• History taking - what additional questions to ask
• Differential diagnoses - likely and must-not-miss conditions
• Investigations - which tests to order and why
• Management - treatment approach, medications, referrals

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48M - Tooth Pain / Tooth Decay

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HISTORY TO TAKE (Ask the Patient)

• Which tooth / teeth? Upper or lower jaw? Single or multiple?
• Onset - sudden or gradual?
• Character - sharp, throbbing, dull, or constant?
• Duration of pain after a stimulus - seconds (reversible) or minutes to hours (irreversible)?
• Triggers - hot, cold, sweet, sour, biting pressure?
• Spontaneous pain at rest? (suggests irreversible pulpitis or pulpal necrosis)

• Facial swelling, fever, difficulty swallowing, or trismus? (red flags for deep neck infection)
• Gum swelling or pus discharge near the tooth?
• Any loosening of teeth?

• Diabetes (affects healing, increases infection risk)
• Medications - especially bisphosphonates (risk of osteonecrosis)
• Last dental visit? Any previous dental procedures?
• Smoking / tobacco / alcohol use
• Oral hygiene habits

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CLINICAL EXAMINATION

• Facial asymmetry or swelling? (abscess / space infection)
• Trismus (inability to open mouth fully)?
• Lymph node enlargement (submandibular, cervical)?
• Temporal artery tenderness (rule out temporal arteritis in this age group)
• TMJ: palpate for clicks/pops on jaw movement

• Inspect all teeth for visible caries (black/brown cavities), fractures
• Check gingival health - redness, swelling, bleeding
• Percuss each tooth with a metal instrument - pain on percussion = periapical involvement/abscess
• Check for parulis (small gum swelling with draining fistula near root = indicates periapical abscess)
• Bite test on tongue blade to identify cracked tooth syndrome

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DIFFERENTIAL DIAGNOSIS

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INVESTIGATIONS

• Dental radiograph (periapical X-ray) - first-line; assess depth of caries, periapical changes, widening of periodontal ligament space, lamina dura thinning
• Panoramic X-ray (OPG/Panorex) - if abscess or wider osseous pathology is suspected
• No routine blood work needed unless abscess with systemic signs (then: CBC, CRP, blood sugar)
• Blood glucose - screen for undiagnosed diabetes in a 48-year-old male with dental decay

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MANAGEMENT

Immediate Pain Relief

Note: Avoid opioids for routine dental pain. NSAIDs are preferred by the American Dental Association as they offer better pain reduction with fewer harms. - Tintinalli's Emergency Medicine, p. 1622

Antibiotics - When to Use

• NOT indicated for simple pulpitis without signs of infection
• Indicated if: facial swelling, fever, trismus, cellulitis, or periapical abscess present
• Antibiotic of choice: Amoxicillin 500 mg TDS x 5-7 days OR Metronidazole 400 mg TDS (if penicillin allergy)

Definitive Treatment (Dentist Referral - within 1 week)

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RED FLAGS - Refer Urgently / Hospital Admission

• Facial swelling spreading to neck
• Trismus (cannot open mouth > 2 finger widths)
• Dysphagia or difficulty breathing
• High fever + systemic sepsis
• These indicate Ludwig's Angina or deep space infection - life-threatening emergency

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COUNSELLING THE PATIENT

• Brush teeth twice daily with fluoride toothpaste
• Reduce sugary foods and drinks
• Dental follow-up every 6 months
• Do not delay dental treatment - untreated caries progresses to abscess and can lead to serious complications
• Screen for diabetes - poor glycaemic control worsens dental disease

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Clinical Guide: Heavy Menstrual Bleeding (HMB) x 8 months

First, establish age and reproductive status - "A female patient" - assume reproductive age (not stated, please clarify if perimenopausal as management differs significantly).

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HISTORY TO TAKE

• Exact duration of each episode of bleeding (how many days?)
• Frequency of pad/tampon change (>1 pad/hour = severe)
• Presence of clots - size and frequency
• Any intermenstrual bleeding or post-coital bleeding?
• Cycle regularity - regular or irregular cycles?
• Any dysmenorrhoea (painful periods)? - suggests adenomyosis
• Age at menarche

• Fatigue, breathlessness, pallor (anaemia symptoms)
• Weight gain, acne, hirsutism, hair thinning (PCOS features)
• Pelvic pain or pressure (adenomyosis / fibroids)
• Symptoms of thyroid disease - cold intolerance, weight gain, constipation (hypothyroidism)
• Galactorrhoea (hyperprolactinaemia)

• Gravida / para? Any pregnancies planned in future? (impacts treatment choice)
• Last pregnancy, any complications?

• Anticoagulant use (warfarin, aspirin, heparin)
• Antiepileptics, antipsychotics
• Any bleeding disorders in family? (Von Willebrand disease)
• Liver or kidney disease
• Diabetes (associated with PCOS)

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EXAMINATION

• Pallor (anaemia), BMI / obesity (PCOS association)
• Signs of hyperandrogenism: acne, hirsutism, male-pattern hair loss
• Thyroid enlargement

• Uterine or adnexal mass palpable?

• Cervical pathology - polyps, erosion, discharge, suspicious lesions
• Source of bleeding: cervical vs uterine

• Uterine size, tenderness, mobility
• Adnexal tenderness or masses

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DIFFERENTIAL DIAGNOSIS (PALM-COEIN Framework)

Most Likely Diagnoses in This Patient:

1. Adenomyosis - bulky uterus, 8 months HMB, likely with dysmenorrhoea
2. PCOS / Ovulatory dysfunction - bilateral PCOM, anovulatory cycles causing HMB
3. Combined adenomyosis + PCOS - both often coexist
4. Endometrial hyperplasia - chronic anovulation (PCOS) leads to unopposed oestrogen → endometrial buildup → must exclude

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INVESTIGATIONS

Bedside / First-Line

Blood Tests

Imaging

Procedures

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MANAGEMENT

Step 1: Treat Anaemia (if present)

• Oral iron supplementation: Ferrous sulphate 200 mg TDS until stores replenished
• If severe anaemia: IV iron or transfusion

Step 2: Medical Management of HMB

For this patient specifically: Given bulky uterus (adenomyosis) + bilateral PCOM, a Levonorgestrel IUD or COCP is an excellent dual-action choice. Add tranexamic acid for acute heavy days. Cyclic progestins protect endometrium from hyperplasia in PCOS.

Step 3: Address PCOS

• Lifestyle modification - weight loss if overweight (even 5-10% weight loss restores ovulation)
• If insulin resistance confirmed: Metformin 500-1000 mg BD
• Treat acne/hirsutism with COCP

Step 4: Surgical Options (if medical treatment fails)

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RED FLAGS - Urgent Action

• Haemodynamically unstable (tachycardia, hypotension) → Emergency IV access, fluids, transfusion
• Endometrial thickness significantly increased → Urgent biopsy to exclude carcinoma
• Fever + pelvic pain → Rule out pelvic infection / endometritis
• Suspicious cervical lesion → Urgent gynaecology referral

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REFERRAL

• Gynaecology OPD referral within 2-4 weeks for endometrial biopsy, hysteroscopy, and definitive management planning
• Urgent referral if red flags above

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SUMMARY PLAN FOR THIS PATIENT

1. Rule out pregnancy
2. CBC, iron studies, TSH, prolactin, LH/FSH, androgens, fasting glucose
3. Endometrial biopsy (PCOS + chronic anovulation = risk of hyperplasia)
4. Start tranexamic acid for immediate bleeding control
5. Start COCP or cyclic norethisterone to regulate cycles and protect endometrium
6. Treat iron deficiency anaemia
7. Gynaecology referral for hysteroscopy and definitive management

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REVISED GUIDE: Age 17 Years - Heavy Menstrual Bleeding x 8 Months + Bulky Uterus + Bilateral PCOM

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KEY CLINICAL CONTEXT FOR THIS AGE

At age 17, the hypothalamic-pituitary-ovarian (HPO) axis is still maturing. It is normal for cycles to be anovulatory for up to 18 months after menarche. Anovulatory cycles are the most common cause of HMB in adolescents. - Textbook of Family Medicine

In adolescents, structural causes (adenomyosis, fibroids) are much rarer than in older women. COEIN causes (Coagulopathy, Ovulatory dysfunction) are far more likely. - Berek & Novak's Gynecology

Two Leading Diagnoses in This Patient:

1. Anovulatory bleeding due to immature HPO axis / PCOS - bilateral PCOM supports this
2. Bleeding disorder (especially Von Willebrand Disease) - up to 24% of adolescents with menorrhagia have an undiagnosed coagulopathy - Textbook of Family Medicine

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HISTORY TO TAKE

• Age at menarche? (How many months since first period?)
• Are cycles regular or irregular?
• How many pads/day? Soaking through in <1 hour = severe
• Clots? Size (>coin-sized = significant)
• Duration of each period (>7 days = abnormal)
• Any intermenstrual bleeding?
• Any dysmenorrhoea (painful periods)?

• Easy bruising or prolonged bruising?
• Prolonged bleeding from cuts or tooth extractions?
• Nosebleeds that are hard to stop?
• Family history of bleeding disorders?
• Any previous surgical bleeding complications?

• Weight gain, difficulty losing weight?
• Acne, oily skin?
• Excess facial/body hair (hirsutism)?
• Hair thinning on scalp?
• Skin darkening at neck/armpits (acanthosis nigricans = insulin resistance)?

• Fatigue, breathlessness, palpitations (anaemia symptoms)
• Any medications (anticoagulants, antiepileptics)?
• Sexual activity (confidential, non-judgementally) - to determine if pregnancy test needed
• Stress, extreme weight loss, excessive exercise? (cause hypothalamic suppression)
• Symptoms of thyroid disease - weight gain, cold intolerance, constipation

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EXAMINATION

• Pallor (conjunctival, palmar) - anaemia
• BMI - obesity/overweight (PCOS)
• Acanthosis nigricans (neck, axilla, groin) - insulin resistance
• Acne, hirsutism (Ferriman-Gallwey score)
• Petechiae, ecchymoses - coagulopathy
• Thyroid palpation

• Uterine enlargement (adenomyosis / rarely fibroid in this age)

• Should be performed sensitively; transabdominal USG preferred over transvaginal in adolescents who are not sexually active
• Speculum if sexually active or if cervical pathology suspected

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DIFFERENTIAL DIAGNOSIS

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INVESTIGATIONS

Mandatory (All Adolescents with HMB)

Hormonal Workup (PCOS / Anovulation)

Imaging

Note on "Bilateral PCOM" in a 17-year-old: PCOM (polycystic ovarian morphology) on ultrasound alone is NOT sufficient to diagnose PCOS in adolescents. Multifollicular ovaries are a normal finding in puberty. PCOS diagnosis in adolescents requires both irregular cycles AND clinical/biochemical hyperandrogenism - not just scan findings. - Rotterdam criteria modified for adolescents

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MANAGEMENT

Step 1: Treat Anaemia

• Ferrous sulphate 200 mg BD-TDS orally with Vitamin C to enhance absorption
• Continue for 3 months after Hb normalises to replenish stores
• If Hb very low (<7 g/dL) with symptoms: consider IV iron or transfusion

Step 2: Control Bleeding - Medical (Preferred over Surgical in Adolescents)

Emphasize to patient and parents: hormonal therapy is being used to regulate the menstrual cycle and treat heavy bleeding - not as contraception. Reassure about safety of low-dose preparations.

• IV conjugated oestrogens (Premarin 25 mg IV q4-6h) - rapid endometrial stabilisation
• OR high-dose COCP (e.g., 3-4 tablets/day, taper over days) under gynaecology supervision
• Hormonal therapy effective within 12-24 hours
• Surgery (D&C) is last resort in adolescents - only if hormonal therapy fails

Step 3: Address Underlying PCOS (If Confirmed)

• Lifestyle: regular exercise, healthy diet; 5-10% weight loss significantly restores ovulation
• COCP is also the treatment for PCOS symptoms (acne, hirsutism, cycle regulation)
• If insulin resistance confirmed: Metformin 500 mg BD (off-label in teens, but widely used)
• Do NOT diagnose PCOS definitively before age 18 - wait for HPO axis maturity; label as "at risk for PCOS" or "possible PCOS"

Step 4: If Bleeding Disorder Found

• Refer to haematology
• Specific treatment per disorder (e.g., desmopressin / DDAVP for VWD, tranexamic acid is also effective)
• Tranexamic acid is highly effective for HMB in coagulopathies

Step 5: Surgical Options (Last Resort Only)

• D&C - only if hormonal therapy fails in an acute severe bleed
• Endometrial ablation / hysterectomy - NOT appropriate for a 17-year-old (future fertility consideration)
• Surgical intervention in adolescents should only follow failure of all medical options

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IMPORTANT COUNSELLING POINTS

• Explain that anovulatory cycles are common and expected at this age - reassurance is therapeutic
• PCOM on scan does NOT mean she definitely has PCOS - this should be reassessed after age 18
• Treatment with hormones is safe and will not affect future fertility
• Iron-rich diet: green leafy vegetables, meat, beans, fortified cereals
• Keep a menstrual diary to track cycle pattern, number of pads, and clots
• Follow up in 3 months to reassess cycle pattern, Hb, and medication response

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REFERRAL

• Paediatric/Adolescent Gynaecology OPD - within 2-4 weeks
• Haematology - if coagulation screen or VWD screen is abnormal
• Urgent admission if: haemodynamic instability, Hb <7 with symptoms, uncontrolled acute heavy bleeding

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SUMMARY ACTION PLAN

• Need height to calculate BMI exactly, but 46 kg at 17 years is likely low-normal to underweight range
• If height ~155 cm → BMI = 19.1 (low normal); if ~160 cm → BMI = 18.0 (borderline underweight)

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UPDATED: 17F | Weight 46 kg | HMB x 8 months | Bulky Uterus | Bilateral PCOM

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WHAT WEIGHT 46 KG TELLS US

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HOW THIS CHANGES THE DIAGNOSIS

🔑 New Priority Diagnosis: Hypothalamic Dysfunction / Functional Hypothalamic Anovulation

• The PCOM on scan may be secondary to low-weight HPO axis immaturity, NOT true PCOS
• The "bulky uterus" at this age with low weight - adenomyosis is even less likely - the uterus may simply be at the upper end of normal size variation
• Do NOT assume PCOS just because of bilateral PCOM - lean/underweight PCOS exists but must be properly confirmed

Ask Specifically:

• Any deliberate dietary restriction or fear of weight gain? (eating disorder screening)
• Excessive exercise (athlete)?
• Any recent significant weight loss?
• Does she feel cold all the time? Constipated? Hair falling? (hypothyroidism more likely in thin girls with menstrual irregularity)
• Screen for anorexia nervosa / orthorexia - 17-year-old female, low weight, menstrual irregularity is a classic triad

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REVISED DIFFERENTIAL DIAGNOSIS (Priority Order)

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ADDITIONAL HISTORY (Weight-Specific)

• What is her usual diet? Meal skipping?
• Deliberate restriction of food / fear of gaining weight?
• Is she an athlete or involved in heavy exercise?
• Any other symptoms: cold hands/feet, hair loss, constipation, fatigue (hypothyroidism)?
• Any recent illness causing weight loss?
• Screen for Female Athlete Triad: low energy availability + menstrual dysfunction + low bone density

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ADDITIONAL INVESTIGATIONS (Weight-Specific)

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REVISED MANAGEMENT PLAN

⚠️ Critical Change from Previous Plan: Do NOT assume PCOS needs Metformin

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Priority 1: Nutritional Assessment and Rehabilitation

• Refer to dietitian / nutritionist
• Target: gradual weight gain to BMI ≥ 18.5 (approximately 48-52 kg at average height)
• Weight gain alone may restore ovulation and reduce HMB - treat the root cause
• Screen and refer for eating disorder assessment if dietary restriction confirmed (CAMHS / psychiatry)
• High-calorie, iron-rich, calcium-rich diet

Priority 2: Treat Iron Deficiency Anaemia

• Check CBC and serum ferritin first - after 8 months HMB she is almost certainly iron deficient
• Ferrous sulphate 200 mg once or twice daily (lower dose to minimise GI side effects in a small 46 kg patient)
• Take with orange juice (Vitamin C) on empty stomach for best absorption
• Avoid with tea, coffee, calcium
• Recheck Hb in 4-6 weeks

Priority 3: Bleed Control - Medical

Important: If the cause is hypothalamic dysfunction from low weight, oestrogen levels are already LOW. Starting a low-dose COCP is reasonable to protect bone density AND regulate cycles. However, the primary treatment must remain nutritional rehabilitation - not just hormonal suppression of the HPO axis.

Priority 4: Bone Protection

• Low weight + low oestrogen at age 17 = peak bone mass will not be achieved = long-term osteoporosis risk
• Calcium 1000-1200 mg/day (dietary + supplemental)
• Vitamin D 1000-2000 IU/day
• If oestradiol confirmed low: COCP or oestrogen replacement to protect bones

Priority 5: PCOS - Defer Definitive Diagnosis

• Do NOT label as PCOS at this age with this weight
• PCOM on scan is common in all adolescents; needs reassessment at age 18 with full Rotterdam criteria
• If after nutritional rehabilitation cycles remain irregular and hyperandrogenism confirmed - then diagnose and manage PCOS

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RED FLAGS - Act Urgently

• BMI <16 → Possible anorexia nervosa → Urgent eating disorder service referral
• Hb <7 g/dL → Consider IV iron or transfusion
• Signs of haemodynamic instability (tachycardia, hypotension) → Hospital admission
• Absent periods (amenorrhoea) after bleeding stops → Low oestrogen state, bone risk

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REFERRALS

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SUMMARY TABLE

• Name: Chandiraselvi | Age: 57 | Sex: F
• Department: OG | Hospital: Govt Medical College, Virudhunagar
• DOA: 9/- | DOS: 18 | DOD: 25 (i.e. ~7-8 days admission)
• Final Diagnosis: PL2/Prior 2NVD / Rectocele / SHTN / AKI (Recovered)
• Procedure Done: Vaginal Hysterectomy & Pelvic Floor Repair
• History: 57 yr old woman came c/o mass descending per vaginum x 3 months, lower abdominal pain x 3 months
• K/C/O: SHTN, AKI (Recovered) | No DM, Thyroid, Epilepsy
• Investigations: WBC-6.3, RBC-3.92, Hb-9.6, MCH-24.5, MCHC-30.9, PLT-3.79, Urea-22, Creatinine-1.4, RBS-88, Na-136, K-4.4, Cl-108 | HIV-non reactive
• Treatment: Inj Cefotaxime 1g IV BD x 5 days, T.Metronidazole 200mg 2-2-2 x 5 days, T.Ranitidine 150mg 1-0-1, T.Paracetamol 500mg SOS
• Discharge Advice: Cap Amoxycillin 250mg BD x 3 days, T.FST 1-0-1, T.BCT 1-0-1, T.Ca 0-2-0 x 1 week

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New Patient: Post-Operative Complication After Vaginal Hysterectomy

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PATIENT SUMMARY (From Discharge Summary)

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CLINICAL SITUATION

• Discharge date was around day 7-8 post-op
• Ask: How many days since surgery / since discharge?

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HISTORY TO TAKE

• Exact date of surgery and date of discharge?
• Was she discharged on Cap Amoxycillin 250mg BD x 3 days? Did she complete it?
• Any problems noted at time of discharge?

• Pus discharge: From where exactly?
  • Vaginal vault (most common) - surgical site
  • Abdominal wound (if any)
  • Perineal/vulval area (pelvic floor repair site)
• Colour of discharge: yellow, green, brown, blood-stained?
• Amount: spotting vs heavy discharge?
• Odour: foul-smelling? (anaerobic infection)
• Fever:
  • How high? >38°C?
  • Any rigors/chills? (suggests bacteraemia/sepsis)
  • Continuous or truly intermittent?
• Lower abdominal or pelvic pain? Worsening?
• Difficulty urinating or pain on urination? (UTI, urinary tract injury)
• Any bowel symptoms - constipation, rectal pain? (rectovaginal fistula, pelvic abscess)
• Any bleeding?
• Blood pressure reading at home? (known SHTN)

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EXAMINATION

• Pallor (Hb already 9.6 at discharge; blood loss/infection worsens anaemia)
• Signs of dehydration

• Tenderness (suprapubic, pelvic)
• Guarding or rigidity? (peritonitis / pelvic abscess)
• Any palpable mass (vault haematoma / pelvic abscess)

• Speculum examination - mandatory
  • Inspect vaginal vault suture line
  • Is the vault intact or are there wound dehiscence / breakdown signs?
  • Nature of discharge: frank pus, serosanguinous, foul-smelling?
  • Vault haematoma (bluish bulge at vault)?
• Bimanual examination
  • Vault tenderness
  • Pelvic mass / fullness (abscess)?
  • Adnexal tenderness

• Pelvic floor repair suture line - signs of infection, dehiscence?

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DIFFERENTIAL DIAGNOSIS

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INVESTIGATIONS

Urgent / Bedside

Blood Tests

Imaging

Urine

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MANAGEMENT

Step 1: Assess Severity - Sepsis or Localised Infection?

• Temp >38°C or <36°C
• Pulse >90 bpm
• RR >20
• WBC >12,000 or <4,000

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Step 2: Antibiotic Therapy

⚠️ Critical note on Gentamicin / Aminoglycosides: She had AKI (recovered) - creatinine at discharge was 1.4. Avoid nephrotoxic antibiotics until renal function is reassessed. Prefer cephalosporin + metronidazole combination.

Culture-guided therapy: Start empirical antibiotics, then de-escalate or adjust based on HVS culture & sensitivity results (usually available in 48-72 hours).

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Step 3: Local Wound Management

• If vault haematoma: If small and not infected - conservative; if infected and fluctuant - drainage of haematoma by gynaecologist
• If wound dehiscence at vault: Gentle irrigation with normal saline; povidone-iodine wash; re-suturing if needed
• If perineal repair site infected: Saline irrigation, antiseptic dressing, assess for re-suturing

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Step 4: Supportive Care

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Step 5: Surgical / Gynaecology Review

• Admit to gynaecology ward if fever persists, systemic signs, or pelvic abscess found
• Gynaecology review for vault examination and wound assessment - mandatory
• If pelvic abscess on USG/CT: image-guided percutaneous drainage or surgical drainage
• If fistula (VVF/RVF) suspected: urology/colorectal co-management needed

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RED FLAGS - Admit Immediately

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SUMMARY ACTION PLAN