History Taking

Gynecological History

A systematic clinical interview gathering information about menstruation, obstetric history, contraception, sexual health, cervical screening, and gynecological symptoms to assess a patient's reproductive health.

Gynaecological History Taking

2. Chief Complaint & HPI — Focused Symptom Analysis

The gynaecological chief complaint generally falls into one of these buckets: pain (痛), bleeding (必 = 血), mass (媽 = 瘤), or discharge (叉 = 差/discharge) [1]. The mnemonic 痛必媽叉 is your anchor for associated symptoms regardless of what the patient presents with.

3. Menstrual History — The Cornerstone

This is non-negotiable in any gynaecological history. Even if the patient presents with a pelvic mass, her menstrual history provides crucial diagnostic and prognostic information [1][4].

4. Past Gynaecological & Obstetric History

5. Sexual & Contraceptive History

This is sensitive territory. Prepare the patient before asking [10]:

Practical phrasing: "I need to ask you some questions about your sexual health — these are questions I ask all patients in similar situations, and I ask only because it's important for me to know how to best manage your condition. Everything you tell me is confidential." [10]

(我需要問你一啲關於性健康嘅問題,呢啲係我對所有類似情況嘅病人都會問嘅問題,因為對治療計劃好重要。你講嘅嘢我哋會保密。)

6. Targeted Systems Review

7. Risk Factors, PMHx, Medications, Allergies, FHx, Social History

8. Focused Differentiating Questions by Presentation

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