Case 1 (manay Chuchi Pocha Jb Deo Direk)

Villafuerte, Shayne Villanueva, Irene Suzeth Villapando, Leda Villegas, Jose Bernabe Wong, Deo Adiel Yang, Caprice

GYNECOLOGY Section III-D

Case #1 A 48 year old G2P1 (1-0-1-1) consulted for a gynecologic check-up. She is a known hypertensive for 5 years. 1. What other data should be asked?  Identifying information o May also include the name and occupation of the patient aside from her age. The date of onset of the last menstrual period (LNMP) is also important.  Chief complaint o Usually best elicited by asking, “What kind of problem are you having?” or “How can I help you?"  History of present illness o The patient should be asked about the principal symptom including its onset, duration, frequency, quality, quantity or severity, location, the setting in which they occur, factors that aggravated or relieved the symptoms, and associated manifestations. o May include medications, allergies, habits of smoking and alcohol  Past History Ask the patient for childhood illness, adult illness with dates for at least four categories: a. Medical: illnesses such as diabetes, lung, heart and liver disease and whether hospitalization was required. Medications should also be asked including its name, dose, route, and frequency of use. Since she is hypertensive, what antihypertensive drug does she take? Aside from this, also ask for nonprescription drugs, vitamins, mineral or herbal supplements, and oral contraceptives taken. Allergies and specific reactions to each drug like rash or nausea, as well as allergies to foods, insects, or environmental factors should also be asked. b. Surgical: includes all operations, dates performed and associate postoperative or anesthetic complications c. Obstetrics: includes each patient’s pregnancies listed in chronological order. The date of birth; sex and weight of the offspring; duration of pregnancy; length of labor; type of delivery; type of anesthesia; and any complications. d. Gynecologic: menstrual history: age at menarche, interval between periods, duration of flow, amount and character of flow, degree of discomfort, and age at menopause; history of STD; sexual history; use of contraceptives  Family History

o Includes the state of health of immediate relatives. The incidence of familial heart disease, hypertensive renal or vascular disease, diabetes mellitus, vascular accidents, hematologic abnormalities, cancer especially breast and ovarian cancer  Personal and Social history o Education, family of origin, habits, personal interest, coping style. Type of work the patient does. Also ask about her daily food intake, dietary supplements or restrictions, lifestyle habits such as engaging into sports or exercise including its frequency and health screening examinations.  Review of systems o Pertinent positives and negatives 2. How should be the physical examination be conducted? There are some important things to note in doing a physical examination. The environment should be aesthetically pleasing to the examinee. Privacy is of major importance for delicate parts of the patient’s body would be examined and exposed. Furthermore, physicians must be aware of the possible fears or anxieties that the patients may have. This is especially occurring to first-time-gynecologic-exam patients. General  Vital signs – the weight and BP must be taken; the height must be taken to determine if there is loss of height especially in osteoporotic and fractured women  The chest should be examined for skin lesions and movement symmetry.  Auscultation and percussion of the heart and lungs are also crucial. Breast Examination a. Should be a routine part of the PE b. Ideal time to ascertain the frequency and methodology of breast self-examination c. Mammogram – every 1-2 years from age 40-50 and yearly thereafter Abdominal Examination a. Done to detect uterine, ovarian, or urinary bladder problems (i.e. Enlargement) in suprapubic palpation b. Aside from the aforementioned, physician should also take note of any abnormality in the abdominal organs: liver, gallbladder, spleen, kidneys, and intestines. Pelvic Examination a. External genitalia • Pubic hair – note the pattern (masculine/feminine); nits of pubic lice, infected hair follicles • Vulva and mons pubis – inspect skin • Perineal area – find any evidence of dermatitis and/or discoloration

• Inspect the glans clitoridis and clitoris • Check for asymmetry and infection in the major and minor labia • Note the color of the urethra • Vestibular glands and anal abnormalities b. Hymen • Check whether it is completely imperforate, cribriform, or septate for it may indicate pathology. c. Perineal support • Confirm if the pelvis is in relaxation. By doing so, this will show urethrocele, cytocele, rectocele, or uterine prolapse. d. Urethra • Note any presence of discharge from the paraurethral glands Vaginal Examination a. Use a speculum to check for any abnormality and to be able to obtain a pap smear for more detailed examinations. b. During the exam, a rough, inelastic and tender vaginal wall may indicate pathology. c. Examine for the presence of blood, discharge and mucosal characteristics and structural abnormalities Bimanual Examination (Moderate palpation and manipulation of the anatomy will define position, size, shape, mobility, consistency, and tenderness of the pelvic structures. Note any abnormality.) a. Cervix – inspect its firm structure likened to the consistency of the tip of the nose; inspect any shape abnormalities and nodularities; normally, it is round and about 3-4cm in diameter b. Corpus of the uterus – check for inconsistencies in terms of its size, shape, position, consistency and mobility; normally, it is half the size of the patient’s fist c. Adnexia – check for masses and tenderness over the adnexal structures; if present, this indicates further investigation Rectovaginal Examination – feel for tenderness, masses or irregularities; should always be performed after the bimanual pelvic exam especially after the age of forty. 3. What examination should be requested? Why? a. Cervical Cytology/ Papanicolaou Smear of the Cervix

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this is a screening test only; positive tests are an indication for further diagnostic procedures such as colposcopy and biopsy for screening in apparently healthy and symptom-free women, to discover those who deserve further investigation to see if they have malignant disease; aside from premalignant and malignant changes, local conditions such as viral and fungal infections can be seen in cytology

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annually beginning no later than age 21 years; every 2-3 years after 3 consecutive negative test result if age 30 years or older with no history of cervical intraepithelial neoplasia 2 or 3, immunosuppression, HIV infection or diethylstilbestrol exposure in utero

 Human Papilloma Virus (HPV) DNA Testing  In a study conducted by Agorastos et al, entitled Human papillomavirus testing for primary screening in women at low risk of developing cervical cancer, they compared the performance of HPV DNA detection against routine Papanicolaou smear for the detection of low- and high-grade cervical intraepithelial neoplasia in a low-risk population. Their results revealed that HPV DNA testing showed a significantly better sensitivity than the Papanicolaou smear in detecting cervical intraepithelial neoplasia (75% versus 50% for high-grade lesions and 81.2% versus 50% for lesions of any grade, respectively). Specificity, and positive and negative predictive values did not significantly differ. Their conclusion was, HPV testing could be useful in screening women at low risk for cervical cancer, either as an adjunct tool to augment existing cytology programs or as a unique test of its own. b. Mammography  this is done every 1-2 years beginning at age 40 years  high risk factor includes women who have had breast cancer or first degree relative or multiple other relatives who have a history of premenopausal breast or breast and ovarian cancer c. Lipid Profile Assessment  this is done every 5 years beginning at age 45 years  high risk factor includes diabetes mellitus, multiple coronary heart disease risk factors like hypertension, which is found in the patient d. Bone Density Screening  done on high risk factor patients such as post menopausal women younger than 65 years e. Fasting Blood Sugar  this is done every 3 years after age 45 years  patient is a known hypertensive, which is a high risk factor f. Pelvic Ultrasound  to diagnose earlier those conditions that require a surgical approach  to avoid surgery in those conditions that should be managed medically  one of the most common uses of ultrasound is the diagnosis and evaluation of pelvic masses

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ultrasound has a major role to play in the diagnosis of trophoblastic diseases and the differential diagnosis of pelvic and abdominal masses

REFERENCES: 1. Agorastos T, Dinas K, Lloveras B, de Sanjose S, Kornegay JR, Bonti H, Bosch FX, Constantinidis T, Bontis J: Human papillomavirus testing for primary screening in women at low risk of developing cervical cancer. The Greek experience. Gynecol Oncol. 2006 Dec;103(3):1169 2. Bickley, L.S. Bates’ Guide to Physical Examination and History Taking 9th Edition. 3. Novak’s Gynecology, 14th ed. 4. LANGE: Current Diagnosis & Treatment Obstetrics & Gynecology, 9th ed.