Diagnostic Tests for Cerebral hemorrhage
Cerebral hemorrhage Tests: Book Excerpts
Home Diagnostic Testing
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Cerebral hemorrhage Diagnosis: Book Excerpts
Diagnostic Tests for Cerebral hemorrhage: Online Medical Books
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Vaginal bleeding, postmenopausal:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Determine the patient’s age and her age at menopause. Ask when she first noticed the abnormal bleeding. Then obtain a thorough obstetric and gynecologic history. When did she begin menstruating? Were her periods regular? If not, ask her to describe any menstrual irregularities. How old was she when she first had intercourse? How many sexual partners has she had? Has she had any children? Has she had fertility problems? If possible, obtain an obstetric and gynecologic history of the patient’s mother, and ask about a family history of gynecologic cancer. Determine if the patient has any associated symptoms and if she’s taking estrogen.
Observe the external genitalia, noting the character of any vaginal discharge and the appearance of the labia, vaginal rugae, and clitoris. Carefully palpate the patient’s breasts and lymph nodes for nodules or enlargement. The patient will require pelvic and rectal examinations.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Vaginal bleeding, postmenopausal:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Determine the patient’s age and her age at menopause. Ask when she first noticed the abnormal bleeding. Then obtain a thorough obstetric and gynecologic history. When did she begin menstruating? Were her periods regular? If not, ask her to describe any menstrual irregularities. How old was she when she first had intercourse? How many sexual partners has she had? Has she had any children? Has she had fertility problems? If possible, obtain an obstetric and gynecologic history of the patient’s mother, and ask about a family history of gynecologic cancer. Determine if the patient has any associated symptoms and if she’s taking estrogen.
Observe the external genitalia, noting the character of any vaginal discharge and the appearance of the labia, vaginal rugae, and clitoris. Carefully palpate the patient’s breasts and lymph nodes for nodules or enlargement. The patient will require pelvic and rectal examinations.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Postmenopausal Bleeding:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Vital signs. Blood pressure and pulse can indicate the degree and acuity of blood loss; orthostatic changes can be evidence of significant volume depletion. Fever suggests infection as a potential cause (Chapter 2.6).
B. Abdomen. Tenderness or guarding suggests an infectious or inflammatory cause. Palpation for suprapubic masses is necessary as part of the evaluation for malignant causes.
C. Pelvis. Examine external genitalia, vagina, and cervix for lesions or lacerations that could be the source of bleeding. The uterus and ovaries must be palpated to assess for enlargement, masses, and tenderness.
D. Rectum. Rectal examination and anoscopy may be warranted to rule out hemorrhoids or other intestinal source of bleeding (Chapter 9.11).
Testing
A. Office laboratory testing. Urinalysis, stool guaiac testing, or both can be useful to look for nongenital sources of blood. A complete blood count may be helpful in assessing the degree of blood loss and likelihood of infection. Testing for gonorrhea and chlamydia may be warranted when tenderness or fever is present.
B. Pap smear. Many sources recommend a pap smear as part of the evaluation, although its diagnostic yield in these cases is low. Cervical lesions or friability raise the possibility of a cervical bleeding source. Endometrial cells found on the pap smear of a postmenopausal woman not on HRT warrants further evaluation of the endometrium.
C. Biopsy
1. Visible lesions of the vulva, vagina, or cervix should be sent for biopsy.
2. In the absence of a clear nonuterine source of bleeding, endometrial biopsy is usually recommended. This office test can cost-effectively identify endometrial hyperplasia and carcinoma, with a sensitivity of 85% to 95% (3), and it is lower in cost and risk than other procedures (2).
3. Traditional wisdom required dilation and curettage (D&C) for diagnosis if endometrial biopsy was negative. Recent evidence indicates this is unlikely to be of benefit (despite higher risk and cost), except in cases where other procedures are not possible (2–5).
4. If bleeding continues after normal biopsy, consider repeat biopsy or assessment by another method (5).
D. Diagnostic imaging
1. Palpable adnexal abnormalities should be evaluated by ultrasound or other imaging as appropriate.
2. Transvaginal ultrasound (TVUS) is gaining popularity as an alternative or adjunct to endometrial biopsy. A clearly identifiable endometrial stripe less than 4 or 5 mm in thickness is highly unlikely to contain hyperplasia or carcinoma, and biopsy may not be necessary (2,4). Fluid in the endometrial cavity has been associated with carcinoma, and its presence warrants further investigation (5). TVUS should not be used in place of biopsy in women on tamoxifen, as the drug is known to cause misleading ultrasound findings (3,5).
3. Hysteroscopy is becoming the “gold standard” against which other methods of endometrial assessment are compared (4,5). Flexible hysteroscopy allows direct visualization of the endometrium in the office setting, and can be used for directed biopsy and removal of small polyps. Rigid hysteroscopy allows greater intervention, but requires greater anesthesia.
4. Sonohysterography (ultrasound evaluation after instillation of fluid into the endometrial cavity) appears to offer promise as another alternative that provides additional information on the uterine architecture (3,5). This is the subject of ongoing study, especially in comparison with hysteroscopy, which provides similar information and may allow simultaneous biopsy of identified lesions.
Diagnostic assessment
Initial clinical evaluation may identify a nonuterine source. Postcoital spotting in conjunction with vaginal atrophy or cervical friability suggests cervical or vaginal mucosal bleeding. Gross hematuria or visibly bleeding hemorrhoids suggest that the bleeding source is not genital. If no other source is identified, however, the key to diagnosis is imaging and tissue sampling of the endometrium. A thin endometrial stripe in a woman in a low-risk category suggests endometrial atrophy. Findings on biopsy can include atrophy, proliferative changes, various degrees of hyperplasia (simple, complex, and atypical, in increasing order of risk), or carcinoma. If neither biopsy nor TVUS provides sufficient information, hysteroscopy is the recommended next step. D&C should be reserved for cases in which other methods are unsuccessful or unavailable.
References
1. Shelly MS. Endometrial biopsy. Am Fam Physician 1997;55(5):1731–1736.
2. Feldman S, Berkowitz RS, Tosteson ANA. Cost-effectiveness of strategies to evaluate post-menopausal bleeding. Obstet Gynecol 1993;81(6):968–975.
3. O’Connell LP, Fries MH, Zeringue E, Brehm W. Triage of abnormal postmenopausal bleeding: a comparison of endometrial biopsy and transvaginal sonohysterography versus fractional curettage with hysteroscopy. Am J Obstet Gynecol 1998;178(5):956–961.
4. Emanuel MH, Verdel MJ, Wamsteker K, Lammes FB. A prospective comparison of transvaginal ultrasonography and diagnostic hysteroscopy in evaluation of patients with abnormal uterine bleeding: clinical implications. Am J Obstet Gynecol 1995;172(2):547–552.
5. Good AE. Diagnostic options for assessment of postmenopausal bleeding. Mayo Clin Proc 1997;72:345–349.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Vaginal bleeding, postmenopausal:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Observe the external genitalia, noting the character of any vaginal discharge and the appearance of the labia, vaginal rugae, and clitoris. Carefully palpate the patient’s breasts and lymph nodes for nodules or enlargement. The patient will require pelvic and rectal examinations.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Vaginal bleeding, postmenopausal:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Determine the patient's age and her age at menopause. Ask when she first noticed the abnormal bleeding then obtain a thorough obstetric and gynecologic history. When did she begin menstruating? Were her menses regular? If not, ask her to describe menstrual irregularities. How old was she when she first had intercourse? How many sexual partners has she had? Has she had children? Has she had fertility problems? If possible, obtain an obstetric and gynecologic history of the patient's mother and ask about a family history of gynecologic cancer. Determine whether the patient has associated symptoms and if she's taking estrogen.
Observe the external genitalia, noting the character of vaginal discharge and the appearance of the labia, vaginal rugae, and clitoris. Carefully palpate the patient's breasts and lymph nodes for nodules or enlargement. The patient will require pelvic and rectal examinations.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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