Recent Changes

Tuesday, April 12

  1. page 10 OBG Tips edited ... - minor surgery: endometrial ablation/resection - major surgery: hysterectomy Gynae History…
    ...
    - minor surgery: endometrial ablation/resection
    - major surgery: hysterectomy
    Gynae History and Examination
    Patient name, age,
    Presenting complaint: primary reason for visit today
    Menstrual history:
    - age at menarche/menopause
    - how many days since last menstrual period?
    - are cycles regular? how many days does she bleed? average length of cycles
    are periods heavy? (if so, how long has it been present? Clots/flooding? How many pads used per day? Has she had any previous treatments? If so, how effective were they? Side effects?)
    Are periods painful? (if so, when during cycle? how does it affect daily functioning- e.g. number of days off work? any treatments? effective? side effects?)
    Any intermenstrual bleeding? Post-coital bleeding? Post-menopausal bleeding?
    Sexually active at present? Any problems with intercourse? Dyspareunia? (If so, timecourse, and whether superifical or deep, or related to cycles)
    Contraception- types tried, failures/unwanted pregnancies, side effects
    Vaginal discharge (if present: colour, odour, itch, irritation?); past history; sexually transmitted diseases? (if so, treated? contact tracing? checked for other STDs?)
    Last pap smear? does she have regular pap smears? (what frequency) normal? ever abnormal? (if so, what treatment)
    Last mammogram/breast ultrasound?
    Menopausal symptoms (if age-appropraite, or amenorrhoea)
    Urinary incontinence/symptoms; prolapse/lump in vagina; bowel symptoms
    Pelvic pain (not associated with menses or intercourse)
    Past gynaecological history: past diagnoses (and basis for diagnosis), past operations
    Past obstetric history (see obstetric history-taking for details)
    Past medical history; past psychiatric history
    Past surgical history
    Family history (of cancers, or medical and genetic conditions)
    Social history: home, relationships, work, financial/social stresses
    Smoking history; alcohol intake; other recreational drugs
    Medications; allergies
    Examination
    General appearance (colour, secondary sexual characteristics)
    Vitals (temperature, blood pressure, pulse rate, respiratory rate); body mass index; full ward test (urine pregnancy test if appropriate) - remember: inspection, palpation, percussion, ascultation)
    Thyroid, cardio-respiratory and breast examination
    Abdominal examination
    Inspection of external genitalia (lumps, skin conditions, ulcers, discolouration, atrophy), including urethral meatus
    Bimanual examination: uterine size and shape, antevereted/retroverted; tenderness; mobility; adnexal masses
    Joint vaginal and rectal examination (if appropriate- for Pouch fo Douglas nodules/tenderness)
    Speculum examination
    Bi-valve to inspect vaginal walls and cervix (take pap semars and high vaginal /cervical swabs if appropriate)
    Sims speculum to examine for prolapse (systematically examine anterior and posterior vaginal wall then vault) and urinary incontinence (loss of urine with cough)
    History/examination of the obstetric patient:
    Antenatal history
    patient name and age
    Current pregnancy- spontaneous or assisted conception (IVF/ovulation induction; reason for infertility)
    - planned pregnancy? wanted pregnancy?
    - gestation: last menstrual period (gestation by dates); if by ultrasound, when performed and findings (nuchal translucency, singleton/twins, placenta, other findings, e.g. fibroid, ovarian cyst)
    - on folate or multivitamins prior to conception? Rubella/parovirus/varicella checked prior to conception?
    - Current pregnancy symptoms (ask appropriate to gestation: first trimester- hyperemesis, breast tenderness, urinary Sx; third trimester- backache, gastro-oesophageal reflux)
    - any screening Ix performed to date? what results?
    Past obstetric history- pregnancies in order with their outcomes
    - early pregnancy losses: miscarriages (gestation, treatment, complications); terminations (gestation, mode of TOP, complications); ectopics (type, gestation, treatment)
    - Pregnancies > 20/40 (gestation at delivery, medical complication of previous pregnancies; mode of delivery; delivery complications - post-partum haemorrhage, shoulder distocia, puerperal complications- infections, breast-feeding issues, postnantal depression)
    - Gynaecological and general history as above, but with less comprehensive questioning of gynaecological history
    Examination
    general history as above for gynaecological history, until the candidate reaches the abdominal examination
    N.B. check urine for protein and glucose no dipstick
    abdominal and vaginal examination depending on gestation
    first trimester
    abdominal/vaginal ex: is uterus palpable abdominally? if not, what size uterus on vaginal examination? speculum for pap smear if due
    second trimester/third trimester
    Abdominal Ex: symphyseal-fundal height (SFH); lie and presentation of fetus; single or multiple pregnancy; doppler of fetal heart (present? rate?); miscellaneous findigns (fibroid, uterine tenderness)
    Vaginal Ex (only if appropriate). Cervical length, dilatation, consistency, position, station of presenting part
    Obstetric History and Examination
    Patient name and age
    Parity, single or multiple pregnancy
    Mode of previous deliveries: prior delivery complications
    Brief medical/surgical history
    Medications (including syntocinon), allergies
    Presenting complaint (often called by midwife/junior doctor)
    Progress of labour (contractions, vaginal assessments)
    Status of membranes, colour of liquor
    Use of analgesia (pethidine? how long ago? epidural?)
    Assessment of fetal wellbeing (fetal heart rate, CTG)
    Examination
    General: BP, full ward test of urine, pulse rate, temperature
    Abdominal Ex: Lie, presentation, SFH, fetal heart, contractions
    Vaginal Ex: Presentation, station, position, moulding, caput; cervix-dilatation, length, position, assessment of pelvis.
    N.B. the obstetric encounter is more likely to be fast-paced, focusing on management of emergencies and the history needs to be abbreviated to focus on the crucial issues that pose a risk to the mother and fetus(es). E.g. make sure this is not a trial of scar, a placenta praevia, multiple pregnancy or a breech presentation. Check for gestational diabetes, hypertension, anaemia or concerns regarding IUGR. Exclude significant maternal illnesses such as T1DM, asthma, epilepsy, stroke or cardiac disease.

    (view changes)
    9:56 pm
  2. page 10 OBG Tips edited ... 9. The most important pap test is the first 10. for every woman, ask about Contraception and …
    ...
    9. The most important pap test is the first
    10. for every woman, ask about Contraception and Pap-smear
    OSCEs in general
    General measurs: iron tablets/vitamin C tablets
    Exercise/physiotherapy: not appropriate
    Medical treatment:
    - tablets:tranexamic acid, oral contraceptive pill, NSAIDs, progestagen
    - injections: Depo Provera
    - medicated devices: Mirena IUD
    Surgical treatment:
    - minor surgery: endometrial ablation/resection
    - major surgery: hysterectomy
    Gynae

    (view changes)
    9:37 pm

Saturday, April 9

  1. page Labour & the Placenta edited ... 3. epidural Mx of Labour = = Normal labour 1. education, support, prep ... 2. review,…
    ...
    3. epidural
    Mx of Labour
    =
    =

    Normal labour
    1. education, support, prep
    ...
    2. review, antenatal Hx
    3. evaluation, BP, HR, FHR, urinalysis
    StageAbnormal Labour
    Stage
    1 FHR/15min
    Rx: Amniotomy
    Syntocin (in primigravida; caution in multigravida as uterus may not stand strong contractions)
    Stage 2
    Arrest of descent >3 hours
    arrest of descent without epidural > 2 hours
    Rx: fluid resuscitation, reposition, forceps delivery (if presenting part lower than ischial spine)
    Stage 3
    should be less than 30min-1hour
    N.B. The empty contracted uterus will NOT bleed
    N.B. Routine active Mx of 3rd stage reduces maternal morbidity (syntocin to contract uterus and expel placenta)

    Neonatal Assessment
    APGAR score is recorded at 1 and 5 minutes
    ...
    Haemorrhage
    Eclampsia
    Thromboembolism
    The Placenta
    Origin
    cytotorphoblast and syncial trophoblast
    Day 5 implantation
    Role
    Immune: prevent rejection of the fetal allograft
    Oxygen/nutrition/waste product transfer
    Endocrine (produce betaHCG, steroid homrones)
    Placental praevia
    Placental abruption
    Pre-eclampsia
    Antepartum Haemorrhage
    = bleeding after 20 weeks until end of 2nd stage
    Causes of antepartum haemorrhage include plaenta praevia (30%), placenta abruption (20%), other (50%)
    Ex
    painless (praevia) vs painful (abruption)
    tender-less (praevia) vs tender (abruption)
    Ix
    U/S, Hb, Group and hold
    Kleihauer Test
    Mx
    Rescuscitate and deliver (only if maternal or fetal compliance)
    Anti-D if woman is Rhesus negative
    Placental Praevia
    underlying/prominent to itnernal cervical os
    4:1,000 RF:

    (view changes)
    5:22 am

Monday, April 4

  1. page Clinical Ex in OBG edited ... Colposcopy- follows if abnormal cells are detected by Pap smear. The cervix and vagina are exp…
    ...
    Colposcopy- follows if abnormal cells are detected by Pap smear. The cervix and vagina are exposed by introducing a bivalve vaginal speculum, and inspected with a low-powered microscope. The colposcope is placed in front of the vagina and its focal length adjusted to examine the suspect part of the lower genital tract.
    {colp.jpg}
    Tip in Colp: focus on squamo-epithelial junction!
    {sej.jpg}

    CTG- accelerations and decelerations
    GBS swab- for Group B Strep; identify need for antibiotics during birth; saves baby from potential sepsis
    (view changes)
    3:26 am
  2. file sej.jpg uploaded
    3:26 am
  3. page Conditions in Pregnancy- Pre-eclampsia, GDM edited ... Gestational Diabetes 2hr GTT > 7.9 If at risk, screen at 16 and 24 weeks Illicit Subst…
    ...
    Gestational Diabetes
    2hr GTT > 7.9
    If at risk, screen at 16 and 24 weeks
    Illicit Substances in Pregnancy
    Classification
    (view changes)
    3:24 am
  4. page Spina Bifida & genetic, social counselling edited ... Surgery which frees lateral muscle and skin for coverage Genetic Counselling Thalassaemia M…
    ...
    Surgery which frees lateral muscle and skin for coverage
    Genetic Counselling
    Thalassaemia Major
    Down Syndrome
    extra/partial/whole Cr 21
    flat facial profil
    hypotonia
    loose skin on back of neck
    severe mental retardation.

    General Counselling
    Violence against women
    =
    =
    being empathetic
    specific details of violence
    (view changes)
    3:23 am
  5. page Antenatal Care & Fetus Monitoring edited Antenatal Care History taking ... Breast exam (breastfeeding advice, check for pathologies) …

    Antenatal Care
    History taking
    ...
    Breast exam (breastfeeding advice, check for pathologies)
    Investigations
    Essential Tests
    Screen
    Down Screen
    19 week U/S
    GBS vaginal swab at 36 weeks
    (optional: growth US at 32 weeks; CTG from 36 weeks)
    Tests in order:

    FBE
    Blood group and antibody screen (O+ most common; Rh-ve 10%- give anti-D to prevent erythroblastosis; stillbirth)
    ...
    Treatment via encouragement of 'grazing' on dry bland carbs e.g. biscuits; small amount multiple times.
    Test ketones in urine (Rx saline 2L)
    Folic acid and Vitamin D!!
    Vaccinations
    whooping cough (aka pertusis vaccine) as part of BOOSTRIX- with diphtheria and tetanus
    ...
    1 hr post glucose ingestion
    GTT- glucose tolerance test
    definitive test if greater than 7.9
    2 hrs post glucose ingestion
    Down Syndrome
    (view changes)
    3:22 am
  6. page Conditions in Pregnancy- Pre-eclampsia, GDM edited ... H/T associated with renal, re Pre-eclampsia superimposed on chronic hypertension Gestationa…
    ...
    H/T associated with renal, re
    Pre-eclampsia superimposed on chronic hypertension
    Gestational Diabetes
    2hr GTT > 7.9
    Illicit Substances in Pregnancy
    Classification
    Uppers
    ecstasy
    amphetamine (including ice)
    cocaine (speed, ice...)
    Downers (most worrisome)
    Alcohol
    Cannabis (marijuana, dope, weed)
    Hallucinogens
    LSD
    Magic mushrooms
    Management
    Methadone (for heroine withdrawal effects)
    Buprenorphine (with anti-heroine effect)

    (view changes)
    3:19 am
  7. page Antenatal Care & Fetus Monitoring edited Antenatal Care History taking ... Treatment via encouragement of 'grazing' on dry bland carb…

    Antenatal Care
    History taking
    ...
    Treatment via encouragement of 'grazing' on dry bland carbs e.g. biscuits; small amount multiple times.
    Test ketones in urine (Rx saline 2L)
    Vaccinations
    whooping cough (aka pertusis vaccine) as part of BOOSTRIX- with diphtheria and tetanus
    for mother asap following labour, for child at 6 months
    everyone regularly in contact with baby should be vaccinated

    Referral
    Low/high risk
    ...
    Model of care
    Fetus Monitoring
    CTGCTGCTG
    1. Baseline N110-160bpm
    2. Variability N5-25bpm
    ...
    pH <7.25= acidotic baby
    N.B. lupus- anti-SSA crosses placenta, targets endothlium of heart in fetus
    Maternal Serus ScreenMaternal Serus Screen
    Beta HCG
    Alpha Fetoprotein
    Oestradiol
    Inhibin
    Genetic testingGeneticBiophysical Profile
    =
    =
    CRL N 6-7 cm
    BPD N 2-3cm
    HC (head circumference) 8cm
    AC (abdo circumference) 6.5cm
    FL (femur length) 1.1cm N
    .B. 5mg folate for twin pregnancy instead of 0.5mg
    FWT
    =
    =
    Proteinuria
    Glucosuria
    Special tests
    =
    =
    GDM has a 40% reucrrence rate in subsequent pregnancies
    GCT- glucose challenge test
    screening test
    1 hr post glucose ingestion
    GTT- glucose tolerance test
    definitive test
    2 hrs post glucose ingestion
    Down Syndrome
    combined risks if greater than 1/300 discuss
    Do amniocentesis if greater than 1/200
    Genetic
    testing
    {http://www.billcasselman.com/fetus_amniotic_sac.gif} external image fetus_amniotic_sac.gif
    (view changes)
    3:15 am

More