HISTORY TAKING

Date of Clerking:
1. PERSONAL IDENTIFICATION DATA
Name
Age Resident
Registered ID Address
Race & religion Occupation
Marital Status, duration, no. marriage
Parity P__ + __ ( )
Last child birth
Date of admission (DOA)
Blood type

Summary:
a. Presenting my patient, Puan _________________________, ___ years old married Indian _______(occupation) from
__________________________.

b. She is parity __ + __ (miscarriage at __ weeks)

c. Her last child birth was ____ months / years ago.

d. She was admitted to the ward on ___________.

2. CHIEF COMPLAINT
Take note if:
1. This is a referred case from ___ with complain ________

2. Presented with heavy periods / discharge / heavy menstrual bleeding / lower abdominal pain during menstruation
(dysmenorrhea) / amenorrhoea since ___ days / months ago

3. HISTORY OF PRESENTING ILLNESS (HOPI)

a) Heavy bleeding periods:
- Onset, duration, amount, anemic (weak, fatigue, pale)
- flooding: whether menstrual blood soaks through protection, increased requirements for sanitary protection
- passing of blood clots
- Unexpected bleeding: • between periods (intermenstrual, IMB)
• after intercourse (postcoital, PCB)
• more than 1 year after the menopause (postmenopausal, PMB).
b) Amenorrhea:
- Primary: not started by age 16 y/o
- Secondary: no periods > 6 months, but there was previous menstruation
- Oligomenorrhoea: menstrual cycle > 35 days

c) Lower abdominal pain: SOCRATES

- Site (unilateral, bilateral, midline)
- Onset (sudden or gradual, related to menstruation or not)
- duration, regularity, severity, medication to relieve, exacerbating/relieving factor

- Iliac fossa pain in early pregnancy: a corpus luteum cyst of ovary OR a tubal ectopic pregnancy.
- Ruptured ectopic pregnancy results in generalized abdominal pain, peritonism, haemodynamic instability and
referred pain in the shoulder.

d) Dyspareunia: around the vaginal entrance (superficial) or within the pelvis (deep)?

e) Vaginal discharge: Candidiasis: thick, white, curdy discharge, marked vulval itching
- Consistency Bacterial vaginosis (Gardnerella vaginalis): watery, fishy smelling discharge
- colour STIs: discharge, vulval ulceration or pain, dysuria, lower abd. pain, general malaise
- odour Trichomonas vaginalis: yellow frothy discharge with ass. vaginal itching & irritation
- associated itch, pain or dysuria.

f) Micturition: – frequency, incontinence, pain.

- Stress incontinence: on exertion, coughing, laughing or sneezing
- Urge incontinence: overwhelming desire to urinate when bladder is not full; due to detrusor muscle dysfunction

g) Uterine prolapse: feel something ‘coming down’, particularly when standing or straining.
• Grade 1: halfway to the hymen.
• Grade 2: at the hymen.
• Grade 3: beyond the hymen.
• Grade 4: external to the vagina
- The top of the vagina (vault) can also prolapse after a previous hysterectomy.
- More commonly the bulge relates to the vaginal wall.
- Cystocoele: a bulge on the anterior wall containing the bladder
- Rectocoele: a bulge on the posterior wall containing the rectum.
- Enterocoele: a bulge of the distal wall posteriorly containing small bowel & peritoneum.
 Mass Associated symptoms
Uterine fibroid • Majority cases are asymptomatic
• Abdominal distension
• Menorrhagia
• Any episodes of flooding of passage of blood clots
• IMB? PCB?
• Compressive symptoms (SOB / chronic lower abdominal pain / discomfort / indigestion / urinary
frequency or retention)
• Irregular menstrual bleeding
Risk factors In view of suspicion of malignant, ask about RF of ovarian Ca
• Age (extreme of ages)
• Early menarche and late menopause
• Low parity / nulliparity
• Late age of first childbirth
• Ovulation induction
• Chronic anovulation e.g. PCOS

Mass Associated symptoms

Ovarian mass • Majority cases are asymptomatic
• Abdominal enlargement
• Compressive symptoms (SOB / chronic lower abdominal pain / discomfort / indigestion / urinary
frequency or retention)
• Irregular menstrual bleeding
Risk factors In view of suspicion of malignant, ask about RF of ovarian Ca
• Age (extreme of ages)
• Early menarche and late menopause
• Low parity / nulliparity
• Late age of first childbirth
• Ovulation induction
• Chronic anovulation e.g. PCOS

h) Miscarriage: early (before 13 weeks) and late (between 13 and 24 weeks)

Threatened miscarriage Vaginal bleeding, cervical os is closed, USG shows a viable IU pregnancy
Inevitable miscarriage Vaginal bleeding, cervical os is opened, with or w/out cramping abd pain.
Incomplete miscarriage Vaginal bleeding, cervical os is opened, POC seen on examination.
Complete miscarriage POC have passed, cervical os is closed, USG shows empty uterine cavity.
Missed miscarriage Nonviable IU pregnancy, no symptoms / passage of POC
Recurrent miscarriage Occurrence of 3 or more miscarriages

i) Ectopic pregnancy:
- Abdominal pain - Vaginal bleeding (with or without clots)
- Pelvic pain - Dizziness, fainting or syncope
- Amenorrhoea or a missed period - Shoulder tip pain

Summary:
The patient was apparently alright ______ months / years back when she complained of heavy menstrual bleeding / other:
_____________ which lasts for ________ days in a _______ day regular cycle.
5. PAST OBSTETRICS HISTORY

Year Gestation Gender Birth Mode of Delivery (SVD / Place of delivery Breastfeeding Any comorbidities?
& age weight IVD / LSCS) & indication (home / hospital) duration Post complications?
(kg) Episiotomy?

Summary:
a. She was married at the age of ___ years old in _____. This was a single and non-consanguineous marriage.

b. Uneventful – She had delivered ___ children, __ boys __ girls. Her eldest child was __ years old and the youngest
child was ___ years old, which were all uneventful spontaneous vaginal delivery with babies weight ranging between
___ to ___ kg. All the children were normal, alive and well. Otherwise, she had no intrapartum & postpartum
complications.

c. Eventful / Complicated – She had delivered __ children between ____ until ____ with a history of ___ miscarriage in
the ___ pregnancy.
 Ante-partumly, during her __ pregnancy, she had history of miscarriage at __ weeks of gestation. The
miscarriage was a confirmed pregnancy diagnosed by USG / unconfirmed. No / An ERPOC was performed
and there was no complications following the procedure. During her __ pregnancy, she had GDM on dietary
control // chronic HPT / gestational HT / pre-eclampsia / eclampsia / chronic HT w superimposed PE.
 Intra-partumly, during her __ and __ pregnancy, she had retained placenta and MRP was done in the labour
room successfully.
 Post-partumly, during __ pregnancy, she had history of PPH that requires blood transfusion.
 The rest of the pregnancies were delivered by SVD with babies weight ranging between ___ to ___ kg. All
the children were normal, alive and well.

d. She breastfed all her children for __ year.

e. The miscarriage at __ weeks POA was a confirmed pregnancy diagnosed by ultrasound. An ERPOC was performed
and there was no complication following the procedure.

e. She had a good inter-pregnancy spacing 2 years apart. Her last child birth was ____ months / years ago. (If Hx of
subfertility / miscarriage / IUI / IVF – consider precious pregnancy).
6. GYNAECOLOGY HISTORY

Menarche age Problems

Menstrual cycle - Regular / irregular (when start irregular)
- Cycle (normal 21 – 35 days)
(ask WHY if - Flow (normal 2 – 8 days)
abnormal) - Heavy flow (normal 1st – 3rd days)
- Pad used (~ blood loss 30ml) [1 pad = 10-20ml]
(is the pad fully soaked / change frequently)
- Dysmenorrhea (painful menstruation)
- Menorrhagia (prolonged menstrual flow)
(blood flow > 80ml) / Pad usage?
- Intermenstrual bleeding
- Postcoital bleeding
- Dyspareunia (painful coital)? Superficial / deep

Pap smear history

- When was first time? __________ - Reason of doing it:
- How many times? __ Results? - When was the last one done:
Summary:
a. She obtained menarche at the age of __ years old.
b. She had regular menses with ____ (6-7) days duration of flow in ____ (28-30) days per cycle.
c. She used __ pads per day with minimally-soaked blood.
d. She had no history of dysmenorrhea, menorrhagia and other gynaecological problems
e. She had recent Pap smear for second time done in ____ (year) and the result was told to be normal.

7. PAST MEDICAL HISTORY (PMH) & PAST SURGICAL HISTORY (PSH)

1. History of chronic illness / cancer
o Obesity, HPT, DM, Heart disease, Asthma, TB, stroke, gout, epilepsy, CKD, VTE, C19, breast cancer
2. Any surgery procedure done before? (Laparoscopy, LSCS, BTL) Year of diagnosis, status of the condition
3. Previous admission ? – Why, When, management, treatment
Summary:
a. She was not known to have any underlying disease / chronic illness such as DM, HPN, bronchial asthma, renal failure
b. She was a known case of diabetes mellitus since __ years ago. She had good compliance to medication and was on
dietary control for ___ years / months.
c. She had no history of hospitalization before.
d. She had history of hospitalization in _____ because of Acute Appendicitis. She was admitted for __ days / months and
discharged well.
e. She has not undergone any operation before.
f. She had an Appendicectomy performed at the age of __ years old. There was no intra- or post-operative complication.

8. FAMILY HISTORY
1. Siblings: How many? Any health problem? She is the ____ child in family.
2. Parents: Any health problem?
3. Family history of obesity, HPT, DM, heart diseases, asthma, TB, gout, epilepsy, CKD, VTE, C19, cancer
(ovarian, endometrial, breast), bleeding disorders
4. Family history of twins pregnancy / congenital abnormality / genetic hereditary

Summary:
a. Her father has gout while her mother passed away due to heart problem in ___.
b. She had no family history of DM & HPN.
c. She is the second out of five siblings. All her siblings are fit and well.
d. There was no history of twin and congenital anomalies run in her family.
9. DRUG HISTORY (always ask dose, duration, purpose, compliance, OTC/Prescription)
a. Tamoxifen: oestrogenic effects in postmenopausal women
b. Hematinic: ferrous fumarate, folic acid, vit B complex, ascorbic acid
c. Traditional medications / herbal / complementary
d. History of drug allergy: Name, AE (take note if rashes, swelling, SOB)
e. Antibiotics: vaginal candidiasis
f. Antiepileptic or antituberculous drugs may reduce the effectiveness of oral contraceptives
g. HRT: duration, methods (path, gel, pessary), frequency (cyclical or continuous), type (combined or estrogen only)
h. Others: Anti-HPN, OHA, NSAIDS
i. Immunization: Hep B, Covid 19, rubella
j. Contraceptives:
o OCP / PCP / hormonal injection (Depo-Provera) / IUCD (Mirena or copper) / barrier method (male condom &
female condom) / BTL / vasectomy
o Compliant / Non-compliant, reason:

Summary:
a. She was on haematinics, vitamin B12 and folic acid during her ___ pregnancy.
b. She was on Anti-HPN / OHA / NSAIDS since __ months / years ago and claimed good compliance to the drugs.
c. Otherwise, she was not taking any prescribed and traditional medication or any other supplement.
d. She was not allergic to any foods, drugs or any other substances.
e. She received ___ dose Hep B vaccine, boosted for COVID-19 vaccine, and she got Rubella vaccination during her
school times.
f. She denied practicing any type of contraception.
g. After the birth of her first baby, she was on OCP / injection / Mirena implantation for ___ months / years. She stopped
taking OCP / injection / implantation when she was ready to conceive.

10. SOCIAL HISTORY

Education level
Is her condition affecting her day-to-day job / activities?
Occupation
House condition
Rent / Own / Flat / Terrace / Condo / Kpg; Amenities?
Stay with husband?
If not, how frequent husband visit her?
Husband’s age
Is husband related? Cousin? Distant relative?
Husband’s occupation, income
Who take care of children during admission?
How does she contract her children?
Smoking? Alcohol? Drug? Illicit drug use? Both husband & ptn
Recent travel

Summary:
a. Currently, she lives with her husband and children at single-storey house and well equipped with basic amenities.
b. Her education level was SPM and she is a housewife.
c. She had no unhealthy habits such as smoking and alcoholic.
d. Her husband is doing odd job with monthly income of RM _____. Her husband is a smoker.
e. Currently, her children are taken care by her mother. Her husband visits her every other day.
Sexual History (If single)
• Are you currently in a sexual relationship? • Do you use barrier contraception?
• How long have you been with your partner? • Have you ever had a STI?
• Have you had any (other) sexual partners in the last 12 months? • Are you concerned about any sexual issues?
• How many were male? How many female?
• When did you last have sex with:
- Your partner?
- Anyone else?

11. DIET HISTORY

- How many meals a day? (if is diabetic patient – details diet history– dishes for every meals
- Size (portion)
- Carbs / protein / vege / fat (which one is more) - Obesity is associated with PCOS
- For GDM: on diet control / insulin? - Anorexia - oligomenorrhoea
- Allergy

Summary:
a. She practices a normal adult balance diet. She ate home-cooked meal and had no food taboo.
b. Currently she is under dietary control and she reduced intake of carbohydrate-rich foods.
c. She was not allergic to any foods or any other substances.
d. She was allergic to seafood such as prawns and crabs / oral antibiotics.

SYSTEMIC REVIEW: e) GIT

a) General: Weakness / Fatigue / Appetite - Abdominal pain:
- Nausea & vomitting:
b) CVS : - Hematemesis:
- Chest pain (site): - S1 S2 heard? - Dysphagia:
- Ankle swelling: - Any murmur? - Polydipsia:
- Palpitation: - Palpitations? - Bowel habit: normal diarrhea / constipated
- Orthopnea: - PR bleeding:
- Paroxysmal Nocturnal Dyspnea: - Stool colour

c) Respiratory: f) CNS:
- Dyspnea - SOB? - Headache: - Visual disturbance:
- Wheezing: - Equal chest expansion? - Light headedness: - Auditory disturbance:
- Cough: - Normal breath sounds? - Blackouts: - Sleep habit:
- Hemoptysis: - No rhonchi
- Chest pain: - No crepitations

d) Renal: g) MSK:
- Groin pain: - Hematuria: - Fits / seizure:
- Frequency: - Difficulty in voiding: - Unsteady gait:
- Incontinence / urgency: - Colour: - Paresthesia:
- Dysuria: - Muscle weakness:
GENERAL INSPECTION
Summary:
a. She is a middle age lady with medium-built body size.
b. She is comfortably lying supine in flat position with head supported by one pillow.
c. She is alert, conscious and well-oriented to time, place and person.
d. She looks well, not in pain, tachypnea or respiratory distress.
e. There is no obvious discoloration or peripheral attachment.
f. There is no lump, ascites & engorged veins

VITAL SIGNS:
1. Blood pressure : ___/___ mm Hg, right / left arm in sitting position
2. Pulse rate : ___ beats per minute with regular / irregular rhythm, good volume, normal in character
3. Respiration rate : ___ breathes per minute
4. Temperature : ___ °C, febrile / afebrile
5. BMI : ___ (Weight = ___ kg, Height = ___ cm)

GENERAL EXAMINATION: SUPINE POSITION

• Hand
- Dry/moist, warm/cold, pallor/pink & no palmar erythema.
- HR (radial pulse) : rate, rhythm, radiofemoral delay, radio-radiodelay
- Blood pressure : 15° lateral tilt to left (prevent aortocaval compressions)
• Face
- Conjunctiva: pale / pink
- Sclerae: not jaundice
- Mouth: oral hygiene, no central cyanosis, angular cheilitis (iron deficiency anaemia), beefy tongue
(megaloblastic anaemia)
• Neck:
- Any thyroid enlargement / goitre
- Cervical lymphadenopathy
• Leg:
- Presence of bilateral pitting ankle oedema (common)
- Varicose vein (less likely)

Summary:
a. Hand: Her hand was dry/moist, warm/cold, pallor/pink & no palmar erythema. The capillary refilling time was less
than 2 seconds. Her finger nails had no clubbing, leukonychia and koilonychias.
b. Wrist: Radial pulse was regularly regular with good volume.
c. Eyes: The conjunctiva are pink/pallor and the sclera are white/yellowish.
d. Mouth: The tongue and lips were moist/dry, suggestive of good/poor hydration status. Her oral hygiene was good, no
central cyanosis, glossitis and angular stomatitis.
e. Neck: There was no neck swelling.
f. Lower limb: There was ankle edema and dilated vein was noted.
ABDOMINAL EXAMINATION (specific)
• Make sure introduce yourself again to patient & introduce your examiner to your patient.
• Any discomfort of patient need to tell us
• Exposure: xiphisternum to pubic symphysis
• Make sure check for presence of Pfannenstiel scar. (May be very low & may be missed)
• No need to check for inguinal/femoral hernia

INSPECTION
Inspect for:
• Abdominal distension:
o Describe the site of any findings according to the 9 quadrants
o Suprapubic mass may turn out a gravid uterus, check out for
cutaneous signs of pregnancy: linea alba, striae gravidarum
• Surgical scar:
o Right subcoastal (Kocher): cholecystectomy
o Midline incision: laparotomy
o Subumbilical: laparoscopic
o Left paramedian incision: access to spleen, kidney and adrenals
o Gridiron (muscle splitting) incision: appendectomy
o Transverse (abdominal) incision
o Suprapubic (Pfannenstiel) incision: C-sect, pelvic, bladder
• Dilated veins
• Skin pigmentation, mole, skin tag

PALPATION
1. Light palpation: to elicit tenderness (guarding, rebound tenderness - sign of localized peritonitis), any superficial mass
2. Deep palpation: look for any masses. Search for organomegaly:
 Liver – Hepatomegaly: size (measurement from below costal margin), margin & surface. Nodular – metastases.
3. Spleen: palpation & percussion of Traub’s space
4. Kidney: ballotable or not

Describing a gynaecological mass:

1. Site
2. Tenderness
3. Size: compare to the size of a gravid uterus, a x b
4. Consistency: solid (soft/firm/hard) / Cystic / Mixed consistency
5. Margin / surface
6. Can get below mass / not
7. Mobility: Mobile (up and down / side to side / very mobile) / restricted mobility
8. Presence / absence of ascites
9. Presence / absence of organomegaly

PERCUSSION (not for gynaecological cases, because dull; but for outlining borders of the mass)
AUSCULTATION
✓ Any bruit over mass. Bruit reflects increased vascularity of mass.
✓ Bowel sound.

Summary:
I think the mass is ovarian / uterine in origin and it is most probably ____________________________

Non-tender mass:
There is a suprapubic mass that corresponds to ___ weeks size of a gravid uterus and measures about __ x __ cm. It is
non-tender and has a cystic / solid consistency. It has a/an regular / irregular surface and margin. I can get below the mass
and the mass is mobile up and down and side to side. There is no ascites and no organomegaly.

Tender mass:
There is a tender, suprapubic mass that corresponds to a ___ weeks size of a gravid uterus and it measures about __ x __
cm. The mass is firm in consistency. However, I am unable to assess the mass further since the mass is tender and causing
the patient pain.

Uterine Fibroid Adenomyosis

Commonest benign uterine tumour; nulliparous Less common; parous, reproductive age
30 – 45 y/o 35 y/o and above
Menorrhagia, back pain due to heavy menses Severe dysmenorrhea, bleeding starts before actual cycle
Mass of any size 14 weeks of size (mass = collection of blood w/in myometrium)
Non tender Tender, especially around premenstrual period
 Ovarian mass Uterine mass
Site Suprapubic mass / RIF / LIF Suprapubic mass (never in RIF / LIF)
Consistency Cystic (most common feature, since most masses Solid (usually firm, the usual consistency of
in the reproductive age are benign cysts) / Hard / fibroid / soft as in degenerated fibroid e.g. red
Solid-cystic (mixed) degeneration in pregnancy)
Mobility Up & down and side-to-side Side-to-side but up & down
Below mass Can get below mass Cannot get below the mass
Percussion Dull to percussion Dull to percussion

ABDOMINAL EXAMINATION (GYNAECOLOGY)

Fibroid:
On inspection:
a. The lower abdomen was distended and it moves symmetrically with each respiration.
b. The umbilicus was centrally located and inverted.
c. There was a well-healed transverse surgical scar measured 12 cm at the suprapubic area.
d. There was no prominent vein, skin discoloration or cough impulse seen.
On palpation:
a. Tenderness: The abdomen was soft and non-tender.
b. There was a mass palpable extend from umbilicus until suprapubic correspond to 20 weeks gravid uterus (pelvic mass).
c. lt was non-tender, firm to hard in consistency, irregular margin, lobulated surface.
d. The mobility was restricted and can't get below the mass.
e. There was no hepatosplenomegaly and ballotable kidney.
f. There was no scar tenderness.
On percussion:
a. There was no shifting dullness and fluid thrill.
b. The Troube's Space was resonant.
On auscultation:
a. The bowel sound was present with normal intensity.

I would like to complete my examination by per rectal examination to exclude gastrointestinal bleeding and bimanual
palpation to rule out the origin of the mass.

CASE SUMMARY:
__________________ is a ___ year-old _______ (job) from __________. She was admitted ___ days ago due to
__________________. Her LMNP was _______, which was _____ days / months ago. She complained of
__________________ (Ssx). Upon examination, __________________________________________________________
_________________________________________________________________________________________(findings).
I would like to further my investigation with _____________________________ to confirm / rule out _______________.
PROVISIONAL DIAGNOSIS

DIFFERENTIAL DIAGNOSIS
Mass
Uterus: fibroid / adenomyosis
Ovary: Functional ovarian cyst, benign / maglinant tumors
Mesentery: Mesenteric cyst

INVESTIGATION – GYNAECOLOGY

Blood Imaging
FBC, BUSEC, LFT Ultrasound – TAS & TVS
PT/aPTT, GSH/GXM Hysterosalpingogram – HSG
Serum β-hCG Examination under anesthesia (EUA)
Se Tumour Marker – CEA, CA-125, AFP CT abdomen & pelvis
Hormonal profile – LH, FSH, estrogen, progesterone, testosterone, prolactin, TFT Hysteroscopy
Other specimen
PAP smear Colposcopy
Endometrial sampling Semen analysis

Fibroids

 P/S: The vagina and cervix are normal. No descent and discharge.
 P/V: The midline mass moving with the movement of cervix, corresponding to ____ weeks of gestation, anterior &
posterior vaginal wall is smooth. Groove sign is absent.
 Drugs: GnRH analogue, Danazol, Mifepristone
 USG: bulky uterus, with multiple fibroids, right hydronephrosis
 Conservative: hysterescopic resection, myomectomy, HIFU
 Radical: abdominal hysterectomy, vaginal hysterectomy

Ovarian mass:
➢ Serum tumour markers: CA125, α-feto protein, β-hCG, CEA
➢ USG, IVU, CT of abdomen, GI endoscopy, LFT, liver U/S, bone scan, CxR, FBC, BUSE
➢ Ovarian Ca:
o TAH + BSO + omentectomy with or w/out lymph nodes clearance + adjunct ERT
o Adjunct radiotherapy & chemo