Annotation R: Can you make a probable diagnosis?

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The algorithm was set up to teach you what we do to approach a new patient in a large full-time vulvovaginal specialty practice.  When seeing patients, we have two “stopping places” where we ask ourselves: “What do I know?” The first is after the history, (taken with the patient clothed), while waiting for her to undress for the exam. The second occurs after we have completed all of the steps of the algorithm, usually while standing at the microscope, the last stop before going back into the room to re-join the patient after the exam, pH, and microscopy.

I.  After the history, while awaiting the patient’s readiness for exam, summarize the history for yourself and ask:

a.  Do I understand who the patient is: her age, relationship status, occupation, lifestyle, etc? (Annotation J: Lifestyle issues). Did flags come up about sexuality, relationship issues, abuse, stress and anxiety, adherence to medication or treatment?
b.  Do I understand exactly what the complaint is? (For example, the complaint is “recurrent itching and burning,” not “recurrent Candida albicans;” you will make that diagnosis only by microscopy or adjunctive testing.) (Annotation A: Patient symptoms and signs).
c.  Do I understand the context of this complaint, e.g. When it started, what was going on at the time, etc.? (Annotation B: The patient’s history).
d.  Do I understand where the complaint is located? For example, is the symptom over the entire vulva, in a single focus, centrally around the entire vestibule? Or, is she having a problem localizing her own complaint that will need to be explored with the examination? Although you will do a complete exam, one area may require extra attention. (If the complaint is vaginal discharge, the speculum exam will be especially important. For itching, scrutiny of the vulva with mapping locus of itching will be a primary focus.)
e.  Do I understand what health history risks she may have for vulvovaginal disease and what pathology I look for based on that history? (For example, hypothyroidism and lichen sclerosus or lichen planus may occur in the same patient; Crohn disease may cause knife cut-like fissures in the vulvar area.) (Annotation B: The patient’s history).
f.  Do I understand what other systems have problems that may be influencing the vulva and vagina, e.g. urinary, bowel, musculoskeletetal, dermatological? (Annotation B: The patient’s history).

II. After the examination did I come up with physical findings that can connect with the complaint?

a.      Was the patient able to be touched at all for the exam? (Annotation D: Patient tolerance for exam)
b.      Did I note a vulvar architectural abnormality? (Annotation F: The vulvar architecture).
c.  Did I note a vulvar epithelial abnormality? Was there an alteration in color, texture, or integrity of the skin? (Annotation H: The vulvar skin, and the Atlas of Vulvar Disorders).
d.  Did I map symptoms to correlate with the chief complaint? Did I find pain with or without any associated lesions? (Annotation I: Pain and symptom mapping and the Q-tip test and Annotation K: Vulvar pain and provoked or unprovoked vulvodynia).
e.  Did I find hypertonicity of the pelvic floor? (Annotation L: The pelvic floor).
f.  Was there a vaginal lesion? (Annotation O, The vaginal epithelium).
g.  Did I find a cervical abnormality that might cause the complaint? (Annotation M: Speculum exam and examination of the cervix).
h.    Was there a normal hymenal ring and a normal bimanual exam? (Annotation Q: Hymenal ring and bimanual exam).
i.  Were the pH, wet mount, and microscopy normal or abnormal? (Annotation P: Vaginal secretions, pH, microscopy, and cultures).
j.  Was there more than one problem?

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III.   Is the diagnosis clear and based on evidence from exam and microscopy? More than 80 gynecologic disorders can present with vaginal discharge, vulvar pruritus, or dyspareunia.
IV.   Am I considering the differential diagnoses for the symptoms and exam findings or am I focusing only on what other people have thought the patient has, what she herself thinks she has, or a common and convenient diagnosis? (See Table R-1: Differential Diagnosis for Vulvovaginal Pain and Irritative Symptoms below).
V.   Have I missed any skin findings? Do I need to do a biopsy? (Annotation G: Vulvar biopsy).
VI. Consolidate all the pieces in your head, on a chart or diagnostic summary table work sheet. See Diagnostic Summary Examples table below.
VII. If the diagnosis is not clear:

a.  Await test results.
b.  Remove irritants (Annotation J: Lifestyle issues).
c.  Provide comfort measures (General Vulvar Care handout).
d.  Consult with a colleague if necessary.
e.      Schedule  appointment to re-evaluate. Keep looking.

Diagnostic summary tables

We have created the following table to show the way the “clues” you have identified during your interview with the patient and your exam will point the way to a diagnosis. This table can be printed as a blank work sheet to practice your skills with either case study patients or your own patients in the office. (Diagnostic summary table worksheet).

Click here to see table