OG35.4-6 | Focused Gynaecological Case Approach — Summary & Reflection

KEY TAKEAWAYS

The focused gynaecological case approach is a four-phase framework: OG-specific history (menstrual, obstetric, sexual, systemic) → structured examination (general, abdominal, speculum, bimanual) → differential diagnosis in order of likelihood → targeted investigations. For suprapubic lump, the key differential includes fibroid uterus (commonest; irregular, non-tender, uterine origin; associated menorrhagia), ovarian cyst/tumour (lateral, separate from uterus, smooth or irregular), full bladder (exclude by catheterisation first), ectopic pregnancy (exclude with β-hCG in reproductive-age women), and PID/TOA (adnexal, tender, fever); pelvic ultrasound is the cornerstone investigation. For vaginal discharge, physiological is distinguished from pathological by colour, odour, and associated symptoms; bedside pH, whiff test, and wet mount diagnose BV (Amsel criteria: clue cells, pH >4.5, fishy odour, homogeneous grey-white discharge), candidiasis (pseudohyphae, normal pH), and trichomoniasis (motile trichomonads, elevated pH); treatment is pathogen-specific (metronidazole for BV/trichomonas, clotrimazole/fluconazole for Candida, ceftriaxone for gonorrhoea). For genital ulcers, pain is the primary discriminating feature: syphilis (painless, indurated, VDRL/TPHA); chancroid (painful, undermined edge, tender bubo); herpes (painful grouped vesicles/ulcers, Tzanck smear); LGV (painless primary, inguinal buboes, groove sign); granuloma inguinale (painless, beefy-red, Donovan bodies). Co-infection is common; syndromic management covers syphilis and chancroid simultaneously where laboratory confirmation is unavailable.

REFLECT

Think about the last time you saw a patient in the gynaecology OPD. Did you take the menstrual, obstetric, and sexual history components systematically, or did you focus only on the presenting complaint? Did you perform a bimanual examination or defer to the ultrasound result? Did you examine a vaginal discharge under the microscope, or accept 'discharge noted' in the notes? The structured case approach requires deliberate effort — it is faster to skip a step, but slower to correct the diagnostic error that follows. Use your remaining OG posting to practise each phase of this framework until it becomes automatic.