IB CSL O&G

HISTORY TAKING

Dr D Cheng

O&G

Tues 17-09-02

OBJECTIVES

INTERPERSONAL SKILL IN HISTORY TAKING

3 steps

  1. Opening
  2. Exploration
  3. Close

Tasks of opening

  1. Greet the patient
  2. Attend to patient’s comfort
  3. Introduce yourself
  4. Attend to your own comfort
  5. Minimise distraction
  6. Use open-ended question ® eg. " How can I help you today?" or "Why do you come to the clinic today?"

Exploration

  1. Ascertain all major concerns ® eg. Ask "what else?"
  2. Negotiate the priorities of problems to be discussed.
  3. Facilitate the patient’s story of her illness.
  4. Use open-ended questions (why, what and how) to closed ended (who, when) questions.
  5. Clarify any unclear statements made by patient.
  6. Interrupt to redirect.
  7. Ask one question at a time.
  8. Summarise the patient’s story.
  9. Acknowledge the transition of conversation.

Tasks of closing

  1. Ask if patient has anything else to add.
  2. Find out if the patient has any questions.
  3. Find out if patient understands what to do.
  4. Make follow up arrangements.

HISTORY TAKING IN OBSTETRICS & GYNAECOLOGY
  1. Personal information ® Name, age, date of birth, marital status
    2.
  2. Chief complaint ® Symptoms, duration and its periodicity
    3.
  3. Menstrual history ® Menarche/ menopause; LMP; Regularity (interval from 1st day of one period to 1st day of the next); Duration of each period; Amount of menstrual flow (blood loss); Any blood clots passed; Dysmenorrhoea; Other symptoms assoc. w/ menstruation (eg. headache, vomiting, bloating)
    4.
  4. Vaginal discharge ® Character of discharge, mucoid, purulent, colour, blood stained, quantity, irritation
  5. Micturition ® Frequency, day or night, pain on micturition (dysuria), stress or urge incontinence
    6.
  6. Bowels ® Regularity, use of laxatives, history of haemorrhoids, pain in defecation, history rectal bleeding
    7.
  7. Obstetric history ® Number of pregnancies (date of each); Abortions (eg. spontaneous or therapeutic); Ectopic pregnancy; Deliveries (eg. Preterm delivery, full term birth, stillbirth or intrauterine death); Problems of pregnancy, labour, delivery, puerperium; Problems of the newborn; Birth weight of the children and their present state of health.
    8.

    If previous record is required, write to the previous medical attendants.

  8. Past medical history ® Surgical procedures; Medication; Anaesthetic difficulties; Medical disorder; Blood transfusion; Psychiatric disorder; Allergies; Thrombo-embolism
    9.
  9. Family history ® HT; DM in 1º relative; Twins; Genetic disorder
    10.
  10. Social history ® Marital status; Smoking; Home and family situation, Alcohol; Occupation of patient & husband
    11.
  11. Contraception ® Method used; Pregnancy planned? Length of time trying to conceive; Hx of Infertility
    12.
  12. Risk factors ® Any factors from the above list liable to increase maternal or foetal morbidity should be highlighted in the case notes