1
Q
Amenorrhea
A
absent periods
2
Q
Primary amenorrhea
A
Failure to start menstruation by 16
3
Q
Secondary
A
- Previously had periods
- Not had for 6 months
- Include pregnancy and menopause
4
Q
Most common cause of primary amenorrhoea?
*
A
- Turners
- 45XO
- Coarctation of aorta
- Streaky ovaries
- Short
- Web neck
5
Q
Secondary amenorrhea causes x2
A
Problem with HPG axis
outlflow problem
6
Q
- Problem with HPG axis
A
- Hypothalamus (GnRH)
- Exercise
- Stress
- Anorexia nervosa, bulimia nervosa
- Pituitary (LH, FSH)
- Sheehans syndrome (when lots of blood loss during pregnancy)
- hyperprolactinemia
- Gonads (oestrogen and progesterone)
- Menopause
- PCOS
7
Q
Diagnosing amenorrhoea
A
- Age
- If patient is between 45-55–> menopause?
- Family history
- Sexual history
- Mental health
- Eating disorders
8
Q
16 yo Beth visits the GP concerned about having irregular periods for a year and subsequent amenorrhoea for 6 months. She’s also noticed weight gain, more facial hair, and is feeling insecure about it. what are the differential
A
Gonadal: PCOS, ovarian cancers
Adrenal: Adrenal cortical adenoma/ adrenal hyperplasia
Pituitary: Pituitary tumours, also causing Cushing’s syndrome, gigantism or acromegaly
External sources: Abuse of Anabolic sterorids
9
Q
Hirsutism
A
– excessive, male pattern hair growth in women / pre-pub boys
10
Q
Hirsutism causes
A
Increased level of male hormones or oversensitivity of hair follicles to hormones
11
Q
A
12
Q
What is the term for excessive, non male pattern hair growth?
A
- Hypertrichosis
- Cause unknown but can be congenital
13
Q
The GP highly suspects that Beth has PCOS. What can she do to confirm the diagnosis?
A
blood test
US of ovaries
14
Q
what is PCOS
A
- Multiple fluid filled space in the ovary
15
Q
hyperandronism causes
A
cyst and hirsutism
16
Q
PCOS LH/FSH blood test results
A
- LH produces androgens
- Therefore more androgen
- Less FSH–> less androgen converted to oestrogen
- More androgen overall = hirsutism and acne
- No ovulation due to no LH surger
- Insulin resistance – hyperandronism
17
Q
Insulin resistance
- Increased risk for
A
- T2DM
- CVD
18
Q
management of insulin resistance
A
- Lifestyle
- Diet
- Smoking
- Exercise
- Drug
- Metformin
- Statin
- COCP
19
Q
Diagnosis of PCOS made based on exclusion
A
2 out of 3
• Chronic Anovulation- History
- Hyperandrogenism - Blood test
- Polycystic ovaries- US
20
Q
summary of menstrual cycle
A
21
Q
difference between hormonal interactions in PCOS to normal
A
insuffieicnt FSH to stimulate granulosa cells
22
Q
PCOS can also cause depression in women. The GP guides Beth through a self- assessment questionnaire and determines she has a mild form of depression. What are the three core symptoms of depression?
A
- Low mood
- Lack of energy
- Anhedonia (lack of interest + enjoyment)
23
Q
treatment for PCOS
A
COCP
24
Q
what is a herbal remedy which will reduce the effectiveness of the COCP
A
- St Johns Wart
- Induces P450–> which speeds up metabolism of COCP
25
**Placenta praevia**
*
Placenta attached over internal cervical os
26
**Placental abruption**
placenta detaches
27
**Placenta accreta**
- placenta attached to myometrium
28
**Placenta increta**
- penetrates myometrium
29
**Placenta percata**
- placenta perforated through myometrium into the uterine serosa
30
Why do pregnant women have a raised body temp?
Higher progesterone levels
31
Progesterone causes
* Systemic smooth muscle relaxation
* Dropping blood pressure
* Therefore heart rate increases in response
32
Explain why Beth requires a caesarean section with placenta praevia
* Birth canal obstructed by placenta
* Foetus has to be expelled from the uterus by other means
33
Give two reasons why it is normal for pregnant women to have a low blood pressure.
* Progesterone
* Gravid uterus compressing on vena cava
34
Beth is suffering from a UTI. What might her urine dipstick results show to support this?
* Raised/ Positive for leukocyte esterase • Raised/ positive for nitrites
* Turbid urine (cloudy)
35
hydronephrosis in pregnancy
1. Raised Progesterone levels during pregnancy
* Smooth Muscle dilation
* Renal Pelvis + Ureter have SM --\>hydronephrosis
2. Compression of ureters by gravid uterus)
36
identify risk factors for UTI
Catheterisation – infection from surfaces
Gender – Women have shorter urethras
Decreased renal glucose threshold during pregnancy
Hydronephrosis (stasisàinfection)
Immunosuppression during pregnanc
37
Suggest two (most common) organisms that could have caused her UTI.
E.coli
S.aureus
38
E.coli is a gram
gram negatuce bacilli
39
Staphylococcus aureus
gram positive
- bunches of cocci
40
AKI and pregnancy
*
* Why is it important if someone has just undergone labour
* Creatinine clearance increases (higher eGFR in pregnancy)
* Serum creatinine decreases
* So a pregnant women with normal creatinine clearance is likely to have AKI
* Could be due to increases in:
* Metabolic waste products
* Blood volume
* Kidney perfusion and GFR
41
Suggest a suitable management of her UTI.
Drug and Length of treatment
Complicated UTI
Trimethoprim, nitrofurantoin
7 day course
Remember: culture before empirical Abx
Check local guidelines – factor in local resistance pattern
42
Give two reasons why amoxicillin should not be used to treat this patient
* This patient is penicillin sensitive / allergic
* Anyway, amoxicillin is not used for complicated UTI’s because it increases risk of bacterial resistance
43
Identify the 3 stages of the triple approach to the investigation and diagnosis of breast cancer?
* History
* Examine
* Scan- mammogram
* Histology
44
Beth’s lump is diagnosed as early stage ductal cell carcinoma. At what age bracket are women typically invited for mammographic screening?
• 47-73 years (every 3 years)
45
tamoxifen is a
Selective Oestrogen Receptor Modulator- - Binds to the Oestrogen Receptor (ER)
46
why is tamoxifen used for breast cancer
Antagonist to Oestrogen receptor at breast
- Inhibits proliferation of cells
(need to make sur epatient is estrogen receptor (ER) positive before giving tamoxifne
47
Why is Beth at risk of endometrial cancer by taking Tamoxifen
* Endometrium also an oestrogen sensitive tissue
* ButTamoxifenactsdifferentlyatthebreastand
* at the endometrium
* Partialagonistattheendometrium
* Stimulates tissue proliferation there
* More cell cycles Increased risk of mutation Cancer
48
A 45 year old Man, Mr X, presents with urinary frequency and a burning sensation on urination. List three differentials that could explain the symptoms Mr X is experiencing.
* UTI
* STI
* BPH
* Pyelonephritis
* Chronic prostatitis
* Urethral stricture
* Ureteric calculi
* Loin to groin pain
49
Discharge coming out of tip of penis
* Gonorrhoea
* Yellow
* Chlamydia
* creamy
50
Upon taking further history, Mr X admits to having multiple sexual partners and mentions he has noticed discharge coming out of the tip of his penis. What is your next step to confirm a diagnosis?
Take a swab of the discharge
MSU sample
Swab collected from other affected areas
51
MSU
midstream urine sample
52
what is this
Neisseria gonorrhoea
diplococci,gram-negative bacterium that can cause meningitis and other forms of meningococcal disease such as meningococcemia, a life-threatening sepsis
53
How would you treat Neisseria Gonorrhoea?
Ceftriaxone + azithromycin
54
Mr X mentions how none of his partners had STI symptoms before his presentation, and asks you to explain how its possible that he got it from them.
women are often asymptomatic
May only present once they develop PID
55
56
Mr X, presents to clinic 3 months later with a lump in his right groin. Suggest three differentials for it.
* inguinal hernia
* direct
* indirect
* inguinal lymph node
* femoral hernia
* femoral aneurysm
* saphenous varix
* psoas abscess
57
On closer inspection, the lump is firm, immobile and has irregular edges. What do you suspect is the most likely cause of the lump and how could you confirm this?
Neoplasia - lymph metastases (lump is firm, immobile, irregular edges)
* Bedside: DRE, PSA
* Imaging: mpMRI, CT abdo & pelvis
* Special test: Template biopsy, TRUS biopsy
58
Following a series of investigations, you find that Mr X has prostate cancer of a high grade. What does this mean at a histological level and at a clinical level?
Histological - a high grade tumour has poorly differentiated tissue i.e. Does not resemble the normal tissue well
Clinically, this translates to having a poorer prognosis.
59
what is used to stage prostate cancer
Gleasons pattern
60
what makes up the floor of the inguinal canal
inguinal liagment and lacunar ligament (medially)
61
what is the posterior wall of the inguinal canal made up of
transversalis fascia and conjoint tendon (medially)
62
what is the roof of the inguinal canal made up of
internal oblique/transverse abdominus (muscular arches and aponeurosis)
63
anterior wall of the inguinal canal
aponeurosis of external oblique
64
deep ring of the inguinal ligament found
posterior wall closest to the ASIS
65
superficial ring found
anterior wall closest to the pubic tubercles
66
A hernia is defined as
the protrusion of part or whole of an organ or tissue through the wall of the cavity that normally contains it.
67
direct inguinal hernia
(20%) – Bowel enters the inguinal canal “directly” through a weakness in the posterior wall of the canal, termed Hesselbach’s triangle (superficial inguinal ring)
- medial to the inferior epigastric artery and lateral to the rectus muscle.
They occur more commonly in older patients, often secondary to abdominal wall laxity or a significant increase in intra-abdominal pressure
68
indirect inguinal hernia
Indirect inguinal hernia (80%) – Bowel enters the inguinal canal via the deep inguinal ring
## Footnote
They arise from incomplete closure of the processus vaginalis, an outpouching of peritoneum allowing for embryonic testicular descent, therefore are usually deemed congenital in origin
- passes down the inguinal canal lateral to the inferior epigastric artery.
69
hesselbach triangle
same as superficial inguinal ring
Medial – lateral border of the rectus abdominis muscle.
Lateral – inferior epigastric vessels.
Inferior – inguinal ligament.
70
How to clinically differentiate between indirect and direct hernias?
* indirect will be latral to ifneiror epigastric vesse
* not palpable
* common in children
* direct will be medial to inferior epigastric vessel
* may be palpable above the pubic tubercle
* common in old age
71
indirect versuss direct inguinal herniasz
72
Framework for breaking bad news?
*
* Setup
* Perception
* Information
* Knowledge
* Emotions
73
List the 5 stages of grief he may go through following this bad news, to adjust to the idea of dying.
74
The patient now tells you he has a severe pain in his left flank spreading to his groin area, which starts and stops abruptly.
What might be going on?
Prostate cancer ↓
increases PTHrp↓
Hypercalcaemia ↓
Ureteric calculi (stone) ↓
Ureteric Colic (pain from loin to groin)
75
PTH hormone
increases conc of calcium in the blood
76
The patient develops oliguria. He has a reduced GFR and high creatinine. What complication might have arisen?
AKI
- Renal calculi obstructing the ureter
- Prostate cancer compressing the ureter
Could also have pre-renal acute kidney injury: - Hypercalcaemia causes dehydration!
77
symptoms of hypercalcaemia
painful bones
renal stones
abdominal groans
psychiatric moans
78
A hospital research team perform a cohort study, looking into the risk of developing hypercalcaemia in patients with prostate cancer. List two advantages of performing a cohort study.
Allows researchers to establish temporal sequence – can establish that exposure (prostate cancer) precedes outcome (Hypercalcaemia).
Can study a range of outcomes from a range of exposures
79
80
relative risk
to calculate the risk associated with an exposure, we must compare the risk (incidence) among the exposed to those not expose
81
what is the relative risk equation
incidence in exposed/ incidence in non-exposed
82
Mr X comes to you reporting depressive symptoms, possibly due to his hypercalcaemia. Outline a non-pharmacological method of treating his depression.
CBT
## Footnote
Education of cognitive model Monitoring negative thoughts
Examine/challenge negative thoughts
Cognitive rehearsal; role play
Reinforcement and reward of positive thoughts
83
pre renal causes of AKI
caridac failure
sepsis
blood loss
dehydration
vascular occlusion
84
renal causes of AKI
glomerulonephritis
small vessel vasculitis
**acute tubular necrosiss**
- drugs
- toxins
- prolonged hypotension
**interstitial nephritis**
- drugs
toxins
- inflammatory disease
- infection
85
post renal cause sof AKI
urinary calculi
retroperintoneal fibrosiss
benign prostatic enelaregement
prostate cancer
cerbical cancer
urethral stricture/valves
metal sentosis/ phimosis
86
Unfortunately, despite your best efforts, the patient passes away. Suggest some symptoms of bereavement that his family may experience.
Physical - fatigue, infection from reduced immunity as part of a stress response, aches, nausea
Behavioural - insomnia, social isolation, loss of appetite Emotional - guilt, anxiety, depression, anger
Cognitive - lack of memory and concentration
87
Why might a person with vomiting have a metabolic alkalosis?
Severe vomiting also causes loss of potassium and sodium. The kidneys compensate for these losses by retaining sodium in the collecting ducts at the expense of hydrogen ions (sparing sodium/potassium pumps to prevent further loss of potassium), leading to metabolic alkalosis.
88
List the macroscopic and microscopic differences between UC and Crohn’s
**Macroscopic**
• UC: Pseudopolyps, ulcers, hypervascular, oedema
• Crohn’s: Trasnmural, skip lesions, cobblestoneappearance
**Microscopic**
• UC: Neutrophil infiltration, crypt abscess, goblet cell hyperplasia, inflamed mucosa
• Crohn’s: Non-caseating granulomatous
89
What are the causes of Pancreatitis?
I GET SMASHED
idiopathic
gall stones
ethanol (alcohol)
trauma
sterordis
mumps/ malignancy
autoimmune
scoprion string
hypercalcemia/ hypertriglyceridemia
ERCP
Drugs
90
modifiable risk factors for gall storns
* obese
* fatty acids
* crohns/IBS
* drugs: ceftriaxone
* combined pill, oestrogen therapy
91
non-modifiable risk factors for gall storns
female
age
ethnic origin: caucasian
family history
92
what is a murphys sign
1. ask pts to exhale
2. examiner palces hand below costal margin on the right side at the mid-clavicular line
3. patient is intstructed to inspire
the patient will stop breathign in and wince with a catch ib breath (due to the inflammed gall bladder being palpated as it descends on inspiration)
93
6. What investigations would you perform for a patient with suspected colorectal cancer?
Bedside
• FBC: mainly to check Hb
* Tumour marker: CEA
* Fecal Occult Blood testing
Imaging
• CT&MRI
• Barium Enema: Apple core sign
Special Test
* Colonoscopy
* Flexible sigmoidoscopy
94
How would you manage a peptic ulcer?
Conservative: Diet, Smoking cessation, reduce alcohol intake
Pharmacological: Proton pump inhibitor (H. pylori eradication therapy if indicated)
Surgical/interventional: For complications e.g. Bleeding peptic ulcer
95
List the risk factors for renal cancers
Smoking
Aromatic hydrocarbon exposure
Dialysis
Obesity
Polycystic Kidney Disease
