Investigation methods of gynecological patients. General clinical symptoms of gynecological diseases 1. Rationale Professional motivation: The investigation methods in gynecology has a great value for studying subject. The basic and auxiliary methods of gynecological examination can enables to understand of gynecological diseases. These methods are used for verification of the diagnosis. 2. Objectives: 1. To analyze the main clinical symptoms of the gynecological diseases and gynecological anamnesis. -To explain The basic (objective) and auxiliary methods of gynecological examination and methods of functional diagnostics -To suggest tactics of management of patients in different diseases of reproductive system. -To classify the diseases of the , , according to current morphological and clinical classifications and ICD. -To interpret data of laboratory and instrumental examinations of the cervix, endometrium, vulva and endoscopic methods of examination gynecological patients -To draw a diagram of “patient route” and “plan of examination” in the background and precancerous pathology; indications of localization and PID To make the analysis of degrees of cleanness. Cytology types. -To make up the models of clinical cases with various pathology in women of reproductive and premenopausal age.

3. The basic level of expertise, skills, abilities, required for learning the topic

(interdisciplinary integration ) The name of the previous Acquired skills disciplines Normal Anatomy Structure of female genital organs. Topography of abdominal organs and pelvic organs. Histology Histological structure of the cervix, vulva and endometrium in normal and in pathological conditions. Notmal Physiology Physiological changes occurring in the hypothalamic- pituitary-ovarian system of women and target organs of the sex hormones action at different ages. Possession of the methodology for conducting functional diagnostics tests.

Microbiology, Immunology Specific and nonspecific protective factors, antiviral immunity Pathological Anatomy Morphological structure of all types of benign tumors of the female genital organs. Pathological Physiology Hormonal changes in the body during the menstrual cycle and disorders of the microbiota of the female reproductive system. Operative Surgery The main types of surgery on the female genital organs. Mechanisms of therapeutic action of physical factors (electric current, refrigerants, laser radiation, phototherapy). Pharmacology Groups of medications that affect the function of the hypothalamus, pituitary gland, , adrenal glands; mechanism of pharmacological action of hormonal, hemostatic, anti-inflammatory, antiviral drugs.

4. Tasks for independent work in preparation for the lesson and in class.

4.1. The list of the major terms, parameters, characteristics to be acquired by a student to be prepared for the lesson The term Definition Gynecological pelvic  Inspection of the external genitalia examination  Inspection of the cervix and vagina using a speculum  Bimanual examination  Rectal, rectovaginal  Clinical breast exam

 complaints

A specific gynecological  Меnstrual anamnesis, function:

 Sextual function  Reproductive function:  Gynecological diseases

 cytological (PAP-test)

 bacterioscopic laboratory tests in  bacteriological gynecology  virological (HPV-test)  histological from the vagina, cervix, and and  functional diagnostics tests  basal temperature

Endoscopic  Laparascopy research methods in gynecology Interpretation of the data of transabdominal and transvaginal ultrasound examination of Ultrasound examination of the the pelvic organs pelvic organs curettage of the cervical canal and uterine

cavity Instrumental methods of examination gynecological patient.

4.2 Theoretical questions for the lesson: 1. General and specific methods of examination of gynecological patients. 2. Bimanual, vaginal and rectal examinations. Speculum examination. 3. Methods of diagnosing the functional state of the ovaries. 4. History taking, estimation of the laboratory investigations ( general and biochemical blood tests, urine blood coagulation, etc.) 5. Taking material from the vagina, urethra and cervical canal. 6. Evaluate the results of colpocytological study. 7. Evaluate the results of colposcopy. 8. Evaluate the diagnostic tests of the ovaries function. 9. Evaluate the results of the cytological, histological and bacteriological investigation. 10. Evaluate results of X-ray of female genitalia. 11.Estimate results of pelvic sonography. 12. Plan the investigations of patiens with various gynecological diseases.

4.3 Practical activities (tasks) to be performed on the lesson:  To perform gynecological examination (bivalve vaginal speculum, bimanual, rectal, rectovaginal).  To collect a specific gynecological anamnesis, to evaluate the findings of laboratory tests.  To collect material from the vagina, cervix, cervical canal and urethra for cytological, and bacterioscopic studies.  To evaluate the findings of cytological, histological, virological and bacteriological studies.  To evaluate the findings of the ultrasonography of organs of the small pelvis.  To estimate the protocol of the colposcopy of the cervix and vulva.  To make a plan of examination of a patient in various nosological forms of background and precancerous pathology.

4.4 Topic content Investigation methods of gynecological patients. General clinical symptoms of gynecological diseases Examination of the patient, who had been admitted to the gynecological department, consists of anamnesis, objective (general and special) examination, and auxiliary methods.

1.1. Gynecological Anamnesis First, the doctor makes inquiries about the patient’s complaints, then about the development of the given disease (case history, anamnesis morbi), special gynecological history (certificates of the menstrual, sexual, reproductive, and secretory functions, antifertility agent application) (gynecological history, anamnesis ), and after that about living conditions, the history of diseases, allergic reactions (anamnesis vitae). The questioning is conducted according to a certain plan. 1. Passport data: the surname, name, patronymic name, age of the woman. 2. The patient’s complaints. Most often patients appeal to the doctor with complaints of pain, leucorrhoea, menstrual irregularities, bleeding, and also dysfunction of the adjacent organs (urinary incontinence, frequent urination, constipations, pain in defecating). 3. Case history. The doctor should find out how the disease began – acutely or gradually, what might have promoted disease development, whether there have been any examinations or treatment. 4. Gynecological history includes information about the menstrual, sexual, reproductive, and secretory functions of the woman. Menstrual function: the age of the first menstruation (menarche), the presence or absence of pain, menstruation duration, its regularity, menstrual cycle change after deliveries and abortions, the presence and duration of menopause, the date of the last menstruation. Sexual function: at what age the woman began sexual life, if there were any signs of the disease when she began sexual life or changed partner, how many sexual partners the woman has at the same time, what contraception method is preferred. Reproductive function: in what time interval after beginning sexual life without contraception the woman became pregnant for the first time, how many pregnancies the woman has had (deliveries, abortions), if there have been any complications after deliveries or abortions. Secretory function: the information about the quantity, smell, appearance, and periodicity of the . Correctly collected gynecological anamnesis allows giving a provisional diagnosis with satisfactory accuracy. However, the doctor can draw the final conclusion about the disease only after an objective examination of the patient. 5. Life history: under what conditions the woman used to live and develop, what diseases she has had, allergic anamnesis, the presence of any pernicious habits (smoking, alcoholism, drug addiction). 6. Objective examination methods.

1.2. The basic methods of gynecological examination Gynecological examination is carried out on a gynecological chair. The woman is lying on her back with her legs half-bent in the knee and hip joints. Before examination the woman must necessarily evacuate the urinary bladder; if it is necessary, a cleansing enema is given. The doctor examines the woman in sterile gloves. Examination of the external genitals: pubis (its form, the state of the hypoderm, the pattern of hair distribution – adult woman, adult male, or mixed), perineum, large and small lips of pudendum (size, presence of edemas, ulcers, tumors, condylomatous excrescences, the degree of pudendal fissure closure); examination of the external urethral orifice, , internal surface of the large and small lips of pudendum (color, the state of the mucous tunic, pigmentation, ulcers), detecting the size of the Bartholin’s glands (location of their excretory ducts, the character of the secret, the presence of swelling and reddening around the orifice), posterior labial commissure (ruptures, scars), detecting falling and prolapse of the vaginal walls and uterus. The doctor obligatorily assesses the state of the (intact, ruptured, acute ruptures). Simultaneously the doctor finds signs of infantilism (a narrow pudendal fissure, the large lips of pudendum do not cover the small ones, a high or trough- shaped perineum), detects the condition of the pelvic floor muscles. Speculum examination is conducted after the examination of the external genitals.

For this purpose one uses the spoon-shaped Sims speculum with an elevator or the double Kusko speculum. Lately disposable folding specula are being used. Double specula are introduced into the vagina in the folded state. The doctor pulls the patient’s lips of pudendum apart with the left thumb and index finger and introduces the speculum into the vagina, locating the folds parallel to the pudendal fissure. After introduction the speculum is turned by 90°, the folds are opened in such a way that the vaginal part of the uterine neck is between the folds. In case of need the specula may be fixed with a lock. In order to introduce the spoon-shaped specula the doctor pulls the patient’s large and small lips of pudendum apart with the left hand and, having turned the speculum slantwise relative to the pudendal fissure, introduces it into the vagina with the right one, slightly pressing onto the perineum. The plane anterior speculum (elevator) is introduced parallel to the spoon-shaped one, elevating the anterior vaginal wall. Specula allow examining the vaginal walls, the character of mucosa folding and color, the presence of an edema or eruption, excrescences, tumors, and also – the fornices, neck of uterus, its size and form (cylindrical or conical), the form of the external orifice (round or slit-like), ruptures, color (pink-pale, cyanosis, hyperemia), erosion, epithelial dysplasia, discharge character. Internal vaginal examination: the doctor pulls the large and small lips of pudendum with the left thumb and index finger. The middle and index fingers of the right hand are introduced into the vagina, the ring and little fingers are pressed to the palm, and the thumb is turned to the pubis. When the fingers are introduced into the vagina, they are placed in the anterior fornix, the uterine neck is pressed back. Internal vaginal examination shows the width of the vagina opening, the Bartholin’s glands; the state of the perineum and pelvic floor muscles, the urethra following the direction of the anterior vaginal wall, the length and width of the vagina, mucosa folding, the presence of scars, stenosis, septa, infiltrate, tumor, depth, symmetry, flatness, bulging, induration, the form of the uterine neck, its size, integrity violation, the form of the external orifice, its consistency, the location of the neck relative to the pelvic axis, tumors. Bimanual combined vaginal-abdominal examination.

Location of the internal right hand is the same as in internal vaginal examination. The external left hand carefully presses the anterior abdominal wall in the direction to the fingers introduced into the vagina. Thus, the uterus is between the fingers of the external and internal hands. If the uterus is reclinated, the internal fingers are placed in the posterior fornix. When the doctor examines the uterus, he finds its size, form, and location – inclination, flexure, displacement by the horizontal and vertical axes, painfulness and mobility, and consistency (dense, tender). After the uterus is examined, the doctor studies the state of the appendages: usually they are not palpated, their area is not painful, in slim women the ovaries are well-palpated in the form of an amygdaloid body, sized 34 cm, they are rather movable and painless. Unaltered of the uterus and ovaries are not detected, there is no painfullness or infiltration in the parametria. Rectoabdominal examination is administered if vaginal examination is impossible in girls, in case of and atresia, if a more detailed examination of the pelvic organs is necessary (if tumors are found, to detect the degree of their extension onto the pelvic fat and intestinal walls), and also in case of inflammatory diseases to detect the state of the sacrouterine ligaments and pararectal fat.

The left hand is located in the same way as in vaginal-abdominal examination, and the right index finger, previously oiled with liquid paraffin, is introduced into the rectum. This technique may be used for a more detailed examination of the pelvic organs in tumors. Colposcopy. The doctor examines the vaginal part of the uterine neck and the vaginal wall with the help of an optical device – colposcope – which gives 10–30- time magnification. This technique allows finding changes of the uterine neck epithelium, pretumor states, choosing an area for biopsy, and also controlling healing in the process of treatment. There are differentiated simple and extended types of colposcopy. Simple colposcopy gives a possibility to examine the uterine neck without pretreatment with chemical solutions, extended colposcopy – after processing with 3 % acetic acid solution or Lugol’s solution. Taking swabs for the microscopy of urogenital swabs and cytological screening. The doctor puts the patient onto the gynecological chair, makes the toilet of the external genitals, introduces the gynecological speculum into the vagina, and images the uterine neck in the specula. For urogenital swab microscopy the discharge is taken with a sterile disposable brush from the urethra, with the second brush – from the cervical canal, with the third – from the posterior fornix of the vagina, each time applying the discharge in strokes onto different parts of the microscope slide. According to the swab character there are differentiated 4 degrees of vagina cleanness: . 1st cleanness degree – solitary cells of the pavement epithelium, a large quantity of the Doderlein’s vaginal bacilli, there is no other flora and leucocytes; . 2nd cleanness degree – solitary cells of the pavement epithelium, a large quantity of the Doderlein’s vaginal bacilli, solitary leucocytes, a small quantity of saprophytes, small bacilli; . 3rd cleanness degree – a large quantity of pavement epithelium cells, solitary or absent vaginal bacilli, a large quantity of leucocytes and coccal flora; . 4th cleanness degree – there are no vaginal bacilli, a large quantity of leucocytes and cocci, there is a specific causative agent – trichomonads, gonococci, etc. Oncocytologic screening is carried out in the following way: remains of discharge from the uterine neck is carefully taken with a cotton pellet, squeezed in forceps, then a swab of epithelium from the cervical canal is taken with a gynecological sterile disposable brush, with the second brush – in the area of the external orifice – where the laminated pavement non-keratinized epithelium passes into the columnar epithelium, and with the third brush – in the area of altered areas of the uterine neck, found by colposcopy, each time applying the material onto different parts of the microscope slide with one circus movement. There are differentiated such cytology types:  type 1 – unaltered epithelium;  type 2 – inflammatory process;  type 3a – minor dysplasia against the background of benign processes and intact epithelium;  type 3b – moderate dysplasia against the background of benign processes and intact epithelium;  type 3c – evident dysplasia against the background of benign processes and intact epithelium;  type 4 – in situ;  type 5 – cancer;  type 6 – a nondiagnostic swab (the material taken incorrectly).

1.3. The auxiliary methods of gynecological examination Bacteriological study is conducted to find causative agents and their antibiotic susceptibility. Contents of the cervical canal, vagina, urethra, and punctuate may be used as material for the study. The material is taken under sterile conditions with sterile instruments, put into sterile test tubes or vials with conventional medium, which may provide preserving both aerobic and, in some cases, anaerobic microbes, and transported at the constant temperature 37° С. When the doctor takes material for bacteriological study, he must simultaneously prepare not les than two swabs to be Gram stained for approximate express-diagnostics. Material inoculation is performed according to a typical regimen in the bacteriological laboratory during the first 2 hours after the material was taken. If there is no growth during 9–10 days, the result is considered negative. There may be used accelerated techniques of identifying the causative agents of wound infection with the help of multimicrotest systems (for example, ENTERO-SERREN), which allow shortening the time of bacteriological study to 4–6 hours. Combined recto-vaginal-abdominal examination is applied if pathological processes are suspected in the vaginal wall, rectum, or rectovaginal septum. The hands are located in the same manner as in case of rectoabdominal examination except for the fact that the middle finger of the right hand is introduced into the rectum, and the index finger – into the vagina. Examination with the help of bullet forceps is carried out if it is needed to find the connection of the abdominal tumor with the genitals. The uterine neck is exposed with the specula, excessive discharge is removed with a cotton pellet, the neck is processed with disinfectant solutions, after what the anterior lip of cervix uteri is taken with bullet forceps, the specula are taken out. When the doctor conducts bimanual examination, displaces the tumor upwards, if the tumor is connected with the uterus, and also moves the bullet forceps. Uterine probing is indicated if one needs to study the patency of the cervical canal, the length and configuration of the , the presence of tumors in it, before some operations (curettage of uterine cavity, cervicectomy, etc.). Contraindications: acute diseases of the vagina, uterus, and appendages, suspected pregnancy, cancer ulcers on the neck, etc. Complications: hemorrhage, perforation, infection carrying. The manipulation is conducted under the condition of extraordinarily strict aseptics. After the uterine neck is exposed with the specula, it is processed with disinfectant solutions, taken with bullet forceps by the anterior lip, the elevator is taken out, the uterine neck is pulled to the vaginal orifice, straightening the cervical canal. A probe (a flexible metal instrument 20–30 cm long with transverse centimeter points, with a bulb in the form of a button on the tip of the probe) is introduced through the external orifice into the canal and outside the internal orifice, which is felt as nonessential resistance, then into the uterine cavity. If the uterus position is anteflexio, the probe is directed somewhat forwards, if retroflexio – backwards. The probe is introduced to the fundus, the uterus length is measured, then, by sliding on the anterior, posterior, and lateral uterine walls the form of the uterine cavity is detected as well as the presence of bulgings, septa, roughnesses in it. Biopsy is sampling and examination of tissue to determine the cause or extent of a disease. Target biopsy is to be conducted (after colposcopy and from the most suspicious area). Most often the biopsy material is taken from the affected area of the uterine neck, but its also possible to take it from any affected area (one should better use a scalpel, les frequently a conchotome, a loop-knife to get a piece of tissue in the diathermo-coagulation way). Diagnostic curettage of the mucosa of the uterine cavity walls, isolated diagnostic curettage of the cervical canal and uterine cavity walls. Diagnostic curettage is a kind of biopsy, whose material is endometrium. Indications: uterine bleedings, suspected malignant tumor, fetal egg remains, endometrial polyposis, fibromyoma, endometrial tuberculosis, and also to find the reasons for menstrual irregularities (agnogenic cyclic and acyclic bleedings). Contraindications: acute inflammation of the uterus and appendages, the 3rd–4th degree of vagina cleanness, body temperature rise (except for the cases when curettage is carried out medicinally according to vital indications), submucosal myoma with node necrobiosis. The operation is performed under aseptic conditions or under local anesthesia. The uterine neck is exposed with the help of specula, processed with a disinfectant, the anterior lip is taken with bullet forceps and pulled. Then the doctor introduces the Hegar’s dilators into the cervical canal, each dilator is 0.5 mm wider than the previous one from No. 3, 4 to 9, 10. The dilators are introduced carefully, the doctor sees to it that the introductory end rounds the internal orifice and slightly enters the uterine cavity. After dilation one introduces the curette seeing to it that its curve coincides with the uterus curve. The curette end is introduced into the cervical canal, whose walls are scraped out; the scrape is collected into a jar with 10 % formalin solution. Then again the curette end is introduced to the fundus of uterus, the endometrium is gradually and sequentially scraped and removed by means of scraping motions in the direction from the fundus to the cervical canal of uterus, being especially attentive in the uterine angles. The scraped material is poured over with 10 % formalin solution and sent for histological study. Abdominal cavity puncture through the posterior . This is the closest and the most convenient access to the cavity of the small pelvis (the rectouterine pouch), where fluid collectes in different pathological processes, most often of gynecological origin.

Indications: suspected extrauterine pregnancy, inflammatory diseases, which take their course with exudate formation in the rectouterine pouch; to be followed by laboratory investigation. Target puncture is indicated if pyosalpinx, , or pyoovarium is suspected. The uterine neck is exposed with the help of specula, processed with disinfectants, the posterior lip is taken with bullet forceps and pulled forward making the posterior fornix accessible. A 1–2-cm puncture is made with a needle in the middle between the sacrouterine ligaments. After that one pulls the syringe hub and slowly takes out the needle at the same time. Determination of uterine tubes patency. Pertubation is tubes patency determination by introducing air into their lumen. hydrotubation – by introducing liquid. Retrograde pertubation or hydrotubation is insufflation or washing-out of the uterine tubes by indications from the side of the abdominal end if the anterior abdominal wall is dissected. Treatment-and-diagnostic hydrotubation is introduction of medicinal agents into the uterine tubes. Contraindications: pregnancy, acute inflammatory diseases of the uterus and appendages, tumors of the uterus or appendages, colpitises and cervicitises, the 3rd–4th degree of vagina cleanness, pathological bleedings. The procedure is to be carried out on the 10th–13th day of the menstrual cycle. The uterine neck is exposed with the help of specula, processed with a disinfectant, the anterior lip is taken with bullet forceps. The doctor introduces a tip of appropriate size into the cervical canal, tightly presses it to the uterine neck, then joins a special system with liquid or air, and begins to deliver them to the maximum pressure of 150–180 mm Hg. Uterine tubes obstruction is characterized by such signs: the manometer pointer does not fall; auscultation does not show any sound characteristic of air passage through the uterine tubes; pressure rises. Ultrasound study. The technique is based on the ability of organs and tissues to reflect ultrasound waves in different ways due to their varying acoustic counteraction. Ultrasound is high-frequency sonic waves, with the frequency higher than 2–15 MHz, the range of black-and-white sound image. These waves are not felt by the human ear and may be turned into the waves used for body scanning. Ultrasound waves are generated by piezoelectric elements of the sensor, which transforms electric signals into ultrasound waves. The same sensor receives the signal and transforms it back into electric signal. Ultrasound study may be transabdominal and transvaginal two- and three-dimensional (see the Chapter Fetal Condition Assessment in obstetrics). Indications: tumors of the uterus and appendages, suspected uterine and extrauterine pregnancy, determination of tubes condition by means of hydrotubation, ovulation control, etc. Radiologic investigation techniques. (metrosalpingography) is getting a contrast image of the uterine cavity and tubes by means of roentgenography. Indications: pathological processes, which cause changes of the uterine size and form (uterus maldevelopments, tumors); , synechias; to determine uterine tubes patency. Contraindications: suspected pregnancy (uterine and extrauterine), bleeding, acute and subacute inflammatory diseases of the uterus and appendages, colpitises and cervicitises, the 3rd–4th degree of vagina cleanness. The investigation is conducted on the 8th–14th day of the cycle. The uterine neck is exposed with the help of specula, processed with disinfectants, the anterior lip is taken with bullet forceps, a contrast medium is introduced into the uterine cavity with the help of the Brown’s syringe, the image is taken right after introduction, then in 15–20 min, and if oil iodine solution was used – in 24 hours. Lymphography is conducted to find the extension of the tumor of the uterine neck, body, and ovaries. Direct lymphography is based on the fact that the tumor- bearing part of the lymphatic vessel cannot absorb any contrast media (iodolipol, miodil), the roentgenogram shows the filling defect. Indirect radionuclide lymphography is subcutaneous introduction of 198Au into the first interdigital spaces. In specific lesion of the lymph nodes their hatching is not evident in scanning. Angiometrosalpingography is a method based on the contrast study of the pelvic vesels, uterine cavity and tubes. The combination of two research techniques gives a possibility not only to simultaneously study the state of the uterine cavity, uterine tubes, , and vessels, which supply them, but also sharply decreases the radiation dose.

Parietography. The technique is based on simultaneous inflating with gas (О2 or СО2) of the urinary bladder, vagina, and rectum, after what lateral tomograms are made. This gives a possibility to find the correlations between the uterus, rectum, and urinary bladder. Radionuclide diagnostics is based on the fact that malignant cells can intensively absorb radioactive phosphorus (32Р), which is introduced inside. One can find the areas of affection with the help of the radiometer probe. Endoscopic investigation techniques Colposcopy — see above. Cervicoscopy is examination of the uterine neck with the help of special instruments — cervicoscope through the colposcope. Hysteroscopy is examination of the endometrium with the help of the hysteroscope. Cystoscopy is examination of the urinary bladder mucosa with the help of the cystoscope. Laparoscopy is examination of the abdominal and pelvic organs with the help of the laparoscope, introduced into the abdominal cavity by puncturing the anterior abdominal wall. Other special investigation techniques: roentgenography of the Turkish saddle, computer tomography, thermovision, diagnostic laparotomy.

7. Materials for self-control:

TESTS 1.What is a Pap Smear? A. is a screening test for B. is a screening test for C. the analysis the microbial flora D. the determination of vaginal pH E. determination of correlation of cells on different types of ripening 2.The most exact method for the diagnosis of the reason of the uterine bleeding: A. laparoscopy B. colposcopy C. USG D. hysteroscopy E. cystoscopy 3.Tests of functional diagnostics allow to detect: A. all are correct B. two-phase nature of menstrual cycle C. level of estrogen saturation of an organism D. presence of ovulation E. full value of luteinising cycle 4.Treatment of juvenile uterine bleeding provides all of the above, except: A. stimulation of Ovulation with clomifene B. stopping Haemorrhage C. normalization of menstrual function D. antianaemia therapy E. all of above 5.Appearance of “fern symptom” is based on: A. on power of mucus to crystallize at drying B. on the change of type of uterine cervix C. on diameter of cervical canal D. on the rise of viscidity of cervical mucus E. on hyperthermic influence of progesteron on hypothalamus 6.What a diphasic basal temperature testifies about? A. all above B. about the presence of normal menstrual cycle C. about the presence of ovulation D. about the presence of lutein phase E. about the presence of diphasic menstrual cycle 7.Which possibilities does hysteroscopy have? A. all above B. it is possible to examine mucus of the uterus C. it is possible to expose the pathological changes of endometrium D. it is possible to delete the polyps of endometrium E. it is possible to delete a intraepithelial contraceptive 8.For diagnosis which disease a biopsy used? A. cancer of uterine cervix B. cancer of uterus C. uterine myoma D. cancer of ovaries E. all above 9.Which smear is obligatory at routine gynecological examination? A. on oncocytology B. on hormonal cytology C. on microflora D. on the degree of cleanness E. on a “hormonal mirror” 10.The examination of gynecological patient begins from? A. from getting a passport data B. from the life history taking C. from the illness history taking D. from an external inspection E. from gynecological examination SITUATIONAL TASKS 1.A 24-year-old woman presents for a routine examination. She has no specific gynecologic complaints. She is in a monogamous relationship with her husband of 3 years. Her last gynecologic visit was 1 year ago, at which time she had a normal Pap smear. The appropriate screening for STIs includes: 2.A 33-year-old G3P2012 presents for an annual examination. She had a Pap smear showing ASC-US at age 22. She has received annual Pap tests since that time and all have been normal. She is in a monogamous relationship with her husband of 15 years. She had never had an STI. She uses an IUD for birth control. She asks you how she should be screened for cervical cancer. You inform her: 3.A 62-year-old G2P2002 presents for a routine examination. Her last period was 10 years ago and she has had no postmenopausal bleeding. She brings a copy of her records that indicate a history of normal Pap tests for the past 20 years, with the most recent 1 year ago. Her last mammogram was 2 years ago. She takes a calcium and vitamin D supplement. She took estrogen and progesterone replacement therapy in early menopause but stopped 8 years ago. Her vasomotor symptoms are minimal. She is otherwise healthy and on no medications. She has no family history of breast or . You recommend the following screening tests.