History taking

Eliciting a comprehensive patient history is crucial for accurate diagnosis, guiding subsequent physical examinations and necessary investigations. Patient interviews should always be conducted in a confidential setting.

During history acquisition, commence with gathering patient demographics, followed by specific details as outlined below:

Personal History: This encompasses the patient’s biographical information, easily remembered using the mnemonic NAATRENREM:

• Name: Patient’s full name.

• AAge: Patient’s current age.

• Address: Patient’s residential address.

• Tribe: Patient’s tribal affiliation or ethnicity.

• Religion: Patient’s religious beliefs.

• Education: Patient’s highest level of education attained.

• Next of kin: Name of the patient’s next of kin.

• Relationship with the next of kin: Nature of the relationship (e.g., spouse, parent, sibling).

• Occupation: Patient’s current profession or job.

• Marital status: Patient’s marital status (e.g., single, married, divorced).

Presenting Complaints: Ask the patient to articulate their current health concerns. Record these issues in the order they occurred. Initially, allow the patient to speak uninterrupted to gain a full understanding of their perspective. Subsequently, explore each complaint in detail using the “DOPAPRA” framework:

• Duration: How long has the problem persisted?

• Onset: When did the problem begin, and was it sudden or gradual in appearance?

• Progression: Has the problem worsened, improved, or remained stable over time?

• Aggravation: What factors or activities make the problem worse?

• Relieving: What factors or treatments provide relief from the problem?

• Association: Are there any other symptoms or issues that occur alongside the main problem?

NOTE: If the presenting issue involves menstrual irregularities, a complete menstrual history is essential (see dedicated section below). For complaints of abnormal vaginal discharge, specifically inquire about its color, odor, and its timing relative to menstrual periods.

History of Abnormal Vaginal Discharge: Vaginal discharge can be classified as either normal or abnormal. Typical physiological discharge is usually whitish or clear, without associated itching or unpleasant odor.

Conversely, abnormal discharge is characterized by changes in volume, color, presence of irritation or foul smell, and may sometimes be accompanied by abdominal discomfort. Common causes of abnormal vaginal discharge include infections such as trichomoniasis, bacterial vaginosis, and vaginal candidiasis. It’s also important to note that advanced cervical cancer, particularly when complicated by secondary infection, can also manifest with abnormal vaginal discharge.

When taking a history of vaginal discharge, obtain the following details:

• Quantity of the discharge (e.g., scant, moderate, profuse).

• Length of time the discharge has been present.

• Presence and nature of any odor (e.g., foul-smelling, fishy).

• Changes in the color of the discharge (e.g., white, yellow, green, blood-stained).

• Relationship of the discharge to the menstrual cycle (e.g., worse at certain times).

• Presence of any associated lower abdominal pain or discomfort.

History of Pain (using SOCRATES): If pain, such as abdominal pain, is a presenting complaint, systematically evaluate it using the “SOCRATES” mnemonic:

• Site: Precisely where is the pain located? Can the patient point to the area of maximal pain?

• Onset: When did the pain start? Was it sudden and abrupt, or gradual in its development? Is the pain becoming progressively worse or improving?

• Character: What is the nature of the pain sensation? (e.g., sharp, dull ache, stabbing, burning, cramping).

• Radiation: Does the pain spread or move to any other areas of the body?

• Associations: Are there any other symptoms that occur at the same time as the pain (e.g., nausea, vomiting, fever, changes in bowel habits)?

• Time course: Does the pain follow any specific pattern or rhythm throughout the day or over time?

• Exacerbating/Relieving factors: What activities, positions, or treatments make the pain worse? What makes it better?

• Severity: How intense is the pain? (Often quantified using a pain scale of 0-10).

Menstrual History: Gather detailed information regarding the patient’s menstrual cycles:

• Age at Menarche: Age when menstruation first began.

• Cycle Regularity: Are the menstrual cycles predictable and consistent in length?

• Duration of Flow: Number of days of menstrual bleeding each cycle.

• Cycle Length: Number of days from the start of one period to the start of the next.

• Amount of Bleeding: Subjective assessment of blood loss. Excessive bleeding may be indicated by the passage of blood clots or needing to use a large number of sanitary pads or tampons.

• Last Menstrual Period (LMP): Date of the first day of the most recent menstrual period.

Menstrual history can be concisely documented using a format like 13/4/28, meaning menarche at age 13, bleeding for 4 days, and cycles every 28 days.

Past Gynaecology History: Inquire about any previous gynaecological conditions, such as uterine fibroids, rectovaginal fistula, vesicovaginal fistula, perineal tears sustained during childbirth, abortions (spontaneous or induced), etc. Also ask about any prior surgical procedures on the cervix, including dilation and curettage (D&C).

Past Medical History: Investigate for the presence of any relevant systemic medical conditions, metabolic disorders, or endocrine problems (e.g., diabetes mellitus, hypertension, hepatitis). The presence of these conditions is important to note, as they may require special consideration during surgical interventions. It is also pertinent to ask about a history of sexually transmitted infections (STIs). Furthermore, identify any chronic illnesses the patient may have, such as chronic lung disease or cardiovascular disease. Document any current medications, past hospitalizations, and the reasons for hospitalization.

Past Surgical History: Enquire about any prior surgical procedures, including general, obstetric, or gynaecological surgeries. For each surgery, obtain details regarding the type of operation, anaesthesia used, any bleeding or clotting complications experienced, and the course of postoperative recovery. If available, histopathology reports or results from investigations related to previous surgeries can be highly valuable.

Past Obstetric History: For women who have been pregnant, obtain information about the number of pregnancies, any miscarriages or abortions, types of deliveries (vaginal or caesarean), history of birth trauma, prolonged labor, and any complications during pregnancy or delivery. Reiterate menstrual cycle details (menarche, regularity, duration, cycle length, and blood loss volume).

Family History: While sometimes less direct, family history can offer clues. A family history of malignancies like breast, colon, ovarian, or endometrial cancer may raise suspicion for similar risks in the patient. A history of tuberculosis in family members can be relevant in the diagnosis of pelvic tuberculosis.

Past Social History: Explore relevant social factors including marital status, lifestyle habits (smoking, alcohol consumption), occupation, and living situation.

Contraceptive History: Determine if the patient is currently using any form of contraception. If so, document the method and any side effects experienced. If not using contraception, this information is important to consider in relation to pregnancy risk and to assess if the presenting complaint could be related to a prior contraceptive method.

Cervical Cancer Screening History: For women over the age of 35, specifically ask if they have undergone cervical cancer screening (e.g., Pap smear, HPV test). Record the date and results of the last screening if available.

Sexual History: Include a sexual history if it is relevant to the presenting complaints or the patient’s overall health concerns. Acknowledge that patients may feel uncomfortable discussing sexual matters, so approach this topic with sensitivity. Inquire about pain during sexual intercourse (dyspareunia) or difficulties with sexual activity. Note if dyspareunia is superficial (pain upon initial penetration) or deep (pain with deeper penetration). Superficial dyspareunia can be linked to insufficient vaginal lubrication or vaginismus. Deep dyspareunia may be caused by scarring, endometriosis, or pelvic masses.

EXAMINATION

Following history taking, a gynaecological examination is performed. This examination is essential to confirm or exclude potential pathologies suggested by the patient’s history.

Prior to commencing the gynaecological examination, ensure the following steps are taken:

• Clearly explain to the patient the purpose and nature of the examination procedure.

• Obtain informed verbal consent from the patient before proceeding.

• If the examiner is male, a female chaperone (e.g., nurse, female colleague, or attendant) must be present throughout the examination.

• Conduct the examination in a private room to maintain patient confidentiality and dignity.

• Ensure the patient is appropriately draped and covered at all times, exposing only the necessary anatomical areas for examination.

• Verify that the examination room has adequate lighting for clear visualization.

• Instruct the patient to empty her bladder (void) before the examination begins.

• Ensure all required instruments, supplies, and equipment are readily available and within reach before starting the examination.

Note: After completing the gynaecological examination, communicate the findings to the patient in clear, simple language. Use visual aids such as drawings or anatomical models to enhance understanding, if appropriate.

Physical Examination

The overall physical examination consists of two main components:

1. General and Systemic Examination (General Examination)

2. Gynaecological Examination which includes:

   • Breast examination

   • Abdominal examination

   • Pelvic examination

General Examination

1. Body Composition:

   • Built: Assess the patient’s overall body habitus, noting body weight and fat distribution.

   • Significance: Abnormalities in body composition, such as obesity or extreme thinness, can be indicators of endocrinopathies and may impact menstrual cycles and reproductive function.

2. Nutritional Status:

   • Nutrition: Evaluate the patient’s dietary habits and overall nutritional intake.

   • Significance: Nutritional deficiencies or imbalances can have a significant impact on reproductive health and hormonal balance, emphasizing the importance of a balanced diet.

3. Growth and Development:

   • Stature: Assess the patient’s height and evaluate the development of secondary sexual characteristics (e.g., breast development, pubic hair distribution).

   • Significance: Abnormal growth patterns or delayed/precocious puberty may suggest hormonal imbalances or underlying conditions affecting gynaecological health.

4. Systemic Indicators:

   • Pallor: Examine the conjunctivae and mucous membranes for paleness, which may indicate anaemia.

   • Jaundice: Inspect the skin and sclera (whites of the eyes) for yellowing, suggesting possible liver dysfunction.

   • Edema of Legs: Assess for swelling in the lower extremities, which could indicate fluid retention or cardiovascular issues.

   • Significance: Systemic conditions like anaemia or liver disease can have secondary effects on gynaecological well-being and may need to be addressed.

5. Oral Health:

   • Teeth, Gums, and Tonsils: Inspect the oral cavity for signs of infection, dental caries, or potential septic foci.

   • Significance: Poor oral health can contribute to systemic inflammation and may have implications for overall health, potentially influencing gynaecological conditions.

6. Neck Examination:

   • Thyroid Gland and Lymph Nodes: Palpate the thyroid gland for enlargement or nodules and palpate cervical and left supraclavicular lymph nodes for enlargement (Virchow’s node).

   • Significance: Thyroid disorders can affect hormonal balance and menstrual function. Lymphadenopathy may indicate infection or malignancy.

7. Cardiovascular and Respiratory Assessment:

   • Cardiovascular System: Auscultate heart sounds and assess for any cardiac murmurs or irregularities.

   • Respiratory System: Auscultate breath sounds and assess for any signs of respiratory distress or abnormalities.

   • Significance: Pre-existing cardiovascular or respiratory conditions are important to identify, especially if surgical intervention is being considered, as they may impact anaesthetic risk and perioperative management.

8. Vital Signs Monitoring:

   • Pulse: Measure the patient’s heart rate (pulse).

   • Temperature: Measure the patient’s body temperature.

   • Respirations: Count the patient’s breathing rate.

   • Blood Pressure: Measure the patient’s systemic blood pressure.

   • Significance: Vital signs provide essential information about the patient’s overall physiological status and are crucial for monitoring health and guiding clinical decisions in gynaecological care.

Gynaecology Examination

A gynaecological examination is a focused assessment designed to evaluate the health of the female reproductive system.

During this examination, a gynaecologist will carefully inspect both the external and internal reproductive organs, as well as the breasts, to identify any existing abnormalities, diseases, or pathological conditions.

Breast examination

Breast examination should be a routine component of gynaecological assessment, particularly for women over 30 years old, as it is a vital method for early detection of breast pathologies, most importantly breast cancer (carcinoma).

Performing the breast exam before the pelvic exam can help to reduce patient anxiety and promote relaxation.

The breast examination can be performed while the patient is seated on a chair or lying on an examination couch. First, visually inspect the breasts for any differences in size, shape, skin changes, or obvious abnormalities (e.g., nipple retraction, skin dimpling). Then, systematically palpate each breast and axillary region to identify any abnormal lumps, masses, or nipple discharge.

Breast examination also provides an opportunity to educate women on the technique of self-breast examination, empowering them to perform regular self-checks at home for ongoing breast health monitoring.