GYNECOLOGICALCASE TAKING9 May 2013 Osama M. Warda, MD
The gynecological diagnosis:The ideal gynecological diagnosis includes the following:Etiological diagnosis; including the offending cause.Anatomical diagnosis; including the anatomic alterationFunctional diagnosis; including disordered function.9 May 2013 Osama M. Warda, MDThese 3 items are most evident practically in the diagnosis of aExample :.descentgenitalcase ofPostmenopausal [etiological diagnosis] urethro-cystocele,rectocele, 2nd degree uterine descent [anatomicaldiagnosis], supravaginal elongation of the cervix, cervicaltrophic ulcer, positive stress incontinence [functionaldiagnosis].
H I S T O R Y T A K I N GItems of history taking include the following:1-Personal history.2-Complaint.3-Menstrual history.9 May 2013 Osama M. Warda, MD3-Menstrual history.4-Obstetric history.5-Past history.6-Family history.7- Sexual history; only in cases of infertility.8-Present history.
PERSONAL HISTORY; AGEKnowing the age of a gynecologic case is of great help in diagnosis becausecertaine gynecological diseases are common in some age groups than othersAgeperiod Common gynecological disorderInfancy & childhood[birth-to-9 years)Birth crisis, witchs milk, ambiguous genitalia,sarcoma potyroides, some malignant germcell ovarian tumors, precocious puberty,vulvo-vaginitis of children, iatrogenic9 May 2013 Osama M. Warda, MDAdolescence &puberty[9y-16y]Dysfunctional uterine bleeding(DUB),primary amenorrheaChildbearing period[16y-40y]Pregnancy complications, infertility, genitalinfection, benign tumors (e.g. fibroid)Perimenopause[45-55y]DUB, tumors (benign &malignant)Post-menopause Malignancy, estrogen-deficiency sequelae
Personal history.-genital prolapse-Cancer cervixOccupation:-endometriosis.:Marital status & number of living offsprings-. Early age at the 1st coitus (<15 years),…CX9 May 2013 Osama M. Warda, MD. The presence of sufficient number of children may bea determining factor in selection of the surgicalprocedure in certain diseases; (OV. CA), PROLAPSE OPsmoking may be a risk factor forSpecial habits:-cervical neoplasia, however it is said that it hasprotective effect against endometrial carcinoma.see obstetric casePersonal history of the husband:taking for details.
COMPLAINT:- The gynecologic case may complain of one ormore of the following 5 complaints: pain,bleeding, discharge, swelling, or infertility.9 May 2013 Osama M. Warda, MD- Complaints should be in the patient’s own wordswithout using scientific terms.- Complaints (if more than one) should be arrangedchronologically ( i.e. according to the onset oftheir occurrence). Or they may be arrangedaccording their importance from the patient’spoint of view.
MENSTRUAL HISTORY:The items of menstrual history include the followingitems in sequence:st menses in the1st day of the1It is the:Menarche-1woman’s life. Menarche is the climax of the pubertalevents including breast development ( thelarche),axillary hair development (adrenarche), pubic hairdevelopment ( pubarche), and growth spurt.9 May 2013 Osama M. Warda, MDdevelopment ( pubarche), and growth spurt..whether regular or irregular:Cycle rhythm-2st day of1It is the duration from the:Cycle length-3the cycle to the 1st day of the next cycle. The normalcycle length simply ranges from 21 to 35 days.It is the period of time:Duration of menstrual flow-4during which menstrual blood flows through thevagina. The normal duration is 2-8 days
MENSTRUAL HISTORY:the characters of menstrual flowCharacter of flow:-5regarding amount, color,and odor should bementioned.It is a pain related to menses severeDysmenorrhea:-6enough to prevent the woman from doing her usualdaily activities.It is the period fromThe intermensrual period (IMP):-79 May 2013 Osama M. Warda, MDIt is the period fromThe intermensrual period (IMP):-7the last day of flow to the 1st day of the next flow. Thepresence or absence of pain, bleeding, or dischargeshould be asked for.The type of theThe current use of contraception:-8contraceptive method as well as the duration of its useshould be asked for.:st day of the last normal menstrual period1The-9PRE-MID, OR POST MENSTRUAL?
MENSTRUAL HISTORY:MENSTRUAL FLOW INTERMENSTRUAL PERIOD1ST DAY1ST DAY2-7DCycle length = 3-5 WEEKS9 May 2013 Osama M. Warda, MDTerm DefinitionMenorrhagia Excessive and/or prolonged cyclic bleedingMetrorrhagia Irregular (acyclic) uterine bleeding not related to mensesOligomenorrhea The cycle length is more than 35 days (i.e. infrequent menses)Polymenorrhea The frequent menstruation i.e. the cycle length is less than 21 days.Hypomenorrhea Is the scanty menstrual flow.Hypermenorrhea Is a cycle with excessive menstrual flow with normal duration.
OBSTETRIC HISTORY:Gravidity & parity.Full term normal pregnancies (FTNP).Full term normal deliveries (FTNDs).Preterm labors.Stillbirth (SB).9 May 2013 Osama M. Warda, MDStillbirth (SB).Difficult labors.Cesarean sections (CS).Last delivery date.Abortions.Puerperia.
PAST HISTORY:Past history of similar condition.Past history of medical disease: such as diabetes mellitus,hypertension, bilharziasis, tuberculosis, irradiation,drug sensitivity.Past history of surgical operations: the nature& date of operationshould be determined.9 May 2013 Osama M. Warda, MDshould be determined.Past history of gynecologic operation: the nature& date of operationshould be determined.Past history of gynecologic therapy: as gestagen therapy in cases ofabnormal uterine bleeding; the drugs, duration of therapy, andresponse to treatment should be all mentioned.Past history of contraception: if not currently used.
FAMILY HISTORY:Family history of heriditary disease e.g. diabetes,hypertension, chromosomal anomalies,…….etcFamily history of familial non-heriditary diseasese.g. rheumatic heart disease, tuberculosis ( thesediseases result in common bad socioeconomicconditions).9 May 2013 Osama M. Warda, MDconditions).Family history of a similar condition in the family:this is of special importance in certaine diseasessuch as ‘cancer family syndrome’ including ovarian,breast, endometrial cancers plus familial colonicpolyposis. Other conditions requires asking for otheraffected members of the family such as ‘androgeninsensitivity syndromes’ which are inherited as x-linked from the mother resulting in what is called‘testicular feminization syndrome’
SEXUAL HISTORY:It should be taken in cases of infertility. Its items include thefollowing.Frequency of coitus: it is registered per week.Position during coitus: the commonest position is female dorsal position.Presence of libido: it is the female sexual desire. It is mentined as positive ornegative. Lack of libido is called ‘ frigidity’.Presence of orgasm: it is the climax of sexual pleasure. It is mentioned aspositive or negative.Dyspareunia: it is pain during intercourse- superficial or deep dyspareunia.9 May 2013 Osama M. Warda, MDDyspareunia: it is pain during intercourse- superficial or deep dyspareunia.Apareunia d.t. vaginismus ( violent reflex spasm of the levator ani, perinealmuscles, gluteal muscles, and adductors of the thigh on any attepmt atsexual intercourse making intromission impossible. It is usually ofpsychogenic origin).Use of lubricants: to facilitate intromission, should be mentioned.Flour semenis: it means escape of semen from the vagina immediately afterejaculation. In most fertile women some degree of flour semenis occurs.Postcoital vaginal douches: the female should be asked if she perform immediatepostcoital vaginal douches or not. Water per se is considered as spermicidal.
PRESENT HISTORY:The present history of a gynecologic caseconsists of the following items:Analysis of the complaint: regarding itscharacter, the duration, the onset(acute, gradual, insiduous), the course(progressive, regressive, or stationary),9 May 2013 Osama M. Warda, MD(acute, gradual, insiduous), the course(progressive, regressive, or stationary),what increase, what decrease,association of other symptoms,previous treatments (since what time, itsduration, its types, results of treatments).Related urinary & gastrointestinalsymptoms.
2- CLINICAL PHYSICAL EXAMINATIONExamination of a gynecologic case consists basicallyof the following items:1- General examination.2- Abdominal examination.9 May 2013 Osama M. Warda, MD3- Local gynecologic examination:Vulval inspection.Vaginal palpation.Bimanual examinationSpeculum examinationSpecial clinical tests (in certain cases)
General examination.GaitConstitution; feminine, masculineBuilt ; BMI 19-24 kg/M2 >9 May 2013 Osama M. Warda, MDVital signs (BP-Pulse-temp-RR)General examination of the patient fromthe head to the heel: head, neck, breasts,chest & heart, limbs & back
General Examination9 May 2013 Osama M. Warda, MDTanner-p.hTanner-br
General ExaminationAXILLARYHAIRPUBIC HAIRBREASTTANNERSTAGEPre-pubertal,no hairPre-pubertal, nohairPre-pubertal,papilla elevatedonlyIScanty hairPre-sexual hairBreast budIIAdult hairSexual hair butsparseBreast elevationIIISexual over monsonlyAreolar moundIVSexual hair overmons, labiamajora, transverseupper borderAdult contourV9 May 2013 Osama M. Warda, MD
Abdominal Examination9 May 2013 Osama M. Warda, MD
Abdominal ExaminationInspection• contour, movement with respiration, s.c. angle, umbilicus, skin.• hernial orifices, pubic hairPalpation• Suprficial palpation; tenderness, rigidity, superficial masses• Deep palpation; liver, spleen, renal angles, abd. Mass, PA mass9 May 2013 Osama M. Warda, MDtionPERCUSSION• Dullness over a mass• Shifting dullness for ascitesAUSCULTATION• Intestinal sounds, venous hum
Abdominal examinationRT KIDNEYSPLEEN FOOT EDEMA++++9 May 2013 Osama M. Warda, MD+++Liver
LOCAL GYNECOLOGICAL EXAMINATIONIncludes;1. vulvar inspection2. vaginal palpation (P/V)3. Bimanual examination4. speculum examination5. special clinical (not routine), undercertaine circumstances9 May 2013 Osama M. Warda, MD
Local exam; positionsDorsalLithotomy9 May 2013 Osama M. Warda, MDFrogSims’
Vulvar inspection:PERINEUM & EXTERNAL GENITALIA9 May 2013 Osama M. Warda, MD
Vaginal & Bimanual EXAMAVF RVFP/VBimanual Bimanual9 May 2013 Osama M. Warda, MDAVF RVFBimanualPalpating the adnexae
SPECULUM EXAMCusco’sSims’9 May 2013 Osama M. Warda, MDCusco’sSims’Inserting speculum
SOUNDINGWhat are indications?KNOB=4mmHandle depression up9 May 2013 Osama M. Warda, MDShaft=3mm6cm
Uterine sounding; indication1. Measurement of the length of the cervico-uterine canal.2. Determination of the direction of the uterus [AVF or RVF].3. To differentiate uterine inversion from sub-mucous fibroid.4. To differentiate sub mucous fibroid polyp (originating from thefundus) and cervical fibroid polyp.5. Determination of the relationship of the uterus to any pelvic mass.6. In cases of prolapse it differentiate true prolapse from congenital6. In cases of prolapse it differentiate true prolapse from congenitalelongation of the portio vaginalis of the cervix. Also it diagnosessupra-vaginal elongation of the cervix in vagino-uterine prolapse.7. Diagnosis of intrauterine masses e.g. sub-mucous fibroid, uterineseptum, bicornuate uterus [this findings are only suggestive andshould be further investigated].8. Diagnosis of intrauterine foreign body e.g. IUD. “click”9. Probe test of friability for cancer cervix ( Krobac’s test).10. Click test for diagnosis of vesico-vaginal or urethra-vaginalfistulas.9 May 2013 Osama M. Warda, MD
Per rectum examination (P/R)Rectal examination is indicated in gynecology in the followingconditions:1. Pelvic examination in a virgin it substitutes P/V, and bimanualexamination for evaluation of the uterus, adnexa, or pelvicmasses.2. Diagnosis of para-metrial infiltration in cancer cervix.9 May 2013 Osama M. Warda, MD2. Diagnosis of para-metrial infiltration in cancer cervix.3. Detection of mass in cul-de-sac.4. Diagnosis of rectal infiltration in gynecologic malignancy.5. Differentiation between true & false rectocele.6. Diagnosis of recto-vaginal fistula.
Rectovaginal examRecto-vaginal examination is indicated in the followingconditions:1. Evaluation of the recto-vaginal septum e.g.inendometriosis.2. Diagnosis of enterocele (Malpas’ test).9 May 2013 Osama M. Warda, MD2. Diagnosis of enterocele (Malpas’ test).3. Evaluation of the tone of levator ani muscle in cases ofprolapse pre-operatively.4. Diagnosis of recto-vaginal fistula.Rectovaginal septum betweenindex& middle fingers
Clinical tests for urinary stress incontinence1- Marshall stress test: with about 200 ml of urine in thebladder (=some desire to urinate), the patient is asked tocough, a positive test is indicated if there is a brief spurt ofurine loss limited to the period of increased intra-abdominal pressure. If the test is negative in supineposition, it should be repeated in standing position2- Yousef’s test: this test is done to detect inhibitedincontinence in cases of genital prolapse i.e. the patienthas prolapse & she is continent. With the use of avolsellum on the anterior cervical lip, the bladder neck ispushed upwards, and the patient is asked to cough. If theurine comes down through the urethra, the patient hasinhibited incontinence that must corrected during repair ofprolapse and vice versa.9 May 2013 Osama M. Warda, MD
Clinical tests for urinary stress incontinence3- Bonney’s test: this test is done in patients withprolapse & urinary incontinence to differentiatebetween incontinence due to descent of bladderneck (prolapse) and that due to intrinsicsphencteric weakness. Two fingers are put in thevagina to push the bladder neck upwards, and thevagina to push the bladder neck upwards, and thepatient is asked to cough. If the urine comes out theurethra, there is weakness of the sphincter. If nourine comes out, the incontinence is due to prolapse( inhibited by correction of the bladder neck).Another possibility is that the incontinence isinhibited due to urethral compression by the vaginalfingers. [the next 3 tests were designed to avoid thismisleading possibility].9 May 2013 Osama M. Warda, MD
Clinical tests for urinary stress incontinence4- Marshall- Marchetti test:it is exactly as Bonney’s test but using Allis forceps to elevate the bladderneck instead of fingers to avoid urethral compression.5- Hodge-Smith pessary test: it is exactly as Bonney’s test but thebladder base is elevated by inverted Hodge-Smith pessary.6- Hodge-Linson test: it is exactly as Bonney’s test, but the bladder baseis elevated by the largest contraceptive diaphragm.7- Pad test: it is done when all other tests fail to prove stressincontinence. A pre-weighed vulvar pad is applied, and the patient isallowed to perform her usual activities for one hour, then the pad istaken off & weighed. Any increase in the weight of the pad (urine loss)is observed. The one-hour pad test is the most commonly used pad test(international continence society [ICS], 1979).8- Q-tip test ( cotton swab test): the direction of the urethra isdetected by a metallic catheter or by a lubricated cotton swab.Normally, the urethra goes up by about 15 degrees with the horizon. Instress incontinence the angle is increased (+/- 50 degrees) and thisangle is further increased with straining.9 May 2013 Osama M. Warda, MD
Clinical tests or procedures used incases of pelvic mass:To differentiate pelvi-abdominal from purelyabdominal swelling: this is done abdominallyby trying to get below the lower border ofthe mass. If the lower border is reachable,the mass is purely abdominal & vice versa.9 May 2013 Osama M. Warda, MDthe mass is purely abdominal & vice versa.To differentiate large ovarian cyst fromascites: by doing shifting dullness; in ascitesshifting dullness is positive, while in ovariancyst dullness is constantly central withabsent dullness in the flanks when thepatient turned on her side.
To differentiate uterine from adnexal masses:during bimanual examCriteria of uterine & adnexal mass during bimanual exam.Character UterinemassAdnexal mass1- Position UsuallycentralUsually lateral2- Transmission of movement Present Absent .9 May 2013 Osama M. Warda, MD2- Transmission of movementto cervixPresent Absent .3- sulcus between the mass &uterusAbsent . Present .4-Consistency MostlysolidCystic or solid
Clinical tests to diagnose V.V.F:(1)Intravesical dye test:The urinary bladder is filled with diluted solution of methyleneblue or indigocarmine . careful inspection of the anteriorvaginal wall & the vaginal vault with Sims’ speculum for thecolored urine.(2) Three tampoon test of Moir:Three vaginal tampons ( or cotton balls) are placed one afterthe other. Bladder is filled with diluted methylene blue9 May 2013 Osama M. Warda, MDThree vaginal tampons ( or cotton balls) are placed one afterthe other. Bladder is filled with diluted methylene bluesolution. The patient is asked to walk for 10-15 minutes. Thenthe tampons are removed & examined for the colored solution(blue); if the lowest tampon is the only colored one, there isno fistula but there may be transurethral urinary incontinence(stress or urge). If the upper tampon is wet & stained blue,there is a vesico-vaginal fistula. If the upper one is wet butnot stained blue, there is a uretro-vaginal fistula.(3) Flat tire test:The patient is put in the knee-chest position, and the vagina isfilled with water or saline. Intravesical instillation of air orCO2 through a urethral catheter. Localization of the smallfistula is done by visualization of gas bubbles in the vagina.
Clinical tests to diagnose recto-vaginal fistula:Probe test: a small caliber probe is pushed throughthe vaginal orifice of the fistula can be felt on rectalexamination.Methylene blue test: methylene blue instillation fromthe vaginal orifice can be seen in the rectum via a9 May 2013 Osama M. Warda, MDthe vaginal orifice can be seen in the rectum via aproctoscope.Carey’s test: a Foley catheter (10ml balloon) isinserted into the anal canal while the vagina is paintedwith concenterated solution of soap & water. Theballoon is inflated with 10ml saline to make the anustight. As the rectum is ditended with air from a syringeattached to the Foley catheter, air bubbles in the vaginacan locate the site of the fistula.