Pelvic mass Flashcards
6-8 weeks
AMENORRHOEA - sexually active
lower ABDO pain –>
later develops vaginal BLEEDING ?dark
?Shoulder tip pain and
?cervical excitation
Ix? Imaging?
What criteria would you base management of ectopic on?
_________
5-day POST-PARTUM
-neonate bleeding gums
-neonate bleed from umbilical wound
NO FHx of bleed dx…
ddx?
_________
Preg:
ACEi ? Cocaine ? Valproate/Carbemaz = ? -? MOST teratogenic \_\_\_\_\_\_\_ Phenytoin = ?Syndrome -? MOST teratogenic Warfarin courmarins = ? Thalidomide - ? \_\_\_\_\_\_\_ Di-Ethyl-Stil-BESTROL @mum = ? Isotret = ? Misoprostol = ? \_\_\_\_\_\_\_
Downs - ? Noonan = ? William = ? Turners = ? DiGeorge = ? \_\_\_\_\_\_\_ MIFEPRISTONE ONLY USED IN WHAT BASTARD?!
Miscarriage Tx?
When do Med/Surg Mx?
(remember miscarriage = WMVE, abortion =
MMSE 9 13 15)
___________
Abortion tx < 24w 9 13 15 MM SE DS DE
(Remember
miscarriage WMVE,
Abortion MMSE 9 13 15)
_______
ovarian FIGO
- inside ovary
- outside ovary i.e. @pelvis
- abdomen
- distant mets
Ectopic pregnancy
- hcg/preg test
- TVUSS!!!!!!!!!!!!
- HCG
1. <1500
2. >1500
HBeat
- -none
- -visible
- <35mm / Unruptured
- > 35mm / Ruptured
- WW2d / MTX
- Salpingectomy/Salpingostomy
___________
Hemorrhagic Dx of Newborn
-Vit K def
_________
Preg:
ACEi = iuGR, iuRenal-Insuff, Oligohydramnios
Cocaine = Small brain, Limb dx, Urine-tract dx
- mum = PreEcl / Pl.Abruption
- kid = Prem / Abstinence-syndrome
Valproate/Carbemaz = NTDs
-valproate MOST teratogenic
-heart dx
______
Phenytoin = Hydantoin Syndrome = craniofacial dx
-valproate MOST teratogenic
Warfarin courmarins = skeletal dx
Thalidomide - limb dx
______
Di-Ethyl-Stil-BESTROL @mum
-vaginal adenocarcinoma in kid 14 yrs later
Isotret
-CNS/Cranio-Facial/Cardiac dx
Misoprostol = Moebius Syndrome
-cranial nerve dx
_______
Downs 21 - AVSD
Noonan = Pul Stenosis
William 7 = Supravalvular Aortic Stenosis
Turner 45XO = Coarcation
DiGeorge 22q11 = Truncal dx = TOF/TGA/PulAtr-VSD
_____
MIFEProgRecepBlocker ONLY USED IN Abortion BASTARD
MISCARRIAGE: WMVE
WMVE
WW < 2w
- (d/c with f/u in ? week)
- BYPASS WW –> straight to Med/Surg Mx @:
- -Haemorrhage (late T1/blood dx)
- -Infection
- -Prev preg dx
MED:
Vag MMMisoProstaGlandin - > Ut Contract
-Moebius Synd= Cranial Nerve dx
SURG:
OP: VVVacuum Asp Suction Curettage
IP: Theatre EEEEEvacuation
_____________
ABORTION: MMSE
< 9 w: MM
0hrs: MifeProg-ReceptorBlocker
48 hours: MisoProstaGlandin=
- stim ut contract
- Moebius Synd= Cranial Nerve dx
< 13 w: DS
Surg dilation + Suction
> 15-24 weeks: DE
Surg dilation and Evac
medical abortion = ‘mini-labour’
> 24 - ILLEGAL MURDERRRRRRRRR
_____
ovarian FIGO
- inside ovary
- outside ovary i.e. @pelvis
- abdomen
- distant mets
Storage syx? ax?
Void syx? ax?
Noct Polyuria ax?
Stress Incontinence Ax? Tx?
-Relax, Retain, Awareness-decrease, Produce?
Stress Incontinence Tx?
-Refer when?
Urge Incont?
-PSymp -> bladder contract -> piss
–AntiMuscs = block Musc Receptor,
hence
stop PS -> retain
Botox = stop Ach release from Pre-Synap neurone
STORAGE FUNDHS-COUNTS: Freq Urg Noct Dys Haemat Suprapub: -CANCER -Overactive -UTI/STI -Neuro -TInfection - UTI/STI -Stones
VOID/Rentention = SHWD-CANS: Strain/Hesitancy/WeakStream/Dribble-postmic: -CANCER/BPH -Antimusc/Opiods -Neuropathy -SSC: stricture-stones-constipation/ stone-sloughed-papillae-clotsVTE
Noct Polyuria - NERD
- Endocrine (HyperCalc/DM-DI/Addison)
- Renal dx
- Drugs: CCB/SSRI
Stress Incontinence: DIP Drugs/Injury/Prostatectomy -Relax - alpha blockers -Retain - SympathoMimetics/AntiMuscs/Opiods -Awareness -reduce - Benzos -Production
Stress incont tx:
- ACES
- Kegel 3m - - > ArupBCD
Alco/Caff/Fizzy
Constipation ALLOW
Ex/Diet
Sweeteners/Smoke ALLOW
Kegel 3m - - > ArupBCD -ARtificial sphincter -AUtologous rectus sling -APpliance sheath -Bulk/urethral slings -Catheter/Colposuppression -Diversion --> Duloxetene -Refer if NOT had prostatectomy...
Urge Incont:
- Bladder Retrain 1.5m
- Oxybutinin/solefenacin/tolderodine
- MiraBegron
- Botox/ Cystoplasty
Pain=central abdomen –> localising to RIF
Anorexia
CRP + WCC high
Fever, Tachycardia
Sign: more pain in RIF than LIF when palpating LIF?
Sign: press in but pain mild -> let go -> THEN pain develops
___________
MID cycle pain.
- sharp onset
- mild SUPRA-pubic .
May have recurrent episodes.
Usually settles over 24-48 hours.
__________
FEVER;
dysuria / dyspareunia
Pelvic pain + vag discharge = ?SMELLY
-period irregular
Cervical excitation may be found on examination
Mycoplasma genitalium?
Gon high risk?
Gon low risk?
____________
abdominal pain, b/c/d 6 MONTHSSSSSSSSSSSSS
lethargy/ nausea,
BACKache and BLADDER-FUNDHS
__________
Rash - ?
Arthralgia
Serositis - MAPLe?
Haem - ?
Oral - ?
Renal - ?
PS?
ANA
IC - T? HSR
Neuro dx
- Ddx - inflammatory markers?
- AB v AutoAG = ImmComplexes
- T?HSR - Tx?
- which legit in PREG? - RUDEASH* DlE
*TEACH
___________
Clots, Livido-Rash?, Obstetric cx - ? TCP/APTT ? 5. Ddx-antibodies?
ThromboProph Tx?
-APLS + NO prev VTE = ?
-APLS + Prev VTE = ?
-APLS + pregnancy =
? + ?(stop after w?)
- APLS + Prev VTE WHILST on AC =
- –? lifelong + ? lifelong
- –? @Preg + ? lifelong
-APLS + ArtTE = ?
-INR ?-? @initial
-INR ?-? @ArtTE
-INR ?-? @recurrent
________
yellow/green -strawberry cervix -smelly Dx? Tx? \_\_\_\_\_\_\_\_ Cda-Gcc
Chlamydia Tx? Refer for: -GUM -Repeat infection @?/+y/o = high p(re-infection) -Avoid sex till when? -STD screen/ Safe sex -Sex-abuse < ?yrs
Gonorrhoea Tx:
- UnCx:
- anogenital gon = ?
- anogenital/ pharyngeal gon + antimicrobial susceptibility known = ?
- needle phobia = ?
- Asyx = ?Ix ?/+w after ABx end
- Syx = ?Ix ?/+d after ABx end
Syx men = C+T:
- all partners < ?w
- most recent partner if >?w
The rest i.e. Asyx men /Women
- C+T all partners < ?m
_____
appendicitis
Rovsing: more pain in RIF than LIF when palpating LIF
Blumberg Rebound Tenderness
_____________
Mittelschmerz
___________
Pelvic inflammatory disease
PID:
Mycoplasma genitalium
-moxifloxacin / ceftriax -> Azithro
Gon high risk = Ceftriax+Doxy+Metro
Gon low risk = Ceftriax/Oflox
________
IBS ABC!!!!!!!!!
ABDO PAIN
BCD
__________
Rash - malar/discoid Arthralgia Serositis - MAPLe -Myocard/Alveolitis/Pericarditis/LibmanEndocarditis Haem - ANT
Oral - NP ulcers
Renal - GNephritis
PhotoSensitivity
ANA
IC - T3 HSR
Neuro dx
- sl3
S HIGH AF
cRp~norm - AB v AutoAG = ImmComplexes
- T3HSR
3. Tx: HOH, mycophenolate Mild: csteds Mod: DMARDs Severe, Ritux, Cyclophosphamide, Sted HD -maintenance: NSAID, Azo, MTX, bElumimab -lupus nephritis = ACEi @BP high
PREG: AZOTHIOPRINE
4.
RhF, U1 rnp, Ds-dna, Ena
Ana, Smith, Histone* @drugs
Ds-dna, low c3/4 -> high C3d/4d, Esr high-CRP~
* TNFi-TB/cancer Tetracyclines - mino Epileptics - Phenytoin AntiArryhtmics - Procainimide Chlorpromazine Hydralazine \_\_\_\_\_\_\_\_\_\_\_\_\_\_
- APLS:
- Cardiolipin/Coagulant
- gp12b
Clots,
Livido-Retic,
Obstetric cx - miscarriage
TCP/APTT high paradoxical
ThromboProph Tx?
-APLS + NO prev VTE = Asp lifelong
-APLS + Prev VTE = Warf lifelong
-APLS + pregnancy =
Asp + LMWH(stop after w34)
- APLS + Prev VTE WHILST on AC =
- –Warf lifelong + Aspirin lifelong
- –LMWH @Preg + Aspirin lifelong
- APLS + ArtTE = Warf LIFElong
- INR 2-3 @initial/ ArtTE
- INR 3-4 @recurrent
ArtTE = Art ThromboEmbolism
___________
yellow/green
-strawberry cervix
-smelly
Dx? Trichomoniasis Tx? Metro
Chlamydia= Doxy /Azithro 7d//////2d, respectively Refer for: -GUM -Repeat infection @25/+ y/o = high p(re-infection) -Avoid sex after ABx end/Azithro +7d -STD screen/ Safe sex -Sex-abuse < 18yrs
Gonorrhoea
- UnCx:
- anogenital gon = IM Ceft
- anogenital/ pharyngeal gon + antimicrobial susceptibility known = Cipro
- needle phobia = Cefix+Azithro
- Asyx = NAAT 2/+w after ABx end
- Syx = C+S 3/+d after ABx end
Syx men = C+T:
- all partners < 2w
- most recent partner if >2w
The rest i.e. Asyx men /Women
- C+T all partners <3m
_______
Breast cancer 2ww
__________
Ovarian cancer cancer 2ww guideline: Ovarian Cancer Tx? All stages? Stagaes 2-4? \_\_\_\_\_\_\_\_\_\_
Endomet cancer 2ww:
Endomet Cancer Ix:
?scan -> ?biopsy
–inconclusive-biopsy–>
?ix + ?sampling (?d+c)
Endomet Cancer Tx:
-localised disease =
?surg –Hrisk–> post-op ?
Endomet Cancer Tx
@Frail elderly women + NOT suitable for surg ?
?Ix for PMB
__________________
Dyskaryosis - CIN:
When are smears done?
?test
- strains?
- ->
- HPV POS = ?
+ = ? (what’s positive cytology-wise?)
- = ? - HPV NEG = ?
- HPV inadequate?
___________
Old guideline
? /? = HPV test:
-POS = Colpo w
-NEG =?
CIN?/CIN? /? = Colpo w -> ?
Inadequate x? = Colpo w
Preg/PP12w = Colpo w -> ?
-Cerv cancer + St IA tumour + Gold standard tx =
?surg ± ? clearance
-Cerv cancer + St IA tumour + MAINTAIN FERTILITY =
?procedure 2 maintain fertility + ? margins
Cervi Cancer + stage IB /+ =
-? + ?
Breast Cancer Screen: 47-73=mamogram / 3yrs
LUMP: 30/+ lump 50/+ unilat nipple d/c / syx -Mass @Axillary 30/+ -Peau/ Skin changes in ANY age
FHx - DJCOMBS Dx <40 JEWS Childhood cancer Ovarian cancer Male BC / paternal fhx 2/+ B/L Breast cancer <50 Sarcoma <45
1 FDR/SDR w/ Ovarian Cancer
+
1FDR/SDR w/ Breast Cancer
2FDR/ 1FDR+1SDR = BC
3FDR/SDR = BC
__________
Ovarian cancer cancer 2ww guideline:
50/+ w/ Syx x12/m = LAIDS* -> CA125 - 35/+ -> USS-AP -sinister = refer
-O/E Ascites / A-P mass = refer
*
- LUTS -A-P pain -IBS syx
- Distended -SATIETY
Ovarian Cancer Tx?
All stages = LaparoTOMY tumour excision
Stagaes 2-4 = Chemo
_______________
Endomet cancer 2ww:
-55/+ w/ …
PMB = 2ww
vag d/c / HUria -HUria -Hb low -1st time HIGH Plts/BM --> TVUSS
Endomet Cancer Ix = TVUSS, Pipelle, Hystero+Sample
TVUSS -> Pipelle biopsy
–inconclusive–>
Hysteroscopy + directed sampling (dilation + curettage)
Endomet Cancer Tx @ localised disease =
TAH + B/L Sooph –Hrisk–> post-op RT
Endomet Cancer Tx
@Frail elderly women + NOT suitable for surg =
—Progestogen tx
Endometrial biopsy for PMB
_____________
Dyskaryosis:
When are smears done?
- 25/+ / 3yrs
- 50/+ / 5yrs
- 65/+ ask
HPV high risk test
16 18 31 33
–>
1. HPV POS = Cytology: \+ = Coloposcopy -borderline -mild = LG -mod/severe = HG -invasive/glandular
- = HPV @12m
a. @+ = HPV @12m AGAIN -> @+ = Colpo / @- = d/c
b. @- = d/c
- HPV NEG = DTFU=DownToF***U
-d/c unless
-TOC path @6m
-f/u @ incomp excision @borderline/
CGIN-SMILE/CC
-Untx CIN 1
3.
HPV inadequate:
- repeat <3m -> inadequate 2ice = COLPO
-Cerv cancer + St IA tumour + Gold standard tx =
TAH ± Node clearance
-Cerv cancer + St IA tumour + MAINTAIN FERTILITY =
Cone biopsy + Neg margins
Cervi Cancer + stage IB /+ =
-RT + Chemo
_______________
Old guideline
borderline/mild CIN 1 = HPV test:
-POS = Colpo <8w
-NEG = d/c - 25/+ /3yrs ; 50/+ /5yrs
CIN2/CIN3/invasive = Colpo <2w -> smear @6m=TOC
Inadequate x3 = Colpo <8w
Preg/PP12w = Colpo <2w -> smear @6m=TOC
_____________
3 innocent murmurs
PMS tx
a ?-generation COCP may be helpful
- ?‐containing COC taken cont/cyclical?
- ?Antidepressant
Specific lifestyle changes to manage PMS:
- ? hourly
- ?size balanced meals
- rich in ?
(Remeber ? diet @epileptic kids + ? @IBS)
__________________
Infertility in PCOS - clomifene V metformin - which one suprior????? -NORMAL FSH -NORMAL LH -NORMAL Estradiol \_\_\_\_\_\_\_\_\_\_\_\_\_
Hyperemesis gravidarum, diagnostic criteria triad:
Tx? Reassure < ?w = NORMAL / Rest -Avoid ? -B? -Cold ? -Drink=? +? # ?spice -EMETIC - 1. #anti-? 2. #5ht3-blocker # ?brain -FLUIDS - Refer for ? @DEHYDRATION
Scoring system in H.Gravidarum?
________
S1-2 sounds?
-Soft -Loud
Wide split ??
Paradox split??
Fixed split??
S4-3 sounds?
HTN fucking has S2 + S4 sound !!!!
____________
Causes of 1st and 2nd degree HB KIMBAD
Causes of 3rd degree complete HB i-FASC
____________
Pericardial rub - ??
Pleural rub - ??
Pericardial knock - ??
____________
Causes of LBBB
RBBB causes?
________
AD - long QT + NO sensorineural deafness
AR - long QT + sensorineural deafness
AD Asian men pseudoRBBB + ST elevation (downsloping mostly V1-3ish) T-invert Risk? Tx? Gene?
Antiarryhtmics causing long QT?
Others?
Electrolytes?
? = Long QT + J waves
? = Short QT + J waves
_________
Aspirin
Clopidogrel
Enoxaparin/Fonda
Bivalirudin Reversible
Abciximab, eptifibatide, tirofiban ???
TxA2, ADP plt receptor, aAT3 stop f10a, DTi, gp2b3a blocker
_________
Soft, Systolic-ejection
- Short , S1+2 ok, SymptomLESS,
- Standing-Sitting varies w/ position
_______
1.
Short BUZZZZZ @Aorta, OR
Soft BLOWWW @Pul
- Continuous blowing = BELOW the clavicles
- Low-pitched sound @LLSE
3 innocent murmurs
PMS tx:
a NEW-generation COCP may be helpful
- Dros-pire-none‐containing COC taken CONITNUOULSY?
- SSRI
Specific lifestyle changes to manage PMS:
- 2-3 hourly
- small balanced meals
- rich in COMPLEX carbohydrates
(Remeber Ketogenic diet @epileptic kids + FODMAP @IBS)
__________________
Infertility in PCOS - clomifene > metformin -NORMAL FSH -NORMAL LH -NORMAL Estradiol \_\_\_\_\_\_\_\_\_\_\_\_\_
HGravidarum Triad = WED -WL 5% PRE-preg - large 4 dates uterus -Electrolyte imbalance - ketones -Dehydration (not the latter bits like large 4 dates/ketones - just there to help you remember features)
Tx: Reassure < 20w = NORMAL / Rest -Avoid triggers -Biscuit -Cold meals -Drink=little +often #GINGER -EMETIC - 1. cyclizine/promethazine #anti-hist 2. Metoclop #dop-blocker/Ondan5HT3ron #5ht 3-blocker #medulla -FLUIDS - Refer for IVF @DEHYDRATION
Scoring system in H.Gravidarum?
-PUQE N+V score
_________
S1 = AV valves mitral/tricuspid closing
soft @Regurg
loud @MS
S2 = Aortic/pul closing soft @ASten Loud @ -HTN, Hyperdymamic states, -ASD-PulHtn
Wide s2-
delay RV empty
-(PS; PAH{MRegurg severe}; RBBB)
Paradox s2
-WPW-b, AS/LBBB, RVPacing, PDA
Fixed s2 - ASD
S4 = atria contract against STIFF ventricle
HOCM/HTN
ASten
S3 = diastolic filling of ventricle Const pericarditis - pericard knock, X+Y, X ✔️; Dilated CM, MRegug NORMAL<30y
HTN fucking has S2 + S4 sound !!!!
____________
1st and 2nd degree:
K+low; IHD; myocarditis;
Beta-blockers; Athletes; Digoxin
3rd degree complete block:
iHD/ Fibrosis; AS; Surg/Trauma; Congen
____________
Pericardial rub - pericarditis
Pleural rub - pneumonia/PE
Pericardial knock - C. Pericarditis
____________
LBBB=CM, HTN, AS, IHD
RBBB=PE, ASD, Normal
_________
Romano Ward, KCN(Q1+H2) fucked K channels
Jervell Nielsen
Brugada = tachy-arrhythmias, sudden cardiac death. ICD!! Gene SCN5A mutation -> fucked Na Channel
Not FAPS
- SSRI/TCA; APsych; Li
- ABx = MACROLIDES
- Low Mg K Ca/ Low Temp HypoThermia
- Typ»»Atyp
HypoThermia = Long QT + J waves
HyperCalc = Short QT + J waves
________
Aspirin Antiplatelet -
inhibits thromboxane A2 production
Clopidogrel Antiplatelet -
inhibits ADP + plt receptor binding
Enox/fonda = Activates AT3 ->
-stop f8-12a
Bivalirudin Reversible DTi
Abciximab, eptifibatide, tirofiban
GP2b/3a receptor blockers
______
1-Ejections* - turb OUTFLOW tract
2-Venous - turb INFLOW venous tract
3- stiLLSe - LLSE low pitched
_________
*EJECTION:
Pulmonary=soft blowing/Aortic=short Buzzing
-Assoc w/Valsalva
Chronic CYCLICAL pelvic pain
Dysmenorrhoea/Dyspareunia-deep
Infertility
NOOOOOOOO MENORRHAGIA!!!!! DONT GET CONFUSED!!!!!
Dyschezia/Dysuria
Dx? Ix? gold-standard ix!?
Tx?
? used before Myomectomy!!
_________
Dyspareunia types?
Endometriosis NCG
Ultrasound- may show free fluid
LAPARASCOPY GOLD STANDRD
NSAID/Paracet
COCP/POP –> Refer
GnRH Ag / Lap Surg
Goserelin used before Myomectomy!!
__________
Dyspareunia
- superficial
- deep
- orgasmic
- post-coital
InterMenstrual Bleed Ax?
_______
Explain eisenmenger
Sx?
Ax?
____________
ASD:
-RBBB+RAD - Dx? Risk?
-RBBB+LAD - Dx?
___________
Man/Turner’s girl
- HTN in arms
- R-F delay
- E-MSys @ LUSE through to BACK!!
- CXR = notched ribs cos of?
Dx? Anatomy? HTN in which vessels?
_______
MITRAL AREA:
S3: Pansystolic = blowing high pitched ->
Radiate to AXILLA
Pansystolic + EMSyst click
Diastolic @Exp -> opening snap + Rumbling
_______
Collapsing pulse = ? Wide Pulse Pressure = ? Narrow Pulse Pressure = ? Slow-rising pulse \_\_\_\_\_\_\_
Pansystolic @LLSE
- louder @insp #incrVenReturn #carcinoid
- harsh?
__________
_________
—EJECTION Mid-Systoic Murmurs
Andy:
-ASten/Sclerosis
Pandy:
- Syst: innocent/ PS(carcinoid-noonan)/ ASD/ ToF/ HOCM
- Diast: AR / PR
PDA = continous machine, wide/collapsing below clavicle Coarctation = Turner, EMSyst to back Carcinoid = TR/PS
—PANSYSTOLIC murmurs
Teddy:
-Syst: TR carcinoid-ivdu / VSD harsh
-Diast: TSten
Me:
-Syst: MRegurg(high-pitch)/ MVP(EMS click)
-Diast: MSten(Rumbling)
_______
_________
—EJECTION Mid-Systoic Murmurs
Andy:
-ASten/Sclerosis
Pandy:
- Syst: innocent/ PS(carcinoid-noonan)/ ASD/ ToF/ HOCM
- Diast: AR / PR
PDA = continous machine, wide/collapsing below clavicle Coarctation = Turner, EMSyst to back Carcinoid = TR/PS
—PANSYSTOLIC murmurs
Teddy:
-Syst: TR carcinoid-ivdu / VSD harsh
-Diast: TSten
Me:
-Syst: MRegurg(high-pitch)/ MVP(EMS click)
-Diast: MSten(Rumbling)
__________
Diastolic murmur @ LUSE
PR - ? murmur HighPitched
AR - ? Flint Murmur = Rumbling/Sit forward!!!
MADCAT PAQ
ectropion/polyps/cancer
COCP UNDERdosing = breathrough bleed
Depot / IuD / POP
________
If persists #uncorrected, you get: L->R shunt -> PAH + RVH -> R->L shunt @Eisenmenger REVERSAL SHUNT--> -murmur = DISAPPEARS --> infant = CYANOTIC #not shocked
CCPP:
- cyanosis clubbing
- polycythemia PAH
Ax = VSD, ASD, PDA.
_____________
ASD:
RBBB+RAD = secundum dx
-EMBOLUS SHOOT OFF -> STROKE!!!!!!
RBBB+LAD = primum dx
-prime lad
__________
Coarctation -Aorta NARROW near PDA -> -HTN in Bracioceph + LSubclavian -CXR = collats eroding ribs -> notched ribs \_\_\_\_\_\_\_\_
MR
- Pansys blowing high pitched -> Axilla
MVP = Pansys + EMSyst click
MS
-opening snap + Rumbling
________
Collapsing pulse = AR/PDA/ Incr requirement Wide Pulse Pressure = AR/PDA/ 3rdHB -Narrow Pulse Pressure = ASten -Slow-rising pulse = ASten \_\_\_\_\_\_\_\_\_
Pansystolic @LLSE
- louder @insp #incrVenReturn=TR
- harsh=VSD
________
Diastolic murmur @ LUSE
PR - Graham Steel murmur HighPitched
AR - Austin Flint Rumbling/Sit forward
Musset nodding, Austin Flint, Dariosz Fem
Corrigan carotid, Traube PISTOL Fem
Pulse = collapsing/wide split;
Apex displaced;
Quincke nail bed hemorrhage
SUDDEN UNI-LAT lower abdo pain #RIF #LIF
- Recent EXERCISE.
- N+V
O/E: Unilat, tender adnexal mass
WCC NORMAL!!!!!!! SO NOT APPENDICITIS
Uss = ?sign
______________________
- DULLache=intermittent @SEXX/exercise!!
- Unilat
- DysPAREunia
- IF Large -> BLOAT / FUNDHS #bladder
Differentiate from other shit!!!
- No menorrhagia/dysmenorrhoea = r/o?
- No Adnexal tenderness.. = r/o?
- No N+V.. = r/o?
Repeat USS when?
_______________________
Cancer likely in simple or complex cyst?
Common types of ovarian cysts?
Intermenstrual bleed Ax?
_____________
Woman going through
GnRH/hCG due to
IVF treatment….
Abdomen distended, abdo pain
Can eventually get Olig/Anuria, VTE, Ascites, ARDS…
Ovarian torsion
-sudden (unlike cyst)
Ultrasound- may show free fluid
LAPARASCOPY GOLD STANDRD
Uss = whirlpool sign
_________________
Ovarian cyst = RUPTURED
-dull-ache=intermittent (unlike torsion)
- No menorrhagia(i.e. NOT fibroid) / dysmenorrhoea (i.e. NOT endometriosis!!!)
- No Adnexal tenderness.. not PID/Ectopic
- No N+V.. - not Preg/PID/Ectopic
Repeat USS = 8-12 weeks
__________________
Cancer @ complex cyst
FOLLICULAR > Corpus luteum
InterMenstrual Bleed =
-Ectopic/ Polyp/ Cancer
-COCP underdose breakthrough bleed / Depot / IuD - POP
____________
Ovarian hyperstimulation
Seen in OLDER women
Sensation of pressure, heaviness, ‘bearing-down’
Urinary symptoms: incontinence, frequency, urgency
________
PPHemorrhage tx
_________________________
Premature labour tx?
After W?
symphysis-fundal
height in cm = ??
________
Oligohydramnios definition
< ?ml @ T3
AFI < ?th centile
-Ax?
Shoulder dystocia tx?
UVP
_______
-BOE-CAB Bimanual uterine compression Oxytocin - stim ut contract Ergotamine( -5HT/Alpha-adr/Dop=vasc SM constrict -> reduce Uterus BF = less bleed)
Carboprost
Atony = Balloon tamponade
B-lynch UA/Iliac ligation/TAH
________________________
Premature labour:
Admit
Tocolytics and Steds
After W20, S-F height i=
-g.WEEKS +/- 2cm
_______
Oligohydramnios
< 500ml @ T3
AFI < 5th centile
Ax:
Renal agenesis / ACEi
IUGR
PROM/Pre-Ecl/Post-term>42w
Shoulder dystocia: MESZ
McRoberts’ - flexion and abduct
Episiotomy, Symphysiotomy,
Zavanelli / Rubin Wood’s Corkscrew
menorrhagia
infertility
pelvic pain/mass = bulky -> distended/distorted anatomy
?BLACK
- bloating
- cramping abdo pain @period
- FUNDHS/pressure syx @larger ones
Ix? When to refer for fibroids?
Wtf is red degeneration? Worsened when?
_________________
Low p(CHAF) - Mx?
- ?Bloods dx
- ? @Submucosal fibroid/Polyp/Endomet dx
- ? @fibroid,
- ? @adenomyosis
Fibroid <3cm + ? / ? - Mx?
Fibroid >3cm - Mx?
-what can increase fibroid size?
Fibroid distorted + want contraception?
- Risky @ ?
- Rest = legit - ?
__________
PAIN + BLEED
- Dysmenorrhoea
- Menorrhagia
Enlarged, tender/boggy Uterus
Ix??
FIBROID
-A/PUSS + TVUSS
When to refer for fibroids?
- Size >3cm/12cm
- Comp syx
- Infertility
- Malignancy
- Palpable
Wtf is red degeneration? Worsened when?
-growth > blood supply
-worse at preggers
_________________
Low p(cavity dx, histologic dx, adenomyosis, fibroid)
OR
Fibroid <3cm NOT distorted/Adenomyosis:
A) MIRENA iUS
-dct->
B)
NH = TXA/NSAID(mefenamic)
H = Combo/POP
-dct-> IPS
C) 1. Ix - -FBC/Bleed-clotting dx -Hysteroscope @Submucosal fibroid/Polyp/Endomet dx -USS-TA/TV @fibroid, -TVUSS @adenomyosis (MRI best on passmed..) 2. Pharm - NH/H 3. Surg: -T-C Resection -Hysterectomy yes -EAblation 2ndary yes -Myomectomy -B/L Sooph -UAEmbol -MRI guided USS ablation \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Fibroid >3cm - Mx?
- REFER + TXA/NSAID(mefenemic) -> IPS-HUM
- HRT increases fibroid size
Fibroid distorted + want contraception?
-Risky @iUS/iUD
-Rest = legit - barrier/ sterilize/ combo-pop
____________
Adenomyosis
TVUSS > A/PUSS/MRI
Infertility
40+F 5m Hx of Amenorrhoea
Abdo mass!!!! Dx?
How long they gotta try for and how often sex?
-? % conceive @Y1
-? % conceive @Y2
________________
When to refer for infertility?
Mid-luteal Prog-d ??????????
S? - 2ndary*
C?/ C?- ?agonists
G?/ G? Pulsatile I-suv S? Tubal ? \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
When fail, how to Ix?
___________
@Endometriosis/Fibroid/adenomyosis, which surg is recommended for fertility??
- Myomectomy
- Endometrial ablation
- Uterine artery embolisation
40+F 5m Hx of Amenorrhoea
Abdo mass!!!! Dx = PREGNANCY!!!!!!!
UPSI / 2-3days - 1 year -84% conceive @Y1 -92% conceive @Y2 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ GAS MSC GIST:
Genital dx Amenorrhoea/Varicocele STI/Surg/Systemic dx Women 36/+ yrs \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
MSC GIST:
d21 d21 d21 d21 d21 d21 d21 d21 d21 d21
-length of period - 7 !!!!!
Mid-luteal Prog-d21!!!
SHeeP-GOAT - 2ndary*/ Sperm count
Chlamydia/Clomifene-Dop agonists
Gonadotrophins/GnRH Pulsatile
ISCI-UInsem-IVF
Surg
Tubal patency
*Stress
HCG - preggers
Excess Exercise
Prolactin
Gonadotrophins - MP/POF;Asherman;PID;Sheehan Oestradiol - MP/POF Androgen - PCOS TFT \_\_\_\_\_\_\_\_\_\_\_\_
Myomectomy RETAIN lady’s fertility
Endometrial ablation destroys the endometrial lining, therefore meaning that an embryo would NOT implant.
Uterine artery embolisation is NOT RECOMMENDED if trying to conceive as it cuts down the blood supply to the uterus significantly, therefore meaning that the fetus would be unable to implant and grow.
Preg woman A/W with:
?sudden Abdo pain and Circ collapse
-evidence of rupture OR impending rupture
- Preg sx - Gestation EVIDENCE #999
- LMP 10wk i.e. AGES ago
Some vag DISCHARGE is common.
There is usually adnexal tenderness.
Dx?
-most useful next Ix = may demonstrate ????
Types:
?
-os ? #Light-Bleed
-ALIVE -others=?
?
-os ? #HEAVY-bleed
Missed -os ? -gestational sac is > ? mm and -no ? #'? ovum' #'? pregnancy'
Incomplete
- os ?
- ? left
Complete
- os ?
- ? uterus
Miscarriage tx?
- @WW, when d/c + f/u in ? week
- BYPASS WW when?!
Dx: miscarriage
-TVUS which may demonstrate NO fetal heart
Threatened
- os Closed #Light-Bleed
- ALIVE -others=dead
Inevitable
-os open #HEAVY-bleed
Missed -os Closed -gestational sac is > 25 mm and -no embryonic/fetal part #'blighted ovum' #'anembryonic pregnancy'
Incomplete
- os open
- clots and material left
Complete
-os Closed
-empty uterus
________
WMVE
WW < 2w
- (d/c with f/u in ? week)
- BYPASS WW –> straight to Med/Surg Mx @:
- -Haemorrhage (late T1/blood dx)
- -Infection
- -Prev preg dx
MisoProstGlandins - Moebius Synd
Vacuum Asp Suc Curettage - OP tx
Evac @Theatre - iP tx
PainLESS nodue @Thyroid
-cervical LNopathy
-YOUNG
____________
Solitary thyroid nodule
-Encapsulated
Invades vascular
___________
Calcitonin raised
-diarrhoea+flushing
-hard upper lobe
____________
OOOOLD woman -dysphagia, hoarseness, SOBOE -hard mass @unilateral lobe -cervical LNopathy \_\_\_\_\_\_\_\_\_\_
Parathyroid/Pit/Panc
-insulinoma gastrinoma
Parathyroid/pheochromocytoma
MED THYROID CANC
Pheochromocytoma
-Marfanoid - Neuroma
MED THRYOID CANC
Papillary cancer
- –papillary projections
- –pale empty nuclei
- –NOT encapsulated
LN mets common
________
follicular adenoma
Follicular carcinoma
________
Medullary carcinoma
-Lymphatic and haematogenous metastasis
-Poor prognosis
_______
Anaplastic - ANNA the old woman
________
MEN 1
MEN 2a RET
Men 2b RET
leaking small amounts when coughing or laughing
_________
detrusor overactivity
__________
BPH -> bladder outlet obstruction #blocking!
-similar concept to constipation……
Stress incontinence
________
OAB/urge
__________
overflow incontinence
Urge Tx?
________
Codeine to PO morphine
PO morphine = to…
SC moprhine /?
OXYCOD PO /?
SC diamorphine /?
IV moprhine /?
OXYCOD SC /?
- SP—SI–S
- MO-DM-O
- 22—33–4
Alcohol units?
-AST > ALT (ratio usually> 2:1)
-toAST
________
Monoplegia -?
Hemiplegia -?
Quadriplegic -?
-Paraplegia -?
ACA–MCA–PCA*
*PCA - midbrain Weber
________________
Amaurosis fugax - which vessel?
Locked in syndrome - which vessel?
__________
- Absent < – > horizontal eye-move
- Miosis
- Paralysis=Quadriplegia
- Same FACE: PD/PT (paralysis/deaf // pain/temp)
- Opp limb
- Nystagmus
- Ataxia
- Same FACE: PD/PT (pain/temp)
- Opp limb
- Nystagmus
- Ataxia
__________
- Unilat sensory/motor FAL
- Cog dx - VisuoSpatial/Dysphasia
- HomoHNopia
1 of: -Sensory -AtaxicHemiParesis -Motor PURELY + HTN
CN dx + CONTRALAR motor/sensory dx
Conjugate EYE dx
CEREbellar dx - ataxia/nystag/vertigo
HomoHNopia
4-6-4 H:
CN4 present?
CN3 present?
CN6 present?
________
Nystagmus: central v peripheral? -B/? -Assoc with ? syx -Direction = ? / purely ? \_\_\_\_\_\_
Brainstem Death: C? unknown Ax R? ax excluded S? X E? fine
B? stim -> no cough Response to ? / ? ? Reflex absent ? Reflex absent Disconnect ventilator 5-mins -> ?
_________
Delirium > Dementia
________
?vessel lesions (dominant side - i.e. most ppl are ?-handed so ?-sided MCA fucked):
Lesion -> SPEECH = FLUENT sentences that make Sense -Repetition = FUCKED -AWARE of Errors making Comprehension is NORM
Lesion -> SPEECH = FLUENT sentences that make NO Sense -word substitution / neologisms #word-salad Comprehension FUCKED Repetition NORM
Lesion -> SPEECH = NON-FLUENT sentences that make Sense -Laboured + Halting -Repetition = FUCKED Comprehension NORM \_\_\_\_\_\_\_\_\_\_
-Can't read/calculate/recognise #RCR alexia(cant read) acalculia(can't calculate) finger agnosia (can't to recognize objects) -RIGHT-LEFT disorientation -?
? involuntary, irregular, non-rhythmic movements of UNILATERAL side of the body
? involuntary, flinging, violent movements of UNILATERAL side of the body
_______
PONV -?
@Medulla
______________
ICP high
Motion-labrynthine / MECH Bowel Obst
Preg
?
RT/Cancer = ?
_______________
?=CYTOTOXICS=?
- ?=cannabinoid
- ?-NK1 blocker
Opiod -?
________________
OCDMPH:
Ondan5HTron - 5HeroTotinin3 blocker
-medulla
CycliZINE - antihistaMINE
-ZINES - promethazine NOT prochlorperazine
FOR HIGH ICP!!!!!!!!!!!
DopBlockr: Domp = NOT cross BBB so can use in Parkinson's MetocloProkinetic Prochlorperazine Haloperidol - METABOLIC stuff ?highCa/RF
Funct - metoclop / Mech - Cyclizine
Alco/Caff/Fizzy
Constipation ALLOW
Ex/Diet
Sweeteners/Smoke ALLOW
Bladder retrain 1.5m Oxybutinin/tolterodine #AMusc Mirabegron Botox/Cystoplasty \_\_\_\_\_\_\_\_\_
Codeine to PO morphine /10
PO morphine = to…
SC moprhine /2
OXYCOD PO /2
SC diamorphine/3
IV moprhine /3
OXYCOD SC /4
Alcohol units = %.mls / 1000
-make a toAST with alcohol > ALT. 2>1
_________
Monoplegia - 1 limb
Hemiplegia - Unilat 2 limbs
Quadriplegic - 4 limbs
-Paraplegia - Bilat LOWER limbs
ACA MCA PCA*
L>UL ; UL>L
< – HemiParesis
……..Aphasia – > Agnosia
……..Sensory
….HomoHAnopia – > Mac-Sparing
*PCA - Weber Midbrain
-Same CN3, opp HemiParesis
-Agnosia
-Macular sparing HomoHNopia
________________
Amaurosis fugax - Retinal/Ophthalmic Artery
Locked in syndrome - Basilar Artery
____________
Pontine bleed: PAMP
- Absent < – > horizontal eye-move
- Miosis
- Paralysis=Quadriplegia
AICA: Lat Pont
- Same FACE: PD/PT
- ——(paralysis/deaf // pain/temp)
- Opp limb
- Nystagmus
- Ataxia
PICA: Lat Med Wallenburg
- Same FACE: PD/PT (pain/temp)
- Opp limb
- Nystagmus
- Ataxia
______________
Anterior Circulation Stroke:
3=TotalACS
2=PartialACS
-UCH
- Unilat sensory/motor FAL
- Cog dx - VisuoSpatial/Dysphasia
- HomoHNopia
LacACS = L-SAMP 1 of: -Sensory -AtaxicHemiParesis -Motor PURELY + HTN
POstCS
_________
4-6-4 H:
CN4 vertical nystagmus
CN3 Ptosis, Dilated, Vertical nystagmus
CN6 horizontal nystagmus
Nystagmus: Central v Periph:
central is:
- B/L
- Assoc sens/motor dx
- Direction = multi / purely uni or rotatory
Brainstem Death: Coma unknown Ax Reversible ax excluded Sedation X Electrolytes fine
Bronchial stim -> no cough Response to sound/Supra-Orb Pressure Occ-Vestib Reflex absent Corneal Reflex absent Disconnect ventilator 5-mins -> no resp support \_\_\_\_\_\_\_
-Emotions = fear, agitation
-Fluct Syx = worse @night, normal periods
-GCS impaired
-Hallucinations/Illusions/Delusions #perception
_________
MCA lesions (dominant side - i.e. most ppl are right-handed so left-sided MCA fucked):
Conduction aphasia
- Arcuate Fasciculus
- Fluent + Sense + Comp NORM
- Repetition fucked
Wernicke Receptive
- SUP Temp gyrus
- Fluent + NO Sense + Comp FUCKED
- Repetition NORM
Broca Expressive -INF Frontal gyrus -NON-Fluent + Sense + Comp NORM -Repetition fucked \_\_\_\_\_\_\_\_\_\_
alexia, acalculia, finger agnosia
RIGHT-LEFT disorientation
-Gerstman’s
hemichorea: involuntary, irregular, non-rhythmic movements of one side of the body
hemiBALLismus: involuntary, flinging, violent movements of one side of the body
PONV - Ondan5HT3/Ginger
@Medulla
______________
ICP high
Motion-labrynthine / MECH Bowel Obst
Preg
-AntiHist > DopBlock
RT/Cancer = DopBlock
_______________
Ondan5HT=CYTOTOXICS=DopBlock
- Nabilone=cannabinoid
- Rolapitant-NK1 blocker
Opiod - OCD
-Ondan5HT/Antihis/DopBlocker
-ChemoreceptorTrigger zone - CT-zone
________________
OCDMPH:
Ondan5HTron - 5HeroTotinin3 blocker
-medulla
CycliZINE - antihistaMINE
-ZINES - promethazine NOT prochlorperazine
FOR HIGH ICP!!!!!!!!!!!
DopBlockr: Domp
MetocloProkinetic
Prochlorperazine
Haloperidol - METABOLIC stuff ?highCa/RF
Funct - metoclop / Mech - Cyclizine
Stress tx
Alco/Caff/Fizzy
Constipation ALLOW
Ex/Diet
Sweeteners/Smoke ALLOW
Kegel 3m - - > ArupBCD -ARtificial sphincter -AUtologous rectus sling -APpliance sheath -Bulk/urethral slings -Catheter/Colposuppression -Diversion --> Duloxetene -Refer if NOT had prostatectomy...
surgical procedures: e.g. retropubic mid-urethral tape procedures
Testicle: Painless lump and non-tender (Onset is chronic, but the lump may have only just been discovered) or there may be a DRAGGING sensation in the scrotum.
Most common in men 20–40 years of age, but can occur in older men, when it is usually a lymphoma.
Usually presents with testicular enlargement.
On palpation, there is a solid, firm swelling involving all or part of testis
-CAN’T be separated from testes
back or flank pain, SOB , supraclavicular nodes, abdominal mass (enlarged para-aortic lymph nodes),
WEIGHT LOSS, BOOOBS!!!!!!! , epididymo-orchitis, or a hydrocele.
Pain is present in ?% of people with testicular cancer.
- Germ 20-30
-NSemi
Choriocarc-Tropho
Embryonic
Teratoma
Yolk Sac
-Semi 40+
- Non-Germ = Sex Cord
Leydig/Lymphoma ;
Sertoli/Sarcoma
50+
RFs?
Ix?
AFP( ?%) / LDH( ?%) is elevated
in around ? cell tumours
Seminomas: hCG may be
elevated in around ?%
-Non-semi=Choriocarc.Embryonic.Teratoma.Yolk-sac #germ
-Seminoma #germ
-Non-germ=Leydig-Lymohoma.Sertoli-Sarcoma
_______________
Germ = NSemi+Semi
-AFP( ?%) / LDH( ?%) is elevated
in around ? cell tumours
-Seminomas: hCG may be
elevated in around ?%
……..(NSemi……Semi)….NGerm
AFP/ hcg: high/low?
…………………
Age: …..(20-30……40)…….50
Prognosis:…………good)
FHx Undesc Crypto-Orchid Kleinfelter Infertility TIN --> size/shape/texture change = 2WW + USS TESTES !!!
Testicular cancer
Pain is present in 20–27% of people with testicular cancer.
GERM 95% > Non-Germ-SexCord 1. Germ 20-30 -NSemi Choriocarc-Tropho Embryonic Teratoma Yolk Sac
-Semi 40+
hCG may be elevated in around 20%
- Non-Germ = Sex Cord
Leydig/Lymphoma ;
Sertoli/Sarcoma
50+
FHx, Undesc, Crypto, Kleinfelt, Infertility, TIN
Ix = USS
AFP(60%) / LDH(40%) is elevated
in around GERM cell tumours
Seminomas: hCG may be
elevated in around 20%
-Non-semi=Choriocarc.Embryonic.Teratoma.Yolk-sac #germ
-Seminoma #germ
-Non-germ=Leydig-Lymohoma.Sertoli-Sarcoma
_______________
Germ = NSemi+Semi
-AFP(60%) / LDH(40%) is elevated
in around GERM cell tumours
-Seminomas: hCG may be
elevated in around 20%
……..(NSemi……Semi)….NGerm
AFP/ hcg: high
…………………
Age: …..(20-30……40)…….50
Prognosis:…………good)
FHx Undesc Crypto-Orchid Kleinfelter Infertility TIN --> size/shape/texture change = 2WW + USS TESTES !!!
PAIN = Sudden <6hrs,
Severe, Unilateral, N+V
@neonatal / puberty.
Hx of severe, SELF-LIMITING PAIN
CREMASTER = ABSENT
Testis is ELEVATED #TRANSverse lie.
Neonatal = scrotal swelling + discoloration (similar to scrotal haematoma).
Hx of previous trauma
___________
PAIN = SUDDEN/GRADUAL over a few days.
-HEAD of the testis/epididymis
Nooooooooo N+V
O/E: Early NODULE @UPPER testis/epididymis –> scrotal OEDEMA.
Torson V Appendage-torsion = hard 2 diff
But @appendage, testis =
mobile + normal size,
-CREMASTER = PRESENT.
Infarcted appendage = seen through the skin (the ‘BLUE DOT sign’).
Testicular torsion (torsion of spermatic CORD) \_\_\_\_\_\_\_\_\_\_
Torsion of appendix testis or appendix epididymis
T1/2 bleed causes?
T3 bleed causes?
- Bleeding @T1/earlyT2
- exaggerated syx e.g. HyperEmesis.
- LARGE 4 dates uterus
- hCG = high AF!!! = HYPERthyroid
- ? @USS
Tx????????
Complete V Partial mole?
? % = develop choriocarcinoma
___________
Delayed 3rd stage labour
Pt w/ prev
-PMH: PID
-PSH: c.section / p.praevia
?-types - what invades what?
Tx: ?
_______________
@preggers
•shock OUT OF KEEPING w/ visible loss
•tender, tense, hard woody uterus #CONSTANT-pain
- lie /presentation - NORM
- fetal heart: absent/distressed
- coag dx=DIC / pre-eclampsia
- NO fetal distress + <3? w
- NO fetal distress + >3? w
- Fetal distress - tx?
___________
@preggers
•shock IN PROPORTION to visible loss
•painLESS
- lie /presentation - ABnormal
- fetal heart: FINE
- coag dx=none..
Ix? - what to avoid?!
- If low-lying placenta @16-20 week scan
- rescan at ?weeks - If still present @ ?-weeks and
grade 1/2 then ? - If high presenting at ?weeks then ?
- If high abnormal lie at ?weeks then ?
_____________
Rupture of membranes –>
- immediately get vaginal bleeding
- Fetal BRADYcardia #classically seen
T1/2 = Ectopic / Miscarriage-Molar preg
T3 = Praevia / Abruption
_________________
Complete HyDatiDiForm Mole (MOLAR)
Tx = EVAC -> CONTRACEP 12m
COMPLETE=46 XX/XY
-EMPTY egg + 1 sperm –> DNA duplicates –>
ALL 23x2 male genes
-Honeycomb/Grapes/SNOWstorm @USS
PARTIAL=69 XXX/XXXY
- haploid egg (23) + 2 sperm (23x2)
- partial fetal parts
Around 2-3% = develop choriocarcinoma
___________
Accreta
- delayed labour #3rdstage
- prev c-sec/praevia/PID
3-types = chorionic villi:-
- invade PPerimetrium #PPercreta
- IInvade myometrium #IIncreta
- AAttach* 2 myometrium #AAccreta
*-instead of decidua basalis #accreta
Tx: hysterectomy w/ placenta left in-situ
___________
P.Abruption - PainFUL PV bleed
-OUT OF KEEPING w/ visible loss
- feta heart fucked + DIC/Pre-Ecl
____________
- NO fetal distress + <36w
- observe+steroids
- ?adjust delivery threshold - NO fetal distress + >36w
- vag delivery - Fetal distress - tx?
-immediate c-section
_____________
P.Praevia - PainLESS PV bleed
- IN PROPORTION to visible loss
- Lie = abnormal
Ix? - what to avoid?!
-TV-USS - avoid PV exam till praevia excluded!!
LLP @W-16-20 = Rescan @w34
-34 + G1/2 = TVUSS/2w
-37 = high-presenting-part/abnormal life = C-SECTION
- If low-lying placenta at 16-20 week scan
- rescan at 34 weeks - If still present at 34 weeks and grade 1/2 then
- scan every 2 weeks - If high presenting part at 37 weeks then
- C-section - If abnormal lie at 37 weeks then
-C-section
_______________
Vasa praevia
-ROM - >PVbleed + BradyBaby
Onset is usually GRADUAL over hours to days.
Usually painful and tender. Relieved @ ELEVATE testis = Prehn sign
?palpable swelling, erythema, oedema, hydrocele
?Urethral discharge, UTI Syx, parotid swelling (mumps orchitis usually occurs 4–8 days after parotitis), or vomiting.
-Dx? Organism? Tx? 3 causes: -? - (anal sex/ catheter) -> ? -? - (Age <35) -> ? -? - (supportive) - ?
–f/u?w->
f/u =? + Refer ?
2ww:
45/+ vHU
45/+ vHU + (UTI + Tx fail)
60/+ nvHU +
-dysuria/WCC
-Recurrence/Persistence
__________
@?, the epididymis = HARD, IRREG surface, the spermatic CORD is THICK, and the vas deferens feels hard and irregular (like a string of beads)
Painless and non-tender if tuberculous.
________
Fever
Storage: FUNDHS
Sterile Pyuria (puss in piss)
-INfertility
O/E: testic swelling, perianal SINUS, ulcers
________
When to USS testicle?
_________
Varicocele - Refer:
_________
When 2 refer for Urology:
_________
Fluid AROUND testicle
#CANNOT FEEL testes
-TRANSILLUMINATES
Dx?
For CONGEN hydrocele:
-when 2 reassure - @?yrs
-when 2 refer for paeds?
Hydrocele @?
Hernia = ?
For non-CONGEN hydrocele?
__________
Varicoceles - how 2 manage:
-G1/subclin = ?
-@G2/3
Symmetrical - ?
Asymm = ?
Syx OR Abnormal semen = ?
Asyx AND Normal semen = ?
Most are on the left,
left varicocele = RCC cos left testicular vein drains into left renal vein
_________
Lump in INGUINAL groin area
Reducible disappears when laying flat scrotum fine
<6w - surg < ?
<6m - surg < ?
<6y - surg < ?
__________
BLACK kid
symmetrical bulge
@UMBILICUS
Dx? Tx? Resolve by?
Assoc w/?
-If syx/ large = Surg @ ? -? yr
-If Asyx+Small = ?Surg @ ? -? yr
E-Orchitis
3 causes:
- E.coli - (anal sex/ catheter) -> Cipro
- STD - (Age <35) -> Ceft+Doxy /Cipro
- Mumps - (supportive) - MSU/dipstix
–f/u2w->
f/u =
?ABx change + Refer @UTI/ GUM-STI/ Fail
45/+ vHU
45/+ vHU + (UTI + Tx fail)
60/+ nvHU +
-dysuria/WCC
-Recurrence/Persistence
___________
Tuberculous E-Orchitis
______
GUTB
-genito-urinary-TB
Sterile Pyuria: Partially/Recently Tx UTI Chlamydia Tumours - renal/bladder TB/Schisto/AppendicitisDivertic-ureter irritation
Cystoscopy RT/Drugs Atrophic vaginitis Preg InterstitialNephritis/ATN \_\_\_\_\_\_\_\_\_
When to USS testicle? Hematocele @non-trauma -if < x3 V contralat = chill Hx of pain/ persistent/ trauma Hydrocele = 20-35 Uncertain ddx Testicle = ETvTesticle ? \_\_\_\_\_\_\_\_\_
Varicocele - Refer: -Sudden pain -Not drain @supine -R-sided varicocele -TGA = low volume \_\_\_\_\_\_\_\_\_
When 2 refer for Urology: -Torsion -AEOrchitis -StrangHernia -Hematocele TRAUMA \_\_\_\_\_\_\_\_\_ Dx = Hydrocele
For CONGEN hydrocele:
-Reassure < 2yrs
-when 2 refer for paeds:
Hydrocele @SCord /Abdo-Scrotal Hernia
Hernia = Inguinal /Strang
For non-CONGEN hydrocele:
-Surg/Sclero/Asp
__________
Varicoceles - how 2 manage:
G1/subclin
-Reassure, Analgesia, Infertile 33.3%, Supportive underwear
-@G2/3
Symmetrical - Annual exam
Asymm = Urology ref
Syx OR Abnormal semen = Urology ref
Asyx AND Normal semen = Semen analysis
__________
Congenital inguinal hernia – paediatric surgery ASAP incarceration risk <6w - surg <2d <6m - surg <2w <6y - surg <2m \_\_\_\_\_\_\_\_\_\_\_\_\_
Infanta UMBILICAL hernia No tx - resolve <3yrs -Assoc with HypoT !!! If Syx/ Large = Surg @2-3yr -If Asyx+Small = ?Surg @4-5yr
painless, non-tender, soft, fluctuant, smooth, round nodule in the epididymis. It is usually small
Onset is chronic.
__________
Pain onset may be sudden / chronic.
Does NOT transilluminate as well as a hydrocele.
Usually caused by trauma/cancer –>?testicular rupture
__________
Not possible to ‘get above’ the swelling or feel spermatic cord
Onset may be acute or chronic.
Dull dragging
Often painless but pain may be present, particularly if the hernia is incarcerated or strangulated.
May enlarge with Valsalva-type manoeuvres, and disappear on lying down (if reducible).
Positive cough impulse.
Epididymal cyst or spermatocele
______
Haematocele
_______
Indirect inguinal hernia
Dysmenorrhoea, - PAIN
Menorrhagia - BLEED
Enlarged, tender/boggy Uterus
Dx ? Ix?
Adenomyosis
TVUSS
Intermenstrual bleeding ONLY = ??
Intermenstrual bleeding Postcoital bleeding Pelvic pain -dx? \_\_\_\_\_\_\_\_\_\_\_\_
Menorrhagia
- NO underlying pathology i.e.
- -no masses felt i.e. No..?
- scans all normal so no cancer
- -ALL Ix all frikn normal bastard
Endometrial polyps
-Ectropion/Polyp/CC
Endometrial hyperplasia / carcinoma
_______
Dysfunctional uterine bleeding
- -no masses felt i.e. No FIBROID
- MORE COMMON THAN FIBROIDS
- MOST common cause of heavy bleed
Risk factors of cancers:
Ovarian ELN-B
ENDO ELN-DOH+ht
Cervical
young woman
post-coital bleed
o/e friable, oedematous lesion
move side-2-side
Early menarche, Nulliparity, Late menopause
BRCA
Early menarche, Nulliparity, Late menopause
DOH+ht : DM/Obesity/HNPCC Lynch + HRT/Tamoxif
Cervical: literally all bad things…
Cervicitis
PCOS
Hirsutism and acne
Tx - ?? –> ?? and what else??
Infertility Tx -
? —> (? > ?)
Amenorrhoea tx?
-TVUSS - Endomet thickness
(THICK = ?action … due to ? )
(NORM = ?hormonals )
Hirsutism and acne -
Dianette/COCP –>
-Eflornithine +
-Flutamide/Finasteride/Spiro
Infertility -
WL –> (CLOMIFENE #refer > metformin)
Amenorrhoea:
- Cyclical Prog = Medroxyprog = NOT contracep dose !!!
- COCP (not @fatso/UKMEC3-4)
- Levonorgest-iuS= fat+need contracep
-TVUSS - Endomet thickness
(THICK = refer ?hyperplasia/cancer)
(NORM = MMC
mirena / medroxy-prog cyc-prog / cocp)
Aside from ovarian cancer, what else can CA125 be rasied in? C-OPE
Ovarian cancer types: MOST COMMON CAUSE OF OVARAN: -CANCER = ? cancer -BENIGN tumour < 25y = ? -ENLARAGEment @reproductive age = ?
Epithelium
Germ-cell
Sex-cord
Type of Ovarian Cyst
-Follicular > Corpus luteum
Complex cyst = ?dx = Mx?
Ovarian teratoma –>
Psych dx, memory dx, encephalitis, seizures, dyskinesias, autonomic dx, language dx = Anti-?
CA125
- Ovarian Cancer/Cysts,
- Periods,
- Endometriosis
Ovarian cancer types: MOST COMMON CAUSE OF OVARAN: -CANCER = SEROUS cancer -BENIGN tumour < 25y = DERMOID Teratoma -ENLARAGEment @reproductive age = FOLLICULAR cyst
-Epithelium - sero / mucinous –>
(@rupt = pseudomyx peritonei)
MUCIN IN ABDO!!!!! BLUERGH
-Germ-cell ChorioTropho/ Embryonic/ Terotoma-dermoid/ YolkSac/ Dysgerminoma
-Sex-cord = Granulosa / Thecoma / Leydig-Sertoli
Type of Ovarian Cyst
-Follicular > Corpus luteum
Complex cyst = cancer = REFER
Ovarian teratoma –>
Psych dx, memory dx, encephalitis, seizures, dyskinesias, autonomic dx, language dx = Anti-NMDA
________________HRT*
_____________Cycli ¦ Contin
Predictible______ ? ¦ ?
bleed_________@? ¦ @?
LMB _________?yr / >?yr
@?
*HRT = Endomet? (Y = ? / N = ?)
O+P (?=protect against Endo cancer)
Vasomotor syx tx?
Atophic vag?
________________HRT*
_____________Cycli ¦ Contin
Predictible______ Y ¦ N
bleed_____i.e.@peri-mp ¦ i.e.@mp
LBP _________<1yr ¦ >1yr / >2yr
@POF
HRT = Endomet? (Y = O+P / N = O)
O+P*(P=protect against Endo cancer)
__________
Vasomotor syx tx?
- Clonidine - NH
- SSRI - NH
- SNRI - NH
- HRT = hormonal
Atophic vag -
top oest ± Lubricants and moisturisers
@MenoPause - Bleed Stopped:
LMB-age ¦ contraception until…
- –<50 ¦ ?
- –>50 ¦ ?
@STILL bleed >40yr
____Age ¦ COCP/Combo ¦ Depot
—<50 ¦ ?
—>50 ¦ ?
@STILL bleed >40yr
____Age ¦ IuS/POP//Implant
—<50 ¦ ?
—>50 ¦ ? / check ?pattern ->
test what pit test?:
- check if stop b4 when?
- > 30 = cont ? for how long?
@MP - Bleed Stopped:
LMB-age ¦ contraception until…
- –<50 ¦ 2yr AFTER LMB
- –>50 ¦ 1yr AFTER LMB
@STILL bleed >40yr
____Age ¦ COCP/Combo ¦ Depot
—<50 ¦ cont till 50
—>50 ¦ NH/ius-pop-implant
@STILL bleed >40yr
____Age ¦ IuS/POP//Implant
—<50 ¦ cont till 55
—>50 ¦ cont till 55/check bleed pattern ->
FSH:
- check if stop b4 55
- > 30 = cont ius-pop-implant for 1 year
OCP-BV : BEVif
Pros and cons of OCP (ocp bv)
__________________
Cons of HRT - BEVif the biddy comes in for HRT
___________
hot flushes,
vaginal dryness / atrophy,
sleep dx / irritability.
POF: Premature Ovarian Failure =
? syx + ? FSH/LH < ?yrs
—— ?% women
menopause =
?? months of amenorrhoea
AFTER the LMB
FHx
Chemo/Radio
Autoimmune
Avg age women MP = ?
Pros: OCP Cancer: OOOvarian, EEEndo, COLORECTAL Periods: heavy=fibroids / pain-endomet
Cons: BV
BBBreast/CCCervical*
VTE
*(Ectropion) (ECTZ column cells - Cold Coag)
__________________
Cons of HRT: BEVi Breast (prog increases this) Endomet (prog reduces this) VTE / IHD (Transdermal HRT reduces this) iNC Fibroid size \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Ovarian Failure - MP
Premature ovarian failure =
MP syx + high FSH/LH < 40yrs
—— 1% women.
menopause =
12 months of amenorrhoea
AFTER the LMB
Avg age women MP = 51
-Primary CMFT
-Secondary SHeeP GOATmaps
causes of amenorrhoea
Anorxia b4 puberty - primary or secondary amenorrhoea?
____________________________
Infertility in men?
VINDICATE
________
pros and cons of OCP
PRIMARY: CMFT Anorexia B444* puberty!!! #PRE-pubertal CAH/5alphaReduct, Malformation, Feminisation-AndInsensSynd, Turner + genetic dx
*GnRH release will be delayed, hence PRIMARY - otherwise Anorexia generally = SECONDARY
SECONDARY:
SHeePGOAT
Stress
HCG - preggers
Excess Exercise
Prolactin
Gonadotrophins - MP/POF;Asherman;PID;Sheehan
Oestradiol - MP/POF
Androgen - PCOS
TFT
________________________________
Infertility in men?
V - HF/LF/RN I - orchitis (STI/mumps) Neoplasm D - saulfasal/infliximab I - Trauma/Surg/WARM BALLS C - Cryptoorchid Ai Thyroid dx T - Trauma/Surg/WARM BALLS E: DM / HYPERTHERMIA \_\_\_\_\_\_\_
pros:
Ov/Endo cancer prevent
Colo cancer prevent
Periods lighten(fibroid)/pain ease (endometriosis)
cons:
breast/ cervical cancer
VTE
25 F =5 months AFTER dilation+curettage for a miscarriage.
Since procedure = not had period.
HCG negative.
Hysteroscopy reveals diagnosis.
Asherman’s syndrome
gestational sac >25mm
contains a dead fetus
BEFORE 20 weeks
NOOOOOOOO expulsion sign/symptom
AKA ‘blighted ovum’ or ‘anembryonic pregnancy’
The most useful next ?, may demonstrate ????
Missed miscarriage
-TVUS = no fetal heart.
H
H
Pain typically starts JUSTTTT/HOURS before period
Pain appears within 1-2 years after menarche
-YOUNG PERSON w/ DYSMENORRHOEA
DYSSSSmenorrhoea
Tx??????????????????
________________
primary AAAAAMENorrhoea
(failure to ?? menses
by the age of ?? years)
________________
Premature ovarian failure????
_________________
Primary Infertility =
couples who have ??? conceived.
Primary Dysmenorrhoea
Nsaid/paracetamol
Cocp/pop
Gnrh agonists/surg
________________
primary AMENorrhoea
(failure to START menses
by the age of 16 years)
_________________
POF =
MP syx
+
high FSH/LH < 40yrs —— 1% women.
___________________
Primary Infertility = couples
who HAVE NEVER conceived.
Pain occurs 1-2 DAAAAAYS B4 period
Pain started YEEEEEEARS after the menarche
-Older PERSON w/ DYSMENORRHOEA
DYSSSSmenorrhoea dyspareunia
Tx??????????? Ax?????????
________________
Secondary AMENorrhoea =
bleeding previously ? - - >
now stopped for at least ? months
________________
Secondary Infertility in couples who ?? ?? conceived.
Secondary DYSSSmenorrhoea
REFER TO GYNAE ASAP!!! UNDERLYING PATHOLOGY
C-CHAF:
- Cancer-Cavity dx(PID/IuD/Polyp) ,
- Histolog dx,
- Adenomyosis,
- Fibroid,
- Endometriosis)
REMEMBER menorrhagia=CHAF/Dysmen=Endometriosis but for this condition it all could cause Dysmenorrhoea so Ix for both 🤷🏽♂️🤦🏽♂️
________________
Secondary AMENorrhoea =
bleeding PREVIOUSLY occurred - - >
now stopped for at least 666666666666666 months
________________
Secondary Infertility in couples who
HAVE PREVIOUSLY conceived.
Menstruation:
MFOL? - follicles?
Physiologic changes @preggers
-rises: ?
-drops: ?
______________
- MENSTRUATION d ? - ? - >
mucus = ? + forms what where?
2. FOLLICULAR phase (Endomet ? phase) d5-13 a. -FSH peak = ? - - > -oestradiol peak = ? - - > -LH peak - - > ?
b.
mucus = ? , ? , low ? , ‘stretchy’ ?
just b4 ovulation
- OVULATION d ?
- Tertiary follicle - - > ? - LUTEAL phase (Endomet ? phase)
a.
Corpus Luteum secrete ? ->
Body temp ? after ovulation
b. If fertilisation NOT occur, -what happens to corpus luteum? and -what happens to prog lvl?) d15-28 \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Oestrgoen secreted -> so body temp ?? B4/after ovulation
Prog secreted by the corpus luteum -> so body temp ?? B4/after ovulation
BASICALLY, temp @period + BP @preg = U-wave relationship bro FFS remember that shit
MFOL
- Menstruation d1-5
- Follicular - Endomet PROLIF phase
- Ovulation d14
- Luteal - Endomet SECRETORY phase
Follicles: primordial, primary, secondary, tertiary
Physiologic changes @preggers
-rises: everything else
-drops: Hb + BP
______________
- MENSTRUATION d1-4 - >
mucus = THICK + forms a PLUG @EXT OS - FOLLICULAR phase (endomet prolif phase) d5-13
a.
-FSH peak = follicle development - - >
-oestradiol peak = body temp falls - - >
-LH peak - - > ovulation
b.
mucus = clear, acellular, low viscosity, ‘stretchy’ spinnbarkeit just b4 ovulation
- OVULATION d14
-Tertiary follicle - - > corpus LAD
#Luteum, Albicans, Degraded. - LUTEAL phase (Endomet SECRETORY phase)
a.
Corpus Luteum secrete Prog ->
Body temp RISES after ovulation
b.
If fertilisation NOT occur, corpus luteum degenerate and prog lvl fall) d15-28”
___________________
Oestrgoen secreted -> so body
TEMP FALL B4
Ovulation
Prog secreted by the Corpus Luteum -> so body
TEMP RISE After
Ovulation
Vulval ?? are commonly
@labium ?
ULCERATED
-Melanomas = usually ?.
Vulval ?? tend to be
WHITE/PLAQUE-like
NOTTTTT ulcerate
Vulval carcinoma = commonly
@labium MAJORA.
ULCERATED
Melanomas = usually PIGMENTED.
VIN =
WHITE/PLAQUE-like
NOTTTTT ulcerate
When to give anti-D @rhesusNEG mums:
If mum had Acne Rosacea, tx?
Preg + Pit.Versicolor, tx?
Abortion/Miscarriage >12w TransPlacentalHaemorrhageRisk(procedures) -procedures/abdo trauma/iuDeath Ectopic Evac after miscarriage
- I AM DE
Acne Rosacea tx = 8-12 weeks
mild/mod - ltd pap/pust =
-TOP: Ivermectin / Azelaic/Metro @preg/BFeed
mod/severe - ext pap/pust ± plaques
-PO Doxy / Erythro @preg/BFeed
______
Pityriasis versicolor Ix: skin scraping MCS @preg/BFeed = give Ketoncon Preg/BFeed CI: Selenium / Flucon/Itracon Tx: ASKIF
