This document provides a guide for gynaecology and obstetric internships, covering topics such as:
- Taking patient histories and filtering diagnoses
- Common tests, investigations, and treatments for conditions like preterm labor, PIH, dribbling, and more
- Clerking, monitoring, and discharge instructions for conditions like hyperemesis gravidarum, PIH, GDM, and postnatal/post-op care
- Sample operation notes for procedures like D&C, LRT, and ERPC
- Referral letters and follow up plans
- Useful tips and reminders for managing complications
Recurrent pregnancy loss is a significant redroductive medical problem, influencing 2%–5% of couples. ... Throughout the years, proof based medications, for example, surgical correction of uterine abnormalities or asprin and heparin for antiphospholipid syndrome have improved the results for couples with repetitive pregnancy loss.
In settings with limited access to health care, misoprostol is an important intervention that could reduce maternal deaths both directly and through the more cost-effective use of health services. Misoprostol is, however, a powerful drug that needs to be used with care. Evidence-based information about the safest regimens should be widely disseminated so as to prevent its inappropriate use
Recurrent pregnancy loss is a significant redroductive medical problem, influencing 2%–5% of couples. ... Throughout the years, proof based medications, for example, surgical correction of uterine abnormalities or asprin and heparin for antiphospholipid syndrome have improved the results for couples with repetitive pregnancy loss.
In settings with limited access to health care, misoprostol is an important intervention that could reduce maternal deaths both directly and through the more cost-effective use of health services. Misoprostol is, however, a powerful drug that needs to be used with care. Evidence-based information about the safest regimens should be widely disseminated so as to prevent its inappropriate use
Anatomy of the breast for medical/dental students. This presentation also contains MCQs to test your knowledge as well as clinical scenario to apply your knowledge.
Also known as GP note, "Pol" note, PP note
Medical students/ pre-interns/ Family physicians use various notes to guide their general practice at the begining, specially drug doses, common treatments for common diseases etc. These "guides" have been used by many seniors but need to be careful revision before prescribing. Hope to update once I go through them completely.
Also known as GP note, "Pol" note, PP note
Medical students/ pre-interns/ Family physicians use various notes to guide their general practice at the begining, specially drug doses, common treatments for common diseases etc. These "guides" have been used by many seniors but need to be careful revision before prescribing. Hope to update once I go through them completely.
Also known as GP note, "Pol" note, PP note
Medical students/ pre-interns/ Family physicians use various notes to guide their general practice at the begining, specially drug doses, common treatments for common diseases etc. These "guides" have been used by many seniors but need to be careful revision before prescribing. Hope to update once I go through them completely.
Medical students/ pre-interns/ Family physicians use various notes to guide their general practice at the begining, specially drug doses, common treatments for common diseases etc. These "guides" have been used by many seniors but need to be careful revision before prescribing. Hope to update once I go through them completely.
The original teachings of Jesus Christ were an outcome of
Buddhism, says Holger Kersten, a German theology teacher.
Hence one of the titles of the chapters in his book, "The
Original Jesus" (sub-titled 'Buddhist sources of Christianity') is 'Jesus the Buddhist'!
Examination of lower limb in neurology-Short case approach for Final MBBSYapa
Examination of lower limb in neurology-medicine short case approach.
This document was prepared based on the teachings of Dr.Kahathuduwa.
Fonts in blue indicate sample way of presenting the case.
By: Ajaan Mahā Boowa Ñānasampanno
Translated by: Ajaan Paññāvaddho
A senior disciple of Ajaan Mun, Ajaan Khao Anālayo was one of the foremost meditation masters of our time. He always preferred to practice in remote, secluded locations and with such single-minded resolve that his diligence in that respect was unrivaled among his peers in the circle of Thai forest monks. In his frequent encounters with wild animals, Ajaan Khao exhibited a special affinity for elephants.
“The Gift of Dhamma Excels All Other Gifts”
—The Lord Buddha
Dhamma should not be sold like goods in the market place.
Permission to reproduce this publication in any way for free distribution,as a gift of Dhamma, is hereby granted and
no further permission need be obtained.
Reproduction in any way for commercial gain is strictly prohibited.
By: Ajaan Mahā Boowa Ñānasampanno
Translated by: Thānissaro Bhikkhu
This collection of talks was originally given for the benefit of a lay disciple who had come to Ajaan Maha Boowa’s monastery to receive his guidance as she faced her approaching death from bone marrow cancer. These talks offer important lessons about how to learn from pain, illness and death, by seeing through to their ultimate nature and detaching the mind from the suffering associated with them.
“The Gift of Dhamma Excels All Other Gifts”
—The Lord Buddha
Dhamma should not be sold like goods in the market place.
Permission to reproduce this publication in any way for free distribution,as a gift of Dhamma, is hereby granted and
no further permission need be obtained.
Reproduction in any way for commercial gain is strictly prohibited.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Hemodialysis: Chapter 3, Dialysis Water Unit - Dr.Gawad
Guide for gynaecology & obstetric internship
1. Guide for gynaecology & obstetric internship- Yapa Wijeratne
Guide for gynaecology & obstetric internship
By Yapa Wijeratne
History taking
6 questions to filter the diagnosis
1. Abdominal pain?
a. ↑ frequency & duration, colicky
2. Back pain?
3. PV bleeding?
a. Mucoid, brownish, scanty amount → show
4. Dribbling?
a. Watery, clear, copious amount which wets bed sheets/ garments →true dribbling
b. False dribbling: DD: 1. Show 2. Candidiasis 3. Urine 4. Hind water rupture
5. Fetal movements?
6. PET symptoms?
a. Headache, epigastric pain, visual disturbances
Mx
1. CTG-stat & daily
2. FHS-tds
3. KCC
4. USS
5. FBC
6. PPBS
7. UFR
8. Continue haematinics
9. On any suspicion of going for a LSCS- fill DT 1Θ
PCM 1g 6hrly or Panadine 1g 6 hrly (outside chit)
If already on any drugs you need to add here
e.g. metformin 500mg tds
if < 37 wk & having a possibility of early delivery give IM dexa 6 mg 12 hrs apart 4 doses or 12 mg 2
doses. Dexa can be given IV if needed immediate action.
Dribbling
1. HVS
2. Bed rest
3. Erythromycin 250mg 6hrly 10 days or 500mg 6hrly
4. Sterile pads
5. QHT
6. Better check FHS frequently ( ¼ hrly if possible, like in labor room as there is a risk of cord
prolapse)
7. Inform PMO (Paediatric Medical Officer) for PBU care if preterm or any risk of PBU/SBU care
Preterm labor
1. Lung maturity → IM dexamethasone 12mg 12 hrly 2 doses or 6mg 4 doses in 48 hours
a. Dexamethasone action lasts for 7 days. But within a month no need to repeat.
b. Need to monitor CBS if GDM before giving dexamethasone
2. Guide for gynaecology & obstetric internship- Yapa Wijeratne
2. Tocolytic → Nifidipine 20mg 6 hrly x 48 hrs
PIH
1. PET screening
a. BU
b. S.cr
c. SGPT/SGOT
d. SE
e. PT/ INR
2. Urine albumin stat & chart
3. BP tds
4. Nifidipine 20mg bd
Need same day FBC if going for EM-LSCS
Look for PLT, PCV (there will be haemo-concentration)
Placenta previa
Ready 3Θ DT always in the ward
Bed rest
GDM
Insulin 10 U mane
Metformin 500mg tds
BSS
1. FBS
2. BS-post BF
3. Pre lunch BS
4. Post lunch BS- urgent chit
5. Pre dinner BS- urgent chit
6. Post dinner BS- urgent chit
OGTT
FBS : 92 mg/dl
1st
hr : 180 mg/dl
2nd
hr : 153 mg/dl
IUGR
CTG daily/ bd
2 weekly growth scan- tabulate them clearly
Every 3rd
day / EOD doppler
Pruritus
Risk of IUD: reason not clear
If bad obs history but still not willing early delivery, always document everything
Total bilirubin with fractions
PET screen
Mx
Piriton 4 mg tds
1% hydrocortisone cream
3. Guide for gynaecology & obstetric internship- Yapa Wijeratne
Aqueos cream local application
Routine growth scan- sample
TAS- Dr.----- (Reg)
SLF, CP
BPD 33+2
HC 33+5 33 +5
AC 34
FL 33+ 6
Placenta- fundal/ anterior/ posterior
Liquor average or AFI 8cm
Doppler good diastolic flow. RI 0.7 PI 0.9
EFW (estimated fetal weight)
In early USS, (1st
trimester & early trimester scans) , USS EDD is important
In twin pregnancy, EFW of both twins important- twin to twin transfusion
In IUGR, →EFW, Doppler diastolic flow, RI PI values
1st
scans → CRL (in extended position)
In early scans till about 13-15 weeks, BPD & HC alone is enough.
Routine clerking
P1C0
38+1
P/C
No complains
FM+
Plan:-
Foley insertion
VE
Os has to be less than 1.5cm
Cuscos speculum & visualize Os.
Foley inserted & catheter balloon was filled with 60 or 70 ml of N/S.
Traction is applied till the balloon get stuck at Os.
Keep NBM till CTG in ½ hr
Inform when the folley is fallen.
Then do a VE & assess the cervix
PG insertion
Primi 2mg → 1mg → 1mg (can insert 4mg 6 hrly)
Multi 1mg → 1mg → 1mg (can insert 3mg 6 hrly)
PGE2 inserted.
Keep NBM.
4. Guide for gynaecology & obstetric internship- Yapa Wijeratne
CTG in ½ hr, 2hr, 6hr (It is always better to take a CTG prior PGE2 insertion, as fetus may already in
distress & PGE2 can worsen)
ARM (Artificial rupture of membranes)
1. ARM done under aseptic conditions.
2. Liquor- clear/ thin to moderate / thick meconium.
3. No hand or cord prolapse.
4. VE
a. Os-1cm
b. Effacement- 30%
c. Station- (-1)
5. Mx
a. Start IV syntocinon 5U (primi)/ 2U (multi) in 1Θ N/S.
i. Drop rate 10/min → maximum 60/min.
b. CTG in ½ hr.
c. FHS ¼ hourly
d. Pain relief
i. IM pethidine 75mg (1mg/kg) stat
ii. IV maxalone 10 mg or IM phenagan 25 mg (here giving phenagan is beneficial as
its sedative effect can reduce the labor pain)
iii. Entonox SOS
e. R/v in 3 hrs.
f. In PIH patients- BP ½ hourly
g. In GDM patients- RBS with CBS 4 hourly
Episiotomy
1. Episiotomy sutured under aseptic conditions.
2. No active bleeding.
3. Swabs & clots removed.
4. Per rectal examination-PRE done.
5. Placenta & membrane examination-PME done.
6. KUO for bleeding.
7. If bleeding occurs
a. Start 20 units of IV syntocinon in 1Θ N/S.
b. Inform HO stat.
8. If no bleeding within 2 hrs, send the pt to ward ----.
LSCS premedication
IV ranitidine 50 mg mane
IV maxalone 10 mg mane
Or
Omeprazole/Famotidine 20 mg nocte/mane
O. maxalone 10 mg nocte/mane
Gynecology
Vomiting
5. Guide for gynaecology & obstetric internship- Yapa Wijeratne
How many episodes? – to assess the severity
Blood stained? –– to assess the severity
Content? – partially digested foods?
Can tolerate oral? → if yes oral antiemetics (domperidone 10mg stat & tds or oral maxalone 10mg) to
control the vomiting & then without cannulating the patient, you may be able to manage the vomiting.
Abdominal pain?
Urinary symptoms? UTI also can cause vomiting
Hyperemesis Gravidarum
Oral metochlopramide 10mg tds
IV ondansetron 4mg tds
UFR & urine for ketone bodies- ward test
SE (can be done if you suspect severe dehydration)
RBS stat with CBS (expensive, but less painful & you get quick results)
1 vial of polybion in 1Θ N/S
IV ranitidine 50 mg stat & bd
IV maxalone 10mg stat tds
N/S 6Θ – 24hrs
Hartmann 3Θ
Some patients develop reactions for polybion / ranitidine. Try managing with IV hydrocortisone 200mg
stat
(Here you may request FBC to exclude other causes of vomiting, but hyperemesis gravidarum is
common. Common things are common. )
If ketone bodies positive
1l → 0.5 hr
1l → 1 hr
1l → 2 hr
1l → 4 hr
Threatened Miscarriage
Do TVS
If FHB seen then
IM Prolutan 1 vial stat & weekly or
Vageston 200mg daily x 2/52 till 13 weeks
PV bleeding – in non- preganant
Norethisteron 5mg tds (10mg tds) for 21 days
Tranexamic acid 500mg tds during bleeding
Mefanamic acid 500mg tds during bleeding
FeSO4 1 or 2 tab daily
Vit C 1 tab daily
If pale, DT 1 or 2 pints
Before ANY blood transfusion, take blood for blood picture
6. Guide for gynaecology & obstetric internship- Yapa Wijeratne
Surgery
Pre-op investigations
FBC
UFR
FBS
CBS stat
SE
S.Cr
>40 years
ECG
CXR
2D ECHO
HIV 1 & 2 antibody
HepBsAg
Clean enema- just to empty the feces from sigmoid colon/ rectum
if past surgeries- need to give Klean prep
Diclofenac sup 100mg- for post op pain relief
Postnatal
LSCS
D0
Active PV bleeding
Abdo soft
Uterus hard
Pallor
Pulse Volume
D1
Complains?
Active pv bleeding?
UOP → >1000 ml → OK. Remove catheter
Pallor
Pulse rate, volume
Abdomen soft?
Uterus hard
Mobilize
Diclofenac 50 mg tds
Famotidine 20 mg bd
PCM 1g tds
D2
Fever
7. Guide for gynaecology & obstetric internship- Yapa Wijeratne
Bowel open
Urine output
FBC
PPBS
D3
Wound inspection → bath
VE→ No clots. No swabs
→ Discharge
PIH
D1
Check BP
Normal > stop drugs
> 150/90 & PET symptoms: urine albumin & continue drugs
NO diclo sup. Give Tramadol 50 mg tds
BP is highest in D3-D6. So need to measure that BP.
Nifidipine 20 mg bd → if not controlled + HCT 25 mg mane
Admit if > 150/100mmHg
R/v in 2/52 or 6/52 for BP
GDM
RBS stat
D1: stop metformin & insulin
D2: PPBS → (Normal 7.1) → Discharge
On discharge
No fever
Haemodynamically stable
Abdomen soft
Wound healthy
Plan on discharge
Calcium lactate 1 tab daily for 6 months
Family planning advices given
R/v at MOH clinic in 6/52 for family planning advices
If anemic→ (8-10g/dl) FeSO4 tab daily x 1/12
If GDM→ R/v at ward in 2/52 with PPBS
R/v at ward in 6/52 with OGTT Dr.Janaka
Post partum fever
Episiotomy?
LSCS wound?
3 undiagnosed
Neck stiffness for meningitis (LSCS patients- spinal anesthesia- risk of infection → may be misdiagnose as
pp psychosis
Calf tenderness for DVT
8. Guide for gynaecology & obstetric internship- Yapa Wijeratne
Saturation for atypical pneumonia
Clinic
If Rh (-)→ unexplained antibody level
UFR Pus cells >10
U culture → cephalexin 500mg 8H x 5 days → repeat UFR
Referral letters
Gyn/ Medical clinic
[ ] hospital
DMO/MO/RMO
[ ] hospital
Dear Doctor,
Ref: Mrs. ………………………..
Could you kindly arrange the follow up of this patient with ……………………….
[e.g. T2DM] at your institution.
We shall review the patient, if the necessity arises/ in one year.
Thank you.
………………..
VOG/ MO
Follow up plans
Gyn/ Medical clinic
Follow up plan
1. Review in ……………… weeks/ months
o Red number-
o Blue number
2. Referred to local hospital/ other clinic
3. Review SOS
Some useful tips
Past section patient suddenly collapse-think of “Uterine rupture”
Patient collapsed following “precipitated labor”- para vaginal hematoma. Needs to open & ligate
internal iliac.
Patient complains continuously of pain- may be meconium. Keep nill by mouth (cz she may need LSCS).
Do ARM & see liquor.
IUGR patient- document to compare two weekly growth scan.
Chronic pelvic pain- Meloxicam 15 mg mane. Amytriptiline 20 mg nocte
9. Guide for gynaecology & obstetric internship- Yapa Wijeratne
Infected LSCS wound- Iodosorb
Dysmenorrhea- Etovax 120mg 5 tab monthly during menstruation
CTS- keep hand over 2 pillows when sleeping
Candidiasis- Gynoperyl vaginal pessary for 3 days
Primapore plaster- non allergy plaster cheaper than “Tegaderm (LSCS size 25 x 10 cm)
Metformin- Panfor SR daily for 3/12
GDM mother delivers baby:
Check cleft palate & anus
Mx
Early assisted breast feeding
RBS in 2 hrs & 4 hrly for 24 hrs
Diane-35 tablet contains cyproterone acetate 2 mg + ethinyl estradiol 0.035 mg.
Yasmin (drospirenone and ethinyl estradiol)
Primolut N (norethisterone)
Ovidac 5000 iu/ml (Freeze Dried Powdered HCG Injection)
10. Guide for gynaecology & obstetric internship- Yapa Wijeratne
Op notes
These are sample diagnosis cards that you may write.
MINOR SURGERIES
EUA + DIALATATION AND CURRETAGE
By Dr (SHO)
Under GA By Dr. (MOA)
On 0/0/2016
Indication-
Heavy menstrual bleeding
P4 C3
EUA:
Cervix firm and healthy
Uterus anteverted. 8wks sized
Curettage done:
Curettings ++ and sent for histology
TVS by Dr (SHO)
Endometrial thickness 6.8mm
R/S ovary- dominant follicle seen
L/S ovary polycystic
No products
Investigations
Hb: 13.3 g/dl
Plt: 2267,000
UFR : normal
FBS : 6.4 mmol/L
Discharge plan
Review in Gyn clinic with histology report In 4 weeks
( on 00/00/2016)
B/L LRT + ERPC
By Dr (Reg)
Under GA By Dr. (MOA)
On 05/0/2016
Indication-
T1 - Missed miscarriage
P4 C3
Skin incision supra pubic
11. Guide for gynaecology & obstetric internship- Yapa Wijeratne
B/L ligation and resection of tubes done
Skin sutured with subcuticular vicryl
TVS by Reg
Gestational sac diameter 26.3mm
Foetal pole seen. Diameter 8mm
No foetal heart beat seen
Management
Misoprostol 600micg inserted PV.
TVS on discharge
No products
Investigations
Hb: 13.2 g/dl
Plt: 250,000
UFR : normal
FBS : 5.4 mmol/L
Discharge plan
Review SOS
T1 INCOMPLETE MISCARRIAGE
P3 C2
POA: 9wk + 5d
TVS by Reg
Retained products of conception seen
Endometrial thickness 19mm
Management
Misoprostol 800micg inserted PV
TVS on discharge
Uterine cavity empty
Investigations
Hb: 11.8 g/dl
Plt: 244,000
UFR : normal
RBS : 5.2 mmol/L
Discharge plan
Folic acid 1 tab daily
Ferrup 1 cap daily
R/V sos
12. Guide for gynaecology & obstetric internship- Yapa Wijeratne
MAJOR SURGERIES
EM/EL LOWER SEGMENT CAESAREAN SECTION
On -
Done under SA GA
Done By :…Dr
Assisted by :…Dr
INDICATION:
Procedure:
Pfannenstiel incision made
Peritoneal cavity opened in to.
Routine LSCS done.
Liquor : clear/ meconium
Single live non asphyxiated baby delivered.
Placenta and membranes delivered completely.
Uterus sutured in two layers.
B/L tubes and ovaries appeared normal.
Complete haemostasis achieved.
Routine closure done.
Skin sutured with S/C vicryl
Post op
1. NBM 6 hrs
2. QHT
3. IP/OP chart
4. Monitor BP, PR, RR
a. ¼ hrly x 2hrs
b. ½ hrly x 2hrs
c. 1 hrly x 2hrs
5. Pain relief
a. IM pethidine 50mg SOS
b. IV metochlopramide 10mg SOS
c. Diclofenac sodium 100mg sup stat
d. Diclofenac sodium 50mg bd
e. Omeprazole 20mg bd
f. PCM 1g SOS
6. IV fluids
a. IV NS 80cc/hr
b. IV NS 2Θ
c. IV hartmann 2Θ 24hr
d. IV 5% dextrose 1Θ
7. Antibiotics
a. IV Cefuroxime 750mg tds x 24hrs
13. Guide for gynaecology & obstetric internship- Yapa Wijeratne
IV Metronidazole 500mg tds x 24hrs
O. Cefuroxime 500mg bd x 3d
KUO for bleeding
[PIH → urine albumin stat & tds- chart]
In GDM monitor RBS
LAPAROSCOPIC CYSTECTOMY
By Dr. (VOG), Dr (SR), Dr (Reg)
Under GA By Dr. (MOA)
Indication- Left side ovarian cyst
Procedure –
Loyd Davis position
Closed verrus needle technique. Pneumo-peritonium acheived.
4 port entry into peritoneal cavity
Findings –
Large Left side ovarian cyst found.
Endometrioma. Size 8x 8 cm.
POD adhesions present, Grade 4 Endometriosis
Large bowel adhered to ovarian cyst.
Adhesions separated.
Cystectomy done. Part of cyst wall sent for histology.
Extensive surgery not done as POD adhesions were severe
Skin –subcuticular-vicryl
Discharge plan
1. Needs GnRH analogues – not affordable
2. DMPA started monthly for 6 months
3. May need second laparoscopic surgery
EXPLORATORY LAPAROTOMY +TUMOUR DEBULKING
By Dr. (VOG), Dr (SR), Dr (Reg)
Under GA By Dr. (MOA)
Indication- Right sided ovarian tumour
Procedure –
Midline paramedian incision made.
Findings –
1. Moderate amount of ascetic fluid present in the peritoneal cavity. Straw in colour
2. R/S multilocular 6*8cm sized ovarian tumour found adhered to bowel loops.
3. L/S ovary and the uterus densely adhered to the rectum and lateral pelvic wall.
4. No macroscopic tumour deposits observed on the omental surface or under surface of the liver.
Procedure:
Peritoneal fluid sent for cytology. Tumour debulking done.
L/S Oophorectomy done along with the tumour.
14. Guide for gynaecology & obstetric internship- Yapa Wijeratne
L/S ovary and uterus were not dissected due to dense adhesions found with the sigmoid colon and
the rectum.
Omental biopsy taken.
Skin –interrupted nylon.
In any case of ovarian tumor/ suspicious cyst or suspicion of malignancy document about omentum,
bowel, rectum, liver, undersurface of diaphragm, ascetic fluid (if present) as that information is essential
for staging of tumor if histology came as malignant.
Total Abdominal Hysterectomy + Bilateral Salphingo-oophorectomy
By Dr. (VOG), Dr (SR), Dr (Reg)
Under GA By Dr. (MOA)
On 03-10-2016
Indication: Heavy menstrual bleeding not responding to medical treatment/ multiple fibroid uterus
Procedure:
Pfannenstiel / midline incision made. Peritoneal cavity opened into.
Findings:
B/L ovaries and tubes appeared normal.
Three pedicles identified, ligated and resected.
Routine TAH + BSO done. Uterus- Multiple fibroids.
Complete haemostasis achieved
Vaginal vault and Rectus sheath sutured with vicryl.
Skin sutured with Vicryl subcutucular.
Specimen sent for histology.
Investigations:
Hb: 12.8 g/dl
WBC: 10.0 x 103/ul
Plt count: 350 x 103/ul
BU: 3.5 mg/dl
SE: Na 145mmol/L K 4.5 mmol/L
FBS: 5.9 mmol/L
CXR: NAD
ECG: SR
2D Echo: Good LV function. EF >60%. No RWMA. Mild MR
HIV I, II Ab:
Hep B sAg:
Post Op:
Recovery uneventful.
IV Cefuroxime 750mg 8 hourly
IV Metronidazole 500mg 8 hourly
Post op Hb
Management and follow-up:
15. Guide for gynaecology & obstetric internship- Yapa Wijeratne
O. Cefuroxime 500mg bd x 5 days
O. Metronidazole 400mg 8 hourly x 5 days
Review in Gyn clinic with histology report in 4 weeks ( on 00/00/2016)
ANTERIOR REPAIR
Done Under SA
INDICATION: Cystocele
Procedure:
Patient in lithotomy position.
Bladder emptied.
Vertical incision made.
Bladder separated from vaginal wall.
Buttress suture applied.
Anterior repair done.
Complete haemostasis achieved.
LAPAROSCOPIC + DYE TEST+ OVARIAN DRILLING under GA
INDICATION: Primary Sub fertility
Findings –
Uterus Normal Size and Anteverted,
B/L Ovaries polycystic. B/L Ovarian Drilling Done
POD Normal.
No evidence of PID or Endometriosis
Bilateral Fallopian tubes appeared normal
Sub mucus Fibroid (2*2cm) in posterior aspect.
Dye test - both tubes patent.
Discharge plan
- Wait for menstruation
- Ovulation induction with clomephine citrate 100mg daily from D2-D6
-Metformin 500mg nocte
-D12 TVS for follicular tracking (at ward at 8:30 am)
EXPLORATORY LAPAROSCOPY + Rt-SALPHINGECTOMY DONE under GA
Findings –
Haemoperitoneum noted (approximately 50ml of blood)
Right sided TUBAL ECTOPIC
Left tube appears normal
BL ovaries looks normal
Uterus Normal looking
No adhesions, cysts or masses
Rt- Salphingectomy done – Sample sent for histology
16. Guide for gynaecology & obstetric internship- Yapa Wijeratne
MANCHESTER REPAIR Done Under SA
Procedure:
Patient in Lithotomy position.
Bladder emptied.
Tear drop shaped incision made.
Bladder was separated from the vaginal wall.
Partial amputation of the cervix done.
Utero-sacral ligaments were cut and anchored tightly to the anterior aspect of the cervical stump
Amputated part of the cervix sent for histology.
Anterior repair done.
Haemostasis achieved.
Vaginal wall sutured with vicryl .