450 SBAs in Clinical Specialties - Surgical Gynaecology and Oncology Flashcards Preview

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Flashcards in 450 SBAs in Clinical Specialties - Surgical Gynaecology and Oncology Deck (22)
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1. Gynaecological oncology (1)

A 28-year-old woman attends her GP clinic for routine cervical screening. Liquid-based cytology (LBC) shows mild dyskaryosis. A repeat sample again shows mild dyskaryosis. What is the most appropriate management?

A. Repeat the LBC smear test in 6 months

B. Repeat the LBC smear test in 3 months

C. Arrange colposcopy at the gynaecology clinic

D. Knife cone biopsy of the cervix

E. Large loop excision of the transformation zone

C. Arrange colposcopy at the gynaecology clinic

1 C Cervical screening is an important public health strategy introduced to reduce the morbidity and mortality of cervical cancers. It is based on the premise that abnormal cells can be detected early, well before they undergo malignant change and appropriate treatment can be instituted to prevent progression to invasive disease. Women in the UK are first invited for cervical screening at 25 years of age and then every 3 years until 50, whereafter they are screened every 5 years. The programme ends when they are 65 years of age unless abnormal results have been shown. Mild dyskaryosis detected on one sample should prompt a repeat smear within 3 months. A second sample reported as mild dyskaryosis warrants referral for colposcopy (C). Knife cone biopsy (D) and loop excision (E) are normally performed only after a histological rather than cytological diagnosis of dyskaryosis. Referral for colposcopy should also be made after three consecutive borderline results at LBC, after two results of mild dyskaryosis, or when there is any moderate or severe dyskaryosis.

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2. female pelvic anatomy (1)

When assessing the fetal presenting part in labour it is important to know the anatomy of the pelvis. What are the bony landmarks of the pelvic outlet?

A. Pubic arch, ischial tuberosities and the coccyx

B. Pectineal line, ischial spines, coccyx

C. Pubic symphysis, pubic rami, sacrum

D. Pectineal line, ischial tuberosities and the coccyx

E. Pubic arch, ischial spines, sacrum

A. Pubic arch, ischial tuberosities and the coccyx

2 A The pelvic outlet is delineated by the inferior margin of the pubic symphysis (pubic arch), the ischial tuberosities (left and right, sometimes called the ischial spines) and the tip of the coccyx. Answer (A) is correct. The pectineal line is part of the pubic bone forming the pelvic inlet so (B) and (D) are wrong. (C) and (E) are wrong because the sacrum forms the posterior aspect of the pelvic inlet.

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3. Postoperative complications (1)

A 26 year old undergoes potassium-titanyl-phosphate (KTP) laser laparoscopic excision of endometriosis. Her postoperative haemoglobin is 8.1 g/dL. Six hours postoperatively she complains of increased umbilical swelling, abdominal pain and shortness of breath and she appears pale. A repeat full blood count now shows a haemoglobin count of 6.5 g/dL. What are the most appropriate steps you should take next?

A. Transfuse one unit of cross-matched packed red cells and await events

B. Volume replacement with colloids and reassessment of the haemoglobin level

C. D-dimer and computed tomography (CT) pulmonary angiogram (CTPA)

D. Insertion of a large-bore nasogastric tube on free drainage

E. Transfuse four units of cross-matched packed red cells and return to theatre for further laparoscopy

E. Transfuse four units of cross-matched packed red cells and return to theatre for further laparoscopy

3 E In a postoperative patient, a low haemoglobin count which is continuing to fall must always be treated as due to ongoing haemorrhage until proven otherwise. In this patient, the combination of the haemoglobin drop and increasing abdominal distension, alongside the umbilical pain, points towards an umbilical port site bleed. Where there is evidence of continuing blood loss, as in this case, resuscitation followed by reoperation (E) is the most appropriate management. Her paleness and shortness of breath are probably due to blood loss. Volume replacement (B) and blood transfusion (A) are appropriate management methods but they are ‘holding options’ and by no means definitive in correcting continuing surgical bleeding. Although abdominal distension may point to obstruction, requiring a nasogastric tube (D), in this situation and in the absence of vomiting it is an unlikely diagnosis. CTPA (C) to exclude pulmonary embolism is not indicated in the absence of other more specific signs pointing towards this diagnosis, and D-dimer would be raised after surgery anyway.

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5. Acid-base physiology

A 24-year-old woman is admitted to the gynaecology ward with a 4-day history of severe hyperemesis gravidarum. She has been unable to tolerate food or fluid orally for 2 days. On the second day of admission she develops signs of a severe pneumonia. This is presumed to be a hospital-acquired infection. She deteriorates rapidly. An arterial blood gas shows:

pH 7.68 PO2 10.0 kPa

PCO2 4.26 kPa

HCO3 32 mmol/L

K+ 1.9 mmol/L

Lactate 1.2 mmol/L

What is the most accurate description of the acid-base disorder?

A. Metabolic alkalosis

B. Respiratory alkalosis

C. Mixed respiratory alkalosis and metabolic acidosis

D. Respiratory alkalosis with inadequate respiratory compensation

E. Mixed metabolic alkalosis and respiratory alkalosis

E. Mixed metabolic alkalosis and respiratory alkalosis

5 E This woman is clearly very unwell with a profound alkalosis. As there is a low PCO2 as well as a raised bicarbonate, there is a mixed acid-base disturbance (E). In a purely metabolic alkalosis (A) the PCO2 should be higher, whereas with a pure respiratory alkalosis (B) one would expect a much lower compensatory bicarbonate, given that the respiratory alkalosis is likely to have been chronic. This is therefore a mixed respiratory and metabolic alkalosis (E). In this case, the respiratory alkalosis is most probably due to a high respiratory rate due to the significant acute pneumonia while the metabolic alkalosis is most probably due to the hypokalaemia (potassium 1.9 mmol/L), in turn caused by her repeated vomiting of potassium-rich gastric contents secondary to hyperemesis gravidarum. Answer (D) is a distractor which most candidates can easily dismiss: respiratory alkalosis is marked by low PCO2 due to an increased respiratory effort ‘blowing off’ the carbon dioxide, and a respiratory compensation would mean the patient had reduced but not normalized their respiratory rate. All respiratory alkaloses therefore have ‘inadequate respiratory compensation’!

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6. Oncology

A 61-year-old woman has recently been diagnosed with a stage 1a endometrial carcinoma. She has had four children, she has mild utero-vaginal prolapse and she has never been operated on. She needs to have surgery. You see her in clinic and talk about the different operations available to her. Which is the most appropriate operation?

A. Wertheim’s hysterectomy

B. Total abdominal hysterectomy

C. Laparoscopic hysterectomy

D. Subtotal hysterectomy

E. Posterior exenteration

C. Laparoscopic hysterectomy

6 C A Wertheim’s hysterectomy (A) is an operation for cervical cancer. It involves removing the uterus, upper third of the vagina and all the parametrium. A total abdominal hysterectomy (B) would be an appropriate choice as it is important that the ovaries are removed as well. This woman may well be an ideal candidate for a laparoscopic hysterectomy as she is multiparous, has mild prolapse, has an early stage endometrial cancer and has had no operations. The recovery time is much quicker compared to a laparotomy. For this reason answer (C) would be most appropriate. Subtotal hysterectomy (D) is inappropriate since not removing the cervix may inadvertently leave some malignant endometrial tissue. A pelvic exenteration (E) usually involves a Wertheim’s hysterectomy as well as a bowel resection of sorts (either abdominoperineal or anterior resection). This is employed for significant recurrent cervical and upper vaginal cancers.

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7. Endometrial cancer

A 58-year-old woman presents to the clinic with post-menopausal bleeding. A pipelle biopsy confirms adenocarcinoma of the endometrium. Further imaging of the pelvis shows that there is spread of the tumour outside of the uterus into the left adnexa. There is no other spread. What is the most likely stage of the tumour?

A. Stage 1A

B. Stage II

C. Stage IIIA

D. Stage IVA

E. Stage IIIC2

C. Stage IIIA

7 C Endometrial cancer is the most common genital tract cancer. It usually presents between the ages of 50 and 60 with post-menopausal bleeding. FIGO (the International Federation of Obstetrics and Gynaecology) changed the staging of endometrial cancers in 2010 to the following:

•  IA tumour confined to the uterus, no or ½ myometrial invasion

•  II cervical stromal the invasion, but not beyond the uterus (B)

•  IIIA tumour invades the serosa or adnexa

•  IIIB vaginal and/or parametrial involvement

•  IIIC1 pelvic lymph node involvement

•   IIIC2 para-aortic lymph node involvement, with or without pelvic  node involvement

•  IVA tumour invasion bladder and/or bowel mucosa (D)

•   IVB distant metastases including abdominal metastases and/or  inguinal lymph nodes

This tumour is a IIIA tumour – answer (C).

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8. Gynaecological oncology (2)

A 65-year-old woman is referred by her GP to the gynaecology clinic with increasing bloating and a raised CA 125 level. A CT scan shows an irregular, enlarged left ovary and several well-circumscribed nodular lesions in the liver and on the omentum which are highly suspicious for metastatic ovarian cancer. What is the most appropriate treatment regimen?

A. Total hysterectomy, bilateral salpingo-oophorectomy and omentectomy along with concomitant stereotactic radiotherapy of the liver lesions

B. Total hysterectomy, bilateral salpingo-oophorectomy, omentectomy, aortopelvic lymphadenectomy

C. Staging laparotomy and optimal cytoreduction

D. Palliative care

E. Total pelvic exenteration

C. Staging laparotomy and optimal cytoreduction

8 C The diagnosis and management of ovarian cancers is principally surgical. A full work-up for women undergoing evaluation for ovarian cancer includes CT of the abdomen. This may, as in the case here, reveal extra-abdominopelvic disease which is classified as stage IV (metastatic) ovarian cancer. However, imaging does not replace the need for histological diagnosis at operation. A staging laparotomy establishes the type and extent of the primary cancer and allows optimal cytoreduction (or ‘debulking surgery’) (C) where as much of the disease as possible is removed at operation. Even in advanced cancers, the preferred treatment for all women who are fit for operation is optimal cytoreductive surgery. Chemotherapy may also be indicated since ovarian cancers are highly sensitive to platinum based agents and the vinca alkaloids. Indeed, many centres now pre-empt debulking surgery with chemotherapy (so-called interval debulking procedures). In an otherwise fit woman of 65 years, offering no active treatment for a disease (D) which can be effectively managed is inappropriate, unless the patient expressly wishes it. Total hysterectomy, bilateral salpingo-oophorectomy and omentectomy are often employed during surgery for early ovarian cancers. However, performing radiotherapy of another organ system (A) at the same time as radical surgery has significant risk attached. Aortopelvic lymphadenopathy (B) is not widely used given that it does not increase 5-year survival and is associated with operative risk.

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9. Pleural effusion

A 62-year-old woman presents to accident and emergency with shortness of breath. Examination reveals reduced breath sounds and a swollen, distended abdomen. Chest x-ray demonstrates a left-sided pleural effusion. On further questioning the woman has had a poor appetite for the last 6 months and recently had some vaginal bleeding. An ultrasound revealed large quantities of ascites, which were drained. Analysis of the ascites shows a high protein content. What is the most likely diagnosis?

A. Congestive cardiac failure (CCF)

B. Carcinoma of the ovary

C. Meigs’ syndrome

D. Cirrhosis of the liver

E. Carcinoma of the cervix

B. Carcinoma of the ovary

9 B This woman is unwell as a result of the pleural effusion and ascites. All of the options can cause ascites and pleural effusions. The high protein content of the ascitic fluid suggests an inflammatory or malignant cause rather than CCF (A) or cirrhosis of the liver (D). CCF involves both left and right ventricular failure. Left ventricular failure will lead to pulmonary oedema while right-sided failure leads to hepatomegaly, ascites and peripheral oedema. Cirrhosis of the liver is characterised by ascites and hepatomegaly. Other complications may include oesophageal varices and hepatic encephalopathy. The history of decreased appetite and vaginal bleeding raises the possibility of an advanced gynaecological cancer with metastatic spread outside the abdomen – (B) or (E). CCF (A) and hepatic cirrhosis (D) do not cause vaginal bleeding. Once an ovarian tumour (B) has spread to the pleural cavity it is by definition a stage IV tumour. Ovarian cancers usually present late because symptoms are often non-specific. This woman needs investigation to rule out ovarian cancer as a matter of urgency. Cancer of the cervix (E) tends to present earlier than ovarian cancer so distant spread is not as common. This patient is most likely to have an ovarian tumour. Meigs’ syndrome (C) is a pleural effusion associated with an ovarian fibroma which is rare. It is benign and classically causes a right-sided pleural effusion.

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10. Emergency gynaecology

A 28-year-old woman attends accident and emergency unable to walk because she is so faint. She has had heavy vaginal bleeding for 4 hours since she engaged in sexual intercourse with a new partner, which she described as ‘rough and very painful’. She is still bleeding and cannot tolerate vaginal examination due to the pain. A point-of-care haemoglobin estimation is 6.4 g/dL and she is haemodynamically unstable. What is the most appropriate management?

A. Discharge with oral iron supplementation and follow up in the gynaecology clinic in 2 days

B. Discharge with oral iron supplementation and follow up on the ward in 24 hours

C. Admit, resuscitate and prepare her for immediate transfer to theatre

D. Admit to the gynaecology ward, cross-match four units of packed red cells and send a formal full blood count

E. Admit to the gynaecology ward having packed the vagina

C. Admit, resuscitate and prepare her for immediate transfer to theatre

10 C This woman must have bled a significant amount to cause such a marked degree of anaemia and faintness. Furthermore, she is still actively bleeding. Since it is not possible to examine her, packing the vagina (E) would be impossible. Discharging a woman (A, B) in this condition would be negligent. Both of the two remaining options – theatre (C) and cross-matching blood (D) – would be appropriate but this woman requires examination under anaesthesia and primary treatment of any vaginal trauma to prevent further blood loss. It is likely that she will require transfusion, so requesting cross-matched blood and a formal blood count would also be appropriate, but only in tandem with definitive management of her genital tract trauma.

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11. Peri-operative management

A 64-year-old woman with asthma is admitted to the ward prior to an elective vaginal hysterectomy for symptomatic uterine prolapse. Her medications include Seretide (fluticasone/salmeterol 500/50) four times daily and oral prednisolone 20 mg twice daily. What is the most important peri-operative consideration?

A. Steroid cover with 50 mg hydrocortisone intravenously at induction of anaesthesia

B. Steroid cover with 100 mg hydrocortisone intravenously at induction of anaesthesia

C. Steroid cover with 50 mg hydrocortisone intravenously at induction of anaesthesia and 50 mg 8-hourly for 3 days

D. Bronchodilator cover with intravenous salbutamol infusion postoperatively

E. Continue regular medications and postoperative review by respiratory physician

C. Steroid cover with 50 mg hydrocortisone intravenously at induction of anaesthesia and 50 mg 8-hourly for 3 days

11 C Patients on long-term steroids prior to surgery are at risk of postoperative shock as a result of secondary corticosteroid insufficiency. Most studies have shown that patients taking less than 10 mg of prednisolone/day (or the equivalent) have a normal hypothalamic-pituitary axis (HPA) response to major surgery and do not need additional steroid cover. However, evidence suggests that those on more than 10 mg/day for 3 months or more prior to surgery require adequate steroid supplementation. For major gynaecological surgery, such as vaginal hysterectomy, 50 mg of hydrocortisone 8-hourly from induction (C) is the standard practice, and may be stopped after 2 or 3 days, or when normal gut function returns and the patient can resume oral steroids. Giving a single dose of steroids and anaesthesia induction (A, B) is unlikely to cover the patient for the increased postoperative demand on the HPA, and cover is necessary until such time as the patient can resume oral steroids. Peri-operative cover for asthma (D) is not routinely employed in surgery. Patients whose asthma is uncontrolled, or who are having a mild asthma attack, would normally have their elective procedure cancelled. Patients should continue to take regular asthma inhalers before and after surgery. Postoperative exacerbations should be managed as for any other non-surgical patient. Respiratory physiotherapy may be useful postoperatively to encourage the use of accessory muscles and full inflation of the lungs and reduce the risk of atelectasis or postoperative respiratory tract infection. Inpatient review by a respiratory physician (E) is not warranted in an otherwise well and well-controlled asthmatic.

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12. female pelvic anatomy (2)

A woman is undergoing surgery to enhance the cosmetic appearance of her labia. A bleeding vessel is encountered at the labia majora which cannot be controlled through pressure alone. The surgeon believes it to be a branch of the posterior labial artery. The posterior labial artery is a branch of which artery?

A. Internal pudendal artery

B. Inferior gluteal artery

C. Uterine artery

D. Obturator artery

E. Inferior vesical artery

A. Internal pudendal artery

12 A The labia majora are supplied by branches of the posterior labial artery, which is supplied by the internal pudendal artery (A), itself originating from the internal iliac artery. The inferior gluteal (B), uterine (C) and obturator (D) arteries are similarly all supplied by the internal iliac artery, and supply, respectively, the buttock and posterior thigh, the uterus, and the medial compartment of the thigh. The inferior vesical artery (E) is a branch of the internal iliac artery and often arises in common with the middle rectal artery. It supplies the lower part of the bladder.

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13. female pelvic anatomy (3)

Following surgery to place a tension-free transobturator tape for stress incontinence, a 54-year-old woman loses some sensation in part of her labia anterior to the anus. Damage has most likely been caused to which nerve?

A. Perineal nerve

B. Peroneal nerve

C. Pudendal nerve

D. Dorsal nerve of clitoris

E. Inferior anal nerve

A. Perineal nerve

13 A Damage to the perineal nerve (A), which is a branch of the pudendal nerve, can cause localized loss of sensation of parts of the labia (usually anterior) and perineum. Damage to the pudendal nerve (C) itself would likely cause much more extensive sensory loss over the entire perineum, perianal skin and some of the labia. The dorsal nerve of the clitoris (D) and inferior anal nerves (E) are similarly branches of the pudendal nerve and supply part of the clitoris and the anal skin and external anal sphincter, respectively. The peroneal nerve (B) is a distractor which should be easily dismissed. Also referred to as the common fibular nerve, it originates from the sacral plexus (L4–S3) and innervates the anterior and lateral compartments of the lower leg.

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14. Postoperative complications (2)

A 54-year-old woman with a history of significant ischaemic heart disease undergoes vaginal hysterectomy for symptomatic uterine prolapse. She develops significant surgical site bleeding which is repaired at reoperation the same day. Her postoperative haemoglobin is 6.4 g/dL. Later the same day she develops chest pain. Her observations, blood gas and cardiac enzymes are within normal limits. An electrocardiogram (ECG) shows sinus rhythm without ST changes. She is charted for thromboprophylaxis. What is the most likely cause of the chest pain?

A. Non ST-elevation myocardial infarction

B. Anaemia

C. Pulmonary embolism

D. Atelectasis

E. Postoperative sepsis

B. Anaemia

14 B This woman has a history of significant ischaemic heart disease. In the presence of such a profound anaemia, the myocardium will be sufficiently deprived of oxygen that chest pain can develop, even if this is not significant enough to cause frank infarction (A). Myocardial infarction is very unlikely in the presence of normal troponin-I and a normal ECG. Pulmonary embolism (C) is a possible differential diagnosis, although this woman is on thromboprophylaxis. Atelectasis (D) would typically occur some time later, after surgery, usually after 48 hours. Similarly, this would be a very rapid onset for sepsis (E) and an unusual presentation in the absence of fever.

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15. Postoperative complications (3)

A 46-year-old woman is returned to the ward from the recovery room following a routine vaginal hysterectomy for heavy periods and prolapse. The estimated blood loss at operation was 200 mL. Two hours later the ward sister becomes concerned that her urine output is low and calls the doctor. Her observations show: pulse 115 bpm, BP 90/62 mmHg, temperature 37.1°C. What are the most appropriate next steps in her management?

A. Aggressive fluid resuscitation, alert the operating surgeon and prepare for a return to theatre

B. Fluid challenge, haemoglobin estimation and arterial blood gas

C. Vaginal examination, haemoglobin estimation and arterial blood gas

D. Establish large-bore intravenous access, alert the operating surgeon and perform arterial blood gas

E. Establish large-bore intravenous access, alert the operating surgeon and perform a fluid challenge

A. Aggressive fluid resuscitation, alert the operating surgeon and prepare for a return to theatre

15 A In a postoperative patient, signs of shock must be assumed to be due to haemorrhage until proven otherwise. In a fit 46 year old, significant blood loss is required to invoke a response of tachycardia, hypotension and reduced urine output. The concerns of a senior nurse should always be treated seriously. Although a fluid challenge (B, E) may help to stabilize the patient, it is not definitive management. Similarly, arterial blood sampling (C) and haemoglobin measurement (which may be estimated on an arterial blood gas machine) may assist diagnosis but in this case they should be performed concurrently with definitive, life-saving actions. The only response which combines these two is (A). This woman needs returning to the operating theatre, where even if surgery does not take place, invasive monitoring and aggressive resuscitation facilities, as well as anaesthetists, are more readily on hand. Always alert the operating surgeon (D) when a patient on whom they have just performed surgery develops signs of significant postoperative haemorrhage.

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16. female pelvic anatomy (4)

The peritoneal lining drapes over the pelvic viscera and forms the part of the peritoneal cavity. Which is the most inferior extent of the peritoneal cavity?

A. Vesicouterine pouch

B. Paravesical fossa

C. Rectouterine pouch (Pouch of Douglas)

D. Pararectal fossa

E. Rectovesical pouch

C. Rectouterine pouch (Pouch of Douglas)

16 C The rectouterine pouch, or Pouch of Douglas (C), is formed by the draping of the peritoneum over the pelvic organs. It is the extension of the peritoneal cavity between the rectum and the posterior aspect of the uterus. A second pouch, the vesicouterine pouch (A), lies between the anterior surface of the lower uterine body and the posterior surface of the bladder. The vesicouterine fold is dissected off the anterior wall of the uterus at caesarean section to deflect the bladder inferiorly and reduce the likelihood of iatrogenic bladder damage when incising the uterus. The pararectal fossa (D) is formed by lateral reflections of the peritoneum over the superior third of the rectum. The rectovesical fossa (E) does not exist in the normal female pelvis as the bladder and rectum are separated anatomically by the uterus. The paravesical fossa (B) is formed by the anterior pelvic wall peritoneum covering the superior surface of the bladder; either side of this is a depression that is termed the paravesical fossa.

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17. Cancer risk

A 74-year-old woman has an annual health check up with her private insurer. They arrange an ultrasound scan that shows a cyst on her right ovary. It is multiloculated and has solid components. She is post-menopausal and otherwise well. A doctor has sent for a CA 125 which comes back as 120 U/mL. What is her risk of malignancy index score (RMI)?

A. 120

B. 240

C. 60

D. 720

E. 480

D. 720

17 D Ovarian cysts in post-menopausal women may be managed conservatively if they meet certain criteria. A risk of malignancy can be calculated using the CA 125 value, the characteristics of the cyst on ultrasound and the menopause status. The concerning ultrasound features include the presence of bilateral cysts, multiloculated cysts, cysts with solid components, ascites and metastases. The score is calculated as one point for every ultrasound feature (0 to 5) multiplied by the CA 125. This is then multiplied by three if they are post-menopausal. Thus, with two features on ultrasound, RMI = 2 × 120 × 3, which is 720. RMI 250 has a 75 per cent chance of cancer. This woman should be referred to a specialist cancer unit for work-up and surgery.

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18. Irregular vaginal bleeding

A 21 year old comes to the clinic with a history of intermenstrual bleeding for the last 6 weeks. She has regular periods and does not experience post-coital bleeding. She is not on the oral contraceptive pill and has no other past medical history. What is the most appropriate first line investigation?

A. Hysteroscopy and biopsy

B. Cervical smear test

C. Triple swabs for pelvic infection

D. Ultrasound scan of the pelvis

E. Pipelle biopsy

C. Triple swabs for pelvic infection

18 C When assessing intermenstrual bleeding, a full history and examination need to be performed. Pelvic swabs (C) are essential as pelvic infection is a very common cause of new-onset intermenstrual bleeding. If the woman does have an infection such as chlamydia, early treatment can prevent the long-term sequelae of pelvic inflammatory disease, including subfertility. As she is only 21, it is unlikely this woman will have had a cervical smear test (B). However, as she is sexually active it would be prudent to perform a cervical smear as well. There is no need to perform biopsy of the endometrium (A) yet, given the short duration of her symptoms. If she has no cause identified on these first line investigations and the bleeding continues, then an ultrasound (D) estimating endometrial thickness should be undertaken. Only if this were abnormal, in someone so young, would you consider obtaining an endometrial biopsy (E).

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19. Postoperative complications (4)

Two days after undergoing posterior exenteration for recurrence of cervical adenocarcinoma a 53-year-old woman develops a tachypnoea, tachycardia of 125 bpm and a fever of 39°C. Blood cultures have grown methicillin-resistant Staphylococcus aureus (MRSA). She requires intravenous vasopressors. What is the most appropriate diagnosis?

A. Sepsis

B. Systemic inflammatory response syndrome

C. Septic shock

D. Septicaemia

E. Adult respiratory distress syndrome

C. Septic shock

19 C Systemic inflammatory response syndrome (SIRS) (B) is evidence of the body’s continuing inflammatory mechanism against a pathological insult and is present when two of the following are present: temperature 38°C, pulse >90 bpm, tachypnoea >20 min or white cells 12 × 109/L. This patient meets the requirement for a diagnosis of SIRS, but in addition there is microbiological evidence of infection with MRSA: this meets the definition of sepsis (A) (SIRS in the presence of a demonstrated pathogen). The fact that she requires intravenous vasopressor support to maintain a cardiac output is evidence of haemodynamic shock, and coupled with sepsis means that the patient is in septic shock (C). Septicaemia (D) is simply the presence of a proven pathogen in the bloodstream. Adult (or acute) respiratory distress syndrome is caused by insult to the lung parenchyma causing impaired gas exchange. There are also systemic effects resulting from associated massive release of inflammatory mediators.

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20. female pelvic anatomy (5)

A 60-year-old woman is undergoing abdominal hysterectomy for a fibroid uterus. During suture ligation of the right uterine pedicle, iatrogenic injury to the ureter is confirmed. Which of the following statements is correct?

A. The ureter passes through the mesometrium and posterior to the uterine artery on its course to the urinary bladder

B. The ureter passes outside of the mesometrium and anterior to the uterine artery on its course to the urinary bladder

C. The ureter lies posterior to the internal iliac artery and lateral to the obturator nerve opposite the lower part of the greater sciatic notch

D. The ureter passes inferior to the cardinal ligament before coursing anteriorally to enter the urinary bladder

E. The ureter is not closely related to the uterine arteries

A. The ureter passes through the mesometrium and posterior to the uterine artery on its course to the urinary bladder

20 A Understanding of pelvic anatomy and the course of the ureters is of vital importance if ureteric injury is to be avoided during hysterectomy. The ureters run down the lateral pelvic side walls, along the anterior border of the greater sciatic notch and under the peritoneum. Medial to the obturator nerve, the ureter lies anterior to the internal iliac artery. It enters the pelvis crossing over the iliac vessels at the level of the bifurcation. The ureter passes underneath the uterine artery about 15 mm lateral to the supravaginal cervix (remember ‘water under the bridge’) before coursing towards the urinary bladder. Iatrogenic injury is most common during hysterectomy during ligation of the uterine artery pedicle.

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21. Vaginal bleeding

A 57-year-old woman has been referred by her GP under the 2-week suspected cancer referral approach with vaginal bleeding. She has been post-menopausal for the last 4 years and she has been taking Elleste Duet to treat her vasomotor symptoms. Two weeks ago, after reading about the risks associated with hormone replacement therapy (HRT) she stopped taking any medication. This is the first unscheduled bleeding she has ever had. She had a normal smear 2 years ago and is otherwise well. What would be your first line investigation?

A. Pipelle biopsy

B. Hysteroscopy

C. Smear test

D. Ultrasound of the pelvis

E. CT abdomen and pelvis

D. Ultrasound of the pelvis

21 D Post-menopausal bleeding can be a symptom of ovarian, endometrial and cervical cancer. It is likely that this woman’s post-menopausal bleed is secondary to her stopping HRT. However, it is important that these symptoms are investigated. A pipelle biopsy (A) is invasive and sometimes technically difficult to perform in a post-menopausal woman. A hystero scopy (B) will be necessary if there is a thickened endometrium on ultra sound. Her smear tests (C) are up to date, so repeating this test is unnecessary unless abnormality is seen at speculum examination. Ultrasound (D) would be the investigation of choice. If the endometrium is smooth in outline with a thickness less than 4 mm the woman’s vaginal bleeding is most likely due to withdrawing the HRT. There is no indication for a CT (E) though one would be performed as a staging tool if endometrial cancer were discovered.

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22. Gynaecological pathology

A 39-year-old woman attends the gynaecology clinic complaining of long-standing pelvic pain. Routine bimanual examination and abdominal ultrasonography do not detect any abnormality. At diagnostic laparoscopy, multiple tiny dark brown nodular lesions are noted covering the surface of the uterus, tubes and left ovary, as well as in the Pouch of Douglas. Which finding is most likely from histological examination of the excised lesions?

A. Krukenberg tumour

B. Vacuolated clear cells

C. Endometrial glands with stromal cells

D. Multiple leiomyomata

E. Enucleolated hyperplastic smooth muscle cells

C. Endometrial glands with stromal cells

22 C It should be fairly obvious that the findings described during the operation are those of endometriosis. Pelvic pain is a prominent feature. Once you understand that endometriosis is simply the deposition of endometrium-like tissue outside of the uterine cavity then it follows that the histology of any excised samples of endometriosis will be similar to that of normal endometrium: that is, containing endometrial glands, stroma and/or epithelium (C). Krukenberg tumours (A) are metastatic neoplasms of the ovary from a gastric primary. Smooth muscle cells (E) would have suggested a diagnosis of fibroids, also called leiomyomata (D), while vacuolated clear cells (B) are seen in clear cell adenocarcinoma.

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23. Operative laparoscopy

A 21-year-old woman with dysmenorrhorea, dyspareunia and dyschezia has been scheduled for a laparoscopy to investigate possible endometriosis. You are asking for her consent and you describe the risks of laparoscopy, which include bleeding and damage to blood vessels, viscera and nerves. Which of the following is not at risk when inserting a lateral port?

A. Superficial epigastric artery

B. External iliac vein

C. Iliohypogastric nerve

D. Superior epigastric artery

E. Ilioinguinal nerve

D. Superior epigastric artery

23 D Laparoscopies are not without risk. Risks include damage to bowel, bladder and blood vessels. Blood vessels can be damaged deep in the pelvis or superficially. When inserting a transverse port the skin should be transilluminated to avoid the superficial epigastric artery (A) that arises from the femoral artery and ascends to the umbilicus. In addition, care is needed to avoid the inferior epigastric artery that runs medial to the obliterated umbilical artery. It begins at the external iliac artery and anastamoses with the superior epigastric artery around the umbilicus. The superior epigastric artery (D) can therefore not be damaged by lateral port insertion. The ilioinguinal (E) and iliohypogastric (C) nerves both originate from L1 and are at risk of damage with lateral port insertion. The ilioinguinal nerve passes through the superficial inguinal ring and provides sensation over the thigh and the labia majora. The external iliac vein (B) originates at the inferior margin of the inguinal ligament and is nowhere near where a lateral port could be placed.