OBS AND GYNAE

PRECONCEPTION ASSESSMENT

1. Hx of previous pregnancies if applicable

2. Plan for timing of next pregnancy,
 I.e, when are you planning to get pregnant?
 How long have you been trying?

3. Lifestyle- SADES
4. Menstrual hx including cervical smear
5. Hx of previous STIs

6. Vaccinations-
 MMR
 if she’s had chickenpox before in childhood
 plans to travel abroad (Zika is endemic in Brazil)

7. PMHx
8. Medications

9. Risk factors for pre-eclampsia

• Family hx, personal hx of pre-eclampsia
• Family hx or personal hx of HPT, DM

10. Finish MAFTOSA

• Ask about partner

11. EXAM: BP, urine test, abdominal exam, BMI

12. IMPACT OF AGE ON PREGNANCY

Unfortunately, women >33 years are at increased risk of
• Miscarriage
• Complications during pregnancy

13. CHANCES OF GETTING PREGNANT

• 80% of women who are trying to get pregnant will do so within 1 year
• Half of those who fail to get pregnant in the first year will get pregnant in the
second year
ADVISE:
a) Regular intercourse 2-3x a week
b) Folic acid- start before pregnancy and continue up to 12 weeks
c) Normal dose= 400micrograms, but if there is a high risk of NTD we give 5mg

d) Diet- balanced diet

e) Obesity carries risk of complications like miscarriage, stillbirth, gestational HPT and DM-
Lose weight before getting pregnant

f) Stop smoking, Avoid drinking, Avoid recreational drugs

g) Cervical smear recommended if it hasn’t been done.
h) Offer immunisations where necessary- MMR, varicella, Hep B, avoid countries with Zika
virus

14. DM HIGHLIGHT
o People with DM need to be referred to the pre-conception diabetic clinic /
diabetic team
o Usual blood glucose targets and current meds need to be reviewed

EFFECTS OF PREGNANCY ON DM
• Increased risk of hyperG, DKA
• Increased complications of DM such as retinopathy, nephropathy

EFFECTS OF DM ON PREGNANCY
• Increased risk of miscarriage, still births and complications during delivery

15. HYPERTENSION HIGHLIGHT

• Refer to specialist before getting pregnant
• Advise there is an increased risk of pre-eclampsia
• CT current meds unless directed by specialist (OB/GYN)
• CT contraception

PRECONCEPTION CARE- HYPERTENSION

FY2, GP, 42yo F, has made an appointment to see you she has HPT well maintained on ramipril.
BP= 128/63
PT INFO: She would like to get pregnant, she made an appointment to ask for advise. She does not
drink or smoke. She is on a healthy diet, cooks herself.
How can I help?

P-Pregnancy
P-Periods
P-Pills
P-PAP Smear

DX: PRECONCEPTION CARE- HYPERTENSION.

MGT:
1. Preconception approach+ exam
2. Talk about her chances
3. Hypertension highlight
4. Needs to see OB/GYN (routine referral),
• CT Ramipril and use Effective contraception till they see the
specialist for change of meds (refer back to the specialist who
prescribed the medication)

 may Consider giving Labetalol, Nifedipine, Methyldopa. ACEi can cause adverse
effect for the woman, fetus, and newborn infant during pregnancy

5. Folic acid
It's is important that you are monitored throughout your pregnancy to make sure your high
BP is not affecting the growth of your baby (pre-eclampsia). Please make sure you go to all
your ANC appointments.

She will also ask- I am 42, will this affect my chances?

• Unfortunately, there is increased risk with advanced age
• but don’t worry we will monitor your progress

PRECONCEPTION- WANTS AN ABORTION IF A GIRL

FY2, GP, 36yo F, made a non-urgent appointment to see you. She had 3 daughters, she is taking
currently cOCP. Talk to the pt, address concerns.
She wants a 4th child. All her children are girls, her husband wants a boy. She has had an abortion
before and she knows that abortions can be done in the UK.

QUESTIONS:
I heard that having sex in a standing position will make me have a boy?
• Why do u think so?
• Unfortunately there is no scientific evidence. There are different stories concerning
this but they are all just myths as no scientific evidence has been given.
If I find out it is a girl can I get an abortion?
• Is there any other reason u want it?
• Abortion is legal up to 24 weeks in the UK, however this requires a valid reason
(medical/psychological harm to the mother).

• If you want one, 2 doctors will assess you and if they do not find any of these
reasons, they might not agree to the abortion. In your case, with your reason for
abortion, there go ahead cannot be given.

a. Can I use my sister having cancer as a reason for an abortion?

• I am really sorry to hear about your sister? How is she doing?
• If your sister’s condition affects u and will make it difficult for u to carry the
pregnancy, in terms of it affecting your psychological health or physical health, then
you will undergo assessment by 2 senior doctors and if proven, then u may be
offered treatment, however this is quite an unusual reason
• If not, then it is not a valid reason to terminate the pregnancy.

APPROACH: Preconception approach

MGT:
1. There is a 50-50 chance of having a boy/girl and there is no way to know the sex of
the baby before the pregnancy. There is the option of IVF, it is expensive, not
funded by the NHS, not 100% effective

2. Advise to discuss with her husband that they can try and get pregnant only if they
will be able to continue with the pregnancy even if it turns out to be a girl.

3. Abortion has got complications- Depends on the method of termination- can cause
infection and rupture of the uterus

PREGNANCY
FY2, 17yo F, presents with vomiting, take a hx, assess the pt, discuss mgt.
PT INFO: vomited 4x in the last 24 hours, vomit is yellowish, brought in by her parents. LMP= 6wks,
periods are a little bit late. She is not sure the cause of her vomiting. She has been sexually active
for the past 6 months with her boyfriend who is 19. Relationship is good, he doesn’t abuse her, she
thinks he is caring. She is afraid to talk about sexual life cuz she does not want her parents to
know (they dunno she has a boyfriend, they dunno she is sexually active, parents are Roman
Catholic). She doesn’t use any form of contraception, does not use condoms, they use the
withdrawal method, she is disappointed that she is pregnant
Will my parents know about this?
What are you going to do for me?

I'm feeling sick, and I have vomited a few times.

 Can you tell me more?
 when did it start?
 What were you doing when it started?
 Is it there all the time or does it come and go?
 how many episodes?
 Is there anything which makes it better? worse?

 Do you feel thirsty? (dehydration)

 Is your urine dark yellow? (dehydration)
 Do your mouth and lips feel dry? (dehydration)
 Do you have any tummy pain?
 Do you have fever?
 Do you have loose stools?
 Did you hurt yourself recently? (trauma)
 Do you have headache?
 Have you been diagnosed with any medical condition
 Any previous surgeries or procedures done?

 When was your LMP?

 Are they regular? How long does your period last?
 Any bleeding or spotting between your periods?
 Any painful or heavy periods?
 Have you been pregnant before?

 Are you currently sexually active? R u in a stable relationship?

 How old is your partner?
 Do you and your partner(s) use any contraception or protection against STIs?
 Do you use condoms?
 Do you smoke? drink alcohol? Tell me about your diet? Are you physically active?
 Who do you live with? How is your relationship with her? Do your parents know that u r
sexually active? How do u think they will react

EXAM FINDINGS: observations= normal, abdominal exam= normal, UPT= positive

APPROACH: Gastroenteritis, UTI, Pancreatitis, Headache

EXAM: observations, Abdominal, Bedside UPT, urinalysis

DX: PREGNANCY- from what you have told me and the tests we have done, it appears you
are currently pregnant.
Finding out you’re pregnant when you’re a teenager can be daunting, especially if it wasn’t
planned, but help and support is available.
As your pregnancy test is positive, it’s understandable to feel mixed emotions: excitement about
having a child, worry about telling your parents, and anxiety about pregnancy and childbirth.

Make sure to talk through your options and think carefully before you make any decisions.
Try talking to a family member, friend or someone you trust. I would like to suggest you
discuss your pregnancy with your mother for support and understanding.

U r entitled to confidentiality. But if I may ask, why do u ask whether we will tell your parents?

MGT:
1. Encourage fluid intake
2. Anti-emetics
3. Discuss with parents and partner for support
4. Options:
• Continuing with the pregnancy and keeping the baby
• Continuing with the pregnancy and having the baby adopted
• Having an abortion

5. Can go to GP or family planning clinic for advice and to discuss options further
LIKE what to expect in pregnancy and schedule ANC if she decided to keep the baby

7. Safety netting- if she can’t keep food/fluids down, dark coloured urine/has
not gone to pee in 8 hours, feeling severely weak, dizzy faint, high temp, tummy pain,
vomiting blood, weight loss
8. Leaflets on pregnancy and symptoms

Don’t tell my mom I am pregnant.

 Of course, as this conversation is confidential, we will not be discussing this with your
mother without your consent

ANTENATAL CARE- 2 PREVOUS MISCARRIAGES

FY2, OBGYN, Mrs Audrey Jones is a 25yo F, who came for routine antenatal follow up. LMP= 6
weeks ago. This is her first antenatal visit. Please assess the patient and discuss further
management plan.
PT INFO: You are Mrs Audrey Brown, 25 year old lady. You had 2 previous miscarriages at 8 weeks.
The miscarriage was 2 years ago. You are taking folic acid at the moment. You smoked for 5 years
but then stopped last year. This is your 3rd pregnancy. You did a pregnancy tests and you know
you are 2 weeks pregnant. After the 2 miscarriages, you went to see the GP but nothing was
found. The GP simply said that you should try again.

APPROACH: GRIPS
Paraphrase the scenario:
 I understand you have come for first antenatal follow up. Welcome to the practice. Do
you know what happens during the first antenatal visit?
 Usually it involves asking you some questions, doing some examinations and
arranging some investigations.
 Shall I start by asking you some questions?

Current pregnancy hx
 So, how is your pregnancy so far?
 Any vomiting?
 Any bleeding through vagina?
 Any tummy pains?

Previous pregnancy hx
 Is this your first pregnancy?
 Any miscarriages before? How many weeks? Did u attend ANC then? Any scans?
How did it end?
 Any fever, rash (Rubella)

 Do you have any health problems like increase BP, blood sugar or clots in lungs or legs?
 Are you using any medication? Any allergies? Fam Hx of miscarriages
 Are you in a stable relationship? How many partners in last 6 months?
 Do you practice safe sex? Do you know the biological father of the baby?
 Have you ever been diagnosed with any STI?
 What you do for your living?
 Do you smoke? Recreational drugs?

EXAM: Observations, BMI, ABD, PV

MGT:
1. FBC, BUE/CR, Urine R/E, Infection screen (Syphilis, Hepatitis, HIV, Rubella, Syphilis),
USS of the abdomen, OGTT

Do you think everything will be fine? Is it going to happen again?

2. Reassure- You have got an equal chance of having a normal pregnancy like every
other woman because you had only 2 miscarriages. The chances of having another
miscarriage increases after 3 consecutive miscarriages.
If that happens, we will do more tests to see what might be the cause.

How can I make sure that I do not have another miscarriage?

3. Advice lifestyle:
• Exercise; continue moderate exercises
• Alcohol; High consumption may result in fetal alcohol syndrome
 • Smoking; is associated with miscarriage, intra-uterine deaths, premature delivery
• Diet
• Folic acid supplement, Vitamin D

4. Give antenatal care information e.g "The Pregnancy Book”

***NOTES:
A miscarriage is defined as loss of pregnancy before 24 weeks
Recurrent miscarriage is defined as loss of 3 or more consecutive miscarriages

Risk factors:
• Endocrine cause (PM, thyroid disease, PCOS)
• Inherited through syphilis
• Infections
• Structured anomalies (e.g. Uterine septum)
• Genetic abnormalities

Why do I have these miscarriages?

 If a miscarriage happens during the first trimester of pregnancy, it's usually caused by
problems with the baby.
 If a miscarriage happens during the second trimester (between weeks 14 and 26), it may be
the result of an underlying health condition in the mother.
 We will keep monitoring you and your baby. Hopefully everything will be fine.

Is it possible to have another miscarriage?

 For most women, it’s a one-off event and they go on to have a successful pregnancy
in the future.
 Most women are able to have healthy pregnancy after a miscarriage, even in cases
of recurrent miscarriages.

RH NEGATIVE, RUBELLA- NON IMMUNE

You are an FY2 in Antenatal Clinic.
Mrs. Chelsea Stokes, aged 30, is 14 weeks pregnant and has come to the hospital for the
reports. She came to antenatal clinic when she was 12 weeks pregnant for routine antenatal
clinic. Talk to her and address her concerns.
Report:
Rubella; nonimmune
Rh –ve or O Rhesus antibodies were negative.
Blood: Normal
Urine: Normal
1st preg. Not sure who the father if the child is. She uses recreational drugs. Drinks excess alcohol
everyday
 • GRPS- I understand u r here for ff up and had some blood investigations done
• Before I do can I ask a few questions
• How is the current pregnancy? Pain? Headaches, vomiting? uti symptoms....
• First pregnancy?
• Planned?
• Sexual hx- Do u know the father of the child?
• Past STIs?
• Immunization status
• MAFTOSA- Uses Recreational drugs, Smokes, Drinks
• ICE

EXAM- vitals, GPE, Obstetric exam, Urine dipstick

RUBELLA ANTIBODY NEGATIVE

a) The good news is that the scan of ur tummy shows u r 12 weeks pregnant and u r completely
fine
b) We also have done some blood tests for u and they are normal
c) But the tests show that u do not have antibodies for rubella, so u r at risk of catching rubella
infection
d) It is an infection that is very similar to measles, and people are vaccinated for it in their
childhood.

e) It is one of the serious infections in pregnancy

f) It can cause serious damage to the baby and there r high chances of catching this within
the first 16 weeks of pregnancy
g) This may have happened because u did not have MMR vaccination as a child

h) Unfortunately, it is not advisable to have MMR vaccination in pregnancy

i) But we need to watch out for any infection
j) Therefore if u develop any rash, seek immediate help
k) As I told u it is a serious infection and can damage the brain of your baby
 Unfortunately, if u catch this infection in the first 16 weeks of pregnancy, your pregnancy
may have to be terminated. It can alsocause loss of the baby (miscarriage).

l) So wash u hands frequently, eat fruits and vegetables after washing them properly
m) Eat a thoroughly cooked meal

 After you’ve had your baby, you should have the 2 vaccinations, so you’re
protected next time you get pregnant.

 Congenital Rubella Syndrome (CRS)- hearing loss, cataracts, heart problems that require
significant hospital treatment and affect the child throughout their life.
 MMR immunisation during pregnancy is not recommended.
Before pregnancy. Get the MMR vaccine. Wait 1 month before trying to get pregnant after getting
the shot.

RH NEGATIVE
 We also did a blood test to check for your blood group and one of the markers called rhesus
came back negative.
 Red blood cells sometimes have another antigen, a protein called RhD antigen.
 If this is present, your blood group is RhD positive. If it’s absent- RhD negative
 It means u have O negative blood group
 That means if u have a baby who has a positive blood group, ur body will form antibodies to
fight the blood cells of the baby and this is likely to happen in the future pregnancies

 To prevent this from happening, we offer a medication- antiD Ig (at 28weeks and 32weeks)
 It stops ur body from forming any substance that will destroy the baby’s blood in future
pregnancies

Rhesus disease can only occur in cases where all of the following happen:
 The mother is rhesus negative
 The baby is rhesus positive
 The mother has previously been exposed to RhD positive blood and has developed an
immune response to it (known as sensitization)

RECREATIONAL DRUGS.
Also u have noted that u take recreational drugs.
U will need more frequent ff up appointments to asses for any problems

Alcohol:
 When you drink, alcohol passes through the placenta to your baby.
 Drinking alcohol, especially in the first 3 months of pregnancy, increases the risk of
abnormalities in the baby

Smoking cigarettes and cannabis:

 harmful chemicals in cigarette smoke increases the risk of a baby being born small or
premature, sudden infant death syndrome/ “cot death”, more likely to be admitted to
hospital for bronchitis and pneumonia during their first year.

 The main reason that people smoke is because they are addicted to nicotine. We can offer
you nicotine replacement therapy
It can help reduce unpleasant withdrawal effects such as bad mood and craving which may
happen when you stop smoking.
 The NHS Smoke free helpline offers free help, support and advice on stopping smoking and
can give you details of local support services.
  Leaflets about the pregnancy
 Safety netting- rash on ur body, Pregnancy book

PRE-ECLAMPSIA
FY2, Maternity Assessment unit. 30yo F, Alice Smith who has come for routine antenatal follow-
up. She is 36 weeks pregnant and she has been seen by the midwife who has made the following
note:
BP today is 160/110. Urine Dipstick shows protein 3+++. Her booking BP: 110/70. Take a focused
history and discuss management with the patient.
CUBICLE NOTES:
Water birth is not recommended in the following situations:
• Hypertensive
• Pre-eclampsia
• Epilepsy
• Foetus Distressed
• Induced Labour

SCENARIO A: You are Alice Smith a 30 year old lady who is 36 weeks pregnant.
You have come for a routine antenatal follow up. You have been having head ache for two hours
and leg swelling of your legs bilaterally for 2 weeks. The midwife examined and checked your
blood pressure and sent you to the obstetrics ward.The midwife in the antenatal clinic found
your BP to be high but she did not explain this to you. You have attended all the antenatal follow
up. Does she understand what booking BP is? This is your 2nd pregnancy; the previous pregnancies
all went fine and it was normal vaginal delivery. Your children are 2 and 5 years. Your pregnancy
was OK, no problems in current pregnancy. You are able to feel the kicks of the baby

SCENARIO B: 1st pregnancy, Swelling of the ankle, Attended all antenatal clinics. Works as a
secretary; in 3 days time you will be having maternity leave. No visual problems. You have been
trying for 2-3 years to get pregnant and you really wanted a water birth. Your husband and
yourself have been planning to have water birth.

APPROACH:
 I understand that you have come for routine antenatal follow up.
 And I understand that the midwife has checked your BP and tested your urine. Has
she explained the results of the BP and urine test.
 I will explain the results of these tests before that can i just ask you a few questions?

Pregnancy hx-
  Could you confirm the age of your pregnancy?
 Is this your first pregnancy?
 How was the pregnancy confirmed?
 Do you know your BP on your first visit?
 Estimated date of delivery (EDD)

 Planned method of delivery?

 Have you got any scans done?
 Do you know how many babies are you expecting?
 How has your pregnancy been so far?

 Have you got any symptoms now?/ Any problems so far

 Able to feel the kicks of the baby?
 Any tummy pain?
 Any Headache
 visual changes
 swelling of feet, ankles or face
 Fits

 medical condition in the past? HTN, DM. Medical illness during pregnancy?
 Any medications during pregnancy? Iron or folic acid?
 Have you attended all your antenatal check ups?
 Past pregnancies- any complications?
 Family hx- increased BP or increased Blood Sugar?
 OSA

EXAM- Antenatal exam

DX: Pre-eclampsia-
• potentially dangerous condition as you can develop seizures.
 Early signs include having high BP and protein in your urine.
 We checked your BP and its high and your urine test shows there is protein in your
urine.
 When this happens after the first 20 weeks of pregnancy, it points to a
condition called Pre-eclampsia
 Thought to be caused by the placenta not developing properly due to a
problem with the BVs supplying it. The exact cause isn't fully understood
In your case it is most probably due to your first pregnancy .

MGT:
1. Admit
2. Give medication (Labetalol) through your vein control BP less than
150mmhg
3. Examine the baby-Antenatal examination (presentation, lie, position)
4. CTG machine (To check that the baby is not in distress. If the baby is in
distress we might suggest a cesarian section)
5. USS to check that the baby has been growing well.

6. Continue monitoring vitals i.e. BP, temp, pulse

7. Blood tests especially LFTs to rule out HELLP syndrome as well as FBC and
RFT
8. Negotiate the management with patient (Are you okay with it) and address
concerns

9. Explain that water-birth would not be advised due to close monitoring

required in labour as a result of pre-eclampsia. CTG and BP need to be monitored. And if u
develop seizures, we can give u medication for that

10. Will give MgSO4 to prevent a seizure, if the BP is above 160/110.

11. C-section if the monitoring during labour suggests baby is in distress.

12. Offer leaflets for more information about pre-eclampsia

QUESTIONS:
1) What caused it? Unknown but it's thought to occur when there's a problem with the
placenta, the organ that links the baby's blood supply to the mother’s

2) Is it serious doctor?- Potentially serious cuz it can lead to seizures

3) what will happen if i don't get admitted? what are the complications?
You might develop complications such as eclampsia, HELLP syndrome

4) Doctor can I have a water birth? If water birth is not possible, please doctor try to
make it a normal delivery as much as possible.
Due to the nature of your condition, u will require monitoring in the hospital, thus
home birth is not possible in this case
 PRE-ECLAMPSIA- 38 WEEKS PREGNANT
FY2, OBGYN, 34yo F, routine followup, she is 38 weeks pregnant, and she has been seen by the
midwife with the following notes
head= engaged
lie= longitudinal
BP= 150/100
Urine dipstick= protein +++
Booking BP= 110/70mmhg
Take a focused hx, discuss mgt with the pt
PT INFO: headaches since yesterday, routine check up= 2 weeks ago, first pregnancy, no
complaints so far, up to date with jabs, PFM+, due in. 2 weeks, can’t get admitted cuz of work.

APPROACH: Same as above

EXAM- Antenatal

DX: Pre-eclampsia- A common comp but if not treated, can lead to seizures

MGT:
1. Admit
2. Labs, USG to check baby has been growing well, CTG to check if baby is in
distress
3. Term so we deliver- IOL o(as there is engagement). If in distress, C/S
4. Offer flu vaccine (routine for pregnant women)- influenza, whooping cough, covid-19
vaccine

We will have to deliver the baby within 24-48 hours. Your labour needs to be started
artificially by giving you some medication (known as induced labour) or you may need to
have a CS, if things get complicated.

CHICKEN POX IN PREGNANCY

FY2, GP, 30yo F, made an appointment to see you, talk to the pt, address concerns, 37 weeks
pregnant, 3yo child called Joshua, he was diagnosed with chickenpox yesterday, he is unwell, she
is worried her baby might have chicken pox. She has had chicken pox as a child

APPROACH
  Hx of chicken pox in son- symptoms? Doctor? Treatment? How is he?
 Hx of exposure- been in contact with him?/Has he been with u for the last 7 days?

 Symptoms of chicken pox in the mother (CURRENTLY)- fever, rash, itchy,

headaches, N&V,
 Hx of chicken pox in mother- ever had it as a child? had any vaccines for it?

 Hx of current pregnancy:
 Is this your second pregnancy?
 How many weeks along are you?
 Estimated date of delivery (EDD)?
 Can you feel the movements of your baby?
 Medical illness during pregnancy? meds during pregnancy?
 Have you attended all your antenatal checkups? Have you gotten any scans
done?
 Do you have twins in your pregnancy?
 How has your pregnancy been so far? any complications?
MAFTOSA

EXAM: Observations, Antenatal care

MGT:
1. Reassure
⁃ Cuz she got chickenpox as a child, unlikely to suffer from it again
⁃ It is unlikely to affect her pregnancy
⁃ She can play and touch Joshua without any problems

• Even if the baby was to be affected, the baby will be born with chickenpox and
then will be given treatment.
• The baby will not have any abnormalities because the pregnancy is more than 36
weeks

2. Safety-net: fever, rash, unwell

If mother has not had chickenpox/shingles and she has had significant contact
• Age of pregnancy
• Test for Varicella Zoster IgG antibodies
Test results shd be available within 2 days
a. If negative, consult specialist- she might need prophylaxis
 b. If positive, reassure she is immune and cannot get chickenpox

EXTRA NOTES
Complications that can affect the unborn baby vary, depending on how many weeks pregnant you
are. If you catch chickenpox:
 Before 28 weeks pregnant: there's no increased risk of suffering a miscarriage. However,
there's a small risk your baby could develop foetal varicella syndrome (FVS). FVS can damage
the baby's skin, eyes, legs, arms, brain, bladder or bowel.
 Between weeks 28 and 36 of pregnancy, the virus stays in the baby's body but doesn't cause
any symptoms. However, it may become active again in the first few years of the baby's
life, causing shingles.
 After 36 weeks, your baby may be infected and could be born with chickenpox.

Once you have chickenpox, there's no treatment that can prevent your baby getting chickenpox in
the uterus.
After the birth, your GP may consider treating your baby with chickenpox antibiotic called
varicella zoster immune globulin (VZIG) if:
 Your baby is born within 7 days of you developing a chickenpox rash
 You develop a chickenpox rash within 7 days of giving birth
 Your baby is exposed to chickenpox or shingles within 7 days of birth and they aren't
immune to the chickenpox virus
If your newborn baby develops chickenpox, your GP may treat them with acyclovir.

Complications for pregnant women (rare):

pneumonia, encephalitis, and hepatitis and these can be fatal.
However, with antiviral therapy and improved intensive care, this is very rare.

Complications for the newborn baby:

Your baby may develop severe chickenpox and will need treatment if you catch it:
 Around the time of birth and the baby is born within seven days of your rash developing
 Up to seven days after giving birth

If you are pregnant, have chickenpox and develop chest and breathing problems, headache,
drowsiness, vomiting or feeling sick, vaginal bleeding, a rash that's bleeding, a severe rash
you should be admitted to hospital.

UTI IN PREGNANCY
FY2, GP, 30YO lady with abdominal pain
PT INFO: LAP, dull, suprabupic, 5/10, does not radiate, 29wks pregnant, everything has been fine
so far, also has dysuria, frequency
EXAM FINDINGS: suprapubic tenderness

APPROACH:
• DDX: UTI, renal stones, PID

Questions about pregnancy:

• I can see from my notes you are 29 weeks pregnant
• How has it been going so far? Any problems?
• How was the pregnancy confirmed? Any scans done yet?
• Are you on any meds- iron, folic acid
• Are you attending ANC checkups?

EXAM: Observations, Abdominal exam, Urine dipstick

DX: UTI in pregnancy- waterworks infection

MGT:
1. Meds- Cefalexin 500mg Bd x 7/7
2. Paracetamol- pain and temp
3. Drink plenty fluids
4. Avoid sex till after treatment. You cannot pass a UTI on, but sex may be
uncomfortable.
5. Give leaflets
6. Safety net- high fever, loin pain, rigours (pyelo)

**Concerns- UTI won’t affect pregnancy, the antibiotic we give won’t affect pregnancy

ECTOPIC PREGNANCY
FY2, GP, 30yo F p/c abdominal pain- few hours. Assess and manage
PT INFO: LMP= 6 weeks ago, sexually active, married

APPROACH: GRIPS
SOCRATES
DDX:
• Gastroenteritis
• Appendicitis
• Cholecystitis
• PID
• UTI
• Ectopic pregnancy- Social hx to r/o risk factors
P: I have got pain here (Patient points at LIF).
 Are you comfortable to talk? SOCRATES
 Is there anything else that’s bothering you? P: I have got bleeding from my front passage.
 since when? colour of bleeding? any clots in it? How many pads have you changed since the
bleeding started?
 Was there any discharge present?
 anything else?
 Did you vomit?

 When was your LMP? regular? How long does period last? Painful? heavy? bleeding or
spotting between periods?
 Are you pregnant by any chance? Did you test it and confirm? Is this your first pregnancy?
 Did you use any type of contraception before? Have you ever used IUCD or coil?

 Have you had any fever or flu like symptoms?

 Any breast tenderness?
 Any pain around the tip of your shoulder?
 Any bowel problems? Gastroenteritis
 Any problem with your urination? UTI
 Any dizziness or heart racing? Do you feel tired these days? Anemia

 Are you currently sexually active? Sexual orientation?

 When did you last have sexual activity?
 Have you had any other partners previously?
 What kind of sexual contact do you have? Genital? Oral?
 Do you or your partners use any contraception/protection against STIs? use condoms? Any
issue with contraception used?
 When was the last time you had unprotected sex?

 Any PMHx? Any STI or PID? When? how was it treated?

 Are you currently taking any medications, OTCs or supplements? Any blood thinner?
 Do you have any allergy?
 Any procedure or instrumentation?
 Any previous hospital stay?
 Has any member of your family ever been diagnosed with any medical condition
P7MAFTOSA

EXAM: Observations, ABD, UPT (positive in this scenario)

DX: suspected Ectopic pregnancy- this is when the pregnancy is situated outside the womb,
it is potentially dangerous.

MGT:
1. Go to hospital
2. Need immediate assessment at the hospital- need to do further investigations to confirm the
diagnosis-
a) special blood test to check the amount of substance called Beta HCG produced by your
pregnancy.
b) We will do an US scan to confirm the diagnosis and to find out the location and size of the
pregnancy.
c) pain killers for your pain.

3. Explain the ectopic pregnancy would not survive

4. Can be treated medically (methotrexate to terminate it) or with keyhole surgery

5. My husband brought me, can I go with him

Not safe, you’ll go with an ambulance, you may start bleeding at anytime and you may
collapse

I don't want to stay in the hospital doctor? D: May I know why?

1 do understand your concern, but it is important for you to stay in the hospital and Undergo all the
investigations. And if confirmed then you have to be put under observation.
I can come back for the tests tomorrow?
As I told you earlier, we need to observe you, in case of severe Complications- may rupture
and you may go into shock and collapse, which is a serious condition.
If this happens we need to treat you immediately- fluids through your BVs and take you to
operation theatre for emergency surgery to remove the ruptured pregnancy.

In the meanwhile if you get SOB, dizzy or if you develop severe pain or bleeding please inform us
immediately (if setting is hospital and not GP)

ECTOPIC PREGNANCY
FY2 in ER.
Woman, No PV bleed. Pregnancy at home showed she is pregnant. Knows she is 8 weeks
pregnant. No PV beed. The pregnancy was unplanned. She had IUCD removed a yr ago o/a of
infection. Has 2 chilrenn at home. Right sided tenderness on examination.
HX + EXAM

APPROACH- GRIPS
SOCRATES for pain
DDX- UTI, gastroenteritis, ectopic, appendicitis, PID, miscarriage

Risk factors- age, stress, meds, infection

MAFTOSA- Menstrual n sexual hx!!
EXAM- Your heart rate is on the higher side
I suspect u have a condition called ectopic pregnancy which means pregnancy outside he owmb

In the past, u had an STI and that could have contributed

We need to do some test- UPT, Pregnancy test, urine dipstick, routine, USG scan
Admit under obs and gynae
Unfort, this kind of pregnancy does not survive
Will either give u a med
Surgical tx—keyhole surgery

ANTENATAL EXAMS
FY2, OBS. Mrs. Sandra Wilkinson is a 26-year-old lady, para 2, who is 36 weeks pregnant. She has
been seen by the midwife who has found the fetus to be in breech presentation. Examine the
patient and discuss initial management with the patient.
PT INFO: You are Ms. Sandra Wilkinson, a 26 year old lady, P2 who is 36 weeks pregnant.
You have been seen by the midwife who has told you that your baby is in a breech presentation.
This is your third pregnancy. You have two other children aged two and five who were born via
normal vaginal delivery. You are 36 weeks pregnant. You can feel the kicks of the baby.
You are sitting right next to the antenatal manikin. If the candidate wants to take a history from
you just tell them that you are fine, you have come for routine follow-up. Do not give any history
to the candidate.

COMMENT: If the doctor says your baby is in a breeched Presentation says i did not know anything
about that.

QUESTIONS:
Is breech abnormal?
• It’s not. It s a variation, majority of babies are cephalic but a small percentage can be
breech.
• Is breech dangerous?
• What are you going to do for me?
• Will I have a normal vaginal delivery?
• Why did my baby become breech?
• If the doctor says you may have a caesarean section,
• Ask them why caesarean section?
• How is caesarean section done?
• Are there any complications?
 • Will you put me to sleep?
• Why not just vaginal delivery because everything was
• Fine in my previous two pregnancies?
• Will I have a scar if I go undergo a caesarian section?

APPROACH:
• GRIPS
• Paraphrase question:
One of the midwives examined you and I am here to examine you. Is that ok?
Did the midwife explain what she found when she examined you earlier?
Do you know anything about breech presentation?

History taking:
• How have you been so far, has everything been ok with your pregnancy?
• How many weeks?
• How many babies are you expecting?
• Are you feeling the kicks of the baby?
• Is this your first pregnancy?
• Any problems in previous pregnancies?
• Any bleeding?
• Preeclampsia: headache, visual problems, tummy pain, leg swelling, fam hx of
preeclampsia?
• Any high blood sugar or high blood pressure?
• Meds?
• Allergies?

EXAM:
Explain procedure
• Involves me looking at and touching your belly and baby’s position, taking some
measurements and listening to your baby’s heartbeat. Is that okay? Any pain?
• 4 the purpose of the exam, I will like to expose your belly, is that okay? (Expose
to just beneath the breast)
• Lie comfortably on your back
• Let pt empty bladder
• Get consent- R u ready to proceed?

Now after saying the above to the pt, go to the mannequin

Items needed
• Pinnard Steth
• Tape measure
General- Look at hands- capillary refill, peripheral edema, palmar erythema, feel pulse
Eyes- conjunctival pallor, jaundice, melasma, edema

ABD exam
Inspection
1. Discharge, Swelling
2. Fetal movements
3. Redness
4. Sinuses
5. Surgical Scars
6. Uniform enlargement of belly
7. Linea nigra
8. Striae gravidarum

Palpation
Superficial- Im now going to touch u lightly
• Temperature- warm hands, feel 9 quadrants with back of hands
• Do u feel any pain anywhere, if u do, pls let me know- Check Tenderness

Obstetric palpation= Now I will be going a bit deeper if u feel any discomfort do let me known okayr-
to check for the lie of the baby.

1) Lie- longitudinal, transverse or oblique

• Use both hands- one to stabilise then one to palpate
Inform pt palpation will be firm
• Use a snake movement when palpating
Change sides
• back= smooth
• limbs= irregular

2) Presentation-cephalic or breech
• Then feel for upper and lower pole
• Upper pole first- check consistency
• Use both hands together
• Head is hard
• buttocks= firm

3) Engagement- If fingers can go between head and pubic symphysis then its not engaged and
vice versa
Pawlik grip- only done if presentation is cephalic, if head is ballotable then head is not engaged
 4) SFH
• From pubic symphysis to fundus
• Measure with inches side facing upwards
• But read in cm
• Normal= gestational age. +/- 2

Small SFH= OligoH, IUGR, Wrong dates

Large SFH= Poly H, Large babies (DM), Twins

Auscultation- FH
• On the side where the back is
• Below the umbilicus - cephalic pres
• Above the umbilicus- breech
• When you listen- Turn face towards legs
Listen for 15secs, then multiple HR by 4

 Thank u for allowing me to examine u

 Cover up the mannequin
 I will explain my findings to u when u r ready

Explain the findings:

START WITH GOOD NEWS

o I can hear the foetal heart beat and the tape measurements were also
normal.
o There is only one thing I found; the baby is lying in breech position. Have u
ever heard about that?
o Breech presentation means that the baby is lying head up and buttocks
down.
o The majority of babies at this stage of pregnancy would lie with their head
down and buttocks up.

o Explain, if the baby comes out in this position, his limbs may come out first
which may make the baby get stuck, this may lead to the baby going into
distress, and can put baby’s life in danger

o It is not abnormal but it is also not ideal

MGT:
1. Offer External Cephalic Version.
  What we can do is to try to rotate the baby so that the baby can lie with the head
facing down and bottoms facing up.
 Usually done at 37 weeks.
 So we will wait until 37 weeks for the baby to rotate itself.
 This will be done by my senior colleague.

2. Are there any complications?

• Explain that there is a risk that the baby might become distressed during
the procedure.
• But we do monitor the baby during the procedure. If the baby is in
distress, the procedure can be stopped.

3. What is the cause?- It is really difficult to say. It is not known

4. We will try to deliver the baby at 37 weeks and if we are not able to do it, we
may need to do a Caesarean Section.

5. How is Caesarean Section done?

• It is an operation where we will numb your lower half and make a
cut just around your bikini line that will be 10 cm long to take out the baby.
Uterus is cut open, then after delivery of baby, uterus and skin are stitched
back in place

6. Is there a chance of me having a normal delivery?

• It can be tried but there is a high risk of baby getting stuck during
labor.

7. What can you tell me about C section?

• you will not be put to sleep.
• Anaesthetics will be inserted using a needle into your back to block the
nerves.
• You will not be in pain. Operation will last 45 mins to one hour.
• Incision just About 3cm above the bikini line and 10cm long.

8. Will it leave a scar?- Unfortunately the incision line will leave a thin scar.

9. What are the complications?

• During- bleeding, damage to surrounding tissue
 • After
a. Bleeding, Damage to surrounding structures
b. Infection - will give antibiotics to prevent that from happening
c. Pulmonary Embolism and DVT but will give him blood thinners.
d. Long hospital stay - affect bonding with baby.

10. Explain that you will talk to the consultant and get back to the patient.
• Therefore ff up is in 1 week
11. Offer leaflet about breech presentation.

NOTES:
1. Safe mode of delivery is Caesarean section in breech presentation.
2. External cephalic version is contraindicated due to preeclampsia.
3. Usually indicated at 36 weeks in primigravida and 37 weeks in a multipara.
4. The risk of ECV is cord prolapse/strangulation of baby
5. Oxytocin augmentation is not advised.

 If 38weeks, say we will confirm position on USG. Then deliver thru ECV or C/S

BREECH PRESENTATION FOLLOW UP

FY2, OBGYN. Emily Brown is a 30yo F who has come for routine antenatal follow up.
5 weeks ago when the midwife examined her, the baby was in breech presentation. She had come
back today for her follow up. She is 36 weeks pregnant. Examine the patient and discuss
management
PT INFO: You are Emily Brown, 30 year old lady, who has come in for a follow-up antenatal
appointment. Your last checkup was about 5 weeks ago and the midwife told you that your baby
was in breech position then. You have now come for your next routine checkup.
Everything is fine with your pregnancy. No bleeding, no blood pressure problems.
This is your 3rd pregnancy. If a doctor tells you the baby is in cephalic presentation (head facing
down), you are surprised as last time baby was in breech. The midwife did not explain that the
baby can turn on its own.
QUESTIONS:
⁃ Is there anything you are going to do?

APPROACH:
• GRIPS. Paraphrase the scenario:
 o I understand that you have come for routine antenatal follow up, how are you
doing?
o Last visit baby was breech
o Da4 questions

History taking: I just need to ask you some questions to see how your pregnancy has been going.
• How many weeks is your pregnancy?
• I understand that your last antenatal visit was 5 weeks ago?
• Was everything okay at your last antenatal follow up?
• How have you been since your last antenatal follow up?
• How many babies are you expecting?
• Any bleeding in this pregnancy?

Ask about pre-eclampsia symptoms.

• Any headaches?
• Any problems with your vision?
• Any swelling of the legs?
• Any tummy pains?
• Any swelling of your face?
Wellbeing of the baby.
• Are you feeling the kicks of the baby?

• PMHX, DHX, Allergy HX

N.B: If the patient says the midwife said my baby is in breech presentation, acknowledge the
information. I understand that sometimes babies can be breech presentation but I will examine you
today to see how your baby is doing.

EXAM: BP, Antenatal examination

Explain the findings:
The baby is now in cephalic presentation which means the baby is lying with the head facing down.
Explain that the baby may turn on its own which is what has happened in this case.

MGT:
1. How can u be so sure dr? We need to perform an ultrasound scan to confirm that the
baby’s head is lying down
2. Urine test
3. CTG

4. ADVICE:
• We will wait for normal delivery
• Just keep healthy
• Eat healthy food
• Mild exercise is good
 • Ask if she has decided the mode of delivery?
• Ask if she has been going for antenatal classes?- She can get information on what
to expect during labor and also to know any signs of labor.

5. Safety-net:
• Any headaches?
• Vision problems?
• Any tummy pains she should come and see the GP.
Leaflets

GYNAE

SPECULUM EXAMINATION

You are an FY2 in Obstetrics and Gynaecology department. Racheal Parkinson is a 40-year-old lady
who has come for the routine cervical smear. Take a brief history, and perform cervical smear and
address any concerns.

Patient Information:

- ● You are a 40-year-old who has come for routine cervical smear screen
- ● Your last smear was 5/10 years ago and at that time the procedure was painful and
- uncomfortable
- ● You are normally fit and well and not on regular medication
- ● You do not smoke but you drink alcohol occasionally
- ● You have 2 children: ages 5 and 7 years
- ● Who are both healthy

Questions:

● How long will it take for the results to come back?

Approach: GRIPS:

I understand u r here for your routine cervical smear?

This will involve me asking you some questions and performing the procedure.

● Take history:
 - When was your Last smear?
- How was the last smear?

- Should have been every 3 years, any particular reasons she did not come on time?
- It must have been very distressing for you not to have come for your next appointment
- I am sorry about what happened the last time, I will try to be as gentle as possible.
- If you feel any discomfort this time please let me know.

● History:

- Any children?
- Did you use contraception in the past?
- Do you smoke?
- Any STI in the past?
- Menstrual history:
- LMP?
- Regular?
- Heavy?
- Any intermenstrual bleeds?
- Any family history of any type of cancer like cervical or breast cancer?
- Past medical history, drug history and allergy history?

● Rule out the contradictions:

- Is there any chance you could be pregnant? (Pregnancy)

- Perform a urine pregnancy test?
- When was your LMP? (Menstruation)
- Last sexual intercourse? Intercourse in the last 48hrs is a contraindication
- Any PV bleeding at the moment?

● Set up:

- ● Patient sitting on a chair

- ● PV manikin
- ● Sure path or thin prep
- ● There is a lamp with a stand, the lamp has a power button in the middle.

I would like to perform a procedure known as a cervical smear. Is that okay? This will involve me
inserting a tube shaped speculum, that will aloow me take a sample from ur cervix. A brush will be
inserted and be rotated a few times and the sample will then be taken to the lab for analysis. Is that
okay?

Pre - Procedure:

- Empty the bladder (To urinate)

 - Undress below the waist
- Lie on the back with knees and thighs bent, ankles together and knees apart
- Ask for a chaperone- I would need a chaperone for this privacy
- Maintain privacy

● Procedure:

- Trolley (gloves, speculum, gel, light source, thin prep, sure path)
- Inspection
- Apply gel
- Part labia
- Insert slow and then turn the speculum down
- Take smear

● Smear Technique

- Take cervical brush

- Insert it into the cervical OS
- Rotate 5X clockwise- 360 degrees
- Rinse in thin prep or break brush in sure path
- Turn sideways the speculum and then remove it in that way
- Look for any blood on the speculum
- Allow the patient to dress up

● Post – Procedure- Explain the results only if results r given. U can expect your results to be sent by
post in about 2 weeks time

● NOTE:

- Negative smear - repeat every 3 years if Between the ages of 24.5-49 years
- Once u reach the age of 50, it is every 5yrs
- Inadequate: repeat within 3 months
- Borderline changes - colposcopy
- Mild, moderate, or severe dyskaryosis- Colposcopy

TEACHING SPECULUM EXAM

FY2, OBGYN. You have a medical student who wants to learn how to perform a speculum exam.
Teach him how to do it. Don’t ask him to perform the procedure

APPROACH:
• GRIPS
• Build rapport
 • Explain the procedure- same as above but there is no need to explain sample
collection part)

INDICATIONS
 Done to assess the cause of PV bleed or discharge- polyps, cervical erosions, infections
 Also required to take cervical smear and also cervical swabs

PROCEDURE- Let him see the procedure from where the light is shining

• Inspect the vulva- sinus, scars, discharge, swelling

• Inserting the speculum
• Taking sample where necessary
• Removing the speculum
• Inspecting speculum after removal

Explian your findings and what will happen next

The teaching exam is not to do cervical smear exam. It is merely to teach speculum
exam!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

PERIMENOPAUSE- MOOD SWINGS IN A 49YO

FY2, Came cuz she is irritable, been happening for 3-4 months. LMP= 8 months ago, noticed she is
arguing a lot with husband. Mood low= 4/10, does not now hobbies like before, sleep= poor,
appetite poor. Mood swings also. Been avoiding sex cuz she finds it painful and uncomfortable.

MENOPAUSE
Same scenario but LMP- 14months back

APPROACH:
 Menopause symptoms- After u ask LMP and she says it is late for months-
 hot flushes
 night sweats
 excessive palpitations/anxiety
 joint pain, muscle ache
  Recurrent UTIs
 Sleep disturbance
 Sexual hx- vaginal dryness, dyspareunia, loss of libido

 Effects on mood- loss of interest in everyday activities? feelings of

emptiness or worthlessness?

 Assess symptoms and severity

 Husband thinks she is irritable but ask what she herself thinks
 HX OF HYSTERECTOMY

 Assess cardiovascular risk- HTN, DM, smoking, FMHX who have early menopause
 Menstrual history, Sexual
 ICE- Expectations, Want tx for symptoms?
 JARSS

DX: Explain perimenopause/menopause- You are in perimenopause. You are approaching your
menopause and this means your period may stop forever. This is a natural process.

MGT:
1. Routine labs, FSH (to check if it’s high)

2. TX
a. Hormonal (HRT) if she has vasomotor symptoms
 Oral or transdermal combined HRT if no hx of hysterectomy
 Women w/o uterus- Only oral/transdermal estrogen HRT

b. Pharmacological non hormonal tx (if she does not want HRT)-

 Antidepressants- fluoxetine/Citalopram for anxiety/depression
 Vaginal dryness- Lubricants or topical estrogen creams
 Non-pharmacological tx- CBT, Relaxation

3. Lifestyle advise to reduce menopausal symptoms:

⁃ Regular exercise,
⁃ Weight loss,
⁃ Hot flushes, sweating= light clothing, weight loss, exercise
⁃ Stress reduction
⁃ Sleep disturbances= good sleep hygiene
⁃ Mood and stress- relaxation exercises, good sleep
⁃ Cognitive- exercise, good sleep hygiene, CBT
Advise on bone health, osteoporosis

4. To keep up to date with recommended health screening-

⁃ Yearly breast screening (from age 50 in the UK)
⁃ Cervical screening- 3 yearly until 49, then very 5 years

5. Refer to experts in menopause if all treatment does not improve

6. Review in 3 months, Leaflets

7. Safety-net- if symptoms are troublesome come back

PREMATUE OVARIAN FAILURE

I understand u have been referred by the GP and u had some tests done
But before, let me ask a few quest

Sympt of ovarian insuff- hot flush, niht sweat

Mood disturbance, sleep disturbance, irritability, anxiety
Sexual hx
Contraception
Prolactinoma-Headches, visual problems, galactorrhea
Fam Hx
Menstrual hx in full detail
Also ask menstrual hx of mothers and sisters their menarche and menopause
Cardiovasc risk factors
Bone weaknesses
Depression symptoms
MAFTOSA- Positive fam hx
Lifestyle

EXAM-
Observation, BMI
ABD exam, GPE for hirsutism and acne, Thyroid exam

 Results show that FSH and LH are very high and estrogen is low
 Unfortunately this suggests u have a condition called premature ovarian insuff,
means ovarian failure
 Your ovaries have failed earlier than they should have, as u told me your mother had
POF.Unfort, this puts u at risk of developing POF
TX-
1. HRT
2. Avoid stress
3. Relaxation therapy
4. Leaflets on condition

Will she be able to have pregnancy?- Unfort u will not be able to have children on your own
as your ovaries have failed and r not able to produce eggs. The only way to be able to get
pregnanct is by using donor eggs

NO referral needed.
Can follow up

STI SCENARIOS
1. Sexual history
• Are you sexually active?
• Is your partner male or female?
• Do you practice safe sex? By this I mean, do you use condoms?
• What kind of sex do you practice? Oral, anal or vaginal?
• Do you have a stable relationship (I.e regular sexual partner)
• How often do you have sex?
• How many partners have you had in the last 6months
• Do they have any symptoms?

2. Symptoms of STI
• Any burning/pain when passing urine?
• Any discharge from your penis/vagina
• Do you have a temperature?
• Do you have any ulcers in your genital area?
• Do you have any swelling on any parts of the body?

3. Risk factors for blood borne infections

• Have you been tested for any STDs such as HIV/ Hepatitis
• Have you had any blood transfusions in the past
• Any surgeries?
• Any tattoos or piercings?
• Have you travelled recently? unprotected sexual intercourse while abroad?

Finish MAFTOSA
4. EXAM: observations, ABD, genital inspection- PV (female), testicular (male)

5. Investigations
• Swabs (endocervical/vaginal= F, urethral= M)
• Urinalysis

6. MGT:
• Usually, refer to GUM clinic, if pt refuses, you can manage in the GP
• Avoid sexual intercourse during treatment
• Leaflets- STIs, safe sex
• Offer screening for other STIs- HBV, HIV, syphillis
• Encourage them to notify the partner and ask the partner to come for testing and
treatment.
• Follow up in 1 week to have a ‘test of cure’.

GONORRHOEA
FY2, in the GUM Clinic. A 24yo F came to the GUM clinic 1 week ago to be tested for an STI. The
results are back from the laboratory and shows that the patient is positive for gonorrhea infection.
Take a sexual history and discuss management with the patient.
PT INFO: You are a 24-year-old lady who came for STI testing 1 week ago.
SCENARIO 1: She saw a TV advert about STIs. She is in a new sexual relationship for 3 weeks, 2 or 3
sexual partner in the last 6 months. She is married
SCENARIO 2: She had symptoms (PV discharge, LAP) New partner in the last 3 weeks. She was in a
relationship for 5 years before and broke up 1 year ago. She is not married now
SCENARIO 3: Was reading a newspaper and read about STI infections
SCENARIO 4: You are reading on the internet about STI and you decided to come for a check up.
Your partner does not have any symptoms.

APPROACH:
• Paraphrase the scenario:
You came to the hospital to be tested for STI 1 week ago. Has anyone explained
the results to you?
Can I ask some questions to see if there is anything I need to better manage you?
Some of the questions may be personal but if you find it too much, please let me
know and we can stop.

a) What made you come to the clinic to get tested for STI?
b) Have you ever been diagnosed with STI before?
 c) Are you experiencing any symptoms like discharge, tummy pain, fever?
d) Bleeding or vaginal discharge, burning while passing urine,
redness/hotness/swelling around your private parts
e) Are you in a stable relationship?
f) How long have you been with your current partner?
g) Do you practice safe sex i.e. use condoms?
h) Is your partner experiencing any symptoms?

i) Are you using any form of contraception?

j) How long ago was your previous relationship?
k) Have you ever had sexual intercourse for casual purposes?
l) Other than your current partner do you have any other sexual partners?

DX: GONORRHOEA- Break bad news:

Unfortunately the results include bad news as the test shows that you have a STI called
Gonorrhoea
Reassure that Gonorrhoea is a curable condition. There are some antibiotics that can be
given.

MGT:
1. What medications will you give me?
• A single dose (Ceftriaxone 500mg IM in 1 dose and Azithromycin
1g orally in 1 dose)
• We also need to treat your sexual partners

2. Did I get it from my partner?

 Unfortunately, it is a STI, which means you could have gotten it from your
partner.
 But you have had more than one partner in the past. So it could be from any
of your partners in the past 6 months.
 This bug can live in our body for a very long time without showing any
symptoms so we need to treat all sexual partners in the last six months.
 Is it ok if you can give us the contact details of you previous partners so that
we can contact them, invite them for testing and treatment. We will not
reveal that we got the details from you.
Refer to GUM clinic if there is need for contact tracing.-Change of partners in the last 6
months.

3. Are there any complications? How common are these complications?

 Infertility: (there is a solution)
  Ectopic pregnancy: if you notice any tummy pains or miss a period, come
back to the hospital
 Dysmenorrhea: analgesia
 Dyspareunia
 Chronic infection (PID): that can flare up from time to time and present with
PV discharge and lower abdominal pain, fever then you need to go to the
hospital.
But with treatment all complications can be avoided.

4. No sexual intercourse when on treatment.

5. Advise to use barrier methods
6. Follow up in 1 week for repeat swab to make sure that the infection has
cleared.
Avoid having sex until we have repeated the tests and show that you do not have the
infection.

7. Safety-net: LAP, fever, vaginal discharge

8. Advice to get tested for other STIs like HIV and Hepatitis.

10. Prevention: Explain that STI can be prevented by using condoms.

PELVIC INFLAMMATORY DISEASE

FY2, ED, 30yo F, p/c- right LAP. Take a focused history, perform relevant examination and discuss
management with the patient.
PT INFO: You are Ms Nicola Addison a 30-year-old lady who presented with right sided lower
tummy pain for 3 days. It’s 8/10 severity. You felt sick but you did not vomit. You have also noticed
foul, smelly, greenish vaginal discharge for the past 5 days. You are sexually active and you use
IUCD. You are in a new relationship 3 weeks ago. You have had 3 partners in the last 6 months.
Your partner has no symptoms. Your IUCD was inserted 1 year ago. You are normally fit and well,
not on any medication. LMP 4 weeks ago. You feel hot generally, but you did not check the
temperature. You have never been diagnosed with any sexually transmitted infection before.

Observations: T-38ºC, P- 98, BP - 110/70, RR - 14, SPO2- 98%

PV: cervical excitation is positive and greenish discharge on the gloves.
ABD: RIF tenderness, no rebound or guarding and no adnexal masses.

APPROACH:
Empathy - Are you comfortable? Do you need any pain killers?
SOCRATES
Any PV bleeding or discharge?(If any discharge, then is there any colour or smell?)
DDX:
1. endometritis
2. ectopic pregnancy
3. ovarian cyst
4. appendicitis
5. PID
6. miscarriage
7. UTI
8. pyelonephritis
9. renal stones
P3MAFTOSA (Personal - Sexual and Menstrual)
How to check the IUCD/When was it inserted?
Do you know how to check if the IUCD is on place? And when was the last time she got
checked?

EXAM: Observations, ABD, PV, UPT

• You need to rule out pregnancy: No contraception is 100% safe

DX: Pelvic Inflammatory Disease- This is an infection of the womb, tubes, and the ovaries. It is
usually caused by STIs. The common infections are chlamydia and gonorrhoea infections. IUD\CD is
also a risk factor.

MGT:
1. Admission under GYN
2. Blood test:
• FBC, RFT, LFTs, Inflammatory markers - to see how severe the infection is?
• Blood cultures: To look for any infection in the blood.
• Take swabs: Take some swab
• USG: to assess that there is no collection of pus anywhere in the tubes or
anywhere in the body and also to check that the IUCD is in place.

3. IV antibiotics
4. Gynaecologist- sometimes they might remove an IUCD after 3 days if there is no
improvement of the infection.

5. Where did I get the infection from?

• It is a STI which means you got it from one of your partners.
• You mentioned that you have been in a new sexual relationship in the last 3 weeks
and also you had other partners in the last 6 months
• So it could be from your current partner or previous partners unfortunately.

6. Can it be cured?
 • Yes, it is a curable condition. There are antibiotics which we can give you and they
can cure the infection.

7. Are there any complications?

Unfortunately, there are some complications that may occur
 Infertility - difficulty getting pregnant
 Ectopic pregnancy - when you get pregnant, the pregnancy could be outside your womb
Solution: So if you miss your periods and you develop any sort of abdominal pain, you need to
seek medical help. But if that were to happen, there is a solution to that as well.
 Dysmenorrhoea: Which is painful periods. But you can always take painkillers if that happens
 Dyspareunia: This is pain during intercourse- lubes and gels

8. Advise to bring partners to get screened for STI in order to treat this infection effectively.
• We will need to treat your partner as well
• Are you comfortable to discuss this with your partner?

9. Offer leaflets to the patient.

QUESTIONS/CONCERNS: Will I be able to get pregnant?

CHRONIC PID
FY2, surgical department, 22yo, had C-section 5 years ago, depression 3 years ago, on sertraline.
Take a focused hx, assess pt, discuss management.
PT INFO: intermittent abdominal pain for 3 months. Crampy lower abd pain accompanied by foul
smelling vaginal discharge. Had c-section 5 years ago. Is on the mini-pill. Changed your partner x
ago

HX+EXAM STATION

 SOCRATES
 Discharge- When? Color? Smell? Blood? How much was the discharge?
 Fever? Feeling sick?
 Pain or burning when passing urine
 Sexul hx, Contraception, Menstrual
 ICE, JARSS

EXAM:
 Observations- T= 39,
 ABD= mild RIF/LIF tenderness,
 PV- she will refuse it/can it be done another time?- IF she ASKs WHY? Vaginal swab is to
be done in order to be sure of the dx

 DX: PID (647)- inflammation of the womb, tubes and ovaries. Usually the inflammation is
caused by infection which is usually an STI
MGT:
Routine labs, ESR, Urine dipstick, UPT, vaginal swab (will refuse) she’ll say she is not
comfortable. So go ahead and give treatment

 REFER TO GUM CLINIC- IMMEDIATE- WITHIN 24 HRS, where they will give u a cocktail of
antibiotics and will screen u for STIs

 Medications
o 1 injection- ceftriaxone
o 2 oral antibiotics for 2 weeks- metronidazole and doxycycline

 Paracetamol- pain
 Needs to tell partner for testing and treatment
 Avoid sexual contact until completing ATBx

 Swab after treatment

 . Use condoms after to prevent further tx. If u do not get tx, ectopic,
dyspareunia,…
 Safety-net
 Leaflets

STI
FY2, GP, 26yo F, has come for follow up, she came to the GP 2 weeks ago with dysuria, Urine
dipstick= leu= high, nitrites= neg. She was prescribed trimethoprim for 1 week. 1 week ago, she
came to the practice again with dysuria and this time she was prescribed nitrofurantoin. Urine
dipstick= leu= high, nitrites neg. She is here today for follow up.
PT INFO: still has dysuria, come twice, been prescribed 2 different ATBx, still symptomatic, married
for the past 6 months, uses injectable contraception, only had sex with her husband. Normally fit
and well, no other symptoms.

Why am I still having burning discharge on passing urine?

APPROACH:
DDX:
• UTI
• Recent onset sexual intercourse
• STI

EXAM: Observations, ABD, PV, urine dipstick

DX: We have treated you for UTI with no success which means it is unlikely be a UTI, so we need to
check that the cause of your symptoms is not an STI. We thought it was a urine infection that’s why
u we treated with Abx. However, since u are still having persistent abdominal pain and u mentioned
u do not practice safe sex, it is most probably STI

MGT:
1. Refer to GUM clinic for STI testing and contact tracing and treatment of husband
as well
2. Follow up in 1 week
3. Safety-net: high fever, abdominal pain, discharge

Is my husband cheating on me-

• I’m sorry I gave u this impression, but this is something I would advise u discuss with him

GONORRHEA- CONTACT TRACING

FY2, GP, 35yo M, been on ATBx for gonorrhoea since yesterday has come to see you. The nurses
have talked to him about contact tracing but he declined. Talk to the pt and convince him about
contact tracing.
PT INFO: came yesterday cuz of penile discharge, started 2 weeks ago when he was on holiday in
Greece. Started 2 days after having unprotected sexual intercourse in Greece with a prostitute.
Back in the UK, he had unprotected sexual intercourse with his wife, and after that, the discharge
became worse and painful. Businessman, travels a lot. When you mention contract tracing, he will
say- I was drunk, there is no way I can remember the prostitutes’s name. He doesn’t wanna inform
his wife cuz he has been faithful to her- I made a mistake, I was drunk. If you ask questions about
his general health, he will say- what did you wanna discuss with me doctor?

APPROACH: Paraphrase
 I understand you have been diagnosed with an STI and you are being treated with ATBx?
 I was told you had a discussion with the nurse about the need of informing your partner
about the infection, is that true?
 I understand you are not quite happy with that? Is there any particular reason why?
 Can we please go through everything so we are on the same page?

What have u been told so far about your symptom?

Why did u do this test?
What have u been experiencing?
Since when?
Any discharge? Burning sensation when passing urine?
Do u have to go to the loo to pass urine more freq than usual?
Do have any idea how u got gonorrhea
 R u generally fit and well

Sexual hx
 R u sexually active?
 Stable relationship? Married?
 What kind of sexual intercourse do u practice?
 Have u travelled abroad recently? Where? Any chance u had sexual intercourse there? Did u
use a condom? Wahht kind of sex?
 Did u have sex wih ur wife after u returned?
 Have u ever had sex for casual purposes?

DX-
 U have an STI called Gonorrhea
 It is usually transmitted via sexual intercourse
 And it is HIGHLY likely that you transmitted the infection to your wife.
 Do u know if your wife is experiencing any symptoms?
 In order for us to treat you effectively we will need to treat your wife as well.
 Can you inform your wife that you have been diagnosed with gonorrhoea?

MGT:
1. If you are uncomfortable discussing with your partner, we can use the partner notification
program where we will send her a letter informing her to be tested and treated but we will
not reveal that you gave us the details.

2. Unfortunately when she comes and she is diagnosed, she may still bring the conversation
to you, so informing her yourself before she finds out might be better.
Would you like to think about it?

3. If you discuss with your partner, she will come quickly and start treatment
4. If you don’t inform her, she may pass the infection back to you even if you have been
treated.

5. Its important that your partner gets treatment cuz as in women, delay in tx would lead to
complications, e.g PID (inflammation of the womb, ovaries and tubes), which then
leads to complications such as infertility, ectopic pregnancy- that is if she gets
pregnant, pregnancy could be outside the womb, but with quick treatment, all these
complications can be avoided.

6. If your wife dies from the infection, you could be charged with an offense
7. Refer to GUM clinic for proper follow up and treatment- General STI management advise
8. Avoid sex during treatment
9. Leaflets about STI
 SYPHILIS
FY2, GP, 28 yo M, come for follow up, last week, he came to the well-man clinic for STI testing.
Labs= TPHA+VE, all others= -ve. Talk to pt, explain results, address concerns.
PT INFO: 18yo, gay, 2 weeks ago, he had unprotected sexual intercourse. (Oral and anal), all with
male partners. He did not know the people, he met them at the party. He lives alone.

QUESTIONS/CONCERNS:
⁃ Are you sure it’s syphilis?
⁃ Is it dangerous?
⁃ Is it curable?

PC: I have a small ulcer on my penis.

Explore the ulcer question of lesion or ulcer:

How long it's been there?
1. location
2. Shape
3. Size
4. Color
5. Discharge
6. Painful
7. Itchy

 any other skin lesions in the body?

 any fever or flu like illness recently?
 Any lumps or bumps in the body? Do they hurt? ( CANCER )
 Any weight loss? loss of appetite?
 Any tiredness? ( HIV )

 Any headache? Any joint pain? ( Neuro syphilis )

 any weakness in any part of the body? (Neuro/meningosyphilis)?
 Any rash on the palms or soles? anywhere else in the body?(Generalized syphilis)

 Any white patches in the mouth? ( Immunocompromised)

 Any long-term exposure under the sun or skin tanning sessions?

 Have you been exposed to someone having similar skin lesions?
 Did you have similar health condition in the past?
 PMHx

DX: Syphilis- ulcer, discharge, lymphadenopathy, fever. Tests suggest he may have syphilis but
there could be other causes
MGT:
1. Refer to GUM clinic
2. Treatable- Single dose Benzylpenicillin
3. Avoid sexual intercourse and if he infects anyone, he can face prosecution.

4. Complications- can affect blood vessels, heart, brain.

EXTRA INFO
Testing for syphilis in primary care
 If serology= negative, repeat at 6 and 12 weeks calculated from the time of sexual contact.
 If the test at 6 and 12 weeks is negative, refer to GUM clinic.
 If test results are +ve at any point, refer to GUM specialist for interpretation of results and
mgt (this station)

 You should avoid any kind of sexual activity or close sexual contact with another person until
at least 2 weeks after your treatment finishes.
 It is very important to complete the treatment by bringing in your partners and treating
them as well if they have got the infection.
 If you are not able to bring your partners, we can contact them through partner notification
program.
 We usually offer HIV test to those who have any kind of STIs.
 Do you wish to have one

CAN I HAVE IT AGAIN ?

 You can catch syphilis more than once, even if you have been treated for it before.

How can I prevent syphilis?

 practicing safe sex:use a male condom or female condom during vaginal, oral and anal sex
 avoid sharing sex toys – if you do share them, wash them and cover them with a condom
before each use
 If you inject yourself with drugs, do not use other people's needles or share your needles
with others.

SYPHILIS IN PREGNANCY
 Pregnant women with syphilis can pass the infection to their unborn baby.
 If a woman becomes infected while she's pregnant, or becomes pregnant when she already
has syphilis, it can be very dangerous for her baby if not treated.
 Infection in pregnancy can cause miscarriage, stillbirth or a serious infection in the baby
(congenital syphilis).
 Screening for syphilis during pregnancy is offered to all pregnant women so the infection can
be detected and treated before it causes any serious problems.
If negative, repeat at 6 and 12 weeks from sexual contact. If these r negative, refer to GUM clinic

PENILE ULCER- SYPHILIS

FY2, GP, 24yo M, made an appointment to see you, talk to pt, address concerns.
PT INFO: noticed a penile ulcer 4 days ago, painless, sexually active, he has had 2 sexual partners
in the past 2 months, normally fit and well, doesn’t smoke/drink.

APPROACH: GRIPS
• Hx of ulcer
• STI symptoms- discharge, fever, abdominal pain, itching, urinary sympt
• Sexual hx, PMAFTOSA, ICE, JARSS

EXAM: Observations, genital, LN

DX: Syphilis- This is an STI

MGT:
1. Refer to GUM within 24hrs
• ask questions, exam, swabs, will offer to screen for other STIs- hepatitis, HIV, gono,
chlamydia
• Will offer TX- usually procaine penicillin

2. Advise not to have sex until after tx

• Use condoms in the future
• Not to have sex while drinking alcohol
• Testing, treatment and tracing is important cos it can lead to complications
• If he’s found to be spreading through unprotected sexual intercourse, he would be
prosecuted
• Advise your partners esp within the past 6 months so they can get themselves tested

4. Leaflets
5. FF up with GP in 1 week

VAGINAL CANDIDIASIS
FY2, GP, 35yo lady has made an appointment to see you. Take hx, address concerns.
PT INFO: White vaginal discharge for the last 2 weeks, itchy vagina, sexually active, stable
relationship, practices safe sex, never had a cervical smear, worried it could be cancer
 LMP= 6 wks, partner doesn’t have symptoms, she symptoms started 2 weeks ago, she though it
would go away, but they persisted. PV= clear white discharge on gloves. observations= normal,
ABD= normal

APPROACH: GRIPS
• Hx of discharge- how long, color, smell, quantity, smell, bleeding, discharge,
ulcer alongside, consistency?

CONTRIBUTING FACTORS
• Recent partners
• Vaginal douches
• Bubble bath
• IUCD
• Shampoo in the bath

DDX:
• Chlamydia
• Candidiasis
• B. VAGINOSIS
• T. Vaginalis
• Gonorrhea

• P3MAFTOSA- Ask DM, Steroids, Past hx of cancer

• Sexual, menstrual, ICE, JARSS

EXAM: observations, ABD, PV, UPT, Urine dipstick

DX: Vaginal candidiasis- Condition from hx and exam

1. MGT:
2. Clotrimazole 10% cream/tab- insert 5g PV single dose nocte

• Avoid tight fitting clothes

• avoid using scented soaps in vagina
• avoid bubble baths
• avoid excessive washing

3. Leaflets
4. Follow up in 1-2 weeks if symptoms persist

 This is not an STI

 Not due to poor hygiene
Is it cervical cancer? Ask why?
 Unlikely to be cervical cancer cos no bleeding, no weight loss, but I would advise u go for
regular PAP smear to prevent cervical cancer

BACTERIAL VAGINOSIS
FY2, GP, 30yo F has made an appointment t to see you. She had tests done last week, cervical
smear normal, gardenalla +ve, chlamydia, gonorrhea= neg. Explain results, take hx, manage
PT INFO: Greenish copious discharge, 2 months, fishy smelly vagina, underwear staining, avoiding
sexual intercourse with husband due to embarrassment. Has IUCD, has to frequently change her
underwear due to discharge. In the least 2 months, m she has changed soap to foam bubble soap.

APPROACH: I have your results but can I ask a few questions before we discuss them

Da4 questions- Delve into the syptoms

Exclude risk factors
Sexual, menstrual hx
MAFTOSA- Meds
ICE, JARSS

GRIPS, Hx of vaginal discharge

 From how long?
 Does it has a smell? fishy odor.
 color? greenish white in color.
 its amount? copious
 Any other symptoms at all with discharge?

DDX:
• Candida
• Trichomonas vaginalis
• Bacteria vaginosis
• Chlamydia

 Any fever? Any tummy pains? (PID)

 Any weight loss or lumps in bumps in body (Malignancy)?
 Any bleeding through vagina?
 By any chance are you pregnant?
 Is it the first time its happening to you?
 Do you have any idea why are you having this discharge? started using bubble bath. Can it
be the cause?
Yes ,bubble bath can lead to this infection unfortunately.
Contributing factors
• Recent partner
• Bubble baths, Shampoo in the bath
• Vaginal douching
• IUCD

Sexual hx, P3MAFTOSA, ICE, JARSS

EXAM: Obs, ABD, PV

DX: Bacterial Vaginosis-Overgrowth of normal bacteria in the vagina, causing fishy smell in
vagina

MGT:
1. Avoid contributing factors including antiseptics
2. Metronidazole 400mg BD X 7/7
3. If she prefers topical tx, then prescribe intravaginal metro once a day for 5 days
4. If symtoms do not improve, u need to come back so we prescribe other meds like
intravaginal clindamycin gel. If it does not help, we will refer u to a gynae specialist
5. Stop exposure to contributing factors like bubble baths, soap u r using to wash ur
private parts
6. Leaflets

One more thing which is concerning me is IUCD.so for that, we will refer you to gynecologist so that
we can make sure that everything is fine with you. How does that sound?

Did I get the infection from my husband?

 No it is not STI. You did not get it from husband

Side effects of metronidazole-

 Nausea, vomiting, change in taste of mouth headaches
 Can also interact with alcohol so avoid alcohol while taking it

HIV SCENARIOS

HIV (BBN)
FY2, GUM clinic, 30yo M, has been referred to GUM by GP, presented then with lymphadenopathy
and had labs done. Routine labs= normal, HIV 1 & 2 +ve, chlamydia and gonorrhoea= neg.
Talk to pt, discuss results, address concerns.
 PT INFO: Travelled to Thailand 1 month ago with friends, noticed swelling in armpits and inguinal
region for past 2 weeks, flu-like illness for the past 1 month. Had unprotected sex with a prostitute
in Thailand. Married for 3 years, no children. Has had unprotected sexual intercourse with his wife
several times since coming back from Thailand. He works as an IT specialist, willing to bring wife
for testing
SCENARIO 2: not willing cuz he feels it will break his marriage.

APPROACH: GRIPS
• Ive ben asked to come talk to you about your results, I understand you come
last week to do some tests.
• Do you know what they were looking for?/Specific investigations
• Tests been explained to you? – No

• Is there anything that made you get tested? (Symptoms u had)

• Is there anything you are concerned or worried about regarding the results?
OR what do you think the results would show?
• Are you happy for me to explain the results to you?

(NEVER ASK IS THERE SOMEONE U WOULD WANT TO BE WITH U!!!!!!!!!!!!!!!!!!!!!!!!!!!!)

• Explain results- Normal first

You also had testing for some STIs. The chlamydia and gonorrhoea tests came back normal.
Unfortunately, the results do include bad news.
• The HIV tests came back positive suggesting that you have got an HIV infection.
• I can see you did not expect this. I can’t imagine how you may be feeling, but I am
sorry for what has happened.

R u okay? Can I continue?

• Can we do the test again?- We can repeat the test but usually these results have
unfortunately been confirmed
• Are you sure I have HIV?- Unfortunately the tests have confirmed you do have HIV

• How did I get HIV?- Actually I wanna ask you some questions about your sexual life
so see if we can find out how you possible acquired HIV
 Sexual hx, Alcohol, smoking
 Prodromal symptoms of HIV- flu-like illness, Lumps or bumps

MGT:
1. Possible you got it when you had unprotected sex in Thailand
2. Reassure
 • There is treatment for HIV
• The infection can be controlled but it cannot be cured.

3. Start on HIV medications

4. Advise he informs his wife with to get tested

5. He will need to inform his partners or anyone that he will have sex with that he has
HIV infection. This is a legal requirement.
a) If you have unprotected sex with anyone without informing them you have HIV, and
he transmits it, he can face criminal charges of reckless endangerment.

b) In the event that he doesn’t wanna tell his wife- We as doctors have a professional
and legal obligation to protect your wife and we are allowed by law to discuss the
information to your wife if you do not inform her.
c) This is not something that we want to do. I think it will be better if you discuss with
your wife yourself

d) If for any reason, confidentiality is breached, he will be informed that it has been
breached and the reason for the breech.

e) Acknowledge that the situation is difficult- We understand that this may be a difficult
situation for anyone, you might need to take time, gather yourself and discuss this
with your partner

6. How did I get this?

Sharing needles, sex, blood transfusion, needle stick injuries, equipment used in operations

7. How will this affect my life?

• If your job has a high risk of transmitting HIV to others, he will need to inform his
employers.
• You need to inform your insurance- can affect his insurance if he has it/his ability to
get insurance if he doesn’t have it.
• You can’t get mortgage

8. Follow up in 3 days
• To see if he has told his wife
• To discuss any issues

If u do not tell your wife, as doctors we are not allowed to disclose the info to your wife. But
it will be best if u discuss it with your wife
Can u tell my wife?
It is not sth we routinely do

**PARTNER NOTIFICATION SYSTEM DOES NOT APPLY TO HIV.

HIV- DIAGNOSED, WITH FURTHER QUESTIONS TO ASK

FY2, GP, 25yo M, made an appointment to see you. Was diagnosed with HIV 1 week ago, and was
referred to the GUM clinic. He is due to go there next week.
PT INFO: Last week , he came to the GP to be tested for HIV, because he had casual sex when
visiting 3 weeks ago. He had lumps, swelling in the groin, unprotected sex with a male partner,
married, on return had unprotected sex many times with his wife. Tech bro, sacred to tell his wife
he has been diagnosed with HIV. Married for 3 years
APPROACH:
• GRIPS
• Paraphrase
• Sexual hx

Should I inform my wife? Any chance I have transmitted it to her

• Unfortunately, because you have had unprotected sex with her several times, there
is a possibility you might have transmitted it to her.
• I would advise that you inform her cuz knowing early about HIV status, she can start
treatment earlier

Can you help me tell my wife?

• I would suggest that you have the discussion with your wife yourself telling her that
you have been found to have HIV infection so you may be able to discuss other
issues that are related to HIV infection.
• There is a legal obligation to inform any partner he is having sex with that he is HIV
positive

Can I have children with HIV?- Yes you can? There are measures that can be taken to
prevent the baby getting it from the mother

Will anyone be informed?

• This information would be kept confidential, but if for any reason any info would be
needed to be given to any regular authority, you would be informed and given the
reason for doing so.
Can we repeat the tests?- Yes we can so you do not have any doubts

How did I get it?

• It is an STI (so oral, anal or vaginal sex) and also a blood borne infection (blood
transfusions, instruments in operations, instruments used to make tattoos)

What is HIV?
• It stands for ——
• It damages the cells in the immune system and weakens your ability to fight
everyday infections

• AIDS stands for——

• This is the name used to describe a state of very low immune system
• This state develops after HIV has destroyed the immune cells
• You do not have AIDS now, and with treatment, people can live long without
having AIDS

Life implications
• If your job has a high risk of transmitting HIV to others, he will need to inform his
employers.
• You need to inform your insurance- can affect his insurance if he has it/his ability to
get insurance if he doesn’t have it.
• You can’t get mortgage

• Leaflets- available support for ppl with

SUSPECTED HIV
FY2, GP, 30yo M, follow up, visited the GP 2 weeks ago, take a focused thx, assess the pt, discuss
mgt.
PT INFO: initially visited the GP with flu-like illness. He was reassured and asked to come for follow
up today to ensure everything is okay. He has developed groin swelling. He is married. He went to
Thailand 4 weeks ago, unprotected sex with male prostitute, on return, unprotected sex with wife.

APPROACH:
• GRIPS
• Paraphrase
DDX:
• Infectious mono- rash, joint pain, fever, swelling
• Sexual hx
• MAFTOSA
EXAM: Observations, LN (generalised lymphadenopathy +), CVS/RESP, ENT

DX: Suspected STI- possible HIV- cuz of flu-like symptoms

MGT:
1. Refer to GUM clinic for screening
2. Follow up in a week

CONTRACEPTION
FY2, GP surgery. Sue Hale, aged 30, has made a routine appointment to see you. Please talk to the
patient and address her concerns.
PT INFO: You have come to see the GP to request for contraception. You traveled to Australia 1
year ago by flight, a journey which took about 12 hours. You developed swelling in the legs. You
were admitted and given blood thinner tablets (Warfarin) for about 6 months. You have tried
diaphragm and condoms in the past but you got pregnant with your second child so you are very
keen to know about the failure rate of each contraception. You have 2 children. You like the idea
of combined pills but if the doctor advices you it is not appropriate for you, you are okay with it
and you accept his/her opinion. You are a nonsmoker. Your friend recommended you a pill.

QUESTIONS:
⁃ So what options are there for me?
⁃ What is the failure rate? (ask failure rate for each and every type of contraception)
⁃ Are there any side effects?
⁃ Are there any complications?
⁃ Which is the best?

SCENARIO 2: Your boyfriend used condoms and you have tried diaphragm as well. You had DVT 2
years ago and you were treated with warfarin. Last smear was one year ago and it was normal.
Your LMP was 5 days ago.
• Doctor can you tell me which one is the most effective?
• Do the COCP and POP have the same failure rate?
• Are there any risks for a coil?

***Candidate should be able to explain the following types of contraception:

APPROACH: GRIPS
• How can I help?
Okay, we have many types of contraception which we can offer you. There are 15
different methods of contraception currently available in the UK. The type that works best
for you will depend on your health and circumstances
• Is there any particular contraception you want to know or you just want to know the
available options?
• I would like to ask you a few questions to assess your suitability for contraception/
to see which type of contraception is better for you.

• Previous contraception used

• Do you have any children?
• Have you completed your family
• How long are you planning to use the contraception for?

• PMHx- DVT, Migraine, Stroke, heart dx, liver dx

• Any STI or PID or pregnancy outside womb?
• Any procedure or instrumentation through your front passage?
• Medications- blood thinner
• Allergies
• Menstrual Hx (LMP, irregular cycle, dysmenorrhea)

EXAM- BP

MGT:
1. Counselling
 From my assessment you cannot have contraceptive pills as you have got blood clot in your
legs before. And taking these pills can cause you to have blood clot again.

 But don’t worry we have many other types we can offer you.
 There is temporary, short term, long term and permanent methods of contraception.
 There is tablet form, an injection, as a patch on your skin, as an implant under your skin, as a
device inserted into your womb and sterilisation which is permanent and irreversible.

2. Explain each contraception giving advantage and disadvantage of each one

3. Tell the failure rates
4. Recommend contraception according to her history

COCP
• Daily
• 21 days cycle
• Failure: 3:1000
• Contraindicated in this patient

POP
• Daily
 • Failure 3:1000
Advantages:
a) it's useful if you cannot take the hormone oestrogen
b) you can use it at any age - even if you smoke and are over 35
c) it can reduce the symptoms of PMS and painful periods.

Disadvantages:
a) inter-menstrual bleed
b) No protection against STIs
c) Need to take it at or around the same time every day
d) Acne, breast tenderness and enlargement, mood changes, N&V, weight gain

These side effects are most likely to occur during the first few months of taking the POP, but they
generally improve over time and should stop within a few months

PATCHES
• Weekly
• Failure: 3: 1000
• Side effect: inter-menstrual bleed

DEPO PROVERA
• Intramuscular injection
• Have to go to GP
• 3 months once
• Failure 2:1000
• S/E: INTERMENS

Advantages-
a) does not interrupt sex
b) an option if you cannot use oestrogen-based contraception
c) you do not have to remember to take a pill every day
d) safe if breastfeeding
e) the injection may reduce heavy, painful periods and help with premenstrual symptoms
f) Can offer some protection from PID (the mucus from the cervix may stop bacteria entering
the womb) and may also give some protection against cancer of the womb)

Disadvantages:
a) inter-menstrual bleed
b) Weight gain, Headaches, Acne, Tender breasts, Changes in mood, Loss of sex drive
c) Small risk of infection at the site of injection.
d) Rarely, an allergic reaction

IMPLANT
• Device inserted under the skin of the inner arm under LA
 • Protection up to 3 years
• Failure: 1:2000
• S/E: inter-menstrual bleed
Advantages:
a) the implant does not interrupt sex
b) it is an option if you cannot use oestrogen-based contraception
c) you do not have to remember to take a pill every day
d) safe if breastfeeding
e) your fertility should return as soon as the implant is removed
f) implants offer some protection against PID
g) the implant may reduce heavy periods or painful periods after the first year of use

Disadvantages:
a) Disrupted periods
b) headaches
c) acne
d) nausea
e) breast tenderness
f) changes in mood
g) loss of sex drive.

MIRENA COIL
• Intrauterine device
• Mechanical and hormonal block
• Helps with dysmenorrhea, fibroids
• S/E: ectopic, PID
• Protection up to 5 years
• Failure: 2:1000

Advantages of the IUS:

a) It works for 5 years (Mirena) or 3 years (Jaydess).
b) It doesn't interrupt sex.
c) Helpful for heavy or painful periods because your periods usually because much lighter and
shorter, and sometimes less painful – or may stop completely after the first year of use.
d) It can be used safely if you're breastfeeding
e) Good option if you can't take the hormone oestrogen
f) Your fertility will return to normal when removed.
g) There's no evidence of risk of cervical cancer, cancer of the uterus or ovarian cancer.

Disadvantages of the IUS:

a) periods may become lighter and more irregular or, in some cases, stop completely.
b) Irregular bleeding and spotting are common in the first 6 months. This usually decreases
with time.
c) Some women experience headaches, acne and breast tenderness
 d) Uncommonly, small fluid-filled cysts on the ovaries - these usually disappear without
treatment.
e) Damage to the womb
f) Pelvic infections
g) Rejection
h) Ectopic Pregnancy.

IUCD
• Copper T. An Intrauterine device
• Mechanical block
• Protection up to 5 years
• Failure: 8:1000

Advantages of the IUD:

• It doesn't interrupt sex.
• It can be used if you're breastfeeding.
• Your normal fertility returns as soon as the IUD is taken out
• It's not affected by other medicines.
• No evidence it will increase the risk of cancer of the cervix, endometrial cancer (cancer of the lining
of the womb) or ovarian cancer.
• Some women experience changes in mood and libido, but these changes are very small.
• no evidence that the IUD affects weight.

Disadvantages of the IUD:

1. Your periods may become heavier, longer or more painful, though this may improve after a
few months.
2. An IUD doesn't protect against STIs, so you may have to use condoms as well.
3. If you get an STI while you have an IUD, it could lead to a pelvic infection if not treated.
4. Ectopic Pregnancy
5. Uterine perforation- Damage to the womb
6. Rejection

PERMANENT CONTRACEPTION
FEMALE STERILIZATION- 1:200 (about one in 200 women become pregnant after being sterilized)

The surgery involves blocking or sealing the fallopian tubes, which link the ovaries to the womb
This prevents the woman’s eggs from reaching sperm and becoming fertilised.
Eggs will still be released as normal, but they will be absorbed naturally into your body.
There are two main types of female sterilisation:
1. when your fallopian tubes are blocked - for example, with clips or rings (tubal occlusion)
2. when implants are used to block your fallopian tubes (hysteroscopic sterilisation, or HS).
3. Removing the tubes (salpingectomy):- If blocking the fallopian tubes has been unsuccessful
Advantages:
a) more than 99% effective at preventing pregnancy
b) rarely any long-term effects on your sexual health
c) will not affect your sex drive
d) it will not interfere with sex as other forms of contraception can
e) it will not affect your hormone levels.

Disadvantages:
a) No protection against STIs, so you should still use a condom if unsure about your partner's
sexual health
b) it is very difficult to reverse a tubal occlusion

Risks:
a) small risk of complications- internal bleeding, infection or damage to other organs
b) if you do get pregnant after the operation, there is increased risk of ectopic pregnancy
If you miss a period, take a pregnancy test immediately. If the pregnancy test is positive, you
must see your GP so that you can be referred for a scan to check if the pregnancy is inside or
outside your womb.

For each and every contraception, the candidate should give the failure rate, advantages
and disadvantages.

Can you make contraception part of your daily routine?

Methods that are used each time you have sex: male and female condom, diaphragm or cap
Methods that are taken every' day: the pill, COCs
Methods that are replaced every week: contraceptive patch
Methods that are replaced every month: vaginal ring

Methods that are renewed every 2 to 3 months: Depo

Methods that are renewed up to every 3 years: contraceptive implant
Methods that are renewed up to every 5 to 10 years: IUD and IUS

Would you prefer contraception that you don't have to remember every day?
Remember, the only way to protect yourself against STIs is to use a condom every time you have sex.
Other methods of contraception prevent pregnancy, but they don't protect against STIs.

If you miss a period, take a pregnancy test immediately and see your GP

• Unfortunately cnt give COCP due to DVT hx

 • Cn give POP, Mirena or pathch?

WANTS CONTRACEPTION TO SKIP PERIODS

FY2, GP, 26yo F, made an appointment for repeat prescription of contraception pills, talk to her,
address concerns
PT INFO: you have come for a refill of you cOCPs, you’ve been on these for 3 months, she is okay
and doing well on them, she wants to skip a period. Otherwise fit and well.
QUESTIONS:
⁃ I’m leaving the country for 3 months, can you give me a prescription for 3 months?
Yes
⁃ Any meds to stop my period?-

APPROACH: GRIPS
• Paraphrase
• How do you take your pills at the moment- how many pills in a row, any
skips
• Does she take the dummy pills after 21 days
• What is she going to do on the holidays
• And particular reasons why she would want the periods to stop

Any CIs for OCPs- DVT, Stroke, Breast cancer

MGT:
1. She can delay periods by taking 2 packs of pills continuously
without a break but it is important that she does not be taking more than 2
packs without a break

2. if anyone has a contra for COCP, Other options available

• Norethisterone- usually you need to 3-4 tablets, start 3-4 days before your period
starts, and your period would restart 2 -3 days after stopping the med
• However it doesn’t provide contraception so you would need to use another contraception
such as condoms
• Contrindication- DVT
• SE- breast tenderness, nausea, headaches, disturbance of mood

IF SOMEONE IS TAKING POP,

and wants period to be stopped U need to switch to POP
 PCOS- GENERAL MEASURES
• cOCP to control and regularise periods
• Clomiphene can help stimulate ovulation
• Metformin (specialist- cuz not licensed)
• Weight loss- helps with all symptoms- menstrual irregularities, infertility,
acne
• Optimise BMI
• Offer screening- dm, cholesterol, BP
• Dietitian
• USG- to look for cysts
• Support groups

COMPLICATIONS
1. Type 2DM: So emphasise lifestyle- diet, exercise, weight loss, checking blood glucose

2. ACNE: Weight loss

• Firstline= cOCP, others= topical retinoids+/- BPO or topical antibiotics + BPO
• Systemic antibiotics
• Referral- for severe acne or scarring

3. Hirsuitism: Waxing, shaving

PCOS
FY2, GP, 25yo lady, test results review. Had presented initially with acne and irregular periods,
results= LH:FSH= 3:1, BMI= 32
PT INFO: been gaining weight for a year, noticed hair growing on her face, also has some acne.
Periods stopped 6 months ago and before that, they were irregular, she is not sexually active. She
is concerned she may not be able to get pregnant.
QUESTIONS/CONCERNS:
⁃ What is PCOS?
⁃ Can I get pregnant?
⁃ Will say I don’t like exercise
⁃ I don’t want hormones

APPROACH: GRIPS. What made u do these tests in the first place?

Hx- focused on PCOS features
• Hirsuitism, acne, family hx of PCOS, HTN, DM
• Ask about complications- obesity, cancer, OSA
• Depression screen- mood, anhedonia

Yes. I have your results with me but please tell me why you had these tests done?
You did a very good thing by having these tests. Let me ask you few questions first

• Since when have you not been getting your periods?

• Were they regular before?
• Did anything happen before your periods stopped?
• Do you have any pain around your pelvis?
• Any pain in your breasts or discharge from your nipples?

• Tell me about your ACNE?

• Since when?
• Have you done anything about it? Has it improved?
• Any excess hair anywhere?
• Gained weight?

• Any fever/flu like symptoms?

• Do you feel tired
• Any changes in your weight?
• How much in how much time?
• Any bowel problem? feel cold when others are feeling normal? R/O Hypothyroidism

• mood?
• any medical conditions
• any children?
• any contraception?
Sexual and menstrual hx

 Observations, face, abdomen, PR

DX: PCOS- a condition which affects how your ovaries work

 means u have fluid filled sacs in your ovaries which affect its function
 THE TESTS suggest u have hormonal imbalance which causes irregular periods,
facial hair and acne
 Commonly seen in women in your age. If not tx can affect your heart, blood sugar
and fertility
 You have not had periods for the last 3 months and also have acne which is getting
better.
 Your BMI is also on the higher side which suggests PCOS.

MGT:

1) We will refer you (routine) to a specialist for further management- to do a scan of

your tummy to see follicles (fluid filled sacs) in your ovaries, further investigation to
confirm- cholesterol levels and TFTs.
 2) May start u on hormonal tx- COCP to regularize your periods. These also help with
excess hair growth on your face or chest

3) The main stay of PCOS treatment is lifestyle modification and reducing your weight.
4) Lifestyle modifications, regular screening for possible complications.
5) We will refer you to a dietician to help with a diet plan as the diet is not so good and
BMI is also on the higher side. (Counsel about lifestyle accordingly).

6) Complications if not started on tx -infertility, DM, high chol levels, some

cardiovascular risk factors, psychosocial issues- depression

7) Support groups
8) Leaflets

EXTRA INFO
 There is a lack of scientific evidence on the role of herbal med for the tx of PCOS
 Usually prognosis is good with treatment.
 We will follow you up regularly with tests for hormone levels, BP and DM

MILD CERVICAL DYSKARYOSIS

FY2, GP, 36yo F, for follow up. She had a cervical smear done 3 weeks ago which shows mild
dyskaryosis. HPV screen= negative.
PLAN: Back for routine 3 year cervical smear. Talk to the pt, explain results, address concerns.
PT INFO: You received an invitation for a cervical smear 3 weeks ago, had it done. Now made a
routine telephone call to find out about results. No sx of cervical ca. Don’t have results yet.
Mother died of cervcial cancer. Sexually active. In a stable relationship, been with current partner
for last 5 years. Worried you may develop cervical ca

APPROACH: GRIPS
• Paraphrase- follow up
• Was it a routine smear?
• I have your results but wanna ask you a few questions

Any symptoms
• Discharge
 problem with urine or bowel, apetite, weight loss, SOB lumps, lower back pain

Risk factor
 Previous STIs, safe sex, Painful sex, Bleeding after sex
 menstrual hx-LMP, regular, bleeding in between periods
Previous cervical smear
• How long ago? Any abnormalities?
• How many have you had?
• Any abnormalities
 HPV Vaccine?

Complete MAFTOSA
• Children?

Explain results:
1. We’ve checked for a virus called HPV, it is sexually transmitted and is the
cause of cervical cancer, it is negative.

2. Your cervical smear was reported as having mild changes- dyskaryosis

• This means there were some mild changes in the cells of your cervix,
but they are very mild, unlikely to cause any harm/unlikely to be due to
cancer.
• Therefore specialists have decided that you should continue with routine
screening, next is in 3 years

3. Is it cancer?
• It is not, there are some changes, but we hope cells will return back to
normal.

4. Is 3 years not too far away? I’m worried.

• Why? Any particular reason? My mother had cervical ca
Empathise
Explain
• Cervical cancer is not a type of cancer that runs in the family/genes.
• Your mother having it doesn’t bring any risk to you.

• It is caused by a virus called HPV, which is sexually transmitted , and from your
tests, you don’t have this infection.
• At the moment, you are in a stable relationship and you have been with your
partner for the last 5 years.
 For this reason we believe you have very low risk of getting cervical ca.

• However ifs you experience any symptoms such as unexplained discharge,

bleeding after sex, painful sex, please come back for assessment.
The HPV vaccine protects you against the types of HPV that causes the most cases of genital
warts and cervical cancer.

By the time I come back again for screen, can it turn into cancer?
 The reason why we recommend 3 yearly cervical smear screenings is because in this period
of time we can safely assume there will be no concerning changes especially since your virus
screening has come back negative

INVITATION FOR CERVICAL SMEAR- LESBIAN

FY2, GP, 25yo F, has been invited for cervical smear screening. Talk to the pt, address concerns,
telephone call
PT INFO: I am wondering why they invited me for Pap smear. She received a letter, she thinks its a
mistake. Her 3rd relationship was with a male partner many years ago. She is currently a lesbian

APPROACH: Telephone GRIPS, Paraphrase

 How can I help you today? I have been sent a letter to come. I was wandering why?

 Cervical screening (a smear test) checks the health of your cervix. The cervix is the
opening to your womb from your vagina.
 It's not a test for cancer, it's a test to help prevent cancer.
 We recommend having the test done as long as they are within 25-64 years old.

 But doctor I don't think I need to go for the test.

 May 1 ask why do you think so? a lesbian
 Ok let me explain you further. But before that may 1 ask you few questions to assess your
overall health. Some are personal

• Do you have any discharge from your front passage?

• Any bleeding during or after sex?
• Any problem with your urine or bowel?
• Any pain in your lower back or pelvis? Cancer
• Any weight loss? How's your appetite? Do you feel tired these days? Any SOB?
• LMP? periods regular? Any bleeding between periods?
• Have you been diagnosed with any medical condition in the past?

Sexual hx
• Previous Pap smear
• Sexually active
• Ever been in a sexual relationship with a male partner?
• What kind of intercourse?
 • Do you know if your partner has ever been in a relationship with a
male partner
• Have you ever changed your gender
• Do you use any sex toys?
• Do you share sex toys with your partner?
• Have you ever had an STI

MGT:
1. Cervical smear
• Do you understand why it is done and why its usually offered?
• It is offered to women between 24.5 to 50 years.
• It is usually offered every 3 years to screen for pre-cancer conditions
• To check for abnormal changes in the cells of the cervix
• Cervical ca is usually caused by the STI- HPV, you can have it w/o any symptoms.

How can I get it?

• You’ve had a male partner in the past so there is a risk you can have this virus
• Also if your partner has this virus, you could acquire it by sharing toys. We’d like
you to get screened to be on the safe side

2. Procedure-
• The test itself should take less than 5 minutes.
• They need to take a sample from your cervix
• They will usually ask you to undress behind the screen, the nurse will ask you to lie
on your back with your legs bent, feet together, knees apart.
• A smooth tube shaped tool- speculum will be gently inserted into your vagina
• The nurse will open the speculum so they can see the cervix, and a soft brush will
be used to take a small sample from you cervix
• She will remove the speculum and then you can get dressed.

 You should get your results within 14 days.

 As with other STIs, HPV is passed on through body fluids.
 This means that oral sex transferring vaginal fluids on hands and fingers can be
all ways of being exposed to HPV.
 smoking is also a risk factor for cervical cancer

‼ MISSED MISCARRIAGE
Early pregnancy assessment unit. Pt is a 32yo F. She had a TVS which shows a 5/52 gestation.
Fetal pole present. Fetal heartbeat not present. Talk to patient and address concerns
PT INFO: you did pregnancy test 7 weeks ago which was positive.
 You came to what was have an USS because you don’t feel like you’re pregnant.
This is your first pregnancy. You have been trying to get pregnant for the last 6 years;
no sx of pregnancy; you had tummy discomfort and nausea in the beginning but you haven’t felt
them for the last 2 weeks

APPROACH- GRIPS
• Paraphrase

• Why was the scan done? I had some sx

• What kind of sx did you have?
• Nausea? Vomitng?
• Wt gain?
• Abd discomfort?
• Breast tenderness?

Pregnancy hx
• First pregnancy? How far along? Planned?
• Any miscarriage? Any TOP?
 How did you find out you were pregnant?
• When did you do the test?

• Since then have you had any sx

• Abd pain?
• Bleeding PV?
• Discharge of tissue PV?
• Discharge of fluid PV?

Menstrual hx
• LMP? regular?
 Any bleeding between the cycles or after sexual intercourse?

 were you on any contraception? Pills or any devices or copper coil that you have ever used?

A few words about your sexual history if that okay with you
 Are you in a stable relationship? (asked because she was so quiet and awkward I also
thought it could be forced or in depression?)
 That’s great. How is your relationship with your husband?
 How has your mood been lately? Can you please Rate your mood On a scale of 1-10?

Risk factors
• STIs
• Any med problem, Surgeries
• Any medication
• Any Fhx of difficult conception or problems in pregnancy
MAFTOSA- Smoking, Alcohol, Recreational drugs

EXAM: Observation; urine pregnancy test, ABD= normal, PV exam- normal

Explain findings:
 The scan done today shows that you are 5 weeks pregnant.
 It also identified some parts of the baby but unfortunately it couldn’t detect the heartbeat
 You mentioned that you had a positive pregnancy test 7 weeks ago and at the
stage usually we should be able to detect the heartbeat.
 I’m sorry to say Ms xxxx that you may be having a miscarriage. PAUSE.

 The specific type of miscarriage is called missed miscarriage because you do don’t feel
the sx of pregnancy anymore and it looks like your baby has stopped growing

You mean my baby is no more alive.

 I can’t even imagine what you must be going through right now. I wish I had better news.
 But unfortunately jenny I don’t
 (Patient is silent looking down on the floor and not answering.)
 Jenny are you okay? (Silent)
 Would you like a moment?(silent)
 Can I call someone for you?( Still silent)

What are you going to do? (Pt will speak

MGT: Inform seniors
1. Repeat USS in 7-10 days time. If result still the same then it confirms dx

If confirmed-
2. Sometimes meds may be used to deliver the baby. The med will cause contraction of
your womb which will help deliver the baby the same way you will have a normal
vaginal delivery.

3. If this is not possible, you might have a surgical intervention

4. Discuss with seniors

5. Safety-net: Bleeding, Feeling unwell

If patient asks why did it happen?

 Explain there are many possibilities to why this can happen. Ask her did anyone speak to her
about complications in pregnancy in women with age more than 35.
Explain to her that can be one of the causes, chromosomal disorders in the foetus are the
most common reason for pregnancies terminating in the first trimester.

A pregnancy may also be more likely to end in miscarriage if the mother:

• is obese
• smokes
• uses drugs
• has lots of caffeine
• drinks alcohol

Later you can guide her for a check up at the fertility clinic, in case of repeated miscarriage’s
it will be required for her to go through a thorough check up to see if she is fit to be pregnant in the
future or not.
In case you think patient is too depressed you can advise her talking therapy as well.

ABD BLOATING- OVARIAN CA

FY2, GP, 70yo F, made an appointment to see you. She has been complaining of bloating.
PT INFO: bloating for the last 3 months. You are not worried. You came cuz your husband asked
you to check it out. You feel full early, have anorexia, weight loss (dunno how much), mild tummy
pain, bowel habits- 3-4x a weeks which is normal for you. No diarrhoea. LMP= 25 years ago. Your
mother had breast cancer.

HX + EXAM

APPROACH: GRIPS
Bloating- ODPARA
DDX:
• Celiac’s dx
• IBS

• Liver or renal issues, Colonic ca

• IBD
• Pancreatitis- anemia, offensive stool, greasy stools
Cancer symptoms
Anemia symptoms

EXAM: observations, ABD, PR

ABD- mild distension from ascites, mild tummy tenderness, no mass

DX: suspected Ovarian ca – U have a little bit of fluid in your tummy. A lot of things can
cause it like heart or liver problems. Im a little bit concerned it cd be ovarian cancer as u
have a family hx of cancer, u r losing weight, loss of apetite. Unfortunately all these are
symptoms of cancer

MGT:
1. Routine, inflammatory markers. calprotectin, tumor marker- ca-125, USG
⁃ Labs are urgent

2. Urgent referral to gynaecologist.

 Might examine u, explain results to u. They might also do further investigations like
⁃ Might do a CT scan, MRI
⁃ Fine needle biopsy

3. Treatment- if its confirmed

⁃ Surgery
⁃ Chemotherapy

Leaflets, seniors, safety net- if symptoms get worse,…..

‼ DERMOID CYST REMOVAL

FY2, OB/GYN department. Mrs Jenny Thompson is a 30yo lady who has been scheduled for a
dermoid cyst removal. The cyst is 8cm x 8cm in size. It will be removed via laparotomy with an
incision on the bikini line. She is planned to stay in the hospital after the procedure for at least 48
hours. The surgeon will be using absorbable sutures. Consent has been taken from the patient.
Patient has some concerns. Please talk to the patient.
PT INFO: You are Mrs. Jenny Thompson, you have been told that you have a cyst in one of your
ovaries, You know that you are going to undergo an operation. You are normally fit and well and
not on any medications

APPROACH:
 I’ve been asked to come and talk to u about your condition.
 Can I check what u have been told so far about your treatment. CHECK PRIOR KNOWLEDGE

 Have u been told how we will be managing that

 Before we start do u have any quest?

TAKE HX-
 Any symptoms?
 more about your tummy pain? Where exactly is it?
 MAFTOSA
 • Thank you for answering these questions. As you told me, you came to the hospital
with pain, we did US scan of your tummy and we found fluid-filled sac in your ovary
which we call dermoid cyst
• It tends to occur in younger women
• It can grow quite large, up to 15 cm onwards
• Often contains hair, parts of teeth, bone, fatty tissue, etc
• This is because this cyst develops from cells which makes eggs in your ovary
• An egg has the potential to develop into any type of cell
• So this cyst can make different types of tissue

• In about 1 in 10 cases, a dermoid cyst develops in both ovaries

• Dermoid cysts can run in families
• The cyst u have got is quite big- 8x8cm
• If u have a cyst in ur ovaries, it can affect the way ur ovaries function
• The operation is thus essentially to remove the cyst

Is it serious?
 Ovarian Cyst are common and they usually do not cause symptoms. However, if the size of
the cyst is large and the cyst is causing problems then we have to do surgery.

Is it compulsory to undergo this surgery?

 Yes, as you are having pain. If we do not remove this cyst now, it may rupture and
bleed in the future. In that case we have to do emergency operation. To avoid such
situation, it is best if we remove it now

So. what are you going to do now?

 Our consultant has decided to do an operation to remove this cyst

MGT:
1. Explain procedure

Before procedure
• Avoid eating for at least 6 hours before the procedure
• You can drink water up until 2 hours before procedure
Procedure
• Under GA- which means u will be put to sleep
• Open laparotomy- which means they will make an incision in your tummy at the bikini line
• And remove the cyst and close the tummy back
• Tummy will be closed using absorbable sutures, so they will be no need of removing
stitches.
 • They will try by all means to preserve the fertility organ as much as possible
• Unfortunately, the cyst you have is big, and sometimes in a few cases it may be
difficult to remove the cyst only and they might need to remove the whole ovary.

 Operation will be about 1-2 hours long

 you will be taken to the the recovery ward, where you will wake up from GA.
• Once you wake up, you will be taken to the regular ward for IV fluids

After
• Will be given IV fluids
• U may have some tummy pain for 7-10 days but u will be given pain meds, vaginal spotting

POST PROCEDURE CARE

• Recovery may take generally 4-6weeks
• When u retur n home, do the ff to help ensure a smooth recovery
• Avoid strenuous execise until ur doctor says it is okay
• Do not resume sexual activity until your doctor says it is okay
• FF your doctor’s guideline for USG test. This may need to be done if it is likey that the cyst
will return

For how long do I have to stay in the hospital?

 Most people stay for about 48hrs before discharge.
 Our consultant has decided to keep you in the hospital for 2 days after the surgery.
 Hopefully everything will go smoothly and you will be able to go home after 2 days.

**Complications
⁃ Risk of bleeding- Rare, manage accordingly
⁃ Damage to surrounding tissues- Don’t worry this is rare, Manage accordingly
⁃ Infection- If it happens, will prescribe antibiotics
May need to remove the ovay and may decrease the chance of infertility

2. Will I be able to have children?

• The surgeon will try by all means to preserve your ovaries. But if they struggle, they might
need to remove the ovary as well.
• You should be able to not have problems with pregnancy as long as your other
ovary is okay, but if they remove one ovary, it might be difficult to get pregnant.

3. Leaflets

What will be the size of the scar?

 Incision will be up to 8.5 cm long and the scar will be very thin and will be
covered by the bikini so it won't be visible when you wear the bikini.
Is it cancerous?
 Most of these cysts are benign however we will send the samples to the lab
to confirm.

When can I resume my sexual activity? When can I go to work? When can I drive?

 After the surgery, you can start after 4-6 weeks.

‼ SPECULUM EXAM
PAP SMEAR
• 24-49= eery 3 years
• 50-65= every 5 years
• After 65= only if there was a previous abnormal result

QUESTION A: FY2, OBGYN, Racheal Parkinson is a 40yo F who has come for the routine cervical
smear.
Take a brief history, and perform cervical smear and address any concerns.
PT INFO: come for routine cervical smear screen
• Your last smear was 5/10 years ago and at that time the procedure was painful and
uncomfortable
• You are normally fit and well and not on regular medication
• You do not smoke but you drink alcohol occasionally
• You have 2 children: ages 5 and 7 years
• Who are both healthy
QUESTIONS:
⁃ How long will it take for the results to come back?
⁃ 2- 3 weeks, in the post

• Set up:
• Patient sitting on a chair
• PV manikin
• Sure path or thin prep
• There is a lamp with a stand, the lamp has a power button in the middle.

APPROACH:
• GRIPS
• Explains purpose of consultation: This will involve me asking you some questions
and performing the procedure.
• Take history:
 • When was your Last smear?
• How was the last smear?
• Should have been every 3 years, any particular reasons she did not come on time?
• It must have been very distressing for you not to have come for your next
appointment. I am sure everyone in your position will feel the same way.
• I am sorry about what happened the last time, I will try to be as gentle as possible. If
you feel any discomfort this time please let me know.

• Risk factors for cervical ca

• Any children?
• Did you use contraception in the past?
• Do you smoke?
• Any STI in the past?
• Any family history of any type of cancer like cervical or breast cancer?

• CIs:
• Pregnancy- any chance you could be pregnant
• Currently menstruating?/any bleeding PV currently?
• Menstrual history:
• LMP?
• Regular?
• Heavy?
• Any inter-menstrual bleeds?
• Sexual intercourse within the last 24 hours
• Use of spermicidal lubricant

• PMHx, drug history and allergy (latex, plastic)

• Explain the procedure:

• We will be taking a sample from your cervix (neck of the womb) with a soft brush
• Explain exposure and position

• Pre - Procedure:
• Empty the bladder
• Undress below the waist
• Lie on the back with knees and thighs bent, ankles together and knees apart
• Ask for a chaperone
• Maintain privacy

• Equipment
• Disposable speculum
• KY gel
• Wipes
• Clinical waste bin
• Good source of light
 • Gloves
• Sure path
• Thin prep
• Cervical brush

• Procedure:
• Check that you have all equipment
• Open speculum from the side with the arrow
• Apply gel
• Part labia
• Insert slowly= sideways, advance forward and downwards and then turn the
speculum down when it reaches the end
• Open the speculum
• Check cervix is in position
• Secure speculum
• Inspect the cervix
• Bleeding
• Discharge
• Polyps
• Erosion
• Take smear- tip of brush should enter cervical os
• Rotate the brush 5 times clockwise only
• Remove the brush masking sure it doesn’t touch surroundings

• Rinse (dip) brush 10 times in thin prep, then dispose brush

• OR
• Flick the tip of brush into the liquid— sure path

• Remove speculum:
• Pull back slightly
• Release screening completely
• Close
• Rotate sidewards
• Remove gently

• Inspect for bleeding or discharge

• Dispose in clinical waste bin
• Remove gloves
• Offer pt wipes and allow to dress privately
• Label specimen and send to lab
• Thank the pt and explain how and when she would get the results

• Post - Procedure:
• Explain the results- examiner will give you some possible results
• Negative smear - repeat every 3 years as patient is between the ages of 25-49 years
 • Inadequate sample= : repeat within 3 months
• Borderline changes = colposcopy
• - Mild, moderate, or severe dyskaryosis- Colposcopy
• Inadequate sample= contact the pt to repeat sample collection

PRE MENSTRUAL SYNDROME

32 yr old lady made an appointment to see u. Take info and address concerns. PT INFO-My
husband asked me to coe and see u. He says I am no myself. Getting more emotional. Having
mood swings for the pas 4 months. Snaps at husband and children. Low concentration. Mood
swings, 3-4 days before period nd stops 2-3 days into the periods. Periods last 3-4 days. U get your
menstrual period every 28 days. 8 months ago, she stopped using Depo

APPROACH- GRIPS.

• Appreciate the husband for telling her to come. ODPARA- Ask for triggers
• DDX- Depression, hypothy, anemia, dysmenorrhea, IBS
• Go to menstrual Hx
• Do not ask r u sexually active? is your partner male or female cos she says her
husband told her to come
• P7MAFTOSA
• ICE, JARSS

DX- Pre menstrual syndrome

 COCP- Continuous, not cyclical (Main tx)

 Lifestyle- exercise, regular sleep
 Can offer para or nsaids
 Offer CBT
 FF up in 2 months
 Can keep a diary
 Leaflet

MENSTRUAL MIGRAINE
Headache for the last 6/12. starts 3-4 days before your period and stops dys into your period. U do
not have any other symptoms. Your mother has got migraine. U normally fit in well. Not on any
other med. No allergies. U have tried pmol and ibuprofen, but it does not help. Exam- Observation
– Normal

GRIPS, SOCRATES, DDX- FOR Pain

Menstrual Migraine- Cos it is precipitated by your period

TX-

1) Since pmol and Ibuprofen r nor working, then we will prescribe Intranasal
sumatriptan- use during the attack of migraine
2) Keep a diary of when headache starts and end in relation to menstrual cycle
3) Follow up for 3 months
4) If intranasal sumatriptan does not work and Once relationship to cycle is confirmed, give
COCP- continuously
5) Leaflets
6) Lifestyle