History

Adolescent and adult patients presenting to the ED with pelvic pain or bleeding share many common elements of the history and physical examination. Complications related to pregnancy are always possible, and routine inquiries are both appropriate and necessary. Key points that should be routinely addressed when taking the clinical history are age of menarche, menstrual history, date of the last menstrual period (LMP), pattern of abnormal bleeding or discharge, and the presence of dysmenorrhea. Sexually active patients should be asked about contraception, current sexual activity, the use of barrier protection, HIV and hepatitis status, and a history of PID, sexually transmitted diseases (STDs), or ectopic pregnancy. Patients who present with pain should be asked about its quality, timing, location, and radiation, as well as aggravating or alleviating factors. Associated symptoms of the urinary, GI, and musculoskeletal systems, as well as the presence of fever or syncope, should be documented. A history of recent illnesses, psychological stress, weight change, or endocrine problems, including thyroid disease and pituitary tumors, should be obtained. In patients with bleeding, signs and symptoms of a coagulopathy, including nosebleeds, easy bruisability, and menorrhagia, and a family history should be noted in the examination.

Taking the history of adolescent girls is challenging. Honest responses to questioning will require assurances of confidentiality and comfort by the physician. If the patient requests a female physician, honor the request, if at all possible. Always interview the patient without the parent present. Usually this is best done if you ask the parent to leave just prior to the physical examination. Questions regarding STDs and sexual activity can be very disturbing for adolescents. It is important historical information and should be obtained in a nonjudgmental, gentle way that in itself will be educational. It is not realistic to expect an accurate history about the occurrence of periods early in menarche, as the cycle is usually irregular for the first 1 to 2 years and perhaps as long as 5 years.

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