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2012

Group C2 ( 2012)
this was taken from the past OSCE exams
and answerd to add tome more notes to
the Focus Hx notes that we have
Past Years OSCE Answers

1 Typical case scenario for preterm delivery ( 35 year pregnant , 34 week Gestational age , Multipara , previous
2 deliveries in early pregnancy , and now she has lower abdominal pain )



History

1- Age, Gravidity, Parity & Blood group
2- LMP & EDD to determine GA
3- Singleton or multiple
4- Analysis of the contractions
5- Associated abdominal pain, back pain, rupture of membranes, vaginal bleeding ( recurrent ) or fever
6- Any change in fetal movements
7- History of previous preterm labor (in this pregnancy or previous)
8- Known U/S findings in this pregnancy (multiple gestation, placenta previa, fetal anomalies, uterine anomalies &
GA by U/S)
9- Risk assessment
- DM or HTN
- Surgery
- Smoking
- Low body mass index ( BMI < 20 )



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2- Typical case for DUB ( Dysfunctional uterine bleeding ) . 48 year old female , Multipara ,
excessive abnormal bleeding .


History

Profile (age, parity, marital status & work)

History of present illness & Gynecologic history

Analysis of previous normal cycle: duration, regularity, duration of menstrual

flow, no. & size of pads, soaked, presence of clots, associated dysmenorrhea & its type

Analysis of the abnormal bleeding Pattern
Amount, color, clots
Severity (number & size of pads, soaked, symptoms of anemia, impact on life)

Associated post-coital bleeding

Associated symptoms: pelvic mass, symptoms of cancer & metastases
Possibility & symptoms of pregnancy

History of PID or STD

Taking contraceptives or IUD

Last Pap smear

Symptoms of fibroid (urinary symptoms, constipation, mass)

History of fibroid, endometriosis, malignancy

Symptoms of thyroid disease

Obese or not

Past history

DM, thyroid disease or bleeding disorder
HTN

History of breast diseases

Drug history

Anticoagulants or Tamoxifen

Family history

Endometrial cancer, breast cancer, colon cancer

Cervical or ovarian cancers



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3- Scenario-based station , between you and examiner

A- Large for gestational age ( how to asses the GA by exam and the Sonar ? . Give your DDx ? )

ULTRASONIC ESTIMATION OF EDD:
1ST TRIMESTER:
CRL (+/- 5 days)

2ND TRIMESTER:
Bi-Parietal Diameter ( BPD ) Head Circumference ( HC ) Abdominal Circumference ( AC ) - Femur Length ( FL )

And by examination Fundal Height

Fundal height:
Measuring large for GA:
1- Wrong date (corrected by US)
2- Loose abdominal muscles, as in
multiparous women
3- Having uterine fibroids
4- Multiple pregnancy
5- Polyhydramnios
6- Tall stature of mother
7- Baby position is high above the
pelvis, this occurs in case of
breech presentation and in
placenta previa
8- Macrosomia of diabetic mother.
9- Simply carrying a big healthy
baby (Constitutional)

..

B Vaginal Discharge
details about causes , color , smell , consistency , treatment )

1 - Causes for abnormal vaginal discharge:

Infectious
Fungal and yeast
bacterial
Protozoa
viruses
Non infectious
Foreign bodies
Neoplasm
Atrophic vaginitis
Poor hygiene

Types of discharge - 2
White (at first and end of the cycle)
Clear and stretchy (mean ovulation)
Clear and watery (heavy exercise, after cycle)
Brown (after period)
Spotting blood (mid cycle)
Yellow or green (infection)

Clinical Presentations - 3
The vaginal discharge is heavier , thicker than usual (pus -like)
White and clumpy discharge.
Greenish ,yellowish, or blood tinged discharge.
Foul smelling (fishy or rotting meat) discharge.
Accompanied by itching ,burning ,rash, or soreness.
Treatment - 4
Candida ---- Flucanazole or Ketoconazole
Clindamycin cream and Metronidazole -- Bacterial vaginosis
Trichomonus vaginals ---- Metronidazole


Done by : Ahmad Shhadeh










Case1 endometriosis
The Dr gave typical history of endometriosis ( secondary dysmenorrheal , lower
abdominal pain , deep dyspareunia , infertility .. )
1.what is your diagnosis ? endometriosis
2.what investigations to confirm ? biopsy is confirmatory , tumor marker C125
may be elevated ( from lecture )
3.what is the most definitive diagnostic way ? the definitive diagnosis is be
visualization of the lesion by laparoscopy
4.what are the lines of treatment ?
1- medical treatment :
a-symptomatic ( analgesics , NSAIDS )
b- hormonal :the aim is to stop the ovulatory cycle , we use :
1 COCP : prevent ovulation by ve feedback on pituitary so LH and FSH will
drop
When estrogen and progesterone are given at the same time they will have
no effect on endometriosis
2 danazol : 17 alpha ethinyl testestrone , not used anymore , has sever
androgenic side effects
3 gestrinone : androgen derivative
4 we can use high dose of progesterone
5 GnRH analogues : inhibit LH FSH ( pseudo-menopause )

2- Surgical treatment
A conservative surgery : if there is endometroma we remove it , if there are
adhesions we excise them , we use this method in young patient who need their
fertility
B radical surgery : hestrectomy and oopherctomy and removing all the
endometrial spots and adhesions , for old patient

Factors that affect the choice of treatment are : age , symptoms , the extent of
the disease , the reproductive wishes , certainty of the Dx and damage to
other organs


Case2. Normal labor , induction of labor
1. What do u want to see in ur examination ? ass lie , presentation ,
engagement , bishop score and pelvic adequacy
2. When to decide to do cesarean ? normal vaginal delivery is
contraindicated in the following :
a- Absolute :
1-placenta previa
2-previous 2 CS , previous one due to recurrent cause , previous
classical CS
3-abnormal antenatal CTG
4-transverse or oblique lie
5-active genital herpes infection
6-absolute contracted pelvis
7-tumor occupies the pelvis
8-cervical carcinoma
9-successful pelvic floor repair and successful surgical treatment of
stress incontinence

b- Relative :
1-severe preeclampsia
2-breech presentation
3-multiple pregnancy
4-grand multipara
5-polyhydramnios
6-presenting part above the pelvic inlet

For more information go to Dr Fayez hand out page 4


Case3. (partogram )
Go to morning sessions summary

Case4.
Answered

Done By : Mohamad Gasaymeh




























Hx for GDM

Ask about GDM risk factors , including :

Age > 30

Family history of DM ( esp 1
st
degree relatives )

Diabetes in a previous pregnancy;

Previous macrosomic infant;

Previous unexplained fetal demise

Unexplained Intrauterine Fetal Death and Neonatal death

History of polycystic ovarian disease

Congenital abnormalities


Recurrent miscarriages

Large babies > 90th centile for their age

Obesity

Hypertension

Recurrent infections

Significant Glycosuria




Ask about DM symptoms
polyurea polyphagia
ketoacidosis polydypsia
coma wt loss
infections esp UTI
or fungal infections



MANEGMENT & TESTS :
Check list
Check list







for hight risk population we start screening as soon as 1
st
trimister
for NO risk group we can start screening at about 24-28 w
we start by 50gm OGTT if result is above 7.8 mmol ( that means pt is at hight risk of GDM
so we do the 75gm OGTT ( if fasting B sugar was more than 6 ) or ( after 2 hrs from 75gm glucose blood
sugar was more than 9 then we diagnose as GDM )

__________________________

manegment must start from preconseption by
1) controling B sugar aby keeping HBA1c less than 6
2) by giving folic acid supply

Insulin ( must be given in case of GDM ) ( by one of 2 methods )

1) 3 x a day as ( short acting insulin ) + 1 x ( intermediat acting insulin at the evening )
or

2) 2x a day ( as mixed short and intermediat acting insulin

Calculate daily dose
1
st
trimester .6 units x wt
2
nd
trimester .7 X wt
3
ed
trimester .8 X wt





Vaginal discharge
Causes itching
Causes swelling
Has a bad odor
Is green, yellow, or gray in color
Looks foamy or like cottage cheese
redness
Pain or dysurea
Candidal Vaginitis
Risk factors
Contraceptive practices
Use of systemic steroids
Use of antibiotics
Undiagnosed or uncontrolled
diabetes mellitus
Diagnosis:
#Diagnosis is made by history, physical
examination, and microscopic examination of
the vaginal discharge in saline and 10% KOH.
AZOL - Antifungal drugs >>>> fluconazol ( Treatment
antifungals )


Trichomonas vaginalis
Clinical presentation:
half of - symptoms may be noted in up to one No
women vaginal discharge
smell Foul dysuria,

pain
and
yellow or
clolr green.
dyspareunia vulvar
pruritus


On exam >> strowberry spots ( diagnostic for
trichomonas insfection )
Laboratory tests:
vaginal pH is usually between 5.0 and 7.0. The - 1
Saline wet mount of the vaginal discharge - 2
smear Pap - 4
Tretment >>> metronidazol














there was a qustion about Partogram
to be frank I didnt know how to answer the question ..
so I looked google for some info about it plus the morning
session notes I think that may help
sorry agin but I tried my best
Waleed

A partogram is a normal part of a labor and delivery of a baby.
The partogram provides important data about the mother and
child at a glance to medical personnel. The partogram is used
in hospitals and birthing centers. Medical personnel, including
midwives, are trained in reading the data provided by the
partogram.
A belt with sensors is placed around the abdomen of the
mother. The partogram sensors are not uncomfortable nor is
the placement of the sensors. The partogram monitors the
mother is labor and provides information about the progress of
the baby in the birth canal.1
Medical Disclaimer:This page is not a substitute for
professional medical advice. Please contact a doctor before
using the information presented here.
Data Recorded in a Partogram:
Patient Data--Name, Age, Hospital Identification Number,
Time and Date of Admission
Cervical Dilation
Where Baby's Head is
Number of Uterine Contractions in 10 Minutes
















Bacterial vaginosis
Reisk factors
Oral sex - 1
Douching - 2
Black race - 3
Cigarette smoking - 4
Sex during menses - 5
Intrauterine device - 6
Early age of sexual intercourse - 7
New or multiple sexual partners - 8
Sexual activity with other women - 9


Lab diagnosis
The vaginal pH is generally between 5.0 and 5.5. - A
Wet mount preparations with saline reveal a CLUE - B
CELL
Application of 10% KOH to the wet mount specimen - C
produces a fishy odor, indicating a positive WHIFF
test.
A gray, homogenous, malodorous discharge is - D
present.
Treatment: metroidazol // clindamycin


Bacterial vaginosis
Reisk factors
1-Oral sex
2-Douching
3-Black race
4-Cigarette smoking
5-Sex during menses
6-Intrauterine device
7-Early age of sexual intercourse
8-New or multiple sexual partners
9-Sexual activity with other women

Oral and IV Fluids
Medicines
Blood Pressure, Pulse, and Temperature2
Labor Is Divided Into Four Stages:
Latent Phase
From onset of labor until 3 cm cervical dilation
Active Phase
3 cm cervical dilation to full (10 cm) dilation; Once entering the active phase cervical dilation should progress at
1 cm per hour
Birth of the baby
Delivery of the Placenta3

Labor varies from woman to woman and even pregnancy to pregnancy. Call a doctor or midwife immediately if
experiencing:
Contractions 5 to 10 minutes apart
Can no longer walk or talk between contractions
Water breaks (gush or continuous trickle)
Vaginal Bleeding
Bloody, brownish or red-tinged mucous discharge
Lower back pain that will not go away
Baby starts moving less4
_________________________________________________________________________________________
More info about manegment

Failure to Progress
Aka: Failure to Progress, Labor Dystocia, Cephalopelvic Disproportion, CPD


I. Management: Stage One
A. See Labor Coaching
B. Consider Active Management of Labor
1. See Oxytocin Augmentation
C. Consider amniotomy
D. Consider extending definitions of arrested labor
1. Delaying C-section until 4 hours without dilation
2. Typically were indicated at 2 hours without change
II. Management: Stage 2
. Consider Oxytocin Augmentation
A. Avoid exhausting mother early
1. Consider not pushing until involuntary urge to push
2. Consider waiting until vertex approaches introitus
B. Consider Assisted Delivery
1. Vacuum Assisted Delivery
2. Forceps Assisted Delivery
C. Consider correction of malposition: Occiput Posterior
1. Maternal position change
a. Position mother curling forward from hips
Manual Rotation in Occipitoposterior Presentation
III. Management: Dystocia refractory to above management
. Consider Cesarean section


Done By Waleed Al Natsheh

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Station 1
Patient P0+4 came to your clinic. All abortions happened in second trimester, take relevant history..
1. Patient age, blood group
2. Was previous pregnancies singleton or multiple?
3. History of fever or vaginal discharge in previous pregnancies(infection)
4. History of gush of vaginal fluid and decrease in stomach size in previous pregnancies(PROM)
5. Any history of secondary dysmenorrhea, postcoital bleeding, menorrhagia, constipation,
incontinence(fibroid)
6. Family history of recurrent abortion, inherited diseases
7. History of gynaecological surgery or procedure, pelvic floor repair
8. Drug history (exposure to diethylstilbestrol may cause cervical incompetence)


Station 2
23 year old female G2P1+1 complaining of severe dysmenorrhea, take relevant history..
1. Analysis of pain: duration, continuos or intermittent, nature of pain, severity, relation with
menstrual cycle, aggravation factor(menstrual cycle), relieving factor(NSAIDs)
2. Gyne history: Age of menarche, cycle length, cycle regularity, duration and amount of menstrual
bleeding, intermenstrual bleeding, postcoital bleeding, dyspareunia
3. Associated symptoms such as fatigue, nausea and vomiting, diarrhea, lower backache and headache(primary
dysmenorrhea)
4. History of multiple sexual partner, sexually transmitted disease
5. History of gynaecological surgery or procedure,drug history(OCP protective of endometriosis)
6. Family history of dysmenorrhea

Station 3
1. 30 years old P2+0 patient came with postcoital bleeding
What physical exam you like to do (speculum examination to see the cervix)
If the cervix wa normal, what investigation will you do (pap smear)
From where the pap smear is taken (from ectocervix using wooden spatula and endocervix using
brush stick)

2. 28 years old patient G1P0, 26 weeks gestation sure date and pregnancy was induced by clomiphene citrate
Level of fundal height? (between umbilicus and xiphoid process)
Her fundal height was 35. What is the most common cause in this situation(multiple pregnancy
because it was induced pregnancy)
What youll find in physical exam?(2 head&2backs..excessive fetal movement..by Doppler 2 heart
beat)
What is the importance of US in this case? (confirm multiple pregnancy, assess the chorionicity in
early pregnancy, assess the presentation, fetal anomaly scan, assess liquor amount, assess weight of
babies)



Done By Amirol Fadli


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Station 1:
Vaginal bleeding in the 3
rd
trimester Anti-partum hemorrhage take an Hx And what is the management??
It is either placenta previa or placental abruption .
Answer:
The Hx is found in Focused History page 25 and some info about Previa and abruption in pages (26, 27) and dont forget the 1
st

step in management is Admission and in previa if the bleeding is sever we do C\S regardless of the gestational age but if the
bleeding is not sever we start with expectant management which mean we admit and observe her condition and fetal well being till
fetus reach maturity (36,37 week) .
Sometimes we can differentiate between abruption and previa by Hx and Examination in previa the bleeding is painless and causeless
and on examination the uterus is soft and not tender and mal-presentation is common but in abruption the patient come in shock and
there is abdominal pain, discomfort, and backache and on examination the uterus is over distended, rigid, tender, and difficult to feel
the fetal parts esp. in concealed abruption, and evidence of skin ecchymosis.
But we the only thing to confirm our diagnosis is by abdominal U\S and in previa if the placenta located posteriorly (behind the head)
we do trans-vaginal U\S.
Station 2:
Vaginal bleeding in the 1
st
trimester, take an Hx And what is the management??
It is either abortion miscarriage or Ectopic pregnancy.
Answer:
The Hx is found in Focused History page28 some info about abortion and ectopic pregnancy in pages (29-34).
And the management also found in focused Hx too.

Station 3:
Pregnant lady who has also fibroid in the lower part of the uterus, 1
st
(how to deliver her and what type of incision)???, and if
she developed after delivery DVT 2
nd
(what is the cause and what is the management)???
1st we deliver her by C\S and the type of incision is transfer.
2nd the cause is :
Pregnancy
Surgery
Immobility
DM
Hypercoagulability
Age
Previous history of DVT or PE
Metastatic malignancy
Vein disease (such as varicose veins)
Estrogen usage
Obesity
Genetic factors
The management: is after we exclude primary PPH we start with bed rest and compression stocking and we give LMWH for 5 days
followed by three months of warfarin, if there is bleeding we stop heparin and we give the antidote (Protamine Sulfate), according
warfarin we stop warfarin or administration of vitamin K, fresh frozen plasma or coagulation factor concentrates such as prothrombin
complex concentrate (PCC).



Done By : Mohamad Theabat

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35 years, pregnant, 34 weeks gestation, multipara, previous 2 preterm deliveries in the previous pregnancy, now
complaining of lower abdominal pain. Take a relevant history.
1. Ask about the parity and last menstrual period (to determine gestational age)
2. Ask about type of pregnancy (singleton or multiple)
3. Analyze the lower abdominal pain (contractions)
i. How long does it lasts
ii. How often does it occurs
iii. Any association with cervical changes
4. Any association of abdominal pain, back pain, rupture of membranes (leakages of water), vaginal bleeding
and discharge.
5. Any association with fever, chills, restlessness, and change in fetal movements.
6. Details of antenatal visit (any disease, maternal complication, PV, fetal anomalies, uterine anomalies and
gestational age by ultrasound)
7. Past obstetric history (for risk assessment)
i. Previous pregnancies (type of pregnancies and deliveries normal, C/S, multiple gestation)
ii. Any maternal/fetal complication (GDM, chronic HTN, antepartum hemorrhage, association with
uterine abnormalities; fibroid
iii. Detail history of previous preterm labor (hx of IUFD, IUGR, fetal anomalies, history of multiple
gestation)
iv. Any labor complication (assisted deliveries, instrumental deliveries, trauma, PPH)
8. Past gynaecological history (for risk assessment)
i. Any gynaecological surgery/manipulation
9. Past medical (history of DM, HTN, thromboembolic disease, bleeding tendencies)
10. Social history (hx of smoking, drug abuse)

Preterm labours is a labor contraction with progressive cervical changes between 24 and 36 weeks of gestation.
Usually caused by infection, overdistended uterus, antepartum hemorhage, intercurrent illness (UTI), cervical
incompetence, idiopathic.
(OSCE Oriented page 46)

48 years old female non-pregnant, multipara with complain of excessive vaginal bleeding. Take a relevant history.

1. Asses the parity, marital status and occupation.
2. Analysis of chief complain
i. Analyze the previous menstrual cycle (regularity, duration of menstrual flow, association of
dysmenorrhea, any presence of clots, any history of intermenstrual bleeding, aggravating and
relieving factors)
ii. Analyze the abnormal bleeding. (pattern of bleeding, amount regarding the pads, color of blood,
presence of clots)
iii. Any associated gynaecological symptoms (dysparaeunia, post-coital bleeding)
iv. Any restriction of activities (how does the complain affect her life)
3. Associated symptoms
i. pelvic mass, mass effect such as urgency, incontinence and constipation
ii. chronic pelvic pain
iii. symptoms of pregnancy (spotty vaginal bleeding, morning sickness)
iv. anemic symptoms (shortness of breath, palpitation, palor, fatigue)
v. symptoms of throid disease (weather intolerance, bowel habit, palpitation etc)
vi. any history of contraception (COCP, IUDs, copper, ligation)
4. Past medical/disease
i. History of thyroid disease
ii. Chronic illness (DM, HTN)
iii. Any bleeding disorders (ITP, vWD)
iv. History of malignancy (breast, ovarian)
5. Past gynaecological history
i. History of uterine disease (fibroids, endometriosis, malignancy)
ii. History of gynaecological surgeries (DnC, EnC)
iii. Last cervical smear
6. Drugs History
i. Any history of anticoagulants (aspirin, warfarin, heparin), tamoxifen,
7. Family history
i. Any history of early death/cancers (endometrial, breast, colon, ovarian,cervival)
ii. Any bleeding disorders and thromboembolic phenomenon

(OSCE Oriented page 2)

SCENARIO BASED STATION
A. Large for gestational age
i. How do you assess LGA by exam and U/S
a) Fundal Height (fundal height will represent weeks of gestation with margin of error plus minus
two)
b) Ultrasound 1
st
trimester (crown-rump length)
c) Ultrasound 2
nd
and 3
rd
trimester (biparietal diameter, femur length)

ii. Differential diagnosis for LGA
a) Wrong date
b) Macrosomic
c) Multiple gestation
d) Polyhydramnios
e) Pelvic and endometrial masses

B. Vaginal Discharge
i. Types of discharges
a) Thick, profuse, white with sweet odor (candida)
b) Frothy green-yellow foul smelling (trichomonas)
c) Yellow mucopurulent odourless (Chlamydia)
d) Copious mucoid discharge (genital herpes)

ii. Finding on examinations
a) Excoriations, erythematous vulva and vagina

iii. Diagnostic test
- Candidia 10% KOH reveals hyphae, pseudohyphae with budding
- Trichomonas most sensitive test is culture by special media (diamond) but inpractical. So we
use pap smear confirmed by wet mount examination (show vibrating organism)
- Bacterial vaginosis wet mount examination with saline shows Clue Cell. Adding 10% KOHG will
produce fishy smell (Whiff test)
iv. Treatment
- Candida antifungal for 3 day course or 7 days course
- Trichomonas systemic treatment with oral metronidazole for 7 days, twice daily. If resistant,
give IV metronidazole
- Bact vaginosis clindamycin cream , metronidazole cream used topical intravaginall




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Case 1
44 years old female, menopause since 2 years, came complaining something coming out. Take relevant history.
Dx: Genital prolapsed
History
1. Introduce our self.
2. Profile ( marital status, parity, working or not)
3. Chief complaint: Lump or prolapsed
a. Duration
b. Always present or can go back in
c. Aggravated: long standing, coughing, straining, heavy work, usually worse at the end of the day
d. Relieved: lying down
e. Impact on social and sexual life
f. Associated symptoms
i. Uterine prolapsed: low back pain
ii. Cystocele: incontinence, lower urinary symptoms, inability to empty bladder, patient need
to reduce it manually to empty the bladder
iii. Rectocele: constipation, incomplete rectal evacuation, patient need toreduce it manually to
empty rectum
iv. Procidentia: ulcer, blood stained or purulent vaginal discharge
g. Risk factors
i. Multiparity with vaginal deliveries and long labors, instrumental deliveries
ii. Increased intra-abdominal pressure: chronic cough, constipation, masses
iii. Menopause
iv. Pelvic surgeries
4. Gynecologic history
a. Menopause
b. HRT
c. Altered sexual functioning: dyspareunia, avoidance of intercourse, decreased of libido, decreased
self image
d. Vaginal discharge
e. Contraceptive: IUCD
5. Past medical and surgical history
a. Chronic cough or constipation
b. Previous surgeries
Done by Ahmad Syahmi Yahya
6. Family history
a. Same problem
7. Social history
a. smoking
Case 2
Q1: placenta previa, total, GA 30 weeks, presented with heavy vaginal bleeding (1500 ml), what is your finding in
examination?
General exam :
o Sign of anemia: fatigue, shortness of breath, pale, dizziness
Inspection:
o Painless vaginal bleeding with bright red blood (or can evaluate quantity and presence of vaginal
bleeding by speculum
Palpation:
o Malpresentation and high presenting part of fetus
o Uterus is soft and non tender
CTG:
o Normal CTG
ultrasound:
o placenta covering the cervical os
Q2: septic incomplete abortion, what finding you will see in pelvic exam?
Purulent discharge
Cervix open
Cervical motion tenderness
Tender uterus


Case 3
NVD, presented after 2 weeks with fever. Take relevant history
Dx: Puerperal pyrexia
1. Introduce our self
2. Patient profile (parity)
3. Analysis of chief complaint (fever)
a. Duration ( any 2 of first 10 days of postpartum)
b. The temperature ( 38 C or higher)
c. Chills or rigor
d. Associated symptoms
i. Genital tract infection ( endometritis)
1. Lower abdominal pain
2. Vaginal discharge (change in lochia)
ii. Urinary tract infection
1. Dysuria
2. Frequency of micturition
3. Loin pain
4. Tachycardia
iii. Breast infection (mastitis)
1. Breast tenderness
2. Discharge
e. Risk factors
i. PROM >24 hours
ii. Previous digital pelvic examination
iii. Intrauterine monitoring devices
iv. Catherization
4. Past obstetric hx
a. Complication
b. Instrumental
5. Past medical and surgical hx
a. Previous infection (vaginitis, cervicitis)
b. DM
c. HTN
6. Family history
a. DM
b. HTN
c. Same condition
7. Social hx
a. Smoking
b. Low social economic status


Done By : Siti Nabilah Kamarudin

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2009 OSCE exam
1) A 44 year old female, menopause since 2 years, came complaining from something coming out, Take a relevant
history

DDX: Genital Prolapse

1. History
a) Profile (age, marital status, parity,working or not)
b) History of Lump
1. Duration,
2.Always present/ sometimes
3. Aggravated by long time standing/coughing/appeared at the end of day
4. Relieved by lying down
5. Impact on society & sexual Life
6.Associated Symptoms:
Uterine
Prolapse
Cystocele(bladder) Rectocele(rectum) Procidentia
Back pain 1. Sx of vaginal
fullness(heaviness,
pressure)
2. Discomfort progress at
the course of day
3. Noticeable after
prolonged stand
4. Incontinence, urgency
5. Increased frequency of
urination, nocturia
6. Need to empty the
bladder manually
7. Can cause urethra
obstruction urinary
retention.
1.difficulty in bowel
function &
defecation
2. constipation
3. incomplete rectal
evacuation
4.need to reduce
the rectum
manually.
Effect Quality of life!!
1. Excessice
purulent
discharge
2. Decubitus
ulceration
3. Bleeding
4. Rarely: CA of
cervix

Risk Factor: Multiparity/ Prolonged labor
Increased intra-abd Pressure (ch.cough/constipation/obesity/masses
Menopause
Pelvis surgeries (hysterectomy/composuspension)

c)Gynecology History
(menopause & HRT/ surgery/ previous prolapsed)

d)Past history
( Ch. Cough/constipation/previous surgery/ excersice stretching/ diff. NVD/ prolonged labor)

e)Social history
(smoking)

2.Examination
1. Inspection of Vulva with cough & straining to demonstrate severe prolapsed/incontinence
2. Speculum examination either dorsal (bivalve) / left lateral position (sims)
3. Rectal examination to diff between reectocele ( finger goes through) from enterocele( finger goes high up)

3.investigation
1. urine analysis
2. renal u/s & IVU in case of procidentia & severe cystocele to exclude hydroureter & hydronephrosis
3. cystometry in case of incontinence


4.prevention
1. preventing during childbirth ( good labor mngmt, postnatal pelvic floor exercise, fam plan)
2. avoiding intra-abd pressure ( obesity, smoking, ch.,cough, constipation)
3. Prevention postmenopausal (balanced diet, exercise, calcium & by the increase use of HRT)

5. treatment
1. pessaries (for those unfit/refuses for surgery, during/ after pregnancy, waiting time for surgery)
2. Surgical Treatment
Uterine prolapsed ; Vaginal hysterectomy (complete family) ,
Manchester (forthergill) operation ( young & not complete family)
Sacrohysteropexy (comple family & want to conserve uterus)
Vaginal Prolapsed : Cystocele & Urethrocele ( ant. Colporrhaphy)
Rectocele ( post. Colpoperineorrpahy)
Enterocele ( resection of enterocele sac)
Vault Prolapsed ( abdominal sacrocolpopexy)
Lefort's operation .

2. Placenta Previa , GA 30 weeks, presented with heavy vaginal bleeding, (1500ml), what is your finding on
examination.

History
1. Profile ( age, parity, gestational age, blood group)
2. Present pregnancy ( LMP & EDD, Dx of pregnancy, U/S finding- multiple/singleton, anomalies, position of
placenta)
3. Present illness - amount/ color/ clots/ severity of shock, oliguria/ associated sx (pain, labor contraction)
4. Risk factor for placenta previa multiparity, multiple gestation, previous previa, previous C/S, increased age
5. Risk factor for abruption PET/HTN, smoking, multiparity, trauma, ROM, overdistention ( polyhydramnions,
multiple gestation)
Examination
1. General (sx of shock) & Vital Sign( pulse)
2. Obstectric (tenderness, high fundus or not, presentation, lie, engagement, contraction)
Presentation of placenta previa: painless, recurrent episode of small bleeding, vaginal bleeding with
contractions, abdomen soft & non tender, malpresentation.
Investigations
1. Blood for grouping, cross-match & Hb
2. Transvaginal U/S (100%), abdominal U/S(95%)
3. Double set-up examination (old)

Management
1. Resuscitation & blood grouping & match
2. Give steroid for lung maturity
3. Assess fetal well-being
4. Give anti-D
5. Delivery by C/S if Severe or NVD if in grade 1
6. Observe for PPH


Maternal complications Fetal complication
1. Massive bleeding
2. Increased mortality rate
3. PPH DIC
4. Sepsis
5. Higher risk anesths & surgery
6. Air embolism
7. Deliver c/s
1. Prematurity (increased mortality, IUGR)
2. Mal-presentation
3. Cord compression
4. Congenital malformation




3. Septic incomplete abortion, what finding you will see on pelvic examination.

History
Profile(age, parity, GA, blood group)
History of present illness
Blood-amount/color/clot/severity of sx (shock / oliguria)/ product of conception
Associated sx ; (incomplete abortion)-vaginal bleeding, with/without hx of evacuation
(pelvic infection) tachycardia,fever, malaise, lower abd. Pain,pelvic tenderness, purulent vaginal
discharge

Presentation : open Cervix
U/S: empty uterine cavity

Investigation
Cbc/ blood grouping/ xm 2 units of blood
Cervical swab for culture & sensitivity
Coagulation profile (DIC), serum electrolytes & blood culture if pyrexia >38.5 C

Management
1. Iv Antibiotics ( IV cephalosporin + metronidazole)
2. Surgical evacuation of uterus ( 12hours after antibiotic therapy)
3. Post-abortion management






4. NVD presented after 2 weeks with fever, Take a relevant history. Puerperal Pyrexia
Causes:
1. Genital tract infection: upper tract/ perineal infection
2. UTI
3. Breast infection (mastitis)
4. Resp. tract infection (common after anesthesia)
5. Thrombophlebitis & DVT
6. Wound infection ( anemia)
7. Premature & Prolonged ROM
8. Prolonged labor
9. Frequency vaginal examination during labor
10. C-sec/ forcep/ vacuum delivery
11. Cervical/vaginal lacerations
12. Manual removal of placenta
13. Retained product of placental fragments/fetal membranes

History
1. Profile (age,parity,blood group)
2. History of Present illness
Degree of fever?
When is the peak fever?
Associated symptoms:
a) Endometritis lower abd. Pain
-change in lochia : more profuse, foul smelling / purulent
b) mastitis breast tenderness/redness/swollen/hot /discharge
- - cellulitis/nipple trauma
-
c) UTI frequency, dysuria, hematuria,
-loin pain (pyelonephritis)
-tachycardia & pyrexia

d) C-sec painful red suture line, deep tenderness on palpation, lochia pink/coloured


3. History of past delivery
a) PROM >24h?
b) Prolonged labor?
c) Used of vacuum/forcep?
d) Sutures required?
e) Was the placenta completed?
f) Was there any bleeding during/after delivery?
Examination:
a) Take the patient's temperature.
b) Palpate the uterus to assess size and tenderness.
c) Assess any perineal wounds and lochia.
d) Examine the breasts(discharge, color, tender, swollen).
e) Examine the chest for signs of infection.
f) Examine the abdomen.
g) Examine the legs for possible thromboses (size of the calf, color, painful).


Investigations
- High vaginal swab.
- Urine culture and microscopy.
- Other swabs as felt necessary, e.g. wound swabs, throat swabs.
- FBC.
- Blood culture.
- Ultrasound scan may be required to assist diagnosis of retained products of conception.

Management:
a) Endometritis: admit to hospital
Evacuation of retained products of conception under Ab cover
Parenteral broad-spectrum Ab, stopped once the patient is febrile for 24-48h
(ampicillin & cephalosporin)

b) Mastitis: isolation of the mother & baby
Ceasing breast feeding from affected breast
Expression of milk either manually/ electric pump
Microbiological culture & sensitivity of a sample of a milk
Flucloxacilli can be commenced while awaiting for the result
10% develop abscessneed surgical incision & drainage under GA






Done by: ungku yasmin soraya
Resources: hackers, lecture notes & internet.

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Done by : Siham.k
Q4:ddx >> larg for gestational age
A:osce oriented pg35

Q5:hx of early pregnancy bleeding with past hx of ectopic &pelvic surgery&minipill use..?
1-ddx:first should find out if she is pregnant or not if yes..then you think of obstetric causes : ectopic,molar,
miscarriage,or implantation bleeding(dx of exclusion)
gynecological causes:cervical polyps,cervical cancer,fibroid,ectropion,vaginal
laceration,infection(cervicitis,vaginosis,endometritis...ect)

systemic causes:drugs,bleeding tendencies...

2-what is the risk factors from hx?
hx of ectopic,minipill,pelvic surgery

3-how ectopic present?
silent
acute>>rupture
subacute>>variable presentation>>most common

4-what invest to do?
pregnancy test,transvaginal US and abdominal,laproscopy,draw blood for blood grouping
and cross matching,cbc

5-what you see in US?
no intrauterine sac,adenxial mass,fluid in pouch of douglas.

6-B-HCG is 1500 with empty uterus what is ddx??
if it is 1500 with empty uterus>>>it is inconclusive>>should be repeated when it is 2000>>
if find sac then it is intrauterine preg ,,,if no sac we presum ectopic...

7-mang??
addmition
if pt not in shock >>resuscitation:o2,fluid,blood trans...them monitor responce by vital signs and urin output...
maneg according to the cause.....go back to mangment of each cause !!!


q6: case of APH ...painless,recurrant???
1-ddx:previa,abruption,show,vasa previa,local causes(same as above),systemic cause
2-from hx what suggest previa?painless bleeding and the GA...and recurrant.
3-presentation of previa ,want 4?
causeless ,painless,recurrent bleeding...this the only presentation i found ..
may be malpresentation,,preterm birth,IUGR...not sure...

4-US(placenta site,presentation,fetal alive or not,signs of abruption)
CBC,coag prof,rh,grouping and cross match
kft,lft
apt test (kleihaure betke test)

5-mangment?
if in shock >>same as in early preg bleeding ,,,and mangment according to cause !!
6-complication after delivery??
PPH,sepsis,air embolism.DIC.
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Question number 1
genital prolapsed

History
Profile (age, marital status, parity, working or not)
History of lump
Duration
Always present or goes in
Aggravated by long-time standing and mostly appearing at the end of the day
Relieved by lying down
Impact on social & sexual life
Associated symptoms:
Uterine prolapse: back pain
Cystocele: incontinence, lower urinary symptoms, inability to empty the bladder,
the patient needs to reduce it manually to empty the bladder
Rectocele: constipation, incomplete rectal evacuation, the patient needs to
reduce it manually to empty the rectum
Procidentia: ulceration, blood staining or purulent vaginal discharge
Risk factors:
Multiparity with vaginal deliveries & long labors
Increased intra-abdominal pressure (chronic cough, constipation, masses)
Menopause
Pelvic surgeries
Gynecologic history (menopause & HRT, surgeries, previous prolapse)
Past history (chronic cough or constipation, previous surgeries)
Social history (smoking)
Examination
Inspection of the vulva with cough & straining to demonstrate prolapse or incontinence
Speculum examination
Rectal examination to differentiate between rectocele & enterocele
Investigations
Urine analysis
Renal U/S & IVU
Cystometry
8
How prolapse can be prevented?
Preventing pelvic floor injuries:
Avoiding prolonged labor, bearing down before full dilatation & difficult instrumental
deliveries
Postnatal pelvic exercises
Family planning
Avoiding & treating causes of increased intra-abdominal pressure such as obesity, smoking,
chronic cough & constipation
HRT after menopause
Treatment
Treat UTIs, cause of increased intra-abdominal pressure & give HRT
Pessaries
Surgical options
Uterine prolapse (vaginal hysterectomy, Manchester or sacrohysteropexy)
Vaginal prolapse (anterior colporrhaphy, posterior colpoperineorrhaphy, resection of
LeForts operation


the End





this was a group effort to solve the past years OSCE
questinos and add more notes for the Foucus Hx notes that
we have
.
.
.
.
.
these notes are done by group C2
Ahmad shhadeh Amirol Fadli Ahmad Syahmi Waleed Al
Natsheh Mohamad Theabat Ayman Al Dobosh -Mohamad
Gasaymeh Siti Nabilah Qamaraldeen - Ungku Yasmin
Soraya - Jomana Azzam - Siham Kanakrieh
.
.
thank you all for the great job

and good luck to all