Assessment, Diagnosis & Management
This booklet is intended as a practical guide to patient care for registrars, medical officers, interns and medical students attached to the gynaecology units at the University of the Witwatersrand Academic Hospitals. Anyone can use it.
In most patients, a diagnosis or differential diagnosis will be made on clinical findings. If you are a junior, or more senior & in doubt, always discuss the patient with other staff members (any).
- Make a problem list based on the history & examination
- Write the diagnosis or differential diagnosis clearly
- List investigations required (if any) & make arrangements for them
- Write up emergency or initial treatment plan - drugs, fluids, surgery
- Discuss the findings & treatment plan with the patient
- For admitted patients, order the nursing observations
- Indicate when and by whom the patient will be reassessed or seen again
Pregnancy tests
Always consider pregnancy. The history & examination may make it obvious.
Pregnancy tests are sensitive (the threshold for urine hCG is 30-50 mIU/mL) & positive at the time of the first missed period or before. Tests remain positive for up to two weeks after loss of a pregnancy or evacuation(long half-life of hCG). A single drop of urine from a pregnant patient in a partly washed urine jug in the clinic can make the next non-pregnant patient’s test positive. If a test from a clean ‘Universal container’ is negative it is either truly negative or check from another batch.
Ultrasound
Is an important, often vital assistance in clinical assessment. A scan should follow & never replace history taking & examination.
ALWAYS look after the ultrasound equipment. Before removing a probe from its cradle on the machine ALWAYS check that the cable is free and not trapped around a wheel otherwise the probe will fall as you lift it. Never leave ultrasound gel and used condoms on the probes. Always clean the probes before & after use. Get consent for the scan. Document all findings in detail.