FAMILY DOCTOR WANNABE
  • Home
  • About
  • Blog
  • Learn Medicine
  • Contact

I'll be back. Currently meditating...

Procedure: Endometrial Aspiration Biopsy

4/20/2018

0 Comments

 
Endometrial biopsies are performed to sample tissue from the endometrium to rule out suspected endometrial cancer in the setting of abnormal uterine bleeding. Although not a first-line investigation in a patient who presents with vaginal bleeding without risk factors for endometrial cancer, it is always a first-line investigation in a postmenopausal woman with abnormal uterine bleeding. The procedure can be done in the office, and often is done after transvaginal ultrasound to assess thickness and character of the endometrial lining. The only absolute contraindications are current pregnancy or a bleeding diathesis. Although I haven't yet seen one been doing ever in real-life yet, let alone having had the opportunity to try my hand at this procedure, we did have a clinical skills training day where we got to practice performing endometrial aspiration biopsies on kiwis... Apparently that's what it's like. I personally think doing it on a young coconut would be a better analogy, based on my understanding of what the texture of the endometrial lining must be like, but alas  we don't live in Southeast Asia.

Equipment
  1. Large vaginal speculum
  2. Nonsterile gloves, gown, mask, and eye protection
  3. Antiseptic solution
  4. Cotton balls
  5. Ring forceps
  6. Uterine sound
  7. Single-toothed tenaculum
  8. Topical benzocaine gel (20%) or benzocaine spray
  9. Buffered formalin specimen containers with patient identification labels (two)
  10. Endometrial Aspirator 

Procedure
  1. Ensure Pap is up to date. If not, obtain Pap smear before performing the endometrial biopsy.
  2. Obtain consent (indication/risks/alternative options, ensure understanding and answer any questions) *Risks: Uterine perforation, excess uterine bleeding, false negative from missing areas with pathology, vasovagal response and/or pain immediately post-procedure, infection
  3. Optional: The patient may take an NSAID 30-60 min prior to the procedure to decrease cramping/pain from the procedure.
  4. Timing of the procedure: Best to be done when there is no active bleeding, if possible.
  5. Positioning: Position the patient in dorsal lithotomy.
  6. Don gloves, gown, mask, and eye protection (universal precautions)
  7. Perform a a bimanual exam to determine orientation and size of uterus
  8. Insert large speculum. Visualize the cervix and clean off any mucus or debris using antiseptic solution, cotton balls, and ring forceps. 
  9. Use the uterine sound to dilate the cervical os
  10. Proceed with endometrial biopsy. Technique will depend on endometrial biopsy instrument. Avoid contaminating instrument by touching vaginal side walls. Generally insert tip of instrument to uterine fundus and create suction, drawing up endometrial tissue. Continue to move catheter about the uterus, sampling circumferentially from a variety of areas. Enough sample is acquired when about half of the catheter is filled with endometrial tissue.
  11. After the procedure is done, the patient should remain supine for 10 minutes.
  12. Advise patients to return for assessment if they develop fever, bleeding heavier than a normal period, or cramping >48 hours after the procedure (the patient may take NSAIDs to manage cramping/discomfort in the first 48 hours).
  13. Document the procedure.
Picture
0 Comments

Procedure: Insertion of Intrauterine Device

4/19/2018

0 Comments

 
Today in clinic I watched as my preceptor demonstrated how to insert an IUD. The patient was a 22 year-old nulliparous woman who was excited but nervous to have an IUD inserted. I reassured her that the pain of insertion would be better than the pain of having a baby. Haha. She tolerated the procedure well, and like most IUD patients, will probably go on to happily every after for at least 5 years (how long the Mirena, the most common form of the IUD, is guaranteed to last).

The intrauterine device (IUD) is a wonderful little form of contraception. With an extremely high rate of success in staving off pregnancy (<1% chance of becoming pregnant), with a correspondingly low risk of failure (because once inserted, the patient doesn't need to do anything for it to work), it is a preferred method of contraception in any woman who is not contraindicated from having it. There are two types of IUDs, the original copper IUD and the levonorgestrel-containing IUD. The levonorgestrel-containing IUD is generally preferred because it contains locally-acting progesterone that prevents the endometrial lining from building up, which means that despite ongoing ovulation, a few months after insertion the woman generally no longer has menstrual periods (bonus!). However, it is contraindicated in women who have contraindications to using progesterone. The copper IUD can be used in women who have a contraindication to the hormone-containing option, although it tends to produce somewhat heavier periods than the woman normally has. Whenever the device is removed, the woman returns to having whatever menstrual cycles she would have without an IUD, and her fertility is back to what it would be for her natural history (this is why it is called a form of reversible contraception). Contraindications to receiving either form of IUD include:
  1. Pregnancy
  2. Current or recent (within the past 3 months) sexually transmitted infection
  3. Abnormal vaginal bleeding that is not yet diagnosed
  4. A structural uterine abnormality
Ruling out pregnancy, performing STI screening, and ensuring a woman is up to date with her Pap testing are important before inserting an IUD. 

Equipment
  1. Prepackaged IUD
  2. Speculum
  3. Sterile basin with cotton balls moistened with a water-based antiseptic (ex: chlorhexidine)
  4. Ring forceps
  5. Cervical tenaculum
  6. Uterine sound
  7. Nonsterile gloves (for bimanual examination before insertion procedure)
  8. Sterile gloves (for IUD insertion phase)
  9. Sterile towel to cover tray
  10. Long suture scissors (to cut IUD threads after insertion)
  11. NSAID, to be taken before procedure (optional)
  12. Local anesthetic 
  13. Cervical dilators may be needed in some nulliparous patients.

Procedure
  1. Obtain consent (benefits, risks, alternatives, opportunity to ask questions, clarify understanding). The patient should be counselled on the cramping/discomfort/spotting that tends to go along with with insertion and removal. 
  2. Preparation: Position patient in the dorsal lithotomy position, with appropriate draping. Prepare the needed equipment.
  3. Visualize the cervix with the speculum.
  4. Clean the cervix with the antiseptic solution.
  5. Anesthetize the cervix.
  6. Clamp the tenaculum to the anterior aspect of the cervix.
  7. Sound the uterus, which means to take the uterine sound device and insert it through the cervical os to the top of the uterine funds. This is to measure the depth of the uterus. In a women with a stenosed cervix, you may need to use cervical dilators to accomplish this step. The uterine depth is normally between 6.5 and 8.5 cm. If outside of this range, do not insert the IUD as there is increased risk of complication.
  8. Prepare and insert the IUD using an insertion tube (specific steps depend on the model)
  9. Cut the strings so that they are 2-3 cm long protruding from the external cervical os (so that the woman can self-check her strings, but also because if they are shorter, they can feel like unpleasant pokey whiskers for a male sexual partner)
  10. Remove the tenaculum and speculum
  11. Book a pelvic ultrasound to assess IUD placement and book a follow-up appointment for a string check in about 1 month.
  12. Document the procedure

Illustrations demonstrating how to insert a Mirena (the most common levonorgestrel-containing IUD):
0 Comments

Priority Topic: Gender Specific Issues & Procedure: Pap Smear

4/18/2018

0 Comments

 
Key Feature 4: Establish office policies and practices to ensure patient comfort and choice, especially with sensitive examinations (ex: positioning for Pap, chaperones for genital/rectal exams).
Skill: Professionalism
Phase: Physical

Although many people think this test is synonymous with STI testing, it is completely not the same thing; the Papanicolaou (aka Pap) test examines purely for cervical cancer. Guidelines have been changing almost every other year it seems like. At the time of writing this blog, the Canadian national screening consensus is to begin Pap screening at the age of 25 (sooner if the patient has risk factors) and to screen every 3 years until the age of 69. There's no absolute contraindication to every doing this test per se, though the results may not be as accurate if there is current infection of the vaginitis, cervix, or pelvic inflammatory disease (so is in fact ideally NOT done when there is suspicion for an STI), or if the woman is menstruating. Not that if the bleeding is not a regular menstrual bleed but rather abnormal vaginal bleeding, obtaining a Pap would be important as a diagnostic as opposed to screening tool and would thus be indicated for that purpose.

Equipment
  1. Examination table appropriate for placing the patient in the lithotomy position, in a warm, well-lit examination room.
  2. Various-sized speculums
  3. Water-soluble lubricant
  4. Nonsterile examination gloves.
  5. Large swabs for gentle blotting of excess discharge.
  6. Method for warming the speculum (warm water or speculum drawer warmer [light bulb]).
  7. Wooden spatulas or plastic spatulas for ectocervical sample. Cytobrush for endocervical sample. As an alternative to taking two samples, a "broom" device can be used for ectodermal and endocervical samples 
  8. Microscope slides, fixative (consult with reference laboratory performing cytology for their preference) or media for liquid-based testing. Materials and solutions for liquid-based Pap smears.
  9. Appropriate patient identification, history forms to accompany Pap smear and other tests.
  10. Culture or transport media and swabs as necessary for gonorrhea, chlamydia, herpes, fungal, and potassium hydroxide (KOH)/wet mount. (Although the Pap test does not test for STIs, this does not mean that the clinician cannot screen or sample discharge to look for evidence of an STI when performing a Pap).
  11. Cervical tenaculum or cervical hook (rarely needed).
  12. Ring forceps.

Anatomy of a cervix
  1. The cervix is the distal portion of the uterus, and the external opening on the cervix is the external os. 
  2. The area of the squamocolumnar junction marks the transition from the squamous epithelium of the exterior cervix to the columnar epithelium of the endocervical canal. The area is also called the transformation zone and it's where we want to sample the cells of the cervix for evidence of malignant transformation (this is the are where cancer arises when it does). 
  3. In women who have had a hysterectomy for concerns of malignancy, the cervix is gone (because the whole uterus has been removed) and we sample cells from the blind pouch at the top in case there have been some cervical cells left behind.
Picture
Procedure
  1. Obtain consent and offer chaperone
  2. Ideally plan to perform the procedure in the middle of a patient's cycle. Prior to performing the patient, the patient may wish to void urine. She should have her bottoms off but be draped until the procedure is done.
  3. Prepare equipment. Label sample holders (glass slide or liquid Pap vial, depending on the type of Pap equipment being used). 
  4. Position patient in the lithotomy position with feet in stirrups.
  5. Don a pear of gloves that do not need to be sterile. It is a clean but not a sterile procedure.
  6. Begin the procedure, placing a small amount of water-soluble lubricant on the speculum prior to insertion (see this post where I explain the steps of a speculum exam for details). Make sure to identify the cervical landmarks, including the transformation zone with its squamocolumnar junction. This will increase the likelihood of getting a good quality sample.
  7. Document the procedure.
  8. Followup with the results of the testing and proceed to further investigations or else repeat the Pap screening test in approximately 3 years, in keeping with national cervical cancer screening guidelines.
0 Comments

UBC Objectives: Care of the Elderly & Procedure: Placement of Transurethral Catheter

4/17/2018

0 Comments

 
By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
  • Describe the use and risks of indwelling catheters versus intermittent catheter

Bladder catheterization is a procedure that is done frequently in the emergency room, operating room, and in-patient hospital setting. It may be done for investigations such as monitoring urine output or to obtain a sample of urine for analysis, or it may be done as a therapeutic intervention to relieve urinary retention or to manage urine output while undergoing an operation. Depending on the reason, it may be done as an in-and-out catheter, or may remain in-situ for some amount of time, which comes with increased risk of infection, which could evolve into urosepsis, and so is avoided when possible. It is contraindicated if there is suspected urethral disruption from pelvic trauma based on history +/- the observation of blood at the urethral meatus. If there are features complicating the patient's case, such as recent urethral surgery or a known urethral stricture, consider consulting a Urologist to perform the procedure. If someone has a urinary tract infection, consider if they truly need the procedure, and if so, proceed as indicated. 

Equipment
  • Urethral catheter
    • Size measure in French units, with one French being approximately 0.33mm in diameter. The standard size used in an adult is a 16 or 18 French.
    • There are different types of catheters, but the one the general practitioner needs to be comfortable inserting is the Foley catheter, which has 2 or 3 lumina. Urine flows through the main large lumen, a second is used to inflate the balloon to keep the Foley in-situ, and the occasional third lumen is used if fluid is to be irrigated into the bladder
Picture
  • Lubricant 
    • Water-soluble or with a local anesthetic such as 2% lidocaine jelly, the latter is preferred. For adult and adolescent patients, 10 mL is sufficient, with smaller amounts for infants and children.
  • Sterile towels and gloves
  • Sterile cotton-tipped applicators
  • Antiseptic solution
  • Closed urinary drainage system, if needed

Anatomy considerations
  • Female
    • The female urethra is around 5 cm long. The urethral meatus is the first of three orifices encountered when examined cephalad to caudad in the lithotomy position. It may appear as a slit, and may be especially hard to locate in young children and elderly patients. The angle of the urethra changes with age, such that in young children it is typically better to angle the catheter on insertion toward the umbilicus. In the elderly, it is typically better to angle the catheter on insertion toward the sacrum.
  • Male
    • The male urethra is 4 times the length of the female urethra at around 20 cm long the external urethral meatus to the bladder neck. Unlike the straight and readily catheterised female urethral tube, the male urethra has bends, 2 of which are more pronounced and can be areas that cause a catheter to be obstructed. The first is where the bulbous urethra meets the membranous urethra, and the second is at the neck of the bladder.
Picture
Procedure
  1. Obtain consent (discuss benefits and risks or procedure,  as well as alternatives including the option to do nothing; clarify understanding and answer questions; solicit patient choice and obtain permission to proceed)
    1. *Risks of catheterization: 
      1. Urinary tract infection
      2. Transient hematuria
      3. Tissue perforation
      4. Urethral stricture further down the line
  2. Prepare equipment. Check balloon to be sure it is functioning properly.
  3. Position patient (female in frog-legged position, male with legs straight or slightly abducted)
  4. Contact precautions (sterile gloves, gown, mask, eye guard)
  5. Drape patient for this sterile procedure (Isolate genitalia with sterile drape)
  6. Identify urethral meatus and cleanse along with the adjacent surrounding area with antiseptic solution.
  7. Anesthetize the urethral meatus. I've mostly just seen people coat the catheter tip with lidocaine jelly and insert both at the same time. However, this doesn't allow time for the anaesthetic agent to work prior to inserting the catheter. An alternative is to draw up lidocaine jelly into a string without a needle, inject about 10mL for an adult or adolescent into the urethra, and wait 5-10 min for the freezing to take effect. Afterward, the catheter can be inserted with jelly (with or without lidocaine) into the anesthestized urethra. This can be a very uncomfortable procedure, so taking small efforts to ease the discomfort may go along way. Depending on the indication for catheterization, however, this just may not be feasible.
  8. Pass the catheter into the urinary bladder. You know you will have reached the bladder when you get urine output from the catheter (be sure the urine from the distal end of the catheter will be collected in some sort of basin before insertion).
  9. Inflate the balloon with 5 mL of normal saline or water. Then gently pull catheter distally until the balloon rests against the bladder neck and resistance is encountered. 
  10. Secure the catheter to the patient's leg to prevent it from being dislodged if the catheter is not just an in-and-out catheter.
  11. If urine is not flowing freely from the catheter upon reassessment, the tip of the catheter could be obstructed by jelly. Consider flushing the catheter with normal saline and aspirating it back into the syringe be. If this is not effective, the catheter may need to removed with a new catheter reinserted.
0 Comments

    RSS Feed

    Categories

    All
    Abdominal Pain
    Addiction Medicine
    Advanced Cardiac Life Support
    Allergy
    Anemia
    Antibiotics
    Anxiety
    Asthma
    Atrial Fibrillation
    Bad News
    Behavioural Medicine & Resident Wellness
    Behavioural Problems
    Breast Lump
    Cancer
    Care Of Children + Adolescents
    Care Of Men
    Care Of The Elderly
    Chest Pain
    Chronic Disease
    Chronic Obstructive Pulmonary Disease
    Collaborator
    Communicator
    Contraception
    Cough
    Counselling
    Crisis
    Croup
    Dehydration
    Dementia
    Depression
    Diabetes
    Diarrhea
    Difficult Patient
    Disability
    Dizziness
    Domestic Violence
    Dysuria
    Earache
    Eating Disorders
    Elderly
    Family Medicine
    Fatigue
    Fever
    Fractures
    Gender Specific Issues
    Genitourinary & Women's Health
    Grief
    Health Advocate
    HIV Primary Care
    Hypertension
    Immigrants
    Immunization
    In Children
    Infections
    Infertility
    Injections & Cannulations
    Insomnia
    Integumentary
    Ischemic Heart Disease
    Lacerations
    Learning (Patients)
    Learning (Self Learning)
    Manager
    Maternity Care
    Meningitis
    Menopause
    Mental Competency
    Mental Health
    Multiple Medical Problems
    Newborn
    Obesity
    Obstetrics
    Osteoporosis
    Palliative Care
    Periodic Health Assessment/Screening
    Personality Disorder
    Pneumonia
    Poisoning
    Pregnancy
    Priority Topic
    Procedures
    Professional
    Prostate
    Rape/Sexual Assault
    Red Eye
    Resuscitation
    Schizophrenia
    Sex
    Sexually Transmitted Infections
    Smoking Cessation
    Somatization
    Stress
    Substance Abuse
    Suicide
    Surgical + Procedural Skills
    Transition To Practice
    Trauma
    Urinary Tract Infection
    Vaginal Bleeding
    Vaginitis
    Violent/Aggressive Patient
    Well Baby Care
    Well-baby Care
    Women's Health

Proudly powered by Weebly
  • Home
  • About
  • Blog
  • Learn Medicine
  • Contact