Urogenital: History (F)
- Presenting complaint
- History of presenting complaint
- Menstrual history
- Obstetric history
- Sexual history
- Urinary history
- Past medical, surgical history
- Family, social,
drug history
- What is the problem lately [pt. may omit sexual items, cover with
questions].
- See SOCRATES.
- Timing: worse at a particular time in cycle.
- Alleviating factor: better after menstruation.
- Discharge: colour, consistency, amount, smell.
- Weight changes: anorexic (amenorrhoea) or obesity (polycystic ovary, OCP).
- Feverish.
- Itch, dryness, irritation, relieved by cream.
- Hirsutism, hair loss: severity, how controlled (polycystic ovary).
- Voice changes, acne (androgen-secreting tumour).
- Prolapse, air expelled from front passage.
- Does it interfere with your day-to-day life.
- Bowel, stool problems (RLQ pain from IBD).
- General health: good?
- First day of your last period.
- Length of cycles, length of period.
- Periods regularity, shortest and longest times.
- Severity increasing as time goes on.
- Spells of no periods in absence of pregnancy.
- Periods heavy, clots, flooding.
- Pads or tampons used, number required.
- Periods painful.
- Bleeding between periods, after intercourse.
- Time of menarche, menopause.
- If menopause: hot flushes, night sweats [assesses severity of decreasing
estrogen].
- Bleeding before puberty, after menopause.
- Possibility of currently pregnant.
- Number of children, weights at birth.
- Number of times been pregnant [do math for miscarriages, terminations]: what month, why, how.
- Problems during gestation, delivery.
- Bleeding during pregnancy.
- Sexually active.
- Number of partners.
- Contraception: on OCP? which one?
- Contraception: others currently using, used previously.
- Physical, other difficulties during intercourse.
- Pain during, after intercourse: deep/ superficial, always/ sometimes.
- Difficulty in conceiving.
- Pap smear: last smear's date, result.
- Colour change.
- Blood in urine.
- Frequency, amount changes.
- Pain, burning sensation.
- Feeling of incomplete emptying.
- Hesitancy, nocturia, dribbling.
- Incontinence, overflow incontinence, stress incontinence.
- Similar problem in the past. If so, how treated (D&C, hormones).
- Recent front passage injuries.
- UTIs, urinary obstructions.
- STD's, salpingitis [tubes infection].
- Hypertension.
- Hemophilia, other bleeding disorders.
- TB, appendicitis.
- IBD (RLQ pain).
- Diabetes, gout [urinary].
- Childhood bedwetting after 3 [urinary].
- MI, cerebrovascular dz [urinary].
- Infertility treatments [if infertile].
- Seen a gynecologist before?
- Previous operations, D&C
- The current complaint in parents/ siblings: health, cause of death, age of
onset, age of death.
- Hereditary dz suspected: do a family tree
- Thyroid dz, diabetes.
- ADKD, Alport's [urinary].
- Smoking: ever smoked, how many per day, for how long, type [cigarette,
pipe, chew] (bladder CA).
- Alcohol: do you drink. If yes: type, how much, how often.
- Present, past 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?
- Prescriptions currently on.
- Steroids, immunosuppressants, drugs 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 »