SAQs
1 A 75-year-old woman presents with vague abdominal
symptoms. She is unmarried and has no children. Over the
past 2 months she has noticed that her abdomen seems
to be swollen and she cannot fasten the button in her
waistbands. She last had a period at age 50 years and has
had no vaginal bleeding since. Her bowels move regularly
and an faecal occult blood test is negative. On
examination, she has a distended abdomen with
noticeable shifting dullness and a fluid thrill.
a. List three initial investigations that you would
perform to help you to establish the most likely
diagnosis? (3 marks)
b. Why are these investigations important in
determining her future management? (2 marks)
c. The investigations reveal that advanced ovarian
cancer is the most likely diagnosis and a laparotomy
is planned. What are the aims of surgery in this
situation? (4 marks)
d. This diagnosis is confirmed. What type of adjuvant
treatment do you need to consider? (2 marks)
e. If she was found to have bilateral pleural effusions
and cytological examination of the fluid taken by a
pleural tap identified adenocarcinoma cells, what
would this additional information mean for her
prognosis? (2 marks)
2 Veronica is a 53-year-old cleaner. She had three normal
vaginal deliveries in her twenties. Her periods stopped 5
years ago. She now complains of increasing incontinence
of urine while laughing, coughing and running. She also
mentions that she has some intermittent urinary urgency.
She consults her GP about this problem.
a. Suggest six relevant questions that you might ask
Veronica to find out more about her presenting
complaint? (Up to maximum of 6 marks)
On clinical abdominal examination, your findings are
normal. On vaginal examination, the anterior vaginal
wall is bulging and visible prior to inserting a Sims
speculum. Her uterus and posterior vaginal wall are
well supported.
b. What is your diagnosis? (2 marks)
c. What test would you arrange for next? (1 mark)
d. Suggest four conservative measures that you could
suggest at the clinic to improve her symptoms.
(4 marks)
Veronica feels distressed by her symptoms as she works
as a cleaner and she feels that it restricts what she is
able to do. She has told her employer that she cannot
do heavy work because of ‘ back problems ’ as she is
embarrassed to reveal her difficulties.
e. What further treatment could you consider?
(2 marks)
Veronica decides to have non - surgical treatment. She
finds the incontinence is still present, but the lump has
disappeared. She tried physiotherapy exercises but they
have not improved her situation and she is getting
more depressed.
f. What investigation would you consider and why?
(2 marks)
Obstetrics and Gynaecology: Clinical Cases Uncovered.
By M. Cruickshank and A. Shetty. Published 2009 by Blackwell
Publishing. ISBN 978-1-4051-8671-1.184 Part 3: Self-assessment
PART 3: SELF-ASSESSMENT
3 A 45-year-old woman, G3 P3, has been referred to the
gynaecology outpatient clinic with a history of heavy
periods. She has been using tranexamic acid as
recommended by her GP, but has not noticed any
improvement in her symptoms. She has no past medical
history of note and she is a schoolteacher. There were no
abnormal findings on examination of the abdomen and
pelvis.
a. What are three differential diagnoses that come to
mind? (3 marks)
b. List six questions you ask when taking her menstrual
history. (6 marks)
c. Name three investigations you would consider to
assist in making a diagnosis. (3 marks)
All further investigations are normal.
d. Name two other medical treatment options available
to this patient, and give one side - effect of each.
(4 marks)
This patient is unwilling to try any other form of
medical treatment. She would like to discuss surgical
options.
e. What would you suggest to her as a reasonable
surgical option? Justify your choice of surgical
treatment and give two side - effects of this option.
(5 marks)
f. Name three different ways in which a hysterectomy
can be performed? (3 marks)
g. In the case of women with high BMI, what other
specialty would you consult with prior to
undertaking any surgical intervention? (1 mark)
4 A 20-year-old girl presents with fresh vaginal bleeding.
Her LMP was 6 weeks ago. She uses condoms for
contraception.
a. List four features in history that will aid diagnosis.
(4 marks)
b. What four features would you look for on
examination? (4 marks)
c. What four non - imaging investigations would you
consider to aid you with the diagnosis and
management of this patient? (4 marks)
d. What imaging investigation would you request to
assist you in the management of this patient?
(2 marks)
5 Mrs Ross is a 72-year-old widow who presents with a
painful ulcer on her left labia majora. She also reports
noticing some bloodstained spots on her underwear. She
has suffered from vulva itch for the last 5 years. The itch is
worse at night and none of the creams bought at her local
pharmacy have helped. She tried a steroid cream
prescribed by her GP with no benefit. She thinks that she
may have damaged her skin by scratching it. On
examination, she has a raised grey plaque of slightly
nodular skin involving most of her perineum with a central
area of irregular deep ulceration.
a. What is the most likely diagnosis? (2 marks)
b. Name three underlying aetiological factors that may
predispose to the development of this condition.
(6 marks)
c. Which investigation should you perform? (2 marks)
d. Her biopsy excludes malignancy. What is your next
course of action and why? (3 marks)
6 Mrs Neale, a primigravida, arrives on the labour ward at
41 weeks +3 days’ gestation. She thinks her labour has
started. She has a mucosy ‘show’ but no leak of fluid per
vaginum. Her uterine contractions were infrequent some
hours ago, but have become more regular and painful
over the last 2 hours. The frequency of these contractions
is about three every 10 minutes, with each lasting for
about 50 seconds. The fetal heart rate is regular at around
140beats/minute. On examination, her cervix is found to
be fully effaced and 4cm dilated, membranes are intact
and the fetal head is at –1 station.
a. (i) Is Mrs Neale in active labour? (1 mark) (ii) What
are the reasons to support your diagnosis? (2 marks)
She requests pain relief.
b. Name four suitable options she could be offered at
this time. (4 marks)
Three hours later her membranes rupture and the
liquor is noted to be meconium stained.
c. (i) What might be the significance of this
meconium? (2 marks) (ii) List one non -
interventional measure you could undertake to
determine fetal well - being. (1 mark)
The fetal condition is shown to be fine. Her
contractions are now about two every 10 minutes and
mild to moderate in intensity. On a vaginal
examination, 4 hours after the last one, cervical
dilation is 4.5 cm.SAQs 185
PART 3: SELF-ASSESSMENT
d. (i) What do you conclude from this assessment?
(1 mark) (ii) What is your next action? (2 marks)
7 A midwife refers a 20-year-old primigravida with a
history of 9 weeks’ amenorrhoea and vomiting over the
past 2 weeks which has worsened over the last 2 days,
with inability to keep any fluids down.
a. What symptoms would you wish to ask her about
(list three)? (3 marks)
b. What clinical signs would you look for to aid
diagnosis (list three)? (3 marks)
c. List at least three investigations you would wish to
do. (6 marks)
d. What would your management plan include?
(6 marks)
e. Apart from hyperemesis gravidarum, what can cause
vomiting in pregnancy (list two)? (2 marks)
8 An 18-year-old para 0 is sent in to the day assessment
unit by her midwife at 36 weeks’ gestation when she was
noted to have a blood pressure of 150/98mmHg and +++
proteinuria at a routine check. Her booking BP had been
110/70mmHg.
a. What particular symptoms would you wish to ask
her about (list five)? (5 marks)
b. Knowing her blood pressure to now be
160/110 mmHg with +++ proteinuria, what would
you look for on examination (list three)? (3 marks)
c. She complains of a headache and her reflexes are
seen to be brisk with clonus 3 beats. What does her
clinical condition indicate? (1 mark)
d. What would the management include? (6 marks)
9 A para 2 at 37 weeks’ gestation is referred by her
midwife to the antenatal clinic as she thinks the baby
might be in an oblique breech lie. You confirm the lie on
abdominal palpation. She has had two previous vaginal
deliveries and has no significant medical or obstetric
history of note.
a. What investigation would you arrange for and what
would you be looking for with this? (2 marks)
b. What would you advise and why? (2 marks)
c. What would you discuss about the procedure?
(4 marks)
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