approach to gynaecology patient
TRANSCRIPT
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APPROACH TO GYNAECOLOGY
PATIENT
DR HALIMATUN MANSOR
SPECIALIST
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
HSNZ
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APPROACH TO GYNAECOLOGY PATIENT Gynaecology history and examination
are a modification of a standardized history taking design for
elucidation of the presenting problems,concluding provisional and differential
diagnosisPlanned for further management
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HISTORY Depending on the presenting complaint
Age of menarche/menopauseMarital status- infertilityLNMPLength of menstruation and cycleFrequency and regularity of cycleMenstrual loss , presence of clots and
floodingDuration of dysmenorrhea and relation to
period
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HISTORY Abnormal bleeding
IntermenstrualPostcoitalPostmenopausal
Abnormal PV dischargeColor, pruritus, offensive odour
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HISTORY Sexual history
DyspereuniaContraceptionPrevious STD
Hormonal therapyOral / injectableHRT
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HISTORY Menopausal symptoms
Pain Onset, duration , nature , siteRelation to menstrual cycle
Symptoms of prolapse, unconfortable lumps in vagina
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HISTORY Urinary problems
Incontinence, (stress or urge)Frequency, nocturia or dysuria
Other systemic review
Past obstetric and gynaecology history Past medical and surgical history
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HISTORY Social history Smoking, alcohol consumption Drug history
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PHYSICAL EXAMINATION Always begin with
InspectionPalpationPurcussion Auscaltation
Genaral examination Specific examination
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GENITAL EXAMINATION Inspection of genitalia and urethral
meatus Evidence of estrogen deficiency,
prolapse or abnormal masses Presence of abnormal bleeding or
discharge
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GENITAL EXAMINATION Speculum Examination
Inspection of vagina and cervixTaking of cervical cytology or microbiology
swab
Assess uterovaginal prolapse and incontinance
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Candidiasis Strawberry cervix: Trichomonas
Bacteria vaginosisHerpes Simplex
Actinomyces infection
Atrophic cervicitis
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Stage IV Complete eversion
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GENITAL EXAMINATION Perform bimanual examination
Assess uterine size, shape, ante/retroverted, mobility of uterus
Tenderness- cervical motion, POD, adnexasPresence of abnormal masses at POD or
adnexaUterosacral ligament- presence of noduleThickness of the rectovaginal space
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Imperforate hymen
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FURTHER MANAGEMENTDifferential diagnosisRevise/Prioritise diagnosisInvestigationsTreatment / Management
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COMMON PROCEDURES IN GYNAECOLGY Ultrasound PAP Smear for cervical screening Colposcopy procedure
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1. PAP SMEAR SCREENING Cheap Acceptable Good sensitivity and specificity Achieved of screening must be 70-80%
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PAP SMEAR
Cervical Biopsy
Exfoliative cytology test cells collected are from normally shedding epithelium .
collected using spatulas or brushes.Specimen is fixed, stained and studied for morphology under microscope.
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HISTORY Initially using vaginal pool smears to
study hormonal status .
Found cancer cells on a slide containing a specimen from a woman's uterus.
Dr. George Papanicolaou reported the usefulness of the technique for detecting neoplastic cervical cells in 1941.
late 1940s to early 1950s, Pap smear became widely used as a screening technique.
Dr. George Nicholas Papanicolaou
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CONVENTIONAL PAP SMEAR
1. Approximately 80% of cells sample containing important diagnostic imformation is removed with sampling devices.
2. False negative rate at least 20% (mainly due to sampling error).
3. Sampling is a factor in up to 90% of false negative pap smear.
( JosephMG. Diagn Cytopathol 1991;7(5):477)
4.Up to 40% of all Pap smears are compromised by blood, mucus and inflammation. (Davey DD.Arch Pathol Lab Med 1992;116:90)
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INADEQUATE SMEARS Sampling
Scanty cells
Blood, mucous, pus
Mainly endocervical cells *
Preparation Too thick due to poor spreading
Air drying artifact
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2.VISUAL INSPECTION TEST
VIA : Visual inspection with acetic acid.
VILI : Visual inspection with Lugol’s iodine.
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COLPOSCOPY A tool for screening as well as treatment
of cervical pathology especially at preinvasive and early stage
Need training and practice Available
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smooth featureless covering of the cervix
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Low grade lesion in a satellite pattern
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