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APPROACH TO GYNAECOLOGY
PATIENT
DR HALIMATUN MANSOR
SPECIALIST
DEPARTMENT OF OBSTETRICS AND GYNAECOLOGY
HSNZ
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
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
HISTORY Abnormal bleeding
IntermenstrualPostcoitalPostmenopausal
Abnormal PV dischargeColor, pruritus, offensive odour
HISTORY Sexual history
DyspereuniaContraceptionPrevious STD
Hormonal therapyOral / injectableHRT
HISTORY Menopausal symptoms
Pain Onset, duration , nature , siteRelation to menstrual cycle
Symptoms of prolapse, unconfortable lumps in vagina
HISTORY Urinary problems
Incontinence, (stress or urge)Frequency, nocturia or dysuria
Other systemic review
Past obstetric and gynaecology history Past medical and surgical history
HISTORY Social history Smoking, alcohol consumption Drug history
PHYSICAL EXAMINATION Always begin with
InspectionPalpationPurcussion Auscaltation
Genaral examination Specific examination
GENITAL EXAMINATION Inspection of genitalia and urethral
meatus Evidence of estrogen deficiency,
prolapse or abnormal masses Presence of abnormal bleeding or
discharge
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
Stage IV Complete eversion
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
Imperforate hymen
FURTHER MANAGEMENTDifferential diagnosisRevise/Prioritise diagnosisInvestigationsTreatment / Management
COMMON PROCEDURES IN GYNAECOLGY Ultrasound PAP Smear for cervical screening Colposcopy procedure
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
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
smooth featureless covering of the cervix
Low grade lesion in a satellite pattern