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Lecture
for medical students at the Faculty of Medicine King Fahad Medical City Riyadh
on January 04, 2015 by Professor Omar Hasan Kasule Sr.
AIMS, OBJECTIVES, AND
LEARNING OBJECTIVES
Aim:
To learn elements of a
comprehensive reproductive history including obstetric and gynecological
history
To introduce students
to obtaining a relevant biological and psychosocial sexual history in females.
Objectives:
To take a comprehensive
reproductive history of a pregnant mother
Learn to elicit a
sexual history relevant to the case scenario of a young woman.
Learn to integrate
biological and psychosocial aspects of a sexual history in a female patient.
INTRODUCTION
Self introduction
Permission to take
history
Age, marital status,
occupation
GYNECOLOGIC HISTORY 1:
History of Presenting Complaint (site, severity, radiation, aggravating
factors, relieving factors, associated symptoms)
Menstrual disorders
Abdominal pain
Abdominal mass
Vaginal discharge:
color, odor
Mass in the vaginal
introitus
Urination and
defecation problems
GYNECOLOGIC HISTORY 2:
Menstrual History
Age at menarche:
precocious / delayed puberty
Start of the last
menstrual period
Length of the cycle
usually 4-7 days
Amenorrhea: primary and
secondary
Polymenorrhea:
frequency of menstruation <21 days
Oligomenorrhea = rare
menstruation every 6 wks – 6 months
Menorrhagia: excessive
prolongation and heavy but regular period
Metrorrhagia =
irregular acyclic menstruation
Menmetrorrhagia /
polymenorrhagia = frequent and excessive menstruation
Menopause = cessation
of menstruation
Post coital bleeding
Post-menopausal
bleeding
GYNECOLOGIC HISTORY 3:
Previous History
Pregnancy complications
Gynecologic surgery
Anesthesia (types and
reactions)
Contraception
Last PAP smear
Hospitalizations
GYNECOLOGIC HISTORY 4:
Previous Medical History
Respiratory conditions
Cardiovascular
conditions
Medications
Allergies
GYNECOLOGIC HISTORY 5:
Family and Social History
Family history: TB, diabetes,
cardiac disease, depression, genital carcinoma, breast cancer
Stresses and problems
Use of drugs, alcohol,
and tobacco
OBSTETRIC HISTORY 1:
History of Present Pregnancy
Last menstrual period
(LMP)-1st day of the last period
Length of the menstrual
cycle (1st day of last period to 1st day of the next
period
Symptoms of pregnancy:
nausea and vomiting, frequent micturition, excessive tiredness, breast
tenderness and heaviness, fetal movements
OBSTETRIC HISTORY 2:
History of Previous Pregnancy
Gravidity (number of
previous pregnancies). Primigravida = first pregnancy
Parity (number of
previous births/abortions/miscarriages). Nullipara = no previous birth.
Primipara=first birth. Multipara = several previous births. Grand multipara =
more than 5 births
Each pregnancy:
duration of gestation, antenatal complications, complications of labor,
duration of labor, presentation (breech?), method of delivery (vaginal or
cesarean), ectopic or abortion, birth weight, sex of infant, condition of
infant at birth (resuscitation, congenital anomalies), post-natal complications
(hemorrhage, infections, venous thrombosis)
OBSTETRIC HISTORY 3:
Previous Medical History
Chronic non
communicative conditions: diabetes mellitus, renal disease, hypertension,
cardiac disease, endocrine disease
Communicable /
infectious diseases: TB, HIV, syphilis, hepatitis
OBSTETRIC HISTORY 4:
Family History
History of genetic
diseases in the family
SEXUAL HISTORY 1: Why
Difficult
Sensitive issues
Embarrassment (patient
and doctor)
Gender
Cultural differences
Sexuality issues
Feelings of guilt,
“dirtiness”
SEXUAL HISTORY 2:
Elements
Menstrual history
Coitarche (age at first
sexual experience), experience (total number of life-time partners), type of
sex, barriers uses? High risk sex
Dyspareunia (pain on
intercourse)
responsiveness,
lubrication, vaginismus
Libido (sexual interest
or desire),
Contraception:
attitudes and practices (types, failures, reasons for discontinuation)
Previous history: STDs,
gynecological, vulval and breast problems
medications taken
Psychiatric and
psychological history: sexual relationships, sexual abuse, body image problems,
social anxiety, drug and alcohol use
SEXUAL HISTORY 3:
Skills Needed
Privacy
Confidentiality
Gentle and positive
Non-judgmental
Validation of patient’s
experiences
Explanation to preface
“difficult” questions
ROLE PLAY ACTIVITY:
Instructions
One of the students
could now elicit a sexual history from the role-play patient, taking into
Consideration the above
discussion.
Tutor and students
should read through the following case.
History, and one
student should interview the tutor or another student as Anna.
PLAY ACTIVITY:
Narrative 1
Anna Benkert is a 23
year old office worker who presents for her first Pap smear. Her GP has asked
you to take a sexual history. Anna lives at home with her parents and a younger
sister. She has always been very shy and finds it difficult to socialize.
When she was 20 she was
married without her consent to her first cousin and had her first sexual
relationship but the couple broke up after about 18 months, and since then she
has not had any other sexual relationships.
PLAY ACTIVITY:
Narrative 2
She did not find the
sexual side of the first relationship very satisfying. When the couple had
sexual intercourse he always came before she felt sufficiently aroused. She
found sex uncomfortable (the discomfort is around the opening to the vagina,
because of lack of lubrication).
She has no past history
of STDs, gynecological or breast problems. She does not take the oral
contraceptive pill or any other medications. Anna would like to develop a
relationship that might lead to marriage and family but she fears that her
shyness and lack of confidence will prevent her from taking opportunities that
may arise.
DIAGNOSTIC EXERCISE
Explain the relevance
of the following questions in cases of amenorrhea:
Pregnant
LMP
Menarche
Weight
Stress
Excessive exercise
Drugs
Hirsuitism
Headaches
Visual problems
Obstetric history
Gynecologic history
http://www.gmp.usyd.edu.au/tutorials/z/5172/dtmmpdrres.doc