Contact us.
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18
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EMQ.
Cervical smears and referral.
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10
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Feb
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2014
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79
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There has been a
recent spate of requests for Caesarean section with no medical grounds. The
Clinical Director has asked you to produce a provisional policy document on
the subject for discussion at a Unit meeting with a view to formulating Unit
policy.
Justify the issues and facts you will include in the paper.
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10
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Feb
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2014
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80
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In relation to coeliac disease and
pregnancy.
1.
What is coeliac disease and how common is it? 4
marks
2.
What are the clinical features in the non-pregnant? 4 marks.
3.
How is coeliac disease diagnosed? 2
marks.
4.
What are the implications of coeliac disease for the pregnant woman? 6 marks.
5.
Evaluate the management options in relation to pregnancy. 4
marks
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10
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Feb
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2014
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81
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A woman
of 38 is referred to the gynaecology clinic as the tail of her IUCD could not
be seen when she recently had a routine cervical smear.
1. Outline the
history you will take.
6 marks.
2. Justify the
investigations you will arrange. 4
marks.
3. Justify your
management.
10 marks.
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10
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Feb
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2014
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82
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With
regard to UKOSS.
1. What is UKOSS? 2 marks
2. Who is responsible for UKOSS and how does it work? 6 marks
3. Critically evaluate the work of UKOSS. 12 marks
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10
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Feb
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2014
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83
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A
patient is referred for management of premenstrual syndrome.
1. Define PMS and its grades of severity. 4 marks.
2. Outline the investigations you will arrange. 6 marks.
3. Critically evaluate the management options. 10 marks
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10
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Feb
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2014
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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.
Scenario 27.
More than 50% of women who develop cervical cancer 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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