gyn Flashcards
Pneumocystis Jiroveci pneumonia lab finding
silver stain of fungus
A pelvic mass with complex papillary architecture, nuclear atypia and the presence of Psammoma bodies is indicative of a
serous cystadenocarcinoma, which is the most common subtype of epithelial ovarian cancer.
Cervical screening: borderline or abnormal cells on cytology always indicate a
colposcopy referral.
Past CIN2, but positive smear next steps
After cervical intraepithelial neoplasia (CIN) 2 has been treated, patient will be referred back to colposcopy if HPV smear is positive on re-screening after 6 months, regardless of cytology.
Lymphogranuloma venereum presents with
a painless genital ulcer and unilateral inguinal lymphadenopathy, typically requiring doxycycline for treatment.
A sexually transmitted infection characterised by small, painless, fleshy papules with central indentation on the genital area is most likely
Molluscum contagiosum.
What is the gold standard for confirming a diagnosis of Pneumocystis jirovecii pneumonia.
Bronchoalveolar lavage is the gold standard for confirming a diagnosis of Pneumocystis jirovecii pneumonia.
An 86-year-old man presents to his General Practitioner with a one-year history of a gradually growing skin lesion affecting his foot. He was born in Cyprus and lived there for most of his adult life. He has a history of hypertension and type 2 diabetes, which are well-controlled.
On examination, there is a large purple-red macule on the dorsal surface of his left foot.
Which of the following is the underlying cause?
Human herpesvirus 8 (HHV-8) infection
This is a case of classical Kaposi’s sarcoma caused by HHV-8 infection. Kaposi’s sarcoma is a vascular tumour that often presents as purple-red macules or nodules on the skin, commonly affecting the lower extremities. This form of Kaposi’s sarcoma is typically seen in elderly men of Mediterranean or Eastern European descent. The patient’s demographic background and the presentation of a purple-red macule on the foot are consistent with classical Kaposi’s sarcoma, making HHV-8 the underlying cause.
A 66-year-old woman presents with sharp pain on defecation and occasional blood on toilet paper. She denies weight loss or changes in bowel habits.
She has a past medical history of type 2 diabetes which is well-controlled on metformin, hypertension and eczema.
On examination, her abdomen is soft and non-tender. Genital exam reveals smooth, dry vulva with porcelain-white shiny areas, particularly on the left. The labia minora and clitoris are not visible, and the labia majora are thickened with red patches. Linear lacerations are present at the posterior fourchette and external anal sphincter.
Digital vaginal examination is not possible. Digital rectal examination reveals no masses and soft stool in the rectum.
What is the most appropriate next step?
Vulval biopsy
This woman has features of lichen sclerosus, an inflammatory skin condition that often affects the vulva. It appears as hypopigmentation of the vulval and perianal skin, characteristically appearing in a “figure of eight” distribution. In severe cases, thickening and scarring occurs, which can completely obliterate vulval structures such as the labia minora and clitoris. Fissures are common, particularly around the posterior fourchette (the thin, v-shaped tissue joining the labia minora inferiorly). Fissures can easily tear and cause discomfort and bleeding.
Vulval biopsy should be performed to confirm the diagnosis of lichen sclerosus. Lichen sclerosus carries an increased risk of vulval intraepithelial neoplasia (VIN) and squamous cell carcinoma. In this case in particular, the distribution of the hypopigmentation is not well-demarcated or symmetrical, raising a concern of pre-cancerous or cancerous changes.
A 53-year-old woman presents to accident and emergency with acute onset right iliac fossa pain. She is taken for an emergency laparoscopy which reveals acute ovarian torsion and a right ovarian mass. She undergoes a right oophorectomy and makes a good recovery postoperatively. Pathology of the ovary reveals a mass containing an invasive proliferation of mucin-producing signet-ring cells.
Which of the following cancers should now be screened for?
Gastrointestinal cancers
Krukenberg tumours of the ovary refer to a tumour containing “signet ring” cells. This is typically a gastrointestinal carcinoma, which has metastasised to the ovary.
chlamydia in breast feeding mother
oral azithromycin
A 31-year-old woman attends the gynaecology clinic to receive the results of her most recent smear test. The results are positive for HPV with normal cytology. She has had normal smears previously. The patient asks what the next steps would be for her ongoing management.
What is the most appropriate next step in the management of this patient?
Reassure the patient and repeat the smear test in 12 month’s time
This is correct. This patient has HPV and and requires closer monitoring until she no longer tests positive for HPV. Guidelines suggest repeat smear testing in 12 month’s time.
A woman with discomfort during urination, irritation around the vulva, and painful sexual intercourse, alongside multiple sexual partners and inconsistent condom use, may have what characterised by what
Trichomonas vaginalis infection, characterised by a strawberry cervix and motile pear-shaped parasites under microscopic examination.
BV pregnancy complications
Preterm rupture of membranes and premature labour are accepted risks of this infection
mid trimester miscarriage
how to confirm herpes diagnosis
Nucleic acid amplification test
nulliparity increases risk of
endometrial cancer
thrush
oral fluconazole
In immunocompromised patients, such as those with HIV and a low CD4 count, Mycobacterium avium intracellulare can cause
abdominal pain due to lymph node enlargement, resulting in elevated levels of alkaline phosphatase and lactate dehydrogenase.
random AIDS defining infection
oesophageal candidiasis
A 40-year-old man presents to the general practitioner with a penile ulcer and fever. In addition, he reports unprotected insertive anal intercourse with a casual male partner three weeks prior.
On examination, there is a small painless ulcer on the glans of his penis and palpable inguinal lymphadenopathy. There is no associated penile discharge.
The man receives antibiotics, and a follow-up is arranged for two weeks.
Unfortunately, the following day, the patient returns feeling more unwell, with a higher fever, high heart rate, and a widespread rash.
There is no respiratory compromise.
What is the most appropriate management?
Reassurance and paracetamol
The patient likely has primary syphilis and has received intramuscular benzylpenicillin. He has then presented with a Jarisch-Herxheimer reaction which is usually self-resolving, and no treatment is needed unless the symptoms are severe.
A 34-year-old woman presents with postcoital bleeding and non-specific suprapubic pain. A PV examination detects pevlic bulkiness.
Which of the following is a risk factor for the likely diagnosis?
Tobacco use
This is correct. The patient’s presentation of postcoital bleeding, non-specific suprapubic pain, and pelvic bulkiness raises suspicion for cervical cancer. Tobacco use is a well-established risk factor for cervical cancer, as it impairs the immune system’s ability to clear human papillomavirus (HPV) infections, which are the primary cause of cervical cancer. Smoking increases the likelihood of developing cervical cancer, making it a significant risk factor.
What is the most appropriate initial investigation to confirm a diagnosis of a ruptured ovarian cyst.
A transvaginal ultrasound is the most appropriate initial investigation to confirm a diagnosis of a ruptured ovarian cyst.
A 23 year old woman is brought to A&E with sudden onset lower abdominal pain and vomiting. She has no past medical history.
She has a low-grade fever and is tachypnoeic. On examination, there is a palpable adnexal mass which is tender.
What is the most appropriate next step?
pregnancy test
A urethral smear with 5 or more polymorphs per high power field and no evidence of gram negative diplococci indicates
chlamydia infection, which should be treated empirically with doxycycline.
First episodes of genital herpes in late pregnancy should be treated with
First episodes of genital herpes in late pregnancy should be treated with oral aciclovir to reduce transmission risk during delivery.
3 x daily
A 22 year old male has attended the GUM clinic with itching and tingling in his genital region.
On questioning, he states that he had a genital herpes infection 4 months ago. He has also been successfully treated for Chlamydia in the past. At present he is not using any form of contraception
What is the most appropriate advice for this patient?
abstain until asymptomatic
A 32-year old woman presents to clinic with a 4 day history of vaginal pruritus and reports a white, curd-like vaginal discharge. She is currently at 32-weeks gestation of her third pregnancy.
Given the likely diagnosis, which of the following is the most appropriate course of management?
Intravaginal clotrimazole
NICE recommend the use of intravaginal clotrimazole in the treatment of vaginal candidiasis in pregnancy
don’t use oral antifungals in pregnancy
A 27 year old gentleman presents to the GUM clinic with a painful lesion on his penis alongside regional lymphadenopathy. He informs you that he has also had some rectal bleeding. He has recently returned from a holiday in the Gambia.
On examination, a painful, soft, ulcer with a necrotic base and irregular borders can be seen. Inguinal adenopathy is present.
HSV is negative.
Given the most likely diagnosis, what is the most appropriate management?
ceftriaxone for chancroid
A 65 year old woman attends clinic for counselling regarding her recent endometrial cancer diagnosis.
Which of the following options is a risk factor for endometrial cancer?
Late menopause
Endometrial cancer is associated with increased lifetime oestrogen exposure. A woman who experiences a late menopause has a greater number of periods throughout her lifetime, and thus a higher oestrogen exposure.
LLETZ smear follow up
6 months
A 43-year-old female presents to her general practitioner with a 6-month history of bleeding between periods and post-coital bleeding. She is very nervous and has never attended her general practice for anything before. She is aware she should have been attending cervical smears, but was too scared. She has a regular male partner and always uses condoms for intercourse.
Which of the following is essential to perform in this patient?
speculum exam
one of the most common causes of post coital bleeding
STI
A 5 year old girl presents to the GP practice with a 3 day history of an itchy right eye and mild discharge.
On examination there are multiple pale, waxy umbilicated nodules near the lower eyelid.
Which of the following is the most likely causative organism?
Poxvirus
This is the organism that is responsible for molluscum contagiosum which classically presents as waxy pale umbilicated nodules. The specific poxvirus is called the molluscum contagiosum virus. The condition is benign, transmitted by direct contact, and resolves spontaneously
bacilli in BV
large amounts of bacilli, small amounts of lactobacilli
well controlled T1DM vs COCP which is a bigger thrush risk factor
COCP
A 48 year old man is brought to A&E. He struggles to articulate, but tells you that he woke up this morning with right sided weakness.
He has been taking cART for the past 10 years.
Given the clinical picture, what is the most likely diagnosis?
Left sided middle cerebral artery infarct
This is the correct diagnosis. Patients with HIV on long term cART are at a significantly increased risk of both ischaemic and haemorrhagic stroke. This is due to the increase in vascular risk factors conferred by both anti retroviral medications and the presence of HIV within the blood
cART dangers
What it is:
CAR-T cells can also affect the nervous system, leading to a condition known as immune effector cell-associated neurotoxicity syndrome (ICANS).
Symptoms:
Confusion
Seizures
Difficulty speaking or walking
Headaches
Shaking or tremors
Changes in consciousness
Trouble speaking and understanding
Loss of balance
Blood disorders:
CAR-T therapy can sometimes lead to low blood cell counts, which can cause fatigue, weakness, or bruising.
Infections:
A weakened immune system can increase the risk of infections.
Allergic reactions:
Some individuals may experience allergic reactions to the CAR-T cells or other components of the therapy.
Fatigue:
Many patients experience significant fatigue, which can be described as “like flu, with myalgias, aches, pains, and you want to sleep more”.
Gastrointestinal issues:
CAR-T therapy can also cause gastrointestinal problems like abdominal pain, diarrhea, nausea, and in some cases, pancreatitis.
61F, high Ca125, Ct shows peritoneal and liver seeding of ovarian cancer. Next step?
surgery aiming to remove all macroscopic disease - done before or after chemotherapy
35F, referred for colposcopy after positive HPV smear. CIN3 - next step?
LLETZ - full thickness of cervical epithelium but have not breached basement membrane. Carcinoma in situ.
cervical smears and birth, miscarriage and termination
delayed until 3 months after
Any 55+ F with post menopausal bleeding should be
referred under 2 week wait for endometrial cancer and first line Ix is trans vaginal ultrasound (TVS) to assess endometrial thickness
24M, painless ulcerative lesion on penis, painful inguinal lymph nodes. Dx?
LGV
Syphilis (chancre- treponema pallidum) would not have inguinal lymphadenopathy
LGV more common in
MSM, men with multiple partners
white atrophic patches on vagina
lichen sclerosus
pregnancy woman genital warts management
Pregnant women with genital warts should undergo safe and effective cryotherapy treatment, which is commonly delayed until after delivery, for the destruction of abnormal skin cells caused by HPV.
genital warts histology
A biopsy of the genital lesions revealed hyperplastic squamous epithelium with koilocytes and squamous cells containing a hyperchromatic nucleus displaced by a large perinuclear vacuole.
A 29-year-old sexually active male presents with several painless wart-like growths on the shaft of his penis. They have been progressively increasing in size over the past few weeks.
What is the first-line treatment for this patient?
Imiquimod
HIV eye emergency
In patients with advanced HIV infection and low CD4 counts, CMV retinitis can cause rapid, painful visual loss characterised by haemorrhagic pizza-like lesions on fundoscopy.
A 20-year-old female presents to the Emergency Department with fevers and swollen, painful joints. The swelling started in the left elbow, and then spread to the left wrist and 5th metacarpophalangeal joint. On examination, there are multiple painless, vesiculopustular lesions on her arms and legs.
She reports having unprotected sexual intercourse 2 weeks ago and just finished her menstrual period which was normal. The pregnancy test is negative. She denies any dysuria or abnormal vaginal discharge.
Blood cultures are positive for a bacteria. What is the most likely pathogen?
Neisseria Gonorrhoeae
Disseminated gonococcal infection typically presents with fevers, migratory small and large joint polyarthritis, tenosynovitis and dermatitis. Skin lesions tend to be located distally on the limbs and are pustular or vesiculopustular in appearance.
Risk factors include asymptomatic infection, recent menstruation, complement deficiency and systemic lupus erythematosus.
disseminated gonorrhoea 3 key points
fevers, migratory joint pain and distinctive distal skin lesions
A young Caucasian male presents to the general practitioner after his boyfriend noted a lump in his lower abdomen. On examination, you observe a small, round, waxy, pink, and non-tender umbilicated lesion in his suprapubic region. He has no other symptoms or past medical history.
Which of the following is the most appropriate treatment option for this lesion?
Conservative management
This is the correct answer. The described lesion is molluscum contagiosum and is typically self-resolves within 18 months in immunocompentent individuals. NICE advise treating with imiquimod 5% cream, or cryotherapy if desired. Presentation with molluscum should prompt testing for sexually transmitted infections including HIV, although patients with immunodeficiency tend to have over 100 lesions or large disfiguring lesions, rather than solitary lesions such as this case.
