Chapter 24: Painful Conditions In Gyn Flashcards
You are a trainee intern in an A and E department i hospital seeing Moana, a 34 year old G3P2 wahine Māori who has 2 hours of severe lower abdominal pain. She is obviously distressed, but her pulse and bp are normal. Abdominal examination showed lower abdominal tenderness with rebound worse in the left iliac fossa. A limited pelvic examination confirmed the pelvic tenderness. Which of the following point-of-care investigations is the most important as part of the initial assessment?
Finger-prick test for glucose
Urine dipstick for leucocytes and nitrites
“Haemacue” finger-prick test for Hb
Urine dipstick for ketones
Urine dipstick for HCG
Urine dipstick for HCG
You are a Trainee Intern in the gynaecology clinic. You are seeing Katrine, an 18 year old Pākehā woman who had stage 1 endometriosis completely resected at laparoscopy for chronic pelvic pain 6 months ago. She has returned, as she has not had any improvement in her symptoms. From the following options, what is the most likely next step in her management?
Refer her to Mental Health services as her pain is psychogenic
Arrange a repeat laparoscopy
Tell her there is no gynaecological cause for her pain and refer her to gastroenterology and general surgery
Validate that she still has suffering and take a comprehensive history and careful examination to identify other contributors to her pain
Start Zoladex
Validate that she still has suffering and take a comprehensive history and careful examination to identify other contributors to her pain
You are a trainee intern in an A and E department in a seeing Barbara, a 34 year old NZ European woman who has moderately severe lower abdominal cramps for two hours associated with bright PV bleeding. She has had some intermittent spotting for the previous three days. Her last normal period was about 9 weeks ago. Her periods had previously been regular (4-5/28) and painless. She and her husband have not used contraception since their second child was born 18 months ago. Barbara had some nausea for the past 3 weeks but that settled over the past week. She has no discharge, and no bowel or bladder symptoms. She has no shoulder tip pain. Barbara is usually fit and healthy and has no significant gynaecological history. Of the following options, what is the most likely diagnosis based on this history?
Inevitable miscarriage
Ruptured tubal ectopic pregnancy
Appendicitis
Threatened Miscarriage
Degeneration of a uterine fibroid
Incomplete miscarriage
Inevitable miscarriage
You are a trainee intern in a gynaecology ward admitting Hine, a 23 year old wahine Māori who has a three day history of increasing right iliac fossa and pelvic pain. Her period finished two weeks ago, and she has had vaginal spotting and a green discharge since then. She has never previously had this pain. She had a Jadelle implant inserted a year ago and her periods have been irregular since then. Her temperature is 39.4 degrees C, her pulse rate is 100, and her BP 100/60. She has rebound and guarding over the RIF. On bimanual examination she has tenderness in both fornices and cervical excitation. From the following options, what is the most likely cause of her symptoms and signs?
Torsion of a right ovarian cyst
Acute pelvic inflammatory disease
Torsion of a right ovarian cyst
Haemorrhagic follicular cyst
Right tubal ectopic pregnancy
Appendicitis
Acute pelvic inflammatory disease
You are a trainee intern in general practice with Diana, a 38 year old Pākehā woman who presents with abdominal pain. She has been feeling unwell for 2 weeks with lower abdominal pain and vaginal discharge. She now also has right upper quadrant pain. Contraception is a Jadelle and she experiences irregular light vaginal bleeding with this. Diana has just left her husband after she learned that he was having an affair with a work colleague. On examination she has a temperature of 38.4 degrees, a pulse of 100 and a bp of 110/70. On abdominal examination she has lower abdominal tenderness and also right upper quadrant tenderness. On vaginal examination she has cervical excitation and bilateral adnexal tenderness. From the following options, what is the most likely diagnosis?
Torted dermoid cyst
Pancreatitis
Psychological stress from her husband having an affair
Borderline ovarian tumour
Fitz-Hugh-Curtis Syndrome (perihepatic chlamydia)
Cholecystitis
Fitz-Hugh-Curtis Syndrome (perihepatic chlamydia)
You are a trainee intern in general practice with Roopi, a 13 year old Indian girl who has been brought in by her mother. Roopi has cyclical pelvic pain and primary amenorrhoea in the context of development of secondary sexual characteristics. Her breast development began two years ago and she has pubic hair development. Of the following options, which is the most likely cause of her pain and primary amenorrhoea?
Imperforate hymen
Bicornuate uterus
Pregnancy
Uterine agenesis
Premature Ovarian Failure
Cervical stenosis with retrograde menstruation
Imperforate hymen
You are a trainee intern in general practice with Sheu, a 15 year old Asian schoolgirl who presents with mother because of period pains that she has had for two years. The pain has become more severe this last term, and she has required time off school. You suspect primary dysmenorrhoea. Which of the following histories is most consistent with primary dysmenorrhoea?
Sheu’s pain occurs 2 days before her period and during her period. She also gets mid cycle pain.
Sheu’s pain starts toward the end of her period. It lasts for 3 days after her period. The pain is central although can radiate to her back and legs.
Sheu’s pain is worst in the left iliac fossa. She has pain throughout her menstrual cycle.
At menarche, Sheu’s periods were not painful. However, 6 months ago she was diagnosed with (and treated for) chlamydia and the dysmenorrhea has been worse since then.
Sheu has had dysmenorrhea since menarche. It starts with the start of her period. The pain is central although can radiate to her back and legs.
Sheu has had dysmenorrhea since menarche. It starts with the start of her period. The pain is central although can radiate to her back and legs.
You are a trainee intern in general practice with Penny, a 15 year old NZ European schoolgirl who presents with her mother as her period pains have become more severe this last term, and she has required time off school. Her pain characteristics suggest primary dysmenorrhoea. Of the following options, which is likely to be the most effective single treatment for her dysmenorrhoea, and thus prevent loss of schooling?
Combined oral contraceptive
Non-steroidal anti-inflammatory drugs (NSAIDs)
A mini-pill
Paracetamol
Tranexamic acid
Opioids
Combined oral contraceptive
You are a trainee intern in the Pain Management Clinic. You are seeing Nina, a 24 year old Pākehā woman with 5 years of pelvic pain. She has previously been fully investigated without a sinister cause for her pain being found. Following the multidisciplinary team (MDT) assessment the team recommendation is for her to have a pain program with the pain clinic psychologist and physiotherapist. She is unhappy with this plan – she had been hoping for a prescription for oxycodone. From the following options, what do you tell her?
That oxycodone is addictive and can be diverted and sold illegally by patients
That chronic pain is different to acute pain and is a complex condition that requires a broader approach
As her tests are normal her pain is not severe enough for opioids
Oxycodone would only mask her symptoms not treat them
That her tests are normal and she has psychogenic pain
That chronic pain is different to acute pain and is a complex condition that requires a broader approach
You are a trainee intern in General Practice. You are seeing Hana, a 40 year old wahine Māori who has just had stage 1 endometriosis resected after a diagnostic laparoscopy for dysmenorrhoea and dyspareunia. Which of the following aspects of her history are risk factors for endometriosis?
Menarche age 16
First and only child born when she was 39 years old
She smokes 10 cigarettes per day
Menstrual cycle lasts 32 days
Periods last for 3 days
First and only child born when she was 39 years old
You are a Trainee Intern in a general practice seeing Masina, a 39 year old G4P4 Tongan woman. In the past year she has had increasing dysmenorrhea and deep dyspareunia. Her periods are regular. Her youngest child is 10 and her husband had a vasectomy seven years ago. On examination she has tenderness and thickening over her uterosacral ligaments. You suspect that she has endometriosis. Masina asks “How common is endometriosis?” Which of the following options is the most appropriate response regarding the prevalence of endometriosis in the population?
Approximately 20% of women with chronic menstrual pain will have endometriosis
50% of women with infertility have endometriosis
About 5% of women having a laparoscopic sterilisation procedure will be found to have asymptomatic endometriosis
Endometriosis is more common in women who are parous (have had children)
About 300,000 women in NZ probably have endometriosis
Approximately 20% of women with chronic menstrual pain will have endometriosis
You are a trainee intern in general practice. You are seeing Lorna, a 31 year old nulliparous Pākehā woman who has recently had stage 1 endometriosis completely resected after a diagnostic laparoscopy for dysmenorrhea. She asks you about ongoing management of her dysmenorrhoea. She currently uses condoms for contraception and does not want to get pregnant currently. She has a history of migraines with aura. Which of the following management options would you suggest?
The combined oral contraceptive pill
A copper IUCD
A laparoscopic hysterectomy
A Mirena
Regular codeine when she has her period
A Mirena
You are a trainee intern working in Family Planning. A 20 year old nulliparous Pākehā woman, Laurel, attends for a Mirena insertion. You take a history from her. She wants reliable contraception and has significant dysmenorrhoea so has been advised to have a Mirena. She keeps good health. She had a chlamydia infection last year that was treated. She and her partner had a negative STI screen 1 month ago. She currently uses condoms for contraception. Her LMP was 1 week ago and she hasn’t had sex in the last week. A urine HCG is negative. What do you advise her?
An IUCD such as a Mirena is inappropriate given she has had a previous chlamydia infection. It will increase her risk of PID. She should use condoms to protect against STIs.
She should have a laparoscopy to investigate the dysmenorrhea in case she has endometriosis.
A copper IUCD would be better management of her dysmenorrhea and is effective contraception. She should use condoms to protect against STIs
A Mirena will provide reliable contraception and is effective management of dysmenorrhea. She should use condoms to protect against STIs.
She should not have a Mirena as she is nulliparous and it may cause intrauterine adhesions that will make her infertile.
A Mirena will provide reliable contraception and is effective management of dysmenorrhea. She should use condoms to protect against STIs.
You are a trainee intern in a gynaecology clinic with Song, a 28 year old G0P0 Chinese woman who has had a laparoscopic excision of severe endometriosis. She has had increasingly painful periods in the last 2 years. She is in a long-term relationship and the couple plan a pregnancy. They are currently using condoms for contraception. (Her partner has two children by a previous relationship.) Pre-operatively a transvaginal ultrasound showed that both ovaries had small 15 mm endometrioma within them. At laparoscopy the endometriomas were not able to be seen. However there was endometriosis on the surface of her ovaries and in the Pouch of Douglas, which was partially obliterated. All visible endometriosis was resected surgically. Which of the following is the best advice to give Song when you see her for her 2 week post-operative check?
Administer an injection of a long acting GnRH analogue to treat the endometriomas that are still present. After 6 months of GnRH therapy then she can try and conceive.
Advise that her best chance to conceive is now. If she hasn’t conceived, review in 6 months with an ultrasound. Ensure she is on folic acid.
Reassurance that the endometriosis is now treated and she can be discharged from hospital follow-up.
Ensure that Song is on folic acid. She should have an injection of depot Provera to suppress the endometriomas and then can try and conceive after 3 months.
Song will likely need IUI to conceive and should be referred to a fertility clinic now.
Song should try and conceive. If she still has dysmenorrhoea then it should be treated with tranexamic acid. Ensure that she is on folic acid.
Arrange an insertion of a Mirena to manage her dysmenorrhoea. She will need IVF to conceive so will need the Mirena in the interim.
Advise that her best chance to conceive is now. If she hasn’t conceived, review in 6 months with an ultrasound. Ensure she is on folic acid.
You are a trainee intern in a gynaecology clinic with Joanna, a 32 year old nulliparous NZ European woman who two weeks ago had a laparoscopic right ovarian cystectomy. She had presented initially with dysmenorrhoea, dyspareunia and mid-cycle pain. Pelvic examination noted a tender right adnexal mass which was confirmed ultrasonically as an echo dense 5cm right ovarian cyst. At laparoscopy the cyst contained a thick brown fluid which was drained prior the cyst wall being removed. Some haemorrhagic nodules on the uterosacral ligaments were excised. You are reviewing the histology report of the cyst with her. From the following options, what is histological report of the wall of the cyst most likely to show?
Mucinous glandular cells
Flattened granulosa cells
Papillary glandular cells
Endometrial glands and stroma
Squamous epithelial cells
Hair and sebaceous glands
Endometrial glands and stroma
