Clinical approach to gynecological patient(part1)


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Clinical approach to gynecological patient(part1)

  1. 1. Prof. M.C.Bansal. MBBS, MS. FICOG, MICOG NIMS medical College ,Jaipur. Founder Principal & Controller ; Jhalawar Medical College And Hospital , Jhalawar. Ex. Principal & controller; Mahatma Gandhi Medical College And Hospital , Sitapur, Jaipur .
  2. 2.  Women patient should be greeted and made comfortable before one starts interrogating.  Let her be sure and confident that her privacy is ensured.  Her preference regarding the presence of her partner , parent or relative during history taking and clinical examination should be asked for and accepted.  Woman herself comes or bring her daughter / daughter in law or any other relative/ friend as patient to her gynaecologist for variety of problems , both gynaecological or non gynaecological, as she feels comfortable and friendly with him or her.  There fore gynaecolgist is her a primary health care taker; more or less a family physician.
  3. 3. Getting elaborate information about her problem will depend on her confidence in doctor, opportunity for gynaecologist to assess the patient‘s general condition ,mood , ability and willingness to communicate and variety of non verbal clues. Patient should be given enough time to narrate her problem in her own words before asking leading questions.
  4. 4.  Age.  Residence– rural / urban ; contact number / postal address.  Assess her socioeconomic status/ marital status .,educational back ground.  Chief Complaints in chronological order with duration.  History of present Illness.  Menstrual History.  Gynaecological history.  Obstetrical history . Contraceptive history.  Sexual history.  Menopausal history in women > 40.
  5. 5.  Medications/ resent surgical procedure done.  Personal habits –smoking , alcohol , substance abuse .  Past medical and general surgical history.  Family History.  Dietary history.  Occupational history / exposure to any occupational hazard .  Symptoms pertaining to other system/ organs.
  6. 6.  Childhood: foreign body , vulvo-vaginitis, vaginal discharge , intra vaginal tumor(cervical grapes sarcoma,hydrocolpos , hemato colpos ), Ovarian tumors ( teratomas, embryomas)  Adolescence: precocious/ delayed puberty , Menstrual disorders, dysmenorrhoea, PCOS, ovarian germ cell tumors , uterovaginal anomalies.  Reproductive age : Menstrual irregularities, Fibroids , PID / STDs , benign lesions of female genital tract , CIN, breast lumps and cancer , pregnancy related problems, contraceptive use/their failure/ side effects.  Older Age: menopause –related problems., malignancies of Cervix, endometrium , myometrium , ovary, vulva ,vagina and secondaries from distant organs like breast/ stomach.
  7. 7.  Knowing her residential address and contact number will help in developing good repot and good follow up.  Certain gynaecological problems are more common in urban and industrialized town dwellers like STDs , Problems due to repeat MTPs, Endometriosis, ovarian tumors, PCOS .  Rural folk is more likely to have problems due to multiparity ---Utero vaginal prolapse and late stages of malignancies etc.
  8. 8.  Woman‘s and her husband‘s occupation and education status give an idea about the socio economical status of the family. Husband living away for long duration on his job like truck driver , military service may be contributory factor in STDs , HIV, Infertility. Patients with poor family back ground need advise to get help from charity, NGOS and GOVT Health schemes.  Marital status :Unmarried, separated , women with live in relation may have problems of STDs, Unwanted Pregnancy.
  9. 9.  Chief complaints / presenting symptoms should be recorded first with point of time or the duration of onset .  Complaints should be noted in chronological order and with patient‘s priorities.  Duration and exact timing of onset of problem gives an idea about it being acute or chronic and even acute exacerbation of pre existing chronic illness.  It is important to ask ― when last she felt normal‖.  The complain which is more worrisome to patient should always be addressed.  Help the patient to narrate the story by her own and if needed some leading questions can be asked to clarify and confirm her statements when she is in state of agony or shocked.
  10. 10.  Amenorrhoea : Primary / secondary; ask for h/o D&C,MTP, TB , Ocs, Prolong lactation ,milk discharge from nipples, anti psychotic drug therapy. Symptoms of premature ovarainfailure. .  Abnormal vaginal bleeding . Detailed H/O menstruation present and past., Rx taking and its response, Anti coagulant therapy, irregular use of sex hormones / OCS, purpura,retained RPOC,IUCD.  Dysmenorrhea- dull aching,spasmodic , day of onset and relief in relation to MC / any medication taken.  Vaginal Discharge– mucoid, watery, curd like thick associated with itching , burning ,fishy/ foul smell or blood staining.  Pelvic Pain –localization : supra pubic, one of the iliac fosse radiating / shifting to back, thigh or above umbilicus ,its nature –dull, heaviness, spasmodic, bursting of organ , twisting.
  11. 11.  Dyspareunia – related to change of partner ,superficial at the introitus( begin with entry— Vaginismus/ tight introitus after perineal repair or vaginoplasty.Deep in fornices in endometriosis external, chocolate cysts , prolapsed ovaries in POD ,RV RF uterus in adenomyosis.  Mass Felt per abdomen above SP.– pregnant uterus, fibroid uterus, ovarian cyst, omental cake in malignancy of ovary , mesenteric cyst, encysted tubercular ascitis, Hydroneprotic pelvic Kidney, to mass, Pyo/ hematometra, chronic ectopic with large haematocoele ,Appendicular lump, retroperitoneal tumor arising in hollow of sacrum and enlarging upwards etc.
  12. 12.  Mass descending per vagina: Isolated Cystocoele and /or rectocoele, uterine prolapse ( congenital), acquired develops in multifarious and elderly women with 3rd degree / procedentia. Inverted uterus , fibroid polyp, polypoidal ectocervical carcinoma, placental polyp, long IUCD Thread / descending down IUCD in the process of expulsion , Molar conceptus ,forgotten vaginal packing/swabs/tampons/ broken and retained piece of condom(male/ female). Urethral mucosal prolapsed , prolapsed hemorrhoids and rectal polyp should also be thought of as patient may think it to be from vagina.
  13. 13. Inability to conceive: age of couple, profession of couple, 1st / 2nd marriage / previous history of having child by any one of both (With same / or another partner), STD/ HIV / Pelvic Inflammation, frequency and timing of coitus, premature ejaculation by partner/ flor seminis. Vaginismus/ dyspareunia,Detailed Obstetric history ( abortion, D&E, MTP, Sepsis etc.) any investigations/ treatment for infertility and its out come.
  14. 14.  Genital Ulcer / Swelling : painful—herpes, primary chencre , gonococal ; painless – secondary / tertiary syphilitic( gamma) lesion, grannuloma venerum, genital warts, condyloma Lata, icthymosis of vulva, tubercular ulcer, pagets disease, rodent ulcer , carcinomatous ulcer or sweliing , bartholin cyst, fibroma, lipoma, neurofibroma,dermoid cyst, elephantitis, insect bite, painful boils. Bartholin abscess etc.  Pruritus vulva---Itching at vulva may be part of systemic disease like diabetes, obstructed Jaundice, drugs, local creams , candidiasis, pin worm infestation or ca Vulva.
  15. 15.  Urinary Symptoms--- burning micturation with or with out fever , dysurea, retention, incontinence ( stress/ true / urge ) loin pain (dull . Colic ).,may be associated in cases of utero vaginal prolapse, myomas. Malignancy and pelvic mass. Burning at vulva may be due to trichomonial vaginitis, neuropathy .  Bowel symptoms : diarrhea constipation as side of drug prescribed for gynaecological or non gynaecological problems. Constipation or feeling of incomplete evacuation in presence of large rectocele/ enterocele, painful defecation(tenesmus) in cases of collection in POD (pus/ blood) . Fecal incontenance in complete perineal tear / rectovaginal fistula.
  16. 16.  Weight gain / Weight loss: weight gain may be due to hypothyroidism, ocps, development of obesity/ type 2 diabetes / PPCOD , Cushing syndrome --- leading to menstrual abnormality and infertility. weight loss indicate– hyperthyroidism , anorexia , tuberculosis , malignancy / chronic ill health . Each presenting complaint should be further detailed in terms of time/ mode of onsetand duration . , associated symptoms , relation to food, vomit , change in bladder and bowel habits, fever and fatigue.
  17. 17. Age at menarche , characteristics of the menstrual cycle like duration of bleeding , pattern of bleeding , regularity , volume , frequency of menstrual cycle, premenstrual symptoms, painless or painful. Early menarche and late menopause are risk factor for endometrial cancer. Characteristics of normal menstrual cycle are :Cycle Length 28 days ( 21-35 days ) Mean Menstrual blood loss 30 -60 ml Duration 2-7 days Pain Mild tolerable pain in sacral / supra pubic region
  18. 18.  Volume of blood flow is assessed by number of pads / tampons used whether the pads are fully/ partially soaked , presence of clots. It can be better assessed by pictorial charts-- Pad Area Soaked 1st day 2nd Day 3rd Day 4th Day 5th day 6th Day 7th Da y X1 // / / X 5 /// // X20 /// Daily Points 89(<1oo) Normal blood loss Tampons X1 // / x5 /// X 15 ////// Daily points 108 Excessive blood loss
  19. 19.  The chart consists of pads and tampons that are soaked lightly, moderately or heavily.  The score is calculated by multiplying the number of pads by a factor of 1 , 5, or 20 for light, moderate or heavily soaking .  Factor 1, 5, 15 are used similarly in case of tampons respectively.  Clots are assigned a score 1 for clot size of 1 penny, 5 for 50 pennies and flooding.  A total score of > 100 indicates excessive bleeding.  Menstrual blood is usually fluid in nature as clots are lysed by fibrinolytics. Presence of clots indicate more than normal and rapid flow.  Menstrual history of past and present ( since onset of problem ) should be taken in same way. LMP should always be noted as to rule out pregnancy , decide the day of many investigations and operative procedure ( in proliferative phase / post ovulatory phase of menstrual cycle.
  20. 20. Past history of gynaecological problem is important., like vaginal infection ,pelvic pain , myomas , ovarian cyst, endometriosis, PID, STD and drug / operative treatment given . Present problem may be recurrence /complication or squeal of previous disease. Previous investigations ,treatment , event during sickness and operative notes if available should always be scrutinized.
  21. 21.  Age of marriage –period of marital relationship when dealing with infertility .  Parity, Number of miscarriage, IUFD , neonatal death ( obstetrical / Neonatal cause? )., MTP , molar and ectopic pregnancy in order of sequence of events.  H/o each pregnancy--- includes any problem(obstetrical ,medical / surgical ) arising in 1st/2ndr or 3rd trimester ; any treatment given and its and response , ended as Ectopic/ abortion/ PROM, preterm /term or post term pregnancy. Mode of delivery(sp N VAG? I9nstrumental / LSCS delivery ?), fetal out come-- IUGR/ IUFD /Small for date / premature / normal weight/ over weight baby . Any resuscitation problem / Apgar score/ Usher score /neonatal problems which are likely to be repeatative in nature.  Thecae all information can be collected from ANC card MCH card and hospital records at which last delivery was managed.  History of postnatal events like fever , sepsis, DVT, convulsions, wound infection , persistent High BP/ Glycosurea /proteinuriaetc.
  22. 22.  Null parity---Endometriosis, fibroids, cancer endometrium , breast cancer .  Multi parity—Adenomyosis, prolapse, cervical cancer , ovarian cancer , urinary incontinence, DUB due to enlarged uterine size.  Recent delivery / miscarriage– sepsis. Chronic PID / Pelvic Pain /RPOC, secondary infertility, cervical erosion/ cervical ectropia , perineal tears, chronic Iron deficiency anaemia, intra uterine synecae , mastitis/ breast abscess.  Molar pregnancy –Gestational Trophoblastic neoplasia.
  23. 23.  Abnormal uterine bleeding/ dysmenorrhoea may be related to IUCD / OCS .  Galactorrhoea- amenorrhea syndrome due to prolong use of combined OCs, they also protect against ovarian and endometrial carcinoma if use for > 5years.May increase risk of cancer cervix.  Tubal ligation may be responsible for DUB due to disturbed ovarian vascularity / pelvic congestion syndrome.  Levonorgestrol containing IUCD (LUG-IUS) causes amenorrhea.  Patient taking Inject able contraceptive can develop osteoporosis and menopause like symptoms.  Barrier contraceptives protect against STD, HIV .HPV and CIN--- decreased cancer cervix.
  24. 24.  Women often feel sigh in giving details regarding their sex life. Gynecologist by now must have earned her confidence and faith; can ask her comfortably regarding timing , frequency , use of contraception, veganism's, lack of orgasm, dyspareunia, vaginal dryness and immediate out flow of semen from vagina.  History about sex life of partner and his habits regarding sex play.  Vaginismus may due to tight introitus or of psychological origin. While lax introitus due to perineal tears/ Prolapse may also be concerned with sexual satisfication. H/o Multiple partner / premarital / extra marital sex per chance by any of life partner may be contributory factor in occurrence of STDs, HIV,/ and infertility/ bartholin cyst/ abscess ,CIN and cancer cervix ( HPV infection ) , PID , TO masses (hydrosalpinx / pyosalpinx.)
  25. 25.  In peri menopausal / post menopausal aged women ;it is useful to know age of onset of menopause any preceding symptoms like hot flashes, night sweating , palpitation, dryness of vagina, decreased sex desire ,sleep disturbances, abnormal ,acyclic bleeding per vagina , post coital spotting , backache, incontinence of urine.  H/o hormone replacement therapy , daily Calcium intake in diet / tab, exercise and exposure to sun light .  Family H/O diabetes/ BP/Stroke/ CAD, osteoporosis ,hip fractures, Cancer uterus and ovary.
  26. 26.  Medication For- >obesity. >Diabetes. >Hypertension, cardiac disease, anticoagulants. >Hormone replacement therapy(in detail) –Estrogen/SERMS / E+P combination(local creams/gels /patch/implants or oral tabs). > NSAIDs / Corticosteroids for joint pains or other medical disease. > Drugs for other gynaecological / medical disorder . > Drugs which can cause amenorrhoea/ galactorrhoea/ blood spotting per vagina. > prolong use of vaginal pessary for procedentia—decubitus ulcer ----carcinomatous changes . > any habituation to drugs– sleeping pill / drinks and smoking . >Hormones should be prescribed cautiously to patient with diabetes/ hypertension/ obesity/ DVT / thyroid/ liver and kidney disorders.
  27. 27. Smoking – since how long and number /day? Alcohol-- since how long and amount of liquor /day? Addiction to cocaine, marrhijuna, tobacco chewing , sleeping pills , crude opium etc. Anti psychotic drugs for depression.
  28. 28.  women with medical disease like diabetes, BP, CAD, obesity are prone to develop uterine cancer., DVT /PE are not uncommon to develop during their post operative period . Asthama , chronic lung disease , constipation increase intra abdominal pressure to develop uterine prolapse.  In young girls obesity – irregular periods, PCOD, Acne, hirsutism , metabolic syndrome .  Women with thyroid disorder are prone to have menstrual abnormality weight gain, infertility and miscarriages.  Adolescent with coagulation disorder and thrombocytopenia can present with DUB.  GI disorder like IBS , intestinal TB, crohn‘s disease may present as chronic lower abdominal pain.  Previous abdominal / pelvic surgery may cause intra abdominal adhesion --- chronic abdominal pain , infertility, incisinal hernia.  Male partner operated for inguino-scrotal disorder may be associated with disturbed testicular function ---impotence / infertility .
  29. 29.  Women with family H/O following; may develop-- Endometrial, breast , ovarian have a familial predisposition. Breast / ovarian cancer / endometrial cancer syndrome occur in women having BRCA mutation carriers in family. women with family background of diabetes , hypertension / obesity / CAD are prone to ovarian and endometrial cancer and need evaluation in peri and post menopausal period. Androgen –insensitivity syndrome and other chromosomal aberrations ( turner, noon ‗s syndrome )causing amenorrhea are also familial.
  30. 30.  Male occupation , drivers , conductors, factory workers with exposure to heat / chemicals are prone to have oligo / azoospermia --- infertility.  Women with Multiple sex partner / sex workers and those on long stays away from life partner are prone to have STD/ HIV/ HPV --- infertility and ca cervix.  Women exposed to radiations/ anesthetic or other chemical and drugs are prone to develop cancers / infertility , habitual abortions and fetal malformations.
  31. 31.  Cardiovascular/ pulmonary / liver and kidney dysfunction have adverse effect on type of anesthesia and surgical procedure.  Hypothalamo-pituitary , thyroid, adrenal disorders may cause menstrual abnormalities and infertility .  Drugs used for psychological / neurological problems may interact with sex hormones an modulate their effect and tolerance.  Lower GIT /uteri vasical –disease may come as chronic pelvic pain similar to PID.  GIT and Uriary tract symptoms may also be due to gynacological diseases like endometriosis, cancer extending to pelvic organs, UV prolapse.  Often women with depression / anxiety/ cancer phobia often present as pelvic pain chronic vaginal discharge and dyspareunia breast tenderness or lump ,which may be present in menopausal women too.  genital prolapse may be part of Generalized visceroptosi due to neuro -muscular disorder.  OCS therapy may modify the dose effective of tubercular drugs like rifampicin.
  32. 32. After taking detailed history patient is Thoroughly and gentaly examined ; using general principals of clinical examination— > Inspection . > Palpation . > percussion ( when and where required ). > auscultation (when and where required) .It should be done as described in details in next lecture –Titled; Clinical approach To Gynaecological Patient(Part-2)