DR MO SOBHY

Obstetrics & Gynecology

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DR MO SOBHY

1.Obstetric History approach

Obstetrics questions :

- How many weeks are you pregnant?

- When was your last menstrual period?
- Have you been pregnant before?
- If yes, how was the outcome of these pregnancies?
- How many children do you have now?
- How are your children doing?I’m sorry to ask, have you had any abortions; surgical or
medical?
- Have you had any miscarriages?
- If yes, at which stage of pregnancy did this happen?

Current pregnancy:
- Have you been having any problems in your current pregnancy?
- Have you been experiencing any vomiting? (vomiting usually resolve in
about 20 weeks in pregnancy)
- Have you suffered any problems such as high blood pressure or high
blood sugar?
- Have you had any per vaginal bleeding or spotting?
- Do you feel the baby’s movement? (after 16 weeks)

Previous pregnancy:
- Have you had any problems in the previous pregnancies such as high
blood pressure or high blood sugar?
- Have you had hyperemesis gravidarum in previous pregnancies?

Family history:
- Has anyone in the family had high blood pressure or high blood sugar or
pregnancy losses?

Antenatal visits:
- Antenatal booking BP; at your first antenatal visit what was your
blood pressure?
- At your first antenatal visit, have you been tested or screened
for the following infections; HIV, Hepatitis B and C, Rubella, and
syphilis?
- Do you have any concerns from the last antenatal visits?
- Have you been attending your follow ups/antenatal visits regularly?

Menstrual
592
history: drmohamedplab2@gmail.com. +47743137345
- Are your periods normally regular? Do they usually come on time?
- How many days do you bleed?
DR MO SOBHY

- Do you experience any pains during your periods?

- Are your periods heavy?

Pills:
-are you on any contraceptive methods ?

Pap smears:

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 DR MO SOBHY

-Are you up to date with you pap smears ?

-what was the result of the last pap smear? When?
-have you ever been diagnosed with any womb disease?

Sexual hx:
-are you sexually active?
-Do you have a stable partner ?
-Do you practice safe sex?
-Have you ever been diagnosed with any stds?

*************************************************

2. Pre -eclampsia at 36 weeks

Where are you?

FY2 in the Maternity Assessment unit
Who the patient is:
Alice Smith, a 30 year-old lady who has come for routine antenatal follow-
up
Other information you have about the patient:
She is 36 weeks pregnant and she has been seen by the midwife who has
made the following note: - Her Blood pressure today is 160/110 mmHg -
Urine Dipstick shows protein +++ - The booking BP is 110/70 mmHg
What you must do:
Take a focused history and discuss management with the patient

Patient information:

SCENARIO A
You are Alice Smith, a 30 year old lady who is 36 weeks pregnant.
You have come for a routine antenatal follow up. You have been having
headache for two hours and swelling of both legs. The midwife in the
antenatal clinic examined and checked your blood pressure and sent you to
the obstetrics ward. She said the doctor will be here to talk to you. She
found your BP to be high but she did not explain more to you. You have
noticed swelling of your feet in the last 2 weeks and you have been
experiencing headaches during the same period. You have attended all
the antenatal follow ups. And you have no problems so far. You can feel
the kicks of your baby. Your booking blood pressure was 110/70. You
are really hoping that all will be fine today. This is your 3rd pregnancy;

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DR MO SOBHY

the previous pregnancies all went fine and they were normal vaginal
deliveries. Your children are 2 and 5 years old.

SCENARIO B
You are Alice Smith, a 30 year old lady who is 36 weeks pregnant.
You have come for a routine antenatal follow up. This is your 1st
pregnancy. You have swelling of the ankle. You have attended all
antenatal clinics. You work as a secretary; in 3 days’ time you will be
having maternity leave. You will call them and inform them. You have no
visual problems. You have been trying for 2-3 years to get pregnant and
you really wanted a water birth. You and your husband have always
wanted this. You have also discussed with the midwife about water birth.

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

obstetric hx from approach +
-any leg swelling ?
-nausea , vomiting ?
-fever?
-SOB?
-frothy urine?
- liver problem?
-kidney problems?
-any fits / seizures ?
- hx of blood clots ?
-problems with vision ?

risk factors of pre-eclampsia :

two or more factors of :
*increased BMI >35
*first pregnancy
*multiple pregnancy
*age > 40
*family hx of same disease
*last pregnancy > 10 years

one factor of :
*chronic hypertension

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DR MO SOBHY

*CKD
*diabetes type 1 or 2
*autoimmune disease

FLAWS

MMA questions

DESA

ICE & PSYCHOSOCIAL

EXAMINATION
vitals + relevant ex urine dip stick + calculate BMI

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), I suspect you are having a condition
called pre eclampsia
it is a new onset of hypertension during pregnancy after 20 weeks ,it can
be serious if not treated probably

MANAGEMENT
-Routine blood tests + clotting profile , folic acid ,vitamin D
-admit to hospital for ongoing monitoring of their condition and of their
baby's well-being.
What will be done in hospital ?
-abd gel scan
-CTG to assess baby, if in distress then caesarian section (surgical
delivery)
- medication through veins to bring blood pressure down (labetalol)
-MGSO4 (magnesium sulphate)
-they may offer blood thinners too
-involve senior

SAFETY NETTING

LEAFLET

Notes:

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 DR MO SOBHY

Regarding water birth / normal delivery

- Water birth would not be advised due to close monitoring is required in
labour as a result of pre-eclampsia, so CTG and BP need to be monitored
- Water birth is not recommended in the following situations:
- Hypertensive
- Pre-eclampsia
- Epilepsy
- Foetus Distressed
- Induced Labour

**************************************************

3. First antenatal visit

Where are you?

FY2 in the obstetrics and gynaecology department
Who the patient is:
Audrey Jones, a 25 year old lady who came for routine antenatal follow up
Other information you have about the patient:
Mrs. Audrey Jones had her last menstrual period 6 weeks ago. This is her
first antenatal visit
What you must do:
Please assess the patient and discuss further management plan

Patient information:
You are Audrey Jones, a 25 year old lady who came for her first
antenatal visit. You had 2 previous miscarriages at 8 weeks. The
miscarriage was 2 years ago. You are taking folic acid at the moment.
You smoked for 5 years but then stopped last year. This is your 3rd
pregnancy. You did a pregnancy test and you know you are 2 weeks
pregnant. You had your last menstrual period 6 weeks ago. This is
why you have come for routine antenatal follow up. You are fit and well
and not on any regular medications. After the 2 miscarriages, you went
to see the GP but nothing was found. The GP simply said that I should
try again.

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

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DR MO SOBHY

obstetric hx from approach +

nausea?
Vomiting?
Fever?
Tummy pain?
Any spotting or bleeding from front passage ?
Any recent tummy trauma?

Risk factors:
Thyroid disease
Family hx of same condition
Any Auto immune disease
Hx of blood clots
PCOS
increase BMI or severe decrease
prolactin impalance

FLAWS
MMA questions

DESA

smoking ?
Alcohol ?
Any vigorous exercises ?

ICE & PSYCHOSOCIAL

how are you coping so far ?
Is your partner supportive ?

EXAMINATION
vitals + relevant ex general assessment + calculate BMI

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), I believe you are pregnant
however due to you past hx of miscarriages there is a chance of this to be
happening in the future unfortunately

MANAGEMENT

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DR MO SOBHY

-Routine blood tests + HCG, clotting profile ,folic acid ,vitamin D ,TFT ,
prolactin level
-anti phospholipid antibodies
-virology test
-abdominal gel scan for assessment of pregnancy and for congenital
uterine anomalies.
-follow up in 12 weeks
-dietary modification and stop undercooked food (sushi ,undercooked beef ,
eggs ) and stop smoking/alcohol aids
-folic acid + vitamin D supplements and decrease caffeine intake
-maintaining a body mass index (BMI) between 19 and 25
- explain as there was no cause previously found, the prognosis for a
successful future pregnancy with supportive care alone is about 75%.
However, the prognosis worsens with increasing maternal age and the
number of previous miscarriages.
-support groups
SAFETY NETTING

LEAFLET

pregnancy book, so that you can read more about what you can expect in
pregnancy and Recurrent miscarriage leaflet

*************************************************

4. Pre conception counselling

Where are you?

FY2 in GP surgery
Who the patient is:
Martina Smith, a 36 year old lady who has made a non-urgent appointment
to see you
Other information you have about the patient:
She has got 3 daughters, Ann 6 year, Helene 4 years and Fiona 1 years
old. She is currently taking combined oral contraceptive pills
What you must do:
Talk to the patient and address her concerns

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DR MO SOBHY

Patient information:
You are Martina Smith, a 36 year old lady. You have to see the doctor
today because you want to have a 4 th child So far you have 3 children;
Ann 6 year, Helene 4 years and Fiona 1 years old All of them are girls
You and your husband want a male child, so this time you want to have a
boy You are currently taking COCP You had an abortion so you know
that abortion can be done in the UK or I have one of my friends who had
an abortion

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

- Is there any particular reason for wanting a male child in specific?
- Are you under pressure to have a male child?
- Before I proceed can I ask you some questions just to have some
background information?
-do you have any children ? What are their names / how old are they ?
- did you ever have have an abortion before ?
Obstetric hx from approach

FLAWS

MMA questions

DESA

ICE & PSYCHOSOCIAL

Why would you not keep you the pregnancy if it is a girl?
What is your expectations from today's appointment ?
Have you discussed this with your husband ?

EXAMINATION
vitals + relevant ex PV examination + calculate BMI

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings)

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 DR MO SOBHY

MANAGEMENT
Routine blood tests
- At the moment there is a very little that can be done in terms of
having a male child specifically as there is no medical way of knowing you
are going to have a male child or not in the UK
- Regarding having sex in standing position; there is no scientific or medical
evidence that suggests it would increase your chances of having a male
child
- Regarding abortion if you find out it is a girl; the abortions are not
conducted on basis of gender
- You should be mentally prepared that if you get pregnant you might have
a girl, and I suggest that you discuss this with your husband so you can
both be prepared to keep the child if you have another girl
- You are right, abortions is allowed in the UK but it needs to fulfil a certain
criteria to be performed
- Most abortions in the UK are carried out before 24 weeks of pregnancy,
they can be carried out after 24 weeks in very limited circumstances such
as; if the mother's life is at risk or the child would be born with a severe
disability
- If they went for abortion, most women will not experience any problems,
but there is a small risk of complications, such as: infection of the womb
(uterus), some of the pregnancy remaining in the womb, excessive
bleeding, or damage to the womb or entrance of the womb (cervix), so if
complications do occur, you may need further treatment, including surgery
- if you are planing for pregnancy , it is advised to stop smocking/ alcohol
-maintain a BMI between 19 and 25
-dietary modification and stop undercooked food (sushi ,undercooked beef ,
eggs )
- if you and your husband insisting on having a boy child , we can refer you
to artificial fertilization clinic ,it will be not funded by NHS

SAFETY NETTING

LEAFLET

**************************************************

5. Pre conception with hypertension

Where are you?

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DR MO SOBHY

FY2 in GP surgery
Who the patient is:
Lisa Drinkwater, a 42 year-old lady who has made an appointment to see
you
Other information you have about the patient:
She has high blood pressure which is well maintained on Ramipril. Today
her blood pressure is 128/63.
What you must do:
Talk to the patient and address her concerns

Patient information:
You are Lisa Drinkwater, a 42 year old lady. You would like to get
pregnant, so you have made an appointment with your GP. Your
opening sentence is, “Doctor, I would like to get pregnant. Do you have any
advice for me?’’ You are on COCP. You have got high blood pressure
and you are taking Ramipril 1.25 mg. Your blood pressure is 128/63 and
it is well controlled. You do not drink alcohol and you do not smoke.
Your diet is healthy. You eat fruits, vegetables, fish, meat and chicken. You
try to eat healthy and you cook at home most of the time.

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

- I am sure I can help you with some advice about pregnancy; can I just
know if you need to talk about something specific about pregnancy?
- Are you worried about anything regarding pregnancy?
- Is there any particular reason for you to think about having a child now?
- Are you under pressure to have a child?
- I’d like to ask you a few questions to know about your general health so I
can be able to advise you appropriately?

obstetric hx from approach

any kidney problems ?
Any problems with waterworks?

FLAWS

MMA questions
any medications ?

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DR MO SOBHY

Are you compliant with the medications ?

Is your BP controlled on them ?
When was the last time you measured your BP ?
What was the reading ?

DESA

ICE & PSYCHOSOCIAL

how are you coping with that ?
Is your partner supportive ?

EXAMINATION
vitals + relevant ex PV examination + urine dipstick + pregnancy test +
calculate BMI

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), I suspect you are having a condition
called

MANAGEMENT
Routine blood tests
-infection / virology screening
-gel scan on abdomen for assessment of your internal organs
- Your current blood pressure medication, Ramipril, can affect the baby if
you get pregnant, so I’ll do a routine referral to the specialist and you
need to take your medication and continue using your contraception to
avoid getting pregnant until seen by the specialist, the obstetrician
- The specialist will review your medication and will most likely change it to
another medication which is labetalol or nifedipine methyldopa, then will
give you some advice on getting pregnant while maintaining your blood
pressure controlled
- it is important to maintain healthy life style : diet, exercise , no smoking
and no alcohol
-Regarding Your age it should not reduce your chances of getting
pregnant if everything is fine, but it could have some risks of your child
having Down syndrome and some risk of miscarriage
- I’ll also refer you to the pre conception clinic and they would do a full
fertility workup for you

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DR MO SOBHY

SAFETY NETTING

LEAFLET

***************************************************
6. Pre -eclampsia at 38 weeks

Where are you?

FY2 in Obstetrics and Gynaecology
Who the patient is:
Emily Brown, a 34 year old lady who has come for routine follow-up
Other information you have about the patient:
She is 38 weeks pregnant and she has been seen by the midwife who has
made the following note: - Head engaged - Lie Longitudinal - Her Blood
pressure today is 150 /100 - Urine Dipstick shows protein +++ - The
booking BP is 110/70mmHg
What you must do:
Take a focused history and discuss management with the patient

Patient information:
You are Emily Brown, a 34 year old lady who is 36 weeks pregnant You
have been having headache since yesterday Your last routine check-up
was two weeks ago and you had no problems You have been attending
your antenatal care appointments You have no problems or complaints
about current pregnancy This is your first pregnancy You are up to date
with all your jabs You can fell the baby kicking You are due in two
weeks You cannot get admitted because of work

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

obstetric hx from approach +
-any leg swelling ?
-nausea , vomiting ?
-fever?
-SOB?
-frothy urine?
- liver problem?

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DR MO SOBHY

-kidney problems?
-any fits / seizures ?
- hx of blood clots ?
-problems with vision ?

risk factors of pre-eclampsia :

two or more factors of :
*increased BMI >35
*first pregnancy
*multiple pregnancy
*age > 40
*family hx of same disease
*last pregnancy > 10 years

one factor of :
*chronic hypertension
*CKD
*diabetes type 1 or 2
*autoimmune disease

FLAWS

MMA questions

DESA

ICE & PSYCHOSOCIAL

EXAMINATION
vitals + relevant ex urine dip stick + calculate BMI

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), I suspect you are having a condition
called pre eclampsia
it is a new onset of hypertension during pregnancy after 20 weeks ,it can
be serious if not treated probably

MANAGEMENT
-Routine blood tests + clotting profile , folic acid ,vitamin D

605 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

-admit to hospital for ongoing monitoring of their condition and of their

baby's well-being.
What will be done in hospital ?
-abd gel scan
-CTG to assess baby, if in distress then caesarian section (surgical
delivery)
- medication through veins to bring blood pressure down (labetalol)
-MGSO4 (magnesium sulphate)
-they may offer blood thinners too
-involve senior
- don’t wont to get admitted because of work ?
She can Take annual off days / talk to manager if all failed then offer sick
leave

SAFETY NETTING

LEAFLET

Notes:
Regarding water birth / normal delivery
- Water birth would not be advised due to close monitoring is required in
labour as a result of pre-eclampsia, so CTG and BP need to be monitored
- Water birth is not recommended in the following situations:
- Hypertensive
- Pre-eclampsia
- Epilepsy
- Foetus Distressed
- Induced Labour

************************************************
7. Chickenpox exposure in pregnancy

Where are you?

FY2 in GP surgery
Who the patient is:
Emily Pearson, a 30 year old lady who has made an appointment to see/
talk you on phone
Other information you have about the patient:
None

606 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

What you must do:

Talk to the patient and address her concerns

Patient information:
You are Emily Pearson, a 30 year old lady. You are 37 weeks pregnant.
You have got a 3 year old boy called Joshua who was diagnosed with
chicken pox yesterday. Your child has had a fever and generally feeling
unwell and yesterday your husband took him to the GP and he was
diagnosed with chicken pox. Your 3-year old boy is doing quite well at the
moment. You are worried that your unborn baby may catch chicken pox.
You are generally fit and well. You have had no problems during this
pregnancy. You have had chicken pox yourself as a child. Your 3-year
old boy is up to date with all his immunizations.

INTRODUCTION
confirm
I am really sorry to hear about little joshua , may I ask how is he doing
now ?
HISTORY & DIFFERENTIALS
PMAFTOSA of chicken box
- What symptoms does he have?
- Did he go to see the doctor?
- Was the diagnosis of chickenpox made by the GP?
- When did he start feeling unwell?
- Does he have a rash?
- Is he on any treatment?

History of exposure
- Do you live with him at home?
- Has he been with you for the past 7 days?
- Have you come in physical contact with him?
- Do you have any symptoms?
- Are you running any temperature?
- Do you have any rash on your body?
- Do you have any headaches?
- Do you have any nausea or vomiting?
- Have you ever had chickenpox before?
- Have you had any vaccinations for chickenpox?

relevant obstetric hx from approach

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 DR MO SOBHY

FLAWS

MMA questions

DESA

ICE & PSYCHOSOCIAL

EXAMINATION
vitals + relevant ex

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), I don’t actually believe there is
anything you need to worry about
the fact that you had previous chickenpox infection / vaccine makes your
body immune against the virus and it is very minimal chance that you can
develop it again so it will not affect your pregnancy

MANAGEMENT
Routine blood tests
- Chickenpox can only be transmitted to those who have never had it
before or immunocompromised
- You can play and touch your son without problems
- Even if the baby was to be affected, the baby would be born with
chickenpox and then will be treated, but the baby would not have any
abnormalities because the pregnancy is more than 36 weeks of pregnancy.

SAFETY NETTING

LEAFLET

NOTES
If she has no history of chickenpox or shingles or and has significant
contact or if she doesn’t know whether she had chickenpox before or not
- Test for varicella-zoster IgG antibodies
- If varicella-zoster immunoglobulin G is negative : seek expert opinion
(obstetrics specialist) as patient might need immunoglobulin prophylaxis.

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DR MO SOBHY

- If varicella-zoster immunoglobulin is positive; reassure the woman that

she is immune and cannot catch chicken pox.

**********************************************

8. First antenatal follow up

Where are you?

FY2 in the antenatal clinic
Who the patient is:
Marry White, a 30 year old lady who came for routine antenatal follow up
Other information you have about the patient:
This is her first pregnancy. She is 14 weeks pregnant. She had some blood
tests done; everything was normal. She has done a FBC, U&E, LFT, RH –
ve, Rubella infections: non-immune, Syphilis –ve, HIV –ve, Hepatitis B and
C –ve, and she is blood group A. She has done her 12 weeks ultrasound
and it was normal
What you must do:
Talk to the patient, explain the results, and address her concerns

Patient information:
You are Marry White, a 30 year old lady who came for her first antenatal
visit This is your first pregnancy You are not in a stable relationship
You have sexual intercourse with different partners and therefore you
are not sure who the father is You use recreation drugs such as
cannabis and heroin You drink excessive amount of alcohol every day
You live with your friends and do not have your own home

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

obstetric hx from approach
*exclude if she is being abused and offer confidentiality

FLAWS

MMA questions

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DR MO SOBHY

DESA
CAGE questions for recreation drugs/ addiction :
-have you tried to Cut down / stop before ?
- feel Annoyed by how people look/think/see him ?
-feeling Guilt after taking it ?
-take it as Eye opener ?
ICE & PSYCHOSOCIAL
how is your mood ?
is your partner supportive ?
How are you coping with what has been recently going in your life ?

EXAMINATION
vitals + relevant ex abd + urine dipstick + calculate BMI

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), I believe you are having a normal
pregnancy
-Your 12 weeks ultrasound showed that the baby is completely fine, we
also screened for sexual transmitted infections and the good thing is all of
them were found negative -
- In regards to what we did check for; we checked if you are immunized
against rubella, unfortunately the test showed that you are not immunized
against an infection called rubella so you are not protected and that can be
a serious infection in pregnancy because it cause damage in 90% of the
time if a pregnant woman catches the infection within 16 weeks of
pregnancy

MANAGEMENT
Routine blood tests
Unfortunately it is not advisable to offer immunization during pregnancy so
you should watch out for any infections and avoid people who have any
infections
-In most times if a pregnant woman develops rubella infection during the
first 16 weeks she may be advised to have abortion but the choice still
remains with her
-The other blood tests were to check your blood group and your rhesus
status was done, and it showed that you have a type of blood called
rhesus negative which means that if you have a baby who is rhesus
positive your body can form antibodies to fight the blood cells of the baby

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DR MO SOBHY

this is likely to happen in the future pregnancies and to prevent this we offer
a medication At 28 weeks of pregnancy called anti-D immunoglobulin
which neutralizes the antigens that enter the mother’s body and this can
stop the body from forming the antibodies, so this is administered routinely
during the 3rd trimester
-alcohol cessation aids (medications / group therapy / support)
-I advise you to come for a regular follow up, you will need more frequent
follow up because of the use of recreational drugs and we have to assess
you for any complications
- smoking can has bad outcome on baby’s health and well-being
-Advice on vitamins and supplements in pregnancy (including folic acid
and vitamin D)
-Advise the woman that if she wishes, her partner is welcome to attend
antenatal appointments and classes with her for support.

SAFETY NETTING
- If you develop any rash or fever at any point please come back and seek
medical attention
- Please come back if you develop any tummy pain or vaginal bleeding or
spotting

LEAFLET

notes:
Routine antenatal care includes: in uncomplicated pregnancy
• 10 antenatal appointments with a midwife or doctor for
nulliparous women.
• 7 antenatal appointments with a midwife or doctor for parous
women.
• An ultrasound scan between 11+2 weeks and 14+1 weeks.
• An ultrasound scan between 18+0 weeks and 20+6 weeks.

**************************************************

9. Contraception

Where you are:

You are an FY2 in GP surgery

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DR MO SOBHY

Who your patient is:

Sue Hale, aged 30, has made a routine appointment to see you
Other Information you have about the patient:
None
What you must do:
Please talk to the patient and address her concerns

Patient information:
Scenario (A)
Opening sentence: ‘’Doctor I want to know about the contraception pill’’
You are a 30 year old lady Sue Hale. You have come to see the GP to
request for contraception. You traveled to Australia 1 year ago by flight,
a journey which took about 12 hours. You developed swelling in the
legs. You were admitted and give blood thinner tablets (Warfarin) for about
6 months. You have tried diaphragm and condoms in the past but you
got pregnant with your second child so you are very keen to know about
the failure rate of each contraception You have 2 children, and you have
a stable partner You like the idea of combined pill but if the doctor asks
you it is not appropriate for you, you are okay with it and you accept his/her
opinion You are a non-smoker, you do not have any medical conditions,
no allergies, and not on any medications Your friend recommended you
a pill

Scenario (B)
Your boyfriend used condoms and you have tried diaphragm as well. You
had DVT 2 years ago and you were treated with warfarin. Your last smear
was one year ago and it was normal Your last menstrual period was 5 days
ago Doctor can you tell me which one is the most effective? Do the COCP
and POP have the same failure rate? Are there any risks for a coil?

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

• Is there any particular contraception you want to know or you just want to
know the available options?
*can you tell me what you already know about contraception pills ?
-relevant obstetric hx from approach
-exclude current pregnancy
-have you tried any previous contraceptive methods ?

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DR MO SOBHY

*assessment to describe suitable contraceptive method :

-BMI
-headaches / migraines
-hypertension
-heart problems
-hx of blood clotting / blood diseases
-smoking
-breast feeding or not
-completed her family or not yet
-diabetes
-any womb diseases (fibroid , ..)
-menstrual hx for menorrhagia / spotting / etc ..
-any neurological diseases

*assessment of sexual rape / abuse

FLAWS

MMA questions

DESA

ICE & PSYCHOSOCIAL

EXAMINATION
vitals + relevant ex + urine dipstick + pregnancy test + measurement of
BMI

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), you seem to be fine

MANAGEMENT
Routine blood tests , clotting profile
explain methods of contraception in uk :
pills : COCP, POP, IUD
Barriers : condoms , diaphragms
Surgery : vasectomy for males / tubal occlusion for female)

613 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

*unless the method is contraindicated : offer the method the woman prefers
given that she understand all the pros / cons about it and how to use it and
how that method works

COCP
-daily -21 days cycle -Failure: 3:1000
• POP
-daily -failure 3:1000 -side effect: inter-menstrual bleed
• Patches
-weekly -failure: 3: 1000 -side effect: inter-menstrual bleed
• Depo Provera
-intramuscular injection -have to go to GP -3 months once -failure 2:1000
-s/e: inter-menstrual bleed
• Implant
-device inserted under the skin of the inner arm under LA -protection up to
3 years -failure: 1:2000 -s/e: inter-menstrual bleed
• Mirena Coil
-intrauterine device -mechanical and hormonal block -helps with
dysmenorrhea, fibroids -s/e: ectopic, PID -protection up to 5 years -failure:
2:1000
• IUCD
-Copper T -Intrauterine device -Mechanical block -s/e: ectopic, PID,
dysmenorrhea, uterine perforation, menorrhagia -protection up to 5 years
-failure: 8:1000
• Permanent contraception
-Female sterilization -1:200

SAFETY NETTING

LEAFLET

notes:
indications of hormonal contraception :
healthy wonam /ectopic pregnancies / uterine fibroids without distortion /
idiopathic menorrhagia / diabetes / breast feeding after 6 months

contraindication of COCP:
smoking/ BMI > 35 / hypertention / dvt/ migraine with aure /smoking / till 4
weeks post partum

614 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

in breast feeding :
48 hours postpartum … IUD
4 weeks postpartum … IUD

***********************************************
10. Contraception in a 15 years old

Where you are:

FY2 in the GP surgery
Who the patient is:
Heather Watson is a 15-year old female who has made an appointment to
see you
Other information:
None
What you must do:
Talk to the patient and address her concerns

Patient Information:
You are 15 year old Heather Watson and you suffer from migraines with
aura. The aura begins about an hour before the migraine and you
experience visual problems where you see zigzag lines. You also
experience associated nausea and sometimes vomit. The headache is
usually left sided. You take paracetamol for the headaches. You are
otherwise fit and well. You have a 15 year old boyfriend and you are
sexually active. Up till now you have been using condoms but your
boyfriend doesn’t like them so you want to see the GP to discuss what
other options you have for contraception.

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

• Is there any particular contraception you want to know or you just want to
know the available options?
*can you tell me what you already know about contraception pills ? (if she
wants pills)
-usually at that age we expect girls to present with their parents ,is there
any reason why you are here alone today ?

615 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

-relevant obstetric hx from approach

-exclude current pregnancy
-have you tried any previous contraceptive methods ?
-Will you be open to talk about your relationship with your parents ?

Relevant obstetric hx
sexual hx
ask about partner age ?
Exclude sexual abuse
*assessment to describe suitable contraceptive method :
-BMI
-headaches / migraines
-heart problems
-hx of blood clotting / blood diseases
-smoking
-diabetes
-menstrual hx for menorrhagia / spotting / etc ..
-any neurological diseases
*assess mental capacity :
do you know what are these pills used for ?
Do you know what happens if you did not take / stop taking them?
Do you know that contraception methods doesn’t prevent STDs ?

FLAWS

MMA questions

DESA

ICE & PSYCHOSOCIAL

has this affected your life by any means ?
Is your partner supportive ?

EXAMINATION
vitals + relevant ex abd +pregnancy test +urine dip stick

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), you seem to be healthy and well

616 drmohamedplab2@gmail.com. +47743137345

 DR MO SOBHY

MANAGEMENT
Routine blood tests
explain methods of contraception in uk :
pills : COCP, POP, IUD
Barriers : condoms , diaphragms
Surgery : vasectomy for males / tubal occlusion for female)
*unless the method is contraindicated : offer the method the woman prefers
given that she understand all the pros / cons about it and how to use it and
how that method works
-offer a screening test for STDs
- offer POP as COCP is contraindicated in migraine with aura as discuused
previously

SAFETY NETTING

LEAFLET

**************************************************

11. OCP repeat prescription

Who you are:

You are a FY2 doctor in the GP surgery
Who your patient is:
Elisa Jones, aged 26 has made an appointment for a repeat prescription of
her contraception pills
Other information we have about the patient:
None
What you must do:
Talk to her and address her concerns

Patient information:
Elisa Jones, a 26 year old lady You have come for prescription of
oral contraceptive pills You have no contraindication to COCP You
want your period to stop / delay her periods You have been on COCP
for three months You are okay and you are doing well on them You
have no clots in the lungs or legs You have no migraines You have
no medical conditions and no allergies Questions: I’m leaving the
country for three months; can you give me a prescription for three months?

617 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

Answer: yes Can I postpone my period for 3 to 4 months?

Answer: Yes, by taking the pills continuously without a break Is there
any medication to stop my period? Answer: offer COCP continuously
Emotions and Attitude: Happy (normal)

INTRODUCTION
confirm
sure we can help you that , may you tell me why you need to repeat the
contraception pill ?

HISTORY & DIFFERENTIALS

relevant obstetric hx
sexual hx
Which type of contraception are you on?
How do you take your pills at the moment?
How many pills do you take in a roll?
Do you normally take a break?
Do you take the dummy pills after 21 days?
Ask what is she going to do on holiday?
Is there any particular reason why you want the period to stop? Do
you have any issue with the pill? (Tummy pain – Feeling sick)

ask about red flags :

-BMI
-headaches / migraines
-hypertension
-heart problems
-hx of blood clotting / blood diseases
-smoking
-breast feeding or not
-completed her family or not yet
-diabetes
-any womb diseases (fibroid , ..)
-menstrual hx for menorrhagia / spotting / etc ..
-any neurological diseases

FLAWS

MMA questions

618 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

DESA
ICE & PSYCHOSOCIAL

EXAMINATION

vitals + relevant ex

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), you seem to be totally fit and healthy

MANAGEMENT
Routine blood tests
*in COCP
We can definitely give you a repeat prescription of the pills and you can
delay your periods by taking 2 packs of pills continuously without a
break for the monophasic 21-day pills. If you are taking the everyday pills
you can take the active pills continuously, just drop the dummy pills and
start a new packet of active pills straight away.
But it is important to avoid taking more than 2 packs of pills
continuously, As there is a risk you could experience some side effects
such as feeling sick, diarrhoea, or unexpected vaginal bleeding
*in POP
You cannot delay your periods by taking POP pills back to back. You will
need to switch to combined contraception pills or take another medication
to delay your periods

SAFETY NETTING

LEAFLET

***************************************************

12. Polycystic ovarian syndrome

Where are you?

FY2 in GP surgery
Who the patient is:
Amanda Evans, a 25-year-old lady who came for the test result review

619 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

Other information you have about the patient:

She had some blood tests done. She had presented initially with acne and
irregular periods.
LH high
FSH normal
LH:FSH 3:1
BMI 32
What you must do:
Explain the results, take a history and discuss management with the
patient.

Patient Information:
You are Amanda Evans, 25-year-old lady. You have been gaining weight
since 1 year. You have also noticed that you have grown some excess hair
on the face. You have also developed some pimples (acne) on your face.
Your periods stopped 6 months ago. Before that your periods were
irregular. You are normally fit and well. You are not sexually active. But you
are concerned that you may not be able to get pregnant. You are not on
any regular medication and you have got no allergies.

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

*relevant obstetric hx
*sexual hx
irregular cycles ?
Spotting/ bleeding between cycles ?
Delayed first menstrual period in childhood ? (when )
family hx of ovarian diseases ?
*menstrual hx
any skin colour change ?
Acne ?
Hair loss in head ?
Hair grow on the body/face ?
Have you tried to get pregnant before ? Any difficulties ?

Differentials : hypo/hyperthyroidism – prolactinoma-cushing $

Any thyroid gland problems ? Feeling cold when it is hot / hot when it is
cold ?

620 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

Have you gained weight recently?

FLAWS

MMA questions
Are you on any steroid medications ?

DESA

ICE & PSYCHOSOCIAL

it seems to be stressful for you , how are you coping with it ?
Has this affected your life by any means ?

EXAMINATION
vitals + relevant ex abd + BMI+ uribe dipstick

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings),and explain test results , I suspect you
are having a condition called PCOS / Polycystic ovary syndrome , im
sorry to tell you that.
The cause of polycystic ovary syndrome (PCOS) is unknown.It is likely to
be multifactorial, with both genetic and environmental factors may be
playing a part
It is characterized by hyperandrogenism (with clinical features such as
acne and hirsutism), ovulation disorder (usually manifested as infrequent or
no menstruation), and polycystic ovarian morphology on ultrasound.

MANAGEMENT
-Routine blood tests + TSH + prolactin levels
- There is a risk of developing DM, so we need to monitor your blood
sugar and HbA1c regularly.
-abd gel scan
-healthy life style and dietry modification to reduce side effects and avoid
complications
-control over BMI
- if no contraindications , offer COCP
-for women with acne,consider adding a topical retinoid, topical antibiotics

621 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

-For women with hirsutism,discuss methods of hair reduction and removal

(such as shaving and waxing) or laser removal sessions
-POP in women with prolonged amenorrhea (1 period in 3 months)
-regular follow ups
-For Infertility / difficulty to get pregnant we can refer you to fertility clinic
-support groups and CBT
-psychologist referal if sever depression
-inform senior for any added management
SAFETY NETTING

LEAFLET

************************************************

13. Amenorrhoea in 25 years old

where you are ?

FY2 oby and gynaecology
who your patient is ?
Mary Smith, a 25 year old lady who came for follow up
other information about the patient :
She was referred from GP with 20 months history of irregular periods
(amenorrhoea) She had blood tests done during last appointment LH and
FSH are very high Estradiol is low The test have been repeated twice 6
weeks apart and results were the same A diagnosis of premature ovarian
insufficiency has been made
what you need to do :
Talk to patient, explain results and address concerns

Patient information:
Mary Smith, a 25 year old lady You have a 20 month history of
amenorrhoea Your mum’s ovaries failed early at the age of 35 Your mood is
good You are preparing for an exam and you feel a little stressed out You
also experience hot flush and you feel anxious You know that your mother
was placed on hormonal replacement therapy You do not know what was
wrong exactly with her and what caused it Referred by GP

INTRODUCTION
confirm

622 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

HISTORY & DIFFERENTIALS

obstetric hx
sexual hx
*causes:
1.Contraception
2.Hypothalamic or pituitary dysfunction due to:
• Stress, excessive exercise, and/or weight loss (functional
hypothalamic amenorrhoea).
• 3.Eating disorders. abnormal BMI
4.Strenuous exercise , vigorous activity
5. Prolactinoma: Headaches, visual disturbance, white discharge from the
nipples
6. PCOS: any excess hair distribution, acnes
8. Oestrogen deficiency: hot flushes and night sweats Irritability, agitation,
anxiety, depression, feeling empty
9. hypo / hyperthyroidism

family hx of similar conditions

assessment of complications : osteoporosis, CVD, infertility, depression

FLAWS

MMA questions

DESA

ICE & PSYCHOSOCIAL

how has this affected your life ?
How are you coping with it ?

EXAMINATION
vitals + relevant ex pelvic +abd + BMI + pregnancy test

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), I suspect you are having a condition
called premature ovarian insufficiency (POI)

MANAGEMENT

623 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

Routine blood tests, prolactin levels , thyroid profile , testosterone

levels
abdominal gel scan
referral to specialist
if abnormal BMI , dietitian referral
CBT, group support and psychiatric review in sever depression
inform senior
*POI may affect her chances of getting pregnant in the future

SAFETY NETTING

LEAFLET

**************************************************

14. Pregnancy in 32 year old

who you are ?

FY2 in early pregnancy assessment unit
who your patient is ?
Flora Parkinson, a 32 year old lady who came for follow up
other informations you know about the patient :
She had trans vaginal ultrasound scan which shows 7 weeks gestation
and fetal pole present, and fetal heart beat is not detected
what you must do ?
Talk to the patient and address her concerns

Patient information:
You did a pregnancy test 9 weeks ago and it was positive You came to
have ultrasound scan because you don’t feel like you are pregnant This is
your 1st pregnancy You have been trying to get pregnant for the last 6
years You don’t have any symptoms of pregnancy You were feeling tummy
discomfort and nausea in the beginning But for the last 2 weeks you have
not been feeling these symptoms

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

624 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

obstetric hx from approach

nausea , vomiting , pain ?
Bleeding , spotting ?
Menstrual hx
hx of previous pregnancies / miscarriages ?

FLAWS

MMA questions

DESA

ICE & PSYCHOSOCIAL

how are you coping with that ?
Is your husband supportive ?

EXAMINATION
vitals + relevant ex pelvic +abd + urine pregnancy test

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings),
explain test results: we did an ultrasound scan and unfortunately the fetal
heart could not be detected, and it looks like your pregnancy has stopped
growing I suspect you are having a condition called missed miscarriage /
abortion , we are deeply sorry to tell you that
*offer tissues if she cries and give her some time before continuing*

MANAGEMENT
Routine blood tests
involve senior
specialist referral who will continue treatment which may be :
-medical : by drugs that stimulate evacuation of uterus remnants
-surgical if the medications failed
repeat abdominal gel scan after 7 days to reasses and follow up
support groups and couples counselling

SAFETY NETTING

625 drmohamedplab2@gmail.com. +47743137345

 DR MO SOBHY

LEAFLET

*************************************************

15. PID RIF Pain

who you are ?

You are F2 in A&E.
Who your pt is ?
Mrs. Johnson, aged 28, presented to the hospital complaining of right
lower abdominal pain (RIF). Please talk to the patient,
other information you know :
none
what you need to do :
take history, do relevant examination, discuss about initial management
with the patient and address her concerns.

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

SOCRATES for abdominal pain
Differential diagnosis:
Ectopic pregnancy
PID
IBD
UTI
endometriosis
appendicitis
Gastroenteritis
Renal Stones
Colonic Cancer
sexual hx & pap smears hx
previous STDS infection
previous surgical hx

FLAWS

MMA questions

626 drmohamedplab2@gmail.com. +47743137345

 DR MO SOBHY

DESA

ICE & PSYCHOSOCIAL

so how are you coping with that?
Has this affected your life by any how?

EXAMINATION
vitals + relevant ex abd+DRE+PV Urine pregnancy test

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), I suspect you are having a condition
called pelvic inflammatory disease (PID) ..
which means inflammation of your womb, your tubes, ovaries, and vagina it
usually caused by sexually transmitted infections

MANAGEMENT
Routine blood tests
-Paracetamol for pain
-Refer to GUM Clinic for swap, infection screening and TTT: CDM
( Ceftriaxone 1g as a single dose IM followed by oral doxycycline 100
mg twice daily plus oral metronidazole 400 mg twice daily for 14 days)
-Avoid sexual intercourse until tested negative
-future safe sex practising
-if swap is +ve : Advise to discuss with partner and invite for testing
-advice partners to come and get screened too
hospital admission if : The woman is unwell and there is diagnostic doubt or
pregnancy test +ve (ectopic pregnancy)

SAFETY NETTING

LEAFLET

*****************************************************

16. PID Lower Abdominal Pain

who you are ?

You are F2 in A&E.

627 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

Who your pt is ?
Mrs. Johnson, aged 40, presented to the hospital complaining of lower
abdominal pain .
Other information you know about the patient :
CS was done 15years hack She is taking desogestrel 150 mg daily. She
was diagnosed with depression and is on sertraline for the same.
What you need to to :
Please talk to the patient, take history, do relevant examination, discuss
about initial management with the patient and address her concerns

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

SOCRATES for abdominal pain
Differential diagnosis:
Ectopic pregnancy
PID
IBD
UTI
endometriosis
appendicitis
Gastroenteritis
Renal Stones
Colonic Cancer
sexual hx & pap smears hx
previous STDS infection
previous surgical hx

FLAWS

MMA questions

DESA

ICE & PSYCHOSOCIAL

so how are you coping with that?
Has this affected your life by any how?

EXAMINATION

628 drmohamedplab2@gmail.com. +47743137345

 DR MO SOBHY
vitals + relevant ex abd+DRE+PV +Urine pregnancy test

DIAGNOSIS

thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), I suspect you are having a condition
called pelvic inflammatory disease (PID) ..
which means inflammation of your womb, your tubes, ovaries, and vagina it
usually caused by sexually transmitted infections

MANAGEMENT
Routine blood tests
-Paracetamol for pain
-Refer to GUM Clinic for swap, infection screening and TTT: CDM
( Ceftriaxone 1g as a single dose IM followed by oral doxycycline 100
mg twice daily plus oral metronidazole 400 mg twice daily for 14 days)
-Avoid sexual intercourse until tested negative
-future safe sex practising
-if swap is +ve : Advise to discuss with partner and invite for testing
-advice partners to come and get screened too
hospital admission if : The woman is unwell and there is diagnostic doubt or
pregnancy test +ve (ectopic pregnancy)

SAFETY NETTING

LEAFLET

****************************************************

17. Ectopic Pregnancy

who you are ?

You are F2 in OBG Dept.
who your pt is ?
Janny aged, 18 presented to the hospital complaining of left iliac fossa
pain. Patient has come with six weeks of amenorrhoea. Pregnancy test has
been done and is positive.
Other informations you know :
none
what you need to do :

629 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

Please talk to the patient, take relevant history and discuss about different
steps of management with the patient.

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

SOCRATES for abdominal pain
Differential diagnosis:
Ectopic pregnancy
PID
IBD
UTI
IO
Diverticulitis
endometriosis
Gastroenteritis
Renal Stones
Colonic Cancer
sexual hx & pap smears hx
previous STDS infection
previous surgical hx
relevant obstetric hx including methods of contraceptions
menstrual hx
pregnancy symptoms : nausea , vomiting , dizziness explore if there is any
spotting , bleeding

FLAWS
MMA questions

DESA

smoking is risk factor

ICE & PSYCHOSOCIAL

how has this affected you ?

EXAMINATION
vitals + relevant ex pelviabdominal + DRE +PV

630 drmohamedplab2@gmail.com. +47743137345

 DR MO SOBHY

Do not palpate for an adnexal or pelvic mass as this may increase the risk
of rupture of an ectopic pregnancy if present.

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), I suspect you are having a condition
called ectopic pregnancy , that means there is pregnancy outside your
womb

MANAGEMENT
Routine blood tests + HCG level
admit her to hospital
involve senior
gel scan of womb Trans-vaginal ultrasound and abdomen
review by specialist who may offer
medications as methotrexate or surgery might be indicated either open or
laparoscopic to remove the pregnancy
Anti-D immunoglobulin is offered to all rhesus-negative women who have
had surgical removal of an ectopic pregnancy.
Advice to avoid getting pregnant after treatment for at least 3 months
SAFETY NETTING

LEAFLET

****************************************************

18. Miscarriage

who you are ?

You are F2 in Antenatal Clinic.
who your patient is ?
Ema aged, 28 is referred by her GP for her first ANC check-up. She is 6
weeks pregnant. Nurse has examined the patient. Urine test has been
done. Vitals have been checked. BP -130/80, Pulse-70, Urine Test
Negative (infection <& protein),pregnancy test-ve
Other informations you know :
none
what you need to do ?

631 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

Talk to the patient, take relevant history, do the initial assessment and
address her concerns.

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

obstetric hx from approach
- hypo / hyperthyroidism
-PCOS: any excess hair distribution, acnes
-Strenuous exercise , vigorous activity
-Eating disorders. abnormal BMI
- any blood clots / diseases
-tummy pain
-nausea / vomiting / diarrhoea
-fever
-bleeding , discharge from front passage
-any trauma recently to tummy / womb
-is this pregnancy planned ?
-family hx of pregnancy problems

FLAWS

MMA questions

DESA

ICE & PSYCHOSOCIAL

is your partner supportive ?

EXAMINATION
vitals + relevant ex abd + pregnancy test (-ve) + PV

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), I suspect you are having a condition
called Miscarriage , I am deeply sorry to tell you that
it is the spontaneous loss of pregnancy before the fetus reaches viability.
The term includes all pregnancy losses from the time of conception until 24
weeks of gestation.

632 drmohamedplab2@gmail.com. +47743137345

 DR MO SOBHY

MANAGEMENT
Routine blood tests + HCG
gel scan on tummy and womb
senior involvement
specialist review
Arrange immediate hospital admission for monitoring and further
assessment
if scans show missed miscarriage she will be offered 200 mg oral
mifepristone and, 48 hours later, 800 micrograms of misoprostol (vaginal,
oral, or sublingual) unless the gestational sac has already been passed.
If incomplete miscarriage the woman is offered a single dose of
misoprostol 600 micrograms (vaginal, oral, or sublingual).
Advise these women: To repeat a urine pregnancy test after 7–10 days and
return if it is positive or any bleeding happens
support groups
• Anti-D immunoglobulin prophylaxis is offered to all rhesus-negative
women who have had a surgical procedure to manage a
miscarriage.

SAFETY NETTING

LEAFLET

****************************************************

19. Premenstrual Syndrome

who you are ?

You are FY2 in General practice.
Who your patient is ?
A 32 year old lady wants to talk to you.
Other information you know :
none
what you need to do :
Talk to her and address her concerns

INTRODUCTION

633 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

confirm

HISTORY & DIFFERENTIALS

relevant obstetric hx
exclude sexual abuse
differentials diagnosis :
Psychological symptoms, such as mood swings, irritability, depressed
mood, anxiety, feeling out of control, poor concentration, change in libido,
and food cravings.
Physical symptoms, such as breast tenderness, bloating, headaches,
backache, weight gain, acne, and gastrointestinal disturbance.
• Behavioural symptoms, such as reduced visio-spatial and cognitive
ability, aggression, and increase in accidents.
• The timing of symptoms in relation to the menstrual cycle
• hypothyroidism
• anaemia
• dysmenorrhoea
• IBS
• endometriosis
• chronic fatigue syndrome

FLAWS
MMA questions

DESA

smoking
alcohol

ICE & PSYCHOSOCIAL

how has this affected your life ?
Is your partner supportive ?

EXAMINATION
vitals + relevant ex Abdominal + BMI

DIAGNOSIS

634 drmohamedplab2@gmail.com. +47743137345

 DR MO SOBHY

thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), I suspect you are having a condition
called premenstrual syndrome ,
a compination of symptoms like you have during mid cycle and resolve with
onset of menses and followed by a symptom-free week .

MANAGEMENT
Routine blood tests
dietary modification
good sleep hygiene
relaxation techniques , yoga and avoid stress
alcohol restriction
avoid smoking
analgesics for pain
CBT, support groups for depression
COCP may be prescribed in chronic conditions
arrange follow ups

SAFETY NETTING

LEAFLET

***************************************************

20. Pregnancy (HTN on Ramipril)

who are you ?

You are an FY2 in the GP Surgery.
Who your patient is ?
Mrs Amy Travis, aged 42, has come to see you.
Other information you know :
She is on Ramipril for her hypertension.
What you must do ?
Talk to her and address her concerns.

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

635 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

- I am sure I can help you with some advice about pregnancy; can I just
know if you need to talk about something specific about pregnancy?
- Are you worried about anything regarding pregnancy?
- Is there any particular reason for you to think about having a child now?
- Are you under pressure to have a child?
- I’d like to ask you a few questions to know about your general health so I
can be able to advise you appropriately?

obstetric hx from approach

any kidney problems ?
Any problems with waterworks?

FLAWS

MMA questions
any medications ?
Are you compliant with the medications ?
Is your BP controlled on them ?
When was the last time you measured your BP ?
What was the reading ?

DESA

ICE & PSYCHOSOCIAL

how are you coping with that ?
Is your partner supportive ?

EXAMINATION
vitals + relevant ex PV examination + urine dipstick + pregnancy test +
calculate BMI

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), I suspect you are having a condition
called

MANAGEMENT
Routine blood tests
-infection / virology screening
-gel scan on abdomen for assessment of your internal organs

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 DR MO SOBHY

- Your current blood pressure medication, Ramipril, can affect the baby if
you get pregnant, so I’ll do a routine referral to the specialist and you
need to take your medication and continue using your contraception to
avoid getting pregnant until seen by the specialist, the obstetrician
- The specialist will review your medication and will most likely change it to
another medication which is labetalol or nifedipine methyldopa, then will
give you some advice on getting pregnant while maintaining your blood
pressure controlled
- it is important to maintain healthy life style : diet, exercise , no smoking
and no alcohol
-Regarding Your age it should not reduce your chances of getting
pregnant if everything is fine, but it could have some risks of your child
having Down syndrome and some risk of miscarriage
- I’ll also refer you to the pre conception clinic and they would do a full
fertility workup for you

SAFETY NETTING

LEAFLET

****************************************************

21. Post -Partum Psychosis

who you are ?

You are an FY2 in GP.
Who your patient is ?
Miss Amanda Lowe, aged 31, came to you with complaint of insomnia.
Other information you know :
none
what you must do :
Talk to her and address her concerns.

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

relevant obstetric hx
any complication / bleeding / special care of baby ?
was the pregnancy planned of not ?

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DR MO SOBHY

insomnia, sleep hygine

anxiety, irritability
mood fluctuation
abnormal thoughts or behaviours
family hx of neurological / psychiatric depression ?
Exclude sexual / domestic abuse
do you hear voices ?
Does anyone else hear these voices rather than you ?
How many voices ?
What do they say ?
Do you think of something bad related to yourself / child ?

FLAWS
MMA questions

DESA

smoking
alcohol
any recreational drugs ?

ICE & PSYCHOSOCIAL

how are you coping with that ?
Is your partner supportive ?
Depression ?
Assess mood 0-10 ?

EXAMINATION
vitals + relevant ex urine dipstick

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), I suspect you are having a condition
called postnatal psychosis
a condition where your brain chemicals gets affected after delivery causing
it to function differenlty

MANAGEMENT
Routine blood tests

638 drmohamedplab2@gmail.com. +47743137345

 DR MO SOBHY

inflammatory and infection marker

vitamin D
analgesics if in pain
avoid smoking
reduce alcohol]
healthy life style , exercise and diet modification
follow ups
arrange to admit both mother and baby in hospital
consider involving community mental health services

SAFETY NETTING

LEAFLET

****************************************************

22. Pregnancy (16 YO) Vomiting

who you are ?

You are an FY2 in GP.
Who your pt is ?
Miss Leanne Bailey, aged 16, has booked an emergency appointment.
Other informations you know :
none
what you need to do ?
Talk to her, assess and manage her concerns.

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

vomiting hx
What is the colour of the vomit?
Did you see any blood in it?
How much did you vomit?
F– Frequency: How many times did you vomit?
O– Onset: Did it come on suddenly or gradually?
D – Duration: When did it start?
P – Progression: Is it getting worse or improving or is it the same? A –
Aggravating factors: Anything that makes it worse?

639 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

R – Relieving factors: Anything that makes it better?

A – Associated symptoms: Differential diagnosis
● Gastroenteritis
gastritis, peptic ulcer, gastroenteritis, pancreatitis, cholecystitis,
cholelithiasis, bowel obstruction, hepatitis, appendicitis.
● genitourinary
urinary tract infection ,end-stage renal disease, uraemia
pyelonephritis ,ovarian torsion
● Migraine
- Did you experience any headaches?
*sexual hx
● Pregnancy
- When was your last menstrual period?

MMA questions
medications side effect

DESA

ICE & PSYCHOSOCIAL

Is there anything you feel could be the cause of your symptoms? Is there
anything you are worried about? Will you tell my parents?
-No, we won’t tell them. It is a part of your confidentiality and everything
going in this room will remain confidential. But is there any particular
reason why you don’t want them to know? They will get mad at me

EXAMINATION
vitals + relevant ex pregnancy test

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), I think you might be pregnant
vomiting is one of the early signs of pregnancy. It is understandable to feel
mixed emotions; were you expecting to be pregnant?

MANAGEMENT
We need to run some routine blood tests FBC – U&E – LFT – Blood sugar
– Urine analysis and we need to do an Abdominal ultrasound.
-Anti-emetic medication such as Cyclizine or prochlorperazine or
chlorpromazine drink lots of fluid to prevent getting dehydrated Reassure

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 DR MO SOBHY

that mild-to-moderate symptoms are common in pregnancy and usually

resolve by 16–20 weeks of gestation.
- Regarding your pregnancy, I suggest that you find a way to discuss this
with your parents and your partner.
You can take your time to think about everything then I recommend that
you talk to your GP to discuss what to expect in pregnancy and to get
advice on any concerns you might have.

SAFETY NETTING

LEAFLET

****************************************************

23. Missed Abortion

who you are ?

Fy2 in obs and gyna department
who your patient is ?
A 35 year old lady, Jenny Anderson is pregnant and got her antenatal
scans done.
Other informations you know about her :
Trans vaginal scan reveal Gestational age of foetus 7 weeks No foetal
heartbeat seen
what you must do ?
Speak to Jenny about the reports and address her concerns.

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

obstetric hx from approach
- hypo / hyperthyroidism
-PCOS: any excess hair distribution, acnes
-Strenuous exercise , vigorous activity
-Eating disorders. abnormal BMI
- any blood clots / diseases
-tummy pain
-nausea / vomiting / diarrhoea

641 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

-fever
-bleeding , discharge from front passage
-any trauma recently to tummy / womb
-is this pregnancy planned ?
-family hx of pregnancy problems

FLAWS

MMA questions

DESA

ICE & PSYCHOSOCIAL

is your partner supportive ?

EXAMINATION
vitals + relevant ex abd + pregnancy test (-ve) + PV

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), I suspect you are having a condition
called Missed Miscarriage , I am deeply sorry to tell you that
it is the spontaneous loss of pregnancy before the fetus reaches viability.
The term includes all pregnancy losses from the time of conception until 24
weeks of gestation.

MANAGEMENT
Routine blood tests + HCG
gel scan on tummy and womb
senior involvement
specialist review
Arrange immediate hospital admission for monitoring and further
assessment
if scans show missed miscarriage she will be offered 200 mg oral
mifepristone and, 48 hours later, 800 micrograms of misoprostol (vaginal,
oral, or sublingual) unless the gestational sac has already been passed.
If incomplete miscarriage the woman is offered a single dose of
misoprostol 600 micrograms (vaginal, oral, or sublingual).
Advise these women: To repeat a urine pregnancy test after 7–10 days and
return if it is positive or any bleeding happens

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 DR MO SOBHY

support groups
• Anti-D immunoglobulin prophylaxis is offered to all rhesus-negative
women who have had a surgical procedure to manage a
miscarriage.

SAFETY NETTING

LEAFLET

****************************************************

24. Premature Ovarian Insufficiency

who you are ?

You are FY2 in OB/GYN.
Who your patient is ?
Sana, aged 26, presented with amenorrhoea. She had blood tests done.
Results are as follows: FSH and LH high oestrogen low.
Other information you know about her :
Diagnosis of premature ovarian insufficiency was made.
What you must do :
Talk to her, explain the results and address her concerns.

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

obstetric hx
sexual hx
*causes:
1.Contraception
2.Hypothalamic or pituitary dysfunction due to:
• Stress, excessive exercise, and/or weight loss (functional
hypothalamic amenorrhoea).
• 3.Eating disorders. abnormal BMI
4.Strenuous exercise , vigorous activity
5. Prolactinoma: Headaches, visual disturbance, white discharge from the
nipples
6. PCOS: any excess hair distribution, acnes

643 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

8. Oestrogen deficiency: hot flushes and night sweats Irritability, agitation,

anxiety, depression, feeling empty
9. hypo / hyperthyroidism

family hx of similar conditions

assessment of complications : osteoporosis, CVD, infertility, depression

FLAWS

MMA questions

DESA

ICE & PSYCHOSOCIAL

how has this affected your life ?
How are you coping with it ?

EXAMINATION
vitals + relevant ex pelvic +abd + BMI + pregnancy test

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), I suspect you are having a condition
called premature ovarian insufficiency (POI)

MANAGEMENT
Routine blood tests, prolactin levels , thyroid profile , testosterone
levels
abdominal gel scan
referral to specialist
if abnormal BMI , dietitian referral
CBT, group support and psychiatric review in sever depression
inform senior
*POI may affect her chances of getting pregnant in the future

SAFETY NETTING

LEAFLET

**************************************************

644 drmohamedplab2@gmail.com. +47743137345

 DR MO SOBHY

25. Combined Pill Prescription

who you are ?

You are an FY2 in OBs/GYN.
Who the patient is ?
Avery Smith, aged 22 has come to you asking for 6 months' prescription of
OCP. She was not using condom for 5 months.
Other informations you know about the patient :
none
what you must do
talk to her and address her concerns

prescribing the combined pill:

It is important to remember that you cannot put in repeat prescription
requests for the Pill or for HRT as you would for other medications. Once
the doctor is satisfied that the contraceptive pill or HRT you are on is the
most suitable one for you, they will usually issue a prescription for a six-
month supply.

INTRODUCTION
confirm
sure we can help you that , may you tell me why you need to repeat the
contraception pill ?

HISTORY & DIFFERENTIALS

relevant obstetric hx
sexual hx
Which type of contraception are you on?
How do you take your pills at the moment?
How many pills do you take in a roll?
Do you normally take a break?
Do you take the dummy pills after 21 days?
Ask what is she going to do on holiday?
Is there any particular reason why you want the period to stop? Do
you have any issue with the pill? (Tummy pain – Feeling sick)

ask about red flags :

-BMI
-headaches / migraines

645 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

-hypertension
-heart problems
-hx of blood clotting / blood diseases
-smoking
-breast feeding or not
-completed her family or not yet
-diabetes
-any womb diseases (fibroid , ..)
-menstrual hx for menorrhagia / spotting / etc ..
-any neurological diseases

FLAWS

MMA questions

DESA

ICE & PSYCHOSOCIAL

EXAMINATION
vitals + relevant ex

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), you seem to be totally fit and healthy

MANAGEMENT
Routine blood tests
*in COCP
We can definitely give you a repeat prescription of the pills and you can
delay your periods by taking 2 packs of pills continuously without a
break for the monophasic 21-day pills. If you are taking the everyday pills
you can take the active pills continuously, just drop the dummy pills and
start a new packet of active pills straight away.
But it is important to avoid taking more than 2 packs of pills
continuously, As there is a risk you could experience some side effects
such as feeling sick, diarrhoea, or unexpected vaginal bleeding
*in POP

646 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

You cannot delay your periods by taking POP pills back to back. You will
need to switch to combined contraception pills or take another medication
to delay your periods

SAFETY NETTING

LEAFLET

***************************************************
26.Antenatal Check-up (Rubella/Rh Negative)

who you are ?

You are FY2 in Antenatal clinic.

Who your patient is ?
A 32 year old lady is coming for her antenatal assessment. She is 14
weeks pregnant. Her lab results are: Blood group: O Rhesus type: Rh -ve
Rubella: Non immune All other blood tests like LFT’s, RFTs and U and E’s
normal. USG: Singleton foetus
other information you know about the patient :
none
what you need to do :
Talk to her and address her concerns.

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

obstetric hx from approach +
nausea?
Vomiting?
Fever?
Tummy pain?
Any spotting or bleeding from front passage ?
Any recent tummy trauma?
Vaccination history

FLAWS

MMA questions

647 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

DESA
smoking ?
Alcohol ?
Any vigorous exercises ?

ICE & PSYCHOSOCIAL

how are you coping so far ?
Is your partner supportive ?

EXAMINATION
vitals + relevant ex abd + urine dipstick + calculate BMI

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), I believe you are having a normal
pregnancy
-Your 14 weeks ultrasound showed that the baby is completely fine, we
also screened for sexual transmitted infections and the good thing is all of
them were found negative -
- In regards to what we did check for; we checked if you are immunized
against rubella, unfortunately the test showed that you are not immunized
against an infection called rubella so you are not protected and that can be
a serious infection in pregnancy because it cause damage in 90% of the
time if a pregnant woman catches the infection within 16 weeks of
pregnancy

MANAGEMENT
Routine blood tests
Unfortunately it is not advisable to offer immunization during pregnancy so
you should watch out for any infections and avoid people who have any
infections
-In most times if a pregnant woman develops rubella infection during the
first 16 weeks she may be advised to have abortion but the choice still
remains with her
-The other blood tests were to check your blood group and your rhesus
status was done, and it showed that you have a type of blood called
rhesus negative which means that if you have a baby who is rhesus
positive your body can form antibodies to fight the blood cells of the baby
this is likely to happen in the future pregnancies and to prevent this we offer

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 DR MO SOBHY

a medication At 28 weeks of pregnancy called anti-D immunoglobulin

which neutralizes the antigens that enter the mother’s body and this can
stop the body from forming the antibodies, so this is administered routinely
during the 3rd trimester
-alcohol cessation aids (medications / group therapy / support)
-I advise you to come for a regular follow up, you will need more frequent
follow up because of the use of recreational drugs and we have to assess
you for any complications
- smoking can has bad outcome on baby’s health and well-being
-Advice on vitamins and supplements in pregnancy (including folic acid
and vitamin D)
-Advise the woman that if she wishes, her partner is welcome to attend
antenatal appointments and classes with her for support.

SAFETY NETTING
- If you develop any rash or fever at any point please come back and seek
medical attention
- Please come back if you develop any tummy pain or vaginal bleeding or
spotting

LEAFLET

notes:
Routine antenatal care includes: in uncomplicated pregnancy
• 10 antenatal appointments with a midwife or doctor for
nulliparous women.
• 7 antenatal appointments with a midwife or doctor for parous
women.
• An ultrasound scan between 11+2 weeks and 14+1 weeks.
• An ultrasound scan between 18+0 weeks and 20+6 weeks.

**************************************************

27. Cyclical Breast Pain

who you are ?

You are F2 in GP.
Who your patient is ?
Jenny aged 40 booked an urgent appointment to discuss her problem.

649 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

Other informations you know about the patient :

none
what you need to do :
Talk to the patient, take history, assess her and discuss the plan of
management and address her concerns.

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

SOCRATIS for pain
relevant obstetric hx
sexual hx
menstrual hx
breast feeding or not ?
Any skin changes?
Discharge?
Lumps ?
Nipple changes ?
Fever ?
Any trauma ?
Any rash ?
Is the pain related to period or not ?
Any sob ?
Any leg pain / swelling ?
Any heart problems ?
Family hx of breast problems / diseases ?

FLAWS
MMA questions

DESA

diet
smoking
alcohol

ICE & PSYCHOSOCIAL

has this affected you life by any means ?

650 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

EXAMINATION
vitals + relevant ex breast examination + LN ex + urine pregnancy test +
ECG

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), I suspect you are having a condition
called cyclical breast pain ,
it is a condition where there is breast pain related to menstrual
cycle ,usually within 2 weeks before menses, increases until menstruation
begins, and improves after menses.

MANAGEMENT
Routine blood tests
reassure it is not a harmful condition and usually improve on its own by
time
analgesics for pain
supportive bra 1-strong support in exercise // 2-soft support at night
make a diary of the pain with factors increasing and relieving the pain
no improvement after 3 months .. consider specialist referral
Specialist treatment options include danazol and tamoxifen.

SAFETY NETTING

LEAFLET

notes :
The following treatments for cyclical breast pain are not recommended as
evidence is limited:
• Evening primrose oil.
• Flaxseed.
• Diets low in fat or low in caffeine.
• Vitamin B6.
• Vitamin E.
• Stopping or changing contraceptives.

****************************************************

651 drmohamedplab2@gmail.com. +47743137345

 DR MO SOBHY

28. Bacterial Vaginosis

Where you are

You are an FY2 in GP surgery
who the patient is
Catherine Ford, a 30-year old lady who has made an appointment to see
you
Other information you have about the patient
She had tests done last week Results are as follow:
- Cervical smear normal - High vaginal swab: negative chlamydia negative
gonorrhoea positive gardnerella vaginalis
What you must do:
whether Explain results to the patient, take a focused history, and address
his concerns.

Patient information
You are Catherine Ford, aged 30. She has had a fishy smelly vaginal
discharge for the last 2 months It is greenish copious discharge The
discharge stains her underwear She has not had sex with her husband
for the past 2 months because she is embarrassed due to the smell She
has an IUCD as a mean of contraception You change your underwear
several times a day due to the discharge In the last 2 months she
changed the soap and use a foam bubble soap

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

I understand you presented earlier to us and had some tests done, I have
your test results with me
would it be okay if I asked you few questions before I explain all results to
you ?
Why did you came before ?
What happened on your previous visit ?
What did they tell you on your last visit ?
Do you have and idea what we were searching for doing these tests ?
Do you have an idea what might have caused you these symptoms?

*Explore disrcharge

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DR MO SOBHY

onset / course
/ colour .. white-grey
/ itchiness .. -ve
/ smell .. fishy
/ relation to anything else
is it the first time to have this kind of discharge ?

*relevant obstetric hx
*sexual history
sexually active or not ?
Stable partner or not ?
If not : How many partners over the past 12 months?
Do you practise safe sex ?
What kind of contraception ? Exclude foreign bodies ex.. as tampons
Exclude problems with water works (colour/irritation) ?
Any back pain?
Tummy pain?
Diarrhoea / constipation ?
Any front passage bleeding ?
Painful sexual intercourse ?
Previous pap smears results
if she up to date or not with pap smears
any hx of STDs before ?

*Personal Hygiene questions :

any change in your bathing routine ?
Any change in bathing / soap ?
Have you recently tried any new personal care / hygiene products / vaginal
douches / deodorants ?

DDs - Candidiasis - Chlamydia – Gardnella vaginalis – gonorrhoea-

trichomoniasis - PID- prostatitis and urethritis in male

FLAWS
exclude malignant

MMA questions
Allergy — for example, to chemicals or latex.

DESA

653 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

smoking

ICE & PSYCHOSOCIAL

how are you cooping with that ?
Has this affected your life by any means ?

EXAMINATION
vitals + relevant ex PV + abd + pregnancy test

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings) & explain test results ,we suspect you
are having a condition called bacterial vaginosis
characterized by an overgrowth of bacteria such as Gardnerella vaginalis
replacing normal vaginal flora,The vagina loses its normal acidity, and
vaginal pH increases to be alkaline causing these symptoms

MANAGEMENT
-Routine blood tests
-it is not a sexually transmitted disease /not caused by partners
-Advise that, where possible, she should avoid exposure to contributing
factors, such as vaginal douching and the use of antiseptics, bubble baths,
or shampoos in the bath.
-instead you can try regular showering
-clean genitalia with water
Prescribe oral metronidazole 400 mg twice a day for 5 to 7days.
-If the woman prefers topical treatment or cannot tolerate oral
metronidazole:
• Prescribe intravaginal metronidazole gel 0.75% once a day for 5
days or intravaginal clindamycin cream 2% once a day for 7 days.
• If she has recurrent episodes with IUD advice about removing it and
consider alternative contraception methods.
• If she has recurrent episodes consider speculum ex with swap for
culture
-Advice about smoking cessation and offer stopping aids if agrees
(smoking cessation clinic / nicotine replacement / group therapy )

654 drmohamedplab2@gmail.com. +47743137345

 DR MO SOBHY

SAFETY NETTING

LEAFLET

extra notes:

Candidiasis—characterized by a white, odourless, curdy discharge that

may be associated with vulval itching and superficial soreness.
Trichomoniasis —characterized by a fishy-smelling,yellow/green frothy
discharge that may be associated with itching, soreness, and dysuria .
Chlamydia — often asymptomatic, but can cause purulent or
mucopurulent vaginal discharge and dysuria and does not usually present
with itch. pH of the discharge is 4.5 or less.
Gonorrhoea —rarely presents with itch and is associated with pain and a
purulent cervical discharge.
Genital herpes — may present with redness, itch, and ulceration;
discharge is uncommon; and acute vulval pain is often the defining
symptom. Sometimes a watery vaginal discharge may appear 7 to 11 days
after primary infection.

*****************************************************

29. Gonorrhoea

Where you are

You are Foundation Year 2 doctor in Genito-Urinary Medicine Clinic.
who the patient is
Ms Helen Parker, aged 24.
Other information you have about the patient
She came to the GUM clinic 1 week ago to be tested for sexually
transmitted infection. The results are back from the laboratory and shows
that the patient is positive for gonorrhoea infection.
What you must do:
Take a sexual history and discuss management with the patient.

Patient information

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DR MO SOBHY

You are Catherine Ford, aged 35. You have had a white vaginal
discharge for the last 2 weeks She experience itching of the vagina
She is sexually active and in a stable relationship You practice safe sex
and you use condoms You have never had a cervical smear so you are
worried it could be cancer Her last menstrual period was 6 weeks ago
Before that she does not have any symptoms When the symptoms
started 2 weeks ago you thought the symptoms would go away but they
have persisted

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

*Explore disrcharge
onset / course
/ colour .. white-grey
/ itchiness .. -ve
/ smell .. fishy
/ relation to anything else
is it the first time to have this kind of discharge ?

*relevant obstetric hx
*sexual history
sexually active or not ?
Stable partner or not ?
If not : How many partners over the past 12 months?
Do you practise safe sex ?
What kind of contraception ? Exclude foreign bodies ex.. as tampons
Exclude problems with water works (colour/irritation) ?
Any back pain?
Tummy pain?
Diarrhoea / constipation ?
Any front passage bleeding ?
Painful sexual intercourse ?
Previous pap smears results
if she up to date or not with pap smears
any hx of STDs before ?

*Personal Hygiene questions :

any change in your bathing routine ?

656 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

Any change in bathing / soap ?

Have you recently tried any new personal care / hygiene products / vaginal
douches / deodorants ?

DDs - Candidiasis - Chlamydia – Gardnella vaginalis -trichomoniasis -

PID- prostatitis and urethritis in male

FLAWS

MMA questions

DESA

ICE & PSYCHOSOCIAL

EXAMINATION
vitals + relevant ex PV+ abd + pregnancy test + urine dipstick (testicular
examination in men)

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings),we believe you are having a condition
called gonorrhoea
Gonorrhoea is a sexually transmitted infection (STI) caused by bacteria
called Neisseria gonorrhoea.

MANAGEMENT
Routine blood tests
if in GP refer to GUM clinic
-Prescribe antibiotic treatment. Ideally, a culture should be taken before
prescribing antibiotics :ciprofloxacin 500 mg orally as a single dose or
prescribe ceftriaxone 1 g intramuscular (IM) injection as a single dose.
-do not prescribe ciprofloxacin in breast feeding or pregnant women ,
instead give ceftriaxone
-encourage to inform partner to get tested and treated also or though
partner notification program

657 drmohamedplab2@gmail.com. +47743137345

 DR MO SOBHY

-Advise the person to abstain from sex until 7 days after they and their
partner(s) have completed treatment.
• -Advise the person on using safer sexual practice in the future as
using condoms
• follow up
•
SAFETY NETTING

LEAFLET
(end of case)

did I get this infection from my boyfriend ?

We can not confirm how you got the infection, we suggest to bring this
conversation with your partner and advice him to come and get tested too
however this infection can be living without symptoms for months so you
could have got it long time ago back and it flared up recently.

***************************************************

30. Emergency contraception

Where you are:

FY2 in GP
Who the patient is:
14-year-old Sarah Perkins, who has come to request emergency
contraceptive pills.
Other information you have about your patient:
She had unprotected sexual intercourse last night.
What you must do:
Talk to Sarah and address her concerns.

Patient information:
Opening sentence “Doctor, I am here to request a morning after pill”. You
are Sarah Perkins, 14 years old. You have come to the GP practice on your
own. You have heard about the morning after pill but you have never used
it before. Your LMP was 2 weeks ago. You did not have any unprotected
sex other than last night. You have not discussed with your parents about
this because you fear that they would be angry, your parents still think that
you are their little girl and they do not like your boyfriend Paul. You feel that

658 drmohamedplab2@gmail.com. +47743137345

DR MO SOBHY

your parents do not really understand how you feel about each other. Paul
is your boyfriend and he knows that you have come to the GP to request
contraception. You have tried to use condoms but you feel they are not
reliable because Paul does not like to use them. Paul is 15 years old. When
the doctor asks you how old is Paul, you should reply “he is 15 but what
difference does that make, I still love him”. You understand the risk of
taking contraception and you know that you should be using condoms for
safe sex, but you feel they are not reliable and You know risk of being in a
sexual relationship is getting pregnant and you don’t want to get pregnant.
And that without condoms you have a risk of getting STIs You feel that if
you tell your parents, they will shout at you and force you to leave the
boyfriend. You had unprotected sexual intercourse last night. Your mum
does not support the idea of sexual relationship before marriage because
she is a Roman Catholic Christian. You know that the morning after pill will
prevent you from getting pregnant.

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

Usually it is a practice policy that anyone under 16 years of age should
attend the practice with their parents.
Have you come on your own or with someone?
And do you parents know that you are here?
Reassure that We can definitely help with contraception.
2. OFFER CONFIDENTIALITY: Reassure that whatever is discussed will
be kept confidential
*menstrual hx
Last menstrual period?
How many days do you bleed?
How many days is your cycle?
Are your periods regular?
Are your periods heavy?
Do you experience any pain during your periods?

*sexual hx
when ?
-exclude being abused/rape
Are you in a stable relationship?
Is this your first relationship?

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DR MO SOBHY

How long have you been together with your partner?

How old is your partner?
How are things between you and your boyfriend?
Does your boyfriend know that you came to the practice?
Generally do you practice safe sex by that I mean do you use
condoms?
Is there any reason why yesterday you didn’t use condoms?
Has your partner ever been aggressive towards you?
Has he ever forced you to have sexual intercourse when you didn’t want
to?
Have you ever been diagnosed with STI before?
Have you ever been screened for STIs before?

assess capacity as she is less than 16:

do you know what are the pills for?
Do you know what will happen if you don’t take them ?
What would yo do if you couldn’t get those pills ?
Will you continue being sexually active after the pills ?
Have you ever tried any method of contraceptions in the past ?

MMA questions

DESA

ICE & PSYCHOSOCIAL

how do you feel about that ?
Have you talked with your partner about it ?
Have you discussed it with you parents ?
Does your parents know you are sexually active ?

EXAMINATION
vitals + relevant ex + pregnancy test

MANAGEMENT
-Routine blood tests
-offer screening for STDS
-reassure and explain confidentiality and advice to inform parents ,Your
parents where of your age at one point, they may understand .

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 DR MO SOBHY

-Explain that Contraception does not protect from STI.

- advice to practise safe sex as using condoms as it protects against STDs
and unplanned pregnancy
-We will offer you a morning pill. It is one tablet called levonorgestrel ,
taken once only
It has got some side effects as Nausea, Vomiting (if you vomit in the
next 2 hours after taking the pill come back to take another pill) , Next
period may be delayed or early. (If it is late do a pregnancy test) ,There
may be vaginal spotting ,Diarrhoea , Breast tenderness
-explain that the pill is not a long term of contraception and offer
informations about long time contraception methods.
-Advise to avoid sexual intercourse until the next period.

SAFETY NETTING

LEAFLET

notes:
The legal age of consent to sexual activity is 16 years in the UK.
Sexual activity under the age of consent is an offence, even if consensual.
• Offences are considered more serious (statutory rape) when the
person is younger than 13 years of age.
• Oral levonorgestrel 1.5 mg tablet— licensed to be used within 72
hours after UPSI
• Oral ulipristal acetate (ella one) 30 mg tablet—licensed to be used
within 5 days
-The copper intrauterine device (Cu-IUD)— can be inserted for EC within 5
days (120 hours) after the first unprotected sexual intercourse (UPSI) , not
to be used in young ages.

*************************************************

31. post partum depression

Where you are:

You are an FY2 in GP.
Who the patient is:
Miss Amanda Lowe, aged 31, came to you with complaint of insomnia.
Other informations you know about the patient :

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DR MO SOBHY

none
What you must do:
Talk to her and address her concerns.

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

FODPARA to explore insomnia
Do you have trouble falling asleep or do you wake up in the middle of the
night?
How often does this happen ?
What time do you go to bed?
Do you wake up after falling to sleep?
For how long has this been going on ?
Were you able to sleep fine before that ?
Can you think of anything might be causing you that?
Any stress / problems in life you facing?
Did you face this problem before in your life ?
Where do you live currently ? Who do you live with ?
Has there been any new changes happened in your life ? Yes I had a child
few weeks ago
explore delivery
was this pregnancy planned ? Congratulations,
what did you name the child ? Is your partner
supportive ?
Are you facing any troubles raising the child ?
How would you describe the bond between you and your child ?
Have you tried anything to help you sleep?

MMA questions

DESA
do you drink any caffeinated drinks ?
Alcohol?
Smoking?

ICE & PSYCHOSOCIAL

-assess mood , from 1 to 10 how would you score your mood as 1 being
the lowest and 10 is the highest ?

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DR MO SOBHY

-Has this problem affected your life ? And Explore that ..

-Some people when they go through difficult times they think about harming
themselves or others. Have you experienced any similar thoughts?
-Do you have a loss of interest in everyday activities?
-do you feel life is worthless or you lost interest ?
-how do you see your future and what are your plans for yourself and
family?
-have you discussed this problem with anyone ,partner, family .. ?

EXAMINATION
vitals + relevant ex general assessment

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), I suspect you are having a condition
called post natal depression
It is a type of depression that many parents experience after having a baby.
Post natal depression can be lonely, distressing and frightening It happens
to many women and we can help you to overcome it and we will give you
all the support and help you need.

MANAGEMENT
Routine blood tests +TFT
-Things you can try yourself including talking to your family and friends
about your feelings and what they can do to help, making time for yourself
to do things you enjoy, resting whenever you get the chance, getting as
much sleep as you can at night
- exercising regularly
- eating a healthy diet avoid caffeinated drinks and alcohol if on it
-think of a hobby you enjoy and start doing it again it can help you a lot
-refer for CBT , talking therapy
-sleeping hygiene routine .. explain close all lights/ slow calming music/
reading a book or taking a warm bath/ fixed time to go to sleep daily / avoid
naps during day/ make bedroom only for sleeping and other activities
outside it /Exercise should be avoided within 4 hours of bedtime
-if all fails , offer anti depressants as SSRI ,TCA and psychiatrist review
-if severe mode affection refer to mental health clinic for specialist
psychiatric review
-if any suicidal thoughts immediate referral to hospital

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 DR MO SOBHY

SAFETY NETTING

LEAFLET

*******************************************

32. endometrial carcinoma

INTRODUCTION
confirm

HISTORY & DIFFERENTIALS

Main symptoms of womb cancer can include:
• bleeding or spotting from the vagina after the menopause

• heavy periods from your vagina that is unusual for you

• vaginal bleeding between your periods

• a change to your vaginal discharge

Other symptoms of womb cancer can include:

• a lump or swelling in your tummy or between your hip bones (pelvis)

• pain in your lower back or between your hip bones (pelvis)

• pain during sex

• blood in your pee

risk factors :
-hormonal contraceptive methods
No previous pregnancy
-hx of PCOS
-menopause after 55
-diabetes
-family hx
-previous hx of cancer.. eg. breast cancer

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DR MO SOBHY

ask about tummy pain / constipation / diarrhoea / back pain

any SOB / leg swelling

FLAWS
fever
losing weight
losing of appetite
any swellings around body ?

MMA questions

DESA

ICE & PSYCHOSOCIAL

EXAMINATION
vitals + relevant ex pv + abd + Lns + BMI

DIAGNOSIS
thank you for letting me examining you From what you've told me and after
examining you(explain +ve findings), I suspect you are having a condition
called endometrial cancer (BBN approach)
pause ,, this must have come as a shock to you and I understand how
difficult that must be. I am really sorry to tell you this, yet we are not sure
about the diagnosis and further assessment and investigations are required
to confirm.

MANAGEMENT
-Routine blood tests
-urgent refer to gynaecologist (2weeks)
-pelvi abdominal ct scan
-trans vaginal gel scan .. a scan of your womb
-blood tumour markers / indicators
-they might do biopsy to confirm
if confirmed the surgeon would be in a better place to explain the following
treatment plan
-they might offer chemotherapy / radiotherapy or surgery depending on the
staging of the disease
-they may also offer hormonal therapy to shrink and control the cancer

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DR MO SOBHY

-one of the options also is Immunotherapy medicines that help your

immune system to find and kill cancer cells.

SAFETY NETTING

LEAFLET

666 drmohamedplab2@gmail.com. +47743137345