Lecture #159: DPR: Introduction to the Gynecological and Obstetrics History

What is the purpose of taking a gynecological history?

To identify areas of concern, assess screening status, and allow discussion of sensitive topics, education, and guidance.

What are the main topics in gynecological history?

Symptoms, menstrual cycle, menopause, breast, pap smear, mammogram, sexual activity, contraception, and family history.

What symptoms should be assessed in gynecologic history?

Breast, thyroid, vulvovaginal, pelvic, and colorectal symptoms including pain, discharge, masses, bleeding, and irritation.

What thyroid-related symptoms should be asked?

Weight changes, fatigue, hair loss, heat/cold intolerance, dry skin, constipation, palpitations, and mood changes.

What discharge characteristics should be assessed?

Color, consistency, and odor of nipple or vaginal discharge.

What is menarche?

The age at which a patient first begins menstruation.

What menstrual history questions are essential?

FDLMP, cycle frequency, duration, flow, intermenstrual bleeding, dysmenorrhea, and postcoital bleeding.

What does FDLMP stand for?

First day of last menstrual period.

How is menstrual flow assessed?

By number of pads or tampons used daily or hourly.

What questions assess menopause?

Age at cessation of menses, symptoms, and any postmenopausal bleeding.

What are common menopausal symptoms?

Hot flashes, night sweats, vaginal dryness, urinary symptoms, mood changes, and decreased libido.

Why is postmenopausal bleeding important?

It may indicate pathology and requires further evaluation.

What breast history questions should be asked?

Lumps, pain, skin changes, nipple discharge, and self-exam practices.

What should be asked about nipple discharge?

Laterality, spontaneity, color, and association with compression.

What is the purpose of a pap smear?

Screening for cervical cancer.

At what age should pap smear screening begin?

Age 21.

What causes most cervical cancers?

Human papillomavirus (HPV).

What follow-up questions are asked about pap smears?

Last test, results, abnormal history, and procedures performed.

What procedures may follow abnormal pap smear?

Biopsy, LEEP, cold knife cone, or hysterectomy.

What questions are asked about mammograms?

Last screening, results, abnormalities, follow-up, and procedures.

What procedures may follow abnormal mammogram?

Biopsy, lumpectomy, or mastectomy.

What is important when taking a sexual history?

Ensure privacy, be nonjudgmental, and normalize questions.

What sexual activity questions should be asked?

Current activity, types of sex, partners, orientation, protection, and STI history.

What STI-related questions should be included?

History of STIs and current concerns including HIV.

What sexual function questions should be asked?

Problems with intercourse, arousal, or orgasm.

What contraception questions should be asked?

Current method, adherence, and pregnancy intentions.

What are common contraception methods?

Pills, injections, vaginal ring, IUD, implant, barrier methods, abstinence, and sterilization.

What should be assessed if contraception is not used properly?

Risk of unintended pregnancy.

What family history is important in gynecology?

Breast, ovarian, uterine, and cervical cancers.

What is the purpose of obstetrical history in non-pregnant patients?

To assess overall health, past pregnancies, and complications affecting long-term health.

What key pregnancy history questions should be asked?

Number of pregnancies, live births, outcomes, gestational age, delivery type, and complications.

What delivery details should be assessed?

Vaginal vs C-section and use of vacuum or forceps.

What complications should be assessed in pregnancy history?

Pregnancy complications, delivery complications, miscarriages, and terminations.

What is a spontaneous miscarriage?

Loss of pregnancy without intentional intervention.

What should be asked about miscarriage management?

Whether medication or surgery was required.

What is elective termination?

Intentional ending of pregnancy via medication or surgery.

What is the purpose of obstetrical history in pregnant patients?

To predict outcomes and identify risks requiring monitoring or intervention.

What questions confirm pregnancy status?

FDLMP, cycle regularity, pregnancy test, and ultrasound findings.

What symptoms should be assessed in pregnancy?

Vaginal bleeding, nausea, vomiting, breast tenderness, fatigue, urinary frequency, and discharge.

What psychosocial questions are important in pregnancy?

Whether pregnancy is planned, emotional response, support system, and partner involvement.

What postpartum questions should be asked?

General wellbeing, fever, pain, discharge, menses return, feeding method, and mental health.

What breastfeeding questions should be asked?

Method (breast/bottle), problems with feeding, and breast issues like mastitis.

What mental health screening is important postpartum?

Assessment for depression or anxiety (e.g., Edinburgh scale).

What contraception should be discussed postpartum?

Family planning and prevention of unintended pregnancy.

What is gravida (G)?

The total number of pregnancies.

What is para (P)?

The outcome of pregnancies including term, preterm, abortions, and living children.

How is para documented?

In order: term, preterm, aborted/miscarried, living children (e.g., G4P2113).

What is the purpose of a SOAP note in OB/GYN?

To document patient-reported history including gynecologic and obstetric details.

What are the two cervical cell types relevant to pap smear?

Columnar (inside canal) and squamous (outside cervix).

What is the squamocolumnar junction (SCJ)?

The area where columnar and squamous cells meet and where most cervical neoplasia occurs.

What equipment is used for a pap smear?

Speculum, cytobrush, spatula, and collection tools.

What is the key clinical takeaway for this lecture?

A structured, thorough history is essential for identifying risk, guiding screening, and managing gynecologic and obstetric care.