Infertility, habitual miscarriage, difficult birth, congenital malformations - all these disorders in the normal reproductive function of women are caused primarily by obstetric and gynecological pathologies.
Practical and seminar classes on obstetrics and gynecology are always present in the course of educational disciplines of young specialists (students of higher educational institutions of a medical profile) along with various disciplines.
And, of course, do not forget that, according to the results of the course, students write a medical history in gynecology. It is important to know: what is the structure of this document, what information should it contain, how is it drawn up.
What is a medical history?
This is a document in which all important aspects of the course of the disease should be recorded. At the very beginning, information about the patient himself (sex, age, name and various contact information) is indicated, then the main disease (the disease that caused the hospitalization) is written, as well as the accompanying pathology.
The next section is the patient's complaints (where all the impaired functions mentioned by the patient, localization of pain, other sensations are introduced).
The medical history of gynecology without fail includes the history of the patient’s disease (which describes the phased occurrence and manifestation of the disease, treatment periods, etc.), as well as the history of his life. The latter includes a list of past diseases, gynecological, allergic and epidemiological history.
The next step is a general examination, which characterizes the general objective state of the patient at the time of his examination. A detailed examination of the patient (his organs and systems) and his results are reflected in the sections of the corresponding systems.
All this information is reflected in the medical history of gynecology.
Uterine fibroids are one of the most common gynecological pathologies. It is this disease that is recorded in most cases during hospitalization of patients. Today, there is also an increase in the number of patients with other diseases that adversely affect the reproductive health of the female body. Various infections, inflammatory processes, as well as neoplasms.
It is worth noting that among inflammatory processes, diseases with a latent clinical picture of a chronic (protracted) course often prevail. All this not only complicates the diagnosis of pathology, but also increases the duration and reduces the effectiveness of the treatment. Along with this, antibiotic-resistant strains of microorganisms are increasingly the cause of such diseases.
The gynecological history of the disease allows us to systematize the data obtained as a result of an objective (general) examination, as well as the data of diagnostic procedures and procedures.
The constructive use of pathology data, as well as the competent and reasonable use of antibacterial drugs (taking into account the sensitivity of an etiological agent to them) helps to avoid the incurable forms.
Today, the history of the disease in obstetrics and gynecology, as in any other disciplines, is increasingly compiled using modern computer programs that not only allow you to speed up the process of entering data on the disease, but also carry out an operational and retrospective epidemiological analysis of the incidence without much difficulty.
Thus, the number of pathologies of the reproductive organs is currently constantly increasing. Along with the emergence of new latent forms of diseases, the methods of diagnosis and treatment are being improved. In addition, the system of medical records accounting is optimized (medical history in gynecology), as well as its gradual translation “from paper to digital” (for example, the medical history of gynecology in electronic form).