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sue



Points : 42144
Join date : 2013-12-26

PostSubject: AMC Clinical discussion-recalls   Thu Dec 26, 2013 1:19 pm

A 20 years old woman who has stopped her OCP three months ago, comes with a history of irregular light period and abdominal discomfort for the last few weeks. She has come in with her partner to ED. Yours task is to assess and discuss management.

Pain comes and go at LLQ for 2-3 weeks, 2 days ago pain started to be more severe, got pain killer from GP but pain is getting worse. Slight Vg bleeding, not Vg discharge. She stopped pills as she wants to get pregnant.




History: Hx of PID, LMP that was regular,

Have you done a pregnancy test?

Do you have any symptoms of pregnancy?




PE: LLQ pain, speculum: brownish fluid, PV: os closed, tender at cervix

Ix UPT, UA, U/S




Ddx 1. Ectopic pregnancy

Missed abortion (PE excluded)

UTI

Twist ovarian cyst

PID

Stop OCP

Appendicitis (if right)

Molar pregnancy




Mx 1. Medical treatment by methotrexate and follow up

Surgery

Post explore lap., can’t drive for 6 weeks.




(Hello, my name is ……., I’m a doctor for you today, what should I address you? As far as I know you have had vaginal bleeding with tummy pain. May I ask you some questions regarding to your problem? Do you want me to give you pain killer before we start?




Can you describe the bleeding for me? Is it bright red? (MC) Or dark red or brown? (EP) Is there any clot?

How many tampons or pads you use?

Can you tell exactly where the pain is?

What it feels like? Have you had the same pain before?

Did the pain started before bleeding? (EP) or you saw bleeding then felt pain? (MC)

What make pain better? Worse?

Do you have other symptoms? N/V? Diarrhea? Anorexia? Vg discharge?

How were your periods? Regular of irregular? When was you last period that was regular?

Why do you stop pills?

Have you done a pregnancy test? Do you think you are pregnant?

Have you ever had ectopic pregnancy before? Any miscarriage?

Any medical problems? Any medications?

I would like to examine you, are you comfortable with that?

Physical examination: general appearance, vital signs, cvs, respiratory system. Abdominal examination. PR examination, PV

Ask for the tests such as ; FBE, Urinalysis, ESR, U&E, B-HCG, transvaginal ultrasound, etc..







Miss……., now, we have had a good look at you tests that we ra>abdominal discomfort for the last few“Ectopic pregnancy” that is a pregnancy outside your womb, this can be in the tubes between your womb and ovaries as in most cases or inside the tummy, which is very rare. As the pregnancy is not in the usual place, it cannot continue to term. I understand that it is very disappointing for you but this condition can be more serious as it may bleed suddenly and can be life-threatening. To avoid this, we have to admit you in the hospital and refer you to obstetrician, she or he will make a definite diagnosis by laparoscopy or key hold surgery. This is the procure by which we insert a tube with lens within a small incision in your tummy, after we put you to sleep, so we could look at your womb and tubes.




The treatment of this condition, it can be done either by laparocopy to inject a medication (Methotrexate if sac is <3cm) or remove the pregnancy.




Another way is by operation to remove the production of pregnancy. Both ways of treatment, the doctor will try to preserve the tube, but if it Ix UPT, UA, U/S




Ddx 1. Ectopic pregnancy

Missed abortion (PE excluded)

UTI

Twist ovarian cyst

PID

Stop OCP

Appendicitis (if right)

Molar pregnancy




Mx 1. Medical treatment by methotrexate and follow up

Surgery

Post explore lap., can’t drive for 6 weeks.




(Hello, my name is ……., I’m a doctor for you today, what should I address you? As far as I know you have had vaginal bleeding with tummy pain. May I ask you some questions regarding to your problem? Do you want me to give you pain killer before we start?




Can you describe the bleeding for me? Is it bright red? (MC) Or dark red or brown? (EP) Is there any clot?

How many tampons or pads you use?

Can you tell exactly where the pain is?

What it feels like? Have you had the same pain before?

Did the pain started before bleeding? (EP) or you saw bleeding then felt pain? (MC)

What make pain better? Worse?

Do you have other symptoms? N/V? Diarrhea? Anorexia? Vg discharge?

How were your periods? Regular of irregular? When was you last period that was regular?

Why do you stop pills?

Have you done a pregnancy test? Do you think you are pregnant?

Have you ever had ectopic pregnancy before? Any miscarriage?

Any medical problems? Any medications?

I would like to examine you, are you comfortable with that?

Physical examination: general appearance, vital signs, cvs, respiratory system. Abdominal examination. PR examination, PV

Ask for the tests such as ; FBE, Urinalysis, ESR, U&E, B-HCG, transvaginal ultrasound, etc..







Miss……., now, we have had a good look at you tests that we ra>abdominal discomfort for the last fewis damaged by this condition, then the only way to deal with it is to remove the tube.




Is everything clear? Do you want me to repeat anything for you?

Are there any questions that you would like to ask me?

You will remain for few days in the hospital (2-3 days).




Regarding the further risk: ectopic pregnancy. Subfetility.

Opportunity: PAP smear. STD screening.



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