History

• Patient Details
• PC + HPC
• Systems Review (4Ps)
  • PV Bleeding → IMB, PCB, PMB
  • PV Discharge → volume, colour, conistency, smell
  • Pain → shoulder tip? cyclical?
  • Pregnancy → any chance you could be pregnant
  • FLAWS, Bloating, N&V.
• MOSCC + Uro-Gynae
  • Menstrual
    • Menarche → how old when you started having periods?
    • LMP → when was your last menstrual period?
    • Frequency → how often do they occur? are they regular?
    • Duration → how long do your periods normally last?
    • Menstrual Blood Flow → do you suffer from excessive bleeding?
    • Dysmenorrhoea → any menstrual pain?
    • Menopause → how old when you went through menopause?
  • Obstetric
    • Gravidity (how many times been pregnant?) & Parity (how many times have you given birth?).
      • Have you been pregnant before? What were the outcomes of those pregnancies?
    • Previous Pregnancies → gestation delivery at? mode of delivery? complications? (GMC)
  • Sexual
    • Are you sexually active? How many sexual partners have you had in the last 3 months? (WITH ONE REGULAR PARTNER?) Have you ever been screened for STIs?
    • Any pain during sex (DEEP OR SUPERFICIAL)? Any bleeding during sex?
  • Contraception
    • Are you currently using contraception?
    • Any previous other types used? Why did you stop?
    • Any plans to have children in the near future?
    • If Post-Menopausal → HRT. Duration of use? Cyclical or continuous? Combined or oestrogen only? Method of delivery?
  • Cervical Smears
    • Are you up to date with your cervical smears?
  • Uro-Gynae (Incontinece or Prolapse) → frequency, urgency, dysuria, haematuria, stress vs urge, pain, bowel symptoms (dyschezia?), chronic cough, dragging sensations.
    • FUNDHIPS → frequency, urgency, nocturia, dysuria, hesitancy, incomplete voiding, poor stream.
• O&G PMH
• PMH
  • Abdominal surgeries
• DH
  • Hormone treatments
  • Allergies + WHAT HAPPENS WHEN YOU TAKE
• FH
  • Women’s cancers (breast/ovarian/endometrial/cervical) / ‘Womens health conditions’
• SH
  • Desire to have children

Investigations

• Bedside → examinations: abdominal exam, speculum, bimanual. Basic Observations (A-E). Urine: dip, pregnancy test. Vaginal Swabs.
• Bloods → FBC, CRP, ESR, U&Es, Group and Save. Serum beta HCG.
• Imaging → TVUSS.