concerns about HIV/AIDS
    • Does patient want STI testing
  • Last STI testing
  • Pap
    • Last Pap test - when, results
      • Pap guidelines: every 3 years starting the age of 21 until the age of 70. If the pap result is abnormal, the testing is done more frequently.
    • Any abnormal Pap tests in the past- when, investigations done
  • If current STI is suspected, ask about symptoms of STI
    • Vaginal discharge: amount, colour, consistency, odour, change from normal
    • Vaginal pruritis (itching): location
    • Sores, lumps, bumps: location, tender/nontender

Past Medical History (PMx)

  • Past and present medications
    • Prescriptions
    • Over the counter medication
    • Pain medications
    • Herbal medication
    • Vitamins, prenatal vitamins, folic acid
    • Hormone replacement therapy (HRT)
    • If patient is pregnant, consider safety of medications
      • Resource Motherisk.org
  • Allergies
  • Medical conditions
    • Bacterial vaginosis, yeast infections
    • Cancers - ovarian, endometrial, cervical, colon
    • Psychiatric problems such as anxiety, depression, bipolar, post-partum depression, post-partum psychosis
    • Diabetes mellitus (DM)
    • Hypertension (HTN)
    • Cardiovascular disease (CVD)
    • Bleeding problems - anemia, coagulopathy
    • Thyroid disease - hyperthyroidism, hyopthyroidism
    • Renal disease
  • Gynecological procedures (e.g. colposcopy)
  • Surgeries- gynecological surgeries (e.g. LEEP- loop electrocautery excision procedure), problems with anesthetic
  • Hospitalizations
  • Immunizations
    • Human papilloma virus (HPV) vaccine (prevention against cervical cancer and genital warts)
      • Ontario: HPV vaccine is approved for females aged 9 to 45. It is available free of charge to all grade 8 females in school-based clinics. If missed in grade 8, it is available free of charge grades 9-12 at a public health unit
      • HPV vaccine does not protect against all HPV strains that cause cervical cancer. Pap tests are still necessary to detect cancerous changes

Family History (Fx)

  • Family members alive/dead
  • Chief complaint in family
  • Gynecological problem in the family
    • Cancers - ovarian, endometrial, colon
  • Other medical conditions in the family
    • DM, gestational DM
    • HTN
    • Psychiatric problems such as anxiety, depression, bipolar, post-partum depression, post-partum psychosis
    • Congenital malformations, hereditary disorders, developmental delay
    • Malignancies (breast, endometrial, ovarian, colon, etc.)

Social History (Sx)

  • Occupation and education
  • Married/single, living arrangements
  • Intimate partner violence (IPV) (all women are at risk, most do not disclose IPV unless asked)
    • Do you feel unsafe or afraid at home
    • Are you afraid of your partner or anyone else
    • Have you ever been hit, kicked, punched, or hurt by someone (if yes, who)
    • HITS
      • H: How often does your partner hit you
      • I: How often does your partner insult or talk down to you
      • T: How often does your partner threaten you
      • S: How often does your partner scream or curse at you
    • Thank you for trusting me with this information and expressing your concern about safety. Would you like for me to connect you with any legal assistance, counseling, shelter, or other services?
    • Offer domestic violence hotline phone number
  • Social/family supports
  • Physical activity

Substance Use

  • Smoking: currently, in the past
    • Amount of cigarettes/packs per day (1 pack= 25 cigarettes), how many years has been smoking for
    • Written in pack-years (# of pack years= # packs/day x # of years)
    • If ex-smoker: how long smoked for, amount/day, when quit, congratulate on quitting
  • Alcohol consumption (see alcohol consumption screening tools)
  • Recreational drug history (see Recreational Drug History)
  • Caffeine - amount
  • Sources of stress

Medications

Gather complete list, including particularly relevant drugs such as:

  • Anticonvulsants (Valproic acid)
  • Pain meds (Gabapentin, opioids)
  • Psychiatric drugs
  • Vitamins

Allergies

Note allergies and ensure they concord with those listed in the EMR

Immunizations

Note immunization history as described in the immunization history section.

Review of Systems

Conduct a review of systems, keeping other etiologies from your differential in mind.

References

  • Link to Ob/Gyn Reference page