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Sexual History Taking & Basic Gynecological Examination

Dec 18 | 1:30 PM

Do you recall your first PV, PS, or valval exam? The anxious patient and the most anxious version of yourself? Over time, we all become accustomed to these processes and they become part of our OPD routine. However, there are a few areas of gynaecological examination and history taking where we still get stuck. Let's take a look at a few nuances with Dr. Tanaya Naresh, the millionaire doctor known as Dr. Cuterus on Instagram. Join us as she performs a live demonstration of a few techniques!

good evening everyone and welcome on behalf of team netflix i'm dr niveda and i hope you all are having a great saturday evening and to make this evening uh even more interesting and to add fun in the fundamental sex education we have with us uh dr panaya narendra famously known on social media as dr cutest uh so this awkward uh um this oxford trained uh doctor talks all about uh sexual health and does fun uh myth busting talks on taboo topics i'm sure all of y'all have already seen her on youtube so you all know the content that she does uh dr pinaya is an internationally trained medical doctor she's an embryologist and scientist who is extremely passionate about medical education and on the nerdy side of things she is an elected fellow of the royal society of public health for public health i'm sorry um so this topic basically uh history taking is like one of the most basic uh things taught in med school and we always start like we all know the demographics followed by the chief complaint the present past history and then depending on the systemic uh presentation the examination varies um sexual history is just one small part of gynac history taking but it's it's it becomes very difficult and it becomes slightly awkward and kind of a little weird for us to talk about these things with our patients so we have her with us today and she'll tell us how to get through it without being judgmental about these questions and without feeling awkward about asking your patients such questions let's begin profession perfect thank you so much for such a kind introduction um this is tanya once again and i have a problem with the way we taught in medical schools i have a major problem with it and i feel like there's two problems there the first is that everything is made entirely too complicated things that we can easily go up and read on our own time and understand in our own sweet way it's presented to us in a highly technical and highly complicated manner which makes it difficult to understand in classroom which means that i will try to keep it as simple as i humanly can and the second problem that i have with medical education is that we have a very judgmental atmosphere in our colleges yeah that's what i remember from my uh mbbs days i remember getting yelled at for taking a detailed sexual history one time so this is something we need to sort of try and start shying away from because my experience in the mbbs world versus the real world in terms of taking a history in any department has been very different compared to the very uh chief complaint hopi format that we normally follow of course we do take a detailed history but it's not it's not like that textbook format that we go through because in the real world you're interacting with a real person which means you have to interact in a very real way try to elicit the most knowledge you can in the most structured format you can yes but everybody has their own format so i'm going to leave that up to you how you decide to go about it what i am here to discuss today is more about how you can ask these questions in a non-invasive but still thorough manner because a part of like we treat sexual history as such a small part but the minute you step into and the minute you become a non-judgmental doctor and you step into consultation taking you find that um so um the minute you find that you step out of the real world you find that sexual history is actually a large component especially if you're working in a gynecology related area you will find that there is a lot of questions you have to ask about a patient's sex life and a patient's gender identity so especially if you work in fertility you have to know quite a lot about some very invasive and intense questions so there is a way and there's a structure in how you can ask these questions without being without coming across as rude without coming across as insensitive and without coming across as homophobic or transphobic now it might sound like this is not stuff that you might face with a medical school audience because mostly medical schools are built in areas that have a moral population where these topics are a bit more taboo to discuss but in my experience i found these questions everywhere i found these questions in medical school i found these questions when i'm practicing with say people from a mall metropolitan background and even from tier 2 and tier 3 cities now um being gay is legal in india now thankfully finally which means that you will have a lot of very confused patients who will turn up to you with very basic questions which is why it's so important to understand the terminology that exists and i understand it can be really confusing and really overwhelming so we'll touch a little bit about sex versus gender and what are the correct terms in like a very very simple and very very easy to remember way so that we don't get caught up because these mistakes can come across as really insensitive so um i'm not going to do a presentation because that's boring and you will start reading instead of listening and then yeah that's nonsense i don't believe in that what i do have instead is i've got two laptops full of notes so i'm going to keep addressing my notes and keep coming back to you guys if at any point you have a question please drop it in the comments i'll try and address that and um if i'm not addressing it at that moment it's quite likely i'm going to address it at the end so i'm going to ask a question to you guys because i want to keep this as interactive as possible and get a background of what you're thinking about this my first question is why do you think your sexual history is important here is is a sexual history important and if yes then why let's take a minute and see if you guys can answer this while i quickly drink some water sure i can put in your uh answers in the comments and you and there is no right or wrong answer by the way okay i'm seeing to prevent stis [Music] okay [Music] okay [Music] okay i'll need maybe three more answers [Music] all coming in now very nice i'm very happy to see the answers that are coming in [Music] you know the gender orientation of the patient that's something i'd really like to discuss [Music] cervical cancer excellent point thank you for making that did you all know that cervical cancer is the second most common cancer in indian women and one out of four women across the world who die from cervical cancer are from india so we have a rampant cervical cancer problem that's happening and we don't discuss this not in medical school i don't remember reading about cervical cancer as well as i did about breast cancer even in surgery postings we used to see so much breast cancer don't think we saw i think i must have seen like five cases all through my final year for cervical cancer um to oil std is very good it is important to know any problem in the anatomy sure because there can be conditions where people can be intersex so we'll try not to label it as a problem and i'll get into why i'm saying that with the help of sexual history we can come to know the mental as well as physical relationship with a partner no fetus should suffer from any stds part of annual checkup and healthy detect any serious disease before so this is fantastic this is the kind of answers i was looking for and um i think the first thing i'd like to establish right away is we have a tendency of using the word sexually transmitted disease instead of sexually transmitted infection and in most unqualified sex educator circles they don't understand that in those circles it's usually very interchangeably used so sti and std is the same thing it's not the same thing but we will try and focus on using the term sti which is a sexually transmitted infection instead of a sexually transmitted disease now since we're doctors we need to know the difference between these and the difference is very simple an infection is just an infection say a parasite or a fungal or a i don't know bacterial infestation when that eventually leads on to long-term issues say you have an hiv infection that leads to the disease of aids say you have an hpv infection that leads to the disease of genital warts so an infection is usually short-term and treatable a disease is usually long-term and impacts the larger quality of your life let's try and use the word sti because it's less scary and i think something that we're really not taught in medical school is communicating with our patient and making sure they're comfortable most often our immediate thought is okay diagnose diagnose diagnosis where is your communication one of the reasons why um pseudoscience pseudoscientific fields of medicine prefer so well in india is because a lot of their patient communication is just listening to the patient something we miss out on and something that i've experienced myself when i go to doctors doctors don't ask me anything when i go to them myself they're just like what's your problem how long have you had this problem okay here's five medicines you know so we really need to change that structure and until we do that people will learn from more unqualified individuals and people will go to more unqualified individuals and people will make polar decisions towards their health so it's a public duty to also be better so um one of the things that i wrote for my answers about why stis are important is it impacts uh sorry sexual history taking is important is because it impacts the quality of life now imagine a patient you have who has vaginisms vaginalness is a condition in which there's an uh automatic sort of contraction or clamping up of the pelvic floor muscles in response to any idea of penetration so it's like you're it's like it's like a touch me not blonde that's happens that's what happens to the pelvic floor and penetration becomes impossible so if somebody has vaginismus it might suggest a history of sexual abuse it might suggest an ongoing infection it might suggest not just this in terms of you know the diagnosis but also in terms of a poorer quality of life because a lot of times patients with vaginis must find that they have a lot of self-blame that i'm not able to satisfy my partner i'm not able to interact with them sexually so things of that sort so this is where taking a good sexual history also gives you a very good insight into the patient's mental as well as physical health which is one of the answers that i got wonderfully so um you know there's this really nice question answer here that the patient may not relate their problem to their sexual issues and that's why it is important for us as doctors to look at the sexual history to make a better diagnosis because say you have a patient with diagnosis maybe you can figure out that they have that they have um that they have more they have more underlying issues that can lead you to say somebody with maybe ptsd so you can refer them to a better area or if they have vaginismus and you find a resistive fungal infection it's a temporary vaginal situation so there's better ways of treating them if somebody has erectile dysfunction it really affects the quality of their life a lot of unfortunately a lot of cases of suicide are related to importance so there's a massive impact on the quality of life of yours and a sexual history should be a basic part of any history taking in any patient interaction something we fantastically somehow always miss out because we've never been taught about it the second is we can also learn a little bit about trauma and intimate partner violence now intimate partner violence is something that happens very commonly in our country um be it whatever social economic status you're talking about people are hit be it men date women their partners do hit them their partners do physically assault them their partners do mentally assault them and again that leads to a better insight not just into the mental health of the patient but also the physical health because if they are being assaulted they might have small undiagnosed fractures they might have undiagnosed concussions from being pushed down the stairs and various things of this sort so taking a sexual history can also lead to an insight into intimate partner violence and one thing that's really strongly associated with taking with the sexual history aspect of it is the substance abuse aspect so when you are taking a sexual history you will be talking a little bit about drug alcohol and i don't know cigarettes or anything of this sort of abuse which also leads you to better understanding of the long-term health care of this patient's overall health for example if you're saying that they have a history of drinking and maybe assaulting their partner so you know that there is a there is an underlying issue there with aggressiveness and this patient needs further referral if there is an issue with drinking and maybe indulging in non-consensual sex you know this partner this patient is at increased risk of facing violence so if there is a history of drug use you know this patient is at a higher risk of getting needle bond infections and things of that sort so you have to you have to make this an integral part of overall history taking your patient and the first [Music] step towards that is to throw a judgment out of your mind now once you get into this area you will find the most bizarre kind of answers from people you will get my favorite story to tell everybody is my my parents had they're both fertility specialists and they had a patient who had a couple who'd been trying to conceive for seven years semen parameters completely normal good ovarian reserve hormonal profile perfect the reason why they weren't able to conceive for seven years was because this man had been fornicating with his wife's belly button so he'd been putting it in like this for a good seven years so you know such a simple thing nobody ever sat down with him and discussed his sexual practices before and then at one point my dad was finally frustrated he was like why is this not working for you you have really healthy semen you have a really good image i think the image was like she was 37 in her name it was 2.5 or something that was pretty good for her age and you know just because my dad at some point got frustrated and out of sheer curiosity i'm not saying my dad was the best doctor in the world i mean he is but out of sheer curiosity he went and sat down and he's like what are you doing and it turns out this patient is so poorly sexually educated that this has been happening and they can see within two months after that so we often neglect to take such an important section of history taking and that's really so um one thing that is really really important to understand here and rocha if you can plug in one of the cool questions about why we don't take this history it will be wonderful over here so um one thing that is really really important to bear in mind here is that we need to [Music] prioritize or also acknowledge the patient's socio-economic history the patient's gender and the patient's culture and sexual orientation because a lot of times these questions can offend the patient but a lot of times you need to know more about these questions because they may be at a higher risk of experiencing infections and violence um i'm going to stop for a little second and talk about um the gender question because i think that's something we need to discuss so uh there is um i find that when i enter the sexual health space i was very intimidated by the gender versus sex question what is the sex that they identify with what is the gender they identify with there's so many new terms that keep coming up so you i'm not saying we have to be perfectly well versed with that but just to get an understanding please let me know in the comments if you know this or not do you have an understanding of gender versus sex do you understand what male versus female versus man versus woman versus trances these are the five general terms which we'll focus on so a little bit no a little bit no yeah i'm i've been in the same boat as you guys dude it took me so much reading to understand what this was because this is not a conversation again we have um if i'm not wrong it was vedic or asia that had this in their textbook that her masqueradism was a term that was used we use hermaphrodite very commonly in medical textbooks i think it's even there and really in love so there's a very relevant question is what do you mean identify as so let's get into that um yes so her macro diet is not a term that we accept anymore it's not considered a polite way and it can often be very very offensive to people so we'll leave that text out of our textbooks if you find that in your textbooks please remember to cross it out and put a small note to yourself so you're constantly reminded in how to treat your patients better and how to treat them with more respect so um we'll start with the very basic question sex versus gender sex is anatomical sex is chromosomal so when somebody is born they're either assigned female at birth or there is a male at birth or they assign data sex this is the three broad domains so most often say i was assigned female at words i continue identifying as a female now what i mean by identifying as a female is that in my head i believe i'm female i believe i have female properties i want to continue living as a female person this means i am a cis person so cis and trans if you remember your chemistry cis is the same trances across so in i think it's organic chemistry i don't remember but sis is on the same side and transfers across the same across the other side if i'm not wrong if you remember your dextron lego rotation so um because i was born something and i stuck on the same side i am cisgender if i was born as i mean or if i was assigned female at words and say i identified or i felt as a man i felt that i actually shouldn't have a vagina i should have a penis i should not have breasts i should have shorter hair and i want to live continue living my life as a man then i would be a trans man because you want to always remember that the gender the the sex that goes on is the one they identify as you want to respect what they identify as so if i identify as a man that goes there so i will not be a trans woman i will be a trans man so i am i'm a man but i'm not sidhastika man i'm a tilde is how i tend to remember it because often these terms can be difficult to remember does that make sense so far are we are you with me so far or should we try explaining this perfect so this is one of the things that you can ask very very simply with your patient when you start doing a um a consultation so what i normally do is this is how i start my concerts hi what's your name um very often most of my concerts are from people with tier 2 tier 1 metro cities so you can phrase this question in whatever way you like hi what's your name how old are you do you identify as a woman because most often i get people who are cis women so this way you're automatically putting your patient at ease they already know that you're going to be accepting of their non-typical if if non-typical their non-typical gender preference and this also gives them space to let them know that let you know that they identify say as a trans person or they've had any surgery in the past which um you know also gives you an insight into their surgical history and their past medical history very very quick very very easy um great insight into their health in general and then lastly if they identify something is non-binary now a non-binary person is something who doesn't believe that they're too gentle who doesn't believe it's male versus female who has an element of maleness in them and an element of femaleness in them so this is a more varied area but i will not get into the specifics of it but sometimes people do identify as non-binary and you can know at this point now one thing that's really important to remember here is that um you don't want to think that just because say i was born in a female body and identify as a man there's something mentally wrong with me this is not a mental health condition this is a very legitimate form of expression this is a very legitimate thing and people who come from trans backgrounds or into sex backgrounds often have faced a lot of trauma all through life also a lot in medicine so don't think that they're something mentally wrong with them they're just living their life as they are so please keep your judgment out of the window it will be difficult at first and you might be intrigued but try to be non-judgmental these are real people on the other side there's a question in the comments this identify as hell because if he is a female is a risk factor for a disease it doesn't matter what they identify is so this is where if when you ask somebody what they identify as they will tell you that they identify as a woman and say they have a male body or say they have been assigned main adverts and you want to understand their this of getting a disease like in the questions you've asked before so if somebody say if i am a trans man and i start speaking to you when you ask me what i identify as i will say i am a man and it is here where most patients will usually stop and tell you i am a trans man they will say i identify as a man but i am a trans man so you get an idea of what the anatomy you have to focus on this is where in your past medical or past surgical history you can ask them have you had any gender reassignment surgery before please don't call it sex change surgery just politely ask have you had any gender reassignment or gender confirmation surgery before and this is where they'll give you a detailed history as well so it sets the stage for making that conversation easy and it also sets the stage for knowing if you need to ask that question at all because sometimes you don't have to ask that question so that's fine so you start with name and pronouns this is where i normally ask you identify as a woman and we've discussed exercise at first we discussed current gender identity okay then is something that we are really never taught to do in medical school and we really really need to learn to do this because uh it's a really important thing and it changes your entire patient experience this happened to me when somebody asked for my consent my doctor asked for my consent and i was amazed i fell in love with the doctor i never went to see them again but i will rate that as one of the top doctor experiences in my life because they didn't just hope or something on me they didn't be like great job and then suddenly start i don't know touching me you know this is how we do it this is how i learned to do it that we walk into the uh examination area and we're like later sorry gutow and then we just go in like that you know there's no explanation and can you imagine that being done to yourself and you'll automatically realize why people don't come to the doctor so um we need to do better guys we honestly need to do so much better to make sure people are in a better state of health so as for consent this is very simple you just say i am going to examine you is that okay and they will say yes if they say no in a very very rare unlikely scenario they say no then you tell them i need to examine you to understand this better and how do you say this he um in hindi usually i'm believing most people are from hilly speaking area you just say information you can choose to sub this in english or hindi or whatever words you want to use very simply just explain to them why you need to examine them they will say yes you don't even have to tell them that so this puts the patient's autonomy back in their hands this makes them believe they're in control which leads them to open up to you better they feel respected they tell you everything now here's the cornerstone of sexual history and this is the main focus of the entire session we're doing which is your five p's if you remember your five p's you're sorted in your sexual history the five ps are very simple partner practices protection past history and pregnancy that's it i'm gonna write this down in the chat box i think so it's easier for everyone to write this um thank you i'm just wondering if you can do the pose at this point uh sure i'm running the second poll so all of y'all uh y'all can see a question on the screen i'll start it now and then you have um options so you can see free uh to select the option that you think is right and submit the words and uh and then we'll have the next pull up [Music] okay what's that okay yeah all right so i really wanted to know this before we got into it because so often we do stops from you know we're afraid of getting hit very very reasonably we're afraid of the patient running out so a great way to enter this conversation is very gently when you're asking them for consent you also tell them foreign [Music] on their side patients want to trust their doctor we just don't allow it to happen i feel like we're so strongly to blame in this section that [Music] if you start establishing um an honest rapport with your patient what you will see is that you will have an enormous uptake in the number of patients that are not finding a place to go somewhere else and are coming to you you will develop that reputation in a good way i'm not saying that something to be ashamed of but say i happen to have a lot of lgbtq patients now because there's a reputation i have developed that i will not touch them for it and then they are able to open up about very serious medical conditions my mom had a patient who was a trans man and she had undergone sorry he had gone serious sexual abuse had a lot of injuries wouldn't go to any other doctor because they were afraid of the kind of judgment they might face you know so this was somebody at serious risk but found one doctor to go so i understand it's a very very scary thing to begin with but just tell them straight up difficult questions you might be uncomfortable it will help me make a better diagnosis it i would appreciate if you to be honest excellent moving forward so let's focus on the five p's which is your partners so this i think you can this is a little bit sort of dependent on your judgment if you're seeing that it's a young person from a more metropolitan or a tier two city background you might find it easier to ask this question if you're finding that of course it's a timid shy girl cover with a head covered sitting there and answering really neatly you will not ask for this question the question is how many partners do you have have you had any partners in the past oh a very important question i have to ask here is can we do poll number three over here please before we delve into this okay this is the third question um and select the option and submit don't forget to submit the word so it gets registered [Music] oh wow i'm so happy to hear this there's 55 people that say yes so this is a very very common joke on instagram and 55 other social medias that gynecologist asking you are you married versus simply asking you are you sexually active and this is a very simple question guys we're all in school we all know a lot of our friends and a lot of us are also sexually active and when we preclude that question we [Music] automatically ignore such a large part of the mental and physical health impacts that can happen there so often if you go to a gynecologist with any itching or any irritation in your vulva they'll immediately give you the fast kit they'll give you anti-fungal anti-parasite so you know assess use your own judgment there and assess if this partner if this patient merits asking this question how many partners do you have how many partners have you had is this your first partner and once they answer that question please make sure to ask if their partner has other partners this is especially important in a more metropolitan audience because sometimes if you have say using casual dating apps they often have multiple partners and their partners often have multiple partners this is also extremely important if your patient is a part of the lgbtq community because a there is a very long process in finding the right partner for you which means it usually involves multiple partners now um if especially if you have a patient in the lgbt community you want to ask about what kind of practices they follow so partners and then practices why i ask about practices is and don't be alarmed when i tell you that this happens because this really happens there's a lot of oral anal sex so if there is oral anal sex that means they the patient has an increased risk of gi infections the patient may come with a very vague history of a gi symptom they'll come with diarrhea they'll come with abdominal pain and then you figure out it's actually fecal orally transmitted in a sexual context not in a food context it may be orally transmitted e coli or it could be some other gi infection so make sure you ask in a very comfortable manner that because a lot of times people think that sex means penetration a lot of people may be sexually active and just having oral sex but thinking sex means penetration so they'll say no i'm not sexually active so this is where you have to again use your judgment figure out if this is the okay question to ask this person and you will have established that by now by the history you must have taken so far and just be very very careful and comfortably ask just say are you okay with discussing this with your partner what kind of sexual practices do you involve yourself so and again you have to use your judgment to see if it's okay to ask them this question ask them this question because another really important factor here is people may be very well using protection all the time but people may not be using protection for oral sex and that's a great transmitter for hpv and that's a great transmitter for other stis so hpv is particularly important we need to remember that because hpv is responsible for our referential cancers it is responsible for cervical cancer it is responsible for anal cancer for penile cancer for so many cancers so just knowing your patient's hpv status is helpful which brings me to my next question you ask them about protection when i mean protection you don't mean just contraception you mean are they protecting themselves from stis there's two ways to ask this there's two things you have to ask here which is in their protection are they using any device which means are they using an intrauterine device are they using order contraceptive pills are they using condoms and do they have the right vaccinations so in terms of vaccinations you want to ask about hpv you want to ask about hepatitis b we might judging by how the news is going soon enough having hiv vaccination keeping our fingers crossed so maybe we'll be able to add that to our list but at the moment you definitely want to ask for hpv and it's um sorry hepatitis b if your patient is not vaccinated against hpv and they're sexually active or they're not sexually active please encourage them to get vaccinated the vaccine is 2 000 rupees it's a 0 1 6 schedule and um if your patient is under the age of 15 i think or 13 i'll check on that and get back to you um it's two doses if they're over the age of 15 to 45 it's three doses so please make sure you get your patient vaccinated i've already told you the importance of cervical cancer in our country it's very rampant and more than 90 percent of also because 99.7 to be precise uh of cervical cancers are linked with an hpv infection and there's like two strains that are most commonly cancerous there's four in on in general but two that are the most common so it's very simple please try and encourage your patients to get vaccinated so we covered three ps partner practices protection now you go to the fourth one which is the past history and in past history you ask about your patient how to deal with women of rural areas with low literacy they even try to tell simple gynecologists like last menstrual dates and all especially when we ask them as a final year student okay so a lot of these uh is the hpv vaccine available for boys in india so merck released their um what is that press release where they said that they've launched gardasil 9 for men as well that's from september 21 but so far i have not encountered a single doctor who has either talked about this or given this so if this may just be your press news i don't know if this is there practically so far in india and all the guidelines i've read they don't give it to them i may be missing this piece of information i will check once again and get back to you but at the moment from what i know we don't give it even though there is this press release that's very commonly cited okay so uh talking about this rural area question i feel like when you're taking your history in final year you don't have the space to ask these questions anyway you have to be more quick with your history you have to be more focused on infectious diseases because that's all your professors will focus on and rightly so we have a lot of intellectual diseases in india generally so you may not have the space to ask this question i am speaking more specifically in terms of when you have your own practice or when you start seeing patients from an area that people will discuss this because let's be honest how many times have you had an sms from a friend panicking about missing their video or their girlfriend missing their period i think maybe once a week maybe once a month at least you would definitely get it so i believe this is more important for a real world scenario in my experience in medical school i genuinely did not get the space to ask these questions with rural patients instead of discussing such a detailed thing what you want to do is you want to start with whatever whatever you want you don't have to ask them the sex assigned at birth you don't have to ask them their current gender identity because most often they will not discuss it even if they identify something else they'll feel they'll get hit at home they won't get into it then you ask for consent this is a simple matter of establishing patient autonomy and respect and it allows them to open a better when you get into the five ps you speak with the partner you ask them about their partner that they have you ask them he generally what we doing in not guinea infertility is the and in this case you can generally ask them instead of going to practices because they will not tell you practices if there's anything happening that is not you know vaginal sex um you can ask them about me which helps you focus on um what kind of conditions this patient might be at risk of say for example in rural areas i find that there's a lot of beauty smoking and they are on asha didi has prescribed them oocps so you already have an increased risk of vascular thromboembolism you would want to avoid your vte risk so you either consult them that bdd or you counsel them keep your contraceptive method used this is something that is impacting the entire health of this patient so you have to be very very careful um which is why i really want to focus on more sexual history taking and this is why that's all i want to talk about today okay so understood thank you um all right so we've talked about partners practices and protection and this is where we ask about past sexual history which is where we ask about any history of stis or any history of sds in their partner or any history of hiv if you are interacting with a rural audience if you are interacting with truck drivers you will know that there is an increased risk of hiv positive patients um people who are involved in the transport business tend to visit um professional sex workers more often and tend to also engage in unprotected sex so very very important to ask them if they had any hiv tests don't say aids they will run out of the window screaming say hiv if they know they will know if you have a more educated patient you can ask them have you had any sti test or any hiv test before what about your partner and the last question is pregnancy this is so important and so frequently missed because this is where you want to ask their intent of pregnancy do they want to get pregnant do they not want to get pregnant which also ties in really well with the protection question the reason why i ask you to ask this question is because there is so many myths about birth control pills everything and birth control bills are very very safe they have a cancer protective effect aside from bt phenomena and say migraines in which situations you want and and knowing your patient's past medical history you will already know what is the best contraceptive for them by this stage do ask them about their intent for pregnancy if they are intending to get pregnant try to cancel them a little bit if they're slightly older say if they're over the age of 32 always ask them to get their amh tested always ask them to get their hormones tested to see what their ovarian reserve is like how their fertility status is if they have a history of obesity you want to counsel them a little bit about weight loss that increases their chances of getting pregnant so holistic picture the pregnancy is a very important question so the five ps just so that if you have a pen and paper you can write down partners partners is how many um have they had other partners who they have other partners at the moment practices what kind this depends on your judgment if you need to ask this question or not next is protection protection is condoms versus vaccines as well for a more educated audience you will find that they might be vaccinated hepatitis b um past history of stis uh you your partner and hiv and pregnancy what are the clinical relevance oh well it's something else okay what are the clinical developments for salpingitis so salvantitis is encountered very often in pid which is often encountered in untreated stis so if somebody has a long-standing history of chlamydia gonorrhea you can find there might be an ascending infection and you might find that salpingitis this is where your longer history taking might help you can ask them if you do your pain and socrates we use socrates in india what do we use the last idea we use socrates so socrates is sight onset character radiation [Music] associated factors you know what i'm talking about yeah so when you take the pain history you take the longer mnemonic in this it's really important actually this is where i'm leading to next so um after your five p's just ask your patient what their concerns are the best way to start any history in my experience is when they start rambling because they often ramble so much and give you such nonsense information you just stop them and say ah what brings you to the hospital today that immediately tells them so you'll know maybe this patient has a history of sciatica and today something happened and you get them right you you delve more into it so ask them their concern ask them why they're at the hospital and you want to start with open-ended questions and then move on to close-ended questions don't then you move on to your patient's specific history where you're going to socrates side onset character radiation association time exacerbation and severity i will not get into this medicine postings so let's move on to the four main things you need to focus on in a grinding history and then the five main things you need to focus on in a um andrological history so pain always make sure you're asking about pain why is pain important it can suggest a history of endometriosis of an ectopic pregnancy somebody said pid so uh somebody says hypnotitis or pid always always ask for pain and when you're asking about pain ask for generalized pain and ask for specific pain in safe sex if somebody is having painful intercourse which is dyspariunia it might suggest a history of vaginismus it might suggest a history of vaginal atrophy it might suggest menopausal people i find it very difficult to ask them this question but if you have a menopausal patient that's having recurrent uti always always always ask them for prosperium as well because recurrent utis and i treated so many of my family members for this by just giving them vaginal estrogen vaginal estrogen doesn't come with the side effects of systemic estrogen and why is this posed it doesn't come with the side effects of systemic estrogen and you treat recurrent utis you treat vaginal atrophy half their problems are solved so always make sure you are asking for a history of pain then you go on to history of bleeding now history of bleeding you can ask in three ways so aside from menstrual history maximum bleeding can be anything it can be a cervical ectropion it can be implantation bleeding it can be ovulation bleeding there can be so many reasons so that will be a more in detailed history probably in your menstrual history section then you ask about post quality this is super super important postcard bleeding immediately suspect c a cervix c endo do not let this go i'm sorry i just saw specific history physio cervix can cause the regions of mucosa which may partially completely block the human of the uterine tubes so are you speaking more in a infertility specific way because i find that we have a tendency of over diagnosing perfect tuberculosis and over treating pelvic tuberculosis if there's a patient with any history of infertility more than six months automatically you should conduct them which we don't require so you might want to be more specific in your um in your history taking and also in your investigations so um going back to post quarter bleeding be very very particular in asking about this because again immediately you can suspect c a and o you can immediately suspect c a cervix and the last is post-menopausal bleeding so many cases so many conditions vaginal atrophy you can assess the need for hrt and things of that sort after bleeding the other and i don't understand why this concept exists so rampantly in our country people think this child is abnormal and discharge needs to be treated discharge is perfectly normal please remember to drill this point inside your patient before you take a specific discharge history but always tell them [Music] that just it's so common so always start with this is normal if they're still extremely freaked out about it i'll describe a probiotic digestive health and a better microbiome which can help them generally in life so when you ask about discharge you want to ask about amount color and smell if the amount has changed dramatically you can suspect bacterial vaginosis you can suspect stis this is where you ask about color and smell if it smells like fish you know what i'm talking you you already know this i'm not going to get into this today you can suspect so many things if always educate them about color and smell and associated factors because if it's itching you know it's fungal if it smells like fish it's bb if it smells like i don't know so many things so um another thing that we forget very very often is skin changes the reason why i see that is because there's so many conditions that are progressive or can be diagnosed easily in skin changes that we don't ask they can process nigricans you have a history of insulin resistance or you have a history of pcos and so sudden pigmentation will change you can ask about sudden redness in the flexural areas so if discharge is large enough still normally it depends on other factors know if the discharge is coming with anything some people just normally have large amounts of discharge but if it's suddenly changing and overnight it's become very little overnight has become extremely large then you want to suspect something um a lot of times people don't have the ability to discern if the smell is normal or not because they've only smelt their own discharge this is where an examination can help and you can figure out if it obviously smells wrong often bv presents with bacterial vaginosis results with lots of discharge with a fishy smell or an ammonia smell so um ask them about any sudden changes that may have happened now for skin changes they can be it can suggest say a fungal infection it can suggest vulnerabilities again you want to link with any stis um i have personally seen that any parasitic infection usually comes with vulvitis i don't know if there's data to pack this up but this is just my personal experience so always make sure you ask about though bleeding and discharge always you always ask about failure to automatic doctor and then lastly remember to ask about skin changes now this is aside from everything you want to ask anyway and for men you want to again ask about pain this is important in diagnosing say orchitis or epididymitis the same comes with swelling so i hope you guys remember testicular cancer and i hope you remember that there's two peaks for it it's a bimodal distribution and the first week is in the late 20s early 30s this is most often when people also become sexually active so you can link this can happen in an sti as well so you can link or understand if this is if this patient is at an increased risk of ca or an increased risk of an sti and help diagnose them and treat them better very importantly remember this because most often men don't present with symptoms as usually their partner that will come into the clinic and if you're getting a partner in the clinic with any history of an sti please make sure to investigate and treat their partner as well i had one patient i'm so stupid it took me three months to understand this i had one patient who kept coming back to me for recurrent candida and i kept treating her with standard suppository and i was like she kept coming back for three months and after three months i realized some clinical infection hair and that's why she keep getting it back treated her partner i haven't seen that patient in a year or something so yeah always always treat the partner as well um so pain swelling discharge another insight into men's sexual health can often be through the urine so when we experience where women experience dyspharyunia this is where you can ask about dysuria or any related symptoms and skin changes its motor motor same same but just a little bit of a different um the last concluding points that i have in terms of sexual history taking is please remember to take three things smoking history this is extremely relevant especially for gynecological cases smoking automatically ups the risk of so many cancers and it's also very strongly linked with the obstetric history of the patient do they want to get pregnant are they trying to get pregnant they need to quit immediately and also the kind of contraception they are using please assess the risk of vte any family history of it or any history of migraine avoid this death so smoking history is extremely important and linking with the smoking history drug history is extremely important a lot of times people are frequent marijuana smokers when you ask them about smoking history they will say nothing any other drug history they'll be like allow them the space to tell you this because it's extremely important that they are able to tell you this and for you to make better health care decisions for them so don't be judgmental don't be like oh and last is wait please please please ask the wait history a lot of times something as simple as people find that they are very insecure about the size of their penis this i believe another a man will always tell other man so if you're a practicing woman doctor you're not going to get this question but say a person is extremely insecure about the size of their penis they lose weight and they think that their penis has grown bigger so weight history is really important it impacts the mental health of your patient weight history is important in terms of conditions like pcos like thyroid if you're finding that there is an obviously increase body mass in your patient you might want to investigate for any endocrine dysfunction there and also in terms of understanding say a risk of fertility issues there's like five percent weight loss ups your risk for getting pregnant by 22 that's the last that i remember unless it's changed but yeah so please remember smoking history drug history and weight history in weight history please remember to ask if the weight change has been sudden if there has been a weight change um and that's it please please please remember to be non-judgmental you want your patients to trust you and once they trust you they will tell you everything do we have any questions aside from the ones we've already covered oh yes sorry i forgot to address this can you explain again what should we ask are you married or sexually active i find again this is more dependent on your clinical judgment um most often if you have a patient from a rural background you want to ask them if you're married and then gently somewhere in the constitution when they start trusting you very gently ask them if they are married so that will they will hesitate but if they trust you by this point they'll tell you which is why i'm saying ask for consent put the autonomy back in their hands they will they'll tell you everything on their own you might not even ask them that question and they'll start telling you everything about their life history other than that i think it was a fabulous fabulous session and very lightly covered every aspect and uh uh it it does become very difficult to ask such questions and then you as a doctor can't really hesitate asking this because it really makes a lot of difference in everything not only understanding and the patient opening up to you but even in the diagnosis it does make a difference about getting all these smaller details um very nicely explained and very simply put so i'm sure all the practicing doctors out there uh are gonna use all these questions and uh in their practice yes without being judgmental about it and having their patients open up to them uh so we have one raised hand request i'll just uh take them up um oh sorry sure yeah we have dr devanchi that way i'm accepting your request hello hi i am just here to say thank you have been following your instagram since a long time and i am so glad we have doctors like you who explain us in ways we weren't taught in our mid school i'm just very glad and very happy with this session thank you so much thank you so much thank you hello hi hi hi hi uh so i'm here to say thanks as well as i have one question like uh so i'm a person who's from the rural as well as the urban i was born in a rural area and grown up in a urban area so there's a kind of this there's a lot more change from the urban areas this is the rural area and the way how they perceive things regarding to sexual care and a lot of things so you know this had a lot of change in my mindset and after watching your videos like i you know i was completely confident about these things so you know it made me brave made me confident in myself so thank you for that so happy to hear that thank you so much for sharing that and i hope i hope you're able to initiate that conversation in the rural space because i don't have the words to do that yeah sure i will but i think it will take some more time for me because after i finish my studies you know i'm gonna practice there so it will be more supportive for me yeah thank you for sharing that thank you thank you so much for coming up we have one question that's good come on info about sexual history create problems in the patient's relationships so my standard practice for this is when the patient comes into the chamber make sure they're alone they're not coming with anybody at all no mommy no daddy no [Music] sauce very important and nobody everybody out only even patient i mean that can be difficult in say a teaching hospital environment but when you have one one table one safe one consultant for resident doctors in that case when you are one of the resident doctors when you when you one of the interns make sure the patient is sitting by themselves and people around them the other patients that are there are not known to them this will enable them to help tell you stuff and just it allows for easier conversation i think yeah thank you um i think that was the end of the question i don't see anymore and you addressed all the questions as we went along through the session um thank you so much for coming in i know it's early in the morning there uh we hope look forward to your next session with us uh and thank you so much for coming in and thanks so much for having me happy weekend everyone bye bye

BEING ATTENDED BY

Dr. Darius Justus & 726 others

SPEAKERS

dr. Tanaya Narendra

Dr. Tanaya Narendra

MBBS, MSc (Oxon), FRSPH, Internationally trained medical doctor | Embryologist | Scientist | Awarded Influencer of The Year 2020 by SH24 - the online sexual health partner of the NHS, UK | After study...

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dr. Rohan Desai

Dr. Rohan Desai

MBBS | MBA, IIM-A | Founder & CEO, PlexusMD

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dr. Tanaya Narendra

Dr. Tanaya Narendra

MBBS, MSc (Oxon), FRSPH, Internationally trai...

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dr. Rohan Desai

Dr. Rohan Desai

MBBS | MBA, IIM-A | Founder & CEO, PlexusMD

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