MBBS Q

 Bsc nursing students:

🛑Notes on Reproductive Health

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Amniocentesis

(a) During pregnancy, the fetus is surrounded by amniotic fluid which is a water-like substance.

(b) Amniotic fluid contains live fetal skin cells and other substances, such as alpha-fetoprotein (AFP).

(c) These substances provide important information about baby's health before birth.

(d) These days amniocentesis is being misused also, i.e., for detecting the sex of the foetus.

(e) Normal foetus is being aborted if it is a female.

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Sexually transmitted diseases ( STDs)

Diseases which are transmitted sexually through sexual intercourse are collectively called as Sexually Transmitted Diseases (STDs) or Venereal Diseases (VDs) or reproductive tract infections (RTI). STDs can be classified as viral, bacterial, protozoan, fungal, etc.

Causes of STD’s

STDs can be spread with any type of sexual activity, depending on the disease. STDs are most often caused by viruses and bacteria.

Types of Sexually Transmitted DiseasesThe various types of sexually transmitted diseases include genital herps, chancroid, gonorrhoea, syphilis and most common HIV leading to AIDS.

(i) Chlamydiasis

  (a) Chlamydiasis is a sexually transmitted disease in humans caused by the bacterium Chlamydia trachomatis.

  (b) It is a major infectious cause of human genetial and eye diseases.

(ii) Gonorrhoea

  (a) Gonorrhoea is transmitted sexually, by oral, anal or genital sex.

  (b) Gonorrhea is caused by the bacterium Neisseria gonorrhoeae

Prevention

STDs are a major threat to a healthy society.

(i) Avoid sex with unknown partners as well as multiple partners.

(ii) Always use condoms during coitus.

(iii) In case of any doubt, go to a qualified doctor for early detection and get complete treatment if diagnosed with disease.

Infertility

(a) Inability to conceive or produce children even after 2 years of unprotected sexual cohabitation is called infertility.

(b) A large no of couples all over India are infertile.

(c) The reasons for this could be many-physical, congenital, diseases, drugs, Immunological or even Psychological.

Assisted Reproductive Technologies (ART)

Includes all fertility symptoms in which both sperms and eggs are handled. These are special techniques that assist couples to have children.

The main ART- techniques include:

(i) In-vitro fertilisation (IVF)

(ii) Zygote intra fallopian transfer (ZIFT)

(iii) Intra cytoplasmic sperm injection(ICSI)

(iv) Gamete intra fallopian transfer(GIFT)

(v) Artifical insemination (AI)

(1) In Vitro Fertilization (IVF)

(a) Fertilization outside the body in almost similar conditions as are in the body.

(b)  This method is popularly known as test tube baby programme.

(c) In this technique, ova from the wife / donor (female) and sperms from the husband / donor (male) are collected and are induced to form the zygote under simulated conditions in the lab.

(d) The zygote or early embryos could then be transferred into the fallopian tube (ZIFT -zygote intra fallopian transfer).

(2) Zygote intra fallopian transfer (ZIFT)

(a) ZIFT is an assisted reproductive procedure similar to in vitro fertilization and embryo transfer.

(b) The difference is that the fertilized embryo is transferred into the fallopian tube instead of the uterus.

(c) As the fertilized egg is transferred directly into the tubes, the procedure is also referred to as tubal embryo transfer (TET).

(3) Intra cytoplasmic sperm injection (ICSI)

(a) Intracytoplasmic sperm injection (ICSI) is an assisted reproductive technology (ART)

(b) It is used to treat sperm-related infertility problems.

(c) ICSI is used to enhance the fertilization phase of in vitro fertilization (IVF) by injecting a single sperm into a mature egg.

(d)The fertilized egg is then placed in a woman's uterus or fallopian tube.

(4) Gamete intra fallopian tube (GIFT)

(a) The process of transfer of an ovum collected from a donor into the fallopian tube of another female who cannot produce one, but can provide suitable environment for fertilisation and further development is another method attempted.

(a) GIFT uses multiple eggs collected from the ovaries, which are placed into a thin flexible tube (catheter) along with the sperm to be used.

(b) The gametes (both eggs and sperm) are then injected into the fallopian tubes using a surgical procedure called laparoscopy under general anesthesia.

(5) Artificial Insemination (AI)

(a) Infertility cases either due to inability of the male partner to inseminate the female or due to very low sperm count in the ejaculates could be corrected by artificial insemination (AI).

(b) In this technique, the semen collected either from the husband or a healthy donor is artificially introduced into the vagina or into the uterus (IUI - Intra Uterine Insemination) of the female.

✅Paediatric Abdominal Examination

General inspection

Appearance and behaviour

Observe the child in their environment (e.g. waiting room, hospital bed) and take note of their appearance and behaviour:

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Activity/alertness: note if the child appears alert and engaged, or quiet and listless.

Jaundice: a yellowish or greenish pigmentation of the skin and whites of the eyes due to high bilirubin levels (e.g. breastfeeding related, hypothyroidism, rhesus factor disease).

Pallor: a pale colour of the skin that can suggest underlying anaemia (e.g. gastrointestinal bleeding, malnutrition).

Weight: note if the child appears a healthy weight for their age and height.

Syndromic features

Pay attention to features that may indicate the presence of an underlying genetic condition:

Stature (e.g. tall/short)

Syndromic facial features

See the end of this guide for a non-exhaustive list of clinical syndromes which can be associated with gastrointestinal system pathology.

Equipment

Observe for any equipment in the child’s immediate surroundings and consider why this might be relevant to the gastrointestinal system:

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NG/NJ tube: often used for bowel obstruction, short bowel syndrome, inflammatory bowel disease, gastroesophageal reflux, glycogen storage disorders, chronic liver disease, malignancy and anorexia.

Gastrostomy: typically only used if an NG/NJ is needed for more than 6 weeks (indicative that the child has a chronic condition).

Colostomy/ileostomy: often performed in the context of inflammatory bowel disease and malignancy.

Intravenous lines/drip: suggests poor oral fluid intake.

Special feeds: underlying intolerance, gastroesophageal reflux and malabsorption.

Medications

Note any medications by the bedside or in the child’s room and consider what underlying diagnoses they may indicate:

Laxatives: constipation

Antiemetics: nausea/vomiting

Pancreatic enzymes: cystic fibrosis

Hands

The hands can provide lots of clinically relevant information and therefore a focused, structured assessment is essential.

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Inspect the hands

General observations

Inspect the hands for clinical signs relevant to the gastrointestinal system:

Pallor: may suggest underlying anaemia (e.g. malignancy, gastrointestinal bleeding, malnutrition).

Peripheral oedema: associated with nephrotic syndrome (loss of albumin) and liver disease (reduced production of albumin).

Nail signs

Inspect the nails for any of the following signs:

Koilonychia: spoon-shaped nails, associated with iron deficiency anaemia (e.g. malabsorption in Crohn’s disease).

Leukonychia: whitening of the nail bed, associated with hypoalbuminaemia (e.g. nephrotic syndrome, protein-losing enteropathy).

Finger clubbing

Finger clubbing involves uniform soft tissue swelling of the terminal phalanx of a digit with subsequent loss of the normal angle between the nail and the nail bed. Finger clubbing is associated with several underlying disease processes, but those most likely to appear in an abdominal OSCE station include cystic fibrosis and inflammatory bowel disease.

To assess for finger clubbing:

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Ask the child to copy you in placing the nails of their index fingers back to back. 

In a healthy individual, you should be able to observe a small diamond-shaped window (known as Schamroth’s window).

When finger clubbing develops, this window is lost.

If the child is too young for this to be possible, you can simply inspect the fingers, looking for soft tissue swelling of the terminal phalanx of the digits.

Pulse

Radial pulse

Palpate the child’s radial pulse, located at the radial side of the wrist, with the tips of your index and middle fingers aligned longitudinally over the course of the artery.

Once you have located the radial pulse, assess the rate and rhythm.

In babies, assess the femoral pulse instead.

Face

Observe the child’s facial complexion and features, including their eyes and mouth.

✅Paediatric Abdominal Examination

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General appearance

Inspect the general appearance of the child’s face for signs relevant to the gastrointestinal system:

Oedema: associated with hypoalbuminaemia (e.g. protein-losing enteropathy, malnutrition, liver disease).

Pallor: may suggest underlying anaemia (e.g. malignancy, gastrointestinal bleeding, malnutrition).

Eyes

Inspect the eyes for signs relevant to the gastrointestinal system:

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Conjunctival pallor: suggestive of underlying anaemia. Gently pull down their lower eyelid to inspect the conjunctiva.

Scleral jaundice: a yellowish or greenish pigmentation of the eyes due to high bilirubin levels (e.g. liver disease, hypothyroidism, rhesus factor disease).

Aniridia (partial or complete absence of the coloured part of the eye): associated with WAGR syndrome which also involves the development of a Wilm’s tumour.

Kayser-Fleischer rings: dark rings that encircle the iris associated with Wilson’s disease. The disease involves abnormal copper processing by the liver, resulting in accumulation and deposition in various tissues.

Xanthelasma: yellow, raised cholesterol-rich deposits around the eyes associated with hypercholesterolaemia.

Mouth

Inspect the mouth for signs relevant to the gastrointestinal system (tip – ask the child to see how long their tongue is or how big their mouth is):

Angular stomatitis: a common inflammatory condition affecting the corners of the mouth. It has a wide range of causes including iron deficiency.

Glossitis: smooth erythematous enlargement of the tongue associated with iron, B12 and folate deficiency (e.g. malabsorption secondary to inflammatory bowel disease).

Oral candidiasis: a fungal infection commonly associated with immunosuppression. It is characterised by pseudomembranous white slough which can be easily wiped away to reveal underlying erythematous mucosa.

Aphthous ulceration: round or oval ulcers occurring on the mucous membranes inside the mouth. Aphthous ulcers are typically benign (e.g. due to stress or mechanical trauma), however, they can be associated with iron, B12 and folate deficiency as well as Crohn’s disease.

Hyperpigmented macules: pathognomonic for Peutz-Jeghers syndrome, an autosomal dominant genetic disorder that results in the development of polyps in the gastrointestinal tract.

Dental caries: may be associated with neglect or gastroesophageal reflux disease (acid erosion).

Macroglossia: enlargement of the tongue associated with Down’s syndrome, hypothyroidism, mucopolysaccharidoses and Beckwith-Wiedemann syndrome.

Neck

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The left supraclavicular lymph node (known as Virchow’s node) receives lymphatic drainage from the abdominal cavity and therefore enlargement of Virchow’s node can be one of the first clinical signs of metastatic intrabdominal malignancy. The right supraclavicular lymph node receives lymphatic drainage from the thorax and therefore lymphadenopathy in this region can be associated with metastatic oesophageal cancer (as well as malignancy from other thoracic viscera).

Palpate for lymphadenopathy

Palpate the supraclavicular fossa on each side, paying particular attention to Virchow’s node on the left for evidence of lymphadenopathy.

Close inspection of the abdomen

Ask the parent or child (if appropriate) to expose the child’s abdomen.

Position the child lying flat on the bed, with their arms by their sides and legs uncrossed for abdominal inspection and subsequent palpation (this is often difficult to achieve in reality).

Inspect the child’s abdomen for signs suggestive of gastrointestinal pathology:

Scars: there are many different types of abdominal scars that can provide clues as to the child’s past surgical history (see image below for examples).

Abdominal distension: can be caused by a wide range of pathology including constipation, Hirschsprung’s disease, ascites, organomegaly and malignancy.

Caput medusae: engorged paraumbilical veins associated with portal hypertension (e.g. liver cirrhosis).

Hernias: observe for any protrusions through the abdominal wall (e.g. umbilical hernia, incisional hernia).

Drains/tubes/stomas: gastrostomy, central venous catheter, ileostomy and colostomy.

Tip: The abdomen is normally protuberant in toddlers and young children.

Examining the abdomen

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If appropriate, ask the child what they ate for their last meal and try to ‘find it’ (palpation). If you can’t ‘find it’, you’ll have to listen – leading you to auscultation (sneaky right?)

Preparing to palpate the abdomen

Before beginning abdominal palpation:

Kneel down and/or raise the bed, your face is level with the child’s face.

Use warm hands.

Relax the child.

Keep the parent close at hand.

Abdominal wall muscles must be relaxed for palpation to be effective. Ensure the child is lying down entirely flat, with their hand by their sides. Take away any pillows or cushions.

Expose the abdomen entirely, lowering the trousers and underwear whilst covering the child with a sheet.

Light palpation

Avoid mentioning to word “pain” or “hurt” (e.g. “Is this painful?” “Does that hurt?”) when examining young children, as this can often provoke fear and upset. Instead, observe the child’s body language and facial expressions to determine if they are in pain.

Perform light palpation of the nine abdominal regions, whilst looking at the child’s face and assessing for rigidity, tenderness, guarding and palpable masses.

Guarding is suggestive of peritonitis and indicates the need for urgent surgical review.

Deep palpation

Repeat palpation of the nine abdominal regions, this time applying greater pressure to better assess intra-abdominal structures (continue to observe the child’s face for signs of discomfort).

If any masses are identified, determine their location, approximate size, shape, consistency and mobility.

Tenderness

Localised in appendicitis (RIF), hepatitis (RUQ) and pyelonephritis (flank).

Generalised in mesenteric adenitis and peritonitis.

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Guarding

Pain on coughing, moving about/walking/bumps during a car journey suggests peritoneal irritation.

A child walking, whilst being flexed forwards suggests psoas irritation (e.g. appendicitis).

Incorporating play may be used to elicit more subtle guarding:

“Can you jump up and down?” – a child will not be able to jump on the spot if they have localised guarding.

“Blow out your tummy as big as you can, then suck it in as far as you can” – this will elicit pain if there is peritoneal irritation.

Abnormal masses

Wilm’s tumour typically presents as a renal mass which is sometimes visible and does NOT cross the midline.

Neuroblastoma typically presents as an irregular firm mass which may cross the midline. The child is usually very unwell.

Faecal masses are typically mobile, non-tender, indentable and often located in the LIF.

Intussusception typically presents with a palpable mass in the RUQ (most commonly) in the context of an acutely unwell child.

Liver palpation and percussion

Palpate from the right iliac fossa and locate the edge of the liver with the tips or sides of your fingers (ask the child to take deep breaths if appropriate).

The liver edge may be soft or firm and you will be unable to get above it. The edge will move with respiration. Measure in centimetres the extension of the liver edge below the costal margin in the mid-clavicular line.

Percuss downwards from the right lung to exclude downward displacement due to lung hyperinflation (i.e. in bronchiolitis). Dullness to percussion can help delineate the upper and lower border. Record the span of the liver (in cm).

Tip: Young children may be more cooperative if you palpate first with their hand or by putting your hand on top of theirs.

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