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Should parents have the right to refuse vaccinations for their children based on personal beliefs, even if it endangers public health?

Does the rise in screen time and technology usage contribute to ADHD symptoms, and if so, how should we adjust our interventions?

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1. a) Egyik betege azzal a problémával keresi fel Önt, hogy már két hete késik a menstruációja és lehet, hogy terhes. Kérdezze meg, hogy:

-Pontosan mikor volt az utolsó menstruációja

- Használ e valamilyen fogamzásgátlást

-Volt e már terhes

-Hányszor volt terhes és hogy volt e valami probléma az előző terhességei során

-Ha terhes szeretné e megtartani a gyermeket

2.
Kérdezze meg betegét:

-          mikor volt az utolsó menstruációja?

-          hányszor volt terhes, hogyan szült?

-          használ-e valamilyen fogamzásgátlót?

-          volt-e mostanában ultrahangon?

-          mikor volt utoljára rákszűrésen?

-          Kérje meg, hogy vetkőzzön le és feküdjön fel az asztalra.

-          Kérje meg, hogy lazítsa el magát, tájékoztassa a beteget, hogy a kenetvizsgálat eredményét két hét múlva kapja meg.

3.

Kérdezze ki a beteget:

-          ez az első terhessége?

-          hányszor volt terhes?

-          volt-e vetélése vagy abortusza?

-          volt-e valamilyen problémája a terhesség alatt?

-          a gyermekei a várt időben születtek?

-          szoptatta-e a gyermekeit, mennyi ideig?

-          Kérje meg, hogy feküdjön fel a vizsgálóasztalra, lazítsa el magát.

-          Kérdezze meg betegét:

-          mikor volt az utolsó menstruációja?

-          hányszor volt terhes, hogyan szült?

-          használ-e valamilyen fogamzásgátlót?

-          volt-e mostanában ultrahangon?

-          mikor volt utoljára rákszűrésen?

-          Kérje meg, hogy vetkőzzön le és feküdjön fel az asztalra.

-          Kérje meg, hogy lazítsa el magát, tájékoztassa a beteget, hogy a kenetvizsgálat eredményét két hét múlva kapja meg.

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How to take a medical history (Calgary Cambridge Guide)

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SOCRATES - OSCE Guide #geekymedics #osce #geekymedics #clinicalskills #medstudent #medschool

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Doctors:

Presenting complaint

History of presenting complaint using SOCRATES (site, onset, character, radiation, associating symptoms, time course, elevaiting or reliving factors and severity)

Past medical, drug history and allergies

Family history.

Concerns, ideas and expectations (what are your patients ideas, concerns and expectations from this consultation)

Summering and checking for understanding

Patients:

UROLOGY

Name: Albert Clower

Age: 37 years old

Job: Internet entrepreneur

Present complaint; left scrotal lump

Whilst in the shower a week ago you noticed that one of your testicles seemed bigger than the other. You weren’t quite sure if they had always been like this, so you asked your girlfriend who is a qualified nurse to examine you. She was concerned and told you to go to the GP.

The lump is not painful, but you have noticed a kind of dragging sensation.

The overlying skin feels normal. You remember that a couple of weeks ago you were kicked in the groin whilst playing rugby and are unsure of this is what started it. You think you might have put on a bit of weight recently as your girlfriend has been making fun of your man breasts.

You are not having any sexual problems. You have not experienced any abdominal pain or other gastrointestinal symptoms or urinary symptoms. You feel well in yourself.

Past medical history

As a child you had an operation to correct an undescended left testicle. As a teenager you were treated for attention hyperactivity disorder (ADHD).

Smoking history

You smoke socially about 20 per week. You indulge in binge drinking at weekends but would rather not tell the doctor exactly how much because you are embarrassed you will get told off. You live with your girlfriend of two years and your relationship is going well.

Family history; Your father suffered with type one diabetes and your mother had breast cancer.

GYNAECOLOGY

Case of Uterine Fibroid:

A 28 year old lady with 5 years history of recurrent lower abdominal pains which became worse with spasms and increased pain score of 10/10 requiring injections of  (NSAID)  and Hyoscine for relief.

The pain does not radiate and not associated with vomiting, no fever and no loose motions.

The lower abdominal colicky pain is not associated with her menstrual flows. She has normal menstrual flow.

She was reviewed by a general practitioner and on examination found a healthy young woman with a lower abdominal mass with FUNDAL HEIGHT at the umbilical level equal to 20 weeks size gestation and requested for an evaluation by ultrasonography

The ultrasound scan revealed she has huge fibroid located on the anterior portion of the Uterus attached to the uterus by a stalk just covered by the uterine ligaments.

The diagnosis of fibroid with twisted stalk was made.

Patient had been counseled for treatment with surgical intervention. she was counseled for Laparoscopic endoscopy removal with a mutilator.

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Lesson Plan - Asking about current symptoms

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- gallstone

- appendicitis

- kidney stone

- urinary tract infection

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Start studying Paediatrics. Learn vocabulary, terms, and more with flashcards, games, and other study tools.

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Patient History Taking: Tutorial Overview of hospital admissions questions in clinic (1/3)

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The security system for this website has been triggered. Completing the challenge below proves you are a human and gives you temporary access.

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How to Recognize the Symptoms of Appendicitis

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Watch more How to Handle a Medical Problem videos: http://www.howcast.com/videos/347260-How-to-Recognize-the-Symptoms-of-Appendicitis Appendicitis occurs when your appendix becomes inflamed and fills with pus. Watch out for the symptoms. Step 1: Know that pain may vary Know that pain may vary depending on the person's age, and the position of the appendix.

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SOCRATES system of questions:
https://geekymedics.com/headache-history-taking/

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A Profex felkészítő könyveket személyesen megvásárolhatják a PTE ÁOK Könyvesboltjában (Pécs, Szigeti út 12. Alagsor) vagy megrendelhető a pecsmedicina gmail [dot] com e-mail címen utánvétellel (utánvételi díj:1500 Ft)

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A Profex felkészítő könyveket személyesen megvásárolhatják a PTE ÁOK Könyvesboltjában (Pécs, Szigeti út 12. Alagsor) vagy megrendelhető a pecsmedicina gmail [dot] com e-mail címen utánvétellel (utánvételi díj:1500 Ft)

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Urinary Tract Infections (UTIs): Most Commonly Asked Questions - Urology Care Foundation

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Signs and Symptoms of Gallstones from Mr Rhys Thomas

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History taking: example: patient with chest pain

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History taking: example: patient with chest pain

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Chest Pain - OSCE history taking for Medical Students | Drs Manual

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Új (2020) PROFEX orvosi szaknyelvre felkészítő könyvek angolból!

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What are the symptoms of a urinary tract infection?

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Sudden infant death syndrome (SIDS) - causes, symptoms, diagnosis, treatment, pathology

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Új felkészítő könyv - Szituációs segédanyag

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Szeptember 9-től megvásárolható a Medicina Könyvesboltban

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Improve Article 👀

The ability to take a gynaecological history is often assessed in OSCEs. This guide provides a structured approach to taking a gynaecological history in an OSCE setting.

Opening the consultation

Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

Confirm the patient's name and date of birth.

Explain that you'd like to take a history from the patient.

Gain consent to proceed with history taking.

Key initial gynaecological details

Gravity and parity

Gravidity (G) is the number of times a woman has been pregnant, regardless of the outcome (e.g. G2).
Parity (P) is the total number of pregnancies carried over the threshold of viability (typically 24 + 0 weeks).

General communication skills

It is important you do not forget the general communication skills which are relevant to all patient encounters. Demonstrating these skills will ensure your consultation remains patient-centred and not checklist-like (just because you're running through a checklist in your head doesn't mean this has to be obvious to the patient).

Some general communication skills which apply to all patient consultations include:

Demonstrating empathy in response to patient cues: both verbal and non-verbal.

Active listening: through body language and your verbal responses to what the patient has said.

An appropriate level of eye contact throughout the consultation.

Open, relaxed, yet professional body language (e.g. uncrossed legs and arms, leaning slightly forward in the chair).

Making sure not to interrupt the patient throughout the consultation.

Establishing rapport (e.g. asking the patient how they are and offering them a seat).

Signposting: this involves explaining to the patient what you have discussed so far and what you plan to discuss next.

Summarising at regular intervals.

You might also be interested in our OSCE Flashcard Collection which contains over 2000 flashcards that cover clinical examination, procedures, communication skills and data interpretation.

Presenting complaint

Provide the patient with enough time to answer and avoid interrupting them.

Open vs closed questions

History taking typically involves a combination of open and closed questions. Open questions are effective at the start of consultations, allowing the patient to tell you what has happened in their own words. Closed questions can allow you to explore the symptoms mentioned by the patient in more detail to gain a better understanding of their presentation. Closed questions can also be used to identify relevant risk factors and narrow the differential diagnosis.

History of presenting complaint

Once the patient has had time to communicate their presenting complaint, you should then begin to explore the issue with further open and closed questions.

SOCRATES

The SOCRATES acronym is a useful tool for exploring each of the patient's presenting symptoms in more detail. It is most commonly used to explore pain, but it can be applied to other symptoms, although some of the elements of SOCRATES may not be relevant to all symptoms.

Site

Ask about the location of the symptom:

Onset

Clarify how and when the symptom developed:

"Did the pain come on suddenly or gradually?"

"When did the pain first start?"

"How long have you been experiencing the pain?"

Character

Ask about the specific characteristics of the symptom:

Radiation

Ask if the symptom moves anywhere else:

"Does the pain spread elsewhere?" (e.g. shoulder tip pain in ectopic pregnancy)

Associated symptoms

Ask if there are other symptoms which are associated with the primary symptom:

"Are there any other symptoms that seem associated with the pain?" (e.g. patients presenting with an ectopic pregnancy may have associated nausea and vomiting)

Time course

Clarify how the symptom has changed over time:

"How has the pain changed over time?"

Ask if the symptom has any relationship to the menstrual cycle:

"Have you noticed if this symptom is worse at a particular time in the month?"

Exacerbating or relieving factors

Ask if anything makes the symptom worse or better:

Severity

Assess the severity of the symptom by asking the patient to grade it on a scale of 0-10:

"On a scale of 0-10, how severe is the pain, if 0 is no pain and 10 is the worst pain you've ever experienced?"

Ask the patient if the symptom is having a significant impact on their day to day life:

"How is the pain impacting your daily life?"

Gynaecological symptoms

We have included a focused list of the key symptoms to ask about when taking a gynaecological history, followed by some background information on each, should you want to know a little more.

Summary of key gynaecological symptoms

Key gynaecology symptoms to ask about include:

Abdominal and pelvic pain: causes include ectopic pregnancy, ruptured ovarian cyst, endometriosis, pelvic inflammatory disease and ovarian torsion.

Post-coital vaginal bleeding: vaginal bleeding occurring after sexual intercourse. Causes include cervical ectropion, cervical cancer, gonorrhoea, chlamydia and vaginitis.

Intermenstrual vaginal bleeding: vaginal bleeding occurring between menstrual periods. Causes include contraception (e.g. Mirena coil), ovulation, miscarriage, gonorrhoea, chlamydia, uterine fibroids, perimenopause and malignancy (e.g. uterine cancer, cervical cancer, vaginal cancer).

Post-menopausal bleeding: bleeding that occurs after the menopause. Causes include vaginal atrophy, hormone replacement therapy and malignancy (e.g. uterine cancer, cervical cancer and vaginal cancer).

Abnormal vaginal discharge: causes include bacterial vaginosis, chlamydia and gonorrhoea.

Dyspareunia: causes include endometriosis, vaginal atrophy, gonorrhoea and chlamydia.

Vulval skin changes and itching: causes include vaginal atrophy, vaginal thrush, gonorrhoea and lichen sclerosus.

Systemic symptoms: fatigue (e.g. anaemia), fever (e.g. pelvic inflammatory disease) and weight loss (e.g. malignancy).

Vaginal discharge

Volume: "Have you noticed any change in the amount of vaginal discharge?"

Colour (e.g. green, yellow or blood-stained): "Have you noticed any change in the colour of your discharge?"

Consistency (e.g. thickened or watery): "Have you noticed that your discharge has become more watery or thickened recently?"

Smell: "Have you noticed any change in the smell of the vaginal discharge?"

Gonorrhoea and chlamydia may present with abnormal vaginal discharge.

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

Trichomonas vaginalis typically presents with yellow frothy discharge with associated vaginal itching and irritation.

Dyspareunia

The location of the pain varies between patients:

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

Deep dyspareunia: pain deep within the pelvis.

You should clarify:

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)

Vulval skin changes and itching

Vulval skin changes and itching are common symptoms which can have several underlying causes:

Infections such as candida (thrush), bacterial vaginosis and sexually transmitted infections (e.g. gonorrhoea).

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

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

Other symptoms

Urinary symptoms such as frequency, urgency and dysuria can be relevant to gynaecological problems (e.g. dyspareunia, vaginal prolapse, pelvic pain).

Bowel symptoms such as a change in bowel habit or pain during defecation can be associated with endometriosis.

Fever may be associated with pelvic inflammatory disease.

Fatigue is a non-specific symptom, but its presence may indicate anaemia or malignancy.

Unintentional weight loss is a concerning feature that may indicate underlying malignancy.

Abdominal distension is often a benign symptom, however, it can be associated with serious underlying pathology such as ovarian cancer with ascites.

Ideas, concerns and expectations

It can be challenging to use the ICE structure in a way that sounds natural in your consultation, but we have provided several examples for each of the three areas below.

Explore the patient's ideas about the current issue:

"What do you think the problem is?"

"What are your thoughts about what is happening?"

"It's clear that you've given this a lot of thought and it would be helpful to hear what you think might be going on."

Explore the patient's current concerns:

"Is there anything, in particular, that's worrying you?"

"What's your number one concern regarding this problem at the moment?"

"What's the worst thing you were thinking it might be?"

Ask what the patient hopes to gain from the consultation:

"What were you hoping I'd be able to do for you today?"

"What would ideally need to happen for you to feel today's consultation was a success?"

"What do you think might be the best plan of action?"

Summarising

Signposting

Signposting examples

Explain what you have covered so far: "Ok, so we've talked about your symptoms, your concerns and what you're hoping we achieve today."

What you plan to cover next: "Next I'd like to quickly screen for any other symptoms and then we'll discuss your menstrual cycle."

Systemic enquiry

A systemic enquiry involves performing a brief screen for symptoms in other body systems which may or may not be relevant to the primary presenting complaint. A systemic enquiry may also identify symptoms that the patient has forgotten to mention in the presenting complaint.

Deciding on which symptoms to ask about depends on the presenting complaint and your level of experience.

Systemic: fatigue (e.g. anaemia), fever (e.g. pelvic inflammatory disease, urinary tract infection), weight loss (e.g. endometrial cancer)

Respiratory: dyspnoea (e.g. anaemia), haemoptysis (e.g. endometriosis)

Gastrointestinal: abdominal pain (e.g. ectopic pregnancy, dysmenorrhoea), painful defecation (e.g. endometriosis), abdominal bloating (e.g. ovarian cancer)

Genitourinary: urinary frequency, dysuria and urgency (e.g. urinary tract infection), abnormal vaginal discharge (e.g. vaginal candidiasis, gonorrhoea)

Musculoskeletal: shoulder tip pain (e.g. ectopic pregnancy)

Dermatological: white patches on the vulva/vagina associated with pruritis (e.g. lichen sclerosus)

Menstrual history

A menstrual history involves exploring the characteristics of the patient's menstrual cycle.

Duration

Ask the patient about the duration of their periods:

"How long do your periods typically last?"

The average duration of menstruation is 5 days, with more than 7 days considered prolonged.

Frequency

Ask the patient about the frequency of their periods:

Periods typically occur every 28 days, however, there is significant variation between individuals (21-40 days).

Menstrual blood flow

Ask the patient about the volume of their periods:

"Are your current periods heavier than your usual periods?"

"Have you been flooding through sanitary towels?"

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

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

The average menstrual blood loss is approximately 40mls (8 teaspoons). Heavy menstrual blood loss is defined as more than 80mls (16 teaspoons) or having periods that last longer than 7 days.

The definition of what is a "heavy period" compared to a "normal period" is highly subjective, therefore you should ask the woman how the current periods compare to her usual loss. If the volume of bleeding is impacting on the woman's day to day life, it is significant.

Menstrual pain (dysmenorrhoea)

Ask the patient if their periods are particularly painful:

It is common for women to experience abdominal and pelvic pain when menstruating. Menstrual pain can sometimes be severe and have a significant impact on a woman's quality of life. Use the SOCRATES acronym shown above to further explore menstrual pain.

Date of last menstrual period

Ask the patient when the first day of their last menstrual period was:

"What date was the first day of your last menstrual period?"

If the patient's period is late, consider performing a pregnancy test, particularly in the context of abdominal pain (to rule out ectopic pregnancy).

Age at menarche

Ask the patient how old they were when they started having periods:

"At what age did you start having periods?"

Early menarche is associated with an increased risk of breast cancer and cardiovascular disease.

Menopause (if relevant)

Ask the patient how old they were when they went through the menopause:

"Do you remember how old you were when you went through the menopause?"

If the patient is perimenopausal ask about symptoms such as hot flushes and vaginal dryness.

Contraception

Clarify the type of contraception currently used:

Combined contraceptives: combined oral contraceptive pill and the contraceptive patch.

Progesterone only pill (POP)

Depot injection (progesterone)

Long-acting reversible contraceptives (LARCs): hormonal coil, implant and copper coil.

Barrier methods

It is useful to be aware of what the patient has previously tried, particularly if considering a change to their current choice of contraception.

Reproductive plans

You should ask the patient if they are considering having children in the future (or are currently trying to fall pregnant).

This is important to know when considering treatments for their gynaecological issue (e.g. you wouldn't suggest endometrial ablation or hysterectomy for menorrhagia if the patient was planning for a future pregnancy).

Past gynaecological history

It is important to ask about a woman's previous gynaecological history, as this may influence further investigations and management options.

Gynaecological conditions

Ask if the patient has previously had any gynaecological problems:

Ectopic pregnancy

Sexually transmitted infections

Endometriosis

Bartholin's cyst

Cervical ectropion

Malignancy (e.g. cervical, endometrial, ovarian)

Gynaecological surgery or procedures

Ask the patient if they've previously undergone any surgery or procedures in the past such as:

Abdominal or pelvic surgery

Caesarean section

Loop excision of the transitional zone (LETZ)

Vaginal prolapse repair

Hysterectomy

Cervical screening

Clarify the patient's cervical screening history:

Confirm the date and result of the last cervical screening test.

Ask if the patient received any treatment (if the cervical screening test was abnormal) and ask if follow up is in place.

Ask if the patient has been vaccinated against HPV.

Past medical history

It is important to ask about the patient's non-gynaecological medical history, as these conditions may impact the gynaecological problem and may themselves be impacted by or prevent the use of specific gynaecological treatments.

Ask if the patient has any medical conditions:

If the patient does have a medical condition, you should gather more details to assess how well controlled the disease is and what treatment(s) the patient is receiving. It is also important to ask about any complications associated with the condition including hospital admissions.

Allergies

It's essential to clarify any allergies the patient may have and to document these clearly in the notes, including the type of allergic reaction the patient experienced.

Examples of medical conditions relevant to gynaecological presentations

Migraine with aura: oestrogen containing medications (e.g. combined oral contraceptive) would be contraindicated.

Previous venous thromboembolism (VTE): oestrogen containing medications would be contraindicated.

Breast cancer (current or previous): use of oestrogen containing medications would be usually be contraindicated or require specialist input before being commenced.

Bleeding disorders (e.g. Von Willebrand's) would be relevant if a patient presented with heavy vaginal bleeding.

Obstetric history

It is important to take a brief obstetric history as part of a gynaecological assessment, as it may be relevant to the patient's presentation. This is less detailed than a focused obstetric history.

Gravidity and parity

Gravidity is the number of times a woman has been pregnant, regardless of the outcome.

Parity is the total number of pregnancies carried over the threshold of viability (typically 24 + 0 weeks).

Current pregnancy

Gather key details about the patient's current pregnancy (if relevant):

Gestation

Symptoms associated with pregnancy (e.g. nausea, vomiting, back pain)

Complications (e.g. pre-eclampsia, cervical neck incompetence)

Recent scans results

Previous pregnancies

Gather key details about the patient's previous pregnancies (if relevant):

Age of children

Birth weight

Mode of delivery

Complications in the antenatal, perinatal, postnatal period

If relevant, ask if the patient is currently breastfeeding, as this is a contraindication to some types of contraceptives (e.g. combined oral contraceptive)

Drug history

"Are you currently taking any prescribed medications or over-the-counter treatments?"

If the patient is taking prescribed or over the counter medications, document the medication name, dose, frequency, form and route.

Ask the patient if they're currently experiencing any side effects from their medication:

"Have you noticed any side effects from the medication you currently take?"

St John's Wort increases the metabolism of the COCP reducing its effectiveness.

Antibiotics may cause secondary vaginal thrush.

Duration of use

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

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

Type of treatment (e.g. combined or oestrogen-only)

Medication examples

Medications commonly prescribed to patients with gynaecological disease include:

Tranexamic acid (e.g. to manage menorrhagia)

Contraceptives (e.g. COCP, POP)

Hormone replacement therapy (e.g. combined or oestrogen-only)

NSAIDs (e.g. to manage dysmenorrhoea)

GnRH analogues (e.g. to manage endometriosis)

Family history

"Is there any history of cancer of the womb, ovaries or breasts in your close relatives?" (e.g. BRCA gene)

Ask the patient if there is any family history of bleeding disorders as menorrhagia may be the first presenting symptom of an inherited bleeding disorder such as Von Willebrand's disease:

"Is there any history of bleeding disorders in your family?" (menorrhagia can be the first presenting symptom of an inherited bleeding disorder e.g. Von Willebrand disease)

Ask the patient if there is any family history of blood clots. Patients who have a significant family history of VTE in a first-degree relative (particularly if they were less than 45 when it developed) may be at increased risk of VTE and therefore medications such as combined oral contraceptives may be contraindicated:

"Have any of your close family members had blood clots in the past?"

Social history

Understanding the social context of a patient is absolutely key to building a complete picture of their health.

General social context

Explore the patient's general social context including:

the type of accommodation they currently reside in (e.g. house, bungalow) and if there are any adaptations to assist them (e.g. stairlift)

who else the patient lives with and their personal support network

what tasks they are able to carry out independently and what they require assistance with (e.g. self-hygiene, housework, food shopping)

Smoking

Record the patient's smoking history, including the type and amount of tobacco used.

Consider if medications such as the COCP are contraindicated because of the patients smoking status:

If smoking more than 40 cigarettes a day, the COCP would be contraindicated.

If over 35-years-old and smoking more than 15 cigarettes a day, the COCP would be contraindicated.

Offer smoking cessation services (see our smoking cessation guide for more details).

Alcohol

Record the frequency, type and volume of alcohol consumed on a weekly basis (see our alcohol history taking guide for more information).

Offer support services to assist the patient in reducing their alcohol intake.

Recreational drug use

Ask the patient if they use recreational drugs and if so determine the type of drugs used and their frequency of use.

If recreational drug use is identified, patients can be offered input from drug cessation services.

Diet and weight

Ask about the patient's current weight:

Obesity significantly increases the risk of developing malignancy and is also associated with polycystic ovarian syndrome.

Anorexia can result in oligomenorrhoea (infrequent periods) or amenorrhoea (absence of menstruation).

A raised BMI may be a contraindication to some treatments, including combined oral contraceptives.

Occupation

Ask about the patient's current occupation and if they are managing ok at work with their current symptoms.

Closing the consultation

Ask the patient if they have any questions or concerns that have not been addressed.

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.

Reviewer

Dr Venkatesh Subramanian
Obstetrics & Gynaecology Registrar in London

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Gynaecological History Taking | OSCE Guide | Geeky Medics

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A guide to taking a gynaecological history (including menstrual cycle and contraceptives) in an OSCE setting with an included OSCE checklist.

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Cystitis is an inflammation of the bladder. Inflammation is where part of your body becomes irritated, red, or swollen.

In most cases, the cause of cystitis is a urinary tract infection (UTI). A UTI happens when bacteria enter the bladder or urethra and begin to multiply.

This could also happen with naturally occurring bacteria in your body that become imbalanced. These bacteria lead to an infection and cause inflammation.

Cystitis does not always come from an infection. For example, certain medicines and hygiene products can also cause inflammation.

Treatment for cystitis depends on its underlying cause. Most cases of cystitis are acute, or occur suddenly. Interstitial cystitis cases are chronic, or long term.

Cystitis can affect anyone, but it occurs most often in women.

Symptoms of cystitis can include:

frequent urge to urinate

urge to urinate after you've emptied your bladder

cloudy or strong-smelling urine

a low fever if in combination with a UTI

blood in your urine

pain during sexual intercourse

sensations of pressure or bladder fullness

cramping in your abdomen or back

If a bladder infection spreads to your kidneys, it can become a serious health issue. In addition to the symptoms listed above, symptoms of a kidney infection include:

Also, two additional symptoms, fever or blood in the urine, aren't symptoms of cystitis in themselves. However, they may occur in association with the other symptoms of a kidney infection.

Seek immediate medical attention if you think you have a kidney infection.

The type of cystitis depends on its cause. Possible causes of cystitis include:

urinary tract infection (UTI)

taking certain drugs

exposure to radiation

ongoing use of a catheter

irritating hygiene products

Cystitis can be either acute or interstitial. Acute cystitis is a case of cystitis that occurs suddenly. Interstitial cystitis (IC) is a chronic or long-term case of cystitis that affects multiple layers of bladder tissue.

Both acute and interstitial cystitis have a range of possible causes. The cause of cystitis determines the type. The following are types of cystitis:

Bacterial cystitis

Bacterial cystitis occurs when bacteria enter your urethra or bladder and cause an infection. This can also result when normally growing bacteria in your body becomes imbalanced. The infection leads to cystitis, or inflammation in your bladder.

It is important to treat a bladder infection. If the infection spreads you your kidneys it can become a serious health issue.

Drug-induced cystitis

Certain medications can cause your bladder to become inflamed. Medicines pass through your body, and eventually exit through your urinary system. Some medications can irritate your bladder as they exit your body.

For example, the chemotherapy drugs cyclophosphamide and ifosfamide can cause cystitis.

Radiation cystitis

Radiation therapy is used to kill cancer cells and shrink tumors, but it can also damage healthy cells and tissues. Radiation treatment in the pelvic area can cause your bladder to become inflamed.

Foreign body cystitis

Ongoing use of a catheter, a tube used to facilitate the release of urine from the bladder, can increase your risk of bacterial infection, and damage tissues in the urinary tract. Both bacteria and damaged tissues can cause inflammation.

Chemical cystitis

Certain hygiene products can irritate your bladder. Products that may cause cystitis include:

spermicidal jellies

use of a diaphragm with spermicide

feminine hygiene sprays

chemicals from a bubble bath

Cystitis associated with other conditions

Sometimes cystitis occurs as a symptom of other medical conditions, such as:

Cystitis is more common in women due to their shorter urethra. However, both men and women are at risk for this condition.

Women may be at a higher risk for cystitis if they:

are sexually active

are pregnant

use diaphragms with spermicide

have experienced menopause

are utilizing irritating personal hygiene products

Men may be at a higher risk for cystitis if they have an enlarged prostate due to retention of urine in the bladder.

Risk factors common to men and women include:

current or recent urinary tract infection (UTI)

radiation therapy

chemotherapy

use of a catheter

diabetes

kidney stones

HIV

spinal injuries

interference with the flow of urine

There are a few different ways to diagnose cystitis. Your doctor may ask for a urine sample to determine the cause of your cystitis and check for a UTI. Your doctor may also perform cystoscopy, or an imaging test to determine the cause of your symptoms.

Cystoscopy

In a cystoscopy, a doctor inspects your bladder with a thin tube that has a camera and light attached. Doctors can use the cystoscope to collect a biopsy of bladder tissue if needed. A biopsy is a small tissue sample used for further testing.

Imaging test

Imaging tests are not often necessary, but they can be helpful in diagnosing cystitis. An X-ray or ultrasound can help rule out other causes of cystitis, such as a structural issue or tumor.

Medications

Antibiotics are a common treatment for bacterial cystitis. Interstitial cystitis can also be treated with medication. Medication for interstitial cystitis depends on its cause.

Surgeries

Surgery can treat cystitis, but it may not be the doctor's first choice. It is more common for chronic conditions. Sometimes surgery can repair a structural issue.

Home care

Home care treatments can help ease discomfort. Common methods are:

applying heating pads to your abdomen or back

over-the-counter pain relievers, such as ibuprofen and acetaminophen

sitz baths to cleanse the pelvic area

Sometimes you can manage cystitis symptoms at home, without taking medication. These should not replace antibiotics if they are needed to treat a UTI. Common home therapy methods are:

cranberry juice or tablets

drinking lots of fluids

wearing cotton underwear and loose fitting clothes

avoiding any food or beverages that you suspect make your symptoms worse

Alternative therapies

There are other nonsurgical procedures for cystitis. Sometimes stretching the bladder with water or gas can temporarily improve symptoms.

Nerve stimulation can lower the frequency of bathroom visits and may relieve pelvic pain. And for cystitis caused by radiation or chemotherapy, medication can help flush the bladder.

The outlook of cystitis is dependent on the cause of the symptoms. In general, the outlook for cystitis is good. However, it is important to treat the underlying condition as soon as possible. If you experience symptoms of cystitis, it's best to contact a doctor.

While recovering from cystitis, you should:

drink plenty of fluids

avoid caffeinated drinks, as these can irritate your bladder

urinate frequently, rather than "holding it"

wear cotton underwear and loose fitting clothes

Women should wipe from front to back after a bowel movement to prevent the spread of bacteria from feces. In addition, taking showers instead of baths may also help. Make sure to wash skin gently in the genital area.

Women should empty their bladders after sexual intercourse, and drink water. Finally, avoid any products that irritate the area.

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Cystitis: Symptoms, Causes, and Treatments

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Cystitis is an inflammation of the bladder. Inflammation is where part of your body becomes irritated, red, or swollen. In most cases, the cause of cystitis is a urinary tract infection (UTI). A UTI happens when bacteria enter the bladder or urethra and begin to multiply.

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​​Jaundice is a common condition that occurs in more than half of all full-term newborns and even more in pre-mature infants. Jaundice is recognized when a baby's skin and whites of their eyes appear yellow. Babies develop this condition when they are unable to get rid of old red blood cells while replacing them with new ones. When the red blood cells break down, a substance called bilirubin is produced. Jaundice results when too much bilirubin accumulates in the body. This is what causes the yellow shading of the skin. In most cases, jaundice is harmless and easily treated.

Signs of Jaundice

To identify jaundice, it is best to examine your baby under natural light. If you press on your baby's skin under natural light and notice an underlying yellow tone (before the area turns pink again), jaundice may be present.

Contact your physician immediately if your baby develops the following warning signs of severe jaundice:

Dehydration (no urine passed in more than 8 hours, dry mouth, poor feeding)

Yellowing of the skin and eyes within first 24 hours of life

Yellow shading becomes a deep yellow or orange color

Fever over 100.4°F

Treating Jaundice

Your doctor may instruct you to treat jaundice by:

Feeding your baby at least every two to three hours to help increase bowel movements, as this is the primary way to clear bilirubin

Using phototherapy (blue light that breaks down bilirubin in the skin). In many cases, this can be done in the comfort of your home, by way of a "bili-blanket" or a set of lights shining down on the baby.

Consult with your physician during office hours if your baby:

Has less than three good-sized bowel movements per day

Has less than six wet diapers per day

Does not get rid of the jaundice by day 14

If you suspect your baby has jaundice, consult with your physician. A simple blood test will measure your baby's bilirubin levels to determine whether or not jaundice is present. As always, call your physician if you have any other questions or concerns.

​

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​​Jaundice is a common condition that occurs in more than half of all full-term newborns and even more in pre-mature infants. Jaundice is recognized when a baby's skin and whites of their eyes appear yellow. Babies develop this condition when they are unable to get rid of old red blood cells while replacing them with new ones.

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Clinical case presentation

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Clinical Case Presentation: Adult/ Inpatient/ Bedside  P3-2 Group 14

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Toxemia /preeclamsia

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7 Symptoms Every Pregnant Woman Should Know

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-pass a kidney stone
-stones can form in weeks or months
-stones can grow very large and can block the kidney, ureter, or bladder
-you may not have symptoms until the stone move down the ureter tubes
-pain in the side of your tummy/abdomen or groin – men may have pain in their testicles
-cloudy and bad-smelling urine
-medications that will help the stone pass
-drink a lot of water to produce a large enough amount of urine to help bring the stone out

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Renal calculi; Nephrolithiasis; Stones - kidney; Calcium oxalate - stones; Cystine - stones; Struvite - stones; Uric acid - stones; Urinary lithiasis

A kidney stone is a solid mass made up of tiny crystals. One or more stones can be in the kidney or ureter at the same time.

The kidneys are responsible for removing wastes from the body, regulating electrolyte balance and blood pressure, and the stimulation of red blood cell production.

This is the typical appearance of the blood vessels (vasculature) and urine flow pattern in the kidney. The blood vessels are shown in red and the urine flow pattern in yellow.

Kidney stones result when urine becomes too concentrated and substances in the urine crystalize to form stones. Symptoms arise when the stones begin to move down the ureter causing intense pain. Kidney stones may form in the pelvis or calyces of the kidney or in the ureter.

In the procedure intravenous pyelogram (IVP), the patient is injected with radiopaque dye and X-rays are taken as the dye travels through the urinary tract. This procedure is performed to confirm the presence of kidney stones, although some stones may be too small to see.

Extracorporeal shock wave lithotripsy (ESWL) is a procedure used to shatter simple stones in the kidney or upper urinary tract. Ultrasonic waves are passed through the body until they strike the dense stones. Pulses of sonic waves pulverize the stones, which are then more easily passed through the ureter and out of the body in the urine.

If you ever have severe pain in your belly or one side of your back that comes and goes suddenly, you may be passing a kidney stone. Let's talk about the painful condition of kidney stones. A kidney stone is a mass of tiny crystals in your kidney or urinary tract. Stones are quite common, and tend to run in families. They can form in weeks or months when your urine contains too much of certain substances. There are several kinds of kidney stones. Calcium stones are by far the most common kind. They often form in men between the ages of 20 to 30. Calcium can combine with other substances found in your food, like oxalate, phosphate, or carbonate, to form stones. Cystine stones can form in people who have cystinuria, a condition passed down through families in which stones are made from an amino acid called cystine. Struvite stones are found mostly in women who have urinary tract infections. These stones can grow very large and can block the kidney, ureter, or bladder. Uric acid stones are more common in men than in women. They can occur in people who have a history of gout or are going through chemotherapy. So, how do you know if you have kidney stones? Well, you may not have symptoms until the stone move down the ureter tubes through which urine empties into your bladder. When this happens, the stones can block the flow of urine out of your kidneys. The main symptom is severe sharp pain that starts suddenly, usually in your belly or one side of your back, and it may go away just as quickly. Other symptoms can include abnormal urine color, blood in your urine, fever, chills, nausea, and vomiting. So, what do you do about kidney stones? Well, your health care provider will perform a physical exam. You may need blood tests, kidney function tests, and tests that look for crystals in your urine. Several imaging tests, like a CT scan, can see stones or a blockage in your urinary tract. Treatment will depend on the type of stone you have, and how bad your symptoms are. Small kidney stones that are less than 5 mm in diameter will usually pass on their own. You should drink at least 6 to 8 glasses of water per day to produce a large enough amount of urine to help bring the stone out. Pain can be pretty bad when you pass a kidney stone, so your doctor may prescribe pain medicines to help as well as medications that will help the stone pass. Other medicines can decrease stone formation or help break down and remove the material that is causing you to make stones. You may need surgery if the stone is too large to pass, the stone is growing, or the stone is blocking your urine flow. Kidney stones are painful, but you can usually pass them without causing permanent harm. However, kidney stones often come back, so you and your doctor will need to work on finding the cause of your stone. Lastly, delaying treatment can lead to serious complications, so if you think that you have kidney stones see your doctor right away.

Causes

Kidney stones are common. Some types run in families. They often occur in premature infants.

There are different types of kidney stones. The cause of the problem depends on the type of stone.

Stones can form when urine contains too much of certain substances that form crystals. These crystals can develop into stones over weeks or months.

Calcium stones are most common. They are most likely to occur in men between ages 20 to 30. Calcium can combine with other substances to form the stone.

Oxalate is the most common of these. Oxalate is present in certain foods such as spinach. It is also found in vitamin C supplements. Diseases of the small intestine increase your risk for these stones.

Calcium stones can also form from combining with phosphate or carbonate.

Other types of stones include:

Cystine stones can form in people who have cystinuria. This disorder runs in families. It affects both men and women.

Struvite stones are mostly found in men or women who have repeated urinary tract infections. These stones can grow very large and can block the kidney, ureter, or bladder.

Uric acid stones are more common in men than in women. They can occur with gout or chemotherapy.

Other substances, such as certain medicines, also can form stones.

The biggest risk factor for kidney stones is not drinking enough fluids. Kidney stones are more likely to occur if you make less than 1 liter (32 ounces) of urine a day.

Symptoms

You may not have symptoms until the stones move down the tubes (ureters) through which urine empties into your bladder. When this happens, the stones can block the flow of urine out of the kidneys.

The main symptom is severe pain that starts and stops suddenly:

Pain may be felt in the belly area or side of the back.

Pain may move to the groin area (groin pain), testicles (testicle pain) in men, and labia (vaginal pain) in women.

Other symptoms can include:

Exams and Tests

The health care provider will perform a physical exam. The belly area (abdomen) or back might feel sore.

Tests that may be done include:

Blood tests to check calcium, phosphorus, uric acid, and electrolyte levels

Kidney function tests

Urinalysis to see crystals and look for red blood cells in urine

Examination of the stone to determine the type

Stones or a blockage can be seen on:

Treatment

Treatment depends on the type of stone and the severity of your symptoms.

Kidney stones that are small most often pass through your system on their own.

Your urine should be strained so the stone can be saved and tested.

Drink at least 6 to 8 glasses of water per day to produce a large amount of urine. This will help the stone pass.

Pain can be very bad. Over-the-counter pain medicines (for example, ibuprofen and naproxen), either alone or along with narcotics, can be very effective.

Some people with severe pain from kidney stones need to stay in the hospital. You may need to get fluids through an IV into your vein.

For some types of stones, your provider may prescribe medicine to prevent stones from forming or help break down and remove the material that is causing the stone. These medicines can include:

Allopurinol (for uric acid stones)

Antibiotics (for struvite stones)

Diuretics (water pills)

Phosphate solutions

Sodium bicarbonate or sodium citrate

Water pills (thiazide diuretics)

Tamsulosin to relax the ureter and help the stone pass

Surgery is often needed if:

The stone is too large to pass on its own.

The stone is growing.

The stone is blocking urine flow and causing an infection or kidney damage.

The pain cannot be controlled.

Today, most treatments are much less invasive than in the past.

Lithotripsy is used to remove stones slightly smaller than one half an inch (1.25 centimeters) that are located in the kidney or ureter. It uses sound or shock waves to break up stones into tiny fragments. Then, the stone fragments leave the body in the urine. It is also called extracorporeal shock-wave lithotripsy or ESWL.

Procedures performed by passing a special instrument through a small surgical cut in your skin on your back and into your kidney or ureters are used for large stones, or when the kidneys or surrounding areas are incorrectly formed. The stone is removed with a tube (endoscope).

Ureteroscopy may be used for stones in the lower urinary tract. A laser is used to break up the stone.

Rarely, open surgery (nephrolithotomy) may be needed if other methods do not work or are not possible.

Talk to your provider about what treatment options may work for you.

You will need to take self-care steps. Which steps you take depend on the type of stone you have, but they may include:

Drinking extra water and other liquids

Eating more of some foods and cutting back on other foods

Taking medicines to help prevent stones

Taking medicines to help you pass a stone (anti-inflammatory drugs, alpha-blockers)

Outlook (Prognosis)

Kidney stones are painful, but most of the time can be removed from the body without causing lasting damage.

Kidney stones often come back. This occurs more often if the cause is not found and treated.

You are at risk for:

Urinary tract infection

Kidney damage or scarring if treatment is delayed for too long

Possible Complications

Complication of kidney stones may include the obstruction of the ureter (acute unilateral obstructive uropathy).

When to Contact a Medical Professional

Call your provider if you have symptoms of a kidney stone:

Severe pain in your back or side that will not go away

Blood in your urine

Fever and chills

Vomiting

Urine that smells bad or looks cloudy

A burning feeling when you urinate

If you have been diagnosed with blockage from a stone, passage must be confirmed either by capture in a strainer during urination or by follow-up x-ray. Being pain free does not confirm that the stone has passed.

Prevention

If you have a history of stones:

Drink plenty of fluids (6 to 8 glasses of water per day) to produce enough urine.

You may need to take medicine or make changes to your diet for some types of stones.

Your provider may want to do blood and urine tests to help determine the proper prevention steps.

American Urological Association website. Medical management of kidney stones (2019). www.auanet.org/guidelines/kidney-stones-medical-mangement-guideline. Accessed Feb 13, 2020.

American Urological Association website. Surgical management of stones: AUA/Endourology Society guideline (2016) www.auanet.org/guidelines/kidney-stones-surgical-management-guideline. Accessed Feb 13, 2020.

Bushinsky DA. Nephrolithiasis. In: Goldman L, Schafer AI, eds. Goldman-Cecil Medicine. 26th ed. Philadelphia, PA: Elsevier; 2020:chap 117.

Fink HA, Wilt TJ, Eidman KE, et al. Recurrent nephrolithiasis in adults: comparative effectiveness of preventive medical strategies. Rockville, MD. Agency for Healthcare Research and Quality (US) 2012;Report No.:12-EHC049-EF. PMID: 22896859 pubmed.ncbi.nlm.nih.gov/22896859/.

Miller NL, Borofsky MS. Evaluation and medical management of urinary lithiasis. In: Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, eds. Campbell-Walsh-Wein Urology. 12th ed. Philadelphia, PA: Elsevier; 2021:chap 92.

Qaseem A, Dallas P, Forciea MA, Starkey M, Denberg TD; Clinical Guidelines Committee of the American College of Physicians. Dietary and pharmacologic management to prevent recurrent nephrolithiasis in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med. 2014;161(9):659-667. PMID: 25364887 pubmed.ncbi.nlm.nih.gov/25364887/.

Ziemba JB, Matlaga BR. Guideline of guidelines: kidney stones. BJU Int. 2015;116(2):184-189. PMID: 25684222. pubmed.ncbi.nlm.nih.gov/25684222/.

Version Info

Last reviewed on: 1/15/2020

Reviewed by: Sovrin M. Shah, MD, Assistant Professor, Department of Urology, The Icahn School of Medicine at Mount Sinai, New York, NY. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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Renal calculi; Nephrolithiasis; Stones - kidney; Calcium oxalate - stones; Cystine - stones; Struvite - stones; Uric acid - stones; Urinary lithiasis A kidney stone is a solid mass made up of tiny crystals. One or more stones can be in the kidney or ureter at the same time.

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https://quizlet.com/_8le9ms?x=1jqt&i=l0s0i

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The first stage of labor happens in two phases: early labor and active labor. Typically, it is the longest stage of the process.

During early labor:

The opening of the uterus, called the cervix, starts to thin and open wider, or dilate.

Contractions get stronger, last 30 to 60 seconds, and come every 5 to 20 minutes.

The woman may have a clear or slightly bloody discharge, called "show."

A woman may experience this phase for up to 20 hours, especially if she is giving birth for the first time.

During active labor:

Contractions become stronger, longer, and more painful.

Contractions come closer together, meaning that the woman may not have much time to relax in between.

The woman may feel pressure in her lower back.

The cervix starts dilating faster.

The fetus starts to move into the birth canal.

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The first stage of labor happens in two phases: early labor and active labor. Typically, it is the longest stage of the process. During early labor: The opening of the uterus, called the cervix, starts to thin and open wider, or dilate. Contractions get stronger, last 30 to 60 seconds, and come every 5 to 20 minutes.

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types of delivery

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Different Types of childbirth options | Types of pregnancy delivery methods

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Kérdezze ki a 55 éves nő beteget, aki nőgyógyászati szűrővizsgálatra jött

mikor volt az utolsó menzesze,

rendszeres-e a ciklusa,

szokott-e pecsételő vérzése lenni a ciklus közepén,

milyen erős a vérzése

tapasztalt-e csomót a mellében,

hányszor volt terhes,

volt e vetélése vagy abortusza,

hogyan szült: elfolyt a magzatvize vagy meg kellett indítani a szülést,

időben érkezett a baba vagy koraszülött volt,

szoptatta vagy tápszert adott a babának,

kapott-e érzéstelenítést a szülések során, ha igen epidurális vagy helyi érzéstelenítést

kellett-e gátmetszést végezni,

volt-e bármilyen komplikáció a szülések során,

a menopauza előtt milyen fogamzásgátló módszert használt?Spirált, pesszáriumot vagy gyógyszert? Vagy esetleg elkötette a petevezetékét

volt e valaha szexuális úton terjedő/nemi betegsége?

Volt e valaha valamilyen nőgyógyászati beavatkozása?

Például mióma eltávolítás vagy méheltávolítás?

milyen tüneteket eredményezett a menopauza? Pl. hűhullámok, ingerlékenység, fáradtság, éjszakai izzadás, hüvelyszárazság?

mikor volt utoljára rákszűrésen

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Work in teams through the case and find the appropriate history taking questions:
https://geekymedics.com/a-lady-with-heavy-menstrual-bleeding/

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Improve Article 👀

You are a junior doctor working in General Practice. Your next patient, Sarah Peters, is a 28-year-old nulliparous woman who is concerned about heavy periods. Work through the case to reach a diagnosis.

You might also be interested in our medical flashcard collection which contains over 1000 flashcards that cover key medical topics.

History
"Doctor, I'm really struggling with how heavy my periods are. It's reached a point where I can't even leave the house for the first two days, and I can't afford to be taking so much time off work!"
What questions would you initially like to ask Sarah?
How long has this been going on for? Were your periods normal before? "My periods were heavier when I was younger, then they were better when I was on the pill. Since I stopped that a few months ago they're worse again!" How many pads or tampons do you use in a day? Do you need to wear both at the same time? "I have to use pads and tampons at the same time, especially for the first couple of days. A heavy tampon will leak after a couple of hours." What colour is the blood? Have you noticed any clots or flooding (a sudden rush of heavy flow)? "The blood is dark red. Sometimes I do get flooding and when it's at its heaviest in the first couple of days I get clots too." Is there anything recently that's prompted you to make an appointment today? "I've had to have a meeting about taking time off at work, so I just want to get this sorted out. I'm so fed up of it." ICE - How is it affecting your life? Your job? Time off work? Is anything concerning you in particular? "It's affecting my job with having time off, and I'm fed up of being stuck in the house for the first couple of days. I'm hoping there's some tablets or something that can help!"
The answers to the first set of questions form the basis of the diagnosis. Although menorrhagia is historically defined as >80ml of blood loss per cycle¹, this is rarely measured - thus, menorrhagia is diagnosed when both the patient and doctor agree the amount of blood loss is significant enough to affect the woman's life.

What further questions would you like to ask Sarah about her periods?

Take a menstrual history

Menarche: How old were you when you started your period?

LMP: When was the first day of your last period?

Cycle: Are your cycles regular? How often do you get your period? How long does the bleeding last?

Other problems: Other than your periods being heavy, do you have any problems with them?

Painful periods (dysmenorrhoea can suggest endometriosis/fibroids)

Bleeding between cycles (intermenstrual bleeding can suggest STI/contraception problems/malignancy)

Bleeding after sex (post-coital bleeding can suggest ectropion/malignancy)

Long breaks between periods (amenorrhoea can be a feature of anorexia/hormonal problems such as hypothyroidism)

"I started my period when I was about 13, and they've always been regular. I bleed every 29 days on the dot and they always last about 6 days. The first day of my last period was 7 days ago. They're not particularly painful and I've not had any other bleeding."
What other questions should you ask?

Complete a full gynaecological history
Sexual and contraception history:

Are you sexually active at the moment? Do you have a regular partner? How many partners have you had in the past 6 months?

Have you had a sexual health screen in the past? When? Have you ever been treated for an STI?

Have you noticed any changes to your vaginal discharge?

Have you noticed any rashes or itching around your vulva?

Do you have pain when you're having sex (dyspareunia)?

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)?

Cervical smears:

When was your last cervical smear? Are you up to date with your smears?

Have you been vaccinated against HPV?

Any abnormal smears?

Any treatment required?

Urinary questions:

Any problems with going to the toilet?

Are you passing urine more often (frequency)?

Do you have any burning or stinging on passing urine (dysuria)?

Do you have any problems with incontinence?

So you have the sensation of "dragging" in your vagina (prolapse)?

Brief obstetric history:

Have you ever been pregnant? Any miscarriages or terminations?

Do you have any children? How old are they? Were they vaginal deliveries or c-sections? Any complications?

Are you currently trying to to get pregnant or have plans for a baby soon? (this will have an impact on management)

Answer
"I am married to my husband of 3 years. I am sexually active and have not had any other partners since I was married. I've never been treated for an STI. I stopped using the pill about 6 months ago because we are trying for a baby. My most recent cervical smear was two and a half years ago, and they've all been normal. I've not had a letter for my next smear yet. I have no problems with my waterworks."
What questions would be useful to complete your history?
Systems review with special focus on the below:

How are you otherwise? Are you in good health?

Are you more tired than usual, short of breath, noticeable heartbeats/palpitations, pale? (anaemia)

Have you been having any abdominal pain or bloating? (malignancy but also endometriosis/fibroids)

Any fever, lethargy, weight loss, night sweats? (malignancy)

Any excessive tiredness, weight gain, dry hair/hair loss, feeling cold when others are not? (hypothyroidism)

Have you had any bleeding problems in the past or does this run in the family?

Don't forget the usual past medical, drug, family and social history.

Answer
"I don't feel particularly tired or pale. My weight hasn't changed, and I haven't had any fevers or night sweats. I wouldn't say I'm particularly sensitive to the cold. I am otherwise well and haven't had to see a doctor for any reason. I'm not on any medications, and I have no allergies. My family are well. I don't smoke or drink alcohol."
Differential diagnoses

Based on the findings in the history, what is your top differential diagnosis?
Dysfunctional uterine bleeding (DUB):

Because this patient has heavy menstrual bleeding as an isolated symptom (i.e. without pain, irregular cycles, a significant sexual history or intermenstrual bleeding), the most likely cause is DUB. However, this is a diagnosis of exclusion and further investigations must be performed before this diagnosis could be made. Her age makes fibroids less likely (typically present in women aged 30-50, rather than being symptomatic from menarche).

DUB is characterised by a lack of histological abnormality of the endometrium. Menorrhagia in these cases is likely due to subtle abnormalities of endometrial haemostasis and/or uterine prostaglandin levels.

What are some local causes of menorrhagia?

Uterine fibroids

Endometriosis

Cervical or endometrial polyps

Adenomyosis

Pelvic inflammatory disease (PID)

Endometritis

Endometrial hyperplasia or carcinoma

What are some systemic causes of menorrhagia?

Hypothyroidism

Bleeding disorders (e.g. Von Willebrand's disease)

Iatrogenic (e.g. anticoagulant treatment; copper IUD)

Climacteric

Examination and investigations

What examination(s) would be appropriate in this case?

Clinical findings

No uterine tenderness or masses, with a normal anteverted uterus that is not enlarged

No adnexal masses or tenderness noted

No cervical excitation

No lesions apparent on the cervix

No discharge or bleeding is noted from the cervical os

What investigations would you like to perform?

Pregnancy test

This should form a part of the workup for almost all cases in which a woman of childbearing age is concerned. It is unlikely to be positive, but pregnancy would be unforgivable to miss!

This test is negative.

Bloods

Check FBC to rule out anaemia. If concerned, also perform iron studies (ferritin, transferrin, iron saturation).

Sarah has a normal Hb of 14.5 g/dL.

Imaging

Refer for a transvaginal ultrasound (TVUS) to exclude local organic causes (e.g. fibroids, polyps or adnexal masses)

Sarah's TVUS results show a normal endometrial thickness and no abnormal masses.

Other investigations

Consider if appropriate based on the history (these investigations were not performed in this case):

Coagulation screen (bleeding disorder e.g. vWD)

TFTs (hypothyroidism)

Endometrial biopsy for histological examination (if worrying features e.g. endometrial thickness > 10mm on TVUS if premenopausal/intermenstrual bleeding)

Triple swabs (if considering STI)

Hormone profile if concerned about premature ovarian insufficiency (POI)

Diagnosis and management
The examination and investigations confirm your diagnosis of dysfunctional uterine bleeding (DUB).
What are the management options for heavy menstrual bleeding?

Dysfunctional uterine bleeding can be managed in primary care if there are no concerning features in the history, clinical examination and initial investigations. Referral to secondary care would be advised if two forms of management were to fail in primary care.

First-line treatment

Levonorgestrel intrauterine system (e.g. Mirena coil) provided that at least 12 months use is anticipated. This is the most effective management solution for heavy menstrual bleeding available in primary care. It can remain in situ for 5 years and also provides contraception.

Second-line treatment

Combined oral contraceptive pill (COCP) reduces menstrual bleeding by up to half. This also provides contraception but confers a higher side-effect profile compared to the IUS.

Tranexamic acid (anti-fibrinolytic) - ~50% reduction in blood loss and is used during or just before the period. Particularly effective in fibroids. Can be used alongside copper IUD.

Mefenamic acid (NSAID) - ~30% reduction in blood loss and is used during or just before the period; it is particularly useful if dysmenorrhoea is also present (not in this case), and it may be taken with the tranexamic acid.

Third line treatment

Norethisterone (15 mg) daily from days 5 to 26 of the menstrual cycle (affects ovulation and has a contraceptive effect, so not appropriate for Mrs Peters)

Medroxyprogesterone acetate injection every 12 weeks. This also provides contraception.

What management option would you choose for Sarah?

For Sarah, a non-hormonal treatment should be chosen as she is trying to get pregnant. Tranexamic acid would be an appropriate choice.

What surgical management options are available to manage DUB?

Surgical treatment of DUB

If medical treatment of DUB has failed, then the patient should be referred to secondary care where surgical management may be considered. Surgical management of DUB results in a loss of fertility and therefore may not be suitable for all patients.

Transcervical resection of the endometrium (TCRE): uses monopolar diathermy or microwave balloons to ablate the endometrium and superficial myometrium of the uterus, resulting in amenorrhoea or lighter periods.

Uterine artery embolisation (UAE): suitable for women who want to retain their uterus and avoid surgery.

Hysterectomy: often used as a last resort used for women who do not want further children.

References

1. Munro, Malcolm G.; Critchley, Hilary O. D.; Broder, Michael S.; Fraser, Ian S. (2011-04-01). "FIGO classification system (PALM-COEIN) for causes of abnormal uterine bleeding in nongravid women of reproductive age". International Journal of Gynecology & Obstetrics.

2. CG44 Heavy menstrual bleeding: Understanding NICE guidance" (PDF). National Institute for Health and Clinical Excellence (UK). 24 January 2007.

Editor

Dr Grace Farrington

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A lady with heavy menstrual bleeding | Clinical Case | Geeky Medics

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Improve Article 👀 You are a junior doctor working in General Practice. Your next patient, Sarah Peters, is a 28-year-old nulliparous woman who is concerned about heavy periods. Work through the case to reach a diagnosis. You might also be interested in our medical flashcard collection which contains over 1000 flashcards that cover key medical topics.

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1. ORVOS- BETEG

HELYSZÍN: GYEREKKÓRHÁZ, LÉGÚTI OSZTÁLY

RÉSZTVEVŐK:
SZAKORVOS (VIZSGÁZÓ)
BETEG ÉDESANYJA (VIZSGÁZTATÓ)

Kérdezze ki 6 hónapos gyermek betege édesanyját a panaszokról:

-          Mióta köhög a gyermek

-          Köhögése milyen: száraz vagy hurutos

-          Orrváladéka milyen: sűrű vagy híg, áttetsző

-          Láza volt-e a gyermeknek? Mi volt a legmagasabb érték

-          Mondja el az édesanyának, hogy köptetőt, orrcseppet és lázcsillapítót ír fel  a gyermeknek

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2. .RÉSZTVEVŐK:
HÁZIORVOS(VIZSGÁZÓ)
BETEG (VIZSGÁZTATÓ)

Kérdezze ki az édesanyát és a beteget, majd vizsgálja meg a gyermeket, állítsa fel a

diagnózist:

-mi a kislány jelenlegi panasza?

-kérje meg a beteget, hogy vetkőzzön le, hogy Ön megvizsgálhassa

-kérdezze meg, hogy az influenza-szerű tüneteken kívül van-e egyéb panasza a gyermeknek

-mióta lázas a gyermek, mennyi volt a láza, mennyi ideje köhög, hány napja vannak kiütések a testén?

-a környezetében előfordult-e hasonló betegség?

-valószínűleg kanyarója van, amely egy fertőző gyermekbetegség, vírus okozza

-mondja el, hogy lázcsillapítót javasol, antibiotikumra nincs szükség

-magyarázza el az édesanyának, hogy a gyermeknek ágynyugalomra, bőséges folyadékfogyasztásra van szüksége

-egy hétig nem mehet közösségbe.

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3. HELYSZÍN: GYERMEKORVOSI RENDELŐ

RÉSZTVEVŐK:
GYERMEKORVOS (VIZSGÁZÓ)
BETEG ÉDESANYJA(VIZSGÁZTATÓ)

Kérdezze ki a beteg édesanyját:

-          Mióta van hasmenése a gyermeknek?

-          Nyák vagy vér volt a székletében?

-          Hányingere van, hányt is esetleg?

-          Érez-e fájdalmat, pl.: izomfájdalom, hasi fájdalom?

-          Tudott-e inni a gyermek, evett-e valamit?

-          Kérje meg, hogy vetkőztesse le a gyermeket, fektesse a vizsgálóasztalra.

-          Mondja el, hogy megtapogatja a hasát, valószínűleg vírusfertőzése van.

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HELYSZÍN: GYEREKKÓRHÁZ, LÉGÚTI OSZTÁLY

RÉSZTVEVŐK:
SZAKORVOS (VIZSGÁZÓ)
BETEG ÉDESANYJA (VIZSGÁZTATÓ)

Kérdezze ki 6 hónapos gyermek betege édesanyját a panaszokról:

-          Mióta köhög a gyermek?

-          Mi váltja ki a köhögést?

-          Köhögése milyen: száraz vagy hurutos, milyen a köpete?

-          Fullad-e a gyermek, éjszaka rosszabbodnak-e a tünetek?

-          Rekedtséget vagy ugató köhögést tapasztalt-e?

-          Láza volt-e a gyermeknek? Mi volt a legmagasabb érték?

-          Mondja el az édesanyának, hogy köptetőt, orrcseppet és lázcsillapítót ír fel a gyermeknek.

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Urinary Tract Infections (UTIs): Most Commonly Asked Questions - Urology Care Foundation