Gynaecology case 1

A 24-year-old woman presented to gynaecology clinic with a one month history of lower abdominal pain. The
pain was associated with reduced mobility, foul yellowish per vaginal discharge and loose bowel motion for the
past 2 days. She denied any fever, nausea or vomiting, shoulder tip pain and urinary symptoms. She has not
missed her menses and is not on any form of family planning.
Obstetric & Gynaecology history:
Gravida 1 Para 1, had a vaginal delivery five years ago.
She reported no issues with her menstrual periods (menarche 14, regular, duration 3 days, not heavy
bleeding); her LNMP was twenty days ago.
Her last PAP smear in 2018 was normal.
She has had multiple previous admissions for PID since 2014.
Past medical history:
Had an appendectomy last year.
Social history:
She has been divorced from her husband (who has since remarried), four years ago.
She does not smoke
Works as a waitress
On examination:
All her vitals were stable and within normal limits.
There was significant tenderness on the lower abdomen (from below umbilicus, suprapubic RLQ & LLQ).
Voluntary guarding was noted. No significant rebound.
A speculum examination revealed creamy, yellowish, foul smelling discharge.
There was positive cervical excitation tenderness (CET) and bilateral adnexal tenderness, no mass was
appreciated.
Investigation results:
WCC was 7400, other hematological and biochemical parameters were normal.
ESR/CRP was not done.
Abdominopelvic ultrasound scan showed no free fluid in the POD, a small right adnexal hypoechoic area (2 x
1.7 x 2.3 cm).
HVS & cervical swab microbiology revealed: +gram-neg cocci, +++ bacilli, ++ beta-hemolytic forms,
N.gonorrhoeae was not isolated.
Serology revealed: VDRL -ve

Summary of her treatment:

She was started on empirical antibiotics; ampicillin 2g IV 6hrly, gentamicin 240mg IV OD, Flagyl 400mg PO
12hrly and doxycycline 100mg PO 12 hrly.
Acetaminophen and morphine were prescribed to manage her pain.
When reviewed 2 days ago, she was clinically improving with decrease in severity of lower abdominal pain
and was tolerating full diet.
Gynaecology case 2

A 60-year-old Para 4 presented to gynaecology clinic with post-menopausal bleeding.

History of presenting complaint:
She had 5 episodes of fresh per vaginal bleeding over the past 8 weeks. Last episode was yesterday, with bright
red blood and clots, her current pad is soaked with blood.
Gynaecology & obstetric history:
Menopausal for the past 9 years. She was on hormones for 3 years right after menopause, since has stopped for
the past 6 years. Prior to menopause she had regular, 4-day menstrual cycle which were not heavy.
Has never had a PAP smear.
Had all 4 normal vaginal deliveries
Past medical history:
She has been on medication for diabetes and hypertension for the past 6 years. No known allergies.
No previous hospital admissions apart from delivery for her 4 children.
Family history:
Father and a brother died of bowel cancer.
Social history:
Retired schoolteacher, lives with her husband, is an active woman who does gardening, most of the household
chores and looks after grandchildren.
On examination:
BMI: 35, BP: 150/90
Breast: normal
Chest: clear, normal heart sounds
Abdomen: obese, flabby, no palpable masses, non-tender
Vaginal examination: vulva/vagina: grossly normal apart from atrophic appearance, speculum: cervix looks
grossly normal, some dark blood coming from the cervical os. Digital examination: no pelvic masses, uterus not
enlarged.
The following are the investigation ordered and their results:
FBC, RFTs, LFTs, FBS, CXR & ECG were all normal
Pelvic ultrasound revealed: endometrial thickness of 10mm, uterus was not enlarged & ovaries were not seen.
Pipelle endometrial sampling revealed: grade 1, endometrioid adenocarcinoma.

A counselling session was done which involved the patient, her immediate family, gynaecology team
(consultant and registrar) and the oncology nurse.
She has been booked for anesthetic & medical review and for TAH, BSO and +/- lymphadenectomy next week.
Gynaecology case 3

A 26-year-old woman had been referred from Oxfam clinic following her routine PAP smear last year. The PAP
smear had shown LSIL (CIN1)

Outlined is the summary of her history as noted in the folder:

Gynaecology history:
She had one previous PAP smear 2 years ago. This was her second PAP smear which she had done 3 months
ago at Oxfam clinic prior to this referral.
She gave no history of post coital bleeding, has normal monthly menses, no dysmenorrhea or dyspareunia.
Past medical history:
Nil of significance
Family history:
Nil of significance
Obstetric history:
Had 1 normal vaginal delivery.
Social history:
A single parent, she lives with her parents. She works as a waitress, she does not smoke or drink alcohol or
kava.
On examination:
Vitals were stable. BMI: 28
Abdomen: soft, non-tender, no masses
VE: speculum: cervix looks grossly normal; digital: no cervical excitation tenderness (-CET), normal sized
uterus, no adnexal masses or tenderness elicited

During this review she was counselled with regards to her PAP smear result and planned for a repeat PAP
smear in 6-12 months.
Advised on contraception and use of condoms.

She returned 8 months later for her repeat PAP smear, which now showed HSIL (CIN3). The registrar had
booked her for colposcopy.

She had a colposcopy examination with acetic acid and Lugols iodine. A punch biopsy was taken.
Histology report came back as HSIL/CIN3, the lesion did not extend up the endocervical canal.

She was counselled with regards to her diagnosis and treatment.

She is currently booked for a LLETZ with fisher cone biopsy next week.