Essentials of history taking and physical examination

History taking is essential in gynaecology and obstetrics, both as a starting point for your diagnostic approach and in order to build a good relationship with the patient. The history should include a thorough medical, surgical, menstrual, and sexual history. Inquiries should be made into the patient’s home and work status, social history, and family history (past and present). The information you acquire during history taking in relation to the stage of life sets the context for the findings in the gynaecological examination. It is important to realize that the gynaecological examination is an intimate examination and can be stressful for the patient. Respectful contact, respect for privacy and a respectful approach are of key importance. The purpose of the examination of the female genitalia is to assess the female genital tract: the vulva, vagina, cervix, uterus, fallopian tubes and ovaries by means of inspection and when indicated, palpation of the external genitalia, inspection of the internal genitalia (with a speculum) and palpation of the internal genitalia (in a bimanual examination). Certain findings can help you in the diagnostic process by either including or excluding certain illnesses as the possible cause of symptoms. The examination can also play an important role in the assessment of lower abdominal pain and in screening for sexually transmitted diseases or cervical cancer.