Development of gynecologic patient histories requires practitioners to recognize the various elements that are necessary to construct a history that is accurate and relevant. This effort requires consideration of the chief complaint and multiple other elements, including effective communication with various populations including those in the LGBTQ+ community, to ensure a productive screening and subsequent examination.
Respond to your colleagues’ posts on two different days and introduce a perspective that they may not have considered and list any additional health maintenance guideline questions that might be relevant. Use the Learning Resources and/or the best available evidence from current literature to support your explanation.
Elements of Gynecologic History
Elements of gynecologic history can be defined as aspects that are useful in the assessment of the female reproductive system. They make a sequence of methodical questioning of a gynecological patient (Likis, 2016). These questions are aimed at identifying a diagnosis or a differential diagnosis according to which additional care can be arranged. Some examples of the elements of gynecologic history include obstetric history, sexual history, medication, surgical history, and menstrual history. Based on these examples, I would recommend various potential screenings for a gynecological patient. Among them is a review of the patient’s usual menstrual pattern. The physician should ask about past gynecological problems, such as pelvic infection, abnormal Pap smears, or sexually transmitted diseases (Likis, 2016). It is also necessary to pay attention to endometriosis and fibroids and ask about abnormal vaginal discharge.
Discussion of a client’s earlier and present sexual activity is also fundamental. It assists in the evaluation of contraceptive needs and assessment of sexually transmitted diseases risk. Furthermore, family history should be considered. Ailments experienced by family members should be listed, namely osteoporosis, cancer, hyperlipidemia, and cardiovascular diseases (Collins et al., 2019). The physician should also screen for past surgical history. They should ask a patient to list all previous non-gynecologic and gynecologic surgical procedures, any complications experienced, and the dates of these procedures. Finally, obstetric history should also be considered. In brief, the client should be asked to list all pregnancies and their results, with the focus being placed on whether the pregnancy was ectopic or intrauterine.
When performing a patient evaluation, various clinical maintenance guideline questions should be considered. For example, there is a need to emphasize the patient’s profile, which denotes to their personal information, such as the current level of daily activity, occupation, and age. Moreover, the patient should be asked to describe their symptoms, including type and location. The physician should also determine how the symptoms behave to assess the irritability and severity of the patient’s symptoms (American Psychiatric Association, 2016). Apart from interviewing the client concerning his or her specific complaint, the physician should ask several questions to identify aspects that warrant caution in physical treatment and evaluation. In this regard, the special questions would create an environment where lesbian, gay, bisexual, and transgendered (LGBT) feel comfortable identifying themselves as such. Lastly, it will help in developing specifically tailored plans of treatments to individuals.
American Psychiatric Association. (2016). The American Psychiatric Association practice guideline on the use of antipsychotics to treat agitation or psychosis in patients with dementia. American Psychiatric Pub.
Collins, M. K., Chuang, M., Deering, S., & Auguste, T. C. (2019). Basic gynecologic encounters and procedures. Comprehensive Healthcare Simulation: Obstetrics and Gynecology Comprehensive Healthcare Simulation, 171–176. https://doi.org/10.1007/978-3-319-98995-2_16
Likis, F. E. (2016). Women’s gynecologic health. Jones and Bartlett Publishers.
Sources within 5 years
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