• Part 1. Approach to the Patient

• Part 2. Approach to Clinical Dagnosis and Staging

Part 1. Approach to the Patient

As delineated in nearly every clinical book and guide, the first step in the approach to the patient is gathering information and establishing the database. This includes taking the history; performing the physical examination; and obtaining selective laboratory examinations or special evaluations, such as umbilical Doppler studies and/or imaging tests. Of these, the historical examination is the most important and useful. The obstetrician should be unbiased and balanced in the approach to the patient; discipline should be exercised to refrain from being influenced by preconceived ideas of the patient's findings or best therapy. An appropriate balance of open-ended and directive questioning is prudent to efficiently determine the diagnosis, yet not ignore other patient concerns. Additionally, because patients may be anxious due to possible serious fetal malformations or genetic disorders, the obstetrician must be nondirective in counseling the patient, and refrain from “coloring” the discussion with excessive preconceived beliefs or notions, but allow the patient and her family to receive the information in an unbiased fashion.

History

1. Basic information:

   1. Age: Must be recorded because some conditions are more common at certain ages; for instance, women younger than 17 or those older than age 35 are at increased risk for hypertensive disease of pregnancy; pregnant women older than 35 years are at increased risk for fetal karyotypic abnormalities.

   2. Gravidity: Number of pregnancies including current pregnancy (includes miscarriages, ectopic pregnancies, and stillbirths).

   3. Parity: Number of pregnancies that have ended at gestational age(s) greater than 20 weeks, including any complications with the gestations.

   4. Abortuses: Number of pregnancies that have ended at gestational age(s) less than 20 weeks (includes ectopic pregnancies, induced abortions, and spontaneous abortions).

2. Last menstrual period (LMP): The first day of the last menstrual period. In obstetric patients, the certainty of the LMP is important in determining the gestational age in pregnancy. Because of delay in ovulation in some cycles, this is not always accurate. Use of hormonal contraception and regularity or irregularity of menses are important to document.

3. Chief complaint: What is it that brought the patient into the hospital or office? Is it a scheduled appointment, or an unexpected symptom, such as abdominal pain or vaginal bleeding in pregnancy? The duration and character of the complaint, associated symptoms, and exacerbating and relieving factors should be recorded. The chief complaint engenders a differential diagnosis, and the possible etiologies should be explored by further inquiry. The chief complaint should be explored with respect to how the pregnancy may affect a disease condition, and also how the disease condition may affect the pregnancy.

   Clinical Pearl

   • The chief complaint, as voiced by the patient or identified by the physician as most urgent, is probed through the clinical database, which yields a differential diagnosis.

4. Past gynecologic history:

   1. Menstrual history

      1. Age of menarche (should normally be older than 9 years and younger than 16 years).

      2. Character of menstrual cycles: Interval from the first day of one menses to the first day of the next menses (normal is 28, +/- 7 days; or between 21 and 35 days).

      3. Quantity of menses: Menstrual flow should last less than 7 days (or be less than 80 mL in total volume). Menstrual flow that is excessive, menorrhagia, should be further characterized as associated with clots, pain, or pressure.

      4. Menometrorrhagia, which involves both excessive bleeding and irregular bleeding should be distinguished from menorrhagia, and usually involves anovulatory cycles or genital lesions such as endometrial or cervical cancer.

   2. Contraceptive history: Duration, type, and last use of contraception, and any side effects. Some agents such as the intrauterine contraceptive device may be associated with ectopic pregnancy in a pregnant woman, or pelvic inflammatory disease.

   3. Sexually transmitted diseases: A positive or negative history of herpes simplex virus, syphilis, gonorrhea, Chlamydia, human immunodeficiency virus (HIV), pelvic inflammatory disease, or human papilloma virus. Number of sexual partners, whether a recent change in partners, and use of barrier contraception.

5. Obstetric history: Date and gestational age of each pregnancy at termination, and outcome; if induced abortion, then gestational age and method. If delivered, then whether the delivery was vaginal or cesarean; if applicable, vacuum or forceps delivery, or type of cesarean (low-transverse vs classical). All complications of pregnancies should be listed.

6. Past medical history: Any illnesses, such as hypertension, hepatitis, diabetes mellitus, cancer, heart disease, pulmonary disease, and thyroid disease, should be elicited. Duration, severity, and therapies should be included. Any hospitalizations should be listed with reason for admission, intervention, and location of hospital.

7. Past surgical history: Year and type of surgery should be elucidated and any complications documented. Type of incision (laparoscopy vs laparotomy) should be recorded. The operative report is useful particularly with attention to the intra-abdominal findings, surgery performed, and possible complications.

8. Allergies: Reactions to medications should be recorded, including severity and temporal relationship to medication. Non-medicine allergies such as to latex or iodine are also important to note. Immediate hypersensitivity should be distinguished from an adverse reaction.

9. Medications: A list of medications, dosage, route of administration and frequency, and duration of use should be obtained. Prescription, over-the-counter, and herbal remedies are all relevant. The patient's symptoms and whether there is improvement or change with the use of medications is important to record. Use or abuse of illicit drugs, tobacco, or alcohol should also be recorded.

10. Review of systems: A systematic review should be performed but focused on the more common diseases. For example, in pregnant women, the presence of symptoms referable to preeclampsia should be queried, such as headache, visual disturbances, epigastric pain, or facial swelling. In an elderly woman, symptoms suggestive of cardiac disease should be elicited, such as chest pain, shortness of breath, fatigue, weakness, or palpitations.

Physical Examination

1. General appearance: Cachectic versus well-nourished, anxious versus calm, alert versus obtunded.

2. Vital signs: Temperature, blood pressure, heart rate, and respiratory rate. Height and weight are often placed here including body mass index (weight in kg/height in m²).

3. Head and neck examination: Evidence of trauma, tumors, facial edema, goiter, and carotid bruits should be sought. Cervical and supraclavicular nodes should be palpated.

4. Breast examination: Inspection for symmetry, skin or nipple retraction with the patient's hands on her hips (to accentuate the pectoral muscles), and with arms raised. With the patient supine, the breasts should then be palpated systematically to assess for masses. The nipple should be assessed for discharge, and the axillary and supraclavicular regions should be examined for adenopathy.

5. Cardiac examination: The point of maximal impulse (PMI) should be ascertained, and the heart auscultated at the apex of the heart as well as base. Heart sounds, murmurs, and clicks should be characterized. Systolic flow murmurs are fairly common due to the increased cardiac output, but prolonged or louder systolic, or significant diastolic murmurs are unusual.

6. Pulmonary examination: The lung fields should be examined systematically and thoroughly. Wheezes, rales, rhonchi, and bronchial breath sounds should be recorded.

7. Abdominal examination: The abdomen should be inspected for scars, distension, masses or organomegaly (ie, spleen or liver), and discoloration. For instance, the Grey-Turner sign of discoloration at the flank areas may indicate intra-abdominal or retroperitoneal hemorrhage. Auscultation of bowel sounds should be accomplished to identify normal versus high-pitched, and hyperactive versus hypoactive sounds. The abdomen should be percussed for the presence of shifting dullness (indicating ascites). Careful palpation should begin initially away from the area of pain, involving one hand on top of the other, to assess for masses, tenderness, and peritoneal signs. Tenderness should be recorded on a scale (eg, 1-4, where 4 is the most severe pain). Guarding, whether it is voluntary or involuntary, should be noted.

8. Back and spine examination: The back should be assessed for symmetry, tenderness, or masses. In particular, the flank regions are important to assess for pain on percussion since that may indicate renal disease.

9. Pelvic examination (adequate preparation of the patient is crucial including counseling about what to expect, adequate lubrication, and sensitivity to pain and discomfort):

   1. The external genitalia should be observed for masses or lesions, discoloration, redness, or tenderness. Ulcers in this area may indicate herpes simplex virus, vulvar carcinoma, or syphilis; a vulvar mass at the 5-o'clock or 7-o'clock positions can suggest a Bartholin gland cyst or abscess. Pigmented lesions may require biopsy since malignant melanoma is not uncommon in the vulvar region. The level of estrogen effect should also be characterized, such as vaginal rugae and vaginal pH.

   2. Speculum examination: The vagina should be inspected for lesions, discharge, estrogen effect (well-rugated vs atrophic), and presence of a cystocele or a rectocele. The appearance of the cervix should be described, and masses, vesicles, or other lesions should be noted.

   3. Bimanual examination: Initially, the index and middle finger of the one gloved hand should be inserted into the patient's vagina underneath the cervix, while the clinician's other hand is placed on the abdomen at the uterine fundus. With the uterus trapped between the two hands, the examiner should identify whether there is cervical motion tenderness, and evaluate the size, shape, and directional axis of the uterus. The adnexa should then be assessed with the vaginal hand in the lateral vaginal fornices. The normal ovary is approximately the size of a walnut.

   4. Rectal examination: A rectal examination will reveal masses in the posterior pelvis, and may identify occult blood in the stool. Nodularity and tenderness in the uterosacral ligament can be signs of endometriosis. The posterior uterus and palpable masses in the cul-de-sac can be identified by rectal examination. Occult blood should not be assessed through digital examination, since false positives may occur.

10. Extremities and skin: The presence of joint effusions, tenderness, skin edema, and cyanosis should be recorded.

11. Neurologic examination: Patients who present with neurologic complaints usually require a thorough assessment including evaluation of the cranial nerves, strength, sensation, and reflexes.

    Clinical Pearl

    • Significant diastolic murmurs in the pregnant woman is usually abnormal.

12. Laboratory assessment for obstetric patients:

    1. Screening laboratory tests usually include:

       1. Complete blood count to assess for anemia and thrombocytopenia.

       2. Basic or comprehensive metabolic panel to assess for electrolytes, renal and liver function tests.

       3. Hepatitis B surface antigen: Indicates that the patient is infectious. Further testing will determine whether this is a chronic carrier status (normal liver function tests), or active hepatitis (elevated liver function tests).

       4. Syphilis nontreponemal test (RPR or VDRL): A positive test necessitates confirmation with a treponemal test, such as MHA-TP or FTA-ABS.

       5. Human immunodeficiency virus test: The screening test is usually the ELISA and, when positive, will necessitate the Western blot or other confirmatory test.

       6. Urine culture or urinalysis: To assess for asymptomatic bacteriuria.

       7. Cytologic examination: To assess for cervical dysplasia or cervical cancer; involves both ectocervical component and endocervical sampling. Evidence is pointing toward the liquid-based media as being superior cellular sampling and allows for HPV subtyping.

       8. Endocervical assays for gonorrhea and/or Chlamydia trachomatis for high-risk patients.

       9. Pregnancy test: Urine pregnancy assays are both sensitive and specific, and quantitative serum hCG assays can be used to follow the progress of a pregnancy.

    2. Other tests are dependent on age, presence of coexisting disease, and chief complaint.

13. Common scenarios:

    1. Threatened abortion: Quantitative hCG and/or progesterone levels may help to establish the viability of a pregnancy and risk of ectopic pregnancy.

    2. Indirect Coombs: Antibody identification and titer are assessed when the antibody screen (indirect Coombs) is positive.

14. Imaging procedures:

    1. Ultrasound: Can be used for establishing gestational age (biometry), estimated fetal weight, fetal presentation, amniotic fluid volume, cervical length.

    2. Doppler flow: Can be used as an adjunct in assessing possible fetal anemia, or in IUGR.

    3. MRI: Can be used to assess for uterine malformations, possible cervical pregnancies, or more recently fetal assessment.

Part 2. Approach to Clinical Diagnosis and Staging

There are typically six distinct steps that a clinician undertakes to solve most clinical problems systematically:

1. Identifying the most important condition

2. Developing a differential diagnosis

3. Making a diagnosis

4. Assessing the severity and/or stage of the disease

5. Rendering a treatment based on the stage of the disease

6. Following the patient's response to the treatment

Identifying the Most Important Condition

The patient's chief complaint is generally the problem to be evaluated and worked up; however, at times, the physician may identify an issue that is more concerning than the patient's reason for seeking care. Whatever the key clinical problem is, that issue should be clearly defined and communicated to the patient. If the clinical problem is different from the patient's chief complaint, then the reason for its priority should also be explained so as not to alienate the patient. Other clinical problems should likewise be listed and noted, but the primary condition should be highlighted.

Developing a Differential Diagnosis

After the key issue or issues have been identified and prioritized, then the next step is to develop a differential diagnosis. The differential diagnosis is usually between three to five disease processes based on clinical presentation, risk factors, disease prevalence, and potential danger of the disease. A seasoned clinician will “key in” on the most important possibilities. A good clinician also knows how to ask the same question in several different ways, and use different terminology. For example, patients at times may deny having been treated for “pelvic inflammatory disease,” but will answer affirmatively to being hospitalized for “a tubal infection.” Reaching a diagnosis may be achieved by systematically reading about each possible cause and disease. The patient's presentation is then matched up against each of these possibilities, and each is either placed high up on the list as a potential etiology, or moved lower down because of disease prevalence, the patient's presentation, or other clues. A patient's risk factors may influence the probability of a diagnosis.

Usually, a long list of possible diagnoses can be pared down to two to three most likely ones, based on selective laboratory or imaging tests. For example, a woman who complains of lower abdominal pain and has a history of a prior sexually transmitted disease may have salpingitis; another patient who has abdominal pain, amenorrhea, and a history of prior tubal surgery may have an ectopic pregnancy. Furthermore, yet another woman with a 1-day history of periumbilical pain localizing to the right lower quadrant may have acute appendicitis.

Making the Diagnosis

The diagnosis is made by a careful evaluation strategy. An efficient, cost-effective, and evidence-based approach is best. The clinician should be careful not to have “blinders” to only focus on one diagnosis, such as a 25-year-old woman with a pelvic mass has uterine fibroids, but rather keep an “open mind” to various diagnosis and be on the alert for “red flags” that may indicate inconsistencies with the primary diagnosis. Patients are conscious of the time, convenience, and number of visits required to reach a diagnosis, and these factors should also be taken into account in formulating the diagnostic plan. Finally, the diagnostic plan should be individualized for the particular patient, since a preconceived algorithm is rarely “one size fits all.” Surgery is sometimes performed for diagnostic purposes to establish the diagnosis. In general, surgery should be reserved after noninvasive methods are unrevealing, or when an urgent condition exists.

Assessing the Severity And/Or Stage of the Disease

After ascertaining the diagnosis, the next step is to characterize the severity of the disease process; in other words, describe “how bad” a disease is. With malignancy, this is done formally by staging the cancer. Most cancers are categorized from stage I (least severe) to stage IV (most severe). Some diseases, such as preeclampsia, may be designated as mild or severe. With other ailments, there is a moderate category. With some infections, such as syphilis, the staging depends on the duration and extent of the infection, and follows along the natural history of the infection (ie, primary syphilis, secondary, latent period, and tertiary/neurosyphilis).

Rendering a Treatment Based on the Stage of the Disease

Many illnesses are stratified according to severity because prognosis and treatment often vary based on the severity. If neither the prognosis nor the treatment was influenced by the stage of the disease process, there would not be a reason to subcategorize a disease as mild or severe. As another example, urinary tract infections may be subdivided into lower tract infections (cystitis) that are treated by oral antibiotics on an outpatient basis, versus upper tract infections (pyelonephritis) that generally require hospitalization and intravenous antibiotics.

Bacterial vaginosis (BV), which has been associated with preterm delivery, endometritis, and vaginal cuff cellulitis (following hysterectomy), does not have a severe or mild substaging. The presence of BV may slightly increase the risk of problems, but neither the prognosis nor the treatment is affected by “more” BV or “less” BV. Hence, the student should approach a new disease by learning the mechanism, clinical presentation, staging, and the treatment based on stage.

Treatment is broadly divided into medical therapy and surgical therapy. The astute clinician will be aware of the various types of medical therapy available, and the indications for surgery. Often, there will be various types of surgical approaches, and possible associated or prophylactic procedures are considered with the primary operation. For instance in a 44-year-old woman undergoing a hysterectomy for symptomatic uterine fibroids that have failed medical management, should the ovaries be removed? Current review of the literature, assessing the risks and benefits of each alternative, and a careful discussion with the patient and her family is paramount.

Following the Patient's Response to the Treatment

The final step in the approach to disease is to follow the patient's response to the therapy. The “measure” of response should be recorded and monitored. Some responses are clinical, such as improvement (or lack of improvement) in a patient's abdominal pain, temperature, or pulmonary examination. Obviously, the physician must work on being more skilled in eliciting the data in an unbiased and standardized manner. Subjective complaints such as uterine pain may be followed by an analogue pain scale and by having the patient point to the location of the pain. Other responses such as amniotic fluid volume or estimated fetal weight are followed by intermittent monitoring. When the patient's symptoms do not respond (pain, fever, anemia), then the practitioner should reconsider the diagnosis, or reevaluate with another approach.

References