TEALE FENNING

bluesky · Guest

A mother brings her 15 years daughter to hospital with heavy P/V bleeding for 10 days and feeling tired. Her BP on arrival is 80/40, pulse 120/ min and urine hCG is negative

1. what initial management is required for her? (5 marks)
2. how would you establish a diagnosis in this case? (9 marks)
3. what long term treatment options are available for this girl? (6 marks)

Nick Raine-Fenning · Posted: Fri Jan 23, 2009 8:09 pm Post subject:

I've edited your post: added a title and some scores - hope they agree with what you had in mind!

manoj · Joined: 22 Jun 2008 Posts: 87

A mother brings her 15 years daughter to hospital with heavy P/V bleeding for 10 days and feeling tired. Her BP on arrival is 80/40, pulse 120/ min and urine hCG is negative

1. what initial management is required for her? (5 marks)
2. how would you establish a diagnosis in this case? (9 marks)
3. what long term treatment options are available for this girl? (6 marks)

1. Initial resuscitation paramount as compromised
Airway , breathing , circulation
IV acess, blood to labs including FBC, XM, U&E, LFT, Coag
IV fluids resuscitation, may need blood for resuscitation
Stabilise patient and admit

2. History from patient may need to avoid mother
Fraser competancy
History of any assault, abuse, rape
Sexually active or not
On contraception or not
History of menarche and menstrual cycle regularity
History to exclude any know disorders of haemostasis like vWD/ITP
History of any liver disease
General physical examination
Examination of abdomen
May need pelvic assessment sedation / anaesthesia
Investigation depending on initial bloods results
May need further investigation for haematological disorders
Vaginal swabs may be helpful to exclude infection
If irregular cycles investigate for PCOS
Pelvic scans - unlikely any pelvic pathology

3. Long term treatment based on diagnosis
Haematology MDT for haematological conditions
Physcians MDT for liver disorders
PCOS may need additional treatment for hyperandrogenism
Cycle control with combined pill compliance problem
Patch is favourite in adolescence
Long acting reversible contraceptive methods may be helpful to control
bleeding

This is a difficult question and I cant make out what is in the examiners mind, this is a good 10 min bubbling, I feel there is more to add

rpwalavalkar · Posted: Sun Jan 25, 2009 9:57 am Post subject:

I'll add the following --

stem 1 -- check response before ABC, call for help. also mention clinical features , cold? clammy? grey?

stem 2--
may need to avoid mother ???? is the patient stable enough to give detailed history? yes, you do need to' avoid mother' but later after the patient is stabilised. your patient is in shock at arrival, the mum may be the only one who knows some history.
keep 'in camera' history taking for later as stage 2.

in history, previous menorrhagia episodes and how were they treated. recent pregnancy event if known

in examination -- please start with pallor, cyanosis, reconfirm observations that you have now given fluids.
pt is 15, say examination after consent and chaperone.
need for examination under anaesthesia -- if trauma suspected
use of virginal speculums

in investigations --

pelvic scans -- why unlikely pathology? could be fibroids.
what about hysteroscopy and endometrial sampling at later stage ( i know she is 15, but that may be needed to complete the picture)
have you considered CT / MRI

also with scans and other invasive investigations there is the need to consent after ascertaining competence. ( you have mentioned Fraser, i would mention this with scan and examination)
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

rpwalavalkar · Posted: Sun Jan 25, 2009 10:05 am Post subject:

long term management----

did you involve the peads? -- she is 15.
what about acute and long term -- tran and mef?
schedule followup
hematinics?

R
_________________
Dr Miss. Raj Walavalkar MBBS MRCOG
TealeFenning Administrator
SR O&G Wessex Region

manoj · Joined: 22 Jun 2008 Posts: 87

Thanks for that Raj

I completely ignored pregnancy when the stem said hcg negative.
Recent pregnancy with infection or retained products could be a possibility.

Apart from age how will we justify the specific need for paediatric input Question

Nick Raine-Fenning · Posted: Sun Jan 25, 2009 5:58 pm Post subject:

It (pregnancy) is even more important than that as 3% of pregnant women have a negative urine hCG - it has come up before on a RCOG marking scheme!

You must do a serum quantitative hCG but I would not write anymore as this essay clearly is directing you away from that discussion.

N

bluesky · Guest

manoj u covered most of the things but I have a query
I think chronic liver diseases cause amenorrhoae , am I wrong,
I think D/D is DUB, PCOS, haematological conditions causing heavy period.
ofcourse endometritis / retained products are included.

Long acting reversible contraceptive methods may be helpful to control
bleeding, I didnt understand this ?????

Raj: hysteroscopy and endometrial biopsy in 15 years old??????????

farha · Century Club Joined: 18 May 2007 Posts: 175

What about involvement of police security agencies if found abused?
Do we have to mention that?

rpwalavalkar · Posted: Mon Jan 26, 2009 8:40 pm Post subject:

rpwalavalkar · Posted: Mon Jan 26, 2009 8:47 pm Post subject: Re: bleeding in young girl

manoj · Joined: 22 Jun 2008 Posts: 87

I meant liver disease which may alter VitK synthesis and increase risk of haemorrhagic diseases.
LARC with Mirena is the first line treatment option for heavy menstrual bleed when no other cause is found, despite her age this is be the best treatment option.

rpwalavalkar · Posted: Tue Jan 27, 2009 1:16 pm Post subject:

chinnu · Joined: 06 Jan 2009 Posts: 105 Location: KSA

Raj, Please can you elaborate on virginial speculums?

rpwalavalkar · Posted: Sat Feb 28, 2009 10:28 pm Post subject:

chinnu · Joined: 06 Jan 2009 Posts: 105 Location: KSA

Thank you raj. First time ever I heard of them is from you.