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Part 1. Approach to the Patient
Part 2. Approach to Clinical Problem Solving
Part 3. Approach to Surgical Therapy
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 urodynamic testing and/or imaging tests. Of these, the historical examination is most important and useful. The gynecologist 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. The practitioner should use an appropriate balance of open-ended and directive questioning to efficiently determine the diagnosis without ignoring other patient concerns, or overeagerly focusing on one diagnosis too early.
The history is usually the single most important tool in obtaining a diagnosis. The art of seeking the information in a nonjudgmental, sensitive, and thorough manner cannot be overemphasized.
Age must be recorded because some conditions are more common at certain ages; for instance, women younger than 30 years with an adnexal mass are more likely to have a benign cystic teratoma or other germ cell tumors, whereas women older than 30 years with an adnexal mass are more likely to have epithelial tumors.
Gravidity: Number of pregnancies, including current pregnancy (includes miscarriages, ectopic pregnancies, and stillbirths).
Parity: Number of pregnancies that have ended at gestational age(s) greater than 20 weeks.
Abortuses: Number of pregnancies that have ended at gestational age(s) less than 20 weeks (includes ectopic pregnancies, induced abortions, and spontaneous abortions).
Last menstrual period (LMP): The first day of the LMP. 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. The LMP and menstrual history is also important in assessing dysfunctional uterine bleeding, or the menorrhagia associated with uterine leiomyomata.
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. For example, if the chief complaint is postmenopausal bleeding, the concern is endometrial cancer. Thus, some of the questions should be related to the risk factors for endometrial cancer, such as hypertension, diabetes, anovulation, early age of menarche, late age of menopause, obesity, infertility, nulliparity, and so forth.
The chief complaint, as voiced by the patient or identified by the physician as most urgent, is probed through the clinical database, engendering a differential diagnosis.
Past gynecologic history:
Age of menarche (should normally be > 9 years and < 16 years).
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).
Quantity of menses: Menstrual flow should last less than 7 days (or be < 80 mL in total volume). Menstrual flow that is excessive, that is, menorrhagia, should be further characterized as associated with clots, pain, or pressure. The number of pads used and degree that they are saturated are helpful.
Menometrorrhagia, which involves both excessive and irregular bleeding, should be distinguished from menorrhagia, and usually involves anovulatory cycles or genital lesions such as endometrial or cervical cancer.
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.
Sexually transmitted diseases: A positive or negative history of herpes simplex virus, syphilis, gonorrhea, Chlamydia, human immunodeficiency virus (HIV), pelvic inflammatory disease, or human papillomavirus (HPV). Number of sexual partners, whether a recent change in partners, and use of barrier contraception.
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.
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.
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.
Allergies: Reactions to medications should be recorded, including severity and temporal relationship to medication. Nonmedicine allergies such as to latex or iodine are also important to note. Immediate hypersensitivity should be distinguished from an adverse reaction.
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 are important to record. Use or abuse of illicit drugs, tobacco, or alcohol should also be recorded.
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, such as headache, visual disturbances, epigastric pain, or facial swelling should be queried. In an elderly woman, symptoms suggestive of cardiac disease, such as chest pain, shortness of breath, fatigue, weakness, or palpitations should be elicited.
General appearance: Cachectic versus well-nourished, anxious versus calm, alert versus obtunded.
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).
Head and neck examination: Evidence of trauma, tumors, facial edema, goiter, and carotid bruits should be sought. Cervical and supraclavicular nodes should be palpated.
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.
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.
Pulmonary examination: The lung fields should be examined systematically and thoroughly. Wheezes, rales, rhonchi, and bronchial breath sounds should be recorded.
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 to 4, where 4 is the most severe pain). Guarding, whether it is voluntary or involuntary, should be noted.
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.
Pelvic examination (adequate preparation of the patient is crucial, including counseling about what to expect, adequate lubrication, and sensitivity to pain and discomfort):
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 5:00 or 7:00 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.
The vaginal pH of less than 4.5 correlates with estrogen effect, whereas a vaginal pH greater than 4.5 can indicate a hypoestrogenic state or various microbial infections.
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.
Bimanual examination: Initially, the index and middle finger of the one gloved hand should be inserted into the patient's vagina, systematically probing the urethra, bladder, vagina, and finally, 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.
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.
Extremities and skin: The presence of joint effusions, tenderness, skin edema, and cyanosis should be recorded.
Neurologic examination: Patients who present with neurologic complaints usually require a thorough assessment, including evaluation of the cranial nerves, strength, sensation, and reflexes.
Laboratory assessment for obstetric patients:
Screening laboratory tests usually include
Complete blood count, to assess for anemia and thrombocytopenia.
Basic or comprehensive metabolic panel to assess for electrolytes and renal and liver function tests.
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).
Syphilis nontreponemal test (rapid plasma reagin [RPR] or Venereal Disease Research Laboratories [VDRL]): A positive test necessitates confirmation with a treponemal test, such as microhemagglutination-Treponema pallidum (MHA-TP) or fluorescent treponemal antibody absorbed (FTA-ABS).
HIV test: The screening test is usually the enzyme-linked immunosorbent assay (ELISA) and, when positive, will necessitate the Western blot or other confirmatory test.
Urine culture or urinalysis: To assess for asymptomatic bacteriuria.
Cytological examination: To assess for cervical dysplasia or cervical cancer; involves both ectocervical component and endocervical sampling. Evidence points toward the liquid-based media as being superior cellular sampling and allows for HPV subtyping.
Endocervical assays for gonorrhea and/or Chlamydia trachomatis for high-risk patients.
Pregnancy test: Urine pregnancy assays are both sensitive and specific, and quantitative serum human chorionic gonadotropin (hCG) assays can be used to follow the progress of a pregnancy.
Endometrial sampling: Sampling the endometrium is useful to assess for endometrial hyperplasia or malignancy as well as to assess for hormonal alterations.
Other tests are dependent on age, presence of coexisting disease, and chief complaint.
Threatened abortion: Serum quantitative hCG and/or progesterone levels may help to establish the viability of a pregnancy and risk of ectopic pregnancy.
Menorrhagia due to uterine fibroids: Complete blood cell count (CBC), endometrial biopsy, and Papanicolaou (Pap) smear. The endometrial biopsy is performed to assess for endometrial cancer and the Pap smear for cervical dysplasia or cancer.
A woman 55 years or older with an adnexal mass: CA-125, carcinoembryonic antigen (CEA), and/or CA 19-9 tumor markers for epithelial ovarian tumors.
A woman aged 25 with a complex adnexal mass: hCG level, α-fetoprotein level, and lactic acid dehydrogenase (LDH) level for germ cell tumor markers.
Adnexal masses evaluated by sonography are assessed for size and echogenic texture; simple (fluid-filled) versus complex (fluid and solid components) versus solid. Various scoring systems are used to assess for malignancy, taking into account septations and the thickness of the septa, papillations, and solid components. Doppler flow may help to distinguish benign versus malignant processes, usually with high flow, low resistance being consistent with malignancy.
The uterus can be characterized for presence of masses, such as uterine fibroids, and the endometrial stripe can be measured. In postmenopausal women, a thickened endometrial stripe exceeding 5 mm may indicate malignancy. Fluid in the cul-de-sac may indicate ascites.
The gynecologic ultrasound examination usually also includes investigation of the kidneys, because hydronephrosis may suggest a pelvic process (ureteral obstruction).
Saline infusion into the uterine cavity via a transcervical catheter can enhance the ultrasound examination of intrauterine growths such as polyps. Emerging frontiers include the use of ultrasonic contrast agents to assess for tubal patency.
Sonohysterography is a special ultrasound examination of the uterus that involves injecting a small amount of sterile saline into the endometrial cavity to better define the intrauterine cavity. It can help to identify endometrial polyps or submucous myomata.
Computed tomography (CT) scan:
Because of radiation concerns, this procedure is usually not performed on pregnant women unless sonography is not helpful and it is deemed necessary.
The CT scan is useful in women with possible abdominal and/or pelvic masses, and may help to delineate the lymph nodes and retroperitoneal disorders.
Magnetic resonance imaging (MRI):
Identifies soft tissue planes very well and may assist in defining mμllerian defects, such as vaginal agenesis or uterine didelphys (condition of double uterus and double cervix), and in selected circumstances may also aid in the evaluation of uterine pathology.
May be helpful in establishing the location of a pregnancy, such as in differentiating a normal pregnancy from a cervical pregnancy.
Intravenous pyelogram (IVP):
Intravenous dye is used to assess the concentrating ability of the kidneys, the patency of the ureters, and the integrity of the bladder.
It is also useful in detecting hydronephrosis, ureteral stone, or ureteral obstruction.
A small amount of radiopaque dye is introduced through a transcervical cannula and radiographs are taken.
It is useful for the detection of intrauterine abnormalities (submucous fibroids or intrauterine adhesions) and patency of the fallopian tubes (tubal obstruction or hydrosalpinx).
There are typically six distinct steps that a clinician undertakes to solve most clinical problems systematically:
Identifying the most important clinical condition
Developing a differential diagnosis
Making the diagnosis
Assessing the severity and/or stage of the disease
Rendering a treatment based on the stage of the disease
Following the patient's response to the treatment
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. The practitioner should clearly define and communicate that key clinical condition 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. Patients or family members often feel as though their concerns are not addressed if this step is not taken. Other clinical problems should likewise be listed and noted, but the primary condition should be given first attention.
After the key issue or issues have been identified and prioritized, the next step is to develop a differential diagnosis. The differential diagnosis is usually between three and 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 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.
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 diagnoses 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 for those instances when noninvasive methods are unrevealing, or when urgent conditions exist.
The first three steps in clinical problem solving include identifying the key issue(s), developing a differential diagnosis, and making the diagnosis.
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 the natural history of the infection (ie, primary syphilis, secondary, latent period, and tertiary/neurosyphilis).
The fourth step is to establish the severity or stage of disease. There is usually prognostic or treatment significance based on the stage.
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 and 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 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, assessment of the risks and benefits of each alternative, and a careful discussion with the patient and her family are paramount.
The treatment, whether medical or surgical, is tailored to the extent or “stage” of the disease.
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 chronic pelvic pain due to endometriosis may be followed by an analogue pain scale and validated questionnaires. Other responses may be followed by imaging tests, such as a CT scan, to establish retroperitoneal node size in a patient receiving chemotherapy, or a tumor marker, such as the CA-125 level in a woman receiving chemotherapy for ovarian cancer. When the patient's condition does not improve, it may be time to reconsider the diagnosis, or to repeat the metastatic workup, or to follow up with another more specific test. Because different physicians may follow the same patient, the methodology and plan for follow-up should be clearly documented so that the clinical assessment is reproducible.
The final step is to monitor treatment response or efficacy, which may be measured in different ways. It may be symptomatic (patient feels better), or based on physical examination (fever), a laboratory test (CA-125 level), or an imaging test (ultrasound size of ovarian cyst).
When surgery is contemplated in treating a patient, the timing, operative approach, optimization of comorbidities, risk-benefit analysis, and alternatives should be explored.
Timing: When the patient presents with an urgent clinical finding, urgent surgical intervention is warranted. For instance, when a woman has abdominal pain and hypotension consistent with a ruptured ectopic pregnancy, expeditious surgery is indicated. Nevertheless, even with emergency situations, patient stabilization is critical. For instance, it may be prudent to initiate intravenous fluid hydration, and perhaps ensure the availability of cross-matched blood. In most conditions, the patient should be treated with medical therapy first, and the symptoms monitored. Nevertheless, with some diseases, surgery is the best initial treatment, such as the postmenopausal woman with a 10 cm ovarian mass, due to the concern of ovarian neoplasm/malignancy.
Operative approach: Once surgery is decided as the best treatment alternative, the surgeon should consider the best operative approach. In women with a vaginal vault prolapse, should the approach be vaginal and a sacrospinous ligament fixation, or a uterosacral ligament fixation, or should it be an abdominal route such as an sacrocolpopexy. Although physicians will naturally have preferences for their favorite method, the patient should not be counseled toward one approach due to the surgeon's limitations. In other words, if the best technique is not within the scope of the physician's expertise, then the patient should be referred to a colleague who can perform that procedure. The patient's underlying pathophysiology should be sought, so that not just the “tip of the iceberg” symptom is addressed, but also the etiologies under the waterline. For instance, in women with vaginal vault prolapse, an enterocele is almost always present, and needs to be repaired to prevent recurrence.
Optimization of comorbidities: The patient's medical conditions, such as cardiovascular disease, pulmonary disease, diabetes, hypothyroidism, and other processes, need to be explored and optimized to reduce the perioperative complications. An understanding of the patient's anesthesia risk is also important. Thus, a history of snoring and uneasy sleep may indicate sleep apnea. Consultants' recommendations are vitally important; yet, blindly following recommendations is unwise, as the consummate surgeon should be aware of the important complications of the more common diseases. For instance, the gynecologist should assess for end-organ involvement from processes such as diabetes mellitus or hypertension.
Risk-benefit analysis: Each individual patient should be assessed for the benefits of the proposed procedure and the risks of doing nothing, an alternative, or the surgery contemplated. An evidence-based approach is best—literature should be used rather than speculation or impression of the past experience. A clear idea of the indication for the surgery should be documented, and the realistic incidence of complications associated with the procedure. Although patients are counseled every day on the possibility of complications, most surgeons and patients do not believe that those complications will happen to them. Thus, it is an important discipline to “fast forward” to the possibility of complications, and ask oneself the question: “If this patient develops a serious complication from the surgery, will the indication and surgery still be viewed as appropriate?”
Alternatives: Before embarking on surgery, the gynecologist should review the alternative therapies one last time before proceeding to the operative approach. The clinician is best served by taking a dispassionate view, trying to look objectively at the patient's condition from an “outsider's view.” This exercise allows for the patient to have the best treatment. The short- and long-term clinical course should be projected for the recommended surgery as well as the alternatives, including doing nothing.