Appendix, PID, Ectopic Pregnancy, Ovarian Cysts

Question 1

32yr old woman with 8hr history abdomen pain
pain in RLQ
no fever or dysuria
menstrual hx - regular cycle 5/28
obstetric hx para 1 NVD
no surfers
young and fit
no smoking lies with partner and social drink
nothing on fam history

pain onset location type severity duration and modifying facotrs will help pin point

what systems should you check here

Answer 1

GI sx - N+V hematemesis, anoxeria, diarrhea and constatino blocco stools and meleana

GU sx - dysuria, frequency urgency and haematuria and icnotninence

gyn sx - vaginal discharge, vagianl bleeding

general - fever and lightheadedness

Question 2

exmaianion of this patient what would you do

Answer 2

general - pallor appearance and distress
vital signs - pulse, BP temp and saturation
cardiac - arrhyias and lungs for pneumonia
abdomen - distension scares, masses, tenderness and rebound and guiding and masses, tympani , bowel sounds and rectal exam
pelvic exam for bleeding and vaginal examination and fullness and discharge

guarding - voluntary - contraction, diminish this by getting patient to flex knees
involuntary - suggests peritoneal irritation

rebound - roving sign appendicitis

Question 3

what is rovsing sign

Answer 3

Rovsing’s sign (a.k.a. indirect tenderness) is a right lower quadrant pain elicited by pressure applied on the left lower quadran

Question 4

investigations for this

Answer 4

urinalysis
preg test
IV fluids
NBM
FBC and beta Hcg
US scan
analgesia
eclectrolytes

Question 5

appendicitis symptoms

Answer 5

periunmbilicla pain, anorexia and N+V
pain localises to RLQ

soem appendicitis are retroceal
pelvic appendicitis can cause suprapubic pain and dysuria

Question 6

triad of symptoms fore ectopic pregnancy

Answer 6

amenorrhea ( irregular menses too)
pelvic or low abdominal pain
vaginal bleeding

Question 7

findings on ectopic pregnancy

Answer 7

pelvic and abode pain
abnormal menstruation
aginal bleeding may be scanty or dark brown
abdominal and pelvic tenderness
tenders on abode and vaginal examination especially on motion of the cervix

US scan - absence of an intrauterine gestational sac
extrauterine sac with an embryo or embryonic remnants
free fluid/blood in peritoneum

Question 8

what are the risk factors for an ectopic pregnancy

Answer 8

previous ectopic
assisted reproduction and infertility
intrauterine device
previous genital infection
previous pelvic or abdomen surgery e.g. ruptured appendices
smoking
c section
tubal surgery

Question 9

ovarian cysts - torsion and haemorrhage present with what

might have history of it

Answer 9

acute onset severe pelvic pain
may wax and wane
may happen mid cycle or during pregnancy
may look like appendicitis
can have acute rigid abdomen and peritonitis , fever and tachycardia and decreased bowel sounds

important to exclude with US scan

may find mass on examination
US confirms cysts

therefore acute pain with scan showing ovarian cysts - torsion or bleeding into cysts is an emergency

Question 10

pelvic inflammatory infection is an ascending infection - will have long lasting sequel such as ectopics, infertility or chronic pelvic pain
what are the findings of this

Answer 10

PV discharge with uterine tenderness
cervical motion tenderness on examination - i.e. worse if you move It
positive swab culture - swabs or from urine ?
temp- may not be raised
FBC - raised WBC

Question 11

ectopic pregnancy you would expect positive pregnancy what is the investigation of choice

what would this show

Answer 11

transvagianl US - demonstatre no intra-uterine pregame, endometrial thickening, free fluid ,adnexal mass and foetal pole not usually visualised

mass separate to ovary
can occur on cerivx in ovaries - different areas

Use bladder to help see structures

Question 12

negative pregnancy test now wha is causing pain - thinking ovarian cysts what examination

Answer 12

transvaginal( not used if never sexually active) or trans abdominal US

2nd line for clarity - MR used for problem solving and characterising masses

Question 13

what method do you use for staging ovarian carcinoma

Answer 13

CT

Question 14

ovarian cysts can be linked to the menstrual cycle - follicular cysts grow inside what happens when the egg is not released

Answer 14

becomes a cyst and swells and is greater than 30mm

this could haemorrhage tort or rupture

Question 15

what are theca-luton cysts

Answer 15

excessive amounts of circulating gonatrophins such as beta HCG

Question 16

corpus luteum cysts what hormone

Answer 16

corpus luteum cysts - occurs in ovulation - ring of fire ( blood supply) due to progesterone

Question 17

what is a neoplasm

Answer 17

An abnormal mass of tissue that forms when cells grow and divide more than they should or do not die when they should.

Question 18

types of neoplasms

Answer 18

cystic neoplasms
- serous cyst adenoma - benign and nodular
mutinous cyst adenoma - multiple septations ( multiseptated cysts_
malignant - solid nodules in cyst, thick wall - obvious
dermoid cysts
- cystic mass containing fat hair bone and teeth and consists of many germ layers also called teratoma - see echogenic shadowing and mural nodules and blurring
- appear like they are floating on CT and MR due to fat

Question 19

ovarian torsion may occur due to

Answer 19

cyst
neoplasm
pregnancy
hyperstimualtion - IVF treatment

Question 20

imaging choice in ovarian torsion and what are the findings

Answer 20

trans vaginal

enlarged ovary
maybe a mass
free fluid
doppler finding can b variable - usually little or no flow

Question 21

is PID related to STI

Answer 21

yes

Question 22

what is PID

Answer 22

infection of uterus fallopian tubes ovaries and peritoneal cavity

Question 23

pyosalpinx ( puss filled )

what is seen on US

Answer 23

infection within non-patent tube - blockage
use US which shows snake like dilated structure in pelvis or maybe cystic mass

Question 24

if the fallopian tube is patent and you inject contrast in to see for hydrosalphinx if normal what do you see and what if blocked

Answer 24

starts of thin and then eventually contrast spreads out

if it is blocked look thick like a poo

Question 25

difference between Pyosalpinx and Hydrosalpinx

Answer 25

Pyosalpinx is a condition in which the fallopian tube fills up and swells with pus
Hydrosalpinx is the blockage of a woman’s fallopian tube caused by a fluid buildup and dilation of the tube at its end. Most often it occurs at the fimbrial end of the tube next to the ovary, but it can also occur at the other end of the tube that attaches to the uterus.

Question 26

what things can cause post coiltal bleeding

Answer 26

Cervical ectropion
Often asymptomatic, but may present with post-coital bleeding or vaginal discharge
Endocervical and cervical polyps
Often asymptomatic, but may present with abnormal vaginal bleeding such as post-coital bleeding, and additionally inter-menstrual bleeding or menorrhagia. They can be diagnosed by speculum examination
Cervical cancer
Can cause post-coital bleeding and well as bleeding at other times, such as spontaneously or after micturition. Other early signs of cervical cancer include urinary symptoms and vaginal discomfort
Sexually transmitted infections
With STIs such as gonorrhoea and chlamydia, discharge and pelvic pain are also common.
Atrophic vaginitis
Atrophic vaginitis is the most common cause of bleeding in postmenopausal women as the vaginal mucosa becomes drier and thinner. This can then bleed, especially when there is contact with the mucosa such as during intercourse

Question 27

This patient has reduced flexion and adduction of their wrist. Both movements are carried out through the action of the

Answer 27

flexor carpi ulnaris