Flashcards in Week 6 - Vaginal bleeding Deck (4)
M.F. is a 48-year-old Anglo- Australian. She rarely consults her GP but today she has booked a long appointment.
Take a history of this patient.
• Irregular light vaginal bleeding ‘spotting’ during last month.
• LMP 10/12, hot flushes, night sweats, feeling irritable.
• Bleeding started last week, red, no pain, no clots.
• Post coital bleeding few times.
• Last year, irregular k (peroids) every 3-8/52, bleeds 5-7/7, heavy.
- Irregular periods, heavy but now not much - only spotting.
• No periods since 12m, severe hot flushes - wakes her up.
• Dry vagina, uncomfortable sex, not interested.
• Breast, Cx smear, OCP*.. history check
• Obesity, hypertension x10y, DVT 10y ago.
• Site of bleeding.
• Character - volume.
• Alleviating factors.
• Timing - experienced it before? Constant or intermittent? How long are the episodes? Worse at a particular time? i.e. post coital
• Exacerbating factors.
• Associating symptoms i.e pain, discharge.
• Post menopause.
• Hot flushes, night sweats, irritable, difficulty sleeping.
• Uncomfortable/painful intercourse, irritable, dryness, itching, burning, soreness.
• Post menopausal bleeding. Fatigue, weight loss, anorexia, anaemia.
• Post coital bleeding. Fatigue, weight loss, anorexia.
• Weight loss, fatigue, loss of appetite, bloating, change in bowel habits, fluid in abdomen, indigestion or nausea, abdominal fullness/lump in abdomen.
• Past medical history of any cancer, reproductive problems?
• Any recent surgeries?
• Any regular medications? i.e. OCP
• Agent, reaction, treatment.
• E.g. Fluvax, pneumococcal.
• When was last pap smear/mammogram? Abnormal?
• Any family history of any cancer, reproductive problems?
• Living Arrangements
• Alcohol/recreational drugs
• Physical activity
• General - weight change, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum or wheeze?
• GI - vomiting, diarrhoea, indigestion, dysphagia, change in bowel habit, abdominal pain?
• UG - dysuria, polyuria, nocturia, urgency, incontinence, urine output?
• CNS - heachaches, nausea, trouble with hearing or vision?
• ENDO - heat/cold intolerance, swelling in throat/neck, polydipsia or polyphagia?
• HAEM - easy bruising, lumps in axilla, neck or groin?
• MSK - painful or stiff joints, muscle aches or rash?
Perform a physical examination on this patient.
• Wash hands.
• Name, patient preferred name.
• Explain procedure - pelvic exam 3 parts.
• Any questions?
• Any pain or discomfort - can stop at any time?
- May be some discomfort at some stages of the examination but I will warn you before and let me know if you would like to me to stop.
• Verbal consent.
• Ask patient if they need to go to bathroom - empty bladder.
• Ask patient if they would like a chaperone.
Pelvic exam - 3 parts
• Prepare for pap smear - open speculum and lube. Wash hands and glove. Ask patient to raise heel towards their bottom and place speculum and bluey on end of bed. Pick up speculum and apply lube (proximal end, not tips if doing pap smear). Ask patient to remove drape to stomach and relax knees apart.
• Inspect external genitalia
2. Speculum insertion to see cervix/take sample
• Tap thigh first.
• Spread labia - lower down
• Insert speculum all the way, open lever, close lock. Never remove hand from handle.
• Obtain specimens. First one 3-5 times clockwise, second one enter cervical os to halfway and rotate once. Smear each sample on slide and fix with spray. Close slide.
• Both fingers on handle and lever, unlock and remove first 5mm. Then remove one finger and release lever. Remove speculum slowly.
3. Bimanual - 2 gloved fingers/palpation
• Apply additional lube to fingers.
• Tap thigh first.
• Spread labia - lower down.
• Insert fingers and apply upwards pressure on cervix. Palpate with ulnar edge down stomach feeling for fundus.
• Move fingers laterally to either side of cervix (fornices) and palpate abdomen for ovaries.
• Remove fingers, give patient tissues and ask them to cover up/get dressed.
What investigations would you carry out on this patient?
• Urine dipstick/MCS.
• Beta HCG.
• FBC, BSL, TFTs.
• Pap smear.
• Bone mineral density test.