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Yr 4 - GOSH > OSCE: Gynae History > Flashcards

OSCE: Gynae History Flashcards

1
Q

Format of gynae history?

A

1) Introduction

2) Key initial gynaecological details:
- LMP
- Gravidity
- Parity

3) HPC

4) Key gynaelogical symptoms

5) ICE

6) Systemic enquiry

7) Menstrual history

8) Sexual & contraception

9) Reproductive plans

10) Past gynaecological history

11) PMH

12) Obstetric history

13) DH & allergies

14) FH

15) SH

16) Closing

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2
Q

If a patient presents with pain, what should you ask about during ‘timing’ of SOCRATES?

A

Ask if the symptom has any relationship to the menstrual cycle - ‘is it worse at a particular time of the month?’

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3
Q

What are some key gynaecological symptoms to ask about?

A

1) Abdo & pelvic pain

2) Post-coital bleeding

3) Intermenstrual vaginal bleeding

4) Post-menopausal bleeding

5) Abnormal vaginal discharge

6) Dyspareunia

7) Vulval skin changes and itching

8) Incontinence

9) Menorrhagia/amenorrhoea

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4
Q

What gynae conditions can cause abdo and pelvic pain?

A
  • ectopic pregnancy
  • PID
  • endometriosis
  • ruptured ovarian cyst
  • ovarian torsion
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5
Q

What are some causes of post-coital bleeding?

A
  • cervical cancer
  • gonorrhoea
  • chlamydia
  • vaginitis
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6
Q

What are some causes of intermenstrual bleeding?

A
  • contraception
  • ovulation
  • miscarriage
  • gonorrhoea
  • chlamydia
  • uterine fibroids
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7
Q

What are some causes of post-menopausal bleeding?

A
  • vaginal atrophy
  • HRT
  • malignancy: endometrial, cervical or vaginal cancer
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8
Q

All healthy women will have some degree of regular vaginal discharge, so it is important to distinguish between normal and abnormal vaginal discharge when taking a gynaecological history.

What should you ask about?

A

1) Colour e.g. green, yellow, blood-stained
2) Volume
3) Consistency e.g. thickended or watery
4) Smell

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9
Q

What are some causes of abnormal vaginal discharge?

A

1) Bacterial vaginosis

2) STIs e.g. gonorrhoea and chlamydia

3) Trichomonas vaginalis

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10
Q

How does BV typically present?

A

Typically presents with an offensive, fishy-smelling vaginal discharge, without any associated soreness or irritation.

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11
Q

How does Trichomonas vaginalis typically present?

A

Typically presents with yellow frothy discharge with associated vaginal itching and irritation.

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12
Q

Is there soreness & irritation associated with BV?

A

No

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13
Q

Is there soreness & irritation associated with trichomonas vaginalis?

A

Yes

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14
Q

Give some causes of dyspareunia

A
  • Infections (e.g. gonorrhoea and chlamydia)
  • Endometriosis
  • Vaginal atrophy
  • Malignancy
  • Bladder inflammation
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15
Q

Superficial vs deep dyspareunia?

A

Superficial dyspareunia: pain at the external surface of the genitalia.

Deep dyspareunia: pain deep within the pelvis.

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16
Q

What should you clarify regarding dyspareunia?

A
  • the duration of the symptom
  • the location of the pain (e.g. superficial or deep)
  • the nature of the pain (e.g. sharp, aching, burning)
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17
Q

What are some causes of vulval skin changes & itching?

A

1) Infections such as candida (thrush), bacterial vaginosis and STIs (e.g. gonorrhoea).

2) Vaginal atrophy: occurs in post-menopausal women and can lead to itching and bleeding of the vagina.

3) Lichen sclerosus: appears as white patches on the vulva and is associated with itching.

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18
Q

What are some relevant non-gynae symptoms?

A

1) Urinary symptoms such as frequency, urgency and dysuria (can be associated with endometriosis)

2) Bowel symptoms e.g. a change in bowel habit or pain during defecation (endometriosis)

3) Fever: PID

4) Fatigue: anaemia or malignancy

5) Unintentional weight loss: may indicate underlying malignancy.

6) Abdominal distension: often benign, can be ascites caused by ovarian cancer

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19
Q

Relevant systemic enquiry in a gynae history?

A
  • haemoptysis (endometriosis)
  • shoulder tip pain (ectopic)
  • fever (e.g. PID, UTI)
  • abdo pain (e.g. ectopic pregnancy, dysmenorrhoea)
  • painful defecation (e.g. endometriosis)
  • abdo bloating (e.g. ovarian cancer)
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20
Q

How does lichen sclerosus appear?

A

White patches on vulva

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21
Q

What should menstrual history encompass?

A

1) Duration

2) Frequency:
- how often?
- regular?

3) Menstrual blood flow

4) Menstrual pain:
- more painful than usual?
- impact?

5) Date of LMP

6) Age at menarche

7) Menopause if relevant

8) Problems:
- menorrhagia
- dysmenorrhoea
- IMB
- PCB
- long breaks between periods (anorexia/hormonal e.g. hypothyroidism)

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22
Q

What duration of period is considered prolonged?

A

> 7 days

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23
Q

What is the average menstrual blood loss?

A

Approx 40mls (8 teaspoons)

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24
Q

What defines heavy blood loss

A

> 80mls (16 teaspoons) or having a period lasting >7 days

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25
Q

Questions to ask regarding menstrual blood flow?

A

o Are your current periods heavier than your usual periods?

o Have you been bleeding through sanitary towels?

o Have you been passing blood clots larger than a 10p coin?

o Are the heavy periods impacting your day to day life?

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26
Q

What to ask about the menopause (if relevant)?

A
  • Determine what age
  • If patient is perimenopausal, ask about symptoms such as hot flushes and vaginal dryness
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27
Q

Questions to ask regarding contraception?

A
  • Clarify type of contraception used
  • Explore previous contraception history
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28
Q

what to ask about regarding reproductive plans?

A

Ask if they are considering having children in the future or currently trying to fall pregnant.

Important to know when considering treatments.

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29
Q

What gynaecological conditions should you ask about in ‘past gynaecological history’?

A
  • Ectopic
  • Endometriosis
  • PID
  • Fibroids
  • STIs
  • Cervical ectropion
  • Bartholin’s cyst
  • Malignancy

Previous surgery or procedures e.g. abdo or pelvic surgery, c-section, hysterectomy

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30
Q

What should you ask about in past gynae history?

A

1) Gynae conditions

2) Previous surgery or procedures

3) Cervical screening

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31
Q

What to ask about regarding cervical screening?

A

1) Confirm date of last one and result

2) Up to date?

3) Ask if received any treatment and ask if follow up is in place

4) Ask about HPV vaccination

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32
Q

What are some relevant PMH conditions to gynae conditions?

A

1) migraine with aura

2) previous VTE

3) breast cancer (current or previous)

4) bleeding disorders e.g. vWb

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33
Q

Relevance of migraine with aura in gynae conditions?

A

oestrogen containing medications (e.g. COCP) are contraindicated

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34
Q

Relevance of previous VTE in gynae conditions?

A

oestrogen containing medications are contraindicated

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35
Q

Relevance of breast cancer in gynae conditions?

A

oestrogen containing medications usually contraindicated

36
Q

Relevance of bleeding disorders in gynae conditions?

A

relevant if patient presented with heavy vaginal bleeding

37
Q

What to ask about in obstetric history in gynae history?

A

This is LESS detailed than a focused obstetric history.

1) Gravidity & parity

2) Current pregnancy (if relevant)

3) Previous pregnancies (if relevant)
- ‘do you have any children?’
- ‘was it a vaginal birth or c-section?’
- ‘have you ever been pregnant?’ ‘what happened?’

38
Q

What do ask about regarding ‘current pregnancy’ in gynae history?

A
  • Gestation
  • Symptoms associated with pregnancy e.g. nausea, vomiting, back pain
  • Complications e.g. pre-eclampsia, cervical neck incompetence
  • Recent scan results
39
Q

What do ask about regarding ‘previous pregnancy’ in gynae history?

A
  • Age of children
  • Birth weight
  • Mode of delivery
  • Complications in the antenatal, perinatal, postnatal period
  • Ask if breastfeeding (contraindication to some birth controls)
40
Q

What are 2 key medications that may cause gynae issues or interfere with gynae medications?

A

1) St John’s Wort: increases the metabolism of COCP (reduces its effectiveness)

2) Abx: may cause 2ary thrush

41
Q

If patients are taking HRT, what should you clarify?

A

1) Duration of use

2) Method of delivery e.g. patch, gel, pessary

3) Frequency of treatment e.g. cyclical or continuous

4) Type of treatment e.g. COCP, oestrogen only

42
Q

What is key to ask about in DH?

A

HRT

43
Q

What are some medications commonly prescribed to patients with gynaecological disease?

A

1) Tranexamic acid e.g. to manage menorrhagia
2) Contraceptives e.g. COCP, POP
3) HRT
4) NSAIDs e.g. to manage dysmenorrhea
5) GnRH analogues e.g. to manage endometriosis

44
Q

What is relevant to ask about in FH?

A
  • FH of ovarian, endometrial or breast cancer
  • FH of bleeding disorders (menorrhagia can be 1st presenting symptom)
  • FH of blood clots
45
Q

Relevant SH to ask about?

A

1) Smoking

2) Alcohol

3) Recreational drug use

4) Occupation

5) Diet & weight

6) Type of accommodation & adaptations

7) Who they live with & support network?

8) Independent tasks & what they require assistance for

46
Q

COCP contraindications regarding smoking?

A

Category 3: aged >35 y/o and smoking <15 cigarettes a day

Category 4: >35 y/o and smoking >15 cigarettes a day

47
Q

Questions to ask regarding menorrhagia:

A

How long has this been going on for?

Were your periods normal before?

What sanitary products used? (and both at same time?)

How often having to change them?

What colour is blood? Any clots? Any flooding (sudden rush of blood)?

Symptoms of anaemia

Impact on life e.g. work/school

48
Q

Questions to ask regarding sexual history

A
  • Are you sexually active?
  • Any pain on sex?
  • Where is the pain e.g. entrance of vagina (superficial), in tummy/pelvis (deep)?
  • Do you have a regular partner?
  • When was your last sexual health screen?
49
Q

Questions to ask regarding contraceptive history

A

Are you using contraception at the moment? Have you used anything in the past?

Is there any chance you could be pregnant (e.g. missed pills)?

Any problems getting pregnant?

50
Q

What are the 2 main types of urinary incontinence in women?

A

Stress & urge (also mixed)

51
Q

What is urge incontinence?

A

Urine leakage is preceded by a strong desire to pass urine, which may occur suddenly.

52
Q

What is stress incontinence?

A

Urine leakage is brought on by actions which increase intra-abdominal pressure, such as coughing, laughing and physical activity.

53
Q

Questions to ask regarding urinary incontinence

A

1) Onset: how and when
- “How long have the urinary symptoms been going on for?”
- “How did the urinary symptoms start? Did they come on suddenly or gradually?”

2) Characteristics:
- “Can you describe what you feel when you need to pass urine?”
- “Which symptom is the most troublesome?”
- How much?

3) Associated symptoms

4) Time course

5) Exacerbating & relieving factors

6) Severity

54
Q

Symptoms that suggest a storage problem regarding urinary incontinence?

A

Storage problems –> Urgency, frequency, nocturia & incontinence.

55
Q

It is helpful to establish whether urinary incontinence symptoms primarily relate to storage or voiding of urine.

What questions can you ask to help distinguish between them?

A

Do you leak urine when you cough, sneeze or exercise?

Do you leak urine if you cannot get to the toilet in time, or do you find it difficult to put-off passing urine once you have the urge to do so?

56
Q

Symptoms that suggest a voiding problem regarding urinary incontinence?

A

Voiding problems –> Difficulty initiating urination, or a feeling of not having fully emptied the bladder.

57
Q

What are some associated symptoms when discussing urinary symptoms?

A

1) Pain:
- dysuria
- suprapubic pain or pelvic pain
- flank pain
- groin pain
- lower back pain
- dyspareunia

2) Fever: infective e.g. pyelonephritis

3) Haematuria

4) Abdo bloating

5) Menstrual abnormalities:
- menorrhagia
- dysmenorrhoea

6) Menopausal/perimenopausal symptoms e.g. hot flushes and irregular periods

7) Excessive thirst: 1ary polydipsia or 2ary to polyuria in diabetes mellitus, diabetes insipidus and hypercalcaemia

8) Bowel incontinence, change in sesation down below

9) Dragging sensation below (prolapse)

58
Q

What can dysuria indicate?

A
  • UTI
  • bladder pain syndrome
  • bladder cancer
  • STIs
59
Q

What can supra-pubic or pelvic pain indicate?

A

Urinary:
- UTI
- bladder pain syndrome

Gynae:
- uterine fibroids
- ovarian cysts
- ovarian tumours

60
Q

What can flank pain indicate?

A
  • ureteric calculi
  • pyelonephritis
61
Q

What can haematuria indicate?

A
  • UTI
  • ureteric calculi
  • bladder cancer
62
Q

What can abdo bloating be a red flag for?

A

Ovarian cancer

63
Q

When may patients with pelvic organ prolapse find that they can pass urine more easily?

A

If they lie down before going to the toilet, as this reduces the degree of prolapse.

They may also need to manually reduce the prolapse before they can pass urine.

64
Q

What is a helpful way to gain objective information about the nature of the symptoms and possible triggers of LUTS?

A

Ask the patient to complete a frequency-volume chart (‘bladder diary’)

65
Q

What are some red flags for ovarian cancer?

A
  • Abdominal distension (bloating)
  • Early satiety and/or loss of appetite
  • Pelvic or abdominal pain
  • Increased urinary urgency and/or frequency
  • Age >50 and symptoms suggestive of irritable bowel syndrome (IBS) in the last 12 months
  • Weight loss
  • Fatigue
  • Change in bowel habit
66
Q

What are some red flags for bladder cancer?

A
  • Haematuria (visible or non-visible)
  • Recurrent or persistent UTI
  • Dysuria
  • Urinary frequency
  • Weight loss
67
Q

Structure of female presenting with LUTS?

A

1) Introduction

2) Presenting complaint:
- site: establish symptoms are urinary and not PV discharge
- onset
- character: how much
- timing
- associated symptoms
- exacerbating & relieving
- severity & impact on life
- previous episodes

ICE

3) Gynae history:
- LMP
- Sexually active
- Cervical smears

4) Obstetric history

5) PMH & surgeries

6) DH & allergies

7) FH

8) SH

9) Systems review (think red flags for ovarian & bladder cancer, gynae symptoms, bowels)

68
Q

What are some possible exacerbating symptoms for stress incontinence?

A

Coughing, laughing, sneezing etc

69
Q

What are some medications that can cause or exacerbate LUTS?

A
  • Loop diuretics e.g. furosemide or bumetanide
  • SGLT-2 inhibtiors e.g. dapagliflozin
  • Ketamine
  • Drugs wtih antimuscarinic effects e.g. TCAs, sedating antihistamines
  • Anticholinergics
  • ACEi
70
Q

How can SGLT-2 exacerbate LUTS?

A

These increase the risk of UTI due to the increase in urinary glucose excretion which they promote.

71
Q

How can ketamine affect LUTS?

A

causes bladder inflammation, leading to pain, urgency, and frequency.

72
Q

How can ACEi affect LUTS?

A

Can cause a chronic cough in some patients, which may exacerbate stress incontinence.

73
Q

What are some medications that patients may already be taking to treat LUTS?

A

1) Anticholinergic e.g. oxybutynin, solifenacin: for detrusor instability

2) Mirabegron: overactive bladder

74
Q

What medication is indicated for an overactive bladder?

A

1) Anticholinergics: oxybutynin, solifenacin (anticholinergics)

2) Mirabegron (this is a β-3-adrenergic drug that is an alternative to anticholinergic medications).

75
Q

What can urinary symptoms increase the risk of in the elderly?

A

Falls - helpful to know how easy it is for the person to get to their toilet and whether they have had any falls due to their urinary symptoms.

76
Q

Investigations in stress incontinence?

A
  • Full set of obs
  • Abdo exam
  • Speculum +/- bimanual palpation
  • Urine dip
  • Consider US urinary tract
77
Q

Management of stress incontinence?

A

1) Trial of pelvic floor exercises for pelvic floor muscle training

2) Consider duloxetine if above doesn’t work

3) Consider potential for surgical intervention if medical treatment doesn’t work

4) Lifestyle: decrease in caffeinated drink intake

78
Q

What type of incontinence is duloxetine indicated in?

A

Stress incontinence

79
Q

Role of duloxetine in stress incontinence?

A

What - a combined noradrenaline and serotonin reuptake inhibitor

Mechanism - increased synaptic concentration of noradrenaline and serotonin within the pudendal nerve → increased stimulation of urethral striated muscles within the sphincter → enhanced contraction

80
Q

Management of urge incontinence?

A

1) Bladder retraining (minimum of 6 weeks, with aim of increasing intervals between voiding)

2) Medical: anticholinergics are 1st line e.g. oxybutynin, darifenacin

3) If concern about anticholinergic side-effects (e.g. frail elderly patients) –> use mirabegron (a beta-3 agonist)

81
Q

Who should anticholinergics for urge incontinence often be avoided in?

A

‘frail older women’

82
Q

1st line medication for urge incontinence in ‘frail old women’?

A

mirabegron (a beta-3 agonist)

83
Q

Why is it important to ask about bowel symptoms (e.g. bleeding, pain on defecation) when taking a history about abdo/pelvic pain?

A

Can be presenting with endometriosis in the bowel.

84
Q

Exploring symptom of PMB.

Can use SOCATES

A

S - where is bleeding coming from?

O - onset

C - type of bleed e.g. gushing/spotting/clots

R - any other areas of bleeding e.g. blood in stools/urine?

A - associated symptoms

E - triggers (e.g. sex) & relieving factors

S - impact on life

85
Q

What associated symptoms can you ask about in PMB?

A
  • weight loss
  • bloating or swelling
  • fevers or malaise
  • abdo pain
  • urinary symptoms
  • abnormal vaginal discharge
  • itching
86
Q

Investigations in PMB?

A

1) Physical exam: speculum & bimanual

2) Urinalysis

3) Referral on gynae 2WW pathway

4) Further: US scan, possible hysteroscopy & biopsy

87
Q

Causes of PMB?

A
  • vaginal atrophy
  • HRT
  • malignany: uterine cancer, cervical cancer and vaginal cancer

Yr 4 - GOSH (45 decks)

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