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NAC-OSCE > Gyn & Obs cases: Overall Approach > Flashcards

Gyn & Obs cases: Overall Approach Flashcards

1
Q

Vaginal Bleeding

A

Can you tell me anything more about your vaginal bleeding?
When you say … what do you mean?
1. OCD (based on what has not been said)
Summary of OCD
2. COCA (fresh vs clots)/Underwear vs wiping
3. Severity: anemia/dehydration sxs
3. AA (aggravates or alleviates)
Empathy:
*This might be a little bit worrisome for you I imagine. Do you have any big concern about it or you would just like to have it investigated?
*I understand this can be ….(irritating, difficult). We will work on this and offer you the best plan of care possible.

  1. Associated
    *Brain: lightheadedness/LOC/dizziness
    *Heart: feel heart racing?
    *Menstrual: LMP / regular/how often/how much/similar to previous ones?
    -If still menstruating:
    *Pregnancy?: N/V; sweating; feeling tired, breast
    engorgement
    *Vaginal: Pain/with intercourse? -> cervical / itching/ redness/ blisters, warts or ulcers
    *Uterus: Abdominal pain? -> (?PID/ectopic) / pelvic fulness, heaviness
    *Bowel and renal: urine changes or symptoms / bowel movements ?
    * General sxs:
    -Constitutional sxs
    -Bleeding disorders, or tendencies/blood thiners, aspirins
    -Thyroid problems or sxs
    * Gynecological:
    -Polyps, fibroids, endometriosis, cancer
    -Hx of pelvic sx or instrumentation
    -Contraceptive hx (OCP, IUD, HRT)
    -Last PAP smear
    *Obstetric: Previous pregnancies?/Abortions/How many/Route of delivery
    *Sexual: Number of partners/safe sex/when did you start activity/ Hx of STIs.
  2. Risk factors
    *Weight
  3. PMH: Breast ca, mammogram (if >40), HTA
  4. FH: Cancer (Breast, ovarian, uterus)
  5. SH: Occupation / SAD and HEAD SSS (if ado)
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2
Q

1st trimester bleeding

A

Can you tell me anything more about your bleeding?
When you say … what do you mean?
1. OCD (based on what has not been said)

Summary of OCD

  1. COCA (fresh vs clots)/Underwear vs wiping
  2. Severity: anemia/dehydration sxs
  3. AA (aggravates or alleviates)

Empathy:

  • This might be a little bit worrisome for you I imagine. Do you have any big (particular) concern about it or you would just like to have it investigated?
  • I understand this can be ….(irritating, difficult). We will work on this and offer you the best plan of care possible.
  1. Associated
    * Brain: lightheadedness/LOC/dizziness
    * Heart: feel heart racing?
    * Menstrual: LMP / regular/how often/how much?
  • Pregnancy:
    - How many weeks?/date based on LMP?
    - How did you know you are pregnant? Was it planned?
    - Any pain or discomfort? Contractions? (OCD/PQRST)
    - A gush of water?
    - Headaches, hand or leg swelling, discharge?
    - Did you have regular prenatal care? F/U visits? When was the last one? BP? Blood sugar?
    - U/S
    - Taking any vitamins?
  • Vaginal: Pain/with intercourse? -> cervical / itching/ redness/ blisters, warts or ulcers
  • Uterus: Abdominal pain? -> (?PID/ectopic) / pelvic fulness, heaviness
  • Bowel and renal: urine changes or symptoms / bowel movements ?
  • General sxs:
    - Constitutional sxs
    - Bleeding disorders, or tendencies/blood thiners, aspirins
    - Thyroid problems or sxs
  • Gynecological:
    - Polyps, fibroids, endometriosis, cancer
    - Hx of pelvic sx or instrumentation
    - Contraceptive hx (OCP, IUD, HRT)
    - Last PAP smear
  • Obstetric:
    - GTPAL
    - Previous pregnancies?/Abortions/How many/Route of delivery
  • Sexual: Hx of STIs.
    6. Risk factors
  • Weight
    7. PMH: Breast ca, mammogram (if >40), HTA, DM, kidney disease, blood group & Rh, medications, blood transfusions
    8. FH: Cancer (Breast, ovarian, uterus), abortions?
    9. SH: Occupation / SAD and HEAD SSS (if ado)
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3
Q

Amenorrhoea

A

Can you tell me anything more about it?
When you say … what do you mean?
1. OCD: During this time, any irregular bleeding/spotting?

Summary of OCD

Empathy:

  • This might be a little bit worrisome for you I imagine. Do you have any big concern about it or you would just like to have it investigated?
  • I understand this can be ….(irritating, difficult). We will work on this and offer you the best plan of care possible.
  1. Associated
    *Menstrual: LMP / regular/how often/how much/similar to previous ones?
    *Pregnancy?: N/V; sweating; feeling tired, breast
    engorgement
    *Previous pregnancies? Abortions?
    *If wishing pregnancy: How long have you been trying to get pregnant?
  • Hypothalamus:
    - Under stress?
    - Excessive exercise?
    - Concerns about your weight?
  • Pituitary
    - Any headaches? Vomiting in morning? Visual changes? Difficulty seeing sides? Milk secretion from breast?
    - History of thyroid disease? Heat/cold?
  • Ovarian
    - Excessive hair growth? Acne? Any weight changes? Family hx of PCOS? Hx of DM? Thirsty?
    - Hx of chemotherapy? Radiotherapy? Hot flushes? Vaginal dryness? Soreness? -> Premature ovarian failure
  • General sxs:
    - Constitutional sxs
    - Bleeding disorders, or tendencies/blood thiners, aspirins
  • Gynecological:
    - Hx of pelvic sx or instrumentation
    - Contraceptive hx (OCP, IUD, HRT)
    - Last PAP smear
  • Obstetric:
    - Previous pregnancies?/Abortions/How many/Route of delivery
  • Sexual: Hx of STIs.
    7. PMH: Breast ca, mammogram (if >40). Psychiatric illness? Medications?
    8. FH: Hx of PCOS, infertility? Cancer (Breast, ovarian, uterus)
    9. SH: Occupation / SAD and HEAD SSS (if ado)
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4
Q

Vaginal discharge

A

Can you tell me anything more about that?
When you say … what do you mean?
1. OCD (based on what has not been said)

Summary of OCD

  1. COCA + B:
  2. AA (aggravates or alleviates)
    - Related to periods?
    - Related to sexual intercourse?

Empathy:

  • This might be a little bit worrisome for you I imagine. Do you have any big (particular) concern about it or you would just like to have it investigated?
  • I understand this can be ….(irritating, difficult). We will work on this and offer you the best plan of care possible.
  1. Associated
    * Menstrual: LMP / regular/how often/how much?
    * Vaginal: Pain/with intercourse? -> cervical / itching/ redness/ blisters, warts or ulcers/Inguinal swellings
    * Uterus: Abdominal pain? -> (?PID) / pelvic fulness, heaviness / fever?
    * Bowel and renal: urine changes or symptoms / bowel movements ?
    * General sxs:
    - Constitutional sxs
    - Sore throat, mouth ulcers? / Joint swelling? Skin rash?
    * Gynecological:
    - Hx of pelvic sx or instrumentation
    - Contraceptive hx (OCP, IUD, HRT)
    - Last PAP smear
    - Hx of STI/PID?
    * Obstetric:
    - Previous pregnancies?/Abortions/How many/Route of delivery
    * Sexual: Complete sexual history for both partners.
  2. PMH: Medications (ATB?)/Breast ca, mammogram (if >40), HTA
  3. FH: Cancer (Breast, ovarian, uterus)
  4. SH: Occupation / SAD and HEAD SSS (if ado)
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5
Q

3rd trimester bleeding

A

Can you tell me anything more about your bleeding?
When you say … what do you mean?
1. OCD (based on what has not been said)
2. COCA (fresh vs clots)/Underwear vs wiping
3. Severity: anemia/dehydration sxs
3. AA (aggravates or alleviates)
-If PAIN: PQRST AAA

Summary of OCD

Empathy:

  • This might be a little bit worrisome for you I imagine. Do you have any big (particular) concern about it or you would just like to have it investigated?
  • I understand this can be ….(irritating, difficult). We will work on this and offer you the best plan of care possible.
  1. Associated
    * Brain: lightheadedness/LOC/dizziness
    * Heart: feel heart racing?
    * Menstrual: LMP / regular/how often/how much?
  • Pregnancy:
    - How many weeks?/date based on LMP?
    - How did you know you are pregnant? Was it planned?
    - Did you have regular prenatal care? F/U visits? When was the last one? BP? Blood sugar? All the rest, OK?
    - Any pain or discomfort? Contractions? (OCD/PQRST) fREQUENCY/LENGTH?
    - Weight gain? welling?
    - Headaches, high BP, flashing lights, vision disturbances, headaches?
    - A gush of water? discharge?
    - Severe abdominal pain followed by decreased fetal movements?
    - U/S. Placental position?
    - Hx of previa? Number of babies?
    - Hx of C-section
    - Trauma/Fall/Cocaine/Smoking
  • Vaginal: Pain/with intercourse? -> cervical / itching/ redness/ blisters, warts or ulcers
  • Bowel and renal: urine changes or symptoms / bowel movements ?
  • General sxs:
    - Constitutional sxs
    - Bleeding disorders, or tendencies/blood thiners, aspirins
    - Thyroid problems or sxs
  • Gynecological:
    - Polyps, fibroids, endometriosis, cancer
    - Hx of pelvic sx or instrumentation
    - Contraceptive hx (OCP, IUD, HRT)
    - Last PAP smear
  • Obstetric:
    - GTPAL
    - Blood group and Rh status (patient & partner)
    - Previous pregnancies?/Abortions/How many/Route of delivery
  • Sexual: Hx of STIs.
    6. Risk factors
  • Weight
    7. PMH: Breast ca, mammogram (if >40), HTA, DM, kidney disease, blood group & Rh, medications, blood transfusions, preeclampsia?, seizures?
    8. FH: Placenta previa, Abruption?
    9. SH: Whom do you live with? Occupation / SAD and HEAD SSS (if ado)
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6
Q

OCP counseling

A
  1. Intro
  2. Concerns:
    - What brings you in?
    - Can you tell me more? Why do you want?
    - How much do you know about OCP?
    - How much would you like to know?
  3. Confidentiality statement: I am glad that you came today and I will be happy to help you.
  • ***OCP Info
    - Content of drug
    - How it works

However, there are some contraindications associated with it. So to better assist you, I need to ask you some questions to find if you would benefit from OCP and which type would be best for you.

  1. History
    *Sexual:
    -Have you used contraception before? Which? When? Why? Why did you stop it?
    -Are you currently in a relationship?
    -Are you sexually active?
    -When did you start your sexual activity and how many partners?
    -Any protection?
    -Hx of STIs.
    *Menstrual:
    -LMP / When was your first?
    -regular/how often/how much/pain?
    *Pregnancy?: N/V; sweating; feeling tired, breast
    engorgement
    * Gynecological:
    -Hx of pelvic sx or instrumentation
    -Last PAP smear
    *OB:
    -Childbearing goals
    -Ever been pregnant before?
    -Methods?
    -Complications?
  2. PMH:
    -Meds/Allergies
    -Headaches or migraine, HTN, Heart disease, dyslipidemia, active liver disease (changes in skin color, itchiness), leg pain, clotting in legs, breast mass, cancer?
  3. FH:
    -Hx of breast, uterine, ovarian, or liver Ca?
    -High cholesterol, diabetes, heart disease
  4. SH: SAD / HEAD SSS (if ado) / SMOKEAD
  5. OCP Info
    -Effective in 99% of the cases
    -Different forms of presentation
    -Advantages/indications
    -Contraindications
    -Red flags -> Signs of alarm
    -Side effects
    -Description of package
    -Missing pills: Approach
    -Particular considerations: Migraines, weight gain
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7
Q

Pregnancy counselling

A
  1. Intro
  2. History
    * Pregnancy:
    - Was this planned pregnancy?
    - How do you feel about that? / How does your partner feel about it? Congratulate
    - When was your LMP? 1st day?
    - Symptoms suggesting pregnancy: N/V? breast engorgement/heaviness?
    - Any discharge? What about blood?
    * Gynecological:
    - Any pelvic surgeries/procedures?
    - When was your Pap?
    * Obstetric: Previous pregnancies?/Abortions/How many/Route of delivery
    * Sexual: Number of partners/safe sex/when did you start activity/ Hx of STIs.
  3. PMH
    - HTA/DM/Kidney/heart disease/Epilepsy
    - Chickenpox as a child
    - Rubella vaccine
    - HBV/HIV
    - Blood group & Rh group
  4. SH
    - With whom do you live? Are you and your partner related? Supportive?
    - Occupation? Hous of work?
    - Pets?
    - Diet?
    - SAD?
  5. Counselling
    * Money: If they struggle financially: Being a pregnant woman gives you priority for social services and I will be happy to get you in touch with some groups or programs that will help you.
    * F/U Schedule:
    - every 4 weeks till 28 weeks
    - every 2 weeks till 36
    - every 1 week till delivery
    * General indications
    - No medication on your own without consulting
    - Diet should contain all necessary vitamins and minerals.
    - Continue taking/start taking prenatal vitamins (folic acid in 1st trimester, Ca, F, Folic acid after that)
    - Coffee max 1 cup/day
    - No uncooked food (including raw fish)
    - No unpasteurized cheese or milk
    - Avoid vit A
    - No exposure to x-rays or radiation
    - No smoking/drinking
    - Exercise: Avoid lifting heavy objects and contact sports, maintain daily exercise
    - Pets: Avoid dealing with cat litter
    - Sexual intercourse: Avoid sexual activity that causes trauma / 3rd trimester: no stimulation of nipple or vigorous sex.
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8
Q

HRT Counselling

A
  1. Intro
  2. Concerns:
    - What brings you in?
    - Can you tell me more? Why do you want?
    - How much do you know about HRT?
    - How much would you like to know?
  3. Confidentiality statement: I am glad that you came today and I will be happy to help you.
  4. Definition:
    During the reproductive years, the women’s menstrual cycle and 2ry characteristics are controlled by 2 hormones… Toward the end of reproductive years, levels decrease. This will lead to symptoms.
    -Do you follow me?

So Ms…., to better assist you, let me ask you some questions to find if you would benefit from HRT.

  1. History
    *Menstrual:
    -Do you still get your periods?
    -LMP / When was your first?
    -regular/how often/how much/pain?
    *Pregnancy?: N/V; sweating; feeling tired, breast
    engorgement
    *Menopause symptoms:
    -Vasomotor: Sweating, hot flashes, heart racing
    -Urogenital: Vaginal dryness, soreness, pain with intercourse, increased urinary frequency and urgency
    -Neurologic: Mood changes, insomnia, depression, anxiety
    -Bone: Fractures or decrease in height
    -Sexual hx:

So Ms. , from what you have told me you clearly are experiencing signs and symptoms of menopause and I can understand why you would like to get HRT.

  1. HRT Info
    - Advantages/indications: Vasomotor, urogenital
    - Different forms of presentation
    - Content of drug
    - Contraindications: No absolute contraindications; however, relatively contraindicated in certain conditions so let me ask you more questions…
  2. PMH:
    - Meds/Allergies
    - Headaches or migraine, HTN, Heart disease, dyslipidemia, active liver disease (changes in skin color, itchiness), leg pain, clotting in legs, breast mass, cancer?
  • Gynecological:
    - Hx of pelvic sx or instrumentation
    - Last PAP smear
  • OB:
    - Ever been pregnant before?
    - Have you used any OCP before?
    - Complications?
  1. FH:
    - Hx of breast, uterine, ovarian, or liver Ca?
    - High cholesterol, diabetes, heart disease
  2. HRT Info
    - Contraindications: Hx of breast cancer, endometrial Ca, fibroids, endometriosis, active liver disease, thrombo, hypercholest

Unopposed estrogen therapy (ERT) is associated with 2-fold to 3-fold increase in cancer. Data suggests that there is no increase in risk when taking at least 12 days of progesteron/month. ANY QUESTIONS SO FAR?

     - Red flags -> Signs of alarm
     - Side effects
     - ANY QUESTIONS?

For this, there are some laboratory investigations that I will have to do before starting HRT if you decide to go with it.

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9
Q

PAP smear counselling

A
  1. Intro
    I understand you are here because you have some inquiries about your last PAP smear, is this right? How can I help you today?
      - What is your concern?
  - When was it?/Where? Why?

Since it is the first time I am seeing you, I would like to ask you some questions to get a better understanding of the situation.

  1. History
    *Menstrual:
    -LMP / When was your first?
    -regular/how often/how much/pain?
    *Pregnancy?: N/V; sweating; feeling tired, breast
    engorgement
    * Gynecological:
    -Hx of pelvic sx or instrumentation
    -Last PAP smear
    *OB:
    -Ever been pregnant before?
    *How many times? Any abortions/terminations? Miscarriages?
    *Number of babies delivered? Full-term or pre?
    -Methods?
    -Complications?
    *Sexual:
    -Are you currently in a relationship?
    -Are you sexually active?
    -When did you start your sexual activity and how many partners?
    -Any protection?
    -Hx of STIs.
    -Have you used contraception before? Which? When? Why? Why did you stop it?
  2. Associated symptoms
    * Vaginal: Pain/with intercourse? -> cervical / itching/ redness/ blisters, warts or ulcers
    * Abdominal pain?
    * Bowel and renal: urine changes or symptoms / bowel movements ?
    * General sxs:
    - Constitutional sxs
    - Bleeding disorders, or tendencies/blood thiners, aspirins
  3. PMH:
    - Meds/Allergies
    - Diseases?: HTN, Heart disease, breast mass, cancer?
  4. FH:
    - Hx of breast, uterine, ovarian, or liver Ca?
    - High cholesterol, diabetes, heart disease
  5. SH: SAD / HEAD SSS (if ado)
  6. Counselling
    * What do you know about…?
    * What (ASCUS) stands for means… That is why I would need further testing.

If the instructions ask you to do a colposcopy, then explain:

  • In case this happens… we could request a colposcopy.
  • The colposcopy is a …
    - magnification of the cervix
    - it is not painful
    - The gynecologist
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10
Q

Incontinence

A
  1. Intro
  2. Concerns:
    - What brings you in?
    - Can you tell me more?
  3. OCD (based on what has not been said)
    Summary of OCD
  4. AA (aggravates or alleviates)
  5. First time?

Empathy:

  • This might be a little bit worrisome for you I imagine. Do you have any big concern about it or you would just like to have it investigated?
  • I understand this can be ….(irritating, difficult). We will work on this and offer you the best plan of care possible.
  1. Associated
    - Obstructive
    - Irritative
    - COCA
  2. Local symptoms
    - Problems passing stools?
    - Masses in groin area?
    - Perineal lesions?
  3. How does it affect your daily life?
  4. Red flags:
    - Constitutional sxs
    - MGOS
    * M: LMP? Menopausal sympts and HRT use?
    * G: Previous abdominal or pelvic sxs
    * O: How many pregnancies? Route of delivery?
    * S: Repeated infections? Dryness? Dyspareunia?
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11
Q

Abortion

A
  1. Intro
  2. Assure confidentiality
  3. Questions:
    - Is there anyone else you would like to be present?
    - How do you feel about this pregnancy?
    - How do you come to know that you are pregnant?
  4. History
    * Pregnancy:
    - Was this planned pregnancy?
    - How do you feel about that? / How does your partner feel about it?
    - When was your LMP? 1st day?
    - Symptoms suggesting pregnancy: N/V? breast engorgement/heaviness?
    - Any discharge? What about blood?
    - Were you sexually abused?
  • Gynecological:
    - Any pelvic surgeries/procedures?
    - When was your Pap?
  • Obstetric: Previous pregnancies?/Abortions/How many/Route of delivery
  • Sexual: Number of partners/safe sex/when did you start activity/ Hx of STIs.

HEADS: Specially MOOD!!

COUNSELLING:

  • What do you know about abortion?
    - It is your choice as well as your right!
    - It is legal in Canada
    - I will support you and respect your decision.
  • If you continue your pregnancy:
    - After birth, baby to government.
    - If you have financial problems: I can get you in touch with social workers
  • If you decide to go with the abortion:
    - I can refer you to the abortion clinic
    - You don’t have to decide today.
    - Keep in mind that earlier than 20 weeks
  • Based on how far you are in pregnancy, it can be either medical or surgical:
    - Medical:
    - <9 weeks: Methotrexate+Misoprostol
    - >12 weeks: Prostanglandins+Misoprostol
    - Sx:
    - <12-16 weeks: Dilation+Curettage
    - >16 weeks: Dilation+evacuation
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12
Q

C-section

A
  1. Intro
  2. Any reason why you have CS?
  3. History
    * Pregnancy:
    - How do you feel about this pregnancy? Your partner?
    - Are you under regular follow-up? If not, offer social support!
    - Last visit history/pre-eclampsia
    - Last F/U visit
    - BP? Headache?
    - Leg swelling? Weight gain? Urine test?
    - High BP before getting pregnant?
    - Blood sugar? Before pregnancy?
    - ABCDE for mother and baby
    - Activity of the baby
    - Bleeding
    - Contractions/pain
    - Dripping/discharge
    - EDD (Expected date of delivery)
    - U/S
    - Have you done U/S before? How many times?
    - # of babies
    - Position of placenta
    - Amount of fluids?
  • Gynecological:
    - Fibroids, genital herpes??
    - Any pelvic surgeries/procedures?
    - When was your Pap?
  • Obstetric: Previous pregnancies?/Abortions/How many/Route of delivery
  • Address patients concerns:
    - The natural route for delivery is the vaginal delivery, and if there is no real indications for CS, we would prefer to go for vaginal.
    - However, I totally understand your concerns (address concerns)
  • Why not C-section:
    - What is your understanding of CS?
    - Risk of bleeding, higher risk of infection, DVT, longer stay.
  • Management:
    - After all, it is the obstetrician who decides
    - I am going to refer you to the obstetrician
    - Take time to think about it
    - Take some pamphlets.
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NAC-OSCE (25 decks)

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