dr. Sigit Nurfianto, SpOG(K)

Depart. Of Obstetrics & Gynecologic Faculty of Medicine Palangkaraya University

A complete picture of the patient and her illness A strongly presumptive diagnosis can frequently be made from the history aloneThe patients full name, her husbands, age, social condition (single, married, divorced, or separated), address, referring physician, and health or hospital insurance, husbands job.I. GYNECOLOGICAL HISTORY

1. Patients complaintThe general nature of the patients complaint In the patients own language.2. Family historyFamilial diabetes, tuberculosis, or cancer. Cancer is not directly hereditary.3. HistoryPrevious illnesses especially of any operations 4. Menstrual historyMenstrual symptoms are of more significance than any other in gynecological patients. Menarche ?, menopause ?Should include any forms of contraception

a. Age at Onset An unusually early menarche, maybe indicative of certain endocrinopathies

b. IntervalUsual menstrual interval is 28 days,

c. Duration A prolonged flow being usually an excessive one, and a very short period being scanty, but a two-to seven day flow represents normal variation.

d. Amount Variations in the amount of blood lost at menstruation A marked diminution is suggestive of an endocrine or constitutional abnormalityMenstrual excess is produced by either functional or structural lesions, often the latter.

e. Character of menstrual discharge. Dark venous appearance, and normally is unclotted. Menstruation is excessive, however, the blood may be right red with clots.

f. Menstrual pain. Pain with menstruation is one of the most common of gynecological symptoms,Anatomical or structural character, for often constitutional, psychogenic, and other general factors may be concerned.

g. Intermenstrual bleeding. After coitus or other contact ?Most characteristic symptom of early cervical cancer.

h. The date of the last menstrual period. Find the patients memory very hazy, Great importance, as in cases of possible early gestation, intra or extra uterine.

5. Vaginal dischargeLeukorrhea is such a common gynecological symptoms The duration of the leukorrhea, the character, color, possible odor, and possible irritativeness of the discharge are among the items of inquiry.

6. Obstetrical HistoryThe history of the pregnancies and labors, with especial reference to their number, character, and possible complications. Miscarriages or abortions, either spontaneous or induced.

7. Urinary SymptomsIncreased frequency, pain, incontinence, nocturia, and hematuria.

8. Gastrointestinal SymptomsAnorexia, bloating, belching, and discomfort after eating, may be secondary to gynecological disease, or they may suggest functional or organic abnormalities of the abdominal viscera. The possibility of pregnancy, Constipation is especially common in gynecological patients

9. Present Illness

History of the present illness, which constitutes a summation of those previously mentioned. Chronological appearance of all gynecological symptoms Evaluation of the sexual habits are of particularly importance in the infertility problems.

Naturally be directed chiefly toward the pelvic and abdominal organs, it must include a general survey of the entire physical make-up.

1. GeneralAmong the general items : are the height, weight, and general build of the patientThe thyroid, the heart and lungs The blood pressure, pulse, respiration, temperatureII. GYNECOLOGIAL EXAMINATION

2. Examination of the BreastHyperpigmentation, milk production.

3.Abdominal Examination ( After voiding )Simple inspection : Abnormalities of asymmetrical contour, pubic hair distribution. Any masses or tenderness Certain cardinal areas, especially the adnexal regions, McBurneys point, the gall bladder region, the epigastric and the kidney areas. Previous surgical scars

PalpationAn abnormal mass of any kind is felt, its position and its relation to any abdominal or pelvic organ its size, shape, contour, consistency, movability, and tenderness or lack of tenderness.

Percussion Ovarian cysts, which must be distinguished from ascites and bowl adhesion. Sonar is often helpful

4. Pelvic Examination Preparation and Position of the PatientThe clothing having been removed, the patient lies in the dorsal recumbent position, with flexed thighs and knees, the feet resting on the stirrups of the examination table, and the limbs and lower abdomen being draped with a sheetThe presence of a nurse, or of a female relative of friendThe patients bladder be emptied just before the examination.The examining hand is covered with a rubber or throw-away plastic glove

Inspection Careful inspection of the external genitalia The presence of any anatomical or pathological abnormalities The presence of any skin lesions or of any inflammation or irritation of the vulvovaginal mucosa and urethra The presence or absence of the hymen, the size of the clitoris, etc.

Speculum

Speculum examination of the cervix is performed before pelvic examination,Smear should be performed at least annually; in addition visualization of the cervix may provide certain information. The presence of polyps, erosion, eversion, or retention cysts The vaginal mucosa.

The Gonococcus may be sought for and cultured from the secretion from the cervical canal or urethra, whereas the Trichomonas can be found in the exudate obtained from the speculum in the posterior fornix. Speculum inspection of the cervix is in cases of suspected malignancy of the cervix

One or more fingers well lubricated, are then introduced into the vagina

Degree of any cystocele, rectocele, or uterine descensus which may be present.Unmarried patients with intact hymen, digital examination of the internal genital impossible or very painful, by rectal examinationExamination under anesthesia is desirable, especially in the case of young girls, obese or clinical staging of cervical cancer

The examination of the internal genitalia

Begins with careful palpation of the cervix, making note of such data as its size and shape, Digital contact with the cervix causes bleeding, as it so commonly does with certain lesions (polyp, cancer).The examining fingers now seeks to determine the size, shape, and position of the uterus, and the external hand is called into play, and the real bimanual procedure begins.

5. Examination of the Rectum

Examination of the rectum is of importance, especially in those cases in which rectal symptoms, especially bleeding or pain, have been complained of. Combined examination, with one finger in the vagina and one in the rectum ( recto vaginal examination ) will be informative to detect recto vaginal lesion, parametria and posterior side of uterus evaluation.

III. GYNECOLOGICAL DIAGNOSTIC PROCEDURES

1. Dilatations and CurettageMost common operation performed by the gynecologist, to investigate any atypical or irregular bleeding 2. BiopsySupplement smear with a colposcopically directed biopsy whenever the smear is other than negative or if there is a suspect pattern by colposcopyTo obtain adequate bits of tissue

3. Schiller Test

Application of iodine solution (Gram or Lugol) may show normal epithelium in deep mahogany color, whereas cancer areas are unstained and present in sharp distinction. Unfortunately, trauma and various benign inflammation processes may like wise lead to a positive Schiller test

Visualy inspection with Acetoacetic acid aplication ( VAI = IVA )Inspect the uterine cervix,after applying 3 - 5% Acetoacetic acid ectocervix will become coagolate and shrink nucleous more prominent opaque white epithelium

4. Conization of the cervixConization of the cervix for diagnostic purpose should be the next step after a doubtful or a positive smear. Could detect ecto and endocervix and the deep of microinvasionA hot conization which is done with the electrocautery A cold conization is simply done with a sharp knife.

5. ColposcopyThe colposcopy is an instrument by which the cervix may be visualized in bright under 10 to 40 x magnification. Detect contour, epithel and vascular pattern

6. ColpomicroscopyThe colpomicroscope gives a higher magnification than the colposcope

Biopsy, Conization, Dilatation and Curretage

Cytopathology, and histopathology are complementary, not competitive. As the early endocervical lesions (dysplasias and in situ) are exremely friable and easily rub off on every gentle manipulation, endocervical biopsies or conization should be obtained before any instrumentation or dilatation of the canal.

7. Endoscopy procedure that uses narrow telescope to view the interior of a viscus space

a. Laparoscopy. Direct visualization of the peritoneal cavity

b. Hysteroscopy. Direct visualization the inside of the uterus,

IV. GYNECOLOGIC CLINICAL CYTOPATHOLOGY

Clinical ApplicationPapanicolaou and Traut initially introduced this technique into clinical medicine in 1943.

Technique for proper cellular specimenSo many methods have been devised and advocated for preparation of specimens for cellular examination that it may first seem unnecessarily complicated to the clinician.

V. LABORATORY EVALUATION1. A blood count including hematocrit, white cell count, and platelet count 2. Serum chemistries and liver function testing 3. Coagulation studies.4. Immunologic test5. Urine analysis6. Vaginal secret analysis

VI. RADIOGRAPHIC, ECG, and IMAGING STUDIES

However, women over 40 years of age and those undergoing major gynecologic surgical procedures should have a chest x ray, electrocardiography, and serum electrolyte analysis preoperatively. Radiographic evaluation of adjacent organ systems should undertaken in individual cases.1. Intravenous pyelography is helpful to delineate ureteral patency and course, especially in the presence of a pelvic mass, gynecologic cancer, or congenital mullerian anomaly.

2. A barium enema or upper gastrointestinal series with small bowel assessment may be of significant value is evaluating some patients before undergoing pelvic surgery3. Other imaging studies, including ultrasound, CT scanning, or magnetic resonance imaging (MRI), are useful only in selected patients n