Common problems gynae triage

Check the following:

• LMP and urinary hCG – has the patient already had a scan?
• Pain: typically unilateral, sometimes accompanied by shoulder tip pain.
• PV bleeding: any spotting or heavy bleeding?
• Haemodynamic stability: is the patient stable?
• Abdominal exam: any signs of peritonism?
• Speculum examination: is the cervical os open or closed?
• Bimanual examination: any cervical excitation, adnexal tenderness, or mass?

Plan:

• Serum bhCG, ultrasound to assess pregnancy location, and discuss with senior.
• If the patient is unwell: establish IV access, order bloods including G&S, keep the patient nil by mouth, and consider laparoscopy if necessary.

• Associated with pelvic pain
• PV discharge
• Take sexual/contraceptive history
• Abdo tender but usually soft
• Speculum examination: often some discharge, take dual swabs
• Bimanual examination: excitation
• If systemically well: oral doxycycline/ofloxacin and metronidazole 14 days
• If systemically unwell: IV Ofloxacin and metronidazole, add in one off IM ceftriaxone if high suspicion of gonorrhoeal infection

• Sudden onset severe unilateral pain
• Nausea and vomiting
• Collapse
• Requires strong analgesia (e.g., morphine)
• Abdo: any peritonism?
• Bimanual examination: excitation, adnexal mass/tenderness
• IV access, bloods, fast
• D/W senior may need urgent laparoscopy/laparotomy
• USS should show ovarian cyst usually > 5cm to tort

• Check LMP and urinary hCG
• Abdo pain usually cramping and central
• PV bleeding? heavy? clots
• Haemodynamically stable?
• Speculum examination: cervical os closed? If cx os open miscarriage is incomplete or inevitable.
• Plan: serum bhCG G&S, USS for viability
• Can be managed conservatively, medically or surgically
• If well: refer PSC. Overnight can go home and be contacted & scanned by them in the AM
• If unwell: IV access, bloods including G&S, fast, may require surgical evacuation of uterus

• Sudden onset unilateral pain
• ? mid-cycle
• Abdo usually tender but soft
• Bimanual examination: adnexal mass?
• USS: may show cyst/free fluid in POD
• RCOG Green top guidelines on follow up of ovarian cysts
• Pre-menopausal (Green Top 62: Dec 2011)
• Post-menopausal (Green Top 34: July 2016)

• Painful vulval swelling
• Can cause great difficulty walking/sitting
• Different from other labial abscesses!
• Describe location/size/surrounding erythema/fluctuant?
• Systemically well?
• If fluctuant may need incision and word catheter insertion. Recurrent cases considered for marsupialization.
• If not fluctuant may need further antibiotics and review in 48 hours