Personal data abdominal distention

							                         Gynecological hi story
Personal data :
Name – age – nationa lit y – occupation- G+ P+0
Chi ef com plai n :
1-Abnormal vaginal bleeding :
Durat ion
Ons et
Amount
Number of pads , it is soaked or not ?
Pass ages of clots or tis s ues or ves ic les
As sociated pain -> whic h s tart 1st ?
His tory of trauma
Bleed ing f rom other s ites
Previous attac ks
Syncopal attac ks or dizzenes s
Blood trans fus ion
In c as e of abortion , ectopic pregnancy → GA, U/S, Cervic al dilat ion .
Symptoms of anemia .
2-Abdominal pain :
Site , durat ion , ons et , c haracter , radiat ion , reliving and aggra vat ing
factor.
Any re lat ion to cycle ( mid c ycle – before period )
Any poss iblty of pregnancy
As sociated s ymptoms
Bowel s ymptoms ( diarrhea- cons tipation )
3- Ame norrhea ( details of mens trual his tory – 1ry or 2ndry )
4- Dys menorrhea ( 1ry or 2ndry )
5- Premens trual tention
6- Fluid retention
7- Leucorrhe a
8- Abdominal dis tention
9-Lower back , sacral pain → utriane prolaps e , enterocele and
rectocele .
10-Urinary s ymptoms :
Colour change
Dys ur ia
Noc touria
Hematourea
His tenc y
Frequency
Urgenc y
Enur es is
Leakage ( s ever ity , as sociated s ymptoms like cough )
11-Vaginal discharge :
Color
Amount
Smell
durat ion
itchines s
ras h
any s ymptoms in the hus band.
12- Me nopausal s ymptoms :
Flus hing
Sweaty epis odes
Mood dis turbance
Vagina l drynes s
Fatigue
Ins omnia
Inc reas e growth of facia l ha ir .
13-Pre me ns trual s yndrome :
Skin changes
Breas t tendernes s \ heavines s .
Mood alter at ion .
Irr itab ilit y
Headac hes .
Systemi c revi ew :
CNS
CVS
RESPIRATORY
Rheumato logy.
Endocrine.
Hematology .
Skin.

Menstrual hi story :
Age of menarche- LMP-durat ion- inter val between per iods – regular.
Charac ter of flow ( normal, hea vy, s cant +\- c lots ,number of pads )
Intramens trua l ble eding
Age of menopaus e – pos tmenopaus al bleeding .
any as s ociated pain .

Contracepti on hi story :
type ( pills combined or proges terone only , injec tab le , s trillizat ion )
durat ion
complicat ion or s ide effect .
Sexual hi story :
date of marriage
Is s he s exually ac t ive (how many t imes per week)
Any dys pareunia →s uperfic ial ( loc al vulval c aus e or vaginal s pas m )
                    → deep ( pelvic pathology c ervix , uterus and adenxia )
Pos tcoital bleed ing .
Sexually tr ans mitt ed dis eas es .
When was her las t cervic al s mear .
Obstetri c hi story :
Number of pregnanc ies .
Age of eac h baby – gender – weight- c r ied immediately – any
abnormality .
GA
ons et of labuor ( induced or spontaneous )
mode of deliver y
any complications ( antenata l – intrapart um – pos tpartum )
 any mis carriages → GA – his tory – how it was diagnos ed – type –
manage ment .
conception diff iculty ( inf ert ility) .
Past m edi cal hi story :
DM- HTN-renal dis eas e-hepat it is - SLE- Ant iphos pholip id s yndrome-
thyro id

Past surgi cal hi story :
Laproscopy – laprotomy – hys teroscopy – hys terectomy – ovarian
cys tectomy
Myomectomy – D&C.

Drug hi story :
Any medic at ion
As k about duration ( durat ion- type – dos e – how many t imes per day –
s ides effec t-
Complainc e )

All ergy :
Penic llin – anes thes ia – food
What type of aller gy reac t ion ?

Bl ood transfusi on :
Caus e – number of units .
Famil y hi story :
DM- HTN- any c ongenital anaoma ly
Breas t cancer – ovarian c anc er .
Ear ly menopaus e
Polycys tic ovary
Premens trual t ent ion

Soci al hi story :
Smoking – alc ohol- drug abus e .
Occ upation, what the impac t of s ymptoms on her life ?
Hus band occupation , bad habits .
Anima ls ( cats ).
wher e s he lif e ?




                                                              D on e by :
                                                           Dr-R eem baghlaf
                                                             R evise d by :
                                                               Dr- E