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indicator. Thank you for joining. Are you able to show your screen everything now? Yeah. We can see your screen. Okay. Can you Can you see it? Full screen? Yeah, we can. I'm sorry about the delay, everyone. We should be starting soon. I'm just not one of you already. You just muted yourself. Sorry. Yeah. Hi, guys. Thinking everyone for coming eso I'll be doing the obscene dining section off. The common things are common risk E Siris. Um so yeah, without further would do I'll just sort of introduce what I'm gonna cover today. And yeah, just a bit about the session. Really? Okay. So with this office and I need a revision session, I'm just going to cover some of stopped, like the main presentations that I think could potentially come up In an excuse scenario, I'm not going to cover everything in OBS, and I need because that would just be too much to cover in the space of a now our and I think it's really important that you focus on what's more likely to come up and just be a smart she can make your vision, um, also sort of cover how to tackle the OB single potential obscene gynie station. So what, You should cover in, like, the history, just some common, like investigations that you would do. And then also, just some key things that you don't really want to miss out that I saw would have found useful to know in the past before hand when I was doing my skis, Um, and actually, before I started can never liked him. Me. Okay, Really? Can you guys see me? Okay. Yes. Okay. Perfect. Cold. Okay, uh, I'll start off with the history side of things. So with the gynie and obstetrics history, when it actually comes to the scenario itself, it's not necessarily going to be that obvious that it will be, ah, gynie history. Or like, um, obstetrics history. For the most part, I would probably just be like an abdomen pain presentation, so it might be, like, quite obscure. But it's important that once you've sort of, like, figured out that this could potentially be like a guy need presentation or an obstetrics presentation that you have your system that you want to work through. So I sort of got this from the ski stop books. I'm sure most of you have this by now on, Dave got a good sort of break down as to how to tackle either like a gyne history or in obstetrics history. So some of the key things that you don't want to miss out after you've explored the history of presenting complaint is your system review. So they sort of mentioned as the full piece of your pee pee bleeding PV discharge, pain and pregnancy. And they're actually for I'd say, four really good symptoms toe. Always ask about because it just helps you rule out a lot of differentials or rule in a lot of differentials. A swell. So whenever you've got a sort of dining related case on obstetrics related case, it's always good to truck in those four questions in your systems of you. Um, when it comes to the dining, history is slightly more different. And as to what you need to focus on, so ask a bit more about their menstrual history s. Oh, just last day of menstrual period. If they're regular things like that. Heavy flow pain, um, obstetric history. You're gonna ask about every any previous pregnancies at topics miscarriages, um, terminations, things like that sexual history is something that you can easily miss out. But try not to forget to ask about seeing if they're sexually active. If they're using protection on, do also finally, just like contraception. Asking if they're on any of those as that can also cause like side effects. And if they're up to date with destiny is and then moving onto the obstetric side of the history. So it is slightly different on as to what you're going to focus on. I would still do the systems of you. So you're sort of four peas. Find out this all that gravida and para. But then you want to explore a bit more about the this current pregnancy itself. If they've had any problems, any sort of complications, admissions related to this pregnancy and past pregnancies as well. Um, and then also it's always handy to find out a bit more about Children if they had any. If they've got any problems or had any problems with their pregnancies as well and say Yeah, that's sort of like an overview off the labs and gynie sort of history side of things, so make sure you do have a structure and at a minimum, ask those four peas. So moving onto the investigations again, it's gonna very depending on the presentation and what actually comes up. But as a sort of like general rule of thumb, these are the ones that I kept having toe say quite a lot. So I'd always have it in the back of my head on, So the way I sort of like, split my investigations. It might be a bit different other people, because they like boxes. But I do sort bedside bloods, imaging, and then special tests s O by the bedside. I include all the examinations I want to do. So either of like I'd say either GI I or like a obstetric abdominal examination by manual and then speculum swabs is always useful. Just so, like, say, to rule out infection, I either say just like double or triple swaps. I know you saw got like the endo serve. I call on the high vaginal, but I feel like that could just be a bit of like a a tongue twister. And in in the skis, you do just want to keep it really simple and just say what flows off of your head. So when you've got your notes as well, just try and make the language as simple as possible. So I just say, like double swabs or triples ones. Um, pregnancy tests, please. Please don't forget to say pregnancy test If you've got potential like, say, ectopic pregnancy because that could then come up that could them potentially be a safe dealer as something that you've missed as that, even though I'm sure that's something that you would have considered, Uh, your analysis is Well, UTI presentations overlap quite a bit with gynie presentations. So that's a noise. Um, a good one to chuck in. Um, a set of obs is usually especially if it's quite an acute presentation and pregnancy wise. CT G's, um, moving on two bloods. I would just say as a reminder. Try not to over investigate examiners like deep a couple lists. Eso say what you do, what blood you do actually need. Um, so for the most part, I would say an F B C is useful CRP and clotting as well. For so like I need obstetrics presentations. Um, if it's more acute, you want to Chucky like a group and save cross match, Um, and then also be to hate c g a swell if you're safe, for example, coring an ectopic and then moving on to imaging. So either pelvic or trans vaginal public is what you tend to go to first just because it's like, less invasive. But I think transvaginal can give you a better picture so it could be so first line in some in some cases, no, I got a question. What's the difference between double swabs and triple swabs? Um, so I think they just test like four different bacteria I can't exactly remember off the top of my head. Um, but I think one say we'll test for, like, 60 Media Gonorrhea BV and then the triple swab. We'll just test for an extra and extra sort of infection down below. But I'd have to check exactly which one it is, and but it just varies, really, depending on which sort of like hospital trust. So that's why I just say either double or triple swell. But I can get the exact answer for you at the end. Um, and then finally, special tests will be like a laparoscopy. It's not always needed and I wouldn't always jump in and just say that, especially if you've got sort of, like quite a vague presentation. So just work for it systematically. Okay, well into the next slide. So in terms of like your potential gynie differentials, which I feel like I could come up, um, in terms of like, different presentations, I'd say like yourself, like painful periods and heavy periods would be like a potential presentation that's, like quite common. And that led to like fibroids or ending The traces, um, very insists is, Well, they're quite common. And then your post menopausal bleeding. That's quite a common gynie presentation so that we do to endometrial cancer and the mutual hyperplasia. And then you've got, like your postcoital bleeding at a bit harsher bio. It's always like having like cover is the infertility and you're sort of like PCOS presentations off like a menorrhea and all ago, menorrhea, um, from the from looking at past Asians. I don't think it's come up before, but I did always something to be aware of. And then, in terms of like, pharmacology sided things, it would be contraception and hate Chart e any of the like counseling someone that wants to start on contraception or hate our teachers. I think that's what there is quite a bit to discuss with that I'm not going to cover in this session because it is pretty much just sort of learning the content and then just practicing with friends. So and I'll be sort of covering more like interactive cases where you're taking a history, Um, and then finally, also, like, pee ideas Well, and in terms of like this sort of less likely things that I think personally would be less likely to come up. That was most of like your ST I your prolapse incontinence like they still come under Dyne and they are seeing. But in terms of like, what would make a good excuse, a shin and what you could get a lot out of a history, I'd say less so. These off conditions, which is why I've put them in the less likely but still try and cover, at least like briefly cover everything. But like I say so, focus on things that would make a better escape resident a shin if that makes sense, okay, and then for obstetrics is well, like those of things can happen in obstetrics, but in terms of like what you'd be expected, Teo know as a medical student and what would be expected to sort of like people to pick up and manage? I did. These were the These are the things that would tend to come up in in this case scenario. So you're antepartum hemorrhoid, your postpartum hemorrhage, ectopic pregnancies, pretty clump shirt, and then less likely. But I think has also come up in the past. Is gestation diabetes and high, permissive read. Um, but I take those top for are your more more common things that would come up and it's And these four are also, like, quite good when it comes to doing things I can ask for and stuff so that could be like your potential communication station. Um, so in terms of like my management, So I started to stick to, like, the conservative medical and surgical, But I also just struck in, like, right at the top, like what I'm going to do immediately, which is either I'm going to, like, admit the patient. Um, you're sort of 80. Assessment. Refer them to whichever team and then what I do, like conservatively. So basically all myself, like non medical management. I chuck in there, your medical management, your surgical or procedural management and then also holistic management s. So that's something as well that can be overlooked and is, um could give you, like, quite good points when it comes to skis, because it's you're thinking off the patient as a whole. So I'll touch when it when we go through the cases. But I'd say like holistic management's important, too. And then finally, just sort of like things not to miss. So when it comes to our obs and gynie, safeguarding is quite an important thing. Toe not forget. Um, especially like with obstetrics of domestic abuse, that sort of that can overlap quite a bit. And you you see a lot in practice, it's asked. Routinely, domestic abuse is asked about routinely. And if that's something you ever worried about in your SK station on, and even in real life, like it's something that you do, you want to try and not Ms and be cautious about, so always worry and like flag up domestic abuse to your senior, that's something you're worried about. A presentation off a younger female, Um, he has come in with, like, an STD presentation or a pregnancy presentation. Um, that you're potentially worried about. We'll flag that up is well to your senior a swell on. But even if you don't get it in the actual history but it's something you're still worried about, mention it in your summary or mention it in your management. Um, asking about like, recess status is, Well, um, I think it's quite important because you need to know whether we whether or not you need to give, like, anti d, um, sexual history as well. I got marked down for this by you need to not forget one not forget to ask about their sexual history, but also not assume someone sexuality is well, s o for my for my, uh, in my ski. I had, um and a very intelligent I was trying to rule out an ectopic, and I sort of like jump to the conclusion that her partner was male when it was actually when she was actually female. So just make sure that you're not so like jumping to conclusions about these sort of things as well. Mm Blood transfusions as well again, making assumptions. You can't just assume that someone actually wants to have blood products if they need them. So if he can always, um, mentioned that too. Um, I understand you aren't able to do a journal Examinations implicit previa. Um, are you able to do trans vaginal ultrasound scan? I'm uh huh. Good question. Good question. Uh, yeah, that was my next point. I was going to say you don't miss out a swell, um, in terms of, like doing a transvaginal ultrasound scan, logically it. And it's sort of like the same mood, like sort of maneuver so it could solve. And, hey, could potentially, like, precipitate more bleeding. So I'd say you would want to be, like, cautious about it, but I'm not 100% sure. So, um, I'd have to I'd have to double check that. And but logically, I would I would probably be quite cautious about doing a transfered, right? Transvaginal ultrasound scan. Um, and then but yes. So that's an important one. Not to forget as well. I did say earlier on you do tempted you like by manuals in most of these examinations. But placenta previa is the one that you really don't want to do it in. And also being more cautious about doing them in ectopics A swell just because you don't wanna potentially rupture the ectopic. Um, how long is it going to last? Um, mental finish at 7. 30. And I'm I think you have to ask the admin. It's if the slides will be available. Uh, I'll happiness. I'm happy to send over my slides. Um, but I should be finishing around 7. 30. Okay. Eso We'll start with some cases now. Eso want this to be as like, interactive is possible just so that you guys can get asthma as you can from it on. Do also just say it's like actually testing you. Active recall is well on. And it's not just me talking at you for the next hour. I did. The introduction was less interactive, but that was really just the sort of, like cover the main points. But yeah, for these off, I'll cover the sort of, like, five cases, five common cases that can come up in obs and gynie, and you just get involved on the chart. Um, and I just put out some questions. Uh, can you deep by manual examination and placental abruption. Ah, in placental abruption. Yes. Well, facet previa visit previa. I'm I'm no 100% sure. Far as the premium, but percentile abruption. And for the most, for the most part, what I've heard is just placenta previa, I think has a previous, unlike eater come up. It would be presented previa like percentile abruption. So I just worry about these two. Okay, um, before I start the cases, Is there Are there any other questions? Okay. Who? Okay, let's get started. Okay, So the first case is a 15 year old female who presents to any with a four hour history off acute abdominal pain. So with this case, I want you guys to tell me what sort of things you'd want to ask about in the history and things You don't wanna miss diagnoses that you don't want to miss. If you just pop it in the chart and we can just talk about it. Socrates yet that's great topics. Are they sexually active? Good sexual history, pregnancy. Say you're asking about their last menstrual period. Appendicitis is a good one that you don't want to miss out a very intelligent. Yep. So they're very intelligent. You want to ask about when the pain actually started? So if it started off with a particular movement that can put you towards that a bit more have their periods started. Gray miscarriage, menstrual history, P i d. Wonderful age of partner. That's that. That's a good one. To not forget A swell because she is 15 years old. And if she is actually active, um, that could be a a safe guarding concern. Um, DKA definitely fever, systematic symptoms. ST I history great and late laser stuff and and family history. Yes, I think you've made some good points. You've made some good points. And now I'll make one too, Um, a bit more about the history. So I've made the history quite brief. But essentially, she was experiencing right now quadrant pain for the past few days. But today was a lot more severe. The only other symptom she really had was some brown discharge. She is sexually active, and she has a boyfriend who's 15 years old. Um and her last menstrual period was eight weeks ago. Should have a past medical history or drug history, but she is known to social services and safe card. Okay, So based off of that, um, what would you guys say? What is your sort of, like top differential topic? Miscarriage, ectopic appendicitis. It can be appendicitis yet. Great. Um, yeah. Perfect. So ectopic would be, please. Um, yeah. So ectopic would be my first and, like, top different Jewell, but like you sort of mentioned before other differentials which would put in the chart. You've mentioned ovarian torsion Z or very insist accident. So any sort of, like rupture, hemorrhage, miscarriage, appendicitis. Not sure if anyone mentioned p i d. But yep. No P i d was mentioned and also renal colic. So it's good that you guys, um, sort of didn't just fixated on toe specifically just kind of stuff, because it can go so beyond that, too. And, yeah, really good with the differentials and in most cases, with the excuse, it is going to be pretty obvious what your top diagnosis is. But just make sure you sort of like keeping an open mind. Then you've got, like, a good, solid, soft four or five light set of differentials that you can say. Oh, and then, um how What sort of investigations. Would you like to do so? Spitting up into So about your bedside, your bloods and any imaging? What do you guys wanna do with this lady pregnancy test? Your analysis. Good swabs? Definitely. Um, Imaging. I saw a trans vaginal which wasn't scaring good blood Hate cg obs. Definitely examination speculum. Great. Say you got included. A bit of everything. I've got a malaise as well. Um, did that be less high on my priorities? Cause she's quite I'm guessing if you were you thinking about pancreatitis? Um, because she's quite young. Um, that wouldn't be something I would jump to do every but yeah, definitely. Imaging wise ultrasounds, gun Abdo or trans vaginal. Okay, I'll move on to the investigation slide. So yeah, I like you guys said you pretty much got everything by the bedside. I also include a set of labs and there haven't written it down. Um, bloods. Um, I haven't Yeah. In terms of like bloods, I would also do like a group and safe if she is hemodynamically unstable. But I did not she give that information key guys. Um but yeah, if they are potentially really on Well, they might need surgery. Always truck in a group and save serum beat. HCG was mentioned and then your pelvic trans vaginal ultrasound scan. I think someone said abdominal like, just this is just being really picky. Per like you've got abdominal and you've got, like, the pelvic ultrasound scans. We just say, like, pel pelvic ultrasound scan. That's usually what's done. Specifically, if you want to rule out an ectopic and as well as well, actually, yeah, okay, I would I would say I would start off with the pelvic. And then if nothing is found, you potentially also do an abdominal. But it would be more so pelvic to start off with and and Okay, so I've got a few more questions in the Cuban A box, can you? Two years. What does 90 social services imply? Oh, before I just kept that really vague. I do. Ah, I don't actually think too much about it. Like it It could be anything that could just be, like troubles at home, or she just could have um yeah, she didn't might just have, like, difficulties at home, which is why she's, like, known to social services. Um, but yet the point was just well, I link in a bit more when we sort of, like, move on to the management side of things. Um, and then in terms of how many differential situates when I presenting back took three. And I would say it's hard to put like a specific number on the amount of differentials you should less. Um, but in general, I I used to see, like, 44 or five. But if you are stuck and you can't think of anything else like that sensible, then just say If you could just say three, then just say your top three like that's fine. Like there isn't a specific number. They have four or five s Fine. Um, de miscarriages typically cause pain, and I think they did it trying to think, Oh, miscarriages from the ones that I have seen, like some can be quite painful because you are like expelling the products off conception so they cut. They can be quite painful. Yeah, um, I'm just trying to think if there are any instances where it's not painful, but for the most part, like miscarriages, um, top painful and but yeah, just I just putting it out there. If anyone in the A C team can like onto the questions a bit better and have got, like, their notes and stuff to back it up, that be really helpful. And but, Yeah, I would say miscarriages, all thankful. Um, okay. Check if there's anything else in the child. Ms. Miscarriages are asymptomatic yet, so I think that's the one I was thinking about. And perhaps thing inevitable are more painful. Okay. See you guys. He does a great, very helpful. Perfect. Yeah. So in some sort of like miscarriages, they are painful. And in the Ms miscarriages, where you just sort of like, don't get any symptoms and it and it's already sort of past, and that's when it's asymptomatic. Ah, but yeah, so it just varies. Some of the type of miscarriage actually is a I think you guys Megan munchies for that. Okay. Living on to the management. Uh, so he took her little quick break, but for the management often ectopic. And if this patient was humor dynamically stable, how would you want to manage this case? Your upper oscopy and D and C uh, I wasn't not sure what you mean by that methotrex a that president Hot be expected. Medical. So she's so She's hemodynamically unstable. Um, and she's in a lot of pain. A t e IV fluids, laparoscope e Yeah, across the p analgesia. Yep. So in this case, because she is hemodynamically unstable, you are gonna go straight for your surgical management. So you pick one of the three you pick expectant management, medical management or surgical management. If they're not stable, you jump and they're in a lot of pain, and it's really severe. And you're clearing a ruptured ectopic. You go straight to your sort of surgical management. Otherwise, um, I think it depends on the B to hate C G levels. If it's less than 1500 you do the expectant management. If it's more than 1500 then you do your medical management, which is your methotrexate and things like that. But if they're, if they're not well, if they're, he moved on it again stable. The reason why you're jumping straight to surgical management is because that's you're worried that this a ruptured ectopic, they're going to get very unwell very quickly if you don't operate on them soon. So in this case, you go straight for the laparoscope e. So splitting up into the sort of, like, immediate stuff immediately, I'm gonna admit this patient into hospital taken 80 approach and get her reviewed by one of the senior obstetrics and in the one of the senior obstetricians. So that's what what I would do in the immediate management and then moving on to the surgical, um, conservative s. So that's why I put all myself like non medical management. Is that t logical? Kanye's get them fluid, resuscitated and then get them prepped for surgery a swells and make them know by mouth group and save cross match and truck in your like DVT prophylaxis is and analgesia is important to not forget an anti d if she is recess negative and laparotomy let you guys said, or you can do like a laproscopic salpingectomy like both options are fine. Um, And then So this is where I was trying to bring in, like this sort of like, holistic side of things and like, um, no into social services. Um, so it's just important that, you know, she was a 15 year old girl. I would potentially flag up as a safe guarding concern. Talk to her about potentially being on sort of like long term contraception. Follow just she'd have a potentially like a follow up. It's one of the obstetricians and update social services. So, um, it wasn't really important exactly what it was that she was named to social services by. But if you do have something like that in the history, it's important that you bring it back in the management and it's off liaise with different teams. So that's why I like the Hillis stick side of things is important and thinking about the patient as a whole facing Poulton. Um, so I got a few other questions. What's that? Is there an age limit for doing by manual and speculum examinations, for example, can you any perform these in older than that in years old? I actually, um no, I don't No, no one's ever asked me that question, and I've never thought about that. Say, um, by manual. I've seen by my new done in a child that was quite young, and but I don't know if there's an age limit. Specifically, I think if it needs to be that done, then it needs to be done, but I don't know if there's a specific, like cut off a a lower cut off for a judge. Um, what's the difference between expectant medical and surgical treatment for extra pit? Um, expectant management is sort of your watch and wait approach eso You're not actually doing anything you're just actively monitoring on the patient. So that's when the symptoms aren't too severe. They're stable and and then and you'll be too hasty. Gee, levels are below the sort of 1500 and, uh, and then moving on to the sort of medical management that's your methotrexate. And you tend to give that when maybe they're in a bit more pain and they're sort of like specific a zit, like a specific measurement. I think it's like 3.5 centimeter is also on the ultrasound scan and the B to hate CG, um, is above this or 1500 mark, and then your surgical treatment is what we've just covered. Um, yeah, that's a good table for that on past medicine somewhere which off, like breaks it down and into sort of expected medical and surgical um, work. What conditions are by manual is back your examination's contra indicated So contraindications. The main one that I know in that med school have told us is presented previa. And then you would just be cautious about doing it if you if you've got, like, quite a a bad ectopic. Because it could potentially rupture the ectopic, so you would just do it very gently. I think it's like a a relative contraindication. Not like an absolute one. Electoral picks. Um, here depends on the size of the uterus and fetal heart. Be exactly on do what is expectant and conservative Surgical is expected. Um, see, a, um, neti do mine like sciatic sort of just went through the expectant medical and conservative. Was that Was that clear enough, or do you want me to go through it again? Okay. Perfect. Cool. Yeah. So it's not Yeah, it doesn't. It's not the Yeah, You just split it into expectant medical and then surgical. But in this case, we're sort of treating Were going straight for surgical because she's acutely. Um oh, okay. All right. Um, there's a couple other questions on the chat so you can give 2. 50 can give 500. Um, you get like, you can get 500. It's not just basically, the point is just to give, like, fluid resuscitation. Um, how would you know if the patient is need to social services? Um, it's just always like I just put it in the history. Just, uh, mention it. But you can ask, and especially in the peace history can just ask, like, you know, how are things going at home and tease out that way if you feel like something. And if, like, if they're home, life is yeah, yes, that if this stuff going on in their home life, Um, see if you could find that you but usually find out that way in the social history, or like through asking about school and home friends and family. And what kind of DVT prophylaxis wouldn't be giving, um, full surgery? It's usually low molecular weight heparin, but again does not. They wouldn't be asking you specifically. You even need to specifically mention which one you'd give. But I just say as a whole, when you say proper patient for surgery, you want to mention these four things. Um, how would you differentiate between an ectopic and a miscarriage and good question eso with an ectopic pregnancy. It's an extra uteri in pregnancy. So when you do the public ultrasound scan, you're not going to see any sort of like products of conception in the in the in the uterus. So that's why that's how you're gonna different you between a neck topic and a miscarriage. Okay, so I'm just going to move on now. Otherwise, and we might spend too long on each case. Um, And if you've got any other questions, um, I'll just answer them at the end. Or, um, someone from the ACE it team can also just answer as we go along. Otherwise, it might take it. This session might take a bit too long. Okay, Meeting on t the next light. So, in case to we're just going to jump straight into the history. So So you've got 45 year old woman who has ah, five day history off a low grade fever, lower abdominal pain, pain during intercourse, sexually active. She's sexually active with the husband only. And her last menstrual period was two weeks ago. Um, past medical history. She's asthmatic, takes, um and she takes, um, inhalers. Um, she's a long smoker and nondrinker. And on examination, she's got a vaginal discharge. And so what would be your differentials? Full this presentation. Okay. ST I b i d. They can't did. Ah, cheaper. Very an abscess. Great. P i d ectopic e t i a great pilot nephritis that several collect trippy and And any traces, baby to status. Yeah. Perfect. Say all really good differentials. Sorry. More really good differential. So the ones that I've also got the outset p i d e s t i e t I a little mention thrush, endometriosis and potentially an ectopic pregnancy. Um, so, based off of these differentials, how would you wanna investigate this patient to get to your top differential? Yeah. Abdominal exam by manuals Back, um, triple. So definitely swabs your analysis. Yeah. Pregnancy tests. Always good to get some of our labs CRP. Yep. You might potentially want to do an ultrasound scan. Great. So yep, by the bedside. Definitely. Want to get some swabs done as ST I still going to be S t i p. Idea of going to be high on your list. Urine dip, pregnancy. Um, also, if you're creating, like, an ST I, it's always good to just do a blood test. A swell, um, to rule out like blood borne viruses. So, like your hate driving your syphilis, I wouldn't jump to do a transvaginal ultrasound scan, but, um, if there were sort of, like, really cervicis symptoms, um, or you were a bit unsure about, like, the diagnosis you could potentially do trans vaginal, but to start off with, I would I would have just done this off. Swabs you're in debt, pregnancy test and blood. Um, so say the patient comes back and they test positive for, um, chlamydia. And they're diagnosed with P I d. How would you manage a case with P i d and yeah, on TV about it. Ticks doxy. Yeah, I know. Geez. Yeah. Uh, yeah. Fluids, I guess. Um oh, she is in the escalation. You be given a bit more information on the actual state of the patient, so we'll say she's stable at the moment. Okay. Yes, it's safe. She is stable, yet we just We just want to give the antibiotics G um, gp follow up. Yeah. That's sort of your mainstay of management abstaining from sex until he'll, um until fully treated treat. Partner, partner. Notification. Good contact. Tracing. Um Yep. Great. Um yes, a conservative off. So I was meant to put that on the other slide. But yet your conservative just rest. If they are in quite off pain, avoid sexual intercourse until they've done the 14 days of treatment and contact tracing that you guys mentioned Analgesia is really important. And you give your triple course therapy. So you give you I am kept track saying, which is just like a one off days, and then your doxy, our metronidazole and and then surgical management is only indicated if those a knob struck shin on. And that's the sort of like people cannulation. But that's quite like specialists, I would say, for the most part, isn't usually required. Um, and then just holistic. Just give a contraception advice is, well, especially advice about, like, barrier methods and just follow up like you guys mentioned. Is this how you treat PRID from any cause, or is it specific to chlamydia? Um, so with P i d u give s o p i d is just you. You basically try and cover all the bugs, which is why you give your three antibiotics. So that's off covers your chlamydia, your gonorrhea BV, Trichomoniasis. It just covers everything basically. And that's just how P I d. Is, um, treated standardly in the e k. And you have to say all three anti but antibiotics to get the marks in the station. Um, I mean, if you call, if you can't remember them, then you can remember them. It would be good to, say the three antibiotics, But if you know, and you can just remember that you would give her antibiotics than then you can say that. I'm sure you would still get some marks for that. Yeah, no BV is bacterial vaginitis is so that that coworkers quite a lot off with ST I says. Well, okay. And then just in terms of like the second part of the management. So you might want to then admit the patient if there's a risk of like a topic in there. So the test positive for the pregnancy test. If they've got quite severe symptoms that nausea, vomiting, high fever, they've got peritonitis, they're unresponsive. Teo, your antibiotic treatment so then might need IV therapy on def. Say surgical emergency can't be ruled out so it can present quite similarly like appendicitis, for example, can present quite similarly. So if you're still worried that that that could also be differential, then that's what you might consider admission and then complications. It's always good to sort of know. And they could just be like a five. A question at the end. Um, as like a complication of P i. D. So your topics Infertility cheaper. Very an abscess, chronic pelvic pain. And then your peri hepatic adhesions. What is the end? Ah, not sure. Wherever in that and of it to three antibiotics. So two of the antibiotics are oral. One is I am Okay. Okay. So just so that we can keep the time, I'll quickly go through the last two cases. I don't think we'll have time for the fifth one, but yes. So you've got a 33 year old lady presents to the obstetric assessment unit with abdominal pain and vaginal bleeding. So if they come in with these two symptoms, what sort of things do you want to ask about in the history cuts? Yep. Socrates, How many weeks is she pregnant? Definitely quantifying the blood. Yeah, I was also the old blood. Is it new blood? Yep. Color of the blood. Fetal movements, previous pregnancies, smoking, drinking, recess status. Very, very important is the bleeding is bleeding really from the vagina. That's another good point as well. Move if there were any any triggers to it. History of fibroids. History of percent previa or rupture? Yes, so less of good points mentioned. Um, any trauma as well that might have triggered it as well. Um, also, she's quite far along in the pregnancy. Um, if she's had any, like if she's experiencing any contractions, a swell, um, safeguarding issues, yes. And if she's lost, um, if she's like lost whole is that the blood loss of water is basically if her What if her was broken? That's the word. Yes. So you also want to ask about that as well. Um, as she could just be going into labor. Um, so bit more about the history. So she's GTP zero. Um, she the the abdominal pains been going on for about six hours and the vaginal bleeding quite like, um, and read. She's 13 weeks pregnant so quite far along in her pregnancy, hasn't had any issues She just had one miscarriage Previously, Um, she's suffers from hypertension, but she's on the beetle. She's treated with the beautiful. Oh, and she smokes five cigarettes a day. Currently. So, uh, what would your differentials be with a history like this? Placental abruption, Miscarriage abruption. Pretty clumsy, uh, percent of previa. So I collect Ray PN yet? Yeah, yes, a in P i d. So good. She's 30 30 weeks pregnant, and she's presented with some vaginal bleeding. This most likely is gonna be, um, a pH. But there's other other other things you want to consider a swell. So move on to the differentials. They like you guys mentioned the central abruption percent of previous two things we don't wanna miss. She could just also be going into, like, preterm labor. A swell. You do get a bit of bleeding And also obviously abdominal pain when you go into labor. Um, and like you guys mentioned, the sort of, like, lower genital tract leading a swell is Louise, Um, something to consider? Um, so, based off of this, what investigations with GI guys want todo because a bedside bloods imaging. Okay, CTG definitely. Ultrasound scan group and save cry. Hardly test. Yep. That's really good, because it's a possible, like sensitizing event expected, um, exam yet? Fbc lefties. Great. Perfect. So you'd want Teo? Yep. You'd want to rule out a placenta previa before you do, or you're sort of like by manual stuff. Uh, first, recheck BP doing with an ultrasound scan. Okay, great. Um so will move. So, investigations wise. Also, just don't forget to do, like, a sort of like, general. Um, you just just like a general examination, like top to toe examination. Um, just looking for any, like, pallor distress, like CRT. Just because they've presented with a bit off, like blood loss. And you want to always think about placental abruption. Um, abdominal speculum by minute by manual. Like I mentioned only after the center previous excluded. Um, ctg, You guys have mentioned that off. Um, and then you want to do enough? Your fbc lft is clotting as well, because that can occur. Um, you can get the I see. Um, in placental abruption. Quite. Howard test was mentioned group. It's even cross match and pelvic ultrasounds. Gun. Um, say yeah. Say does perfect ultrasounds can rule out the center Previa. Yeah, you can see you do the Yeah. Essentially, your answer is yes. Yeah, eso Quite how a test is basically a test to see how many antibodies anti antibodies you've got. Um, and it's given in women that are resistant. Gatilov that have a recent positive baby Teo. Um, just calculate how much anti D is needed. Because when you've got an event like this, a potential sensitizing event, um, you need to give anti d to the mother. Okay. So quickly, get through this, um, case, uh, CIA, the diagnosis full, We'll skip to it now. But yet the diagnosis for this lady was a central abruption. And on examination, she had she was inquired of shocked out, keeping out of keeping with, like, the visual loss I'm She had quite a soft, like, tender, hard uterus. And the pain was really intense and quite constant. Um, and so just looking at the picture of what placental abruption actually is that I'm quite visual learners. It helps me like to understand why you get the symptoms that you do on by. You actually get so little bleeding. But the patient presents so acute young Well, because you have that sort of like internal bleeding. And then that also gives your so tender heart. You're tender hardware. The abdomen. Yeah, you were doing abdominal exam. See that? You can feel the how sort of like if it's like a sort of like soft abdomen or if it's quite hard, that's going to bring you more more towards an abruption rather than and say presented previa. Okay, so a moving onto the management off percentile abruption. So say, for example, for this lady. She's acutely unwell. She's in shock, and she's in a lot of pain. Um, how you going to manage the case of percent aloe abruption? She's 30 weeks pregnant. This well, have you fluids? Yep. A T e. Topical isis school surgeons analgesia arrange for Nicky across much group and save. Yep. You do. CTG don't want it to the baby. Uh huh. Steroids. Major hemorrhage. Critical. Perfect. Great. So management of percentile abruption like you guys mentioned, you take 80 taking 80 approach, get IV access, get seen your support from the obstetrician midwife and also a lot Nikki, because the baby's going to be if it is quite a bit of fetal distress, the baby's gonna be born quite prematurely and going to have to be admitted to the NICU and then resuscitating the patient. Giving blood products is well, um, monitoring. And in terms of, like, the definitive management, it's gonna be either inducing labor or if there's, like, maternal fetal compromised than they're gonna have to have a name, urgency delivery and then just holistically smoking cessation for the mother. A swell. Okay, so living on two case before. So you've got a 31 year old female who's suffering from pain, severe pain during menstruation, So Okay, um, so what sort of things do you want to consider in the history? Yeah, yet new paying Socrates how long it's been going on for painting? Intercourse? Yes. Um, menstration history. If they're up to date with this Ms Great primary or secondary dysmenorrhea bleeding discharge. Yeah, you're sort of just your typical gynie history. After you explored the history of presenting complaint contraception what they're doing to manage the pain. Perfect. Okay. Into menstrual bleeding postcoital be cooked fertility plans in pregnancy. Yep. That's that's really important as well. If he couldn't fit that in, um, perfect calls, I'll just go into a bit more off the history. Ah, say, yeah. She's was actually been tricked. She had been trying to conceive for with her partner for the past three years, but she been struggling. She's also, like we mentioned, suffering from quite painful periods and pelvic pain. But I had always put this down to sort of her very insists, which was just managed conservatively, Um, drug history. Yes. I could just also add in there. Maybe she takes, um, over the counter medications for the pain. Paracetamol, ibuprofen, but nothing else. And she's a nonsmoker and a non drinker. So with that history, I know you guys have trucked in some differentials already, but are there any other differentials? Okay. Is there any other differentials that you guys would like to mention? Yep. Endometriosis is Ethio s red. The generation I think it's what you meant over fibrate onda dysfunctional. You try and bleeding very much yet Could be that, um, fiber aids at a name? Isis. Perfect. Um, yes. A endometriosis is on afternoon. My says I always put them two together. Five grades, potentially simply. It could be p i. D. Less likely book could also be p I d. And a very insist that is her ovarian cyst might just progress. Um, I think with my knees always good to check in a few, like non gynie different. Just well, just to show that you're keeping an open mind and, you know, you're thinking about, um you just think about differentials beyond the most obvious, like diagnosis. Say, I'd also distracted maybe like, cystitis, so it could just be, like, really severe IBSS is less likely, but just always got to think about non gynie differentials to, um in terms of investigations with push matzos. Well, yep. Um, how do you differentiate between and any traces on? Add in a my isis. Um, so with endometriosis is, um, this diagnosed like napa laparoscope laproscopically. And you see their league? The lesions, like outside off the uterus. Where is adeno? My eyes. This is seen like within the actual muscles off the the uterus. Like the muscle of the uterus. Yeah. Um, I guess you could differentiate that using ultrasound scan or laparoscopy? Um, yeah, moving onto the how you would investigate it, or is he touched on it a little bit now, but, um, any other investigations you'd like to do and yeah, any. Any other investigations? Ah, that you'd want a dif, um, if you were considering And any traces. Oh, fiber. AIDS this public ultrasound scan laparoscopies gold standard. Yep. Trans vaginal ultrasound scan. Great. Swab. F B c crp. Fbc to check anemia. Yeah, your analysis. Great. So, yeah, the ones that I've got abdominal exam by manual examination, speculum and then also, you just don't always, like, rule out pregnancy. Um, because they have been trying to conceive, uh, your analysis, uh, trans vaginal ultrasound scan, I think is the best off imaging to do in this case. And you guys said laparoscopy is the gold standard. Uh, can we go quickly over the fifth case? Yeah. I think we actually have time. Let me skip through. I'll just quickly skip through the management and talk through it. Um What? Um, it certainly it would be a bit less interactive, but so in this case, she was well, say she was diagnosed with endometriosis. Is so terms of like the immediate thing you're gonna want to do Say she sat there in a GP surgery. You want to make a referral to gynecology and then splitting up into, like the sort of conservative medical surgical. Um, if the if it's if it's not causing him any problems, which always in this case it actually is. You can just sort of monitor watching may offer the patient simple analgesia if it is, if they are sort of experiencing a lot of pain. So your paracetamol your and said's, um, To be fair, this would be more into like the whole list. Excited things but like chronic pain support, um, groups and endometriosis is best having an endometriosis like specialist on do, also referring them for fertility treatment. Um, in terms of like the medical management, the first line that you give is your combined or contraceptive pill or progestin gyn contraceptives as well. Um, such as like the i us or the depot or just the mini pill. And then, alternatively, if they are trying to get pregnant, which in this case they are ah generate agonist can be given, um, as well. And then in terms like the surgical management, you basically just want to get rid off the endometriosis lesions, and that can help a bit with, like, fertility, a swell, um but definitively is a hysterectomy and self control. You corrected me. So obviously you want to do that after the patient doesn't no longer wants to have any Children. Okay, so you're living on to the last case quickly. Oh, so just like and stepover less. But I was just gonna just say when it comes to sort of like a bleeding presentation in a non pregnant woman, it's just make sure you do get from the history of presenting complaint a clear picture off, whether it's heavy bleeding, postcoital bleeding, a post menopausal bleeding presentation or interventional bleeding because that can just really help narrow down your diagnoses, your differential diagnoses. So just ask the right questions or you've got a clear picture in your head as toe. What kind of bleeding? What kind of soft? Like I need leading you've actually got here. It's everything onto the last case, eh? So you've got a 33 old woman who presents 35 weeks gestation with a severe headache, acute right up down upper abdominal pain. All scans have been normal in previous investigations have come back. There's normal today. Her only like past medical history, isn't up. Appendectomy at 17 years old. Nothing else off know in the history, I'm say based off this. What? Ah, what differentials? Um, come to mind? Yes. Pre cum shirt, a tension headache, help. Pre cum shirt. Existing hypertension? Yeah, a clump shirt, cola, sister, tissue station. Hypertension. Great. Yeah. Yes, it with this sort of presentation, is quiet. Like it's pretty obvious what it's going to be, but yeah, pretty much is definitely gonna be at the top of your list. Oh, on it. So just to add on examination, her BP was also 165 over 110. And how your analysis showed some protein urea. So we know from this what the diagnosis is going to be, Um, but just when you work station like this, where you it's really obvious what the diagnosis is. You know, it's still sort of like Chuck in your other other things that it could be. So if you mentioned you guys mentioned you're pretty country, your gestational hypertension or just existing hypertension. But if because of the headache, you could just say also could be due to a tension headache or migraine and abdominal pain the right upper quadrant abdominal pain, a liver or gallbladder pathology. So, yeah, sometimes there isn't much to much to say. Um, so yeah, you could just add in a differential about the others off main. Presenting complaint. Okay. Okay. And then moving on. To what investigations would you like to do if you've got a lady with preeclampsia? Yes. Protein to creatinine in pressure. Lefties. Urine be PFB. CNN tease. Yeah, co agree pins even cross match. Um, I would check. Ah, allotting I wouldn't do a group and save and cross match just yet unless they were keeping and unload. Um, your exam CTG Yeah. Okay. Cool. Oh, my mouse is playing up. Okay. Uh, yes. Examination. Wise deal of set of them legs. Um um then your new exam is well ah, you get a urine sample to check for any protein, or you could do the albumin creatinine ratio set of ob ctg Let you guys mention F B C's and D's, um, lefties. You know, you're looking out for your potential Help Complications there. Um, So, like your low platelets, elevated liver enzymes and low hemoglobin due to human isis. Um, and then also don't forget for imaging as Well, you want to just do like, um, an ultrasound scan. Um, toe, look at the fetus and then do a Doppler as well of the uterine artery, because what you'll see is like, impaired flow and yet plotting. Well, say, for D. I see, um, in terms of the management, uh, he's quit. Least get back, eh? So what's just the mainstay of management? Full preeclampsia. So, like the medical management and the definitive management. You guys want to check that into the chocolate key? Libby till Oh, yeah. You want to get the BP down yet? Let me slow, nifedipine. Yes, See? Yep. Monitoring the baby and the definitive is delivery perfect. And then your magnesium sulfate to prevent cruncher. So you have Those are the main things I see took through it. But yeah, if you've got a moderate sleep, recapture a lot of it's just gonna involve sort of like, active monitoring. In most cases, they will be in in just because they do need to keep a close eye on the baby, do regular CT gs, do regular like Doppler scans of like the uterine artery and and just trying to get their BP down as much as possible. But like I said, first line is labetalol Oh, I otherwise hydralazine And the fallopian can also be given, um, magnesium sulfate a, um, for you to prevent your clumps shirt and your cortico steroids. And then surgical management is going to be delivering the baby that's going to essentially be the mainstay, like the definitive management. Sorry, but also secondary prevention after if they have had preeclampsia and you give like aspirin from 12 weeks until the breath of the baby in the following pregnancy. Um, and then what? Your main complications that he get following pre cum shirt. But you can get what the steroids for. Oh, so the steroids are given because if the baby's just born prematurely, which can often happen in like pre cancer in the lungs aren't developed properly, so it just sort of helps to prevent. Yeah, just basically helps prevent the lungs off the baby. And not so just to like developed help develop the lungs of the baby imprint on also of like premature um, deliveries. Yeah, and dexamethasone is the corticosteroid that's given, um, percent a crater. Yet that can happen. A cramp. Sure. Um Yep. Any other complications when nearly done help. Perfect entry trying growth retardation. Perfect. Complicated delivery. Yet between, like, most likely will have to do an emergency. You might have to do an emergency C section if you know, there's a lot of, like fetal distress. Um, PPH Yeah. Okay, so I just quickly move onto that slide, See a clump? Sure. That is the main one again. You treat it with what you prevent it with, so your magnesium sulfate. But the ultimate management is similar to pre cum sugar. Same with help syndrome, Um, and then other complications of entry trying growth retardation. Like you guys said prematurity. Um, and you get placental abruption Z and in the mother stroke renal failure, pulmonary edema. Um, but yeah, it's a country and help our e main ones and back. That's it. Thank you, guys for for the ones that stayed Toby and thank you guys for sticking around. And it's like revision sessions could be a bit long and tedious. But I hope you guys find useful. And here are a couple resource Is that I just found useful. A swell, um, for my preparation for excuse And I think they've put in the, uh, feedback form and the slides. I believe he should be getting a swell. Oh, no, He's done. Yeah. Can you just say the history? Slight of the beginning. One small. Ah, this one? Yeah. Think they want the feedback link again? A swell in the case. Three investigations. Thank you guys for coming out. Just stop sharing my screen now.