Obstetrics and gynaecology history talking in MBBS final year

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Obstetrics & Gynaecology History Taking - MBBS Final Year

Here is a structured, examination-ready guide to taking an OB/GYN history, based on Berek & Novak's Gynecology and Schwartz's Principles of Surgery (Gynecology section).

Structure of the OB/GYN History

1. Patient Identification

Name, age, occupation, marital status, religion
Address, date of admission/consultation

2. Chief Complaint (CC)

State the presenting complaint in the patient's own words with duration. Common OB/GYN complaints include:

Vaginal bleeding (normal or abnormal)
Vaginal discharge
Lower abdominal / pelvic pain
Amenorrhoea
Mass per abdomen
Infertility
Urinary symptoms (incontinence, frequency)
Postmenopausal bleeding

3. History of Present Illness (HPI)

Explore the complaint using the SOCRATES framework:

Site - pelvic, lower abdomen, vulval, etc.
Onset - sudden or gradual
Character - nature of pain/bleeding/discharge
Radiation - to back, thigh, shoulder tip (ectopic)
Associated symptoms - nausea, fever, dyspareunia, urinary/bowel symptoms
Timing - relation to menstrual cycle, coitus, pregnancy
Exacerbating/relieving factors
Severity - impact on daily life

4. Menstrual History (ALWAYS ask in every OB/GYN history)

Parameter	What to Ask
Menarche	Age of first period
LMP	Date of last menstrual period
Cycle	Length of cycle (days); normal = 21-35 days
Duration	Number of days of bleeding; normal = 2-7 days
Amount	Number of pads/day, passage of clots
Regularity	Regular or irregular
Dysmenorrhoea	Primary or secondary (suggest endometriosis, adenomyosis)
IMB / PCB	Intermenstrual or post-coital bleeding
Menopause	Age; method (natural / surgical / drug-induced)
PMB	Post-menopausal bleeding (always a red flag - cancer until proved otherwise)

Mnemonic for menstrual history: "MLDCAR" - Menarche, LMP, Duration, Cycle, Amount, Regularity

5. Obstetric History (Gravida, Para, Abortus)

Use the G P A or GTPAL notation:

G = Gravida (total number of pregnancies including current)
T = Term births (≥ 37 weeks)
P = Preterm births (28-37 weeks)
A = Abortions (spontaneous + induced, < 28 weeks)
L = Living children

For each pregnancy, record:

Year and outcome (term/preterm, live/stillbirth, abortion/MTP)
Mode of delivery - SVD, instrumental (forceps/vacuum), LSCS (indication)
Birth weight
Complications - PPH, sepsis, preeclampsia, gestational diabetes
Neonatal outcome - NICU admission, neonatal death

"Number of pregnancies, dates, type of deliveries, pregnancy loss, abortion, and complications should all be systematically recorded." - Schwartz's Surgery

6. Sexual History

Ask sensitively and non-judgementally:

Age of first intercourse (coitarche)
Number of partners (current and past)
Type of sexual activity (vaginal, anal, oral)
Dyspareunia (superficial or deep)
Post-coital bleeding
Partner's health / STI risk
Pregnancy intention / desires fertility

7. Contraceptive History

Current method of contraception and duration of use
Past methods and reasons for discontinuation
Any complications from contraceptive use (IUD: pelvic pain, menorrhagia; OCP: thrombosis)
IUCD in situ?

8. Gynaecological Screening History

Last Pap smear / cervical smear - date and result
HPV DNA testing / vaccination status
Prior abnormal smear and any treatment (LEEP, CKC, cryotherapy)
Last mammogram / breast ultrasound

9. Past Medical History (PMH)

Diabetes, hypertension, thyroid disorders (strongly linked to menstrual irregularity and infertility)
Bleeding disorders (von Willebrand disease - consider in menorrhagia)
Autoimmune conditions (SLE - recurrent pregnancy loss)
Tuberculosis (Asherman syndrome, infertility)
Previous malignancies

10. Past Surgical History (PSH)

Abdominal or pelvic surgeries (risk of adhesions, tubal damage)
Previous gynaecological procedures: D&C, hysteroscopy, laparoscopy, myomectomy, LSCS
Anaesthetic complications

11. Drug History

Current medications including OTC drugs
Hormonal drugs (OCP, HRT, progesterone injections)
Anticoagulants (warfarin, heparin, aspirin - affect bleeding)
Herbal medications
Drug allergies (drug name + type of reaction)

12. Family History

Focus on:

Breast cancer (especially first-degree relatives, premenopausal or bilateral)
Ovarian / endometrial / cervical cancer
BRCA1/BRCA2 mutations, Lynch syndrome
Gestational trophoblastic disease
Diabetes, hypertension, thyroid disorders
Bleeding disorders

13. Social History

Smoking (cervical cancer risk, placental problems)
Alcohol use
Illicit drug use
Occupation (stress, chemical exposure)
Marital status and relationship dynamics
Domestic violence / sexual abuse (ask sensitively, alone with patient)
Diet and exercise
Housing conditions

14. Systemic Review

Briefly enquire about symptoms in other systems that may be relevant:

Breast - lumps, nipple discharge, skin changes
Urinary - frequency, urgency, stress incontinence, haematuria
Bowel - constipation, blood in stool, rectal pain (endometriosis)
General - weight loss, fatigue, appetite

Key Points for Exams

Always ask LMP - essential for all women of reproductive age (rules out pregnancy before any investigation or treatment).
Gravity/Parity notation - examiners specifically test this; be clear with G/T/P/A/L.
Post-menopausal bleeding = endometrial cancer until proved otherwise.
Menstrual history is distinct from obstetric history - do not conflate the two.
Sexual history must be taken sensitively and confidentially - examiner looks for communication skills.
Past surgical history in gynaecology must include prior uterine surgeries (scar uterus risk in subsequent pregnancies).
For a pregnant patient (obstetric history), additionally ask about: antenatal visits, booking investigations, fetal movements, symptoms of preeclampsia (headache, visual disturbance, epigastric pain, oedema).

Specific Obstetric History (for Antenatal Patient)

Additional points for a pregnant woman:

Domain	Key Questions
Current pregnancy	EDD (by LMP and USS), gestational age, ANC bookings
Antenatal investigations	Blood group, Rh factor, VDRL, HIV, blood sugar, anomaly scan
Symptoms	Morning sickness, bleeding (antepartum haemorrhage), PV discharge, fetal movements
Risk factors	HTN, GDM, thyroid, multiple gestation, placenta praevia
Social	Domestic situation, support at home

Sources: Berek & Novak's Gynecology (16th ed.), p. 54-55; Schwartz's Principles of Surgery (11th ed.), Table 41-1, p. 1815

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gynaecology medical terms meaning dysmenorrhoea dyspareunia amenorrhoea menorrhagia metrorrhagia MBBS

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OB/GYN History Taking - Medical Terms Explained Visually

PART 1 - PAIN SITE DIAGRAM (Abdomen Regions)

Female abdomen regions showing gynaecology pain sites with all 9 regions labelled

What Each Region Means in Gynaecology

Region	Location	Gynaecological Causes
Right Iliac Fossa (RIF)	Lower right	Ovarian cyst (right), ectopic pregnancy (right tube), appendix (surgical overlap)
Left Iliac Fossa (LIF)	Lower left	Ovarian cyst (left), ectopic (left tube), endometriosis
Hypogastrium / Pubic	Lower centre (above pubis)	Uterine pain, dysmenorrhoea, fibroids, UTI, PID, bladder
Umbilical	Centre	Referred pain from pelvic organs (early appendix, ovarian cyst torsion)
Lumbar (flanks)	Either side of umbilicus	Ureteric colic, renal causes
Epigastrium	Upper centre	Referred shoulder-tip pain (ectopic rupture - diaphragm irritation by blood)

Key exam point: Ectopic pregnancy rupture causes shoulder-tip pain (referred) because blood in the peritoneum irritates the diaphragm (phrenic nerve = C3,4,5 = shoulder region).

PART 2 - TYPES OF PAIN (with diagrams)

Types of gynaecological pain - colicky, constant, sharp, burning

Pain Types Explained Simply

Pain Type	What it feels like	Gynaecological Causes
Colicky	Comes and goes in waves, like cramps	Dysmenorrhoea (uterine contractions), miscarriage, labour
Constant / Dull ache	Always there, heavy dragging feeling	Chronic PID, fibroid, ovarian cyst, endometriosis
Sharp / Stabbing	Sudden, severe, knife-like	Ectopic rupture, ovarian torsion, follicle rupture (Mittelschmerz)
Burning	Hot, irritating	Vulvitis, vaginitis, UTI, herpes
Deep Dyspareunia	Pain deep inside during sex	Endometriosis, PID, ovarian cyst, retroverted uterus
Superficial Dyspareunia	Pain at the vaginal entrance during sex	Vaginismus, vulvodynia, atrophic vaginitis

PART 3 - GYNAECOLOGY MEDICAL TERMS (Word by Word)

Bleeding Terms

Medical Word	Meaning	Simple Explanation
Menorrhagia	Meno = menses + rrhagia = excessive flow	Heavy periods (> 80 mL per cycle OR > 7 days)
Metrorrhagia	Metro = uterus + rrhagia = flow	Bleeding between periods (irregular, not related to cycle)
Menometrorrhagia	Combined	Heavy AND irregular bleeding
Polymenorrhoea	Poly = many + meno = menses	Periods coming too frequently (< 21 days apart)
Oligomenorrhoea	Oligo = few	Infrequent periods (> 35 days apart)
Amenorrhoea	A = absence + meno = menses	No periods at all
Hypomenorrhoea	Hypo = less	Scanty/very light periods
Spotting	-	Light bleeding, just staining underwear
IMB	Intermenstrual bleeding	Bleeding between periods
PCB	Post-coital bleeding	Bleeding after sex (red flag - think cervical cancer)
PMB	Post-menopausal bleeding	Bleeding 12+ months after last period (RED FLAG - endometrial cancer)

Amenorrhoea Types

Type	Meaning
Primary amenorrhoea	Never had a period by age 16 (with secondary sex characteristics) or 14 (without)
Secondary amenorrhoea	Previously had periods, now absent for > 3 months (if irregular) or > 6 months (if regular)
Physiological	Pregnancy, breastfeeding, menopause - NORMAL
Pathological	Caused by disease (PCOS, hyperprolactinaemia, thyroid, Asherman's)

Pain Terms

Medical Word	Meaning	Simple Explanation
Dysmenorrhoea	Dys = painful + meno = menses	Painful periods
Primary dysmenorrhoea	No underlying pathology	Prostaglandin-driven cramping, starts within 1-2 years of menarche
Secondary dysmenorrhoea	Caused by underlying disease	Endometriosis, adenomyosis, fibroids, PID - starts LATER in life
Dyspareunia	Dys = painful + pareunia = intercourse	Painful sex
Superficial dyspareunia	Pain at the vaginal opening	Vaginismus, infections, vulvodynia
Deep dyspareunia	Pain deep in pelvis during sex	Endometriosis, PID, ovarian cysts
Vaginismus	-	Involuntary tightening of vaginal muscles - prevents penetration
Mittelschmerz	German: "middle pain"	Ovulation pain - mid-cycle, unilateral, RIF or LIF
Chronic pelvic pain	-	Pain below umbilicus lasting > 6 months

Discharge Terms

Medical Word	Meaning	Simple Explanation
Leucorrhoea	Leuco = white + rrhoea = flow	Normal white/clear physiological vaginal discharge
Vaginitis	-	Inflammation of the vagina - often infected discharge
Cervicitis	-	Inflammation of the cervix
Pruritus vulvae	-	Itching of the vulva
Bartholinitis	-	Infection of Bartholin's gland (swelling at vaginal entrance)

Obstetric Terms

Medical Word	Meaning	Simple Explanation
Gravida (G)	Gravidus = pregnant	Total number of pregnancies (including current)
Para (P)	Parere = to deliver	Number of deliveries after 28 weeks (live or stillbirth)
Nulligravida	Nulli = none	Never been pregnant
Nullipara	-	Never delivered
Primigravida	Primi = first	First pregnancy
Multigravida	Multi = many	More than one pregnancy
Grand multipara	Grand = large	5 or more deliveries
LMP	Last Menstrual Period	First day of the last period - used to calculate EDD
EDD	Expected Date of Delivery	LMP + 9 months + 7 days (Naegele's rule)
EGA / POG	Estimated Gestational Age / Period of Gestation	How many weeks pregnant
Quickening	-	First felt fetal movements (16-20 weeks)
Antepartum	-	Before delivery
Postpartum	-	After delivery
Stillbirth	-	Baby born dead after 28 weeks
Abortion	-	Loss of pregnancy before 28 weeks
MTP	Medical Termination of Pregnancy	Induced abortion

GTPAL Notation (Exam Favourite)

G2 T1 P0 A1 L1 means:

2 total pregnancies

1 term delivery (≥37 weeks)

0 preterm deliveries (28-37 weeks)

1 abortion (miscarriage or MTP)

1 living child

Other Important Gynaecology Terms

Term	Meaning
Menarche	Age of first menstruation
Menopause	Last menstrual period (confirmed after 12 months of amenorrhoea)
Perimenopause	Transition period around menopause
Endometriosis	Endometrium-like tissue outside the uterus
Adenomyosis	Endometrial glands within the myometrium (muscle of uterus)
Fibroids / Leiomyoma	Benign smooth muscle tumour of the uterus
PCOS	Polycystic Ovarian Syndrome - irregular periods + excess androgens
PID	Pelvic Inflammatory Disease - infection of upper genital tract
Ovarian torsion	Ovary twists on its pedicle - surgical emergency
Ectopic pregnancy	Pregnancy outside the uterus (usually fallopian tube)
Hydatidiform mole	GTD - abnormal placental tissue, no viable fetus

PART 4 - PALM-COEIN Classification (AUB)

Modern classification of Abnormal Uterine Bleeding (replaces old term "dysfunctional uterine bleeding"):

PALM = Structural causes         COEIN = Non-structural causes
P - Polyp                        C - Coagulopathy
A - Adenomyosis                  O - Ovulatory dysfunction
L - Leiomyoma (fibroid)          E - Endometrial
M - Malignancy                   I - Iatrogenic
                                 N - Not yet classified

Normal blood loss per cycle = 35 mL | Abnormal = > 80 mL Normal duration = 2-7 days | Normal cycle = 21-35 days

(Source: Rosen's Emergency Medicine & Berek & Novak's Gynecology)

PART 5 - QUICK HISTORY-TAKING CHECKLIST (Exam Flowchart)

START → Patient ID → Chief Complaint
         ↓
         HPI (SOCRATES for pain/bleeding)
         ↓
    ┌────────────────────────────────┐
    │       MENSTRUAL HISTORY        │
    │ Menarche → LMP → Cycle →       │
    │ Duration → Amount → Regularity │
    │ Dysmenorrhoea → IMB/PCB/PMB   │
    └────────────────────────────────┘
         ↓
    ┌────────────────────────────────┐
    │       OBSTETRIC HISTORY        │
    │ G P T A L → Each pregnancy:    │
    │ Date, mode, complications,     │
    │ birth weight, baby outcome     │
    └────────────────────────────────┘
         ↓
    Sexual Hx → Contraceptive Hx → Screening Hx
         ↓
    PMH → PSH → Drug Hx → Family Hx → Social Hx
         ↓
    Systemic Review (Breast / Urinary / Bowel)

Sources: Berek & Novak's Gynecology (16th ed.); Schwartz's Principles of Surgery (11th ed.), Table 41-1; Rosen's Emergency Medicine

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