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Tonight we had two EMQs and 4 SAQs.
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21
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EMQ. Down syndrome screening.
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22
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EMQ. Cx smear management and follow-up.
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75
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A woman attends the A&E Department complaining that
she has been raped. The A&E consultant says he has no experience in
dealing with this problem and asks you to take care of the woman.
1. Discuss the risk management issues relating to such
a case for the average DGH. 4 marks
2. Justify your immediate management. 10 marks
3. Outline the
subsequent management. 6 marks
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76
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A 55 year old
woman is referred with loss of libido.
1. Outline the key points in the history. 8 marks
2. Outline the investigations you will arrange. 4 marks
3. Critically evaluate the management. 8 marks
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77
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An 88-year-old
woman with severe Alzheimer’s disease has been admitted to the orthopaedic
ward after a fall. Vaginal bleeding has been noted. You have been asked to
see her.
1. Justify the history you will take. 6 marks
2. Justify the investigations you will arrange. 2 marks
3. Justify your management.
12 marks
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78
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With regard to
uterine rupture:
1. how is uterine rupture graded? 2
marks
2. critically evaluate the risk factors for uterine
rupture. 6 marks
3. critically evaluate the diagnosis of uterine
rupture. 6 marks
4. outline the management.
6 marks
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Lead-in.
The following scenarios relate to screening for Down’s
syndrome.
Pick one option from the option list.
Each option can be used once, more than once or not at
all.
Scenario 1.
a.
What is the
age-related risk of DS at 20 years?
Scenario 2.
b.
What is the
age-related risk of DS at 30 years?
Scenario 3.
c.
What is the
age-related risk of DS at 35 years?
Scenario 4.
d.
What is the
age-related risk of DS at 40 years?
Scenario 5.
e.
What is the
age-related risk of DS at 45 years?
Scenario 6.
AFP levels are lower in Ds.
Scenario 7
Inhibin levels are raised in
DS.
Scenario 8
Oestriol levels are raised in
DS.
Scenario 9
β-hCG levels are raised in DS.
Scenario 10
1st. trimester PAPP-A levels are lower in DS.
Scenario 11
2nd. trimester PAPP-A levels are normal in DS.
Cervical smear management.
Lead-in.
There
are too many scenarios and the option list is too long. And some of the
“scenarios” are really MCQs. Don’t tell me – I know! I have tried to think of
all the questions that could arise. At some point I’ll chop it into several
bits to make the option list more sensible. A smaller option list would also
allow me to introduce more “tempters” that sound as though they should be the
correct answer.
The
following scenarios relate to the management of cervical smears.
Pick
one option from the option list.
Each
option can be used once, more than once or not at all.
Abbreviations.
ALOs: actinomyces-like organisms
BSCCP British Society for Colposcopy and
Cervical Pathology. http://www.bsccp.org.uk/
CIN: cervical intraepithelial
abnormality
CGIN: cervical glandular intraepithelial
abnormality
FSRH: Faculty of Sexual and Reproductive
Health: http://www.fsrh.org/
GUM
clinic: genito-urinary medicine clinic
LBC: liquid-based cytology
LLETZ: large loop excision of the
transformation zone
NEC: normal endometrial cell
NHSCSP: NHS Cervical Screening Programme: http://www.cancerscreening.nhs.uk/cervical/
POP: progesterone-only Pill
TZ: transformation zone
Option list.
a.
repeat the test
b.
repeat the test after 6 months
c.
repeat the test at 6 and 12 months
d.
repeat the test at 6 and 12 months and then
annually until she has had 10 years’ follow-up followed by repeat tests at the
normal intervals for her age
e.
repeat the test after 3 or 5 years according to
her age as per routine follow-up
f.
repeat the test after HPV testing
g.
repeat the test after giving an appropriate
antibiotic
h.
repeat the test after removing her IUCD.
i.
repeat the test after removing the IUCD and
giving an appropriate antibiotic
j.
repeat the test after treating the TZ with
diathermy
k.
repeat the test after treating the TZ with
cryocautery
l.
discharge from follow-up
m. refer for colposcopy
n.
refer for colposcopy within 2 weeks
o.
refer for colposcopy within 8 weeks
p.
refer for colposcopy within 12 weeks
q.
refer for colposcopy only if she has other
significant signs or symptoms
r.
refer for cone biopsy
s.
refer for fractional curettage
t.
refer for “see and treat” LLETZ
u.
refer to GUM clinic
v.
recommend that she go back to America
w. there is insufficient information to formulate a management plan
x.
false
y.
true
z.
none of the above
Scenario 1.
A woman with no previous abnormal smears has a routine smear
showing an inadequate sample . What management will you suggest?
Scenario 2.
A woman with no previous abnormal smears has had a smear showing
borderline nuclear changes. What
management will you suggest?
Scenario 3.
A woman with no previous abnormal smears has had a smear showing
borderline nuclear changes. Cervical ectopy is noted. What management will you suggest?
Scenario 4.
A woman with no previous abnormal smears has had a smear showing
borderline cells of endocervical origin. What management will you suggest?
Scenario 5.
A woman with no previous abnormal smears has had a smear showing
inflammatory changes. What management
will you suggest?
Scenario 6.
A woman with no previous abnormal smears has had a smear
showing inflammatory changes and ALOs.
What management will you suggest?
Scenario 7.
A woman with no previous abnormal smears has had a smear
showing inflammatory changes. She takes
the COC for contraception. What management will you suggest?
Scenario 8.
A woman with no previous abnormal smears has had a smear
showing inflammatory changes. She has a
copper IUCD. What management will you suggest?
Scenario 9.
A woman with no previous abnormal smears has had a smear
showing inflammatory changes and ALOs.
She has had hysteroscopic sterilisation with ESSURE. What management will you
suggest?
Scenario 10
A woman with no previous abnormal smears has had a smear showing
borderline changes. A repeat smear after 6 months is normal. A repeat smear
after 3 years shows inflammatory changes. A repeat smear after 6 months is
normal. A repeat smear after 3 years shows borderline changes. What management
will you suggest?
Scenario 11
A woman with no previous abnormal smears has had a smear showing
mild dyskaryosis of squamous cells. What management will you suggest?
Scenario 12
A woman with no previous abnormal smears has had a smear showing
moderate dyskaryosis of squamous cells. What management will you suggest?
Scenario 13
A woman with no previous abnormal smears has had a smear showing
severe dyskaryosis of squamous cells. What management will you suggest?
Scenario 14
A woman with no previous abnormal smears has had a smear
suggestive invasive disease. What management will you suggest?
Scenario 15
A woman with no previous abnormal smears has had a smear showing
borderline nuclear changes in glandular cells. What management will you
suggest?
Scenario 16
A woman with no previous abnormal smears has had a smear showing ?
glandular neoplasia. What management will you suggest?
Scenario 17.
A
woman with no previous abnormal smears has had a smear showing normal endometrial cells. What management will you suggest?
Scenario 18.
A
woman with no previous abnormal smears has had a smear showing atypical endometrial cells. What management will you suggest?
Scenario 19
A woman with no previous abnormal smears has had a smear with a
normal result. Clinical examination was normal, but contact bleeding was noted
when the smear was taken. What management will you suggest?
Scenario 20
An American woman with no previous abnormal smears has been used
to having annual smears. She has had a smear with a normal result and requests
a repeat in 12 months. What management will you suggest?
Scenario 21
A woman with no previous abnormal smears is on renal dialysis and
has had a smear with a normal result. What management will you suggest?
Scenario 22
A HIV +ve woman with no previous abnormal smears has had a smear
with a normal result. What management will you suggest?
Scenario 23
A woman with no previous abnormal smears has had a smear with a
normal result. She smokes 20 cigarettes daily and has a long history of
recurrent genital warts. What management will you suggest?
Scenario 24.
A woman of 70 presents with postmenopausal bleeding. She had
smears at the recommended intervals from the age of 22. All were normal. The
last was taken at the age of 64. What is your management in relation to taking
a smear?
Scenario 25.
A woman of 55 presents with hot flushes since her periods stopped
at the age of 54. She wishes to go on HRT and there are no contraindications.
She had smears at the recommended intervals from the age of 25. All were
normal. The last was taken two years ago. What is your management in relation
to taking a smear?
Scenario 26.
Women
who have been treated for CIN are 2 – 5 times more likely to develop cancer
than women who have not been treated. True or false?
Scenario 27.
More than 50% of women who develop cancer
after treatment for CIN have been lost to follow-up. True or false?
Scenario 28.
Which
of the following statements are true and which false?
a. cone biopsy is linked to ↓risk of recurrence
compared to LLETZ.
b. excision margins that are not CIN-free ↑ the
risk of recurrence, with endocervical margins that are not CIN-free posing a
greater risk that similar ectocervical margins.
c. age > 35 years increases the risk of
recurrent disease.
d. follow-up after treatment for CIN should start
between 3 & 6 months from the time of treatment.
e. the initial examination should be with
colposcopy plus cytology.
f. a failure to achieve negative results in the
year after treatment means colposcopy should be done.
g. a required standard for treatment success is
that ≥ 90% of women should have no evidence of dyskaryosis in the year after
treatment.
h. a required standard for treatment success is
that there should be ≤ 5% of histologically-confirmed treatment failures by 1
year after treatment.
Scenario 29
Women
who have had normal follow-up results for 2 years after treatment of CIN 1 can
revert to the routine recall.
Scenario 30.
Follow-up
should continue with increased frequency for 5 years after treatment of CIN 2
& 3, after which recall at routine intervals is OK if all the follow-up has
been normal. True or false?
Scenario 31.
A woman with LLETZ for CIN3 twelve months ago had a normal smear 6
months later. A smear taken 12 months
after treatment is also normal. What management will you suggest?
Scenario 32.
A woman with LLETZ for CIN3 twelve months ago had a normal smear 6
months later. A smear taken 12 months
after treatment shows mild dyskaryosis. What management will you suggest?
Scenario 33.
A woman on normal recall has hysterectomy for menorrhagia. There
is no evidence of CIN on histology. What follow-up would you recommend?
Scenario 34.
A woman who was not on normal recall has hysterectomy for
menorrhagia. There is no evidence of CIN on histology. What follow-up would you
recommend?
Scenario 35.
Women who have had hysterectomy and require follow-up with vault
smears cannot be managed within the NHSCSP. True or False?
Scenario 36.
A woman who was not on normal recall has hysterectomy for
menorrhagia. There is evidence of completely excised CIN3 on histology. What
follow-up would you recommend?
Scenario 37.
A woman who was not on normal recall has hysterectomy for
menorrhagia. There is evidence of incompletely excised CIN3 on histology. What
follow-up would you recommend?
Scenario 38.
A
woman has conservative treatment for early stage cancer of the cervix. What
follow-up should be recommended?
Scenario 39.
A
woman is referred with severe dyskaryosis, but colposcopy is normal. What
follow-up should be recommended?
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