Spot Diagnosis Flashcards
Neonatal Jaundice
G6PD deficiency
G6PD deficiency how would this present in a new born
Neonatal Jaundice
A 24 year old woman, 7 days’ postpartum, presents to her GP because she has noticed foul smelling vaginal discharge. She is feeling a little feverish and on examination she has a temperature of 37.9°C, pulse 95bpm, BP 110/78. She is tender in the suprapubic area and her uterine fundus measures 1cm above the umbilicus. When asked about the birth she mentions that the doctors had to manually remove the placenta.
D - Endometritis
This lady is suffering from endometritis, probably due to manual removal of the placenta. There is subinvolution of the uterus and so it remains above the level of the umbilicus - normally the uterus will shrink down to the level of the umbilicus immediately after birth, by two weeks it should no longer be palpable above the pubic symphysis and by 6 weeks it should be back to normal. Endometritis commonly occurs 5-10 days postpartum and examples of risk factors are prolonged labour, prolonged rupture of membranes, retained products of conception, caesarean section and manual removal of the placenta. The uterus is tender on palpation and lochia may be offensive/purulent or normal. It is often polymicrobial but group A strep must be treated with particular caution due to the risk of fulminating sepsis.
A 26 year old woman, 8 days’ postpartum, presents to her GP due to suprapubic pain and dysuria for the last 2 days. During the birth she sustained a 3rd degree tear and for a few days after found it painful to urinate so she tried to go as little as possible. Her temperature is 37.4°C, pulse 78bpm and BP115/84
Urinary Tract Infection
This lady has a UTI due probably to inadequate pain management. She was not urinating regularly due to the pain leading to stagnant urine and so there is risk of infection. Other examples of UTI causes in the postpartum period are intermittent catheterisation and trauma to the bladder, which she probably had as she would have been catheterised immediately postop. Often no symptoms are present other than a fever. There is risk of pyelonephritis.
A 31 year old woman, 4 days’ postpartum, explains to the health visitor that she has been experiencing pain in both breasts for the last day and a half. She describes the breasts as feeling heavy, warm and more firm than normal. She began breast feeding after the birth but decided to stop after the second day due to finding it too difficult
Breast Engorgement
This lady has breast engorgement, which is common among women who are not breast feeding their baby or feeding has become interrupted for some reason. Both breasts typically feel heavy, painful, warm and firm and this is due to vascular and lymphatic stasis. It commonly occurs 2-4 days postpartum but it may accompany the start of expression of mature milk on days 4-5. Treatment involves wearing a tight fitting bra, ice-packs, analgesia and possibly bromocriptine, which suppresses prolactin production.
- A 35 year old lady, 9 days’ postpartum, presents to A+E following a collapse at home. Her husband reveals that she was feeling extremely short of breath beforehand and that she complained of a pain in her chest particularly on breathing in. When asked, he did not remember her complaining of any calf or thigh pain, swelling or redness
Pulmonary Embolus
This lady has had a PE. There is an increase in production of clotting factors during the 10 days postpartum increasing the risk of DVT and PE. DVTs commonly occur at 7-10 days compared to amniotic fluid embolism, which occurs at or just after birth. The DVT may be silent and so a history of calf pain, swelling or redness is not always available. DVT/PE is more common in those who have had a caesarean section, prolonged labour, women who are more immobile during the postpartum period, those with thrombophilias etc. Important points on management - PE treated the same as with non-pregnant women (with slightly higher heparin doses in pregnancy) but if a thromboembolic event occurs during pregnancy the heparin/lmwh is discontinued during labour and recommenced shortly after delivery due to the risk of bleeding. Heparin does not cross the placenta but warfarin is teratogenic. Effects on the fetus include frontal bossing, midface hypoplasia, saddle nose, cardiac defects, short stature, blindness and mental retardation. Warfarin should be avoided during the first trimester. It should also be avoided around the time of delivery.
A 19 year old girl presents to the sexual health clinic with frothy yellow vaginal discharge, vulval itching and pain on urination. She had a one night stand with a man she met in a bar four nights ago. On examination the discharge smells offensive and a strawberry cervix is visualised.
Trichomonas vaginalis
Trichomonas vaginalis is a flagellated protozoan, which can cause a green/yellow frothy discharge, offensive odour (fishy), dysuria, dyspareunia, vulval/urethral itching and rarely prostatitis in males. On examination a strawberry cervix may be seen in females and tests include wet preps of vaginal/urethral swabs - sample is mixed with some normal saline and then put onto a slide to be visualised under a microscope. The protozoan should be seen as it is motile and has special features. Treatment is with metronidazole. It increases the risk of HIV transmission in those who are exposed and there is an increased risk of IUGR and preterm delivery in women who are pregnant.
A 20 year old male presents to his GP with white, cloudy discharge from his penis, pain on urination and painful swollen testicles. He has a long-term girlfriend but their relationship has been strained recently and he fears they may be breaking up. She has no symptoms herself.
Chlamydia trachomatis
This man is most likely to have chlamydia trachomatis - due to the symptoms (including epididymo-orchitis). His partner has been having intercourse with another man who was infected and she has passed it on to him - she is not symptomatic because 90% of those infected are asymptomatic. Chlamydia trachomatis can cause intermenstrual/postcoital bleeding, dyspareunia and white cloudy vaginal discharge in women and in both - urethral discharge and dysuria. Proctitis is rare. Complications in women include pelvic inflammatory disease in 5-20% (resulting in increased risk of subfertility, ectopic pregnancy and also chronic pain), early miscarriage and premature birth if pregnant and transmission to the baby at birth resuting in trachoma (infectious eye disease) or pneumonia. Trachoma is contracted in other ways and is the most common cause of preventable blindness in the world. In men it results in fewer serious complications including epididymo-orchitis). In both it may cause reactive arthritis. Treat using doxycycline or azithromycin. Contact tracing is important.
An 18 year old girl presents to the sexual health clinic with a fishy smelling vaginal discharge but no other symptoms. She is beginning to find it embarrassing so wants some advice. The discharge is thin and white, there are clue cells noted on the gram-stain and the PH is 4.8.
Bacterial vaginosis
Bacterial Vaginosis is the most common cause of vaginitis and although it is not strictly an STI, it is more common in those who are sexually active. As the name suggests, it only affects women and it is caused by an overgrowth of anaerobic organisms replacing the normal commensals, lactobacilli. The patient may have fishy smelling vaginal discharge (particularly after sex or in immediate post-menstrual phase of cycle) but pruritis/soreness are often not present. 50% are asymptomatic.
BV is diagnosed using the Amsel criteria:
1) Thin, white, yellow, homogeneous discharge
2) Clue cells on microscopy
3) pH of vaginal fluid >4.5
4) Release of a fishy odour on adding alkali-10% potassium hydroxide (KOH) solution. At least three of the four criteria should be present for a confirmed diagnosis.It is treated if symptoms/pregnant/pre-op with metronidazole for 5-7 days.
A 27 year old male presents to his GP with a painless ulcer on the end of his penis. He said it has been there for 3 weeks. He has no other symptoms. He mentions that he slept with a prostitute around 4 weeks previous to this and is worried that he may have HIV. On examination the ulcer is shallow and he has lymphadenopathy.
Syphilis (Treponema palidum)
This man has primary syphilis and this is characterised by a primary chancre 3 weeks post-infection. It is a shallow/painless ulcer, which persists for 2-6 weeks and then spontaneously heals. It typically occurs at the site of entry, which may be the vulva, penis, anus or even mouth and lymphadenopathy is present. In the UK this infection is more prevalent in homosexual men and sex workers. It is diagnosed by taking a swab of the chancre and examining it under a microscope using the dark-field examination technique. For secondary syphilis onwards blood tests are taken to look for serology. This is negative up to 4 weeks post-infection. T. pallidum is highly penicillin sensitive.
A 24 year old student presents to her GP complaining of PV bleeding after intercourse. It is only small amounts, mainly spotting. She has no past medical history to date and has taken a pregnancy test recently, which was negative.
This is a history suggestive of cervical carcinoma. It typically presents with postcoital and/or intermenstrual bleeding. Pain is a late sign. It may just be an incidental finding on smear testing - screening is every 3 years from 25-50 years and every 5 years up to 65 years. 75% are squamous cell carcinoma and 25% adenocarcinoma. HPV is a risk factor - types 16+18 confer a 10x increase in risk.
A 33 year old woman presents to her GP complaining of heavy periods, which are also very painful. She has finally decided to seek medical advice. She has had no children and currently has no partner so is not taking any contraception. She had a tonsillectomy aged 9 years but there is no other past medical history. A smoothly enlarged uterus is found on bimanual examination.
Adenomyosis
Adenomyosis occurs in 20% of women and presents as dysmenorrhoea and menorrhagia. Examination reveals a smoothly enlarged uterus and investigations should include pelvic ultrasound +/- MRI. Hysterectomy is the definitive treatment.
A 57 year old postmenopausal lady who presents to her GP due to intermittent PV bleeding. It started off as small spots but has increased over the last couple of weeks resulting in the need to use about 6 sanitary towels per day. Her last period was 7 years ago. She has been on holiday in Spain and so has not had a chance to see anyone about it. She does not complain of any pain. Examination is unremarkable and the GP refers her to the gynaecological team. She has a transvaginal ultrasound, which reveals an endometrial thickness of 5cm.
Endometrial Cancer
This is likely to be endometrial carcinoma. It is predominantly a disease of postmenopausal women (75%) but can present before the menopause as intermenstrual bleeding (5% <40 yrs). Risk factors associated are those that involve an excess of oestrogen. The COCP is said to confer some protection. Investigations involved are endometrial biopsy (pipelle), transvaginal/pelvic ultrasound (endometrial thickness <4mm is considered normal but it doesnt completely rule the diagnosis out) and hysteroscopy/biopsy. Patients with low risk stage I disease i.e. well differentiated, only superficially invasive, may be treated with a total abdominal hysterectomy and bilateral salpingo-oophorectomy. Patients with high risk stage I disease i.e. poorly differentiated, deeply invasive, are treated as above with additionally, post-operative radiotherapy. Stage II disease is managed as for high risk stage I. Stages III and IV (rare) are managed on an individualised basis. Surgery is rarely used. Progestogen therapy may be helpful. Chemotherapy may occasionally be used in metastatic disease.
A 14 year old girl presents to her GP because she has not started her periods yet and is worried because all her friends have. However, she does get cyclical abdominal pain and on examination she has a palpable swelling in the suprapubic area and a bulging bluish swelling at the entrance to the vagina
Imperforate Hymen
This is a typical history of a young girl with an imperforate hymen. They may also have problems with micturition. It is often picked up earlier on in the neonate/infant but some may go undiagnosed up until menarche.
A 32 year old lady presents to her GP due to amenorrhoea. She had a baby around 18 months ago and has not had a period since. She thought it was normal but her friend told her to ask her GP. The baby was delivered via caesarean section and the delivery was complicated by a massive postpartum haemorrhage.
Sheehan’s Syndrome
This lady has had a pituitary infarct due to the postpartum haemorrhage. This is rare. Hypertrophy and hyperplasia of lactotrophs during pregnancy results in the enlargement of the anterior pituitary, without a corresponding increase in blood supply. The posterior pituitary is usually not affected due to its direct arterial supply.
