Clinical approach to gynaecological patient(part 2

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  • 1. CLINICAL APPROACH TO GYNAECOLOGICAL PATIENT(PART-2) Prof. M.C.Bansal. MBBS, MS. FICOG, MICOG NIMS medical College ,Jaipur. Founder Principal & Controller ; Jhalawar Medical CollegeAnd Hospital , Jhalawar. Ex. Principal & controller; MahatmaGandhi Medical CollegeAnd Hospital , Sitapur, Jaipur .
  • 2. Pre requisites for clinical examinations  Thorough clinical examination is essential and integral part of clinical approach to any patient ; to reach the provisional diagnosis one should co relate and analyse the positive as well as negative points noted in history taking and findings of clinical examination.  On the basis of probable cause; necessary and relevant investigations should be ordered . , their interpretations must be done in the light of above findings and analysis done ___ final diagnosis so derived is more likely to be exact and true.  Reaching to diagnosis by short history / few clinical finding is always deceiving.
  • 3. Pre requisites for clinical examinations--- Ensure adequate Privacy .  Good and sufficient light (As good as natural color).  Take consent of parent/ guardian if patient is minor / patient herself when major.  A female nurse/ her relative should also stand near by when female patient is examined., so that intensions of gynaecologist are not misunderstood.  Keep all necessary equipments before patient ‘s examination is started; weighing machine, measuring tap, height measuring scale stand ,Bp. Instrument, torch, Pair of gloves, appropriate size and variety of vaginal speculum, swabs ( dry, soaked with antiseptic), swab sticks for collection of discharge for office procedure for wet film- microscopic examination / culture , glass slide and cover slips, Ayres spatula ,carrying /preservative media and cervical brush for pap smear , acetic acid 1-5% , Lugols iodine, saline for colposcopy or simple naked eye inspection of cervical lesion.  This will make the examination quicker, complete and comfortable to both patient as well as patient.
  • 4. General physical examination  Height , weight –calculate BMI.  Nails , palms --- for pallor , pigmentation, palmer arrhythmia, clubbing, platynaechia ,fungal infection of nails.  Carrying angle of elbow in turners .  Axilla –hair growth, lymph nodes .  Neck –Webbing of neck , thyroid goiter, lymph nodes tubercular chain / healed sinus scar/ wircow’gland in left supra clavicular region – metastasis in ca cervix / ovary.  Eyes– conjunctiva—pallor, sclera--- jaundice.  Face– hair growth--- hirsutism(use Ferriman-Gallway score ) / familial hypertrichosis , achne – PCOD / steroid or OCs therapy.
  • 5. Skin Pigmentation (palms) in secondary Syphilis
  • 6.  Increased carrying angles, shield chest, no development of secondary characters , stunted growth ( height and weight)
  • 7. Webbed Neck
  • 8. Female Development Height Age
  • 9. Hirsute
  • 10. Klinfelter’s syndrome
  • 11. Precocious puberty in girl at 8years age.
  • 12. Well developed Breast No Pubic hair
  • 13. 7 & ½ years old Girl with well developed Thalarche, puvarche and regular menses ( Homlogous precocious puberty)
  • 14. Testicular faminizing syndrome—Breast developed, tall girl , primary amenorrhoea. , no pubic hair inguinal hernia may be there containing testicle absence of testicular receptors at end organs prevent in development of wolfian duct, but neutral development makes one to look like female ; as mullerian system development enzymes are also not secreted by testicles the mullerin duct development is also not fully supressed . It remains under developed as estrogen is not produced . Brest development is under adrenal androgens
  • 15. 16 years old girl with 46xx , dysplasia , no secondary sex characters yet developed , reporting as a case of delayed menarche
  • 16. General Physical Examination cont-- Scalp—hair loss –secondary to chemotherapy, receding hair line in musculinizing conditions .  Note --- BP, Pulse , respiration, temperature,Gait, edema, vericos e veins .  Other group of lymph nodes --- inguinal.  Development of secondary sex characters --- > Breast development. > Axillary Hair. > Pubic Hair.
  • 17. Blood Pressure Recording
  • 18. Stages of development of breast
  • 19. Examination Of Breast  One should never forget to examine the breast  Adolescent girls presenting w2ith amenorrhea(primary)—may have under / undeveloped breast for the age and breast development should be assessed according to tanner’s staging .  Women with secondary amenorrhea may have galactorrhoea---Post Pill, prolactin secreting pituitary tumor, hypothyroidism, drug induced .  Woman. Should be taught to-do self breast examination.
  • 20. Method of breast examination  Clinical examination of breast should be carried out with the pads of 3 middle fingers of both hands , with the patient(raised arms above her head and arms by side of her chest ) while she is sitting on stool / in supine position lying down on examination coach.  Each breast should be examined systematically for lumps if present –size location mobility , consistency and nipple discharge if present should be collected on glass slide for microscopy.  Compare both the breast in each aspect .
  • 21. Systematic Breast Examination  Position –sitting with arms raised.  Extent ---lateral boarder of sternum to posterior maxillary line and from clavicle to costal margin.  Inspection ---col0r of skin, pigmentation , engorged subcutaneous blood vessels, edema , dimpling , puddie –orange skin. Nipple retraction , nipple eczema.Any visible swelling, ulcer, accessory nipple.  Palpation --- nipple discharge , palpable mass / cyst---its size location, boundaries , mobility , consistency , adherent to skin / underlying pectoral muscle, tenderness, local rise in temperature and surrounding tissue thickening.  Regional lymph nodes --- axillary group and supraclavicular.
  • 22. Picture of self examination
  • 23. Stepwise Self Examination of Brest Stand in front of mirror and look at your breast well expose as in previous slide- Step 1-- to look at breast while standing with arms hanging next to the body . Step2– Look at breasts when arms are behind your head. Step 3– look at breasts while arms are by the side with hands resting at hip bones. What to look for ? Look for any change or difference in color, size shape, dimpling , any visible prominent swelling in any part of either breast. Look for any in drawing / retraction of nipple. Step 4– feeling of( palpation ) whole surface and consistency of either breast with flat of all the fingers pressed firmly against breast( right hand for left and left hand for right breast ) in a circular fashion ; starting from areola to its margins e.g from chest bone to the fold of arm pit and from collar bone to lower limits of rib boarder. Brest is even and any abnormality can be appreciated easily in the form of nodule/ swelling . . Feel the arm pit for ant nodule / swelling in the tail of the breast / lymph nodes. Step 5--- Nipple is picked in thumb and index finger, lit it out , sqeez for any discharge --- milk, watery/ blood stained. Step 6--- Feel for breast and nipple in the same manner as in step 4&5 , but
  • 24. Picture of clinical examination
  • 25. A & B Pagets disease of nipple C –Benign Reactive Dermatitis
  • 26. Inflammatory carcinoma of breast
  • 27. Systemic Examination  CVS– heart sounds, any murmur , parasternal heave , Epigastric pulsation, prominent jugular veins. Compare all the peripheral pulses in cases of turnner’s syndrome as coarctation of aorta may co –exist.  Respiratory system--- Rate, breath odour, cynosis , clubbing , breathlessness at rest / exertion/ bilateral lung examination--- air entery, chest movements, percussion (any dullness or hyper resonance) , breath sounds and adventitious sounds( crepitation , ronchi, plural rub etc).  Spine-- scoliosis, lordosis. Kyphosis, fracture spine / tenderness over any spinal vertebra especially in menopausal women .  Mental function – orientation to place, time . Pituitary dwarf are intelligent and have poor sex development while thyroid dwarfs are having low IQ.  CNS--- when intra cranial lesion is suspected.
  • 28. Abdominal Examination  Inspection---color of skin, pigmentation , caput medusa, prominent veins and direction of blood flow in them, protrusion of umbilicus/ its displacement. Umbilical slitting –transverse or vertical, thoraces-abdominal respiration , shape( saphead / distension may be due to fat , as cites, fetus , mass. Distended bladder, flatus and faeces).Hernia sites ,striae gravidorum , linea nigrans and albicans, bruises ., visible pulsations --- intestinal / aneurism of abdominal aorta.cunter irritation marks/ scar of previous surgery.
  • 29. Hernia site in Anterior Abdominal Wall
  • 30. Hernia sites and type of hernia in Inguinal region Femoral
  • 31. Scaphoid abdomen
  • 32. Abdominal wall Hernia
  • 33. Ventral hernia
  • 34. Pelvic mass
  • 35. Giant abdominal Aneurism
  • 36. Abdominal Palpation  Palpation should be started from the are which has no pain .  Palpate for liver , spleen and kidney enlargement if any present and describe it well in terms of size, shape margin ,consistency surface, margin and tenderness ?  If mass is present – its localization and extension in abdominal quadrant quadrants; is it arising from pelvis (lower pole can not be reached as it is below symphysis pubis joint) ,is it arising in abdomen and growing down?. feel for its shape, margins all round, consistency(soft, solid . Firm. Hard, variable , mobility—(up --down , side to side or tangential to line of attachment of mesentery, does the abdominal wall moves over it with respiration), nodularity , oblation. Any tenderness ,muscle guarding / rigidity. Rebound tenderness.
  • 37. Bimanual palpattion for lumber mass
  • 38. Abdominal percussion  For generalized dull note --- ascites ,fluid thrill and shifting dullness can be noted.  Abdominal mass maybe dull with in its boundary ( if cystic fluid thrill may be present) rest abdomen will be resonant as in cases of large ovarian cyst / hydronephrosis.  Solid tumors will be dull.  Hyper resonant abdomen present in cases of intestinal obstruction due to distended bowel loops with gases.  Liver dullness is obliterated in intestinal perforation / or after pneumoperitoneum create in laparoscopy.
  • 39. Percusion of enlarged spleen
  • 40. Abdominal Auscultation  Very useful to auscult intestinal sounds --- if absent, paralytic ileus –high pitched exaggerated sounds in intestinal obstruction ; rarely a bruit may be heard on hyper vascular fibroid .  Pulsatile tumor may be aortic aneurism / solid tumor sitting over normal aorta may also conduct sound .  Bruit in renal angle present in cases of renal artery aneurism ---- secondary Hypertension
  • 41. Abdominal Auscultation
  • 42. Examination of Female Genital Tract Positions --- dorsal, left lateral ( sim’s ), Knee elbow .  Examination is usually performed in dorsal position with hip and knee flexed and feet resting on the examination couch . Her buttocks are brought down to the edge of tail end of the couch.  Lithotomy position with legs in strips is to combersom to patient for examination in OPD. It is used in MOT while doing short office procedure with / with out sedation.  Gynaecologist stands on her right side nearer to her foot end.  Head of patient can be with pillow raised to relax the abdominal muscles.  Examination is conducted in the same order as described in next slide
  • 43. Lithotmy postion for office procedure and surgery through vaginal route
  • 44. Examination 0f Child Examination of small child by putting Her in the lap Of Her Mother
  • 45. Common sites of tenderness at vulva
  • 46. Photomicrograph of Burrows with Scabies . A Mite is seen (far right ) with seven eggs
  • 47. Pubic Lice in Hairs & Lice
  • 48. Benign skin Tag at vulva
  • 49. VitiligoOfVulva
  • 50. VitiligoOfVulva
  • 51. InjuryVulva --Haematoma
  • 52. PsoriasisOfVulvaal SkinAs a Part of Generalized Skin disorder
  • 53. Cadidiasis in diabetic Old women
  • 54. Lichen Sclerosis ofVulva
  • 55. Cancer of vulva
  • 56. Labial Adhesions
  • 57. D/D of thee CommonTypes OfVulvar Ulcers
  • 58. Kissing ulcers atVulva ( chancre ---Primary Syphilis )
  • 59. Condylomat Lata --Secondary Syphilis
  • 60. Shallow, Painful, multiple ulcers due to Herpes simplex viral Infection
  • 61. Genital warts (HPV infection)
  • 62. Groin Sign In Lympho grannuloma inguinal BUBOS ( enlarged L. N. Inguinal Ligament
  • 63. Deceits Ulcer
  • 64. Uterovaginal prolapse Cervical Rim Inversion of Uterus
  • 65. Vulval Contracture—narrow Introitus ---Leucoplakic changes in old women
  • 66. High Gr5adeVIN with Pigmentation atVulva
  • 67. Vin and Leucoplakia Vulva
  • 68. Molusca Contasosium
  • 69. Bartholin Cyst
  • 70. SolidTumor ofVulva Biopsy revealed Endometrial Carcinoma ; MetastasisTo clitorus
  • 71. Shapes of Hymen
  • 72. Imperforated Hymen
  • 73. Genital Ambiguity GirlWith 46,XX
  • 74. !9Yrs old girlWith Secondary Amenorrhoea Acne, Hirsutism, Flattened Breasts -- < in height than her younger Sister and mother
  • 75. UlcerVulva In Childhood
  • 76. Male Pseudo Hermophrodite
  • 77. Female child 46 XX with congenital adrenal hyperplasia -----clitoral enlargement , fusion of poorly developed labia with narrow vestibule --- urethral and vaginal openings
  • 78. Clitoral Enlargement In female hrmophrodyte secondary to congenital adrenal hyperplasia
  • 79. RudimentaryVulva, small phallos , hypospedius
  • 80. Candidasis of vulva in Child Girl with Dermatitis
  • 81. Botryoid Sarcoma Protruding throughVaginal Introitus in Girl
  • 82. Vaginal Per Speculum ExaminationVagina Cervix Color Dryness / discharge Mucosal Lesions Cysts Growth Bleeding from vaginal Mucosa. Structural anomalies Color External OS Tears lacerations Ectropion Erosion ulcer Sqamo columnar Junction Transitional Zone . Discharge. Nebothian Follicle / cyst Polyp / growth/ protruding IUCD thread Bleeding on touch Bleeding through os Examination after application of acetic acid and Lugol’s iodine with naked eye if needed ---Colposcopy as office procedure
  • 83. Bi valveVaginal Speculum
  • 84. Bivalve Cusco’s Speculum Examination
  • 85. Sim’s speculum with anterior vaginal wall retractor
  • 86. Endo Cervical Speculum Exposing the Cervical Canal
  • 87. Endo Cervical POLYP Cervical Rim
  • 88. Scamo columnar Junction
  • 89. Chronic Cervicitis -- hypertrohied Cervix -- Nebothian Follicle
  • 90. Distilbestrol Exposed ( Inta uterine life)—Cervix with vaginal fold ( arrow )
  • 91. Cervix After application of AceticAcid 5% cervical Erossio Aceto white Area
  • 92. Cervix After ApplicationOf Lugol’s Iodine Unstained area –site of immature / cin Collumner Epithelium Iodine stained Area– high glycogen content in healty mature Sqamous epithelium
  • 93. Low Grade CIN
  • 94. CINGrade 3With Mosaic pattern
  • 95. Abnormal vascular pattern in CIN
  • 96. Inasive Cancer Cervix
  • 97. Post coital injury --- Eversion of vagina
  • 98. Abdomino- pelvic Bimanual Examination  Gloved, lubricated index and middle fingers are insert in vagina after cleaning vulva and vestibule with antiseptic lotion and separating both labia with the finger and thumb of left hand.  Once internal finger reach the cervix the palmer surface of all fingers of left hand are placed parallel to S.P. over supra pubic lower abdomen.  Direction of cervix is decide – forte ward ( if external is facing to and anterior lip is near to S.P. / Backward when external os is facing posterior fornix and anterior lip is facing posterior vaginal wall. Feel for its consistency(soft in pregnancy / firm – normal / hard in malignancy . tender Cx on movement --- ectopic/ acute inflammation. Ulcer / protruding growth /polyp / valvety erosion and IUCD thread may also be felt ; protruding down in / through cervical canal , slippery shaft , smooth mucous polyp may some time be present.
  • 99. Abdomino- pelvic Bimanual Examination Now put your both fingers in posterior fornix , uterus is pushed upward and anteriorly towards the abdominal hand and uterus is palpated between two hands --- its size , shape , surface , consistancy and tenderness.  If uterine fundus and its posterior surface can be palpated ---uterus is ante flexed (AF) ante verted (AV) , if uterus can not be lifted and its fundus is posterior in POD ---it is retro flexed (RF) and retro verted ( RV )
  • 100. Abdomino- pelvic Bimanual Examination  The normal uterus is anteverted, anteflexd , pear shaped firm,6-7 cm long and 4cm wide at its fundus. mobile regular and non tender.  Normal adnexa is not palpable , all fornices are free / empty, non tender .  Ovaries are about3x2 cm in size and usually not palpable unless enlarged.  Palpable ovary in menopausal women should be viewed with suspicion.
  • 101. Bimanual Abdomino –vaginal examination
  • 102. Abdomino- pelvic Bimanual Examination  Vaginal fingers are now to lateral (right and left ) fornices respactvely to palpate ; while abdominal hand is placed just medial to ipsilateral anteriosperior iliac spine well above the poupart’s ligament and adnexa is palpated in between two hands.  Some time to palpate thickening / induratin / infiltration in recto vaginal fascia one has to per0form bimanual rectal and vaginal examination at the same time ---index Finger in vagina and middle finger in rectum with their pulp facing anteriorly; left hand is put on abdomen as usual for performing bimanaual palpation.
  • 103. Bimanual Pelvic Examination – PV and PR simultaneously; to palpate the involvement of anterior Rectal and posteriorVaginal wall By malignancy / Endometriosis
  • 104. Bimanual examination – findings to be noted-----1. Uterus Anteverted / anteflxed / midposition / shifted to right or left side of mid line/ retroverted / retoflaxed. Size—normal / enlarged ( measured in terms of enlargement as in gestational period ) Shape –regular/ irregular Surface – smooth / bossed / uneven consistency– firm / soft / heard / variable Mobility– mobile / fixed / restricted. Tenderness– absent / present
  • 105. Bimanual examination – findings to be noted----- 2.Adnexa--> Palpable / not palpable size –in approx Cm in all diameters—longitudinal / transverse / oblique. Shape Surface – regular smooth / nodular / lobulated. Unilateral / bilateral consistency--- soft/ cystic / firm / hard / variable. Mobility --- mobile/ fixed / restricted . Tenderness --- absent / present . Induration . Attachment to uterus --- does it move with uterus or cervcal movements / while moving the adnexal mass uterus/ cervix also move . 3. Pouch Of Douglas  Any mass / thickening nodules fixed / fullness / tenderness / raised local temperature / consistency of mass / fullness. 4.Per rectal Examination  thickening / indurations / adherent / ulcerated anterior rectal wall / sacral ligament / recto vaginal fascia.
  • 106. Bimanual Examination --- Uterus1. Consistency Soft--- Pregnancy , pyrometer Hard --- Malignancy, calcified momma 2. Enlargement Regular---- Pregnancy, adenomyosis, pyometra , Haemtometra , carcinoma . Irregular--- Myoma, endomatrioma. 3. Mobility  Mobile--- Myoma , adenomyosis, pregnancy. Fixed / restricted---PID, Endometriosis,malignancy. 4,TendernessAdnomyosis, pyometra, haematrometra / PID
  • 107. Bimanual Examination ---Adnexa Size Large >10cm Bilateral Malignancy Malignancy Shape Retort Shaped Hydrosalpinx Mobility Mobile Fixed Benign ,non inflammatory mass Endometriosis , PID , Malignancy. Consistency Cystic Solid Variable consistency Benign tumor Malignancy, broad ligament fibroid Inflammatory / malignancy Tenderness Tender Inflammatory ,
  • 108. Bimanual palpation of Uterine fibroids
  • 109. PV examintion in OvarianTumor __lump is separate from normal sized Uterus
  • 110. pelvic mass in left Fornix lateral and separate from Uterus , there is free area ( cleavage in between Cervix and medial side of lower pole of tumor Cleavage/ free area Cervix tumor
  • 111. Differentiating uterine from adnexal mass Criterias Uterus Adnexal mass Location Central lateral Size normal in size uterus / if enlarged its size varies Palpable if enlarged adenexa Groove between mass and uterus absent present Transmitted mobility present Absent
  • 112. Special situations  Children, adolescent and old women present special situation.  Children – local examination of vulva and vestibule should be examined in presence of and with the help of her mother in separating thighs and labia apart, speculum and pv examination is not done if indicated ; it can be done under general anaesthesia by using nasal speculum . Pr with little finger will replace pv examination.  Adolescent Girls  avoid speculum/ pv examination , pr can be done, if pathology is highly suspected USG can help ; still some vaginal examination / procedure is must the it should be done after proper counselling , proper consent and under sedation / anaesthesia.  Post menopausal women with narrow introitus due to estrogen deficiency --- small size speculum with lubrication should be used.
  • 113. Screening / diagnostic procedures done at the time of gynaecological examination  Pap Smear .  Examination of vaginal / cervical/ nipple discharge. A- saline preparation ; B- KOH preparation ;C- Gram staining.  Endometrial sampling.  Culdoscentesis.
  • 114. Current Recommendations For Pap Smear.  Start at the age of 21 year --- if sexually active.  Once in 2 years till 30 years age .  Once in 3 years there after --- if HVP DNA negative , low risk factors present for developing Ca Cervix, last 3 samples are negative.  Annual Screening ---High risk for cancer / HVP DNA positive.  Stop at 65 age if no positive smear in last 10 years.
  • 115. Diagnosis of vaginitis by Examination Of DischargeDiagnosis (Chief complain) Wet Film KOH Preparation Gram Stain BacterialVaginosis ( Watery vaginal discharge with bad smell) Clie Cells Fishy odour (Amine) T.Vaginalis Vaginitis ( cream colored frothy vag. Dis.With burning at vulva) FlagillatedOrganism Candida Albicans ( thick curdy vag. Dis. With itching at vulva) Fungal Hyphae , Spores Gonococcal cervicitis ( dysurea, mailase feverish ness Gram Negative , intra cellular diplococci.
  • 116. Clue cells in Vagnalis vaginosis (Squamous Epithelium Cells Loaded with Anerobes – Gardenella Gondi
  • 117. Large Motile Protozoa--- Trichmonas Vaginalis. Flagella Nuclus Undulant Membrane Inclusion Bodies in Cytoplasm
  • 118. Candida Albicans ( Hyphae & Heads)