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Part 1. Approach to the Patient
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The transition from textbook and/or journal article learning to the application of the information in a specific clinical situation is one of the most challenging tasks in medicine. It requires retention of information, organization of the facts, and recall of a myriad of data in precise application to the patient. The purpose of this book is to facilitate this process. The first step is gathering information, also known as 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 the most important and useful. Sensitivity and respect should always be exercised during the interview of patients.
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Basic information:
Age: Age must be recorded because some conditions are more common at certain ages; for instance, pregnant women younger than 17 years or older than 35 years are at greater risk for preterm labor, preeclampsia, or miscarriage.
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).
CLINICAL PEARL
Some practitioners use a four-digit parity system to designate the number of term deliveries, number of preterm deliveries, number of abortuses, and number of live births (TPAL [Term, Preterm, Abortions, Living] system). For example, G2P1001 indicates gravidity 2 (two pregnancies including the current one), parity 1001: 1 prior term delivery, no preterm deliveries, no abortuses, and 1 living.
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. The estimated gestational age (EGA) is calculated from the LMP or by ultrasound. A simple rule (Naegele’s rule) for calculating the expected due date (EDD) is to subtract 3 months from the LMP and add 7 days to the first day of the LMP (eg, an LMP of November 1 would equal an EDD of August 8). Because of delay in ovulation in some cycles, this is not always accurate.
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.
CLINICAL PEARL
The first line of any obstetric presentation should include age, gravidity, parity, LMP, EGA, and chief complaint.
Example: A 32-year-old G3P1011 woman, whose LMP was April 2 and who has a pregnancy with an EGA of 32 4/7 weeks’ gestation, complains of lower abdominal cramping.
Past gynecologic history:
Menstrual history
Age of menarche (should normally be between 10 and 15 years of age).
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 less than 80 mL in total volume). If menstrual flow is excessive, then it is called heavy menstrual bleeding.
Irregular and heavy menses are called abnormal uterine bleeding (AUB).
Contraceptive history: Duration, type, last use of contraception, and any side effects.
Sexually transmitted infections (STI): A positive or negative history of herpes simplex virus, syphilis, gonorrhea, chlamydia, human immunodeficiency virus, pelvic inflammatory disease, or human papillomavirus. The history should also include the number of sexual partners, any 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. Family history can be placed here or in a separate heading.
Past surgical history: Year and type of surgery should be elucidated and any complications documented. Type of incision (laparoscopy vs laparotomy) should be recorded.
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. 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.
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CLINICAL PEARL
In every pregnancy greater than 20 weeks’ gestation, the patient should be questioned about symptoms of preeclampsia (headaches, visual disturbances, dyspnea, epigastric pain, and face/hand swelling).
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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.
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 and 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 should be ascertained, and the heart auscultated at the apex of the heart as well as the base. Heart sounds, murmurs, and clicks should be characterized. Systolic flow murmurs are fairly common in pregnant women due to the increased cardiac output, but 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, distention, 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. Bowel sounds should be auscultated to identify normal versus high-pitched sounds 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.
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 because it 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 because malignant melanoma is not uncommon in the vulvar region.
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 fingers 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 palpated 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 (Figure I–1).
Figure I–1. Bimanual pelvic examination. The examiner evaluates the patient’s uterus by palpating her cervix vaginally while simultaneously assessing her uterine fundus abdominally.
NOTE: At the time of this writing, there is debate about the utility or necessity of the annual internal pelvic examination for low-risk, nonpregnant, asymptomatic women. While the American College of Physicians states that the internal pelvic examination is not helpful, the American College of Obstetricians and Gynecologists states that there is no definitive evidence either way and that the decision should rest with the patient and her health care provider.
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.
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.
Osteopathic perspective: One of the basic tenets of osteopathic medicine is that the body is a unit. Thus, the physiologic changes in the maternal body affect soft tissues as well as the bony pelvis. Although complaints of pelvic pain are often considered the result of increased laxity of the pelvic girdle, etiologies may include dysfunctions of the sacroiliac (SI) joint, pubis, or pelvic innominate bones. As a unit, the lumbar and sacral spines, the pelvis, and the legs are affected by the enlarging uterus.
The primary function of the SI joint is to bear the load of the upper body, which increases in pressure during pregnancy. Gait is one of the most descriptive evaluations that can be assessed during the osteopathic examination. Motion preferences during activity can lead to pain with the patient’s attempt to return to neutral positioning. Therefore, during walking, the physiologic motions of the sacrum and ilium can be altered by somatic dysfunctions affecting either the sacrum or ilium, resulting in gait changes and discomfort. There are four categories of sacral motion: postural, respiratory, inherent, and dynamic. The sacrum supporting a gravid uterus flexes and increases lumbosacral extension. Evaluation of the sacrum may be difficult during pregnancy, with the inability to place the patient prone. However, the seated flexion test may be helpful. Treatment should be directed at the lower extremities and to restore a neutral position of the sacrum, such as with a sacral or SI release, counterstrain, or the frog leg sacral articulation, all of which can be done in supine or lateral recumbent positions.
The same holds true for evolution of the pelvic bones, as patients should not be left completely prone for an extended period of time. The pelvic innominate bones and pubis rotate anteriorly and posteriorly around the transverse axis of the sacrum, but each ilium can be considered a function of the ipsilateral lower extremity, with the sacrum following. When evaluating the pelvis, the anterior superior iliac spine compression test may be easier to perform than the standing flexion test to establish the affected side.
CLINICAL PEARL
The vaginal examination assesses the anterior pelvis, whereas the rectal examination is directed at the posterior pelvis.
Posterior sacrum somatic dysfunctions are associated with dysfunctions of the ipsilateral piriformis and pelvic floor.
Management of sacroiliac joint dysfunctions should always involve evaluating for a hypertonic psoas muscle.
With the anterior pelvic tilt caused by pregnancy, the psoas muscles can contract, causing side bending of the lumbar spine, sacral torsion, pelvic translation, and contralateral piriformis contracture.
Laboratory assessment for obstetric patients:
Prenatal laboratory tests usually include the following:
Complete blood count (CBC) to assess for anemia and thrombocytopenia.
Blood type, Rh, and antibody screen are of paramount importance for all pregnant women; for women who are Rh negative, RhoGAM is administered at 28 weeks’ gestation and at delivery (if the baby proves Rh positive) to prevent isoimmunization.
Hepatitis B surface antigen (HBsAg): Indicates that the patient is infectious. At birth, the newborn should be given hepatitis B immune globulin and the hepatitis B vaccine in an attempt to prevent neonatal hepatitis. Hepatitis B viral load may assist in counseling about antiviral medication to reduce vertical transmission.
Rubella titer: If the patient is not immune to rubella, she should be vaccinated immediately postpartum; because it is a live attenuated vaccine, this immunization is not given during pregnancy.
Syphilis nontreponemal test (RPR [rapid plasma reagin] or VDRL [venereal disease research laboratory]): A positive test necessitates confirmation with a treponemal test such as MHATP (microhemagglutination assay for antibodies to Treponema pallidum) or FTA-ABS (fluorescent treponemal antibody absorption). Treatment during pregnancy is crucial to prevent congenital syphilis; penicillin is the agent of choice. Pregnant women who are allergic to penicillin usually undergo desensitization and then receive penicillin.
Human immunodeficiency virus 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: Assesses for asymptomatic bacteriuria that complicates 6% to 8% of pregnancies.
Pap smear: Assesses for cervical dysplasia or cervical cancer; involves both ectocervical component and endocervical sampling (Figure I–2). Many clinicians prefer the liquid-based media because it may provide better cellular sampling and allows for human papillomavirus subtyping.
Figure I–2. Pap smear with cytobrush for liquid-based cytology. The brush is used to sample the exocervix and endocervix, and then the brush is rotated and stirred into the fixative, allowing the cervical cells to be dispersed within the fixative solution.
Assays for Chlamydia trachomatis and/or gonorrhea: Traditionally, this has been endocervical specimens; however, newer technology includes nucleic acid testing of liquid-based Pap smears and vaginal collections with equal sensitivity and specificity as cervical collection. Urine assays are also available at a slightly lower sensitivity rate.
Timed prenatal tests:
Serum screening for neural tube defects or Down syndrome is offered, usually between 16 and 20 weeks’ gestation. First-trimester screening for trisomies with serum pregnancy-associated plasma protein-A, beta-human chorionic gonadotropin (beta-hCG), and nuchal translucency has gained popularity as well.
Screening for gestational diabetes at 24 to 28 weeks generally consists of a 50-g oral glucose load and assessment of the serum glucose level after 1 hour.
Some practitioners choose to repeat the CBC, cervical cultures, or syphilis serology in the third trimester.
If the culture strategy for group B Streptococcus is adopted, then introital cultures are obtained at 36 to 37 weeks’ gestation.
Laboratory tests for gynecologic patients:
Dependent on age, presence of coexisting disease, and chief complaint.
Common scenarios:
Threatened abortion: Quantitative hCG and/or progesterone levels may help to establish the viability of a pregnancy and risk of ectopic pregnancy.
Heavy menstrual bleeding due to uterine fibroids: CBC, endometrial biopsy, and Pap smear. The endometrial biopsy is performed to assess for endometrial cancer and the Pap smear for cervical dysplasia or cancer.
A woman aged 55 years or older with an adnexal mass: Cancer antigen 125 (CA-125) and carcinoembryonic antigen (CEA) tumor markers for epithelial ovarian tumors.
Imaging procedures:
Ultrasound examination:
Obstetric patients: Ultrasound is the most commonly used imaging procedure in pregnant women. It can be used to establish the viability of the pregnancy, number of fetuses, location of the placenta, and the gestational age of the pregnancy. Targeted examinations can help to examine for structural abnormalities of the fetus.
Gynecologic patients: Adnexal masses evaluated by sonography are assessed for size and echogenic texture: simple (fluid filled) versus complex (fluid and solid components) versus solid. 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 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 (eg, ureteral obstruction). Saline infusion into the uterine cavity via a transcervical catheter can enhance the ultrasound examination of intrauterine growths such as polyps.
Computed tomography (CT) scan:
Because of the 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 it may help to delineate lymph nodes and retroperitoneal disorders.
Magnetic resonance imaging:
Identifies soft tissue planes very well and may assist in defining müllerian defects such as vaginal agenesis or uterine didelphys (condition of double uterus and double cervix).
May aid in the evaluation of uterine anomalies in certain circumstances.
May be helpful in establishing the location of a pregnancy, such as in differentiating a normal pregnancy from a cervical pregnancy.
Intravenous pyelogram:
Intravenous dye is used to assess the concentrating ability of the kidneys, the patency of the ureters, and the integrity of the bladder (this test is used less now).
It is also useful in detecting hydronephrosis, ureteral stone, or ureteral obstruction.
Hysterosalpingogram:
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).
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Part 2. Approach to Clinical Problem Solving
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There are typically four distinct steps that a clinician undertakes to solve most clinical problems systematically:
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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.
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The diagnosis is made by careful evaluation of the database, analysis of the information, assessment of the risk factors, and development of the list of possibilities (the differential diagnosis). The process includes knowing which pieces of information are meaningful and which may be thrown out. Experience and knowledge help to guide the clinician to “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 also influence the probability of a diagnosis.
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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 STI 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.
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ASSESSING THE SEVERITY AND/OR STAGE OF THE DISEASE
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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).
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TREAT BASED ON DISEASE STAGE
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Many illnesses are stratified according to severity because prognosis and treatment often vary based on the severity. If neither the prognosis nor the treatment were influenced by the stage of the disease process, there would not be a reason to subcategorize a disease as mild or severe. As an example, a pregnant woman at 34 weeks’ gestation with mild preeclampsia is at less risk from the disease than if she had developed severe preeclampsia (particularly if the severe preeclampsia were pulmonary edema or eclampsia). Accordingly, with mild preeclampsia, the management may be expectant, letting the pregnancy continue while watching for any danger signs (severe disease). In contrast, if preeclampsia with severe features complicated this same 34-week pregnancy, the treatment would be magnesium sulfate to prevent seizures (eclampsia) and, most importantly, delivery. It is primarily delivery that “cures” the preeclampsia. In this disease, severe preeclampsia means both maternal and fetal risks are increased. 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.
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Bacterial vaginosis (BV) has been associated with preterm delivery, endometritis, and vaginal cuff cellulitis (following hysterectomy), but it 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 treatment based on stage.
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FOLLOWING THE PATIENT’S RESPONSE TO THE TREATMENT
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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 student must work on being more skilled in eliciting the data in an unbiased and standardized manner. 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. For syphilis, it may be the results of a nonspecific treponemal antibody test RPR titer over time. The student must be prepared to know what to do if the measured marker does not respond according to what is expected. Is the next step to re-treat, to reconsider the diagnosis, to repeat the metastatic workup, or to follow up with another more specific test?
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CLINICAL PEARL
The fourth step in clinical problem solving is to monitor treatment response or efficacy, which may be measured in different ways. It may be based on symptoms (patient feels better), a physical examination (fever), a laboratory test (CA-125 level), or an imaging test (ultrasound for the size of ovarian cyst).
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Part 3. Approach to Reading
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The clinical problem–oriented approach to reading is different from the classic “systematic” research of a disease. Patients rarely present with a clear diagnosis; hence, the student must become skilled in applying the textbook information to the clinical setting. Furthermore, a reader retains more information when reading with a purpose. In other words, the student should read with the goal of answering specific questions. Likewise, the student should have a plan for the acquisition and use of the information; the process is similar to having a mental “flowchart” and at each step sifting through diagnostic possibilities, therapy, complications, and risk factors. There are several fundamental questions that facilitate clinical thinking. These are as follows:
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What is the most likely diagnosis?
What should be your next step?
What is the most likely mechanism for this process?
What are the risk factors for this condition?
What are the complications associated with the disease process?
What is the best therapy?
How would you confirm the diagnosis?
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WHAT IS THE MOST LIKELY DIAGNOSIS?
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The method of establishing the diagnosis has been covered in the previous section. One way of attacking this problem is to develop standard “approaches” to common clinical situations. It is helpful to understand the most common causes of various presentations; for example, “the most common cause of postpartum hemorrhage is uterine atony.”
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The clinical scenario would be something such as:
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An 18-year-old G1P0 woman undergoes an uncomplicated vaginal delivery at term. After the placenta is delivered, she has 1500 mL of vaginal bleeding. What is the most likely diagnosis?
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With no other information to go on, the student would note that this patient has postpartum hemorrhage (blood loss of greater than 1000 mL with a vaginal delivery). Using the “most common cause” information, the student would make an educated guess that the patient has uterine atony.
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However, what if the scenario also included the following phrase?
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The uterus is noted to be firm.
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Now the most likely diagnosis is a genital tract laceration, usually involving the cervix. With a firm, well-contracted uterus, atony is not likely.
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CLINICAL PEARL
The most common cause of postpartum hemorrhage is uterine atony. Thus, the first step in patient assessment and management is uterine massage to check if the uterus is boggy.
If the uterus is firm and the woman is still bleeding, then the clinician should consider a genital tract laceration.
Now, the student would use the Clinical Pearl: “The most common cause of postpartum hemorrhage with a firm uterus is a genital tract laceration.”
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WHAT SHOULD BE YOUR NEXT STEP?
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This question is difficult because the next step has many possibilities; the answer may be to obtain more diagnostic information, stage the illness, or introduce therapy. It is often a more challenging question than “What is the most likely diagnosis?” because there may be insufficient information to make a diagnosis and the next step may be to pursue more diagnostic information. Another possibility is that there is enough information for a probable diagnosis, and the next step is to stage the disease. Finally, the most appropriate answer may be to render treatment. Hence, from clinical data, a judgment needs to be rendered regarding how far along one is on the road of:
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Make a diagnosis → Stage the disease → Treat based on stage → Follow response
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Frequently, the student is taught to “regurgitate” the information that someone has written about a particular disease but is not skilled at giving the next step. This talent is learned optimally at the bedside, in a supportive environment, with freedom to make educated guesses, and with constructive feedback. A sample scenario describes a student’s thought process as follows:
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Make a diagnosis: “Based on the information I have, I believe that this patient has pelvic inflammatory disease because she is not pregnant and has lower abdominal tenderness, cervical motion tenderness, and adnexal tenderness.”
Stage the disease: “I do not believe that this is a severe disease because she does not have high fever, evidence of sepsis, or peritoneal signs. An ultrasound has already been done showing no abscess (tubo-ovarian abscess would put her in a severe category).”
Treat based on stage: “Therefore, my next step is to treat her with intramuscular ceftriaxone and oral doxycycline.”
Follow response: “I want to follow the treatment by assessing her pain (I will ask her to rate the pain on a scale of 1-10 every day), her temperature, and abdominal examination. I will reassess her in 24 hours.”
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In a similar patient, when the clinical presentation is unclear, perhaps the best “next step” may be diagnostic in nature such as laparoscopy to visualize the tubes. This information is sometimes tested by the dictum, “the gold standard for the diagnosis of acute salpingitis is laparoscopy to visualize the tubes, and particularly to see purulent material drain from the tubes.”
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CLINICAL PEARL
Usually, the vague query, “What is your next step?” is the most difficult question because the answer may be diagnostic, staging, or therapeutic.
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WHAT IS THE MOST LIKELY MECHANISM FOR THIS PROCESS?
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This question goes further than making the diagnosis, and it also requires the student to understand the underlying mechanism for the process. For example, a clinical scenario may describe an 18-year-old woman at 24 weeks’ gestation who develops dyspnea 2 days after being treated for pyelonephritis. The student must first diagnose the acute respiratory distress syndrome, which often occurs 1 to 2 days after antibiotics are instituted. Then, the student must understand that the endotoxins that arise from gram-negative organisms cause pulmonary injury, leading to capillary leakage of fluid into the pulmonary interstitial space. The mechanism is, therefore, endotoxin-induced “capillary leakage.” Answers that a student may also entertain, but that are less likely to be causative, include pneumonia, pulmonary embolism, or pleural effusion.
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The student is advised to learn the mechanisms for each disease process and not merely memorize a constellation of symptoms. In other words, rather than solely committing to memorizing the classic presentation of pyelonephritis (fever, flank tenderness, and pyuria), the student should understand that gram-negative rods, such as Escherichia coli, would ascend from the external genitalia to the urethra to the bladder. From the bladder, the bacteria would ascend further to the kidneys and cause an infection in the renal parenchyma. The involvement of the kidney now causes fever (vs an infection of only the bladder, which usually does not induce a fever) and flank tenderness—a systemic response not seen with lower urinary tract infection (ie, bacteriuria or cystitis). Furthermore, the body’s reaction to the bacteria brings about leukocytes in the urine (pyuria).
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WHAT ARE THE RISK FACTORS FOR THIS CONDITION?
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Understanding the risk factors helps the practitioner to establish a diagnosis and to determine how to interpret tests. For example, understanding the risk factor analysis may help to manage a 55-year-old woman with postmenopausal bleeding after an endometrial biopsy shows no pathologic changes. If the woman does not have any risk factors for endometrial cancer, the patient may be observed because there is not a high likelihood for uterine malignancy. On the other hand, if the same 55-year-old woman were diabetic, had a long history of anovulation (irregular menses), were nulliparous, and were hypertensive, a practitioner should pursue the postmenopausal bleeding further, even after a normal endometrial biopsy. The provider may want to perform a hysteroscopy to visualize the endometrial cavity directly and biopsy the abnormal-appearing areas. Thus, the presence of risk factors helps to categorize the likelihood of a disease process.
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WHAT COMPLICATIONS ARE ASSOCIATED WITH THE DISEASE?
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Clinicians must be cognizant of the complications of a disease so that they will understand how to follow and monitor the patient. Sometimes, students will have to make the diagnosis from clinical clues and then apply their knowledge of the consequences of the pathologic process. For example, a woman who presents with lower abdominal pain, vaginal discharge, and dyspareunia is first diagnosed as having pelvic inflammatory disease or salpingitis (infection of the fallopian tubes). Long-term complications of this process would include ectopic pregnancy or infertility from tubal damage. Understanding the types of consequences also helps the clinician to be aware of the dangers to a patient. One life-threatening complication of a tubo-ovarian abscess (which is the end stage of a tubal infection leading to a collection of pus in the region of the tubes and ovary) is rupture of the abscess. The clinical presentation is shock with hypotension, and the appropriate therapy is immediate surgery. In fact, not recognizing the rupture is commonly associated with patient mortality. Students may apply this information when they see a woman with a tubo-ovarian abscess on daily rounds and monitor for hypotension, confusion, apprehension, and tachycardia. The clinician should advise the team to be vigilant for any signs of abscess rupture and to be prepared to undertake immediate surgery should the need arise.
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WHAT IS THE BEST THERAPY?
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To answer this question, the clinician needs to reach the correct diagnosis, assess the severity of the condition, and then weigh the situation to reach the appropriate intervention. For the student, knowing exact dosages is not as important as understanding the best medication, the route of delivery, the mechanism of action, and the possible complications. It is important for the student to be able to verbalize the diagnosis and the rationale for the therapy. A common error is for the student to “jump to a treatment,” like a random guess, and therefore be given “right or wrong” feedback. In fact, the student’s guess may be correct but for the wrong reason; conversely, the answer may be a very reasonable one, with only one small error in thinking. Instead, the student should verbalize the steps so that feedback may be given at every reasoning point.
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For example, if the question is, “What is the best therapy for a 19-year-old woman who is pregnant at 12 weeks’ gestation and has a nontender ulcer of the vulva and painless adenopathy?” The incorrect manner of response for the student is to blurt out “azithromycin.” Rather, the student should reason it in a way such as the following: “The most common cause of a nontender infectious ulcer of the vulva is syphilis. Painless adenopathy is usually associated. In pregnancy, penicillin is the only effective therapy to prevent congenital syphilis. Therefore, the best treatment for this woman with probable syphilis is intramuscular penicillin (after confirming the diagnosis).”
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A related question is, “What would have best prevented this condition?” For instance, if the scenario presented is a 23-year-old woman with tubal factor infertility, then the most likely etiology is Chlamydia trachomatis cervicitis that had ascended to the tubes and caused damage. The best preventive measure would be barrier contraception such as condom use.
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HOW WOULD YOU CONFIRM THE DIAGNOSIS?
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In the previous scenario, the woman with a nontender vulvar ulcer is likely to have syphilis. Confirmation can be achieved by serology (RPR or VDRL test) and specific treponemal test; however, there is a significant possibility that patients with primary syphilis may not have developed an antibody response yet and have negative serology. Thus, confirmation of the diagnosis would be attained with darkfield microscopy. The student should strive to know the limitations of various diagnostic tests and the manifestations of disease.
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Part 4. Approach to Surgery
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The student should be generally aware of the various approaches to surgical management of the gynecologic patient. Ways to access the intra-abdominal cavity include (1) laparotomy (incision of the abdomen), (2) laparoscopy (using thin, long instruments through small incisions to perform surgery), (3) vaginal surgery, and (4) robotic surgery (use of the console to direct instruments that have been docked). The latter two are considered minimally invasive approaches.
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Some of the relative advantages and disadvantages of laparoscopy versus robotics include:
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Robotics: Better three-dimensional visualization and magnification, better ability to manipulate instruments such as rotating “EndoWrist” stitching, less “fulcrum effect” of long instruments, better ergonomics for surgeon, and restoration of eye-target perspective.
Laparoscopy: Better “feel” of tissue and force used, lower cost, smaller “footprint” of machine, and possibly less operative time.
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Hysteroscopy is a means to examine or perform surgery on the intrauterine cavity by inserting a distention media in the uterus and using a small, thin scope going through the cervix to visualize the endometrial cavity.