The medical history represents a comprehensive overview of the patient’s health, with detailed information regarding the specific issue that has caused the patient to seek medical attention. It is obtained primarily from the patient as well as available past medical records. The history is collected in a logical sequence, allowing the patient’s issues to be organized for the practitioner and other health-care providers as needed. The general outline of the medical history includes the chief complaint, history of the present illness, gynecologic history, obstetric history, past medical and surgical history, medications, allergies, personal habits, social history, family history, and review of symptoms. Regarding the gynecologic history, areas to be included are menstrual history, sexual history, contraception, gynecologic infection, Pap smear history, gynecologic surgery history, urologic history, and gynecologic review of systems.
General guidelines for history taking
The patient interview should take place in a room that ensures complete privacy and has enough space for the patient to feel comfortable. The health-care professional should knock on the door first, and make eye contact with the patient when entering. The health-care professional should introduce themself to the patient and to any accompanying persons. The relationships of those persons to the patient should be ascertained at the beginning of the interview. The health-care professional should always be courteous and professional, and it is always appropriate to address the patient formally. Although this may be difficult at times, the health-care professional should try to be relaxed so that the patient does not feel rushed.
The interview should start with an exploratory approach, using open-ended questions to allow the patient to use her own words and express herself freely. This will allow the patient to bring up issues that are perceived as more interesting and more acute to her. This also affords the interviewer the opportunity to listen for verbal cues that are indications of any other issues that are important to the patient. Listening carefully and attentively will convey to the patient that the physician is interested and concerned about her issues.
As the interview continues, open-ended questions should probe the issue that brought the patient to the health-care provider. Then progress to more directed questions will allow development of a more precise and complete history of the present problem. However, one should try not to ask questions that require only a “yes” or “no” answer from the patient, and be wary of asking leading questions, which may elicit answers the patient thinks her physician wants to hear. If there is a language barrier, make every effort to have an independent, professional interpreter available. If the patient has brought an interpreter with her, be aware of the relationship to the patient and how that may influence the completeness of the history being given, particularly if there are sensitive issues to discuss. Note any additional barriers that may influence the medical history the patient is giving. Issues around substance use, domestic violence, and noncompliance can sometimes influence the accuracy and completeness of the history.
During the interview, try to maintain as much eye contact as possible and make notes sparingly. As many office practices are turning to computerized office note systems, it is imperative that the health-care provider not look at the computer monitor and type while the patient is speaking. Language that the patient will understand should be used, avoiding unnecessarily complex medical terminology. Choose words that are understandable to the patient, yet are not overly simple or demeaning. Avoid any terms of endearment, as they may be perceived as patronizing by the patient.
At the end of the history taking, the health-care professional should try to give a summary of what was understood, and offer the patient the opportunity to add anything she may have forgotten. “Is there anything else you think would be important for me to know?” Further signal the end of the interview segment of the visit by explaining to the patient what will happen during the physical examination, if that is to follow the history.
Taking a comprehensive patient history
The chief complaint is the brief summary of why the patient is seeking medical attention, in the patient’s own words. The health-care practitioner should ask an open-ended questions in order to elicit the main purpose of the visit: “What is the problem that has brought you in to the clinic today?”, “What concerns do you have for today’s visit?”, “What brings you in today?” are examples of a good way to start a conversation that does not assume that there is a problem. The patient should be allowed to express herself without interruption. Other significant secondary issues may surface during this introduction and should be thoroughly explored.
History of present of illness
The history of present of illness describes the detailed information that is relevant to the chief complaint. It should answer when the problem started, the duration of the condition, the detailed symptoms and their development over time. Organizing this section chronologically is a very reasonable way to understand the nature of the problem. It is preferable to start this portion of the interview with open-ended questions and then utilize more directed questions to elicit specific information. The objective of this section is to generate a hypothesis about what could be causing the problem. During this section of the history, the physician can ask specific questions to test further the hypothesis being formulated.
Obtaining a thorough gynecologic history is imperative for the patient who presents for evaluation of female sexual dysfunction. For some patients, the gynecologic history is a sensitive subject that may elicit feelings of embarrassment or shame. The physician should be sensitive to any signs of discomfort. Asking questions in an objective, matter-of-fact way, using formal but understandable language, will help the patient to feel more comfortable discussing sensitive issues.
The health-care professional should start by asking the date of the last menstrual period. Note the regularity of the menstrual cycle, and the duration of the bleeding, as well as the character of the blood loss. Inquire about the symptoms associated with menses. Does the patient have dysmenorrhea, and, if so, does she miss time from work or school because of her pain? Has she always had dysmenorrhea or has this developed recently? Does she have diarrhea, sweating, or migraine with her menses? What kind of sanitary protection does she use? Does the patient describe herself as suffering from premenstrual symptoms? If so, what are her symptoms? When do the premenstrual symptoms start in terms of her menstrual cycle, and are they relieved by the onset of menses? Note also the age of menarche. If there was any developmental delay, inquire about when secondary sexual characteristics appeared and whether any workup was initiated.
This section of the gynecologic history will be covered in great depth later in Chapter 9.4 of this volume.
The patient should be asked whether she currently uses any form of contraception (see Chapter 7.6). If so, what kind of contraception does she use currently and what has she used in the past? Has she had any side effects or complications from any kind of contraception in the past? Does she use the contraception reliably? If she is not using any form of contraception currently, does she want to start some method of contraception? If not, is she taking prenatal vitamins?
Gynecologic infection history
A history of any previous vaginal infections should be obtained, as well as a detailed account of what treatments have been prescribed for these infections, and what medications and treatments the patient has used without a prescription (see Chapter 7.7). Predisposing conditions preceding the infections should be elicited, as well as whether these infections were related to sexual activity. A history of what kinds of soaps, detergents, and perfumes that the patient uses is often helpful. The patient should be asked whether she douches. She should be asked whether she has ever been diagnosed with any sexually transmitted diseases in the past, and, if so, what treatments were prescribed. Did she complete the entire course of treatment? Was her partner treated? Each patient should be asked whether she has been tested for human immunodeficiency virus (HIV) and offered testing again if appropriate.
A thorough history of the patient’s previous Papanicolaou history should be explored. If there is a history of abnormal Pap smears, detailed information regarding colposcopic examinations and any treatment should be recorded. The patient should be asked specifically about any history of genital warts.
Previous gynecologic surgical history
A gynecologic surgical history should be obtained (see Chapter 16.7). If the patient has had gynecologic surgery, detailed information about the indications for surgery, exact surgical procedure, and complications, if any, should be carefully recorded.
The urologic history should be thoroughly taken (see Chapter 17.4). Any history of incontinence, recurrent urinary tract infections, pyelonephritis, hematuria, or kidney stones should be developed in great detail. Any treatment that the patient has received should also be recorded, including detailed information about any surgical procedures.
Gynecologic review of symptoms
Obtaining the gynecologic review of systems at the end of the gynecologic history is a good way to elicit any additional gynecologic issues that would be significant in the patient with female sexual dysfunction. The patient should be asked about any pelvic pain and whether it is related to menses, urination, defecation, or intercourse. A history of abnormal uterine bleeding should be elicited, with careful attention to when the bleeding is happening with respect to the menstrual cycle or intercourse and the duration, frequency, and character of the bleeding. The patient should be asked whether she has any unusual vaginal discharge (see Chapter 9.5). A history of difficulty in getting pregnant should be explored. Patients, especially older and parous women, should be asked about symptoms of pelvic relaxation such as urinary and fecal incontinence, relaxed vaginal introitus, and difficulty in defecating.
All previous pregnancies should be documented (see Chapter 7.5). Dates of all deliveries should be recorded, noting the gestational age at delivery, as well as mode of delivery, outcome, and complications. Indications for all operative deliveries should be recorded, including forceps and vacuum deliveries. If the patient has had a cesarean section, she should be asked whether it was emergent or elective, and uterine scar type should be ascertained. Although this usually requires obtaining the operative report from the previous surgery, many patients will be able to give some clue about incision site. “My last doctor told me that I would always need a C-section because of the way she needed to cut my womb” would suggest that the patient had required a vertical uterine incision.
The gestational age of all spontaneous abortions should be noted, as well as whether the patient had a dilation and evacuation after the event. If the patient has had multiple miscarriages, inquire about any workup she may have had for recurrent pregnancy loss. Any history of therapeutic abortions should be recorded, including the gestational age at time of termination, the date of the procedures, whether they had surgical or medical abortion, and whether there were any complications.
Medical and surgical history
This portion of the medical history is a summary of the overall assessment of the patient’s health. It is of great value in assessing the current complaint and also provides a context for the condition that brought the patient to seek medical attention.
The medical history comprises the general state of health, past illnesses, and surgical history. Inquiring about the general state of health affords an opportunity for the patient to summarize her general health in one sentence, such as “I have excellent general health.” Past illnesses should include all illnesses that occurred in adult life as well as significant childhood illnesses. Details of treatment for any illnesses should be carefully documented to the best of the patient’s recollection. Any hospitalizations should be recorded, including hospitalizations for any psychiatric conditions. The past surgical history should include all surgeries, even dental procedures, documented with the date of the surgery as well as any complications, including any complications of anesthesia.
Medications, allergies, personal habits, social history
All current medications taken by the patient should be recorded, including dosage and actual use by the patient. In addition, nonprescription medications and home remedies should also be recorded. Having the patient bring in her medications can improve the accuracy of this history.
All allergies should be carefully recorded, as well as a detailed account of the reaction. The history should not be limited to allergies related to medications, but should also include food, and environmental agents.
An attempt should be made to elicit a history of childhood immunizations, although many patients will not remember specifics and only be able to state that they were immunized. Information about the last purified protein derivative antigen used to aid in the diagnosis of tuberculosis infection, tetanus, and hepatitis immunizations should also be obtained.
A social history including the personal status of the patient is important to obtain. This includes the patient’s place of birth, current address, and with whom she lives. This is a wonderful opportunity to ask whether the patient feels safe at home from domestic violence, to ascertain whether the patient has a smoke detector at home, and to determine whether the patient has any religious proscriptions in her medical care.
It is important for the health-care professional to ascertain the patient’s personal habits. If tobacco is being currently used, the type should be noted (smoking or chewing) and when the patient started using tobacco. The amount used per day should be documented as well. Be careful to elicit a history of previous tobacco use, even if the patient has ceased use. If the patient has quit, ask whether the patient used or is currently using any medical or pharmaceutic smoking cessation aids.
The US Preventive Services Task Force recommends screening to detect problem drinking for all adult and adolescent patients.1,2 The patient should be asked whether she drinks alcohol, and, if so, how many drinks per week she consumes. A history of binge drinking should be elicited as well. Screening tests for alcohol-related problems, such as the CAGE questionnaire, can be incorporated into the social history. The acronym “CAGE” aids the health-care professional in remembering the questions on cutting down, annoyance by criticism, guilty feeling, and eye-openers. The CAGE questionnaire asks, “Have you ever felt the need to cut down on drinking?”, “Have you ever felt annoyed by criticism of your drinking?”, “Have you ever had guilty feelings about your drinking?”, “Have you ever taken a morning eye-opener?” Appropriate referrals for alcohol-related problems should be made.
Additionally the patient should be asked about any use of illegal drugs, current or past. The type of drug used should be documented as well as the route of administration. Duration of use should be noted as well. The patient should also be asked about use or abuse of any prescription medications.
Each patient should be asked about the frequency and type of exercise done, if any. General questions about diet should be asked, as well as dietary restrictions, and the use of caffeine- containing beverages.
Included in this interview should be questions regarding the patient’s occupational history. A record of where the patient currently works should be obtained, specifically trying to elicit a history of exposure to potential environmental substances that are known to cause illness. The patient should also be asked about stress at work, as well as stress as a result of not working.
It is important for the health-care professional to develop a brief history of each member of the immediate family, including the age and cause of death of any deceased family members. If there is a history of a hereditary disease, it is useful to extend the family history to grandparents, aunts, uncles, and cousins. In certain circumstances, it may be useful to document information in a pedigree diagram. Included in the family history should be a determination of the ethnicity of the patient, as some conditions are seen more often in distinct ethnic groups.
Review of systems
The review of systems should be organized in terms of body systems. The many symptoms that may pertain to the history of present illness and the past medical history will also be elicited in this section, although some health-care practitioners choose to record pertinent symptoms in the history of present illness section. In addition, thoroughly reviewing all the possible symptoms may uncover symptoms of an undiagnosed condition for which the patient is not specifically presenting. It is best to organize the questions in a systematic fashion. It is unlikely that all aspects of each system will be asked at each patient visit; however, the health-care professional should be able to ask some questions about each system. Depending on the history of present illnesses, more detailed questions about an affected system may be asked. Some practices have considered an extensive questionnaire for the patient to complete prior to her visit as a way for thorough review of the extensive review of systems (Table 9.2.1).
In sexual medicine, in particular, obtaining a “good” history is critical to patient management. In general, history taking for women with sexual health concerns involves a detailed sexual, medical, and psychosocial history. This chapter reviewed the key aspects of the medical history; see Chapters 9.3 and 9.4 for detailed information on the psychosocial and sexual history.
Table 9.2.1. Common symptoms asked about in a comprehensive review of systems
General: weight changes, weakness, fatigue, unexplained fevers, chills, malaise
Skin: rashes, changes in mole pigmentation, lumps, bumps, hair loss, hirsutism
Head: headache, dizziness, lightheadedness
Eyes: Visual changes, change in prescription strength, double vision, blurred vision, glaucoma, cataracts
Ears: hearing loss, tinnitus, vertigo, pain
Nose: nasal stuffiness, discharge, polyps, epistaxis, loss of smell
Mouth and throat: mouth lesions, halitosis, sore throat, bleeding gums, petechiae, dental problems, decreased taste
Neck: lymphadenopathy, goiter
Breasts: soreness, lumps, adnexal masses, nipple discharge, asymmetry
Lungs: cough, dyspnea, hemoptysis, wheezing, sputum
Cardiac: angina, dyspnea, dyspnea on exertion, palpitations, orthopnea, paroxysmal nocturnal dyspnea, edema
Gastrointestinal: heartburn, stomach upset, excessive burping, bloating, nausea, vomiting, diarrhea, constipation, abdominal pain (note frequency and location) food intolerance, excessive flatus, jaundice, hemorrhoids, change in bowel habits
Urinary: incontinence, retention, hematuria, dysuria, polyuria, decrease in urinary stream, dribbling, dark, tarry stools, change in stool caliber
Musculoskeletal: joint pain, muscle weakness, leg cramps, varicose veins, history of blood clots, arthritis, gout, stiffness, backache
Neurologic: fainting, seizures, numbness, paralysis, tremors
Hematologic: anemia, easy bleeding or bruising, history of blood transfusions (with year and location of transfusion)
Endocrine: cold or heat intolerance, excessive sweating, thyroid history, polydypsia, polyuria, increased appetite, change in glove size, hirsutism
Psychiatric: depression, mood, anxiety, memory changes, difficulty in concentrating
US Preventive Services Task Force. Guide to Clinical Preventive Services, 2nd edn. Baltimore: Williams and Wilkins, 1996.
Cleary PD, Miller M, Bush BT et al. Prevalence and recognition of alcohol abuse in primary care population. Am J Med 1988; 85: 466.
Barker LR, Burton JR, Zieve PD. Principles of Ambulatory Medicine, 4th edn. Baltimore: Williams & Wilkins, 1994: 30-41.
Bickley LS. Bate’s Guide to Physcial Examination and History Taking, 7th edn. Philadelphia: Lippincot Williams & Wilkins, 1999: 2-38.
Droegmueller W, Herbst AL, Mishell DR et al. Comprehensive Gynecology. St Louis: Mosby, 1987: 131-5.
Jones III HW, Wentz AC, Burnett LS. Novak’s Textbook of Gynecology, 11th edn. Baltimore: Williams & Wilkins, 1981: 3-26.
Sapira JD. The Art and Science of Bedside Diagnosis. Baltimore: Urban & Schwarzenburg, 1989: 33-45.
Seidel HM, Ball JW, Dains JE et al. Mosby’s Guide to Physical Examination, 4th edn. St Louis: Mosby, 1999: 4-46.
Williams JL, Schneiderman HS, Algranati PS. Physical Diagnosis - Bedside Evaluation of Diagnosis and Function. Baltimore: Williams and Wilkins, 1994: 1-32.