Diagnostic Tests for Vagina conditions
Vagina conditions Tests: Book Excerpts
Home Diagnostic Testing
These home medical tests may be relevant to Vagina conditions:
- Home STD Testing
- Menopause: Related Home Testing:
- Vaginal Health: Home Testing:
- Sexuality & Libido: Home Testing:
- Liver Health & Hepatitis: Home Testing
- Breast Cancer: Related Home Tests:
Vagina conditions Diagnosis: Book Excerpts
Diagnostic Tests for Vagina conditions: Online Medical Books
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Review excerpts from medical books online, free, without registration,
for more information about the diagnostic tests for Vagina conditions.
DYSMENORRHEA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Routine studies should include a CBC, sedimentation rate, chemistry panel, and thyroid profile. If there is vaginal discharge, a smear and culture should be done for gonorrhea and chlamydia. A cervical and rectal culture for these organisms may also be necessary. If there is a tubo-ovarian mass or enlarged uterus, abdominal ultrasound may help in differentiating the cause. A pregnancy test should be done. The pregnancy test of choice is
radioimmunoassay
for the beta subunit of human chorionic gonadotropin (HCG), which will be positive within a week of fertilization. If a ruptured ectopic pregnancy is expected, a peritoneal tap or culdocentesis may help if abdominal ultrasound is not conclusive. Laparoscopy may also be helpful in the diagnosis. A fern test and basal body temperature may help diagnose endometriosis. An exploratory laparotomy may be the only way to make a diagnosis in cases of a pelvic mass. If the pelvic examination is perfectly normal, sometimes a course of progesterone hormones is useful in alleviating the problem. A dilation and curettage may also be done to address the problem. Referral to a gynecologist is usually made before doing expensive diagnostic tests.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
MENORRHAGIA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Routine studies include a CBC, sedimentation rate, urinalysis, pregnancy test, chemistry panel, ANA titer, VDRL test, coagulation profile, thyroid profile, and flat plate of the abdomen. A Pap smear and vaginal smear and culture should be done.
If these tests are negative, referral to a gynecologist should be made before undertaking expensive tests such as pelvic ultrasound or CT scan of the abdomen and pelvis. Some clinicians will probably ignore this advice. A gynecologist will often be able to resolve the diagnostic dilemma with a good pelvic examination. Laparoscopy, culdocentesis, endometrial biopsy, and dilation and curettage are just a few of the diagnostic tools at his disposal.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
METRORRHAGIA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Routine studies include a CBC, sedimentation rate, urinalysis, pregnancy test, chemistry panel, ANA test, coagulation profile, thyroid profile, and flat plate of the abdomen. A Pap smear and vaginal smear and culture should also be done.
If these are negative, referral to a gynecologist should be made before undertaking expensive diagnostic tests such as ultrasound or CT scans of the abdomen and pelvis. Alternatively, a trial of cyclical estrogen and progesterone hormones may be done if dysfunctional bleeding is suspected before referral is made. A gynecologist may be able to resolve the diagnostic dilemma with a good pelvic examination or, if that is unsuccessful, may perform laparoscopy or culdocentesis. A dilation and curettage or office endometrial biopsy are among the additional procedures at the gynecologist's disposal. An endocrinologist may be of help in deciding whether pituitary or ovarian dysfunction is responsible. An FSH of greater than 40 ml suggests ovarian failure. The endocrinologist may note hirsutism and order a free testosterone and 17-hydroxy progesterone to rule out adrenal or ovarian neoplasm.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
VAGINAL DISCHARGE:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
The most important test is microscopic examination of a saline and potassium hydroxide preparation. This will diagnose most cases of trichomoniasis and candidiasis.
Gardnerella
vaginalis
can be diagnosed if clue cells are found, and the pH of the discharge will be greater than 4.7. If this is unrevealing, a Gram stain for gonorrhea and cultures for trichomoniasis, candidiasis, chlamydia,
Gardnerella vaginalis
, and gonorrhea may be done. A Pap smear should be done to rule out malignancy. Polyps or inflamed areas of the cervix should be biopsied. Colposcopy may help further differentiate a cervical lesion. A dilation and curettage may be necessary to diagnose endometrial carcinoma and hydatidiform mole. Occasionally, pelvic ultrasound and CT scans are necessary. However, before ordering these expensive diagnostic tests, a gynecologist should be consulted. Patients with documented evidence of gonorrhea should have a VDRL test and HIV testing.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
VULVAL OR VAGINAL MASS:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
Referral to a gynecologist or urologist can obviate an expensive diagnostic workup in most cases. The primary care physician may wish to treat acute bartholinitis or vulvitis, however. A culture and sensitivity is the only procedure required in those cases.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
VULVAL OR VAGINAL ULCERATIONS:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
The workup includes a CBC, sedimentation rate, urinalysis, and VDRL test. A smear and culture of material from the ulceration should be done. A dark field examination may also be necessary. The Frei test may diagnose lymphogranuloma venereum, but a serologic test for this disorder may also be ordered. Biopsy may be ultimately necessary. It is wise to enlist the help of a urologist or gynecologist in difficult cases.
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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Dysmenorrhea:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient complains of dysmenorrhea, have her describe it fully. Is it intermittent or continuous? Sharp, cramping, or aching? Ask where the pain is located and whether it's bilateral. When does the pain begin and end, and when is it severe? Does it radiate to the back? How long has she been experiencing the pain? If it's a recent complaint, obtain a human chorionic gonadotropin level to determine if the patient is or was pregnant, because miscarriage can cause painful bleeding. Explore associated signs and symptoms, such as nausea and vomiting, altered bowel or urinary habits, bloating, water retention, pelvic or rectal pressure, and unusual fatigue, irritability, or depression.
Then obtain a menstrual and sexual history. Ask the patient if her menstrual flow is heavy or scant. Have her describe vaginal discharge between menses. Does she experience pain during sexual intercourse? Does it occur with menses? Find out what relieves her cramps. Does she take pain medication? Is it effective? Note her method of contraception, and ask about a history of pelvic infection. Does she have signs and symptoms of urinary system obstruction, such as pyuria, urine retention, or incontinence? Determine how she copes with stress. Determine her risk of sexually transmitted diseases.
Next, perform a focused physical examination. Take the patient's vital signs, noting fever and accompanying chills. Inspect the abdomen for distention, and palpate for tenderness and masses. Note costovertebral angle tenderness.
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Source: Handbook of Signs & Symptoms (Third Edition), 2006
Menorrhagia:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
When the patient’s condition permits, obtain a history. Determine her age at menarche, the duration of menstrual periods, and the interval between them. Establish the date of the patient’s last menses, and ask about recent changes in her normal menstrual pattern. Have the patient describe the character and amount of bleeding. For example, how many pads or tampons does the patient use? Has she noted clots or tissue in the blood? Also ask about the development of other signs and symptoms before and during her period.
Next, ask if the patient is sexually active. Does she use a method of birth control? If so, what kind? Could the patient be pregnant? Be sure to note the number of pregnancies, the outcome of each, and any pregnancy-related complications. Find out the dates of her most recent pelvic examination and Papanicolaou smear and the details of any previous gynecologic infections or neoplasms. Also, be sure to ask about previous episodes of abnormal bleeding and the outcome of treatment. If possible, obtain a pregnancy history of the patient’s mother, and determine if the patient was exposed in utero to diethylstilbestrol. (This drug has been linked to vaginal adenosis.)
Be sure to ask the patient about her general health and medical history. Note particularly if the patient or her family has a history of thyroid, adrenal, or hepatic disease; blood dyscrasias; or tuberculosis because these may predispose the patient to menorrhagia. Also, ask about the patient’s past surgical procedures and recent emotional stress. Find out if the patient has undergone X-ray or other radiation therapy, because this may indicate prior treatment for menorrhagia. Obtain a thorough drug and alcohol history, noting the use of anticoagulants or aspirin. Perform a pelvic examination, and obtain blood and urine samples for pregnancy testing.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Metrorrhagia:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Begin your evaluation by obtaining a thorough menstrual history. Ask the patient when she began menstruating and about the duration of menstrual periods, the interval between them, and the average number of tampons or pads she uses. When does metrorrhagia usually occur in relation to her period? Does she experience other signs or symptoms? Find out the date of her last menses, and ask about other recent changes in her normal menstrual pattern. Get details of previous gynecologic problems. If applicable, obtain a contraceptive and obstetric history. Record the dates of her last Papanicolaou smear and pelvic examination. Ask the patient when she last had sex and whether or not it was protected. Next, ask about her general health and any recent changes. Is she under emotional stress? If possible, obtain a pregnancy history of the patient’s mother. Was the patient exposed in utero to diethylstilbestrol? (This drug has been linked to vaginal adenosis.)
Perform a pelvic examination if indicated, and obtain blood and urine samples for pregnancy testing.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Urethral discharge:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask the patient when he first noticed the discharge, and have him describe its color, consistency, and quantity. Does he experience pain or burning on urination? Does he have difficulty initiating a urine stream? Does he experience urinary frequency? Ask the patient about other associated signs and symptoms, such as fever, chills, and perineal fullness. Explore his history for prostate problems, sexually transmitted disease, or urinary tract infection. Ask the patient if he has had recent sexual contacts or a new sexual partner.
Inspect the patient’s urethral meatus for inflammation and swelling. Using proper technique, obtain a culture specimen. (See Collecting a urethral discharge specimen.) Then obtain a urine sample for urinalysis, culture, and possibly a three-glass urine sample. (See Performing the three-glass urine test, page 608.) In the male patient, the prostate gland may have to be palpated.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Vaginal discharge:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
Ask the patient to describe the onset, color, consistency, odor, and texture of her vaginal discharge. How does the discharge differ from her usual vaginal secretions? Is the onset related to her menstrual cycle? Also, ask about associated symptoms, such as dysuria and perineal pruritus and burning. Does she have spotting after coitus or douching? Ask about recent changes in her sexual habits and hygiene practices. Is she or could she be pregnant? Next, ask if she has had vaginal discharge before or has ever been treated for a vaginal infection. What treatment did she receive? Did she complete the course of medication? Ask about her current use of medications, especially antibiotics, oral estrogens, and hormonal contraceptives.
Examine the external genitalia and note the character of the discharge. (See Identifying causes of vaginal discharge.) Observe vulvar and vaginal tissues for redness, edema, and excoriation. Palpate the inguinal lymph nodes to detect tenderness or enlargement, and palpate the abdomen for tenderness. A pelvic examination may be required. Obtain vaginal discharge specimens for testing.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
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
Dysmenorrhea:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient complains of dysmenorrhea, have her describe it fully. Is it intermittent or continuous? Sharp, cramping, or aching? Ask where the pain is located and whether it’s bilateral. How long has she been experiencing it? When does the pain begin and end, and when is it severe? Does it radiate to the back? Explore associated signs and symptoms, such as nausea and vomiting, altered elimination habits, bloating, water retention, pelvic or rectal pressure, and unusual fatigue, irritability, or depression.
Then obtain a menstrual and sexual history. Ask the patient if her menstrual flow is heavy or scant. Have her describe any vaginal discharge between menses. Does she experience pain during sexual intercourse? Does it occur with menses? Find out what relieves her cramps. Does she take pain medication? Is it effective? Note her method of contraception, and ask about a history of pelvic infection. Does she have any signs and symptoms of urinary system obstruction, such as pyuria, urine retention, or incontinence? Determine how she copes with stress. Determine her risk for sexually transmitted diseases.
Next, perform a focused physical examination. Take vital signs, noting fever and accompanying chills. Inspect the abdomen for distention, and palpate for tenderness and masses. Note costovertebral angle tenderness.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Menorrhagia:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
When the patient’s condition permits, obtain a history. Determine her age at menarche, the average duration of menstrual periods, and the interval between them. Establish the date of the patient’s last menses, and ask about any recent changes in her normal menstrual pattern. Have the patient describe the character and amount of bleeding. For example, how many pads or tampons does the patient use? Has she noted clots or tissue in the blood? Also ask about the development of other signs and symptoms before and during the menstrual period.
Next, ask if the patient is sexually active. Does she use a method of birth control? If so, what kind? Could the patient be pregnant? Be sure to note the number of pregnancies, the outcome of each, and any pregnancy-related complications. Find out the dates of her most recent pelvic examination and Papanicolaou smear and the details of any previous gynecologic infections or neoplasms. Also, be sure to ask about any previous episodes of abnormal bleeding and the outcome of any treatment. If possible, obtain a pregnancy history of the patient’s mother, and determine if the patient was exposed in utero to diethylstilbestrol. (This drug has been linked to vaginal adenosis.)
Be sure to ask the patient about her general health and medical history. Note particularly if the patient or her family has a history of thyroid, adrenal, or hepatic disease; blood dyscrasias; or tuberculosis because these may predispose the patient to menorrhagia. Also, ask about the patient’s past surgical procedures and any recent emotional stress. Find out if the patient has undergone X-ray or other radiation therapy, because this may indicate prior treatment for menorrhagia. Obtain a thorough drug and alcohol history, noting the use of anticoagulants or aspirin. Perform a pelvic examination, and obtain blood and urine samples for pregnancy testing.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Metrorrhagia:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Begin your evaluation by obtaining a thorough menstrual history. Ask the patient when she began menstruating and about the duration of menstrual periods, the interval between them, and the average number of tampons or pads she uses. When does metrorrhagia usually occur in relation to her period? Does she experience other signs or symptoms? Find out the date of her last menses, and ask about any other recent changes in her normal menstrual pattern. Get details of any previous gynecologic problems. If applicable, obtain a contraceptive and obstetric history. Record the dates of her last Papanicolaou smear and pelvic examination. Ask the patient when she last had sex and whether or not it was protected. Next, ask about her general health and any recent changes. Is she under emotional stress? If possible, obtain a pregnancy history of the patient’s mother. Was the patient exposed in utero to diethylstilbestrol? (This drug has been linked to vaginal adenosis.)
Perform a pelvic examination if indicated, and obtain blood and urine samples for pregnancy testing.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Urethral discharge:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient when he first noticed the discharge, and have him describe its color, consistency, and quantity. Does he experience pain or burning on urination? Does he have difficulty initiating a urine stream? Does he experience urinary frequency? Ask the patient about other associated signs and symptoms, such as fever, chills, and perineal fullness. Explore his history for prostate problems, sexually transmitted disease, or urinary tract infection. Ask the patient if he has had recent sexual contacts or a new sexual partner.
Inspect the patient’s urethral meatus for inflammation and swelling. Using proper technique, obtain a culture specimen. (See Collecting a urethral discharge specimen, page 778.) Then obtain a urine specimen for urinalysis, culture and, possibly,, a three-glass urine test. (See How to perform the three-glass urine test.) Palpation of the male patient’s prostate gland may be necessary.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Vaginal discharge:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Ask the patient to describe the onset, color, consistency, odor, and texture of her vaginal discharge. How does the discharge differ from her usual vaginal secretions? Is the onset related to her menstrual cycle? Also, ask about associated symptoms, such as dysuria and perineal pruritus and burning. Does she have spotting after coitus or douching? Ask about recent changes in her sexual habits and hygiene practices. Is she or could she be pregnant? Next, ask if she has had a vaginal discharge before or has ever been treated for a vaginal infection. What treatment did she receive? Did she complete the course of medication? Ask about her current use of medications, especially antibiotics, oral estrogens, and hormonal contraceptives.
Examine the external genitalia and note the character of the discharge. (See Identifying causes of vaginal discharge, page 792.) Observe vulvar and vaginal tissues for redness, edema, and excoriation. Palpate the inguinal lymph nodes to detect tenderness or enlargement, and palpate the abdomen for tenderness. A pelvic examination may be required. Obtain vaginal discharge specimens for testing.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth 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
Dysmenorrhea:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
As with all menstrual complaints, a thorough physical examination is an essential part of making a diagnosis.
A. The general condition of the patient needs to be assessed. Are the vital signs stable or is the patient showing signs of systemic illness such as fever, which can indicate pelvic infection. Hypotension and pallor can indicate a ruptured ectopic pregnancy.
B. A general physical assessment with attention to the back, sacrum, spine abdomen, and bladder is important.
C. A thorough pelvic examination is key. The external genitalia may show signs of cyanosis, as is seen with pregnancy, or abnormal discharge, as is seen with infection. Palpate the vaginal area for nodules which may present on the anterior cul-de-sac or on the posterior vaginal fornix on bimanual examination; they could indicate endometriosis. Cervical motion tenderness and cervical leukorrhea may be present in PID. Uterine tenderness is often present and uterine displacement and fixation may be noted. Ovarian enlargement or adnexa fixation, which correlates with endometriosis or adnexal mass from neoplastic or infectious cause, may be found. Nodules may also be palpated along the uterosacral ligaments on rectovaginal examination.
Laboratory testing (3)
A. A complete blood count looking for anemia or leucocytosis is helpful.
B. If abnormal bleeding is associated with the dysmenorrhea, thyroid testing and a qualitative serum pregnancy test are indicated.
C. Urine analysis looking for hematuria should be obtained. With any indication of infection, a urine culture is often helpful.
D. A pelvic ultrasound may be helpful if any masses seem apparent on pelvic examination.
E. The definitive diagnosis of endometriosis can only be positively diagnosed with laporoscopy.
Diagnostic assessment (1)
Difficult menstrual periods occur at some point for most women during their reproductive years. If it is recurrent and significantly interferes with daily activity or relationships, it warrants treatment. Primary dysmenorrhea not associated with abnormal bleeding can often be treated successfully with nonsteroidal agents or oral contraceptives. If it does not respond to these agents or if it is associated with abnormal bleeding, further diagnostic testing is indicated. Secondary dysmenorrhea, either with or without abnormal bleeding, may point to a pelvic tumor, infection, or pregnancy. Further testing is essential in this setting.
References
1. Jamieson DJ, Steege JF. The prevalence of dysmenorrhea, dyspareunia, pelvic pain and irritable bowel syndrome in primary care practices. Obstet Gynecol 1996;87:
55–58.
2. Apgar BS. Dysmenorrhea and dysfunctional uterine bleeding. Prim Care 1997;
24(1):161–179.
3. Chan PD, Winkle CR. Gynecology and obstetrics 1999–2000. Laguna Hills, CA: Current Clinical Strategies Publishers, 1999:25–26.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Menorrhagia:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Assess vital signs and the patient’s general appearance. Signs of impending shock (e.g., hypotension and tachycardia) are likely related to pregnancy, particularly in the younger age group, but they can be related to trauma, sepsis, or cancer.
B. Pallor not associated with hypovolemia can be found with chronic blood loss associated with anovulatory cycles, leiomyoma, blood dyscrasia, or malignancy (Chapter 16.1).
C. Fever, leukocytosis, and pelvic tenderness are usually found in acute PID (Chapter 2.6).
D. Pelvic masses found on physical examination point toward abscess, ectopic pregnancy, or malignancy.
E. Signs of thyroid disease (e.g., rapid or slow pulse, reflex changes, hair changes, and thyromegaly) can be associated with menstrual abnormalities.
F. Excessive bruising can indicate nutritional deficiency, eating disorder, trauma, abuse, medication overuse, or coagulopathy (Chapter 15.3).
Testing
A. A baseline complete blood count and serum pregnancy test are essential in most pre- and perimenopausal women.
B. A bleeding disorder should be excluded with a platelet count, a prothrombin time, a partial thromboplastin time, and a bleeding time.
C. Screening for sexually transmitted diseases and thyroid dysfunction, particularly in those of childbearing age, is important.
D. Any nonpregnant woman with irregular bleeding and a pelvic mass requires evaluation with ultrasound, computed tomography (CT), or laparoscopy.
E. Endometrial sampling is recommended before initiating hormone therapy in women aged more than 30 years or in those older than 20 years with prolonged bleeding. Long-term estrogen stimulation in anovulatory patients can result in endometrial hyperplasia, which can result in endometrial carcinoma. This procedure is best done on the first day of menses to avoid an unexpected pregnancy. In the perimenopausal or postmenopausal woman, amenorrhea preceding abnormal bleeding suggests endometrial carcinoma. It is useful to obtain a transvaginal ultrasound prior to the endometrial biopsy because biopsy is often unnecessary if the endometrial stripe is less than 5 mm thick.
Diagnostic assessment (3)
Menorrhagia is defined as excessive menstrual flow. The definition of excessive varies widely among patients but “different” and “worrisome” to the patient appear to be important historical features. When excessive bleeding is regular, pregnancy and systemic illness must be excluded. Of menorrhagia, 90% of cases have no obvious cause and it is thought to be anovulatory or dysfunctional. Dysfunctional bleeding is usually not preceded by premenstrual (molimenal) symptoms. It is seen most frequently at the extremes of the reproductive years, after menarche and before the onset of menopause. Pregnancy must always be excluded as a cause in women of childbearing age. Excessive estrogen stimulation that occurs during anovulatory cycles can lead to endometrial hyperplasia and to carcinoma. Endometrial biopsy is indicated for most nonpregnant women with prolonged, irregular bleeding. Abnormal bleeding following amenorrhea in menopause is endometrial carcinoma until proved otherwise. Any pelvic mass occurring in the context of menorrhagia ought to be evaluated with ultrasound, CT, or magnetic resonance imaging. If confusion still exists, laparoscopy or hysteroscopy with saline infusion may be indicated.
References
1. Rosenfield J. Treatment of menorrhagia due to dysfunctional uterine bleeding. Am Fam Physician 1996;53:165–172.
2. Smith CB. Pinpointing the cause of abnormal uterine bleeding. Women’s Health in Primary Care 1998;1(10):835–844.
3. Nelson AL. A practical approach to dysfunctional uterine bleeding. Fam Prac Recertification 1997;19(8):14–39.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Urethral Discharge:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Focused physical examination (PE) should include vital signs, and urologic and rectal examination. In men, this should include examination of the penis, perimeatal region (for evidence of erythema), urethral meatus, scrotum, testicles, epididymis, prostate, and perianal and inguinal region. Stains present on the patient’s underwear may indicate the characteristics of the discharge, which is particularly useful in a patient who has urinated shortly before examination. Recent micturition can eliminate much inflammatory discharge. Sometimes it is necessary to examine the patient in the morning before voiding to enhance the diagnosis. Perform a complete gynecologic and urologic examination in women.
B. Abdomen. Completely examine the abdomen to rule out intraabdominal pathology, including masses and inflammation, obstruction, or distention of organs.
C. Additional physical examination should include the skin and other systems, as needed. If a patient is suspected of gonococcal infection, it may be essential to check the patient’s joints, skin, throat, eye and other organs.
Testing
A. UD sample collection. Proper collection and handling of UD sample is essential for the diagnosis. When the discharge is not spontaneous, the urethra should be gently stripped. This is best accomplished by grasping the penis firmly between the thumb and forefinger with the thumb pressing on the ventral surface. Then move the hand distally, compressing the urethra. This maneuver may express a small amount of discharge. The urethral meatus can be gently spread and if no urethral discharge is expressed, a calcium-alginate urethral (or nasopharyngeal) swab should be inserted at least 2 cm into the urethra and the discharge collected. The use of cotton-tipped swabs is contraindicated because their large size makes the insertion extremely uncomfortable and the cotton fibers can inhibit the growth of certain fastidious organisms (4).
B. Clinical laboratory investigations
1. UD Gram’s stain. The test involves staining the UD with Gram’s stain and examining it under a microscope. The presence of polymorphs with intracellular diplococci is diagnostic of GC. Polymorphs without the intracellular diplococci are suggestive of NGC disease. Few or no polymorphs are suggestive of other causes. The Gram’s stain is quite accurate for men but it is not very sensitive for women (50%).
2. UD culture is essential to identify specific organisms. Other useful tests are:
a. Detection of bacterial DNA by polymerase chain reaction (PCR)
b. DNA probes
c. Direct monoclonal testing and enzyme-linked assays. These tests have a high sensitivity and specificity. Cultures of throat, rectum, and sometimes conjunctivae may be required to establish the diagnosis.
3. UD wet preparation is done to establish the diagnosis of trichomoniasis, candidiasis, and some viral and bacterial infections.
4. Urine analysis and urine cultures are essential for the diagnosis of urinary infections. Collect the urine specimen [as described by Stamey (5)] with four sterile containers (before and after prostatic massage), which is useful to identify the site of infection in men.
5. Urinary leukocyte esterase is a useful screening test for chlamydial and GC infections in asymptomatic men. The usefulness of other neutrophil enzyme (elastace, myeloperoxidase) studies of urine have been reported.
6. Blood studies, including a complete blood count, serum chemistry profile, serologic test for syphilis, blood test for human immunodeficiency virus infection, and immunologic studies, may be required in an appropriate clinical setting.
C. Diagnostic imaging. Urethrogram, urologic diagnostic studies, and pelvic, vaginal, and rectal ultrasound studies are indicated in some clinical conditions.
D. Diagnostic procedures. Children and elderly patients may need to be examined under anesthesia to evaluate UD. Anoscopy is done for patients who have had anal intercourse or for those with anal and rectal symptoms. Cystourethroscopy and laparoscopy are also useful in certain conditions.
Diagnostic assessment
A. Special concerns. Neisseria gonorrhoeae and C. trachomatis infections are reportable to State Health Departments and a specific diagnosis is essential. UD secondary to STD involves many psychosocial and medicolegal implications to the patient, his or her partner, their families, and society. Sexual partners can be traced, tested, and treated. In children with UD, sexual abuse may be suspected. Pregnant women with gonococcal infection or chlamydia can infect the infant at birth (ophthalmia neonatorum).
B. Complications following UD and urethritis. Some of the complications following UD are postgonococcal urethritis, pelvic inflammatory disease (in women) and infertility, perihepatitis, chronic pelvic pain (Chapter 11.3), adhesions of the intraabdominal organs, obstructions in the gastrointestinal and genitourinary tracts, chronic urethritis, periurethral abscess, fistula, prostatitis, epididymitis, orchitis, urethral syndrome, psychosexual problems, and Reiter’s syndrome.
References
1. Centers for Disease Control and Prevention. National Center for HIV, STD, and TB Prevention. Sexually Transmitted Disease Surveillance. Atlanta: CDC, 1997.
2. American Social Health Association. Sexually transmitted diseases in America: how many cases and at what cost? Menlo Park, CA: Kaiser Family Foundation, 1998.
3. Institute of Medicine. Committee on Prevention and Control of STD. Eng TR, Butler WT, eds. The hidden epidemic: confronting STD. Washington, DC: National Academy Press, 1997.
4. Williams R, Kreder KJ Jr. Examination of UD and vaginal exudates. In: Tanagho EA, McAninch JW, eds. Smith’s general urology, 14th ed. Norwalk, CT: Appleton & Lange, 1995.
5. Stamey TA. Diagnosis, localization, and classification of urinary infections. In: Stamey TA, ed. Pathogenesis and treatment of urinary tract infections. Baltimore: Williams & Wilkins, 1980:262.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Vaginal Discharge:
Physical examination (4)
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A general physical examination should be performed if systemic illness is suspected. Record vital signs, including temperature, blood pressure, and pulse.
In most cases, a genital examination with the patient in the lithotomy position is adequate.
The external genitalia is carefully inspected for evidence of trauma, blisters, lymph nodes excoriations, swelling, erythema, ulcerations, tenderness or pain.
The amount, color, texture, odor, and location of the discharge should be noted. A complete pelvic examination should be performed with particular attention given to the cervix for evidence of friability or inflammation and a cervical motion test which may indicate pelvic inflammatory disease.
Testing (5)
A. Vaginal fluid pH. Immersing pH paper in the vaginal discharge or the lateral wall of the vagina will give the vaginal pH.
A pH greater than 4.5 indicates BV or T. vaginalis.
B. Saline wet mount. Obtain a drop of vaginal discharge from the posterior fornix; place it on a slide with a drop of saline and apply a cover slip.
1. Clue cells, which are bacteria-coated, stippled epithelial cells, are characteristic of BV.
2. Trichomonads, which are mobile, oval flagellated parasites, confirm the presence of trichomoniasis.
C. Potassium hydroxide (KOH) preparation. Place a second drop of vaginal secretions on a slide containing a drop of KOH; “a positive whiff test” indicates the presence of BV. Threadlike hyphae and budding yeast observed microscopically are characteristic of a candidal infection.
D. Cultures for gonorrhea and chlamydia are not routinely indicated, but should be taken with a history of a new sexual partner, prurulent cervical discharge, or cervical motion tenderness.
Diagnostic assessment
BV causes 40% to 50% of vaginitis, followed by candidiasis (20% to 25%) and trichomoniasis (15% to 20%). Together, these infections account for more than 90% of vaginitis diagnoses.
When evaluating a woman with a vaginal complaint, be sure to hear her true concern. Evaluate and treat appropriately those with acute symptoms (e.g., pain or swelling) and be careful to understand the effect of pretreatment with OTC preparations in the presumptive diagnosis. It is wise to be mindful of the possibility of sexually transmitted diseases with any vaginal complaint and to test appropriately for these diseases. If a vaginitis, presumably infectious, does not respond to initial therapy, consider other causes including trauma, herpes, menopause, contact dermatitis, toxic shock syndrome, steroid-responsive inflammatory vaginitis, and collagen-vascular or other systemic disease.
References
1. Lash DJ, Garcia TA. Diagnosis and treatment of vaginitis. The Female Patient 1998;23:25–41.
2. Carr PL, Majeroni BA, Robinson JC, Talarico LD. Vaginitis: solid diagnosis means effective treatment. Patient Care 1999;33(2):86–106.
3. Miller KE. Sexually transmitted diseases. Prim Care 1997;24(1):179–193.
4. Chan PD, Winkle CR, eds. Gynecology and obstetrics’ 1999–2000 edition. Laguna Hills, CA: Current Clinical Strategies Publishers, 1999:73–79.
5. Sabel JD. Vaginitis. N Engl J Med 1997;337:1896–1903.
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Vaginal Discharge:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Symptoms of vaginitis include vaginal discharge, pruritis, irritation, soreness, odor, and less commonly bleeding, dysuria, or pain with intercourse. It is important to distinguish burning on urination due to cystitis, which is internal and accompanied by irritative signs (urinary frequency), from dysuria due to vaginitis, which feels external as the urine passes over an inflamed vulva. Similarly, it is important to distinguish vaginitis, characterized by discharge and pruritus, from cervicitis, with discharge and pelvic pain.
On examination, the vulva appears normal in bacterial vaginosis, while erythema, edema or fissures suggest candidiasis, trichomonas or dermatitis. An erythematous, friable cervix with a mucopurulent discharge is consistent with cervicitis rather than vaginitis. This must be distinguished from ectropion (normal endocervical glandular tissue visible on the exocervix), which is not friable.
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Source: Field Guide to Bedside Diagnosis, 2007
Vaginal Bleeding:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
Passage of clots or inability to control bleeding with tampons is consistent with heavy flow (menorrhagia). Bleeding between normal cyclic menses is metrorrhagia. Remember to establish that bleeding is uterine and not from the rectum or urethra.
In adolescents, anovulation is the cause in 90% of cases of metrorrhagia, although pregnancy should be considered. An underlying bleeding diathesis is found in about 20% of adolescents with menorrhagia. In adult premenopausal women, pregnancy and malignancy are the most important considerations, although leiomyomas (fibroids) are the most common. In perimenopausal women, anovulatory cycles and progesterone deficiency with long periods of unopposed estrogen lead to endometrial hyperplasia and polyps. Bleeding in postmenopausal women should be thoroughly evaluated for endometrial cancer, which will be found in 10% of cases.
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Source: Field Guide to Bedside Diagnosis, 2007
Urethral discharge:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Inspect the patient’s urethral meatus for inflammation and swelling. Using proper technique, obtain a culture specimen. (See Collecting a urethral discharge specimen, page 664.) Then obtain a urine specimen for urinalysis, culture, and possibly a three-glass urine test. (See How to perform the three-glass urine test, page 665.) In the male patient, the prostate gland may have to be palpated.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Vaginal discharge:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Examine the external genitalia and note the character of the discharge. (See Identifying causes of vaginal discharge, page 680.) Observe vulvar and vaginal tissues for redness, edema, and excoriation. Palpate the inguinal lymph nodes to detect tenderness or enlargement. Palpate the abdomen for tenderness. A pelvic examination may be required. Obtain vaginal discharge specimens for testing.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
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.
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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Vaginal Discharge:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Nonspecificvulvovaginitis is most common cause of vaginal discharge in prepubertal girls.If discharge fails to improve with good perineal hygiene or if itis purulent, specific bacterial infection, sexually transmittedinfection, or foreign body should be suspected. Wet mounts (salineand KOH), Gram stain, and vaginal cultures should be performed.Exam under anesthesia may be necessary for suspected foreign body.In pubertal girls who are not sexuallyactive, most common causes of vaginal discharge are physiologicleukorrhea, bacterial vaginosis, and C. albicans. Wet preparations(saline and KOH) and Gram stain should be performed. Bacterial andfungal cultures also should be considered.In girls who are sexually active, thesame diagnoses described for pubertal nonsexually active femalesare possible, but sexually transmitted infections also are likely.In addition to wet preparations and Gram stain, cultures for C.trachomatis, N. gonorrhoeae, and other aerobic and anaerobic bacteria shouldbe performed. In some centers nucleic acid amplification technologyis available for detection of C. trachomatis and N. gonorrhoeaefrom endocervical and urine specimens. Laparoscopy may provide definitivediagnosis in suspected pelvic inflammatory disease with negativecervical cultures.If sexual abuse is suspected at anyage, vaginal, rectal, and throat cultures for N. gonorrhoeae andvaginal and rectal cultures for C. trachomatis should be performed,even in an asymptomatic child. HIV testing should be considered.So should pregnancy prophylaxis, which depends on whether menarche hasbeen reached and on nature of abuse.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Vaginal Bleeding:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Before Menarche
Trauma,vulvovaginitis, and foreign body are most common causes of abnormalvaginal bleeding before menarche.Complete history and physical examshould be performed, including exam of external genitalia and vaginalintroitus. Exam under anesthesia is necessary with significant trauma,foreign body that cannot be removed, or suspected genital tumor.Approach to precocious puberty andvulvovaginitis is described in Chap.48, Precocious Puberty, and Chap. 71,Vaginal Discharge,respectively. After Menarche
Girls withabnormal vaginal bleeding should have complete history and physicalexam, which includes speculum exam of vagina and cervix and bimanualvaginal exam. Source of bleeding must be determined, whether vulvar,vaginal, cervical, or uterine. If significant vaginal trauma hasoccurred from injury, exam of vagina and cervix may have to be performedunder anesthesia.Diagnostic approach to vulvovaginitisin this age group is discussed in Chap.71, Vaginal Discharge. If uncertainty about pregnancyexists, urine pregnancy test should be performed.If bleeding is from normal-sized uterus,most common cause is from anovulatory cycle, but this is diagnosisof exclusion. Other common causes include ovulation and oral contraceptiveuse. Abnormal vaginal discharge and abdominal pain suggest pelvicinflammatory disease. Heavy cyclic bleeding suggests coagulationdisorder, and certain tests should be performed: CBC with differential,analysis of blood smear, platelet count, prothrombin time, activatedpartial thromboplastin time, and bleeding time. Uterine tumors arerare in adolescent age group.If bleeding is from enlarged uterus,it is likely that there is complication of pregnancy (e.g., spontaneousabortion, ectopic pregnancy, placenta previa, or abruptio placenta).If individual is <20 wks pregnant and has normal BP, eitherectopic pregnancy or spontaneous abortion is likely. In either case, pregnancytest should be performed unless it is a known pregnancy, and obstetricconsultation should be obtained.In girl who is <20 wks pregnantand hypotensive with severe bleeding, ectopic pregnancy is mostlikely cause. If uterine bleeding occurs during third trimesterof pregnancy, placenta previa or abruptio placenta is likely. Externalgenitalia should be inspected and obstetric consultation shouldbe requested. An intravenous line should be placed, CBC drawn, andblood sent for type and cross-match. If patient is hypotensive,fluid resuscitation should be started immediately. >>
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Dysmenorrhea:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient complains of dysmenorrhea, have her describe it fully. Is it intermittent or continuous? Sharp, cramping, or aching? Ask where the pain is located and whether it's bilateral. When does the pain begin and end, and when is it severe? Does it radiate to the back? How long has she been experiencing the pain? If it's a recent complaint, obtain a human chorionic gonadotropin level to determine if the patient is or was pregnant, because miscarriage can cause painful bleeding. Explore associated signs and symptoms, such as nausea and vomiting, altered bowel or urinary habits, bloating, water retention, pelvic or rectal pressure, and unusual fatigue, irritability, or depression.
Then obtain a menstrual and sexual history. Ask the patient if her menstrual flow is heavy or scant. Have her describe vaginal discharge between menses. Does she experience pain during sexual intercourse? Does it occur with menses? Find out what relieves her cramps. Does she take pain medication? Is it effective? Note her method of contraception, and ask about a history of pelvic infection. Does she have signs and symptoms of urinary system obstruction, such as pyuria, urine retention, or incontinence? Determine how she copes with stress. Determine her risk of sexually transmitted diseases.
Next, perform a focused physical examination. Take the patient's vital signs, noting fever and accompanying chills. Inspect the abdomen for distention, and palpate for tenderness and masses. Note costovertebral angle tenderness.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Menorrhagia:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
When the patient's condition permits, obtain a history. Determine her age at menarche, the duration of menses, and the interval between them. Establish the date of the patient's last menses, and ask about recent changes in her normal menstrual pattern. Have the patient describe the character and amount of bleeding. For example, how many pads or tampons does the patient use per period? Has she noted clots or tissue in the blood? Also ask about the development of other signs and symptoms before and during her menses.
Next, ask if the patient is sexually active. Does she use a method of birth control? If so, what kind? Could the patient be pregnant? Be sure to note the number of pregnancies, the outcome of each, and any pregnancy-related complications. Find out the dates of her most recent pelvic examination and Papanicolaou smear and the details of any previous gynecologic infections or neoplasms. Also, be sure to ask about previous episodes of abnormal bleeding and the outcome of any treatment. If possible, obtain a pregnancy history of the patient's mother, and determine if the patient was exposed in utero to diethylstilbestrol. (This drug has been linked to vaginal adenosis.)
Be sure to ask the patient about her general health and medical history. Note particularly if the patient or her family has a history of thyroid, adrenal, or hepatic disease; blood dyscrasias; or tuberculosis because these may predispose the patient to menorrhagia. Also, ask about the patient's past surgical procedures and recent emotional stress. Find out if the patient has undergone X-ray or other radiation therapy, because this may indicate prior treatment for menorrhagia. Obtain a thorough drug and alcohol history, noting the use of anticoagulants or aspirin. Prepare the patient for a pelvic examination, and obtain blood samples and urine specimens for pregnancy testing.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Metrorrhagia:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Begin your evaluation by obtaining a thorough menstrual history. Ask the patient when she began menstruating, the duration of menses, the interval between them, and the average number of tampons or pads she uses each month. Establish when metrorrhagia occurs in relation to her menses. Does she experience other signs or symptoms? Find out the date of her last menses, and ask about other changes in her normal menstrual pattern. Ask for details of previous gynecologic problems. If applicable, obtain a contraceptive and obstetric history. Record the dates of her last Papanicolaou (Pap) smear and pelvic examination. Ask the patient if she is sexually active. Next, ask about her general health and any recent changes. Is she under emotional stress? If possible, obtain a pregnancy history of the patient's mother. Was the patient exposed in utero to diethylstilbestrol? (This drug has been linked to vaginal adenosis.)
Prepare the patient for a pelvic examination if indicated, and obtain blood samples and a urine specimen for pregnancy testing.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Urethral discharge:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient when he first noticed the discharge, and have him describe its color, consistency, and quantity. Does he experience pain or burning on urination? Does he have difficulty initiating a urine stream? Does he experience urinary frequency? Ask the patient about other associated signs and symptoms, such as fever, chills, and perineal fullness. Explore his history for prostate problems, sexually transmitted disease, or urinary tract infection. Ask the patient if he has had recent sexual contacts or a new sexual partner. Obtain a complete drug history.
Inspect the patient's urethral meatus for inflammation and swelling. Using proper technique, obtain a culture specimen. (See Collecting a urethral discharge specimen.) Then obtain a urine specimen for urinalysis, culture, and possibly a three-glass urine specimen. (See Performing the three-glass urine test, page 613.) In the male patient, the prostate gland may have to be palpated.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
Vaginal discharge:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Ask the patient to describe the onset, color, consistency, odor, and texture of her vaginal discharge. How does the discharge differ from her usual vaginal secretions? Is the onset related to her menstrual cycle? Ask about associated symptoms, such as dysuria and perineal pruritus and burning. Does she have spotting after coitus or douching? Ask about recent changes in her sexual habits and hygiene practices. Is she or could she be pregnant? Ask if she has had vaginal discharge before or has ever been treated for a vaginal infection or sexually transmitted disease. What treatment did she receive? Did she complete the course of medication and were all sexual contacts treated? Ask about her current use of medications, especially antibiotics, oral estrogens, and hormonal contraceptives.
Examine the external genitalia and note the character of the discharge. (See Identifying causes of vaginal discharge.) Observe vulvar and vaginal tissues for redness, edema, and excoriation. Palpate the inguinal lymph nodes to detect tenderness or enlargement, and palpate the abdomen for tenderness. A pelvic examination may be required. Obtain vaginal discharge specimens for testing.
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Source: Nursing: Interpreting Signs and Symptoms, 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.
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Source: Nursing: Interpreting Signs and Symptoms, 2007
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