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We're probably gonna wait until about three minutes past for people to start joining in. I'm surprised how many people actually registered for the session given the fact that it is the third of January. Um I think people are just very keen to do some obs and Gynae in early 2024. I thought we'd start off with this one. Because it is my absolutely least favorite thing to do. I'm not a fan, Bob Zing Goi as a specialty. We will be using venti throughout the session. So I've just popped the code in the chat there. It is also on the slides if you forget later on. Um There's a chat both obviously here, there's also a, a live chat um on mental as well. If you wanna do stuff a little bit more anonymously, I'm hoping that you can all hear me. Uh You wouldn't actually be able to answer it if like you couldn't hear me. Could you someone react to, to let me know just in case before I embarrass myself any further? Brilliant. Thank you very much. Um Cool. Ok. Um So just whilst we're waiting for people to filter and I'm going to squish us on to the next slide here. Um So you can either answer this and chat, you can go on the ment and ask it or answer it on there. Um But you're obviously here for an OBS and Gyne revision session for the ki what's the biggest concern? What's your biggest question? What's the issue with an OBS and Gynae session from your perspective so that I can make sure that we cover all of that, not actually checked if the, the ment is currently presenting. So I'll join as well just to see and yeah, the code is 47364610. It is walking. Give myself a thumbs up. Ok. Yeah. So somebody's put on the not done the Obs and Gyne placement. Yeah, it's the, it's the biggest issue for about a third of you is that not only will you not have done it by the mock for sure. A third of you won't have done your woman, child and family placement and guarantee if you have done it, you'll have only done like the pediatric half or the opposite Gyne half, meaning it's all fairly up in the air. The Psychiatry, the PMC and O block is a bit less heavy. Yes, a psychiatry station will come up and you will have to take that history. But I just think that we're taught how to take psychiatric histories a little bit earlier on. Whereas S and G impedes, sort of just get pushed to year four. And then it's suddenly you have to learn all of it. Any other things, um, biggest concern about the opposite. Gyne ones. Emergency obstetric scenarios. Yes, certainly. Fortunately when it comes to emergency scenarios with OB and G stuff is that you're just gonna go through the same emergency scenario that you would for literally anything in the sense that you're going to go, ah, call for help and then work through, um, through an A to E approach. And if you follow that structure and like I said, always say that you're getting somebody to come and help because you are junior, um, and you won't have seen anything. Um, then you're remaining safe. Hello, new people coming in. We're just answering this first question on here. You can either answer it on the chat or on ment. I've got a few answers through so far about not having started the OB and Gyne placement yet in emergency scenarios. Are there any, any questions particularly about OB and G again? I'll just put the mental code in the chat. Yeah, having to safeguard. Um, now the, if you've done the Obs and Gynae block, you've probably done that communication skills session spoilers if you're not where they present you with a really awful scenario of abusive partner, pregnant person, that sort of scenario and you have to deal with that. And the idea of that station is you don't win. Um, and they'll do it again in year five as well. Um, where they'll just give you an unwinnable station and if you have the misfortune of being assigned to that station, everyone I've seen do it has cried. Um, it is quite unfortunate. You won't be given something like that in the IY. That's just something that we keep, especially for communications concessions. Um, but yeah. Um, so yeah, when it comes to safeguarding, you just wanna make sure that you've asked in at, at the beginning of your social history. I do it in, I do safeguarding in all of my histories where I asked, who have you got with you at home? Do you feel safe at home? And then yes, you move on. Uh And you might get the occasional snarky actor, usually the men in their fifties who will be like, why wouldn't I be safe at home and then you have to defend yourself and it's kind of awkward and embarrassing that you've asked it, but you're better off asking it and feeling embarrassed rather than not asking it and missing, missing something important. And I would ask it like I said to all to all actors, to all patients. Um Because if you do start taking people with the same brush and say, you don't ask men over the age of 50 guarantee, you're gonna miss people who needed to be safeguarded. So, all right, so men's on the screen here and it'll pop up in the corner as we go through as well. But we will get started now that we've given some time for people to filter in soap again, just a little bit of a summary of this. Some of the stuff got smushed around a little bit just because there were the idea of having an ob and gurney session before the winter break wasn't particularly popular. So we've put that one here. We've got a data interpretation session next week and then that will be the last actual session that we do of teaching before. Um your mocks. We've got the next session then on the 26th, which we may change cos it's just a little bit close to your mock and you might want a little bit of a break, but we'll see what you guys think about that as we go through. So we've got Obs and Gynae this week and then I'm gonna do some stuff on data interpretation. And the reason that we're doing data interpretation is uh you guys are all probably pretty happy with the, the science of it. But what you need to be able to do is do it in your head on the fly and be able to um come up with them and have a little bit of a script for it. So that's why we're going through it and it's fairly close. Do you have some time to consolidate these lectures as we go through Um, yeah, it, like I said before. Um, if you want us to have a look at your CBD for you, we're very happy to look through them. I know a lot of people were fairly worried about the CBD after the first session that we went through. Uh, we've gone through a fair few at the moment. I know that I have, I think I have two left, um, at the moment. So if anybody does want their CBD reviewed before the mock, please do just send it through. I hope to the people that have received it back that it was useful. Um But yeah, so just my email on the screen there or you ii email you all the time. So if you, if you want this at any point, do just send it through. OK, dokey. So today we're gonna be looking at how to structure both the obstetric and the gynecological histories, the important conditions that it is that you need to know. Um as well as going through some example stations, feedback from the last session was to have more um more stations. So we've got an extra one this week. Um We also said to try and keep it a little bit shorter. So I will try my best. But as you all know, I'm a waffler, so it's a bit of a challenge. Um And yeah, I do appreciate the one person who in all of the feedback every time I ask what do you wanna see next? I always get everything you need to pass the EK. It's like three or three or four people always say the exact same thing. I'm like, I'm trying. Um So let's get on with it then. Obs Gyne history. So obviously these are two separate things. Um, an obstetric history and a gynecological history aren't the same thing. Um I'll scooch on to the next page on the mentee at the moment. What is different about an obstetric history? What's different about an history again? You can answer and chat if you would prefer what's different about an obstetric history or a G. Yeah, just an obstetric history. Um, what do we need to ask? Is it, is it advanced at all? What's different about an obstetric history? Anything? I'll repost the mental code in the chat. But like I said, if you wanna respond in the chat here, that's perfectly fine. Do we need to ask anything differently? Do we do it all the exact same as we would in the other history? I'll go over here so we can see it over here too. Look, you know, thanks for those thumbs up. I appreciate that. Um, so look, here you go. Ask about previous pregnancies. Yeah, certainly. Um, sorry. And I was like, go away. Uh, ok. Ask about previous pregnancies. Yes. Um, ask about previous previous births, mental health and any complications that have been experiencing in the current pregnancy also? In any previous pregnancies as well. Mosk. Yeah, will come on to Mosk later on. It's a really good way to structure both obstetric and gyne histories. Um, strictly speaking, Mosk is what you're supposed to use in a gynecological history. Um, but I think that it really nicely applies to both and it also applies to sexual health histories. Um, uh, if you're speaking to somebody who has, who has the ability to become pregnant and also menstruates, um have they attended all of their appointments and scans? Yep, you don't need to learn the entire like antenatal screening timetable for the issues, they won't ask you that it won't come up, but it is a good idea to know roughly will this patient have had a scan? For example, like we said, in the pediatric history, if you've got a two day old baby in the majority of babies, it's inappropriate to say, have they had all of their vaccines because the vast vast majority of patients in the UK who are two days old have not had any vaccines. Sort of a silly question to ask. Um So yeah, if you've got somebody who uh pre uh like has attended and they found out that they're pregnant, you're not gonna ask them if they had any scans, they found that they're pregnant today, that sort of thing. Uh Scans in pregnancy so far, family history of obstetric complications. Yep. And what's the big thing that we don't want to do when we're taking a history when it comes to pregnancy. If they've just found out they're pregnant. Mm. Exactly. Um, a lot of people have that instinctive reaction. If somebody tells you that they're pregnant, you go. Wow. Congratulations. Um, I'm autistic. That's why that doesn't sound very sincere. Cos, I probably wouldn't say that, but a lot of people do and yes, you've assumed that it, by saying, congratulations that they're happy with the situation that they wanted it. And you've assumed that the circumstances around the conception were positive, right? Don't assume that they are happy. Just ask a question. Like, so if somebody tells you that they're pregnant, you say, oh, and how do you feel about that? How do you feel about that is more general as well than saying like, oh, was, was it planned because then you have to sort of go down a whole separate route. But, yeah, certainly that's what's different about an obstetric history. It's a decent chunk of what we need to go through. Um, what about a Gyne history again in the chat or on the screen here? I've kept them separate because although we say obs and gy and we smoosh it altogether, they are distinctly separate systems that, well, distinctly separate histories that we need to take and different differentials that we want to be considering. Are they sexually active? And if so explore that? Yeah, certainly. Um, if they're sexually active who they are sexually active with how many people that is, um, uh, are they using contraception or any other methods? Um, and also, what kind of sex are they having? Detailed menstrual history, con contraception history and smear history. Yep. Talking about the HPV vaccination status. So now for the past couple of years or so anyone, uh, both boys and girls over the age of like, what is that? 1312, 13 now, um, should be going through the HPV vaccine. So you asked of both sexes um periods of pain, sexual history, contraception. Yep, smears discharge matress. Yeah. To be clear, I talked here a little bit about sexual histories. Sexual health histories are unlikely to come up. It is worth being aware of what you should ask and the actors won't be embarrassed by it if you do feel embarrassed by asking a question that is ok. A lot of people are very fussy when it comes to talking about sex. That's ok. It's embarrassing. Um Well, when it comes to actually doing that, you can just acknowledge the fact that you're uncomfortable in that situation. Um You can just say sorry, I feel a bit embarrassed about her. Um Not that what we're talking about is uncomfortable. Um But I'm sorry that I reacted that way and you can just continue, just apologize, just be frank. Like if you've reacted poorly, don't roll with it or lean further into it. Just just acknowledge it periods and bleeding Yeah, you want to know, uh, and pain as well as another one to ask about sexually active contraception type of sex. They're having cervical smears, safeguarding pain with sex. Any pain. Yep. Yep. And, yeah, like I said, here, it's, it's worth asking both the sex and the gender of the pa, of the partners that they're having sex with as well. Um, it's important to know gender so that you can use correct pronouns for um their partners. But also, uh you need to know what k they're presenting with, right? Um And that's also like you said, what type of sex, um, screen for red flags of gynecologic cancers? Certainly one that really gets missed in Gynae uh in my experience for students is that I think just medical students tend to think about Gynae being like young people. Um, but a decent chunk of the stuff that will come up in Gynae will be something like endometrial cancer, cervical cancer. Um, and things like vaginal atrophy, not that those can't affect young people, but they also do affect uh older people as well. And I think that's a big thing that we tend to miss. Um Right. OK. So the histories themselves, these obs and guiding ones are most likely to come up in one of these three stationss. We've talked about what these stations entail before. Um, so when we're talking about these ones, we've got the acute station, the sr and the communication skill station. Now, why have I not put the examination station on here? It would be very unlikely that you would get a pregnant person who is happy to come in and be prodded for four hours or whatever ridiculous length of the day. It is. Um, so unlikely to do that. Gynecological um could be a uh I think in my, my mock ek for example, um I had a patient presenting with that classic picture of maybe ectopic, maybe appendicitis. Therefore, that one came in as a gi examination, but you can see what I mean by like that's not a gyne focused examination. I'm just considering that as a differential diagnosis. Um Yeah, so these works most likely to come up in my is the last year. Um It was an acute station. Um Mine was pelvic inflammatory disease in a four minute history. Ok. So this is the bit of what actually we needed to ask about in the history of your obstetrics. Um This is why I don't really like obs and gyne this one in particular, the obstetric history is less similar to other histories than other specialties might be like the, you still are going to go through your presenting complaint. There's just more extra stuff that you need to consider with all of the specialties. You've got extra stuff that you need to consider. I just think the obstetrics history is the worst for it. Um But as a result because you have more other questions to ask, like with the psychiatric history in those four minute ones, they will be very simple histories for the, the majority of the rest of the history. Um So because you have to ask, for example, about the Four PS, you're less likely to have a detailed family history than you would be in a seven minute station about something else. So four PS, then I not really a fan of uh things uh acronyms where you have the same letter repeated over and over again because it's just hard to learn. Um But this is what people recommend to learn is you've got PV, bleeding PV, discharge, pain and pregnancy. So these are just four things that you want to make sure that you are covering in that presenting complaint or the history of presenting complaint. Part of an obstetric history is, do you have any bleeding down below? Have you noticed any abnormal or changes to your discharge? Do you have any pain anywhere? And then like you're talking about abdominal pain but also pain um whilst having sex? Um and is there any chance that you might be pregnant? So those four things PV, bleeding, discharge pain and pregnancy, you also specifically want to screen for both gastrointestinal and urological causes. These ones are really easily missed. Obviously, you should do your systems review and consider all of your differentials regardless. But when you're standing outside of a station and it says you have a pregnant person coming in, you tend to think about pregnancy related difference. But I want, when you're taking this history to specifically ask about common, uh, causes of both gi and neuropathology that may overlap. So I was thinking about things like ibs cancer and appendicitis or uti S and incontinence. These are the ones specifically that I think overlap quite a lot with obstetrics. You want to assess the health of the current pregnancy. So you want to be asking about the last menstrual period. Um, uh, what scans and investigations that they've had, uh, if they've had any issues at the moment and if they've had any episodes of vomiting and lastly, you want to ob obtain your obstetric history and put in brackets here. I use GMC for this, which is quite nice. You got your gravida in power, miscarriages, ectopics, terminations and living Children. So to summarize what those bits mean, remember the gravis, the number of pregnancies this person has had parity is how many fetuses they've given birth to that were more than 24 weeks, right? Um, miscarriages is topics and terminations. I hope that's all self explanatory of what those three things are. Um, and then with Children, you will know how many, how old they are. Were there any issues with the pregnancies and what were the types of delivery that you went through they went through? Oh, yeah. So it's our obstetric one. Fortunately, the overlap with the gynecological stuff fairly similar, except for the fact that a gyne history is a bit more similar to our regular history. We still wanna ask about our four PS. Remember RPV, bleeding RPV, discharge, pain and pregnancy, you still wanna ask about your Gi New Euro causes. So again, things like IBS cancer, appendicitis, anything that can affect the tummy because a lot of this stuff is internal organs, right? And then we wanna do the gynae focus which we can use MOSK for which stands for menstrual, obstetric, sexual contraception and smears. And I'll go into that in a bit more detail on the next slide, as I said before, I think that Mosk is a really nice way of covering a lot of this stuff. I would use Mosk in um in an obstetric history. It's just a good way to structure it where if push comes to shove and you can't actually remember anything to ask in obstetric history. Menstrual obstetric sexual contraception is a really solid way um to just, just cover all of these both gyne and obstetric issues. Um And if you can remember the Mosh thing, you can also start thinking about asking that if you're taking a GI history just to help rule stuff out. They don't need to, you don't need to be asking loads of in depth questions and a gastro history, but it would be good just to show the examiner that you're thinking along the lines of these are also things that can cause an acute abdomen. So for Gyne, you've got those four p screen for your G in neuro causes um are specifically um about the pregnancy and then when it comes to the, the gynecological one, steal your four ps, still those Gi New Euro causes but then try and focus a bit more narrow it down using MOSK. Sorry, I'm just checking that there are no questions um on the no, no questions on you. Can you can ask any questions if you want to on um on ment or on the, on the main thing we do. Um As always, if you fill in the feedback form afterwards, you get the slides and the recording for this. So do that. I can also go back if you want me to. So Mosk, then menstrual obstetric, sexual contraception and cervical smears. So when it comes to the men bit, what I've done here is I've put in detail what it actually is on the right hand side. That's just if I was gonna smush it down to like the basics of what you need to do. Um So when it comes to the menstrual cycle, uh you want to ask about what the, when the first day of the last period was um when they started their period of men, if they've been through the menopause and cycle length and regularity. So last menstrual period, Menno menopause and length when it comes to the obstetric stuff. Like I said, you want to do GMC and underneath of summarize what that is. So for the Gravida para bit, that's the number of pregnancies and the number of births. It's your miscarriages, ectopics and terminations and their living Children ages, delivery and difficulties, talked about method of delivery on the previous slide as well. Grabbed a power miscarriages, Children. That's how I remember that in terms of sexual history. Are they sexually active? If so with who do they have any pain or bleeding during intercourse? And are there any issues with fertility? And again, sex infertility, it would be very unlikely that in is they would give you an underage person for a sexual history. The main thing that you just want to make sure that you mention when you're summarizing is that you're, you're trying to treat and manage alongside your Fraser guidelines. I just remember that the Fraser guidelines don't apply to Children under the age of 13. Again, very, very unlikely that you'd have to take that history or manage that patient in an is, but I do think that's just an important one to be aware of. And lastly, contraception and cervical smears. Do they use contraception? If so, what are they using and how are they using it? Had a patient come in a couple months ago to GP um who had basically presented with signs of pregnancy, the they'd missed their, their last two periods, but they were on the contraceptive pill. But both they and their partner had been taking the, the contraceptive pill. So in a 30 day pack, they were taking one each. So it only lasted 15 days. Um So just worth asking how people are taking stuff a bit like how you double check with um patients with asthma that they are taking uh the inhalers correctly. Um I think we probably all heard the, the story of the person um who was shown how to inject insulin drawing up on a needle and then they demonstrated it by, by injecting it into an orange. Um because it mimics the skin person went away. Yes, demonstrated it all perfectly. Um What the person was then actually doing was then peeling the orange and eating it after putting the insulin in, in the orange. Um So, although that's potentially a little bit of a stretching of the truth, that particular story, that one is one that we tend to get told about a lot. So just check with your patients how they're taking the medication. So yeah, this structure can get you through the majority of differentials. Definitely for a gyne history. It covers a lot of stuff for an obstetric history. We just remember this bit here is probably not enough, this obstetric bit here. If you are doing taking a history from a pregnant person, you probably want to ask a little bit more detail about the current pregnancy and what's been going on and ask specifically about those red flag symptoms. So I suppose that's our next question. Um uh OK, before we go into this one here, um, just a few questions on the ment chat that we'll just go through. Um, first one being does the prompt outside of the station tell you which examination or history you're expected to be doing. Um, so strictly. No, but it will tell you, for example, take a four minute history in which case, you know that it's the acute session, a four minute history and handover to another member of the MDT. In which case, you know, it's the, what's it called? The Interprofessional Communication Station? A seven minute history is the communication skills patient, a focused history on their medications is then your pharmacology station. Um what else we got? So uh carry out an examination on the patient like you stand outside, it will tell you which exam. Uh I'm sure I've missed another station. But so from those we know already which station it is. So that's nice. Now, does it tell us which type of the folks of the history? No, but it will tell you some details about the patient. So for example, if you're standing outside and it says take this history from the 13 year old child, then you know that you're about to go in and be faced with a 13 year old. So that is a pediatric station. If it mentions that they're pregnant, then, you know, there's going to be obstetric focused but don't rule out other causes. Um And then you just generally, they might just have a presenting complaint that points to you in one way or another, for example, abdominal pain, chest pain cough. So standing outside the session, w when I ask you, when we do, when, when I present the cases at the end, I always ask, what are our differentials before we go in the room? I ask that because when you're standing outside of it and you have those two minutes to read that thing in front of you is you wanna start getting into the habit of, ok, it says abdominal pain. So I'm thinking about Xy and Z but because you have those two minutes to think when you're not in front of a patient, that's when you can think to yourself. Ok. Well, I think it might be obstruction, appendicitis or a low hepatitis just standing there to abdo pain. But you then might also think, ok, well, I might also need to be thinking about things like ectopic pregnancies, torsion, that sort of stuff as well. I hope that makes sense where. So they don't directly tell you what it is, but you do have a decent idea standing outside of that se station which way it's gonna go. ABDO pain in itself is a frustrating one cos that can go down the gastro route, it can go down your your Gyne route and it can all or obstetric gynae route and it can also go down um a vascular route and be a AAA. There's another question here. Do you need to define menopause for them or is there not enough time? Um So what I would probably say is considering the age of the patient ask, do you still have periods is how I would ask it. Um And if the answer to that is no, I'd say, have you gone through the menopause um which you've sort of answered your own question then because menopause is not having experienced periods, right? So ask, just ask if they've, if they more have have their periods stop and when was the last time that they had one? Will it tell you which specific exam examinations? Yeah, it will tell you which specific examination that you're doing but it won't tell you which um what am I trying to say? It won't tell you what the specialty focus of a station is. So if it's a communication skills session, it might say patient comes in with chest pain, you still don't know standing outside that door, whether it's a respiratory or a cardiac history. For example, I'm hoping that's making sense. Cool. If there are any other questions, like I said, just pop them in the chart are in there. Um I'm gonna move this on to the next slide though for now. Uh Bush, what conditions might come up then that's why I'm asking here what conditions might come up for obstetrics or gynecology, like I said, are different ones, but we tend to smush them all in together. What do we need to know about when it comes to S and G conditions? Ectopic pregnancies. The big one, it's the big scary one for obstetrics in early pregnancy, endometriosis. Yep. Common one that comes up in gynae topics. Yep, preeclampsia. Yeah. Scary one for obstetric histories. Um, recording is available once you fill in the feedback. Yeah. And the, the, the powerpoint slides also go up. I don't have the powerpoint slides for Megan's one yet, but when I have them, they will go up. So, apologies for that. That's the pharmacology. Stationary one. Um preeclampsia, top of pre miscarriages. Yep, uterine fibroids. Yeah. I think a miscarriage would be unlikely to come up in an ey. Um, but worth being aware of um Yep, fibroids is one that's difficult to determine where if you had a patient come in with symptoms of a fibroid. Right. Let's say they have uh bleeding or just generally like a bloating as well. Can you with any confidence from just a history? Tell somebody that it's a fibroid? The reason I ask that is when it comes to an EY, they're not trying to catch you out. They are trying to give you histories that you are able to determine in the time classic one. The, the ITP history, right? Despite it being the worst thing in the world ever, you very clearly can demonstrate that something is, is itp given blood test results? Now, you could very clearly show me that something is a uterine fibroid with an ultrasound. But can I as after my six years at uni tell you that it's a fibroid from a uterine ultrasound? Um So from my perspective, unlikely to come up, I'd put that low down my list. I think that's a low yield for an E and I make sure on cervical cancer. Yes, it is important to remember that this, you don't have an oncology station, right? So, cancer is an important one to do eclampsia. Yep, placental abruption, abruption again. Big important, acute one previa, yeah. Less important to, to know about, less scary. Um, but yeah, certainly, I think it's fairly, again, like I said, with, when it comes to cholestasis, it would be really difficult to determine the difference in a single history and subsequent investigation. Whether cholestasis w what caused cholestasis in a particular patient? Was it just diet? Was it the fact that they're pregnant? That's a real challenge. I probably put that low down my list. Threatened miscarriage. Yeah. Um, gestational diabetes. Yeah, gestational diabetes could come up. Um, uh, ectopics, ovarian cyst. Yep. Mhm. Rashes in pregnancy again. Not so much because you would have to have the patient come in with the thing. So could dermatology come up? Yes. But it's not one of the specialties that they specifically have to do one for, they would have to have a patient in the community who is living with it and will definitely have it by the time of the is so it can't be something that flares and goes away. So, dermatology exams not really gonna examinations, not really gonna happen. You're not gonna get a dermatology examination. Could you get a history for it? Yeah. But I think that they would mm prob from my perspective again, we up risk and benefits for yourself. But for me ration pregnancy, would the medical school rather me know about a ration in pregnancy or placental abruption? I feel like they probably more want me to know about the abruption, right? That's my perspective on it an Yeah. Um yeah, I think it's covered it like I said before I cover things on here. What that I revised for these, that I think are important conditions. Um You may have different uh priorities for the same for the same bits. These are not exhaustive lists from my perspective. These are the ones that I covered. Um, did topics, miscarriages, preeclampsia, gestational diabetes, postpartum, hemorrhage, and premature prelabor rupture of the membranes. Do I think that placental abruption is probably good and should be on here too. Yes. Now that I've seen it, I'm glad it didn't come up. Um Yeah, these are the obstetric ones I'd consider. You can see that compared to the conditions that we talked about for pediatrics and the list of medications that we talked about for the Pharmacology Station. This is about half the size of the conditions that I recommended that you look at for pediatrics. Why is that? Oh, because the other half is in the gyne bit. Um, so what I've recommended here, the ones that I think are important are pelvic inflammatory disease. I'm gonna say quote simple ST I, because I know a lot of people would put PPI D and ST S together, endometriosis, cervical cancer, endometrial cancer and Poly Polycystic Ovarian syndrome. Um I think PCOS is a likely one to come up. Um because uh it covers a nice bit of endocrinology as well. So those are all things together there. They all are all at once. Obstetric on the left Gyne on the right. What have I put those ones are? Why are these ones in bold? What do they mean? Why have I done that? You can put it on the, the previous question or, or in the truck? Why are those ones like that? Anyone know? No, I'm checking so many different chats at once to see if anybody is joining in, but it seems like no, that's ok. It's ok that you guys don't support me when I'm asking these questions is fine. These ones are all emergency ones, right? These are the ones that could become bad. They put those in an emergency station, your ectopic pregnancy is then shock your preeclampsia and eclampsia, your postpartum hemorrhages, a worse hemorrhage, your P I is sepsis, right? These are the ones that can come back. Not saying that the other ones can't become an acute emergency. But these are the ones that I think that if you are going to learn how to take that history for four minutes, those are the ones that I would learn that for. Ok, so I'm trying to leave this on for a long time so that if anyone wants to take a picture of it or anything like that, it's happening. But like I said, if you fill in the feedback form at the end, I'll send it through. Now, look pew to the feedback form, the recording and the slides will go to you. That being said, we're gonna go through some cases. Now, I'm gonna wait here for a moment to see if anybody's got any questions. If you have any questions, feel free to put them in uh on ment there, sh there's AQ and a bottom uh button in the right bottom right corner or in the chat here, anyone got any questions about obstetrics and gynecology. Nobody's complained yet about me drinking tea during the session. So I'm gonna keep doing it. You liked my pure noise? Thank you. I appreciate that. I don't even remember making it, but I do make a lot of sounds. So I'm sure that is true. Any questions about obviously going honestly, I know compared to the pediatric one, people said that it was too long. So I've tried to cut it down a little bit so that we can focus on the stations. So I know that I've done less stuff. Are we good? I'm gonna assume that we're all good. There's quite Q and A's open the whole time. The chat is there. If you have more questions, go for it. Um, by that. Oh, just as I was about to click through, there's another one. Oh, I'm glad uh somebody said this is already helpful. I'm glad I hope that it is helpful. Um Let's go through and let's do these stations then. Um So case number 128 year old Miss Pond is brought into the early pregnancy unit with abdominal pain. You're the medical student that reviews her. So again, like I was saying earlier, are they telling us that this is an obstetric history? No, but they are telling us that it's in the early pregnancy unit. So I'm gonna think it's to do with that, you know. Um So hopefully, is this the right one? No, that's the wrong side. This is the right side. What are your initial differential diagnoses squish when it comes to an early pregnancy unit and abdominal pain? Remember you're standing outside, you've got two minutes to think of what you're gonna ask and you wanna cover all bases. You wanna think of what are my obvious things that are gonna come up or my less obvious things that I don't wanna miss or in the trap or placental abruption chorionitis. Ok. I'm looking at those, that first one and I'm thinking, oh, does, can anyone in the chat or on or on me? Tell me why place, placental abruption or chorioamnionitis not super likely. In this case, it's good to think about obstetric things. Yeah. Yeah. So this is the early pregnancy unit. So these are both, these are both definitely obstetric differentials that are important to think about, especially with abdominal pain, but in the early pregnancy unit less likely. Um, miscarriages. Yep. Certainly, topic pregnancies. Uti S. Yep. If you have tummy pain and you are pregnant, you sort of just tend to lump it all with the fact that you're pregnant. Um, you've got that diagnostic overshadowing like people do if they have a chronic condition or a genetic condition, um, or it's equally called trans broken arm syndrome where we just relate everything to one particular diagnosis. I'm sorry, the fact that they're pregnant, the fact that they have a genetic condition, the fact that they have a chronic condition, the fact that they're trans, apparently the fact that you're on testosterone is the reason that you broke your arm, right. It's that sort of stuff where like you see the immediate thing of, oh, they're pregnant. That means that it has to be pregnancy rated. It doesn't UTI S could be certainly, ectopics, miscarriages again, placental abruption, less likely at this stage. Appendicitis. Yep. Ovarian torsion. Yep. Just because they're pregnant doesn't mean it couldn't be gyne still. Um, pelvic inflammatory disease. Um, anything else here? Yeah. Constipation. Yep. Yeah. Very hyper stimulation syndrome. Yeah. Depending on uh how fertilization happened. For sure. Yeah. So you would take the history and we're gonna try and go through it and we're gonna use MOSK as our structure. Um We've got a 28 year old female. I actually, I just uh who has severe crampy, right sided abdominal pain, they feel dizzy. They have no change in appetite, they have no changes to their bowel habits, menstrual history. They had their last menstrual period six weeks ago. They're normally 30 days long and regular in terms of obstetrics, never been pregnant before sexual or sexually active with a male partner with no recent ST is contraception smears uses the C ACP although II presume not recently did not attend her smear appoint appointment. So actually II was gonna, I'm gonna scooch this forward one. My next question is, what are your top differential diagnoses? Now, my question that I'd actually like to ask you is why have I asked about appetite? May I ask about appetite on the or in the chart here? Yeah. So people are saying appendicitis, um, appendicitis is the main reason why I'm asking for appetite. A lot of people experience anorexia when they have appendicitis. Does it mean, if you don't have an, uh, if you don't have an appetite that you don't have appendicitis. No. But remember is they're trying to give you their barn or stuff and it's, if it's not bar or in the history, it certainly will be by the investigations. Um, so bear that in mind. So, when I've asked that I've asked that for a specific reason and the examiner will know why I've asked that too. Um Yes. So again, the question is now, what are top differentials now? And people are putting here, which I think I think are very fair, reasonable. So we've got appendicitis, ectopics, appendicitis, ovarian cancer. Definitely. So you ovarian cancer can result in two different things. It actually reduces your appetite. Um And you can call it get bloating, which then results in early satiety. So people will feel less hungry. So, definitely worth asking. Um And ST yeah, uh let me move this out of the way. Um Have we been ruptured ectopic? Yep at the moment again, on here or on the chat. Have we got anything to suggest this is ruptured? I'm not saying it's wrong. Certainly could be erupted. Ectopic could just be an ectopic though. Um could be with the generation of a fibroid. Yeah, feeling dizzy. So, yeah, I think feeling dizzy is, are you saying like maybe like a low BP situation, potentially pointing more towards your topics? I had a patient in GPA couple of months ago, I probably told this before already who I had a conversation with had taken pregnancy tests was pregnant. Um, and just had this tummy pain, wanted to get checked out. Um, and as I was talking to them throughout the course of taking this history, their consciousness level just dropped and dropped and I was like, I don't know what's happening here. This patient is becoming acutely unwell and the thing they were worried about was an ectopic when they had this tummy pain. And yeah, what they had was an ectopic pregnancy that ruptured in the minor illness clinic. Um And so that was an entire ordeal in itself. Um but the difference between a a ruptured and a nonruptured is, is how unwell the patient is, is that this patient in front of me is becoming increasingly dizzy because of their dropping BP and then became confused ovarian to Yeah. So could be worth having a little differential list. Let me smush this bug over here. So we've talked about, sorry, they didn't miss any of the chart today. No, talked about why has that done now? Oh, yeah, talk restaurant. Now, remember this is an is station and as we're standing outside, running through our top differentials that we're thinking, what skills might they ask us to do now? So we've got this patient this 28 year old early pregnancy unit who come in with tummy pain. What might they ask us to do? Oh, sorry, investigations or what might they ask us to do? There's only a set number of skills that you have to do for an ey. So pregnancy test, pregnancy test is the main one that they're gonna get you to do here. People do not revise, doing urine dips and doing pregnancy tests. Right. Pregnancy tests on the, the thing as do the, the, the, the dipsticks as well. They tell you how to use them, they tell you how long you should wait. Don't learn three minutes for a pregnancy test. Look at the kit that you have a guarantee. If you just learn it off the top of your head, they'll give you something weird in the exam. It'll be a different one to what you've got in the actual clinical skills department. So make sure that you are happy doing it, make sure that you've got a bit of kitchen roll or whatever it is laid out beside it for you to put the thing on afterwards. It's a real pain trying to get that out once you've got it in your hand. Trust me. I know E CG. Certainly we have a patient who has the potential to be deteriorating. If we're doing an E CG, we've also got the potential of doing uh vital signs. Generally. Make sure you know how to go through a news chart and don't get into too much of a routine with it, um which is literally against my nature to say. Um but a decent chunk of the time when it comes to doing a news chart with a patient, they will have done part of the news chart before you and it will trip you up when you're presented with one and you go to check their oxygen saturation, but it's already filled in my gyne history, like I said, was pid, I had to do a news chart um and I had to do everything except for BP, respiratory rate and something else. A V pu. And so when I'm going through it instantly mess me up, but just make sure you know how to fill it and you're confident with it. And remember once you've got that new score, what do we do? We turn it over cos it tells us what to do and you tell the examiner that you're doing that as well. It demonstrates that you are familiar with the kit that you're using pregnancy test, abdominal examination. So in terms of investigation, you wouldn't, they wouldn't ask you to do an ABDO exam after a history, but it, you would want to do an abdo exam on this patient. Yes. Um uh pains test urine. Yeah, venipuncture, venipuncture, you can shove uh cannulation on it as well. This patient might become acutely unwell. So certainly you're in it. That's, yeah. So a few people are sort of answering it there already. I'll shove it over here again. So you can see in terms of the investigations that we would request, we wanna make sure that we're going through in a systematic way, um, to cover the differentials that we have. So our main differentials that we have really at this point was an ectopic pregnancy, um, uh, appendicitis, people said, uh, and there are a few others as well. So we just wanna make sure that we're ruling those in or out. Does anybody want to add anything to what we've got on the screen or add it to the chat? What investigations would we send? Remember? I think it's a good way to structure using bedsides, bloods, imaging, special tests. So at the bedside, what can we do? We can do those vital signs so we can do our news chart. I would list them because otherwise you could just get away with it like you wanna know what it is that you want from a new shot. I want the new chart including specifically the BP. That's what I'm really looking at. I also wanna have the heart rate, the respiratory rate, right? And of temperature as well. Those are my most important ones for that. I do want an EC G. You could do that at the bedside alongside a pregnancy test and a urine dip. Those are the things that I can do at the bedside bloods wise, some people have got some on the screen here. Anybody else want to add any what bloods. Would we do blood test with group and safe? Yeah. Oh, is that the chat function? I love that. Yeah. Group and safe. So, why are we doing group and safe group and safe and cross match? Because we, if we think this is a ruptured topic, we just wanna make sure that if this patient does end up deteriorating that we've got them covered. Yeah. So you need to be able to go through what they are and why the majority of patients. I think it is reasonable to say FB CSE LFT S sometimes you can go into T FT S, the ones that you don't wanna miss out group and save and cross match and blood cultures. I just think that those, they really just stand out is that they are blood tests. I just think that we tend to forget them. You can say FBC is using these LFT S really easily. We just tend to forget about group and group and save cross match and Black Co. So those ones, um, I'll also do a serum, uh beta HCG. We've got the urine blood test as well. Um Anyone know why it would be important to get a, a serum HCG if we're thinking it's an ectopic, see what happens to it and if the levels drop. Yeah. Yeah. So it will be up persons pregnant. If it's an ectopic, the, the H CG doesn't increase as fast. And also it's important. Exactly. It's important to help indicate the management. And we'll come on to that in a second as to how specifically indicates the management. But again, I think we've had this whole thing before at the moment, I'm not focusing on teaching you the actual thing about the, uh, not focusing to teach you about, um, um, teach you specifically about the, where is it? There is, um, about the pathologies that we're talking about just trying to make sure that you understand how to do it for history. But yes, we do want to have the serum, um, bedside bloods, imaging, ultrasound, transvaginal ultrasound we have here. Uh any special tests? Probably good, probably not really much. But yeah, good job. I'll just check the other chart treatment. Depends on it. Yes, in the chart. Exactly. So what investigations do they provide us with? Then we have some blood test results. What do the blood test results show us? The blood test results show us. So when it comes to interpreting these again, we're gonna go through it next week. But you want to say exactly step by step, what the results show summarize it with a sentence. Link it to your deferential. That's how I would aim. Somebody said anemia with a raised HCG. Yep. Anybody else, normocytic anemia, raised HCG in line with a pregnancy, a normocytic anemia? Mhm. And how are these linking to our differentials then? Which differentials does it is and does it point towards any of them. Yeah, an ectopic. I agree. It is pointing more towards an ectopic than other things. I think. So, what part of this is pointing you away from appendicitis? No cystic anemia, rose HCD, pregnant. Yep. Yeah. Normal white cell count. Exactly. Yeah. Good job. Um, I've not included CRP here. Why probably be normal. Why would CRP be normal if we've got an ectopic? It would also likely be normal if we've got. Yep, likely ectopic if we had acute appendicitis as well, anyone know why the CRP is likely normal at this point? Yeah, C RPL. Um CRP lags behind um the pathology by between 12 hours and days, right? It's why if you treat uh yeah, so uh white blood cells aren't up either, but white cells are quite uh quick to respond to stuff. Um Whereas if you have a pneumonia, for example, and you treat it CRP is likely to skyrocket by day 23 and then let's say you treat it on day three. CRP is still likely high by day five and will start to taper off. So it's just a little bit delayed. Um So with acute stuff, it's not brilliant. Um Yeah, so, um like I said, if we were gonna present this for an is we'd say these are the blood test results of MS Pond with this date of birth. I would cross reference this with the information I have for the patient. The test results show a low hemoglobin of 100. A normal white blood cell count, normal platelets, a mean cell volume of 92 and a raised beta hcg of 3500 overall. This demonstrates a normal cystic anemia with a raised HCG indicating pregnancy. These blood test re re um blood test results support my most likely diagnosis of an an ectopic pregnancy due to the anemia and the positive pregnancy test. Somebody in the thing said very high HCG this this will go higher. Why is less than five? The normal reference range less than five is a non pregnant person? Um male or female, less than five, right? Um So it is high and it should be less than five but for a pregnant person, 3500 is not, it's not super high or anything like that. Um Right. Good job. So we are still thinking along the lines of our um we're thinking along the lines of our ectopic pregnancy. Now, how do you manage an ectopic pregnancy? I'm gonna scoot this over here. So you guys can all see again, how do you manage this patient? And again, think about it again like two years from now in the absence of in and years out, et cetera, you'll be in this position. What would you do as an F one? Yeah, I referred to senior. That's what I would do. Um I'm not gonna do this in five months. I wanna go for to see you, this patient is acutely unwell. What kind of approach do I want to take an a two year approach? Brilliant. You want to take an a two week approach and make sure that they are stabilized. I do think analgesia is definitely an important one very often in is skis when you listen to people's presentations and when you practice with each other, remember, try and practice in threes. Um people miss out pain, but like the majority of presenting complaints for people will be that they come in with pain, make sure that you've treated their pain. You've got three different types of management. You're conservative, medical and surgical, certainly. Um, and yeah, it's, your management will depend on the severity of the, the issue and how unwell they are. Um, HCG is definitely one of them if they have a fetal heartbeat, uh instability of the patient. Yep, can be conservative. You watch and wait medical with methotrexate, um, or surgical depending on HCG levels. Uh, patients with an ultrasound medical treatment could be expected. Management. Certainly. And I've got nothing in the major either. Ok. Um, so yes, this is all entirely right. I agree with all of these. Um, and I think, I don't know if you've, maybe it was just me, maybe I'm just dumb. But when you see f ones you're only manage, meant to identify an unwell patient and start basic management, deciding whether you're watching, waiting, giving methotrexate or doing your self inject myotomy thing. That's complex management. That is not what an F one needs to know. You need to be able to identify that this patient is unwell, that you need help and start basic management. Basic management is maintaining their BP if they are septic, treating the sepsis. Um gosh, I start to sound like professor lab to the treating the sepsis. Um oh notify senior review by Gynae. Yeah, medical management, including a pain relief. Yeah. Um So is there anything else that I would add? No, but in terms of just talking it all through, you wanna make sure that this patient is admitted at the moment, you're in an outpatient early pregnancy unit. Um You want to get uh senior involvement early from, from either obstetrics or gynecology. It's, it's a gyne procedure that you'd be forgiven for saying obstetrics. You want a full set of observations, you want to make sure that you've put in two wide bore cannulas for this patient. And you want to start fluid resuscitation if the BP necessitates it. Um you want to ensure that this patient has their transvaginal ultrasound and this will guide further treatment. If it's small, unruptured and there's no significant pain, then you're likely to use expectant management. If it's more than 35 millimeters ruptured and there is a visible or there is a visible fetal heart rate. Then you'll go with a surgical management with either a salpingectomy or salpingotomy. And you need to have a discussion with the patient regarding fertility risk factors going forwards and this patient is likely to need significant patient counseling. Have that in there because it's always good to include involving the multidisciplinary team. I hope that is all clear. If you have questions, please do put them in the chair or on the M I can see them. Um But hopefully that is all good ectopic is one of those bound or ones where you don't wanna miss the next topic you're forgiven for missing an itp. Trust me. Uh missing a topic in an ki cos there will be big red flags for it. A little bit more difficult to get around. Cool. Ok. It doesn't seem like any questions coming through. But do please put in a question if you have any um phase two, then we've got 35 year old Miss Mix Noble attending the GP with a vaginal discharge. You're the medical student reviewing her? Oh, reviewing, yeah, reviewing her. Um What were we thinking then? With vaginal discharge in a 35 year old pop this over here? Oh, 35 year old. How are the management slide? They actually have a slide on management. Did you mean this one? Is it cos I talked through it, it's on the notes for this slide um that I'll upload afterwards with the, the feedback form. Sorry, that's on me. Uh You know what with the wonders of technology. Uh, one sec, the wonders of technology are failing me slightly. Uh, why did I have so much faith in the wonders of technology if I hadn't led up to it like that, it would have been fine. But I did, uh, one, it's like it's happening. Don't worry. It goes. Sure. In the chat on me all. You're welcome. Uh, yeah, for about, uh, I saw answers come in but I've lost my tab. There. It is. ST IP ID uti cervical cancer. Yep. Thrash bacterial vaginosis. Yeah. ST I pelvic inflammatory disease. Yeah. Changes in discharge of IUD insertion. Wow. Yeah. Um STIs SB VPI D. Yeah. Cancer, yeast infection. BV. ST Yeah, ST IV. Yeah. Not really many things that they can really be with discharge. But I think you've got the Oh, no. See, look, this is what tries that happens when I try to use a metaphor. You've got the nail on the head. There we go. Here's the history. Then 35 year old female vaginal discharge. It's become a yellow, smells bad. It's not normal for her. She's also got dull, lower abdominal pain in terms of the menstrual history. The some irregularity varying between 24 and 28 days. No, heavy bleeding, obstetrics never been pregnant before sexual, regular sex with a male partner pain during penetrative sex, vaginally and anally, contraception and cervical smears uses condoms, smears normal for the past decade and it's, and they smoke 25 per day. Somebody's also popped in cancer, placenta previa miscarriage. And as asked, is their blood. It's definitely worth him. Ask him. Yeah. Yeah. Now, does this help narrow down our differential diagnosis too much? Maybe, maybe not. I'm gonna change the slide to the next one to ask. Have our differential diagnosis changed? Now, what are our top differentials with this history? I leave it on the screen just because there's a lot of detail for this one. By the way, people just using ment your the comments, the chat doesn't stay for me, it disappears. It just comes in as a bubble. So if I've not answered something that you've put in that chat, please do just like spam it. Um It might have just been, I was looking away at the time. Um What are top differential diagnosis with this? We stood outside the room and we said, wow, this sounds like um this sounds like an sti it sounds like pid it sound like a uti cervical cancer thrush. Oh Is have we changed anything ST I had to put that one in there for proof? Yeah. P I I'm moving this out of the way so that people can still see the stuff. But yeah. Uh Pid Thrush BV, trichomoniasis BV. Yeah. So we're still sort of thinking the same thing. It didn't massively help narrow it down for us. Do we still think that uh well, so, so things that are pointing away from certain diagnoses they were using condoms. So, s ti transmission less likely than it would have been if they were using the, uh, like a contraceptive pill correctly or an implant because there's no protection to get S TI S, but it doesn't necessarily mean that they're using them correctly and that they haven't broken, um, smoking. Why is that important in a gyne history? Mm. Cervical cancer risk factor specifically. But, yes, um, cancer. It's not, uh, it's smoking, it's not good for you. Big risk risk for cancer. Cervical cancer specifically. Yes. Cervical cancer risk. Good job in the chart. Um, right. So again, same things that we wanna do. We wanna make sure that we're up to date with our top differentials didn't really change that much. What skills might they want you to do then with this, this is more just a question for you to ask yourself. So, when you're standing outside the door, look, I'll be honest with you, the curtains they have, they're really small. They're like this big and they don't cover that much of the actual room if you've not had what, uh, like an in person look. Yeah, you'll know what I mean when you see it and if you have seen it, hopefully it makes sense you can see. Right. They're tiny little curtains. You can see what the skill is when you're standing outside, but it's useful when you're making your own stations and you're revising to have a think, what skill would I have to do here and would I be able to do it? Um, oh, there was a comment there and it was therefore I missed it. I missed it. I'm sorry, how do I? Surely there's a way to see it if I could this live chat. Right. I'm sorry, that one comment that popped up, but I didn't see it. I'm gonna stare at it for a little bit just in case swabs. Yes, could be. Um, so in theory, you could be asked to do APV or APR exam. Um, in uh your, are they likely to do that? No, why would they be unlikely to do it? Well, in the same way FC. Yeah, certainly in the same way as with a catheter. A, it sounds kind of gross but your, your, your PV and your PR models get more gross, the more you use them because everyone presenting to that model will put lube on their fingers and therefore it will be in the model. And I don't know if you've been to the clinical skills session at the end of the day, it's not pleasant and it's because everyone's using the correct amount of gel, which is a decent amount of gel. So the quality of your pr exam at the end of the ISK rotation compared to the beginning would be worse, right? And they don't wanna make things worse for you. Ok. So unlikely, doesn't mean that I wouldn't revise it but I would be annoyed if they came up with a catheterization in it. Um, or PR or PV, it's just not super likely. Ok. Um, urinalysis blood. Yeah. Um, so, yeah, I suppose that's then the next question, what investigations do I want for this patient with the version of discharge? And this is the question that they would ask you, what investigations would you want to do with this patient? So again, bedsides, bloods, imaging, special tests, try and think in your head in that structure, bedsides, bloods, imaging, special tests in an ideal world. All the investigations that you'd like to do. What would you do for this person? Yeah. Triple swabs. Yes. Both a bedside and a special test, I suppose. Yeah. Always we wanna do our news chart. We wanna have your basic observations. Bloods, white cell count, cop. Yeah. Urine dip na A high vaginal swabs. Yeah. Yeah. Your speculum exam. Yeah. So pregnancy test important change in discharge can be due to pregnancy. So it's always worth having a go um CRP swab urine dip. Yep. Um Again another one for bedside that people tend to miss as an ECG. Is it indicated in this patient? Maybe not necessarily. We just keep it in your mind. Blood cultures. Yeah. So if we think that this patient is septic, I would have a very low threshold for saying sepsis in an exam. Um I talked about this last time when I said about how some people don't, not last year, Megan's year, the year before they had a classic child with a non Blunchen rash, headache, neck stiffness. Um That diagnosis is meningitis with a meningococcal septicemia. If you didn't say sepsis, you got a huge chunk taken off. That's a red flag, not recognizing sepsis. If you have a sign of an infection, I would say I have a low threshold for sepsis. Who would have that? Those words come out of my mouth and consider doing the sepsis six. If I've said it, then like I've got that mark for considering it. Even if I don't think it's super likely do. I think it's super likely in this patient? Maybe, maybe not, but it's just worth bearing that in mind. Ok. So blood cultures um so yeah, bedside, I want to do an abdominal examination. APV examination also a rectal exam because just described pain. Um uh Yeah, you can do your swabs at that point as well. Uh During your speculum examination, full set of observations. Um bloods again, I probably still do oh sorry. Um urine dip and uh pregnancy test. Um I'd still say I'd want my FBC. I probably wouldn't be able to justify an LT in this patient. So I probably wouldn't say it. Um FBC us be two HCG S uh CRP um and blood cultures, like somebody said, um imaging, what imaging would you wanna do in this patient if you were going to, at this point, I'm not sure it's entirely indicated, but if it's anything, it's probably gonna be an ultrasound of some kind. Right. On special tests. I think we've probably talked through the special test that you do for this patient. So, let's see what investigations we've shoved on here. So, ok, some vaginal swabs. These ones are always a little bit, a little bit silly. Um, cos you have to tell me what that shows but kind of inherent in it, isn't it? What's this patient got? Oh, sorry. In the interest of time, I would say this patient may noble date of birth blah, blah, blah, blah is the results from um the sample from a vaginal swab. I'd like to make sure that the quality of the swab itself um was of high quality. Um uh Yep. And wasn't compromised in terms of the results itself. It was positive for both the chlamydia trachomatis and the bacterial vaginosis. Um It's positive for both of those and it's negative uh for gonorrhea. Exactly if people have just popped in. Yeah, that's what it says. What do we wanna do in terms of this case here? What is the, the big thing that we just wanna make sure that we're covering from in a patient that's got pain discharge and now positive T two types as well. And chlamydia is the most common cause of it as well. That's why we just wanna make sure that we've covered for it. Any ideas? Yeah. Pid. We wanna have a low threshold for pelvic inflammatory disease. We do wanna make sure that we have the correct use of the contraception. Um for sure. Um but yes, um we just wanna make sure that you're covered for pelvic inflammatory disease. Um and you're at the GP. So again, you're gonna discuss this case with your seniors. Um take your full set of observations and you, you treat empirically and the way that you treat for pelvic inflammatory disease, is he giving you the axil and metroNIDAZOLE? I am Kef Doxy and me as well. You need screening for complications. Um And also we'll need an explanation for both the diagnosis as well as the increased future risk for fertility and things like ectopic pregnancies. Also consider ST testing for the partner. Is that all? OK? Were you all happy with that? Can I see that the complexity of the management is often less than what you would need to know for pass med because in reality, I've given specific ones there according to Nice. Yeah. Um According to nice guidelines, a Floxin Mezer that stuff. But in an esky, the way that you'd probably present that is I would treat you empirically with antibiotics according to local guidelines because they change, right? Um Yeah. Have you got any questions? Are we getting on? OK. Hope so I send the feedback form through again just because I know that some people have to, oops, why am I responding to the feedback form? Oh, you are really cool. No. Um, ok. Um, so we'll keep going on to do the last two cases that we've got left um, to put questions or anything in the chart or there's AQ and a function on, um, ment if you would like. Now we've got 30 year old Missus Khan attending the emergency department with abdominal pain in her 22nd week of pregnancy. So again, it's not told us, oh, this is an obstetric history but her says in the 22nd week of pregnancy. So differential diagnosis as we are standing outside the door, what we thinking about going through our head. Let's go through this one snappy. If I changed it to, how do you manage this patient? That's not what I mean or do you think we have to include the investigation? Yeah, I can do the we sorry somebody has asked coming. Let me look at this choice. Is it the same one? Um So they would never press you for an antibiotic? No, I and I would err on the side of being more so sorry. The question was they would never press you for an antibiotic. The answer is no. And I would err on the side of being cautious rather than not because if you didn't ask allergies and you give penicillin to a penicillin allergic patient, that's a massive safety red flag worse than if you just hadn't asked allergies. Um, yes. So, the reason that we don't, I don't at the moment have the management and investigations on the slides is that these are at the moment are designed just to be focusing on the, the way that you'd present the actual thing rather than teaching you the stuff for the pathologies. I'm happy to put it on in the future, but it's just because people said to cut the powerpoints down as why that's not on there. Um If people want that though, I can do that for next time. Uh So, yeah, just so that people don't think that I'm just being lazy. I'm just trying to make people happy is what you asked for. Oh, right. Placental abduction, pre preeclampsia. Yeah. Things that we're concerned about or about preeclampsia does present with abdominal pain as well like this here. It's not like your classic, like all high BP in pregnancy or seizures or anything like that. But abdo pain very common. Like with DK A DK. A main symptom is tummy pain, placental abruption. Yeah. Placental abruption, miscarriage. Yeah. Preeclampsia or help. Yep. Cool. Uh Anything here? Nope. Uh, let's keep going. Let's look at the actual history that we've got a 30 year old female with severe right, lower quadrant pain. The pain started suddenly this morning. It is now getting worse, feeling nauseous but hasn't been sick, not feeling hungry. Hasn't eaten anything in terms of the Mosque part of it, menstrual was previously regular at 32 days. Last menstrual period 22 weeks ago. Um, obstetric GTP one previous C section. The, the two, hopefully this is clear but the, the two is one currently current pregnancy. Uh, the sexual not sexually active currently has one male partner. Contraception from cervical smears up to date on smears, not use contraception whilst trying to get pregnant. In particular, she's worried about early labor. So, top differentials now severe, right, lower quadrant pain suddenly this morning getting worse, nauseous but not sick, hungry, not eating anything. Ah, previous C section, appendicitis. I agree. I think the thing is here is that like if I covered up the pregnancy bit, that's a really classic appendicitis history. It doesn't mean that it can't be other things. Why would this patient be unlikely to be an ectopic? Could be miscarriage? Why is this patient unlikely to have an ectopic? Yeah, it's too late in pregnancy. Yeah. It's more of an issue of early pregnancy. But certainly this, this patient, I presume has had at least two scans at this point, which would have shown, right? If you got your 20 week anomaly scan, this patient would have been well, would have already identified the fact that you had an ectopic, right? So, I like to do that. Yeah. Cool. Ok. So, again, remember as you're standing outside there, you just wanna think what skills might they ask you to do? At this point, we're now thinking down the route of appendicitis. So you're thinking you've got an acutely unwell patient. So you're thinking your classics are take you II might be, I have to take blood, um, might have to put in a cannula, right. Your needle skills would come up very nice and easily here can still do urine dips, can still do pregnancy tests, can still do news charts, you know. Um, yeah. What investigations do you want? Again? If we try and practice using your bedside bloods, imaging, what do we think? Bedside bloods imaging, special tests. How would you structure it? So at the bedside, this person here observations, full blood count. L TSC RP and ultrasound. Yeah. Anyone wanna add anything to that on the chart or on the screen here? Yeah, we've been saving crossmatch. She's got somebody we think so specifically for this patient. If we're thinking down the road of it being appendicitis, this patient is potentially going for surgery. So you wanna make sure that you've got blood for them to go to surgery. Blood culture sepsis six as I have a low threshold for sepsis perfectly phrased. Um Yeah, ultrasound. That's like blood imaging. Yeah. Um You do, you do an abdominal ultrasound for appendicitis anyway. Um but you'd also probably check the health of the fetus as well. Anything else that we want to add in there as long as you're being structured and clear in your approach, that's what we're aiming for. Yeah, you have covered. Yeah, coagulation screen again. We've got a patient going for surgery patient that might be bleeding. Let's have a look at what we've shoved on there. No, I say we like I just look what I have given you to look at blood test results. I was gonna do an Abdo x-ray for this one and I was like, no, don't do an X ray on the baby, right? What's that? What's that show? So again, remember, fracture it in your head. Read through how would you present that you'd present that by reading out name, date of birth? What it is reading out all of the results at once summarizing in a sentence and linking it to your differential diagnoses. Yeah. So somebody said infection, somebody said raised white blood cells and C RP indicating infection, raised white cell count, raised cop suggesting infection or an inflammatory picture, raised white cell count CRP indicating infection, inflammation. Therefore, most likely appendicitis. Yeah. Put that on the screen. So you can see. Yeah. So what we have here, these are the blood test results of missus Cullen date for blah, blah, blah. I cross reference this with the patient in front of me. Blood test results currently show a normal hemoglobin. A raised white cell count at 13.2 normal platelets, normal platelets, a normal mean cell volume and a raised CRP at 12 overall. This shows an yeah, an infective or an inflammatory picture. See the C RP is not that high, why it's lacking. Um Yeah, certainly. And that links to our most likely diagnosis of acute appendicitis. So then the question becomes, how do you manage acute appendicitis? Now, I'm not going to and the pa remember they would ask specifically about the diagnosis that they want you to answer about. If you've said up until this point that it's an ectopic pregnancy, they will ask you about the management of appendicitis. They won't ask you about the management of whatever you've said. So how do you manage appendicitis? I'm not gonna go into huge amount of thing of that. But does anyone want to tell me how you manage appendicitis? Not sobs and Gina, but you can see how they overlap quite easily and you can, you can go down the wrong route for it. How do you manage appendicitis? Are you gonna do the appendectomy? What approach are you going to take? This patient is acutely unwell a approach? Yeah. Escalate. Consider escalating. You are gonna do the appendectomy by yourself. Love that. Uh, fluids. Yes. Stabilize the patient, pain relief. Yeah. Nil by mouth. Yes, surgery, surgeons, laparoscopic removal. Yeah. Anything that we're missing from that. And he has, you need to have before the surgery that you need to give. Like nurse is aware of how acutely unwell the patient is. Oh, I love that. Do regular based on the new store, stabilize patient. N Yeah, certainly. Yes. Antibiotics. You give prophylactic antibiotics. Um, brilliant two canyons. Yeah. And what do we have a low threshold for, in this case? Sepsis? Yeah. Um, right. Last one. Then let's go off. We go 68 year old Miss Sheridan presents to primary care for vaginal bleeding. You're the medical student that reviews her. So, again, standing outside the door. What is it? Oh. Did I just miss a thing in the bottom? Right. Sorry. What were we thinking? Standing outside that door, vaginal bleeding, 68 year old in primary care, endometrial cancer, vaginal atrophy. I agree. I do not feel the need to, to hover much more. But if anybody has anything else to think about endometrial cancer, vaginal atrophy, warfarin overdose people will bleed from anywhere. My patient pathway had a prescribing error of warfarin by a factor of 1000 because of a milligram microgram misp prescribing and came into the medical assessment unit bleeding out everywhere. Everyone else clearly agrees. Endometrial cancer, vaginal atrophy. So brilliant. Good job. Um Right. Let's actually look at the the question here. So 68 year old female noticed occasional vaginal bleeding for the past two months, normally dark brown, no fresh blood about a teaspoon and every day or so otherwise. Well, no pain, weight loss or fatigue, menstrual cycle stopped 17 years ago. It went through the menopause. Obstetric had two Children both by vaginal deliveries, no complications, no miscarriages in terms of sexual history, they've occasionally been sexually active but stopped after the first episode of bleeding and in terms of contraceptives and smears, they used barrier protection and previous smears have all been normal. So, how does that change your differential diagnosis or does it change your differential diagnosis? Like I said, this postmenopausal bleeding, which is what this is, tends to be a big blind spot for students. Yeah. Vaginal atrophy. Yeah, I agree. That's not really how narrow it down too much. Um I think it's been both of them are both ruled in and ruled out. So, endometrial cancer, vaginal atrophy, both are ruled in and out by different aspects of this history. Not brilliant. So we wanna keep both of them in mind and like I said, it's a, it's a, it's a, it's a weird one to get, um, that will not tend not to be very good with. But yes, smoosh, I agree. Postmenopausal bleeding is endometrial cancer until proven. Otherwise, a person with a uterus over the age of 55 with postmenopausal bleeding should be referred through the uh urgent suspected cancer pathway. So, yes, can we actually tell from the, the history at this stage? No, but that's what we're thinking. So top difference was, yep, skills might ask you to do all of these obs and gin ones have kind of been the same, right? Um And what investigations do you want? Does anybody want to, to hop in on this one? Here. Just remember, just take that structure, bedsides, bloods, imaging, special tests. If you think it's vaginal atrophy, what would you do if you think that it's endometrial cancer? Um, or uh endometrial cancer or a fibroid? What would you do? You're in GP. So you're probably gonna do your just was. So, I'm not sure everything else. Yeah. Transvaginal ultrasound. Endometrial biopsy. Yeah. So, those are all specific things for our endometrial cancer. Um When it comes to bedside bloods, imaging, bedside, just say what, what would I do? I'd take their observations. Do an abdominal exam at the bedside, probably would do APV examination to rule in or rule out vaginal atrophy just because they have vaginal atrophy does not mean that they don't have endometrial cancer. So you would also continue to refer somebody said to do an ECG in terms of bloods, full blood count and iron studies. Yeah, LFT S CRP. If you've got somebody bleeding, you do your iron studies. Um Transvaginal ultrasound and biopsy. Yeah, I agree. Good job. Um OK. It always double check your patient because I'm pretty sure that's not this patient. Yeah, that's the last patient which you could say was me copying and pasting the slide and not changing the details or you could say that it was me trying to catch you up. Always check your patient details, read that out and say that you would cross reference with what you have in front of you. So would you do a bimanual or patient? Yeah. So II would, but I'd be looking for signs of vaginal atrophy. The difficulty being is that if the patient does have vaginal atrophy, that is going to be very uncomfortable for them. In actual general practice, the majority of people will present with the symptoms of vaginal atrophy and will not receive a speculum. Um in the same way that if you have a, a four year old with query, vaginal thrush, you don't in GP look for it, you just go on what the parents say according to guidelines, you should always look, you shouldn't treat without doing a full examination. But in the interest of uh patient safety, uh patient comfort, I suppose we tend not to. So would I say to do it in the yy? Yes. Would I actually do it in real life? Probably not. Uh what do the results show then? What's that? Oops, no signs of infection, right? Ca 125 cancer. Yeah. So ca 125 is known as the cancer marker for ovarian cancer. It's actually raised in all Gyne cancers. This is only very slightly raised because it's 35 when it should be less than 35. It's definitely worth, I would probably then include it in my differentials now that it is up, but it is raised in all, well, it can be raised in all Gyne cancers. But yeah, looking through it, hemoglobin is normal white blood cells, normal platelets are normal, alt is normal, ast is also normal ap normal ca 125 slightly risk. Yeah. Um, so does this help point us to a away from our main differential diagnoses because ovarian cancer wouldn't cause postmenopausal bleeding is, is the issue. Um, all normal apart from C A 125 race. Yeah. Um So that's how, that's how our issue rate is. It doesn't really point us in either direction. Uh Which is why that we are glad for the fact that the, the examiner would tell you which way to go from here. But you still use the information provided to inform your differential diagnoses. As you've both said, I would mention the link to ovarian cancer here. So how do we manage this patient? So we've got a patient with postmenopausal bleeding. She is 68 years old. What are we doing with this patient? What is the main thing that we need to do for her? And this is the last one. So if there are any other questions that you wanna smooth through, that would be a good time. Yeah. So what we wanna do here is our urgent suspected cancer referral. So your two week referral um co yes, this is it, even if it doesn't turn out to actually be endometrial cancer, this is a distressing diagnosis where likely they will receive a hysterectomy. Uh They're also likely to receive a all Right. You know what I'm gonna try and say it. But, like I said, I don't, I'm not a huge fan of Gyne, a bilateral salpingoophorectomy. Pretty good. Take out the uterus tubes and ovaries altogether. Um, and if it was particularly, particularly large or invasive you'd also do POSTOP radiotherapy. Right. Um, yeah. And the investigations, like we said, transvaginal ultrasound with a biopsy. How do you biopsy a, uh, uterus what? Or the endometrio endometrium? Sorry. What, what procedure is that? Does anyone know? It's not a legit question. I know the answer. Yeah, hysteroscopy. Um So if, if you're going inside a tube to take a sample from inside the tube, it's endoscopy, right? So you go in through vagina, that's scope. Then if you were looking in the bladder, same thing, it's still a scope. If you're looking in the lungs going through a tube, it's still a scope, right? Yeah. Brilliant. Ok. Colposcopy is specifically for Cervix. Um I can see there's a question here. Ok, so sorry, I can't distract your by the question yet, but yes, good job. Ok, so we've wrapped up the I put this here. Is there any questions that you wanna ask? Please do that we know would be, be fairly safe to assume that the termination of pregnancy won't come up for me. Personally, I did not revise termination of pregnancy for is, uh, so I would be a hypocrite if I said it was important because I didn't think it was um mind balloon. Um Yeah. So from my, from my perspective, nn I Yeah, I think you would be safe to, to not revise it. Any other questions? People, if no, I appreciate your early 2024 attendance. In which cases would you order coagulation screen for bloods? If a patient is bleeding is the main thing that I would be thinking with coag screens. Um if a patient, yeah. So if, if a patient is bleeding or a patient's BP has dropped and I don't know why I'm gonna do a coag screen. Um I would also do it if they're on blood thinners, it's not a particularly good thing to do, to be honest. Um because if you're not very good at interpreting the results of it, that kind of sucks. Um But yeah, um also coag screen if you've got bruising as well, which is just extra bleeding. But if I've got an acutely unwell patient, they're likely bleeding or low volume somewhere. So I'm gonna do that. Um Do we still get a cardiac grow specific ses? Yeah. So you, you, you do the only because the thing is is that how do I describe it? Definitely you will have a station that is on the specialties that you cover this year, which is why I we're focusing on them just because they're hard, they're new and people tend to be a bit iffy with them. Um Yes, you still get the other ones, but they will prioritize the specialties over your typical cardio resp gi sorry, I missed that last one that was in the chat on ment. Sorry. Could you say that again? Why can't I see the chat? Would you get a station exploration book? No, no, you wouldn't, you wouldn't get a, a station asking you to explain a, a specific operation or anything like that. The only one that I would recommend learning would be electroconvulsive therapy. And I think that those are the most likely um medication description or communication skills ones that you'll get would likely be psychiatric ones. But yeah, the only one that you're told that you need to know is EC T um Yeah. So on, on the context, sorry, on the in uh on the topic of cardio arrest and stuff. Yeah. If you, if you think that it would be useful for us to cover those main stations, we can, like I said, towards the end to, towards when your exam actually is your will cover content ones rather than structure ones. So we'll just go through a station and then actually summarize the patho physiology, signs and symptoms and management for you. So the stuff that you'd need to know if the is you for those main conditions, we'll do that just for the common and important ones. So we would probably do it for acs, we probably wouldn't do it for Dresler syndrome or eye and Mengers or something, but we'll do it for the common and important ones. Um If you, like I said, that would be before your risk at the end. If you would like specific ones on cardio resp gi we can do those. I just feel like it's probably not what you guys would need the most. I think I missed another one in the chart. I am so sorry they flash up just before my eyes. Let me squish this over here. I will be better see them both at once. I can see this one there. Scope procedure. No. Um Yeah, like the procedures you need to be able to describe are the ones that you can do. Um think about what would you be able to do as a doctor? You can't consent somebody for a procedure that you don't know how to do. The only difference is for some reason, electroconvulsive therapy is the one that's listed that they tell you about. So, does that make sense? I hope and it does and also like, you know how exams go, I'm sure if I say, oh no, you don't need to be able to explain a scope. It'll come up for, of course it will. Um But I, no, I wouldn't learn how to uh how to explain that or anything like that. Seems like people are starting to drift off. So I'm gonna stay here just in case anybody has any more questions. But I hope it's been useful. 01 more. Yeah, you're welcome. Oh, I'm glad that people seem to be finding it useful. Um, I just think that if you don't have something like this that's specific to your course, it just sucks. And, yeah, people don't want to teach you how to pass their exams because then their exams would be too easy. You get me? Hi. Enjoy your time back at uni guys. Oh, ok. All right. I think I'm gonna wrap up here because I think you're probably at this point of people who have left the computer on to fall asleep to my s free voice. Thanks everyone for coming. Good luck with her next week.