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great. So I'm just start off with the sexual health station on. The Honda will be going into breast a little bit later on, so let's get straight into it. So for our first, All right, um, with a a 21 year old female who's presented with some new discharges. So we've got to take a focus history and initiate a management plan for her. So I thought I thought I just start off with just some tips overall for kind of sexual history, taking on examinations that you might have to do just a general point. I think everyone should know. Um firstly, clear language is really, really crucial with sexual health on these presentations. It's really important that you know exactly what the patient is talking about, especially when they might use language, because they feel a bit shy about the topic. But making sure that you're you've got clarification if you need it, you know exactly what they're talking about. That's really, really crucial on. Don't be embarrassed or I'm worried if you feel that you need to ask for clarification. For example, I met a lady and she said she had pain down below on D. Initially, I thought she meant something like vulva pain in that region. But she had she meant just lower abdominal pain. So when I clarified it with her, obviously completely changed my next line of questioning. So it's important to be really clear about what's going, what's going on for both of you. Also, it's only awkward if you make it awkward. The actors obviously very used to the station. And so your examiners, they want to make sure that you can discuss these topics really openly on really emergent nonjudgmental Ia's well, s o trying to be as confident as you can. I know it could be hard when it's a sensitive topic, but if, um act confident, that's what you're asking the other like they got you got put on a show on. So try try not to make you walk would cause them they won't make you, would I'm finally is important as a sensitive topic just to acknowledge the sensitivity of the issue on also the confidentiality around the subject. Eso I've written a little paragraph here or something you could say before you take your history or before you do an examination for your best reading your own time, but basically you just want to say like fire. Some warning shots ahead of time that you'll be asking are examining, since since two various on and you will keep all of the information confidential unless it's called a letter. Need to break it for any risk of harm. But just make sure the patient knows that ahead of time so that they feel more comfortable comfortable in your consultation. So on to our spot diagnoses. Eso surrounding discharge in ST I'd let's start off with our first one. So we have a 18 year old male who presents with burning sensation on urination on thin purely and Molly odorous greenish yellow discharge. He has he had unprotected sex four days ago. This sexual partners male do. They don't know what's going on here as to what? What would I be? Yeah, lots of correct answers coming in. Well, don't I see it? This's gonorrhea so classically gonorrhea presents with this burning sensation so dysuria on this kind of green yellow discharge. What's important with this one is sometimes gonorrhea can present, similar to other ST I see. But what's quite important here is the intubation period. So the incubation period is the period between someone being exposed to the organism that's causing the trouble on their first symptoms. So in this case, he had unprotected unprotected sex. Presumably, this is where he was exposed four days ago, and now he's getting the symptoms. So that lines up with gonorrhea, which has an incubation period of about 2 to 5 days. So that would be in keeping the gonorrhea. Obviously, this is Ah, 18 year old male on. Does anyone know ongoing pop in the chat? Any symptoms that a female might have if a female contracted gonorrhea and developed diarrhea? Any ideas? Yep. Brilliant. Yeah, really good. Yep. Perfect. Yeah, it could be a vaginal discharge very similar to the discharge that I've described here. Could be some pelvic pain thistle or any, Um, somebody said as well as that pain kind of during and around sex on also. Yeah, you can also get kind of intimate stroke bleeding as well. Really well done. So on exercise. So we have a 17 year old male he presents for the burning sensation in urination and white, yellow, cloudy, watery discharge from the tip of his Penis on testicular pain. He had unprotected sex for the new partner about two weeks ago. What do we think this one is? Yeah. Brilliant. Modern. Everyone's. Yeah, this is Comedia so many people with committee and may actually be asymptomatic. Obviously, I couldn't do that as a scenario, because that's no, no, Very interesting. Um typic. Really? With men, you get these sentences well said to Syria, This kind of white, yellow, cloudy, watery type discharge on Do you can sometimes get pain in the testicles as well as it says here on. That's a really important thing to note because if the infection spreads down to the testicles, that can sometimes affect fertility as well. Um, so that's important to know. Once again, it's important to note the incubation period. So here it was two weeks, which is more in keeping with comedia, which has an incubation period of about 7 to 21 days. Um, women can present also with this urea on once again, kind of a similar sounding vaginal discharge to this as well. They might also have abdominal pain dyspareunia on balsa once again that interventional bleeding as well. So they're important things to look out for, so on it. So a 20 or one year old female presents with small, fleshy bumps on her labia Majora. They're not painful, but it's cheap and occasionally bleed. Any ideas? What this could be? Yeah, brilliant. Well, the guy's Yes. So this is genital warts. So genital warts are as it says here, kind of these small, fleshy bumps that you get on areas that traumatized during sexual intercourse. So in this case, in this woman, it would be her labia. Majora. Um, they are usually asymptomatic. Patients might not even know that they're but they may itch, and they may believe s so people might notice blood. And that's how they become aware that they have there. Um, I think people have already got it in the chapped for some people Have any way Can anyone tell me what the cause of genital warts is? Like? What is the kind of infective agent that's causing genital warts? Yeah. Brilliant. Someone's got it. What? Um, yes. So is hate TV on words into those of you that said type six and 11. That is correct. I see some of you have put 16 in 19 anyone pop in the trap. What type? 16 and 18 caused. Yeah. Pretty involved on. Yes, if I could cancel. Well done. Yes. So gentle warts. 6 11. Cervical cancer. 60 90. Well done. So next one. So a 23 year old male presents with a fever and enlarged lymph notes. Hey, has a rash across his trunk. Palms and his souls. Eight weeks ago, he had a painless also on his Penis. Any ideas? What? This is a leading to which SDI This? Yeah. Yeah. Brilliant people. Got it. Amazing. Yes. Well, don't see yet. This is syphilis. There are three stages to syphilis. Does anyone know? Based on his current symptoms? What he's comprehending with today, What stage is he? And yes, perfect. Wasn't too all of you that put the second stage well done. So yeah, placidly. The second stage. Somebody has a fever. They have enlarged lymph nodes or lymphadenopathy on. They have this rash across the trunk, the palms and the soles on. That's usually like a non itchy, reddish kind of popular rash. Basically does. They won't know what the pain. It's ulcer is the end of this scenario. Yeah, pretty, pretty. Good. That's right guys on the pain. Salsa is referring. Also to that is the first stage that he had about eight weeks ago. So people often develop a painless ulcer at the site of sexual contact. So that's why he's had that there. So he's had the promised ages now moved on to the second stage on. Then, as I said, there is a third stage on. That's when you get more systemic symptoms that things like granulomas, aortic aneurysms, things like up so really good. So Announcement one. A 28 year old female presents with gray thin vaginal discharge, which she described the swelling fishy. Her vaginal pH is 4.8 and the ideas of this is pretty. It nice and quick was on everybody. So yes, this is bacterial Vaginosis s. Oh, I want to emphasize first BV. I put it in him because I've broke together some because of discharge. But BV is not an ST I It does present in sexually active women and, um, who are of childbearing age. But it is not directly unless t I, um it does cause this kind of Catholic grave vaginal discharge. It smells a bit fishy. Does anyone know what actually causes bleeding? What? What is it? What's the cause of it? Yeah, brilliant. See? Yeah. It's basically the overgrowth of anaerobic bacteria. Such a Z. You you guys have put the chat things like gardening vaginalis. And what happens is it causes the vaginal pH to go up so they become more alkaline on. That's because of a full in lactic acid. So where all these on aerobic organisms are kind of overgrowing and proliferating there were replacing some lactobacillus so basically bacteria that produce lactic acid that are normally growing in your in a woman's kind of vagina s as you replace those less act less lactic acid is produced on there for the vaginal. PH goes up very well done, guys. So our last know So we have a 19 year old female she presents with fluffy yellow discharge following unprotected sex on speculating examination. Her cervix has a studied appearance with red dots across it's cervix. And I just what's going on here? Yeah, pretty much done by CS. This is a TriCor minutes vaginalis. Does anyone know what organism causes this? What type of organism idea bacterias? That virus purchase. Oh, uh, Yeah. Brilliant. Well done to those of you that Birthdays. Oh, that's right. Um, and it's got the same name as the condition itself. Once again, it causes this kind of fluffy yellow discharged on what's going on with the cervix. Can anyone pop in the chat? What's kind of the description? Buzz word for what I've tried to describe here. Yeah, really good. So it's often called the Strawberry Cervix. If you have a look at it, it's kind of, as it says. It's kind of like a studied appearances. Got loads of red dots over it looks a little bit like strawberry, so really well done. So what I've done here is I've popped together kind of a sexual history taking for your notes, right, go through or now because it's an extensive couple of sides. Well, what I'd recommend is for each of these kind of presenting complaint, if you like. For someone presenting with sexual health related issue. If you take, um, any Socrates for each of these, you'll be able to gleam. A lot of information on Dive also popped here is, well, a few other things that you could ask for each of these as well. Um, obviously with a female, you want to get her menstrual history, any gynie history and obstetric history. She's had some written questions here for you to the cat in your own time. Um and then this these other aspect to the sexual help tree that you might want to take. So, um, really some sex from his tree, who their partners are acceptable. You then might want to go up HIV risk assessment. Identify what risk factors somebody has for hatred be. That's things like if some of the sexual partner is known to be HIV positive, they have sex with many of sex with men, bisexual men, Any IV drug users If people have partners from abroad on, also, people that pay to have sex or have been paid to have sex. Um, another thing to look out for us come sex as well, which is when people basically intentionally used recreational drugs during, during or before sex on. That's commonly seen in men who have sex with men as well, and then you want to get some of the automatically streamside request tree, and then those airways are citizens review on our social family and drop history, but I'll let you guys. We threw this in your own time of it later on, and then you guys passed it on the spot diagnosis anyway. But here's a little table that I may just of the main ST I was that you might come across there organism symptoms, investigations in their management. Just a summary for you guys to read in your in time. So what you take in the straight A of know you got to print present it back to the Examiner Terrell's and presenting complaint, going to a bit more detail about the history presenting complaint, any relevant negatives to make sure that you're aware of the other differentials that that could be. And you've ask questions purposely to rule those out. Um, any relevant past medical history, surgical history, social history of drug, a street ice, what you talk, talk different ways, and then, finally, any other differentials as well. So we'll go on to investigations now for discharge. So a Z you guys know we like to split our investigations into bedside broads on imaging and special tests. Sorry, that revealed a bit early, so if someone presents with discharge, these are the things I think you should do for anybody. So you kind of take some basic observations, as you do with anybody. And if there, if there were other kind of systemic symptoms that we're making them particularly well, then obviously you want to take the basic option doing 80 of someone presented acutely, but that's less common with things like discharge. Then you want to do an abdominal examination. Azelas a bimanual. A speculum examination for a female A Z alluded to before in the spot diagnosis is a lot of clues that you might get from a by manual and a speculum. If you're able to visualize someone cervix and obviously, when you're doing it by manual, you will. You see any discharge. It's there. That's very useful. Um, a pregnancy test is well, if they're female, just to rule out if pregnancy is it caused on dumb? Finally, a urine dip. A swell, especially if along with the discharge, they've got any signs of where you're thinking. Maybe it could be more of a kind of urinary tract, cause it's good to do a urine dip it the same time. So then we go on to our extra investigations. So could anyone tell me what extra investigations you would do? Um, for chlamydia? Yeah. Pretty. And lots of you put in a a T. Can anyone put what that stands for in the job? Yeah. Pretty. Yes. So it's a nuclear. Basically. What those are when you kind of isolate some, uh, I can organism, um, new detectives DNA, and then you can provide. It's that you have more more of it. See a and then that allows you to kind of identify it and see what's going on billion. Yet so did they. Won't know how we would do an n A T for a male and female for chlamydia. What? What some was would you take? What's what's would you take for male and female yet? Urine sample? Um, vagina. So brilliant. So yes. So, for a female, we go for something called a Volvo vaginal swab. Um, and then in the mail, we would use a first pass urine sample, see if I've got it worked. Really Well, um, And for gonorrhea, any idea what we would do for gonorrhea as extra investigations? Yeah. Agreed. Very, very similar this time. Is there anything else that you might do for gonorrhea. Especially if someone had more kind of systemic symptoms. Yeah, some good ideas coming in the trap. Yes. My my cross microscopy you could use is an alternative Teo and a 80. But yes, Coach. I said I was thinking so yes. So very similar to comedy A. You would do the same type of swaps as your own 80 A new may want to consider as well doing blood cultures on. You made me do that. If you think someone's got a December disseminated gonna cocoa infection. So basically where the material gonorrhea spread into the blood on they've got more of a kind of systemic picture when you consider doing blood cultures as well. Brilliant. Any ideas? The trichomonas vaginitis. Any ideas that one? Any investigations you died today across create? Yep. Anything else that we can think off? Yeah. We want to do swabs again. Definitely bringing great stuff, guys. Yes. So, um, for, um, for this condition, what we would do is we would use charcoal swaps this time. They're typically used for things like fresh on, uh, TriCor enemas vaginalis as well. And that's basically because the charcoal that says a way to kind of preserve these bacteria so that you can get a sample of them on, then send them to the lab when they can do what they're processing with thumb there. Um, and as I said before, you can also sometimes use microscopy as as an alternative for these. Um, And as we said before, you can get kind of changes to the vaginal discharge. PH So you can test that as well with this condition. Um, brilliant. I'm finally BV. Any ideas What you would do for this one? Really? In vaginal ph test pretty in yet. You could do. Could do with test anything else any more months today? Yes, Pretty well done. Yes. Well, um, so, yeah, we want to do swaps as before. Vaginal discharge. Ph once again for a very similar reason. As we explained before on, you also want to look for microscopy on someone already that I put in the chart already what we're looking for, which is really good on. So you'd be looking for crease hours, which is basically they're epithelial cells that coverage with the anaerobic bacteria that are causing the BV on bats. What clues. So it's so you could do my cross Peter to look for those. But it well done, guys. Eso in your exam or in your skin. You might also get an interpretation day to interpretation question and so would anyone in the track. Can you just tell me what you'd start off with if you ask to interpret this? Microbiology results, Georgiadis. Yeah, Pretty in. Both done. Yeah. You would confirm the parish to details maybe. Yep. Date. Brilliant allergies. Really good ideas. Yes. So my approach to these is usually as you go. I said, start off. Isn't that the patient's name? Date of birth? When this has performed any information like that that they give to you, then RG state kind of what was taken. So this case we had Ms is Diana Dion, a native year old female, Um, who had a vulva, vaginitis what performed on attempted May 2020. And then what I would do is kind of read through the organisms and the relevant sensitivities that have been found. So I would say that the growth of chlamydia has been broken in this case is resistant to clear for my sin, but it is sensitive to doxycycline and Palestinian. And then as you guys sit in the trap, it's really important to mention the allergies on that you would check drug allergies if it hasn't already been mentioning station eso. At this point, I might say if a patient is known to have a true penicillin allergy, I would not prescribe penicillin. What I would say is, obviously be aware of drugs that contain penicillin that don't have the name penicillin in the title eso things like calm oxcarbin things that contains amoxicillin, which is a type of penicillin. So just be be aware of those. And then, as I say finally state kind of what drug do you think you're gonna go for? So in this case, I would either go for doxycycline, all Palestinian on. But if someone had a penicillin allergy, then okay for doxycycline, and that should cover you pretty well. And then I thought, I just pop in as well. The germ management for chlamydia eso. Obviously, when we're doing our stations, relax that arm management into conservative medical and surgical S O, usually for STD's nothing. There isn't really a surgical management so focusing or conservative medical to start off with. You want to talk about things that patient education so promoting things that condom use access to a free committee, a tests as well. Talk about short A. I'm just promoting over to say sex. Then you want to mention about partner notification. So it's really important that if someone's been picked up a positive for chlamydia, we then want to notify any partners that they've had, because we want to reduce the homes that you could have if you haven't undetected comedia infections. Some things, especially for women who might develop things like pelvic inflammatory disease and topic pregnancies or might have fertility issues because of it. So it's really important that we let any partners no. And then also you could mention things that sexual health charities so things that Terence Higgins Trust, which is basically the UK, is leading Hate IV and sexual health charity that supports people with dealing with the diagnosis, removing stick on your health. Um, and then when you've done the conservative, you can obviously move into the medical management. So in the case of chlamydia, it's doctor music doxycycline on. But if someone's not able to take doxycycline or isn't they're not tolerating it Or, most importantly, probably the fact that they're pregnant. Then you should offer a zit from ice in instead. Okay, so in a couple off, um, Viagra questions. So could anyone pop in the chapped for me when to treatment for partners be given for comedia Who's to be treated? When should they be treated? Any ideas at all? Everything. Those are good ideas coming in the trap. Yes, so I'll talk for it. So if someone has a someone gets a confirmed committee of diagnosis. Um, you first. We'll want to encourage that patient to contact any relevant partners that will be going through in a sec on. They shouldn't have sexual contact with any other partners until both of them have received treatment. Basically, if the patient is concerned about being anonymous, then methods that are anonymous can be used as well on. They can also get support from the genital urinary medicine teams that gum teams on also, GP practice. Nurse is a swell if they won't support with it. Um, because if you have people men that symptomatic, they get a confirmed committee of diagnosis. And so if they have you reached your symptoms. As we said before, things like dysuria any kind of watery, white cloudy discharge or any itching or anything like that, then you need to contact all contacts. Since four weeks prior to the symptoms on Sir So established went in their symptoms started on any contraception context they had four weeks before. I need to have treatment, whereas if you have women or asymptomatic men, then you need to go a bit longer. So you need to look back at all partners that they've had for the previous six months or whoever their most recent sexual partner is on. They should all be contacted regarding this person's committee a diagnosis, Um, in terms of went the timing of treatment, you guys got it right in the trap. You basically want to offer treatment prior to the results of any of investigations. For the them to be confirmed is also having from India. You want to treat them first to treat, and then you test them. As he said, because of the risks surrounding country dictum it, your infections really good. And then our second by the question before we have a little break in anyone describe to me the anything that you know about. Then she'll committee a screening program, and it is and announced to the question of the chat. It depends. The four weeks versus six hours depends on, um, if there isn't a mask or not. But I've had some messages come very, very good. Okay, so was done to those people that put things in the chart is looking really good on for the messages I've got. So yes, so in England, that's where this screen programs focus. The national screening program for chlamydia is open toe all men and women age 15, 24 days Um, in England. If your woman under the age of 25 years old, you will be usually offered test for chlamydia when you access kind of any health services, the things that pharmacy the GP, um, things like that you might be offered to test if your woman who's under 25 is also sexually active. It's recommended that you have a test for chlamydia and you'll e. A Z well, as, um, when you've had sex with a new partner, where that's someone that you know considered to be regular or you're in casual relationships is recommended to you have it annually after sex with a new partner. If you're a man who's sexually active in under 25 in England, it's recommended that you have a committee a test once a year, so annually if you're not using condoms or, um, with any new or casual partners basically on. But as you go, I said, everyone can get access to free confidential Committee, a test at any sexual health clinics, GPS, etcetera. The main limitation of the scheme is that relies on opportunistic testing people coming forward on requesting these tests. There's not a lot of outreach per se. It's more about people coming in and requested to test themselves, which is a bit of a limitation. Hopefully, this label give you a little bit of a summary of what screaming program is about. So that's the end of the first section. Uh, so we're going to our next kind of sexual health presentation now, So we've now got a 21 year old female who is presenting with pelvic pain. So if you mail slot diagnosis for you, so our first one, So you got a 27 year old female okay. How paying present has a deep pain during sex and experiences. Rectal bleeding around her period on go periods are very, very painful. Does anyone have any idea what the diagnosis is? Yeah, but lots of times in the chat world and everybody see how this is endometriosis. Um, this is a 27 year old female, so that's quite classic of endometriosis, which usually presents in women age 25 to 35. Um, it usually causes this kind of chronic pelvic pain type picture. The reason why she's struggling to conceive is because they can kind of be suffer with some fertility so struggling to conceive, they may have this dyspenea area this kind of a deep pain during sex. Um, on. They won't know why she gets this rectal bleeding around her period. They won't know why that because, yeah, pretty, it's yet there might be endometrial teeth, tissue elsewhere in the pelvis. So in this case, there might be some endometrial tissue kind of in her bowel, which them respondents to the hormones released during this part of the cycle, which made them cause some rectal bleeding. Maybe the good sire on it. Fun. So a 25 year old female who presents with sharp, constant right sided, lower abdominal pain and small volumes of vaginal bleeding. Her last period was seven weeks ago. She also reports mild breast pain. Any ideas? What's going on with this one? A couple of months in the chart. Any others? Yeah, well done. To those of you that said, Ectopic pregnancy, that is correct. Um, so to start off with it says her last period was seven weeks ago. So she's had a memory alone or no periods of seven weeks, which is quite classic of erectile pick pregnancy, which usually has a memory A for about 6 to 8 weeks on. That's just because the pregnancy, if you like, is kind of starting even notes in the wrong places is starting level. Stopping her periods. Um, she's getting this kind of sharp one sided lower abdominal pain, which is usually caused by the most common site of a neck topic. Pregnancy is in the troops on, so you get this abdominal pain. Is the tubes kind of spasm as um when the implantation and things a car. And so that's why she's got that abdominal pain you may also get a vaginal bleeding as well on it's often small. It's not as much as a normal period, so women might actually say I've had my period, but it was quite light. But just be aware, could just be it could be an ectopic pregnancy. It's just a small amount of vaginal bleeding. Does they won't know why she's got mold breast pain. What's What's that pointing to? Why is that related Tectonic pregnancy? Yeah, brilliant. Perfect. Yes, So it's symptoms of pregnancy might start. If someone has an ectopic, just because it's no um in the right place doesn't mean that they might not start getting the symptoms of pregnancy, and so she might get some breast tenderness there as well. Billion. So next one. So a 37 year old female presents with cramping bladder abdominal pain during up here is her periods are having and painful, and she experiences bloating on by manual examination. There is an irregularly shaped superpubic mess. Any ideas was going on. Yeah, pretty and also correct answers in the top, especially everyone. Well, don't see a you to write fibroids, so these can be asymptomatic It they're quite small, but It's quite classic to find, like an irregular shape and mass in the Suprapubic pubic region, which is just referring to where, if you've got a large fibroid, is gonna start to distort the shape of the uterus, which is what is masses on. So that's quite classic sign of uterine fibroids. And these are the other symptoms that someone might get with it as well. In this scenario, pretty, it's our last ones. We have a 23 year old female who presents with lower abdominal pain bilaterally, vaginal discharge and deep pain during sex. On examination, her temperature is 38.2 degrees and she's 10 during a bimanual examination. He has a part medical history of a committee or infection. You guys got that one really quickly. Well done. Yes. So this is perfect Inflammatory disease. Well done, s so this is basically as it says on the tin. It's basically information of the female pelvis and the pelvic organ organs, which usually comes after an infections, as in this case, a committee or infection. Um, that's kind of spread up from the cervix and spread up further into the pelvis. I'm so classically it comes with this. Like bilateral abdominal pain, The fever is really important to notice. Well, assay was the discharge on the Vicodin excitation on by manual examination. So what I've done here is well, as I put together a little table with some of the kind of different ones that you might have in a guy named Pelvic Pain History fever eyes to read in your own time. So we're going to do once again some investigation. So what's going to split it into her bedside Bloods on imaging and special tests? So I'm not gonna reveal it this time. Any ideas of the investigations you would do for pelvic pain? What would you do for any presentation? Public pain? A bedside of blood imaging, anything you like? What would you do for pretty much every public playing presentation? Yeah. Brilliant. Also. Good ideas coming in. So yep. Definitely definitely a pregnancy test special. You're in debt. Perfect. Having examined don't exam. Amazing. Yeah. You guys are smashed it without completely correct. So once again, if someone's coming acutely, then you won't do a b c d e on and take some basic ops. And you said abdominal examination really, really important a bimanual a speculum for a female as well. Just to see what's going on internally. Pregnancy tests to rule things out like a topic pregnancy. Want to get a urine dip just to rule out things to do with the urinary system as well, you know. So let's look at our extra investigations. So what would you guys like to do? Extra for an ectopic pregnancy? Yeah, cereal. Be tight, CJ. Yeah, buddy. In trans vaginal ultrasound. Ultrasound? Yeah, really good guys. Yes. So, um, obviously, for an ectopic pregnancy I know is on the any section but off to do a pregnancy test that will help you touch you confirm the pregnancy. That's a must Really trans vaginal or trans abdominal ultrasounds are really important to determine where the pregnancy is. Check that it isn't an intrauterine. It's not within the uterus pregnancy, and that is somewhere else. Transabdominally is less sensitive than trans vaginal. That generally trans vaginal ways. Done a PSA preference A z. I said you could do a serum HCG measure measurement that can confirm the pregnancy if these old some methods have failed. Um, usually the hate CG kind of doubles every couple of days. If someone has an ectopic, then it doesn't rise as much. Then if it was kind of an intrauterine pregnancy, so you can see based on when they concede if it's risen by the expected amount, Um, and then you could also do A You try and aspiration on. So you want to do an ultrasound first just to make sure that there's definitely no electric, you try and pregnancy. You don't want to going aspirate anything. If there's if there's a pregnancy happening there, that would be very, very bad. And the ones that's food out, um, you can aspirate the walls of the uterus just to look for any chorionic villus I that would be used to form the placenta. And if they're absent, But you still got all these markers of pregnancy, then you can diagnose an ectopic. Any ideas to endometriosis? What will we do next? And your extra investigations Brasco pee? Yep, yeah, but I think you guys have got the main more much to do it the good? Yes, so for endometriosis, you would do a diagnostic laparoscopy on but allows you to kind of directly visualize any endometrial tissue that there is a needle to do it with a biopsy as well. Just so that you could check what tissue is You might want to consider an MRI, pelvis, if you want to Look, if there are other endometrial lesions elsewhere in the pelvis as well, which you will be able to see on an MRI. Okay. Moving on to a very intelligent What would you guys like to do? Extra for ovarian torsion. Okay. Yeah. Well done. Someone said the sign really, really good that you would do that. Sounds anything else don't play. You could consider it up there yet. Yeah, so these are the ones I've put together so once again, obviously want to do a pregnancy test cause a very intelligent can present quite similarly to the next topic. Um, so you want to definitely do a pregnancy test, and similarly with urine dip is well, you definitely want to rule out things like a UTI with this one. Um, you don't want to do on FBC on your blood's just because if someone has a very important in, um, on, if there is any kind of hemorrhage involved, sometimes you can get high leukocytes with that one s so you might want to consider doing an F B. C. Um, you might want to do a CRP. If there's not some information that could be raised on, you might wanna consider is, well, group and save in terms of If someone needs to go for surgery, then it will be a good idea to do a group and save on cross much as well. Um, then you guys said, um, he want to do a nerve agent Trans vaginal ultrasound, which someone said shows the well pull sign, which is basically the twisting of the ovary on the broad ligament. So it creates that what it looks like a whirlpool. And then you can also do a laparoscopy, which will show you kind of directly on the torsion of the ovary. Um, and that can also allow you to do the surgery while you're there, detox it and hopefully preserve the ovary on for the ideas. Well, I'm finally P I d Any extra investigations you got to do for PT STD screen? Brilliant swaps yet? Perfect. Any imaging your blood seelert to COPD? Yep. Yep. So happy could consider coaches trans vaginal up. Somebody in yet. Pregnancy test. FBC Yet you guys have got the right here. So you want to do a vaginal swell? Um, to see if you can identify any infection. Sometimes these negative quite often, actually, they are negative, but it's important to do anyway. You want to screen for things like committee and gonorrhea because they could be the cause of your P I. D. Um, you want to do, um, fbc off. See that that will be raised in infection and information. Same with COPD as well. That's gonna be raised if it's any kind of information on down, you got to do a transvaginal Ultrasound and laparoscope be just because that can reveal directly the inflamed tissue that you would get in. P i. D. You were done, guys. Eso Let's go through the acute, um, management of a suspected ruptured ectopic pregnancy. So if a firm someone came in with an acute presentation, what do we what type of approach do we want to take 80 Fabulous. Well done. So we want a PSA say, take an 80 approach. So under our airway offs, even going to check the patient's kind of talking about their airways Peyton on. If they're not, then obviously we went form. I'm And then under breathing, we will do things that Oxford oxygen Saturations taking a rest 30 right test. But considering ABG on for a suspected ruptured ectopic pregnancy, they you would probably consider pretty up area rescue All so prior arrest. It was basically when a patient is kind of very unstable on, do you want to prevent them from progressing onto a cardiac arrest? Most women with a suspected ruptured ectopic pregnancy died due to a loss of blood on gum times. If you have kind of massive acute blood loss that can also call was a cardiac arrest. So put you on a very rescue all ahead of time is a really good idea. Then, under see, we wanna, um, off the excess fluid balance off. See, there's massive blood loss. Then people can be very kind of I've lost a lot of fluid there, quite dehydrated and things. Um, check all the things we used to do polls, but pressure, except what's really important is you want IV access with a wide ball for a full cannula. Because this is, say, people can lose a lot of blood. So you're going to need to give him fluids. You're gonna need to give thumb blood products as well as we want to make sure that we got IV access established so that we can get that going nursing quickly. Um, in terms of the bloods, you take quite routine ones that you would do. But you don't wanna add on serum be to hate. See GI Group save in a clotting screen. Sorry, don't do those mistake A little stream. It's that husband said cross match apologies because if someone's going to surgery on, then you wanna make sure that you've got those ahead of time In case let's say they need to get blood products. They're on. But that's what you would need to get if they are having a blood transfusion. As I say, if they lost a lot of blood, um, and then you need their serum. Beat HCG later on to decide exactly how you're going to manage them because of this major blood loss off. See, Wanna activate the major hemorrhage protocol on you may start fluid resuscitation if you're waiting for things to be processed for you to get blood products obviously is ideal to replace blood with blood, but the same time you don't wanna leave them without the fluid eso considered through resuscitation. And while you're waiting for the blood to come, then under D we want to check things out after food at the people's check bug you coz, as you normally would, and then finally go to eat. So check all the things that temperature, your analysis and pregnancy testing. You ever been out put, especially if they're on stable check for signs of kind of intra abdominal hemorrhage. They might show signs of parroting is, um, and things if it's ruptured. If there's hemorrhage into if it's hemorrhaged into the peritoneal cavity so you might find signs of parroting is, um or, um, in the patient getting one pop in the trap for me, some signs that you might see if someone's I've got part is, um, yeah for it in guarding. Yeah, yeah, you guys have got it pretty great suggestions in the chat with them, um, a Z. Well, as I say, if surgery is indicated, then you want to get kind of early surgical involvement. You want them to know about this case kind of assume as possible. Um, we're going to shortly kind of brought the indications for surgery are and you want to organize the trans vaginal ultrasound just to determine where the pregnancy or the ectopic pregnancy is s O that then you can use that when you're treating them. Um, finally, just consider transit stomach acid, which is often used to treat on prevent excess but loss. And to consider that in these patients, because what that does is it inhibits plasma in which usually carries out footprint license. So breaking down caught something's Teo, right, thin the blood if you like. Um, so if you give transit sample gas it, then footprint allies it won't happen on you won't have as excessive blood loss. So consider giving that to these patients. And obviously, if the pain becomes unresponsive, begin CPR. Start your doctors. ABC keep the patient deal by mouth, especially. They're gonna go to things like surgery. Then you wanna make sure that they're near by mouth and so we don't have any risk of aspiration. Um, when you're explain this to examiner, always off to reassess a B C. D is you go. It's not a kind of check place. You've done it and it's over. You need to keep reassessing on get emergency gynecological assessment as well. It's also another important team that need to know about these patients that get them involved nice and early as well on. But here's a little summary of how we manage that topic pregnancy that Mrs Made. Um so as it did before, take that a B C D approach that we just went through and organize that trans vaginal ultrasound. And if they're in significant pain, they've got quite a large ectopic pregnancy size a Zafy. It'll heart their serum hate CD that you took when your blood's is high on. If they're unable to return for a follow up late one, then you want to get them into surgical management. Um, Teo, basically, remove that. Remove that ectopic pregnancy by taking out the whole overflow peon tube or a part of a fellow peon tube. So that is our next break. We've got one more section after this, and then I will pass over to sauna, but we'll take a break in the meantime, but and so we're going to the last section guys are doing really, really well. So the last bit I'm gonna talk about very briefly is contraception s. So, just to introduce the topic, I'm gonna give you some scenarios. And if you could tell me out of these options here, So the combined oral contraceptive pill, the progesterone only pill, the injection, the implant or the eye us or are you d Which one you were picked for? Each of these women, based on their constraints. Eso starting off with our first? Um, we have a 21 year old female requires contraception. She's considering having a child in the next couple of months. Her be a miser. T four. It's a eczema trip. Time for headache. She has with associated numbers in a hand on the face. Which of those options would you give her? Yeah, Brilliant. Nice and quick guys were done. Yes. So for this lady, you would most like. It used to be a p. Firstly, because she's considering having a child in the next couple of months, so we can't really use are more long term contraceptive agents of things like the IUD. Last 5 to 10 years, the US kind of 3 to 5 the IMF count nose. Three years and the injection is three months. So she's considering having a child in the next couple of months. Then we kind of narrow down to the C S E p in the p o. P. Um, Why did you guys truth? PPI The CCP? Yeah. Brilliant migraines with aura. Perfect. Yes. So, um, the migraines you she's taking sumatriptan. Yep. And we've got this or a swell, so it doesn't have to be visual. That's why I wanted to emphasize here anything like Paresthesia is in this case, numbness is crossed. His aura s o. In this case, that would be a contraindications to the c o c p a B m. I, over 35 is a relative contraindications. The hair bme. Is that your PSA? She's close, but not quite. But you would still, because of the migraines or go with the therapy. Next one. So you have a 18 year old female. She requires contraception. She says she is very forgetful. She's considering having a child in four years. She has a fear of needles. What are we gonna go with? Okay, is a bit of a mix. Okay, I would say her best bump her is the implant. I can see why people put us the reason why we've gone, but implant is so let's work for it. So she's quite forgetful, so we don't want anything. We don't give her anything where she's taking it kind of daily. So that kind of rules out or two pills In the beginning, she's considering having a child in about four years, so we wouldn't want to give the IUD because that's kind of 5 to 10 years on our US is 3 to 5. I would say that's a bit close, especially if you're on the five year end of it. Um, so I'd said, I can see why you put the r us on, but I would then narrow it down to the implant in the injection as a preference. Um, and because she has a fair needles, we're probably not gonna go with the injection. So in this case, we go with the implant. Okay, next one. So we have a 26 year old female. She reprised contraception. She was diagnosed with pelvic inflammatory disease two months ago. She's considering having a child in two years time. She's an air hostess and would be unable to regulate Take any medication at the same time each day. Okay, I think most people go on for the implant with this one. What was Vivus it? Injection injection. Okay, but this one, I will go with the injection. So if we work through this scenario, she had pelvic inflammatory disease two months ago. So if someone has pelvic inflammatory disease in the last three months, that is a contraindication for the eye. Us and the IUD. Just because of the inflammation. Kind of to the perfect way. Don't we've ruled as a rule, those out. We don't want to give her those. I'm She's considering having a child in, um, two years time. So we've said the implant tends to last for three years, so that would take us kind of too far. She would have contraception for to do on the she was having trouble about two years. Um so that leaves us with the first three on because she's unable to regulate take medication the same time each day because her job, um, both the C S, e p and the P. O. P. Have quite strict time constraints and so we probably won't go with those on the injection would be the best cause for for her. So the next 1, 34 year old female requires contraception. She has finished her family and she experiences heavy, painful periods. She's a past medical history of alcoholic liver disease. Any ideas what we would do for this one? Okay, we'll go a bit of a split between us and I d r u day, I think mainly on us, which is the correct answer world. Um, so with this patient working fruits and she's finished her family, so it's probably better to go for, ah longer term type of contraception, so she doesn't have to worry about it. Um, she has a past medical history of alcoholic liver disease. This is a country indication to the combined oral contraceptive pill, the P o. P. The injection on the implant so that roses down to the, uh us on our you day on. Then we're looking at her period, so she experiences heavy, painful periods. If someone has heavy, painful periods, we tend not to give them the IUD because that can make their periods kind of longer heavier on more painful so we don't make it any worse. So we tend to go with the R Us. Yeah. Perfect. Someone popped in the job. Really? Well done. I'm finding out our last in a row. So we have a 17 year old female who requires contraception. She's unsure when she got to start her family. She suffers with heavy menstrual bleeding on at the she'd like to control when her period bleeds occur around events. And she's not keen on any kind of internal contraceptive methods. Yeah, brilliant. Because we'll call it right in the chapped. Well done. Yes. A c o c. P would probably be best for this lady because she doesn't know when she lets start her family obviously kind of the short term, the the better. You wouldn't want to put anything that the US the IUD in that's going to last years, and then she's a bit stuck with it and has to have it taken out, which can be a bit of a pain. And so we want something that we can start and stop quite quickly. Eso probably things like the C S e p p o p. An injection would be best for that. I'm and she suffers with heavy menstrual bleeding. And actually, these are both things that they're combined or acceptable can help with Andi. Don't like to control when her period bleeds around events. You can also do that with the CCP as well, if you what they call that run packets together. So rather than stopping it, you can run them together. And then that means that you have some control over when your period is on. Because she's not keen on any kind of internal records. We also won't go with things like the implant, the R us in the day. So considering all of that, the C. O. C. P is probably the best for her so well done. So what I've done is this a big table? I'm not going to read through the cell, but it's just made a summary of all of the contraceptive methods that you're probably most likely need to know. So I put kind of your daily methods in reds, your barrier methods in orange and your longer acting methods of reversible contraception also learned about a Xolox in blue on discharge, A continuation of that and then we've kind of got our surgical methods in this purple color on family planning as well, when green just for completion. But I'll let you guys read that in your own time. So then I quit. You wanted to talk about counseling for the combined oral contraceptive pill because it's something that could come up in your skin is on bit something that also have come up in general practice quite often as well, cause there's a lot for patients to uh, uh, been starting on. That could be by introducing yourself What, your hands. Introducing your name in a roll on also getting the patients details, their name and the date of birth. Except then, when you want to stay, is established patients understanding of the different types of contraception. So, uh, I would say that the combined or contraceptive pill is probably the most well known kind of form of contraception. Andi, even though we know there's lots of different that's as healthcare professionals, many patients don't that might be the the C S e p, maybe all they know about contraception. So it's important to kind of understanding introduced the idea that there are other types of contraception if they don't feel that this is the method that would suit them. You've got to be quite careful. You don't wanna be too dismissive. You don't want to sound like you don't want to give them the pill. But you just want to understand How much do they know about different types of contraception? Then you want to explore why they want the pill. Eso is it for contraception? Is it for heavy menstrual bleeding? Things like that. So just explore why they actually are requesting it in the first place. Then we want to go through ice. So ideas, concerns and expectations. So do they know about the pill that clearly know about it? What do they know about it? What they concerned about with it? There Any things that they've read that worrying them on, What do they expect out of the concentration today? Do they expect to walk away with it today? Do they just want more information? Do they want to know other options except your? So you understand kind of what they want using that ice? Um, four months. Then we want to start our explanation section off the counseling. So just going through all the things that patient would need to know about the combined or contraceptive pill s. Oh, you want to tell them kind of. What is it? So it's commonly noticed The pill. It contains two hormones. Estrogen and progesterone, which is quite similar to the hormones that are produced by our own ovaries that regulate our menstrual, our menstrual cycle. You could also explain that there's different pill types for the c o C p S o. You have the 21 day monophasic, which is basically where you have 21 pills that will contain the same amount of hormone that a woman would take on. Then she would take seven days off. Um, you also then have the 21 day phasic pill, which is where she has 21 days of pills that contain different levels of hormone. Ondanesetron them in a certain order on, but she has seven days off, and then funny. There's like the every day pill, which is basically when you get a set of 28 pills, but only 21 contained hormone. Seven. Don't on their four. She doesn't need to think about when she's stopping. When she's finished. You can just take a pill every day. So you kind of explain what the pill actually is. Then you can mention a bit about how it works. So the fact that it in here basically it stops neck being released. It thickens the mucus around the cervix, so that can prevent sperm entering up into the cervix and the uterus to reach an egg on it also fins the endometrium is it thins the lining off the you dress to make sure the implantation of the egg, if it's been fertilized, is less successful. And I will say, obviously, the whole time you're doing this use patient friendly language, don't say things like ovulation, they won't understand. But I'm just telling you in that way, but use patient from the language throughout, then you want to say about the effectiveness of the C S. E P S O estimates put it about 99% effective. If it's taken correctly. You don't miss miss Any pills obviously, in in in our ski. If you don't know, don't make it up because that looks pretty bad. Just say that you don't know in that you'd look into it. Um, if the patient questions you on it. Or if you want to say that as well, then after we've done all that explanation, we want to talk about the advantages. So could anyone pop in the chapped for me? Some of the advantages, um, off the, um cuz be Yeah, brilliant. Those graduates yet it's not invasive. It's effective. Helps to periods get regular lighter. It can help with things are actually perfect. Lots of different advantages. Then you go through disadvantages. The things like side effects. They might get headaches, things like that. Then I get break flu break through bleeding off C The C o c. P also doesn't help prevent against ST I things like that. So you talked to the disadvantages talk through the risks of it. So things like, um, venous from embolism s o worrying about things like DVT pa things like that that you could also talk about the slightly increased risk of breast cancer as well on days of I call cancer. If they use it on term, then you can talk through any contraindications that might be relevant to the patient. So I have a look at the UK medical eligibility criteria that told you kind of the relative and complete contraindications, and you can talk through any that relevant to the patient, and then you can expect them how they started. So basically they can start it anytime. Is that? Was there not pregnant on day? Should use condoms for the first seven days while the hormone levels kind of adjust after starting to take the pill, they could talk through Ms Pill rules that will be going through shortly. And then finally, just summarize the key points. Check how the patients doing If they've understood the information, give them further leaflets and things, and then a range of follow up later and obviously the whole way through. Just be really respectful Chunk and check throughout. Make sure the patient understands and offer any leaf. It's a say. It's a natural that they have all the information, So I'm gonna flash this up really quickly. Just cause of time I've just put on here the Ms Pill rules for you guys to go to in your in time for both of the CP and the P. O. P. I've also done is done another counseling slide, for if someone starting hormone replacement therapy. It's very similar instructor to the c o. C. P. Bobbsey. It's for hormone replacement therapy and said so we'll go on to the examination eso We'll start off with the by manual examination. So this is a summary side just to explain the whole examination, but we'll talk through some of it. Can anyone pop in the chapped for me? Why? Why might you choose? What? The indications for doing a bimanual examination? Why would you do a bone marrow and examination on a female? What presentation? What symptoms? What you have that you think? Oh, yeah. I need to do it by manual. Public pain yet? Brilliant. Anything else? We talked three today. Anything else? Any other presentations? Symptoms it yet? Despair union yet paying on psychs discharge. Yeah. Brilliant. Yeah, but it just was brilliant. Yes. If someone has any kind of irregular bleeding menstration problems, pelvic pain, discharge dyspareunia things like that, you would consider doing a biopsy on you. All this is a summary, but I'll just quit. You talk for it for you. So just start off with as always, we do all kind of wipe eso you wash has introduce yourself. Get the patient's name in details and expose them where relevant. So obviously we do that as normal. But we need to add in a few extra things for a bimanual exam on. I like to remember this as a CDC, uh, so this stands for any chance of pregnancy. The presence of a chaperone, the door on getting consent. Eso if I flash up this paragraph, I won't read this. You know, you guys can read it in your own time, but you just need to remember that you need to check if there's any chance that could be pregnant because you don't want to forward by manual if they're pregnant, Um, you want to emphasize them that there will be a female stuff member at he's shepherd who will be present on that. The door will be locked, Um, and obviously, because it's, ah, you do it with any examination. But because it's a very intimate examination, you need to make sure you get explicit consent from the patient that they're happy for you to do this. Another thing is well is when you're explaining the examination to patients, try not to do what I do quite often and move your hands and your hands about because you end up making actions that don't look great. So just keep your hands nice and still on Dalser. Oh, you want to emphasize as well on gas whether the patient would like to empty their bladder before the exam? Um, just recommend they do it because it's quite hard to palpate things if the bladder is quite full in in the way and it can be more uncomfortable for the patient. So I asked him to empty their bladder beforehand. So then we go on to kind of vulvar inspection. I will just put a little warning. I'm going to show some images off presentations and images that you might see involves on. So if you're not into kind of those images than look away, they will be coming on to the screen. So to start off with, you need to get the patient in the correct position. So you'd say to them, Bring your heels up to your bottom and then let your knees fall to the side, and that's how you kind of get them in the position it and then you need to look externally out of over So we're going to show some images now. And if you both can just say what you see on the chart so to start off with Does anyone know what that is? Yeah. Brilliant. Modern. Someone's got in the trap. Yes. So this is on also, which are someone else's. Put his associate it with things like genital herpes. Very well done. Any ideas? What? This is suggesting what it is? Yeah. Perfect. Yeah. Nice. And general. Guys, you had perfect. So discharge. So we talked through some of the different types of discharge. So with committee a gonorrhea, you might get this kind of yellow green picture you might guess. Kind of fluffy yellow with try Premarin eyes is you might get if someone has thrush, you might get that kind of cottage cheese tight discharge. So have a look. The discharge that might be in the air area on patients, underwear. So, yes, And also I've just seen that in the trash can be normal. And if you take a history, you can ask if there's been any changes. But yes, women will have naturally will have a normal discharge as well. So just trying to establish that can be very helpful. Well done. Okay. So obviously you wouldn't see this. But what is this image alluding to that you might see on examination? Yeah. Brilliant. Well done, everyone. Yes, it on a pc, often the scar. So obviously, when you're examining, you look for any scars. But this is quite a common one that you might see. So can someone described me. What? On a PCR to me, actually, is like you're got it. What is it? A PCR to me? Why is it performed? What is it? Yeah. Brilliance. Yes, it's It's a cart diagonally down, kind of from the vagina to make the, um the opening wider during vaginal delivery to prevent it tearing down to the anus. Basically, And so you might see that women have a diagnosis. Carl. Yeah. You guys have got in the chat after after a pregnancy. All done. Any ideas what this one is? This was quite a tricky one. That's probably the hardest one. Yeah. Brilliant. You guys are going correct in the chat world. Done on. So this much in sclerosis is basically an infirmary, a condition which affects the skin and the gentle yoga. Typically in older women on it presents with these kind of white plaques on which can scar and be quite itchy on. People get pain when they have sex of the urinate. So look at these kind of white patches that you might see when you're forming in the examination. But he gets any ideas what this could be? Yeah, it does. Definitely. Look what? Like, Yeah. So this is you guys are very close. This is It doesn't look what, like on this is actually involvement on examples of over malignancy. So these are kind of these obviously quite rare. Vulvar malignancy isn't one of the common cancers it presents with these kind of thick and patch. Is that, as you guys have said, really? Well done. Our, um, kind of walk like they may be painful. They may bleed. They make it so patients might report that on. But this is an example what they might look like. Any ideas what this one is? Yeah. Brilliant world on. You guys got it in the chart. Really? Well done. Yeah, this is a, um um a buffalo. Insist. Does They won't know what? What? The cause of this is what it is what's what's This is coming from what structure? Yeah. Brilliant. Yes. So it's a It's a blocked gland. Really? Well, don't say around, um, the opening to the vagina. You have a bath Olin glands, which basically help to keep the vagina and listen to keep it moist. Um, you kind of have these. If you imagine this is like crap face, you kind of have these at, like, four and eight o'clock. So you can see the one at four o'clock is kind of inflamed here on As you guys said, it's blocked. It's It can be infected as well on that forms assists, which is this kind of unilateral fluctuate mass. You might see if these kind of four and eight o'clock positions when you're doing your vulvar inspection pretty good. Next one. Is that what it's what? The hours pointing to any ideas? Say what you see. You could I'll give you a clue that you can see this elsewhere on the body, sometimes on the legs, things like that Don't stretch marks. Yes, somebody's got it. Well done. Yes, these are varicose veins. So if you have any blocking to the kind of venous drainage off this area. You can sometimes get these kind of varicose veins in the in the pelvis area. So someone say, for example, has a malignancy in the pelvis that blocks venous return. You can sometimes get these varicose veins that you can see kind of here. Great. And then I haven't had an image. But does anyone know what this, um, diagram is? You're fine. Take. Yeah. Pretty modern. Well done, everyone. Yes. So you want to obviously look out for things like F f G m f g m is basically a total or partial removal removal of different structures of the female anatomy. So things like the clitoris, the labia sometimes there's narrowing off the vaginal opening things that that, um if you guys saw this in an under 18 year old, what would you do? Yeah, pretty well done. Yeah. You inform the police if someone's under 18, you need to urgent care for report back to the police. I'm funny. Our last image. Any ideas what this one is? Yeah. Pretty well done. Yes, this is a prolapse. This's basically when the the cervix and the uterus have moved further down on their prolapsing for the vaginal opening. If you ask a patient to cough, that will kind of exacerbate this kind of products material because your increase in the pressure in the pelvis so this will kind of move upwards. Great job, guys. So I'm gonna quit. You go through how to perform the by manual examination so it doesn't start off with starting on the left hand side. You want to, um, lubricate your two fingers so your middle finger and your index kind of pointing finger on Do you do that on your dominant hand? So for me, that's like my right hand. I then use my non dominant hand to separate the labia majora on. Then I would answer, um, the dominant, the lubricating dominant fingers into the vagina. What? I would say the top tip, which isn't the case in this image, is when you're doing it. So you kind of got these to lubricated. If you keep your thumb up, that will stop you from kind of over inserting your fingers into the vagina. But extent to keep the phone kind of right angle. Um, so you've inserted them in, and then you need to turn your hand 90 degrees so that the palm is facing up with Steve. Insert about this thing you need to turn. So it's 90 degrees so once and the things that you need to examine different structures. So you need to start off by examining, Um, I'm feeling the vaginal walls, so you want to make sure that they feel moist and you want to be able to feel rugae as well. So these basically transversus ridges in the vagina. They should be present if it's normal. And obviously you want to feel for any masses as well. So things like vaginal malignancies and things you want to have a feel full, then you'll get up to the cervix. So you want to check its position check. It feels smooth. It doesn't feel irregular. Anything about, um and see if when you move the cervix, if there's any tenderness, so this could be a sign of perfect inflammatory disease or ectopic pregnancy. So you want to look for that. Then you want to put your fingers into the posterior for Nick. So the pharmacies are basically the small, um, kind of, um elevations, if you like In the vagina, where the cervix is further down. It's kind of these portions of the vagina extending around the sides of the cervix on this four of them. So there's a posterior and anterior and to laterals. But the to laterals on the interior, quite small to the posterior, for next is the biggest one. And you just want to feel for any masses in there, because I'm obviously you just feel run cervix. You might miss them. So, as I said, you do the posterior, and then you feel the two natural for disease in the same way. Um, then you want to have a feel for the uterus on the ovaries in the you trying to, so I'll play that animation again so you would have your fingers inside in in the posterior for nicks on. You would press kind of upwards to bring the uterus further over this way over the bladder. And then what you would do is you on, and you push down on the abdomen to kind of bring the uterus between your between your hands, um, and you want to feel for its size the check. It's about the right size, which is about the size of an orange you want to feel for it shape. So as we said before fibroids condensed or it it so looking for that on check of it's probably antiverted and no retroverted and check it feels smooth as well and not nodulars. If there's any Millikan sees um, once again see if there's a tenderness as well that could suggest things are connected like or perfect inflammatory disease. And then, as I say, we feel the ovaries on the you trying to pieces well, eso to feel those You do very similar movement with your nondominant hand on the tummy kind of press in. But you put your fingers in the lateral forties, I think kind of pushed together and once again check for the size and shape of those as well. And then finally, you would draw your two fingers on. Just have a look, see if there's any blood or any discharge that could be a sign of pathology. So that's the by manual done, and I just got a couple of slides on the speculum examination eso Once again, you do the introduction in the vulvar inspection. Just a sweet explained on. Then you would start off by inserting speculum. So to do this, you lubricate the side. You don't lubricate the tip. Um, and what you do once again, is your nondominant hand separates the labia. You insert the spectrum of them with the blades closed sideways on any angle it down so that you're most likely to visualize the cervix. Then once you started to put your end and you need to rotate it 90 degrees so that the handle that it has is pointing upwards. And then once you are sufficiently in, you can begin to open the blades by squeezing the handle together on then to lock it in place so that you can use both hands again. There is a locking up on the speculum to security and face, and then you will visualize the cervix. And then I put the instructions to remove it. But it's basically the opposite, Um, afterwards, and then I'll see you respect the patient and restore their clothing. So my last side, if we're visualizing the cervix, let's have a look at these. Once again, I'm going to show on some images off services, so just be aware of that. So start off with what's this? Yeah, brilliant Yes. So this is a normal cervix. So this is a normal cervix or someone that hasn't had a vaginal delivery before, so it's usually a circle shape. I'm just going to walk through these because of Time s Oh, this is a normal cervix after pregnancy, so she can see it's more of a line shape. It's just because of the, um, pressure that goes under under vaginal delivery. Then this one here, if you guys have any idea, this is a Opens, uh, vocal loss on this is important to look out for for things like miscarriage and things like that. And then this one you guys might be able to recognize is a cervical ectropion. This is basically when the transformation zone inside moves outwards onto the extra cervix on it creates this kind of different colors things readiness around here, and that could be caused by different things, like pregnancy taking the combined or contraceptive pill basically anything that elevates your Eastern your levels come cause this, Then this image is just showing things that savaiko masses. So when you look in the cervix check, there's no masses that could indicate things like a malignancy. Uh, then This image is just referring to any discharge that you might see when you're visualizing So you could see this this kind of white discharge here, um, to look for any discharge around the cervix. And this image is just continuing to to say, look for any bleedings. If there's any blood around the cervix, then know about as well, which might be caused by trauma, pregnancy, other pathology is inside the uterus. And finally look for these these as well, which are survival polyps on diesel, basically growths of tissue that might occur. And you might see one on or within or coming out of the cervix. So look for those as well. Let's be done. Thank you guys have sticking around. I hope you enjoyed that. I would be passing over to Sana shortly. I think the feedback forms just been released. I'm sorry for the delay with that, and I'll possible Lovely stuff. I can. How everyone if you haven't met me names a Honda on DA. I'm gonna be going through the breast station with you. So just a quick lecture plan for you can expect over the next 20 minutes the main presenting complaint gonna go over today is breast lumps. And then we'll talk about a bit of cancer and how to look for signs, breast cancer and when, well, how to refer them. Like what? The pathways. Some breast pain differential spot diagnoses for those breast examination the techniques to use on depictions of important clinical signs to look out for in your station. Um, and the very important bit is how to describe a breast lump. I think this is really, really important, and carry is like really significant marks and breast or ski station. Um, it's important that you cover like certain domains and describe breast lumps in a certain way. And finally, just completion. A bit of management of mass Isis something it it It's something I could come up easily. Need the finals or your ski station. So, um, we have a 67 year old lady presenting with a new breast lump that she's noticed, and this is the background for a spot diagnoses. So I have a bunch of differentials here for breast lumps. Um, and I would love if you guys could put in the chat. What do you think the diagnosis would be? You know the drill. So the city center lady presents for the new firm and nontender lump in the upper outer quadrant of her left breast. She's noticed that her left breast recently seems larger than her right, and she's reached menopause at the age of 63. What do we think? Um, the diagnosis could be malignancy. Cancer? Yeah, So it is breast cancer on Do have a couple of couple of risk factors and things to look out for. One is her age s over. The age of 65 is usually when they typically present. Most commonly lumps of present with breast cancer usually are painless on by firm, um, rather than rather than, like mobile. And and they don't fluctuate the firm and nontender and they move commonly occur in the upper outer quadrant of your breast. Um, on D. Also, a red flag is asymmetry. So when when someone complains or notice is that their breasts look different from one another, that's right. Like a symmetry is also a sign off currents, cancer and the fact that she reached my own apart in age of 63. But that's quite late, which means she was exposed to a lot more endogenous estrogen, which is also a risk factor for the development of breast cancer. So now we have a 70 year old lady who has noticed a new area with everything notice scaly rash on her right breast. The rash started on the nipple four weeks ago and has since spread to the area. She finds it to be increasingly itchy. Yeah, you got it. Any of a Paget's disease of the breast? Yeah. The Paget's disease of the breast is a type of breast cancer, the time of carcinoma that involves mainly the nipple off the breast. Andi, what's characteristic of it is that it starts in the nipple and works its way out to the air around spreads. You get this area erythematous scaly, rough, hardened nipple. Um Onda? Yes, of the way. So how would this differ from somebody who had eczema on that on the nipple? Can someone tell me the child if someone had eczema? Yeah. So basically, eczema would tend to start on the outside on the breast, are on the Ariola, and then progress to the nipple. And also whereas pageant is the other way around, it starts in the nipple and works its way out. Words also with eczema. You find the rash on other parts of their body is well, not. Maybe not. It's not just on the breast, which is also a sign. Um, yeah, great. Well done. A 24 year old woman presents with a new mobile breast lump in the upper outer quadrant. Right breast. It is Nontender Mobile and has a rubbery consistency on examination. Far as in, um, A Yeah, yeah. Um, what is like the main thing in this in this? That kind of tells you that it's a viral genome. A and potentially not cancer. It's mobile. Yes, on aged. Perfect. So this is the most commonly presenting breast lump in young women under the age of 30 on, but it's usually common in like late other. So the age of 18 onwards, agent and 26 is when it's most common. Onda Um, women get really concerned because they think you know it was cancer, but, you know, given the age on. But the problem with lack of risk factors is probably viral genome A, um so that's that's on green now have a 38 year old woman who presents concerned about multiple tender mass is in her right breast upon palpations that scattered around the breast and a smooth and mobile, she says they seem to fluctuate in size during the month. Yeah, people getting it exactly. It's a cyst. And what what about this tells you that it's assist, what's like one of the main, um, keywords. And this one yet fluctuation. Exactly. It fluctuates. It's psychological, so it changes with hormones throughout the month. Her age? Exactly. She's quite young, which means she's probably pre menopausal. It's more by fluctuate, and it moves exactly so cysts, because they're filled with fluid. Usually they're not full of, like hard, fibrous tissue. The quite mobile? Well, great. And you could have many of them rather than just one, because it's just breast tissue that enlarged due to hormones. Great. A 27 year old woman was playing cricket when the ball hit her breast with great force. She sustained bruising in the area office every days, and she's now I noticed a new lump in the same area and claims that it has grown inside this, but effects fat knickers is great, so this is also a common infection and younger people because, you know, they tend to be active in susceptible to these kind of this kind of trauma. Um, so this is typical. So basically, what happens is when you have trauma to your breast be sustained, drama. The tissue around it, um, the fat, especially that's going undergoing the courses and get and gets fibrosed on this basically like it manifests as what feels like a lump in the breast and you will be associated bruising, most likely in the area as well. Lovely stuff, guys. That's a quick summary of artistic, difficult clinical vignettes for common breast lumps. So let's talk about the breast lumps themselves and how they're present. Um, on a woman you're on, um, on on breasts. So with a breast abscess. Uh, and what is the breast abscess? It's basically when you have mastitis, when you have inflamed breasts usually do the breastfeeding. Um, do you see two breastfeeding? Like if you have engorged breasts or do you think it infected, you get mastitis, and if that continues, you get this abscess on your breast, and that's a definite is in red. So how would a lump present in a breast abscess. The breast office itself is the lump. So how would that present? It's Fluctuating is the main thing because it's a demon tous. It's full of fluid. It's not hard, and it's not firm. It fluctuates and it moves around. Let's contrast this to a fibroadenoma, for example, Um, so a fibroadenoma, on the other hand, would be firm on do. It would be very localized and use usually a single lesion, just one single piece lump that's very well defined. And when you palpate it, you feel what's called a robbery consistency, and it's painless. Um, with the breast cyst like we talked about, you could have single breast cyst or you could have many. You're on the breast because it is just your breast tissue. Um, and this can be tender on power patient and can be painful addressed as well. Um, and it depends on the person's hormonal changes and because it fluctuates in response to hormones and it's mobile because it's filled with, like, more fluid tissue fat necrosis. You would get again nontender lump. It's due to the five virus is off fats within the breast on D very important thing to do about fact that causes lumps is that because they're due to trauma, that not really well defined lesion, it's just a lump of fat that's kind of gone fibro. So it's has irregular borders. That's an important characteristic of those, um, the rest of the stuff of written down here are other characteristics that can help you diagnose either a breast abscess or any of these others. For example, if somebody has a breast abscessed, it's not only going to be a dermatitis and fluctuating, but they also have associated pain on do like a routine, um, off that area, Um, and they may even have fever as well. And even nipple discharge. It was infected, um, with the breast cyst. Again, they will say that it changes with throughout the month that it grows and size and then goes down again because of their hormones throughout the months. If it's fat necrosis following trauma, sometimes fat necrosis can mimic breast cancer to this can be kind of confusing. When you seem very lifelike, the lump will feel irregular, like breast cancer would regular borders, and you might even see a skin retraction or puckering if the fat is deburring to the skin or the neighboring ligaments were talking a restaurant, a presentation more in detail in a second. That's that's That's what you will most likely find. It's some sort of bruising or ecchymosis an area that could tell you that it's actually fat necrosis on not cancer and a gyn the trauma as well to breast cancer. Can someone tell me, um, some common like president? Clinical features of breast cancer? So not specifically the lump, but just like a features of breast cancer discharge. Okay. Yeah. Let boo changes. Take that. Put a rush yet? Blood. You discharged? Yeah. Asymmetry, lumps, dimpling, skin telling. Yep. It's very much Okay. Fatigue. Yeah. Nice. Can you give me a few different ones? Um, lymph node Enlargement. Amazing. Very good. Okay. Yeah. You guys got on the ball. So, like we talked about a judge again. Age this factor and to officially on paper, it's over the age of 65 and increased exposure to Easter gyn. So situations in which somebody would have increased exposure to estrogen would be either endogenous or exogenous. So if it's endogenous and it's things like having early men are key and late menopause, not having breast fed, and it was an exogenous. And it's like taking estrogen externally. So like in the C O. C p, for example, or HRT, great, someone said it lovely stuff. The lump, like we mentioned, is usually nontender painless, and most cases can be single or multiple, depending on the cancer, and is usually firm, and it's quite hard to feel it. It's it doesn't fluctuate as most cancers are. They different sheet, and they they spread out randomly. And there's no fixed fashion to the way they grow, and therefore you get poorly defined margins, and it won't be very well defined circular lump like a fibroadenoma. It would be quite irregular. Borders is what you find on. Like I said, they're most commonly occur in the upper outer quadrant off your breast. And there's a really, really didn't read flag signs to look for in regards to skin changes on nipple changes that you might see on the breast, for example, if you see things like dimpling puckering off the skin, I've got pictures of these later that I'll show you, like changed the nipple like nipple inversion or nipple discharge. If you see signs like Purdue around is basically when the breast looks like orange skin like orange color would like with those little poker dots, um, Onda other signs which I'll go through in a second. But these are the most important things to look for when you're looking at it thinking breast cancer. I've got a little table here that kind of summarizes all the differential we just talked about and what kind of how they present clinically. And you can look at this in your one time, and it kind of helps you different shapes. Different differentials in your head. Um, based on the Harley present. Okay, so let's talk about his to you when you're taking a history from somebody in an Oscar station who presents with the breast lump. What kind of things do you want to ask about? The first things. Obviously you want to have a history of presenting complaint. So we've talked about a bunch of these already, but the main things you will want to ascertain when somebody presents with a breast lump are firstly details about the lump itself. Right? So when did they first notice it? Right? How big is it? you roughly want to ask about the mention that is it the size of 50 50 p. Coin. Ask questions like that. I can help you relate to what the size might be, where it is. So ask them to point around where it is. Um, Onda, how it feels when they touch it. Um, is it is it soft is a hard is it is it robbery on? Does it move? Is there any associated pain either addressed or when they when they when they feel for it. Um, have they noticed any changes at all in their breasts? Eight in changes in asymmetry have they noticed that one breast is bigger than the other? Have they noticed there any random, like, dimpled on that on that breast that their breasts at all, um, changed to the nipple? Any discharge from the nipples? Well, um, and specifically, ask if this lump changes throughout the month, as as we talked about. Breast cysts are heavily influenced by hormonal changes, and therefore they fluctuate in size throughout the month. Also, ask if there's any history, recent trauma, because this would be this kind of help. You rule out fat necrosis as a differential. For example, the insistent review, um, again screen for all the symptoms off breast cancer changes, but also signs of infection. Is it red? Is that a new rash Could be projects Disease? Could it be mast isis? Is there an abscess? There was a devoted does. Is there any associated pain there at all? Any associates fatigue or fever is well, if you're thinking cancer, unless, um, important. Red flag symptoms screen for one of the classic ones you can look for like on explain weight loss, loss, appetite, fatigue, malaise. But important ones are lymphadenopathy because because the breast have a really elaborate lymphatic network, they tend to metastasize and the metastasized quite early, and therefore you would ask if they feel for any if they felt any lumps in the neck or in the axilla under there and the armpits on. You will also ask about any back pain or any pain in their limbs in the context off bone metastases. And, as always, you have, you would do it the full systems review in any history. Any osteo a shin, asking them about the feeling dizzy had to go any chest pain on and shortness of breath recently, any problems with bowels or water works any abdominal pain and syncope and things like that? And then finally, you want to move as well to, um, past medical and surgical history to can someone put in the chat what kind of things you want? Ask specifically in the context of a breast lump in terms of past history? Yep. Someone said, um, OCP use for each exposure perfectly. Previous radiation, family history. Previous cancer diagnosis parity. Previous person cancers Onset of men are key. Amazing. Right on the ball. Amazing stuff. Okay, so if they've had a previous breast lump that's relevant because you want to know what happened to it was it, um was something like a fibroadenoma that has potential to become malignant. Was it just the breast cysts in the past, or have they had a previous breast carcinoma that was a breast lump? You want to know that if they have any proof procedures to the breast any, for example, any history off mastectomies, for example, which is a sign of having had previous breast cancer Brady a sh into the breast. As you know, ideation is a risk factor for any kind of cancer, especially when it's targeted at that tissue. Um, it's, um, okay, um, is involved in, like the molecule er pathogenesis breast cancer as well. Um, in terms of breastfeeding history again and menopause, these point towards increased estrogen exposure and therefore could indicate that these risk factors for developing breast cancer So somebody got that period really early or has that menopause really late? That, for example, means that they've had increasing it exposure to estrogen in their life time compared to the average woman in terms of social history. As usual, you taken alcohol and smoking. History is always the stent to be searched for risk factors for cancer. Genesis IV D, you are specifically is a risk factor for mass itis on development of breast abscess just because they could get infected, um, the port can get infected and find its way to the breast. Someone mentioned the use off the CCP and and, um, the home on replacement therapy, as they do involve increased exposure to estrogen, a family history of any kind of cancer. But specifically, breast and ovarian cancer are major risk factors of the development or breast cancer. Azelas what age. The person in our family developed this cancer is quite important, as would give you an idea of what to expect. This individual, You want it if they've had any Children and how many Children they've had, what age they were when they had them? Did they breastfeed that Children and for how long their breasts had them? And if they had any problems in breast feeding them And finally, just, you know, because there is a potential for this diagnosis to be cancer, you always want to ascertain what the patients like Emotional Support Network is like. Um, because it is, you know, highly is a big diagnosis. It is very emotional. And it's something that you know you you need you would like them to have support for you wanna ask acid and how independent they are at home, in case you need any extra support. Um, any care packages, Any extra help? Well, okay. So how do you present this history? So once you've taken this, how you present it, The thing about presenting any question on skis, you don't have very much time. You can't ramble on and say everything. You've seen everything you've heard from the patient. You have to kind of just give the main details, so you kind of have to quickly some it up in your head and figure out the best way to present it. So even while taking the history, it really helps to summarize in between a different stages during the history. Because this first of all, will not only give you more time to think of questions, doc ask, but also create a picture on your head or what is happening and to It can kind of help you summarize better at the end because you have the main points in your head already. So when it was presenting, the history, obviously introduced patient details, their name, their age and their gender and the Q Presenting complicate complaints. In this case, it would be James Smith, 67 year old woman presenting with new breast lump on her left breast. And then you want to have the his your pathetic complaint. Like we talked about so again have to mention everything. But just say the main things, for example, is there when she notices where exactly it is, how big it is on how it feels when she touches that there's any associated pain as well. Why important dimension? And the next thing is relevant. Negatives. We mentioned this is all about osteo on If you're tender there, you know what this means? But in someone quickly tell me what relevant negatives mean on the chapped? Yeah, Relevant negatives go wherever negatives is basically when you did it, He's stupid someone and you're ruling out things in your head. For example, if you're speaking to someone and they have what looks like mastitis and you asked about if there's any history of trauma Um, sorry, if you're thinking, is even them with a breast lump and you think they have, for example, are fibroids an oma? Okay, given their age on, do things that you also want to ask is an history of trauma like we mentioned on this will help you ascertain if that's, for example, fat necrosis and prom. Um so if they say there's been no trauma that in your head, you can kind of be like our This is potentially not fat necrosis because there's no his your trauma, which is like the main risk factor for fat necrosis and therefore this kind of helps you rule out things relevant. Negatives are basically things in the history that you asked that helped you rule out diagnoses and help you get closer to what might be the diagnosis. The urine. Then you want to move too relevant past medical history, past social history, drug history as well on Do, um like we mentioned a lot of the risk factors we talked about earlier. Um, and then, um, as always, you want. Ask them. You want to mention to the Examiner or where were presented your history to what the patient is most concerned about, what they think it might be on, but what they expecting to happen. So especially if, for example, they're quite young and the concern that it's cancer, for example, this could be something you you mentioned, Um, and then you want to mention your top differentials when you're getting differentials and an Oscar station. The first effectually say is What do you think is most likely? Second, Eventually say is something that presents similarly, but there's something in the history that points you away from it, Um, and then the third differential is something that's quite abstract, a bit different And it's just something you need to be careful about, just in case. So you're getting three differentials on. Explain why. Okay, so once you've done this, I'm sorry. Please ignore The GI Bleed is meant is meant to say breast lump investigations. Can someone tell me what bedside investigations you do for anyone who presents with any breast lump? A breast examination? Yeah, an end of Byetta gram. Great. That would involve yet, like someone said, a breast examination. Um, and you would also do a lymph node examination is world like for any lymph node metastases. General observations, as always, toe ascertain their current status and stability on go over Considered is refer for triple assessment. There certain risk factors that could make you refer someone for triple assessment of breast cancer concern until you triple assessment means triple assessment history exam. Yeah, imaging and biopsy. Yeah. So, basically, it's when you someone has suspected breast cancer. You send them for this thing called trouble assessment of the breast clinic, where they have a clinical evaluation done where someone takes the history and doesn't exam where somebody then has imaging done so either, which will get to imaging done, and then also a biopsy taken as well, which will get. We'll discuss that in a second. Great in terms of blood use. Just do a full blood count. This isn't always indicated, but if you're thinking things like infection, then you want full but count and the CRP as well to look for white blood cells, a swell a CRP for inflammation, and you could just do the chest right chest X ray to rule out any other non breast related issues if you suspect thumb. So if you suspect someone has breast cancer, like I said, a spiritual assessment to get imaging done after history exam. And if they're under the age of 30 they get an ultrasound done or, if it's over 30 to get a mammogram done. The reason this is is because younger women have a lot more fat. How a lot less that in their breasts and a lot more glandular tissue. And this doesn't show up very well on Mama on mammogram like this. Ah, mammogram isn't able to pick up very well on breast masses in younger women because the glandular tissue kind of hides it and therefore, as you grow older, you have less of this tissue and more fat. And a mammogram was just better for that. That's why you do those, Um, and they also have a biopsy done. Either you can do a a fine needle aspiration or corneal biopsy. There are different indications for free, um, but by a piece of tissue can be tested for and the pathology lab to look for. What kind of tissue is in the mark in the in the breast lump. If somebody has breakfast abscess, Um oh, so you're also want to do, um to a market bloods for breast cancer, Specifically C A 1 33 in See A and these could suggest the existence of breast cancer. But these are not diagnostic for it. If somebody has a breast abscess, which is where it's a demon tests and red and really big and swollen, what you want to do is consider breast milk or milk culture. Usually you it's it's a clinical diagnosis, so you just treat them if if it's obvious that it's a breast abscess as infected, Um, but if there's a response to this initial treatment, it means that the bacteria is infected. That I breast is potentially resistant to one of the antibiotic you've given, and then you can do but breast milk cultures ascertain what's happening and fibroadenoma because it's a breast lump you and it's from You need to biopsy it just to make sure that it's no cost the concern. And so you do the same as you would with breast cancer Lung Lab. So what is the referral pathway for best cancer? So if somebody presents to you with a clinical history off the yet suggesting something that may be breast cancer, how do you decide who to refer? How do you decide who is most urgent? So people, these the people who need immediate referral that that is, within two weeks they have to be seen in the breast clinic for a full three per assessment evaluation. And these people are those who are either over the age of 30 on around the age of 30 or under on. Do have an unexplained breast lump with without pain, or they're older over the age of 50 and have more signs like like breast changes like the nipple discharge retraction inversion and these specifically in one breast only because breast cancer is very rarely bilateral in initial presentation. This is like, really urgent this to need to be seen in two weeks. In certain cases, um, it may not be that Herget on. You can consider an appointment with in two weeks if the rest of the clinical been yet points towards suspected breast cancer. This population of people are people who present with certain skin changes that present best. That's just breast cancer, but not really that many other symptoms, like maybe they're quite young. Maybe there's no real breast lump or maybe the breast lump. You can't. It's very easy to palpate or something. But you said, I just want to be sure because they have other breast changes, like a symmetry or something you would consider referring them old of somebody's over the age of 30 on, they haven't unexplained axilla lump concern would tell me why this would be metastases. Exactly. So breast cancer tends to metastasize first to your exam, your exit exam, real influence between exit and therefore, if somebody over the age of 30 presents, it's Lafayette first there quite a while. So there's a higher risk of having developed breast counts up. And second, how have you had it metastasized? That's a red flag, and you would definitely consider referring them to the two week pathway in this case. Now if somebody presents if somebody is really young and presents with breast Lump, um, then really, like there's no real urgency because if they have a lack about the risk factors and all they have is a lump, then you're less worried that this is urgent. And this is a cancer that requires immediate tension, as it could be other things as well. And so you would consider them for a referral. You probably would refer them anyway, but it just wouldn't approve me the two week pathway that makes sense. Okay, great. A few more spot diagnoses to see everyone's around through these would be breast pain differentials. So we have a 33 year old woman presenting your GP complaining of bilateral breast pain. She's on the combined or contraceptive pill, but admittedly irregular with taking it. Her last period was six weeks ago, and she's sexually active. What do we think that diagnosis is? Yeah, perfect. So the early stages of pregnancy, due to the whole morning, changes people can have tender breasts. Um, this is quite common. I was really the first trimester, great 29 year old woman complaining off bilateral chest pain. She's noticed that the plain fact it fluctuates throughout the month and on examination. There are diffuse nodule allusions that could be palpated. Yeah, you got cysts sees this is called, um, It could be cystic exactly because of the diffuse nodular lesions. But we call the cycle mesalamine because it's breast pain that comes and goes throughout the month on Do Response to Hormonal changes on diffuse Nodular lesion kind of have to corroborate that the cysts are also changing with the hormones that before your albumin presents complaining of left breast pain. Three weeks postpartum. The pain is worse during breastfeeding. On examination, the breast is tender, swollen area with arrhythmia tissue. She's fibro. Yeah, perfect spot on. She's breastfeeding. Um, maybe she had engorged breasts and she wasn't emptying properly. It got it got infected, and that was inflamed on. But she has fever. It's on gum. The breast is a little swollen red. Um, this mastitis perfect spot on. So how would you examine a patient who presents for the breast condition was worth of this really quickly. There's, um, key things that I'm going to say that. But you kind of just have to mention on there some key techniques in the breast examination. I'm going to spend more time talking about those and others. So, um, examination, you wash your hands, you introduce yourself, you take the patient details, you take that permission to examine them and you explain the procedure. Okay, he's the main is the four first things you do. So you she's yourself and then explain what you're gonna do. She's going to say, could having a look at their breasts as well as their neck and the armpit because you're also doing having a look at their lymph nodes on a very important thing to mention is that because this is intimate examination, they they are required to expose themselves from the waist up on dc'ing firm that they're comfortable with. Doing this on also make it very obvious and make it very clear when you say that you're explaining the need to have a shop prone in the room to say that you will get a shot part of the room when the examination is taking place. Um, Andi very explicitly asked if you have that consent to conduct examination after explaining what it involves before you start any examination, you also need to ascertain if they have any pain anywhere. For example, if they have mastitis, it can be quite tender. So ask them if they have paid where it is. This is important because you always start examining. The breast will talk about a few minutes on the unpainful side to side. That doesn't pain. The asymptomatic breast is where you always start. Um, and also you could just inform them because it is an osteo Sam that your but you might you might be talking to with the examination to the exam. In a while you examine that. Great. So how do you do the exam? The first thing you do is inspect them, right? You want to look at the breasts? How did you this There are three ways to do this. Okay? And you have to do them in this order. Usually. So first you want once that kind of one saved, like, kind of exposed the chest area, you ask them to sit on the side of the bed, the legs down and their hands on their lap. So relaxed. Okay, this'll make sure that that pectoral muscles are relaxed and you want to just have a general inspection off their breasts. A gross look for any off this abnormalities or skin changes. This is the first thing. The second thing is you asked them to move their hands to the side of the hips like this while they're sitting on the bed. What this does is that it makes them contract that pectoral major muscle, the pectoralis muscles. And this is important because sometimes invasive breast carcinoma, as can tell other toe the pectoral muscles. And therefore you might see there's a breast lump that it might move when, um, the any changes. It might move when they do this maneuver because it's tethered to the muscles when the muscle moves, the lump moves that make sense. This also accentuates any puckering or dimpling on the breast if it's present and it looks like this, um, the third method of inspection is you often to move their hands too behind the head like this and lean forward like that and this makes their breasts hang down. And this would exaggerate any asymmetry or puckering off their breasts to remember to do these three things. The one is hands the lap, hands of the hips have the heads. Pens ahead. Yeah, so I'm gonna I'm gonna flash them pictures now off some breasts, they may not all look for a pleasant thing is a bit of a warning. So the's pictures might make you uncomfortable. Please, look away. I let you know what I'm done. Um, but I'm gonna ask you to kind of help me label what you can see on the screen. Okay. This is the first one. Um, can someone tell me on the chat? What do you think this might be? I'm really sorry. The sessions really overrunning, but I hope this is helpful. Mastitis spot on it. Red. It's It's It's clearly arithmetic cysts. Ah, it's an inflamed breast. Very good. Um, could also be inflammatory cancer. Really? Yeah, it would present. Similarly, I would take that. What is this? Someone has patches. Disease? Yeah. Perfect. You see this cross T hardened nipple on, and it's kind of a remission. Everything which is around areola. And like, because his white scaly stuff here as well. And that's quite classic of projects. What about this one? This is a classic odorata. Exactly. This basically happens when your limb when the carcinoma is blocking your lymph, your lymph lymphatic ducks and therefore, get this, like weird puckering orange skin pattern. This this is like those little dots and you get this orange discoloration. Well, this is a sign of breast cancer. Um, what about this one inversion nipple inversion? Yeah, I saw you earlier. Uh, someone said nipple inversion can be benign on direct to sometimes what you do in unexamined a shin. If you see someone has nipple inversion you after, ask them first if this is normal for them because some women can have like, like nipple inversion. Normally, if they say, um, that it is normal, awesome. If they can even send a pool is unable to do it, then it's likely that there's some kind of benign disease going on underneath that, you know, cause the nipple inversion. But if it's something new that then and it's abnormal, then it's something you want to definitely look into as a red flag. Okay, what about this one? Abscess Perfect. Compared this immerse itis. So this is basically a complication of my scientist. It's much bigger. It's like a sac of fluid, as you can see there. Is there a the Metis? It's very inflamed to breast abscess. What about this one? This one's been harder to see if I had to. Quite hard to find a good picture of this. It's not a lump, right? Um, I just tell you, actually, this is what parking looks like. It's a dimple. It's like if somebody just like, like, put their finger in right now like this, and it just leaves an imprint like a little like a little dip that's called puckering. That's also a sign that the cancer invasive cancer has now tethered to the skin. Some more pictures. What is this? If you see this, an exam. What is this? Finding a mastectomy? Exactly. So you can see how they have a little old mastectomy scar here where the old breast used to be, uh, potentially suggestive of previous breast cancer on that breast. Great. What is this? I want you to compare both side of this person's body lymphedema. Perfect. So one of the complications off breast off breast surgery involving exhilarating node biopsy off. Very no. Clearance is basically lymphedema. Uh, which is what has happened here. So you get this and immitis side. If you compare both of these arms, you can see if this one is just a lot more fluid filled, a lot bigger. And it's a mastectomy on that side as well as you can see. Okay, um, great perfect stuff. Uh, and last one, I think this is the last one. Um, what do we see here? Discharge lipodystrophy bloody nipple discharge. And you can also see that it's coming from different ducks. It's not coming from just one hole. This is suggestive off decia. Yes. Which is Dr Carcinoma in situ as probably coming from the ducks off the breast. Perfect. Lovely stuff. Great. So now let's you want you finished inspection off the person. Now you want to move to, um, you wanna move to examination? Right? The rest examination. Now that they've been sitting on the side of the bed, you want to ask him to lie down on a just the bed to 45 degrees if you do this next thing. Like I said before, I asked them if they have any pain anywhere and always start on the other side on the other breast started asymptomatic breast first, so you can kind of figure out what's normal and then feel the abnormal. That makes us something to compare to. So there are many methods that have been suggested for palpations off breasts. Um, the one I was told a med school was the clock method where you pretend like like the breast is a clock as a clock face and you kind of wanna palpate every hour off the clock. So want you to realize all the way to 12 on this, make sure that you've covered kind of thean tire round off the breast. Well, um, there are other methods and the evidence of many of them. So whatever you're doing a med school, I would go with that for your skis. Good. That's probably what they grade you on. So how do you palpate so in a breast exam? More to the main mistake lots of people make is that they use their fingertips. That's what you want to do, even like a nap during exam. You want to use your palmer areas, you want to use the Palmer's surface off your three middle digits, which is this bit, and you kind of want press like that, um, using the Palmer's office against the breast, fall and feeling for masses. So you want to start at 12 o'clock and then work your way down around the clock all the way up. Yeah. Um, also recognize that the borders of the breast up to the clavicle, down to where somebody's Broward end and then all the way to the side. Um, and I'll talk about that in more detail in the second. Now, when you're palpating, if you feel a mass, there are very specific ways in which you have to describe this Moss. I've saved this for later because it's got its own slide, because that's quite an important part of this station who get that. But like I said, the boundaries of the breast are the clavicle, the bottom off the broad area where someone's Broward end and know that the bra you got an exhilarating Ailes. Every breast has this bit this little tail of the end that extends into the Exelon. So when you palpate, you want to make sure that you're going up towards the armpit as well. That okay, once you've done that, um, you don't want to move to the nipple at the area. A complex right? So you want to look for nipple discharge? This is important. Okay, so basically, if somebody comes complaining of nipple discharge, okay, you need to ask whether it's spontaneous or whether it only happens when they press on their breasts and it gets released. Okay, If it's spontaneous, then it's, um then it's less likely to be malignant. Is what a consultant one's told me, because if it's unsporting, ius and it's triggered by pressing, that means there's most likely a mask, something possibly malignant there. That's pressing one a duct when you press it, and that's that's causing it to come out basically to leave the nipple. Um, so when you when you examine them, ask them if they can. If they can make the nipple discharge come out or whether it's spontaneous and they can't they have no control over it. Now, the different types of discharge, but we saw a picture earlier off blood stained discharge, but this if it's infected, you can get purely discharge. The green or yellow sign of mastitis or abscess. It could be think or watery as well. On that there might be a lot, a little bit of it. If it's a lot, it's less likely to be malignant because malignant causes don't usually result in a lot of nipple discharge. Special was a volume, unless a second time to breast cancer or something. But yeah, ask about color, consistency on volume, sometimes of discharge. Um, we have three main types. Okay, so it's either milky where usually this is normal, as it's called a do something or breastfeeding. If it's abnormal, then it's to do with a prolactinoma. Um, so that's not really a breast emergency. If it's purely it that mean it's cloudy, it's likely an effective cause, and it can smell as well. Especially it's infective on, and it was watery and bloody. It's likely due to a carcinoma off the ducks, and then once you've done this, you want to elevate their breasts and look under and make this really obvious in the exam, just like used the palm of your hand and, like you push the breast up and look under to make sure that you've covered the entirety of the breast. Um, and use your other hand to palpate as well and make sure that there's no more system. Then you wanna move the lymph nodes again like, um, and very important. Don't forget this On D, uh, when you're looking at the breaths, obviously on most, like a big, big proportion off your breast cancers will metastasize. You're jittery lymph nodes first, just because most of the breast drains to the exhilaration nodes. Um, all to remember that the most common site off breast cancer is in the upper outer quadrant off the breast, which is near the exit a retail and therefore was really easy for it to get to the exit. And therefore, that's the most very important place to palpate. So they're actually a bunch of exhilarating nose all around the armpit. And for the sake of time, I'm not gonna spend time explaining that. But geeky medics explains it really well, and they give you a system off. How to a pelvic exam is Well, I would look into that after this. If you're interested on once in the exam, real influence. You also want to go ahead and palpate if you have time? Um, the other lymph nodes in the area specially the supraclavicular lymph nodes. The ones right here. And if you have time, do the cervical lymph nodes as well. The interactive A killer ones on the Paris total ones if you can. And then finally, there's some extra stuff you can do. For example, um, you can, um, for example, if it's in May, if it's a male patient, then you can It could be gynecomastia. And there's a whole separate kind of history. Example that so I'm not going to talk about that today. But I wanted to, but that's something you should look into a sweat when you started your breasts station cause you could get a man a swell, um, And what? Your computer, the exam explained to them the exam is finished. That they can clothes like, put that up back on on, give them privacy to do this. Thank them. Wash your hands. Um, and then get ready to summarize the examiner. Okay. Great. This is a quick diagram. I drew off the breast lymphatic drainage, and I'm gonna go right now. You live in, you're in time, but it just comes up basically how the breast drains. So once you've done this, how you presented examiner? So first, um, again present patient details, age, gender, her name, age, gender on general inspections. Anything found at the bedside, for example. Then you went over close The inspections of gross abnormalities, gross red flags, a century buckling dimpling poder raj nipple changes lumps, right. Nipple changes like just things you can see. And then relevant negatives. For example. There was no nipple inversion or there was no associative nipple discharge because these old mass of red flags to talk about, um and then you talk about what you saw, what you felt on palpations. So if you felt a mass, what was the mask? How did it feel? We'll go over that in a second as well as he felt any lymphadenopathy that anywhere you have created. And if there was any pain on palpation, any tenderness and then once you've done that, you kind of want to say Okay, these findings are consistent with my differential diagnosis off, bub. About what? If you want to say on, then you'd say to manage his patient, I would I I should do these investigations or you're suspecting breast cancer. You can be like giving this patient's age. I would like to do either on ultrasound or a mammography. Refer them for trouble. Like I get them a biopsy as well. On it was something like mastitis. You could say. Consider blood, breast milk, cottage cultures. Think about. Okay. Finally, this is the last bit promise. Um, Onda, Um how do you describe Breast Lump? So I'm gonna I'm gonna tell you some of them I'm going to ask you some of them. So the first one is quite obvious. You're gonna say, Where is the lump? Where do you feel it? So which quadrants? So when you're summarizes the Examiner, the best way to describe it is the quarter of a lump because it sounds professional. The upper outer quadrant lower in a quadrant. That kind of thing is it? Close the nipple far away associated with the area lower region. Say that as well, if it is size so officially, breast lumps are described in size in terms of centimeters of millimeters. So it just try to estimate the size you can't really every second exam say or is the size of a depends coin because, like that's not really very doesn't come across very clean professional. So I would roughly estimate the size of the slump. So like it was a two by two centimeter lump with irregular dimensions. Whoever next shape, like I said, things like fibroadenomas are likely to be well defined masters with clear borders, whereas carcinomas or fat necrosis can be poorly defined and you can't really feel the edges of it. Okay, can someone list me some more? Um, factors you can use to describe breast lumps? Mobility? Someone says Perfect. Um, and the else tethering perfect. Nodular a smooth yes, that's so important. How does the lump feel? Consistency you are. The consistency is smooth. Is it firm? Is that rubbery? Is it nausea? Because that could point you two words. If I wrote an OMA or assist or an abscess? Um, yeah, someone's really good sport on on. Mobility, like someone mentioned, doesn't move freely. Does it fluctuate when you move it? Does it feel fluid filled? If they when they do this position when they contract the Petra list vessels, does it change? Does it move around? Does that tell you that it's tethered to the muscle. Um, and does it move with the skin? Doesn't look, Parker it as a results. Um, yeah, mobility. That's important. Um, then fluctuance you want to know, um is if it's an abscess, for example. It's full of the Dementors. Fluid is very easy to move around. And that's called Flo Very fluctuance mass. And finally, overlying skin changes. So you know, you've described the lump. You said the lump is here. It's this big. It feels well defined. If you'll smooth and mobile on palpations, it's non fluctuance associate. It wave dimpling off the skin and in voted nipples, for example. Something like that. Essentially. So I couldn't think of on ammonic to remember this. But if somebody can please share it with us on our ask Easy. Ah, Facebook community group, where we all share ideas and questions and out. So if you can think of a pneumonic for this, please put it on that it would be so useful. But I think you have to cover all of this to remember, Okay, that I'm not gonna go through this because their way beyond time. But this is just the nice guidelines management pathway off mastitis. I'm not gonna go through it. I think it's self explanatory, but you have any questions about the slide or any of the other side's? Please feel free to email us. Um, Andi, That is the end of my presentation. Thank you so much for those of you to stuck around.