MDCN Clerking Vesico-vaginal Fistula

Introduction and Biodata

Reproductive profile
-LMP -Parity -Gravidity -Last childbirth
Presenting Complaint  Trigger
Dribbling of Urine (from vagina)  Timing
 When?  Aggravating/relieving factors
 Duration  Periodic/constant wetness
 Onset Associated: excoriations, rashes, itchiness, and
 How many pads odour.
Causes  Hx of blood(menses) in urine
 Hx of prolonged labour  Faeces/flatus per vaginum
 Past pelvic surgeries  Past GDM
 Untreated STI  Instrumental delivery/vaginal tear
 Rape/sexual abuse  Unsafe abortions
 Age at first pregnancy  Radiation exposure of the genitals
Complications  Fever and abdominal pain
 Limb weakness/inability to control  Hx of amenorrhea
 Reduced appetite, low mood, insomnia  Gynaetresia, infertility, ulcers, vaginal scarring.
and marital discord.  Dysuria, loin pain
 Spending a lot of money  Feeling of shame and self-pity
Care received
 CBC  Drainage of bladder with catheter
 Urine MCS  Antibiotics
 EUCr  Hospitals for Surgery
 Swab test to differentiate  Prayer house
 Cystoscopy  Traditional medication
Past obstetric history Natal
Antenatal Postnatal
Gynecological History  Use of contraceptives
 Menarche  Pap smear and result
 Menstrual cycle duration, regularity  STD hx
 Dysmenorrhea, menorrhagia, dyspareunia  Abortion hx
Drug history
Past Medical history + cough, pelvic fracture
Family and social history Living condition
Difficult labor Alcohol or smoking
DM or GDM in family Domestic violence
Systems review

Please note that this is not the exam checklist and only aimed to achieve excellence, the questions above
should be asked using properly constructed tenses without abbreviations nor medical jargon.
It is assumed that the parts of the history without questions have been mastered and should compulsorily
be asked without need for a checklist.