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THE GYNAECOLOGY OSCEAZY SERIES DR SHRAYA PANDYA (FY2)Topics Covered History Example Stations & SBAs Spot DiagnosisGYNAECOLOGICAL HISTORYHistory of Presenting Complaint - O&G Menstrual History M • LMP • Cycle (length + duration) • Age of Menarche (+ Menopause) • Associated symptoms (e.g character): pain, amount, flooding Obstetric History • Gravida and Para O • Previous pregnancies including TOP, Miscarriages etc. • Form of delivery for each pregnancy: Vaginal, Assisted, C-Section • Children: ages, birth weights, pregnancy + delivery complications Sexual History • Current or previous partners S • Intercourse: protected vs unprotected • Subfertility C Contraception History Cervical Smear History C History of Presenting Complaint - Obstetrics PV Discharge 4Ps PV Bleeding Pain Pregnancy 1 day of LMP / Duration of gestation + positive pregnancy test Pregnancy Antenatal appointments attended + Scan results Investigations (including Rhesus status & Down Syndrome risk) Hydration status Fetal movements (over 16 weeks) Contractions Obstetric History GMCF • Gravida and Para • Miscarriages, Ectopics and Terminations • Children: ages, birth weights, pregnancy + delivery complications • Form of delivery for each pregnancy: Vaginal, Assisted, C-SectionSystems Review Pain - SOCRATES General Fever Sweats Fetal movements Pregnancy Contractions PV Loss Pre-eclampsia: Headache, Dizziness, PV discharge Gynaecological PV bleeding Storage: frequency, volume, urgency and nocturia Urological Infection: dysuria, haematuria, odour Weight change Gastrointestinal Appetite Nausea and Vomiting Indigestion Bowel Habit ChangePast Medical History • Do you have any conditions you see a doctor for? • Any hospitalizations recently? • Any previous surgeries? Drug History • What medications do you take currently? Any changes recently? • Any Herbal remedies? • Any over-the-counter medications? • Do you have any drug allergies? Family History • Is there anyone in the family who has any medical conditions? Social History • Do you smoke? Or Have you ever smoked? If so, how many cigarettes per day and for how long? • Do you drink? • Where do you work? • Who is with you at home? • Do you feel well supported/safe at home? ICE • Ideas • Concerns • ExpectationsSEXUAL HEALTH HISTORY Sexual History Taking • HPC- Female: – Unusual vaginal discharge- ask about onset/colour/odour/amount – Lower abdominal pelvic pain – Abnormal PV bleeding- IMB, PCB, HMB – Urinary Symptoms - e.g. dysuria, urinary frequency – Genital sores/lumps/ulcers – Dyspareunia- deep (likely PID, endometriosis) vs. superficial (herpes?) – Psychosexual dysfunction Sexual History Taking • HPC- Male: – Urethral discharge – Urinary Symptoms- urinary frequency, dysuria – Testicular pain or swelling – Genital sores/ulcers/lumps – Perianal/rectal symptoms/change in bowel habit – Lower abdominal/pelvic pain – Erectile dysfunction/psychosexual dysfunction • Always clarify the following for all symptoms - duration, associated features, aggravating and relieving factors Sexual History Taking • Partners – Sexually active? Last sexual intercourse episode. Protection- e.g. condoms- how often is it used- sometimes vs. never. Always?- any issues? – Type of sex practiced- oral, vaginal, anal. Oral and anal- receptive or giving? Oral sex- oro-anal or oro-genital? NB/ people often don’t use barrier contraception for oral sex – Relationship of symptoms starting to last UPSI or to intercourse with a particular partner if several partners – How many partners in past 3/12, gender? Regular or casual? Partners from overseas? – Symptoms in partner- have they been tested for STIs/HIV etc? – Sex work- “Have you ever paid for sex, or ever been paid for sex?” Sexual History Taking • Contraception – Patient and partners – Method – Correct usage/any issues? – Duration of use – Missed/late pills- do they know missed pills rules? Sexual History Taking • Previous STI screen/test (when or where) • Result • Previous Diagnosis – What was diagnosis and when? – Treatment – Compliance – Partner notification/treatment Sexual History Taking • Relevant Social History – Smoking – ETOH – Recreational drug use- IVDU- sharing needles- risk of Hep C, HIV etc. • Chemsex, club drugs – Profession – Living situation – Dependents – DVA, sexual assaultEXAMPLE SCENARIOS Role Foundation Year 1 (FY1) Doctor Setting General Practice Patient Anita Johnson, a 47-year-old woman has presented to the practice to discuss her symptoms of increased STUDENT headaches, hot flushes and fatigue. Student task Please take a history from the patient. INSTRUCTIONS [1] At 7 minutes, the examiner will stop you and will require you to state your likely diagnosis and differentials. History of Presenting Complaint • I am 47 years old and have noticed my periods have become irregular. I have not had a period in the last 4 months. • I have two children and I have had a history of two previous miscarriages in the last 16 years. • I have also developed increase headaches, fatigue, mood changes and hot flushes more recently. Summarising the history Patient details, occupation I took ahistory from Anita Johnson, a 47-year-old womanwho has presented with menopausal & key presenting complaint symptoms. Anita has been having irregular periods, and her last menstrual period was4 months ago. She History of presenting complaint also notes headaches, fatigue, mood changes and hot flushesaffecting her life regularly. Relevant negatives She states that currently there isno chance of being pregnant. Relevant PMH/PSH/SH/DH Her mother haspreviouslybeen diagnosed with osteoporosis. There isno breast or ovarian cancer in the family. There isno previous thromboembolic history or history of clotting disorders in the family. Ideas, concerns & expectations She wouldlike to discuss how her symptoms could be managed. My top differential is amenorrhea/oligomenorrhoea due tomenopause. Top differential & why Otherdifferentialsthat I would like to rule out are pregnancy, PCOS. Other differentials Questions To Ask HPC: • Family History: •Onset and duration of symptoms • Early menopause in family? •Hot flushes, night sweats, mood changes, vaginal dryness • Breast or ovarian cancer? •Menstrual history (irregular/missing periods) •Sleep disturbances, memory issues, weight gain •Effect on daily life • Lifestyle & Social History: • Smoking, alcohol, diet, exercise Menstrual & Gynaecological History: • Stress, mood, and libido changes •Last menstrual period (LMP) •Changes in cycle length or amount of bleeding • Closing: •Any postmenopausal bleeding? • Summarizes findings Past Medical History: • Explains menopause and treatment options (HRT, •Previous gynaecological conditions lifestyle changes) •Osteoporosis risk factors (fractures, steroids, smoking) • Safety-netting and follow-up Question 1 A Combined oral contraceptive pill A 49-year-old woman presents with irregular, heavy periods, hot flushes, and night sweats. B Cyclical HRT Her FSH levels indicate she is in the perimenopausal stage. C Continuous HRT She has no contraindications to hormonal treatment and does not require contraception. D Tranexamic Acid What is the most appropriate management? Endometrial Ablation E Question 1 A Combined oral contraceptive pill A 49-year-old woman presents with irregular, heavy periods, hot flushes, and night sweats. B Cyclical HRT Her FSH levels indicate she is in the perimenopausal stage. C Continuous HRT She has no contraindications to hormonal treatment and does not require contraception. D Tranexamic Acid What is the most appropriate management? Endometrial Ablation E Role Foundation Year 1 (FY1) Doctor Setting General Practice Patient Amira Patel, a 24-year-old woman has presented to the STUDENT weight gain and excessive facial hair. She is concerned about infertility. INSTRUCTIONS [2] Student task Please take a history and explore the concerns from the patient. At 7 minutes, the examiner will stop you and will require you to state your likely diagnosis and differentials. History of Presenting Complaint • I am 24 years old and have noticed my periods have become irregular. I have not had a period in the last 2 months. • I have currently not had any children and nor have I had any previous pregnancies. I am worried about possible infertility due to my irregular periods. I am regularly sexually active and attempting to conceive. • I have also had trouble losing weight and have frequently noticed increased areas of acne around my chin and back, as well as extra facial hair. Summarising the history Patient details, occupation I took ahistory from Amira Patel, a 24-year-old womanwho has presented with irregular & key presenting complaint periods. History of presenting complaint also notes weight gain, hirsutism and acne. She has noprevious children orpregnanciesand is currently sexually active. Relevant negatives Relevant PMH/PSH/SH/DH Ideas, concerns & expectations She is currently concerned about possible infertility. My top differential is a PCOS, although a pregnancy test will need to be performed torule this Top differential & why out asa cause. Otherdifferentialsthat I would like to rule out are pregnancy, endometriosis and primary ovarian Other differentials insufficiency. Questions To Ask HPC: • Family History: •Menstrual cycle irregularity (length, frequency, flow) • PCOS, diabetes, infertility in family? •Hirsutism (excess hair growth), acne, scalp hair thinning •Weight gain or difficulty losing weight • Lifestyle & Social History: •Symptoms of insulin resistance (dark patches on skin) •Any previous investigations? • Diet, exercise, weight management efforts • Stress levels Menstrual & Gynaecological History: •Age of menarche • Closing: •Any previous pregnancies or infertility concerns? • Explains PCOS (hormonal imbalance, long-term risks) Past Medical History: • Discusses management (lifestyle changes, medications Diabetes, thyroid disorders, or metabolic syndrome? like metformin, hormonal contraceptives) • Follow-up plan Question 2 A Elevated FSH levels A 23-year-old woman presents with irregular periods, weight gain, and excessive facial hair. B Low LH:FSH ratio Ultrasound shows polycystic ovaries. C Increased Insulin Levels Which additional criterion is required to confirm a diagnosis of PCOS according to the Rotterdam criteria? D Endometrial Hyperplasia Elevated androgens or clinical E hyperandrogenism Question 2 A Elevated FSH levels A 23-year-old woman presents with irregular periods, weight gain, and excessive facial hair. B Low LH:FSH ratio Ultrasound shows polycystic ovaries. C Increased Insulin Levels Which additional criterion is required to confirm a diagnosis of PCOS according to the Rotterdam criteria? D Endometrial Hyperplasia Elevated androgens or clinical E hyperandrogenism Role Foundation Year 1 (FY1) Doctor Setting General Practice Patient Joanna Smith, a 28-year-old woman has presented to the practice to discuss severe pelvic pain and painful periods. STUDENT Student task Please take a history from the patient. INSTRUCTIONS [3] At 7 minutes, the examiner will stop you and will require you to state your likely diagnosis and differentials. History of Presenting Complaint • I am 28 years old and have noticed my periods have become more painful. They have also become heavier. • I have also noticed this deep pelvic pain, which gets worse during sexual intercourse. • I have also recently developed more bloating and sometimes it can be painful to open my bowels. Summarising the history Patient details, occupation periods.history from JoannaSmith, a 28-year-old woman who has presented with painful & key presenting complaint Joanna reports a 6-month history of dysmenorrhea + menorrhagia. She also reports pain during History of presenting complaint sexual intercourse and bowel symptoms including painful defecationand bloating. Relevant negatives Relevant PMH/PSH/SH/DH Ideas, concerns & expectations She wouldlike to discuss how her symptoms could be managed. My top differential is endometriosis. Top differential & why Other differentials Otherdifferentialsthat I would like to rule out are fibroids. Questions To Ask HPC: • Family History: •Pelvic pain (cyclical or continuous?) • Endometriosis in mother or sisters? •Dysmenorrhea (painful periods) - severity, duration •Dyspareunia (pain during sex) • Lifestyle & Social History: •Bowel/bladder symptoms (painful defecation, bloating) •Fertility concerns • Impact on daily life, work, relationships •Any previous investigations or treatments? • Closing: Menstrual & Gynaecological History: • Explains endometriosis as a chronic condition •Menstrual cycle details (regularity, pain severity) • Management options (pain relief, hormonal therapy, •Use of contraception or hormonal treatments surgery if severe) •Previous pregnancies/miscarriages • Referral for gynaecological review if needed Past Medical History: Pelvic infections, surgeries? Question 3 A Pelvic MRI A 28-year-old woman presents with severe dysmenorrhea, chronic pelvic pain, and B Transvaginal Ultrasound dyspareunia. A pelvic ultrasound is normal. C CA-125 Blood Test What is the gold standard investigation to confirm the diagnosis of endometriosis? D Diagnostic Laparoscopy Hysteroscopy E Question 3 A Pelvic MRI A 28-year-old woman presents with severe dysmenorrhea, chronic pelvic pain, and B Transvaginal Ultrasound dyspareunia. A pelvic ultrasound is normal. C CA-125 Blood Test What is the gold standard investigation to confirm the diagnosis of endometriosis? D Diagnostic Laparoscopy Hysteroscopy E Role Foundation Year 1 (FY1) Doctor Setting General Practice Patient Caroline McKinnon, a 62-year-old woman has presented to the practice to discuss post-menopausal bleeding. STUDENT Student task Please take a history and elicit the concerns from the INSTRUCTIONS [4] patient. At 7 minutes, the examiner will stop you and will require you to state your likely diagnosis and differentials. History of Presenting Complaint • I am 62 years old and have noticed some spotting or bleeding in my underwear for the last 3 months intermittently. • I have had three pregnancies, which resulted in 3 children. I began menopause at age 51. • I have also lost 5kg in weight unintentionally over the past 2 months. Summarising the history Patient details, occupation I took ahistory from Caroline McKinnon, a62-year-old womanwho has presented with post & key presenting complaint menopausal bleeding. Caroline has beenhavingintermittent bleeding for the past 3 months. She underwent History of presenting complaint menopause at age 51. She also has unintentional weight loss. Relevant negatives Relevant PMH/PSH/SH/DH There is no endometrial, breast orovarian cancerin.the family Ideas, concerns & expectations She wouldlike to discuss how this could be investigated. My top differential is post menopausal bleeding due to endometrial cancer. Top differential & why Otherdifferentialsthat I would like to rule out are atrophic vaginitis, cervical ectropion. Other differentials Questions To Ask HPC: • Family History: •Bleeding details (amount, duration, color, clots?) • Endometrial, breast, ovarian cancer in family? •Any associated pain or weight loss? •Recent changes in bowel/bladder habits? • Lifestyle & Social History: Menstrual & Gynaecological History: • Smoking, alcohol, diet, exercise •Age at menopause •Previous heavy or irregular periods? • Closing: •Hormone replacement therapy (HRT) use? • Explains importance of further investigations (transvaginal scan, biopsy) Past Medical History: • Referral to gynaecology for urgent assessment •Diabetes, hypertension, obesity? •Any previous gynaecological conditions? • Reassures patient while emphasizing importance of follow-up Question 4 A Routine Gynaecology Referral A 62-year-old woman presents with postmenopausal bleeding. Transvaginal Ultrasound B She has no pain or weight loss. C CA-125 Blood Test What is the most appropriate next step in management? D Endometrial Biopsy E 2WW Gynaecology referral Question 4 A Routine Gynaecology Referral A 62-year-old woman presents with postmenopausal bleeding. Transvaginal Ultrasound B She has no pain or weight loss. C CA-125 Blood Test What is the most appropriate next step in management? D Endometrial Biopsy E 2WW Gynaecology referral Role Foundation Year 1 (FY1) Doctor Setting General Practice Patient Catherine James, a 35-year-old woman has presented to the practice to discuss ongoing vaginal discharge. STUDENT Student task Please take a history from the patient. INSTRUCTIONS [5] At 7 minutes, the examiner will stop you and will require you to state your likely diagnosis and differentials. History of Presenting Complaint • I am 35 years old and have noticed an ongoing clear-grey-white discharge with a fishy smell. • I have tried various hygiene products over the past few weeks to remove this smell, but it is not improving. • I have the mirena coil currently but have made no changes to diet and lifestyle recently. Summarising the history Patient details, occupation I took ahistory from Catherine James, a 35-year -old womanwho has presented with vaginal & key presenting complaint discharge. History of presenting complaint Catherine has beenongoingclear-grey-white discharge over the past few weeks associated with a fishy odour. She has beenusing various hygiene products to avoidthis but has made no other recent changes to her lifestyle. She states that currently there isno chance of being pregnant. Relevant negatives There is a history of diabetes in the family. She hasnot used antibiotics recently. Relevant PMH/PSH/SH/DH Ideas, concerns & expectations She wouldlike to discuss how her symptoms could be managed. Top differential & why My top differential is Bacterial Vaginosis. Otherdifferentialsthat I would like to rule out are candida orother sexually transmitted Other differentials infections. Questions To Ask HPC: • Family & Social History: •Vaginal discharge (color, consistency, smell) • Douching or use of vaginal products? •Any itching, pain, or burning? • Smoking, stress, hygiene practices? •Any post-coital bleeding or pain? •Any recent new sexual partners? Menstrual & Gynaecological History: • Closing: •Last menstrual period (LMP) • Explains BV (imbalance of vaginal bacteria, not an STI) •Use of contraception? • Management (metronidazole, lifestyle advice, avoid •Any previous episodes of BV or STIs? douching) Past Medical History: • Follow-up if symptoms persist or recur •Recent antibiotic use? •Diabetes or immunosuppression? Question 5 A Presence of clue cells on microscopy A 30-year-old woman presents with thin, grey vaginal discharge with a fishy odour. Vaginal pH <4.5 B What is required to confirm the diagnosis of bacterial vaginosis based on Amsel’s criteria? C Negative Whiff Test Presence of motile trichomonads on D microscopy E Thick, cottage cheese-like discharge Question 5 A Presence of clue cells on microscopy A 30-year-old woman presents with thin, grey vaginal discharge with a fishy odour. Vaginal pH <4.5 B What is required to confirm the diagnosis of bacterial vaginosis based on Amsel’s criteria? C Negative Whiff Test Presence of motile trichomonads on D microscopy E Thick, cottage cheese-like dischargeSPOT DIAGNOSIS SPOT DIAGNOSIS A 35-year-old woman presents with heavy, prolonged periods, pelvic pressure, and a firm, irregularly enlarged Fibroids uterus on examination. A 42-year-old woman complains of heavy, prolonged Heavy Menstrual bleeding menstrual bleeding with clots, soaking through pads every hour, but no intermenstrual or postcoital bleeding. A 50-year-old woman with a history of irregular smear tests presents with postcoital bleeding, persistent watery vaginal Cervical Cancer discharge, and pelvic pain. A 60-year-old woman reports abdominal bloating, early satiety, weight loss, and a palpable adnexal mass on Ovarian Cancer examination. A 45-year-old woman complains of urine leakage when coughing or laughing, with no urge to void beforehand. Stress Incontinence SPOT DIAGNOSIS A 22-year-old woman presents with postcoital bleeding, Chlamydia mucopurulent vaginal discharge, and lower abdominal pain. She is sexually active and does not consistently use condoms. A 26-year-old man complains of dysuria and thick green urethral discharge. He recently had unprotected intercourse Gonorrhoea with a new partner. A 30-year-old woman presents with painful genital ulcers, dysuria, and flu-like symptoms. Examination reveals multiple Genital Herpes small vesicles and ulcerations on the vulva. A 28-year-old man reports a painless genital ulcer that appeared two weeks ago. He has no systemic symptoms Syphilis and is sexually active with multiple partners. A 35-year-old woman presents with frothy yellow-green Trichomoniasis vaginal discharge and a foul odour. She also has vaginal irritation and dyspareunia. An associated strawberry cervix has been noted. PLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO OUR REMAINING SESSIONS THIS WEEK osceazyofficial osceazy@gmail.com OSCEazy OSCEazy osceazyofficial