1. Presenting complaint
2. History of presenting complaint
3. Menstrual history
4. Obstetric history
5. Sexual history
6. Urinary history
7. Past medicalsurgical history
8. Familysocialdrug history

Presenting complaint

• What is the problem lately [pt. may omit sexual itemscover withquestions].

History of presenting complaint

• See SOCRATES.
• Timing: worse at a particular time in cycle.
• Alleviating factor: better after menstruation.
• Discharge: colourconsistencyamountsmell.
• Weight changes: anorexic (amenorrhoea) or obesity (polycystic ovaryOCP).
• Feverish.
• Itchdrynessirritationrelieved by cream.
• Hirsutismhair loss: severityhow controlled (polycystic ovary).
• Voice changesacne (androgen-secreting tumour).
• Prolapseair expelled from front passage.
• Does it interfere with your day-to-day life.
• Bowelstool problems (RLQ pain from IBD).
• General health: good?

Menstrual history

• First day of your last period.
• Length of cycleslength of period.
• Periods regularityshortest and longest times.
• Severity increasing as time goes on.
• Spells of no periods in absence of pregnancy.
• Periods heavyclotsflooding.
• Pads or tampons usednumber required.
• Periods painful.
• Bleeding between periodsafter intercourse. 
• Time of menarchemenopause.
• If menopause: hot flushesnight sweats [assesses severity of decreasingestrogen].
• Bleeding before pubertyafter menopause.

Obstetric history

• Possibility of currently pregnant.
• Number of childrenweights at birth.
• Number of times been pregnant [do math for miscarriagesterminations]: what monthwhyhow.
• Problems during gestationdelivery.
• Bleeding during pregnancy.

Sexual history

• Sexually active.
• Number of partners.
• Contraception: on OCP? which one?
• Contraception: others currently usingused previously.
• Physicalother difficulties during intercourse.
• Pain duringafter intercourse: deep/ superficialalways/ sometimes.
• Difficulty in conceiving.
• Pap smear: last smear's dateresult.

Urinary history

• Colour change.
• Blood in urine.
• Frequencyamount changes.
• Painburning sensation.
• Feeling of incomplete emptying.
• Hesitancynocturiadribbling.
• Incontinenceoverflow incontinencestress incontinence.

Past medicalsurgical history

• Similar problem in the past. If sohow treated (D&Chormones).
• Recent front passage injuries.
• UTIsurinary obstructions.
• STD'ssalpingitis [tubes infection].
• Hypertension.
• Hemophiliaother bleeding disorders.
• TBappendicitis. 
• IBD (RLQ pain).
• Diabetesgout [urinary].
• Childhood bedwetting after 3 [urinary].
• MIcerebrovascular dz [urinary].
• Infertility treatments [if infertile].
• Seen a gynecologist before?
• Previous operationsD&C

Family history

• The current complaint in parents/ siblings: healthcause of deathage ofonsetage of death.
• Hereditary dz suspected: do a family tree 
• Thyroid dzdiabetes.
• ADKDAlport's [urinary].

Social history

• Smoking: ever smokedhow many per dayfor how longtype [cigarettepipechew] (bladder CA).
• Alcohol: do you drink. If yes: typehow muchhow often.
• Presentpast occupations:
  • Rubber industry (bladder CA 2° to aromatic amines).
  • Stressful job or runner (amenorrhoea).
• Travel to Africa (bladder CA 2° to schistosomiasis). 
• Who is with you there at home.
• Feel stressed (amenorrhoea).
• Any other factors that you wish to mention?

Drug history

• Prescriptions currently on.
• Steroidsimmunosuppressantsdrugs with disturb renal-function.
• Over-the-counters.
• Estrogen replacements [if menopausal]other hormones.
• Iron replacement.
• Allergies.
• Drug allergies: assess if s/e or allergic reaction.

Urogenital (F) Exam »

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