Reproductive System

Question 1

If a patient has signs/symptoms suggestive of a PE, according to NICE guidelines, what is the initial management?

Answer 1

History
Examination
CXR - to exclude other pathology

Question 2

After a CXR has been performed in someone with suspected PE, what is next done if a PE is still suspected…according to NICE guidelines?

Answer 2

Two-level PE Wells score

Question 3

What are the components of the Wells score? (7)

Answer 3

1. Clinical signs and symptoms of DVT (leg swelling, pain with palpation of the deep veins)
2. An alternative diagnosis is less likely than a PE
3. Heart rate >100bpm
4. Immobilisation for more than 3 days or surgery in the previous 4 weeks
5. Previous DVT/PE
6. Haemoptysis
7. Malignancy (on treatment, treated in the last 6 months, or palliative)

Question 4

What score on the Wells score would indicate a PE is likely?

Answer 4

Greater than 4 points

Question 5

If a PE is likely on Wells score (more than 4 points), what is the next step in the management/investigation pathway after CXR?

Answer 5

CTPA (if there is a delay then give LMWH until the scan is performed)

Question 6

If the Wells score is less than 4, what is the next step?

Answer 6

Arrange a D-dimer test - if this is positive, then performed a CTPA

Question 7

What is the alternative to a CTPA is the patient has an allergy to the contrast media or has renal impairment?

Answer 7

V/Q scan

Question 8

Why is CTPA preferred to a V/Q scan generally?

Answer 8

CTPA is fast, easy to perform, and can provide an alternative diagnosis if PE is excluded.

Question 9

What changes are associated on an ECG with PE? (3)

Answer 9

1. S1Q3T3 - this is only seen in about 20% of patients (Large S wave in lead 1, large Q wave in III and inverted T wave in lead III)
2. RBBB and right axis deviation
3. Sinus tachycardia

Question 10

What is the gold standard test for PE?

Answer 10

Pulmonary angiography

Question 11

What can ovarian tumours be divided into? (3)

Answer 11

1. Functional
2. Benign
3. Malignant

Question 12

In terms of percentage prevalence, what do each type of ovarian tumour account for?

Answer 12

1. Functional cysts 24%
2. Benign cysts 70%
3. Malignant 6%

Question 13

What are the two most common type of benign epithelial neoplastic cysts - which account for 60% of benign ovarian tumours?

Answer 13

1. Serous cystadenoma

2. Mucinous cyst adenoma

Question 14

In which age groups do serous and mucinous cyst adenomas occur? (this is a good way of differentiating them kind of)

Answer 14

Serous = 40-50 years (serous=senile) (20-25% malignant)
Mucinous = 20-40 years (5% malignant)

Question 15

Which type of ovarian cyst or benign tumour is associated with Meig’s syndrome?

Answer 15

Fibroma - small, solid, benign fibrous tissue tumours - associated with Meigs’ syndrome and ascites.

Question 16

What are the risk factors for developing benign ovarian tumours?

Answer 16

1. Obesity
2. Tamoxifen therapy associated with an increase in persistent ovarian cysts
3. Early menarche
4. Infertility
5. Dermoid cysts

Question 17

How can benign ovarian cysts/tumours present? (6)

Answer 17

1. Asymptomatic - chance binding through USS or bimanual examination
2. Dull ache or pain in the lower abdomen, low back pain
3. Torsion or rupture may lead to severe abdominal pain and fever
4. Dyspareunia
5. Swollen abdomen, palpable mass
6. Pressure effects on bladder or causing varicose veins/leg oedema

Question 18

What symptoms may occur as a result of torsion of an ovarian cyst?

Answer 18

1. Severe pain
2. Intermittent episodes of pain
   - due to torsion, infarction and haemorrhage

Question 19

What can happen if a cyst ruptures?

Answer 19

It can cause peritonitis and shock

Question 20

What happens if a mucinous cyst adenoma ruptures and the cells disseminate?

Answer 20

They will continue to secrete mucin and cause death by binding up the viscera causing pseudomyxoma peritonei

Question 21

What are the top differentials for ovarian cysts? (7)

Answer 21

1. Non-neoplastic functional cysts e.g. follicle cyst, corpus luteum cyst
2. Polycystic ovary syndrome
3. Endometrioma
4. Ovarian malignant tumour
5. Bowel tumour/diverticulitis
6. Pelvic inflammatory disease
7. Ectopic pregnancy

Question 22

What investigations should be done for someone with suspected ovarian cyst? (9)

Answer 22

1. Pregnancy test
2. FBC - infection, haemorrhage
3. Urinalysis
4. USS - pelvic
5. CT or MRI scan
6. Diagnostic laparoscopy and cytology
7. Fine needle aspiration
8. Cancer antigen 125
9. Alpha fetoprotein, lactate dehydrogenase, hCG

Question 23

What are the different management options for patients with ovarian cysts?

Answer 23

1. Expectant management - less than 5cm and they may resolve within three menstrual cycles, 5-7cm and they will be monitored - if persist then may need surgical management
2. Surgery - if symptomatic or greater than 5-10cm then surgical removal is normally performed.

Question 24

What are the complications for ovarian cysts? (4)

Answer 24

1. Torsion
2. Haemorrhage
3. Rupture
4. Infertility