EXtended match question Answers.
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EMQ PAPER 1.
Select the most appropriate diagnosis for each clinical scenario. Mittelschmerz Endometriosis Adenomyosis Cervical stenosis Pelvic Inflammatory Disease Ovarian Torsion Uterine prolapse Diverticulitis Irritable bowel syndrome |
Post‐partum haemorrhage Interstitial cystitis Depression Chronic urethritis Placenta praevia Ectopic Pregnancy Threatened miscarriage Ruptured ovarian cyst Pre‐eclampsia Hyperemesis gravidarum Multiple pregnancy |
1. A 17 year old female presents with left sifed pelvic pain which occurs midway through her cycle each month. She is distressed on initial arrival, with nornal observations. The physical examination reveals only mild discomfort on palpation. Investigations show a Hb of 130mg/dL and a serum bHCG <5 IU/L. An ultrasound shows no pathology. What is the most likely diagnosis?
ANSWER: Mittelschmerz. This is a classic history for Mittleschmerz pain, and the normal examinations and investigations effectively exclude any other pathology.
2. A 52 year old femal presents with cyclical left pelvic pain, menorrhagia and dysmenorrhoea. Examination reveals a symmetrically enlarged, slightly tender uterus with a diffusely boggy consistency. Ultrasound is performed and shows generalized uterine elnargement with indistinct myo-endometrial margins. The most likely diagnosis is?
ANSWER: Adenomyosis. The key here are the ultrasound findings in the context of the history of menorrhagia and dysmenorrhoea.
3. A 17 year old female presents with sudden onset severe RIF pain. Her last period was 10 days ago and she describes a regular 28 day cycle. Her observations are: T 37.7 degrees C , HR 94/min, BP 140/70 mmHg. Her urine is clear and negative for bHCG. What is the most likely diagnosis?
ANSWER: Ruptured Ovarian Cyst. Although a torted ovary is possible as a differential, the timing of the pain and the relative frequency of cysts compared to torsion makes the likely diagnosis a ruptured cyst occuring in conjunction with ovulation.
4. A 17 year old female with vague lower abdominal pain presents with a fever and purulent vaginal discharge. On internal examination she has significant cervical motion tenderness. What is the likely diagnosis?
ANSWER: Pelvic inflammatory disease. The clinical information and examination findings are extremely suggestive.
ANSWER: Mittelschmerz. This is a classic history for Mittleschmerz pain, and the normal examinations and investigations effectively exclude any other pathology.
2. A 52 year old femal presents with cyclical left pelvic pain, menorrhagia and dysmenorrhoea. Examination reveals a symmetrically enlarged, slightly tender uterus with a diffusely boggy consistency. Ultrasound is performed and shows generalized uterine elnargement with indistinct myo-endometrial margins. The most likely diagnosis is?
ANSWER: Adenomyosis. The key here are the ultrasound findings in the context of the history of menorrhagia and dysmenorrhoea.
3. A 17 year old female presents with sudden onset severe RIF pain. Her last period was 10 days ago and she describes a regular 28 day cycle. Her observations are: T 37.7 degrees C , HR 94/min, BP 140/70 mmHg. Her urine is clear and negative for bHCG. What is the most likely diagnosis?
ANSWER: Ruptured Ovarian Cyst. Although a torted ovary is possible as a differential, the timing of the pain and the relative frequency of cysts compared to torsion makes the likely diagnosis a ruptured cyst occuring in conjunction with ovulation.
4. A 17 year old female with vague lower abdominal pain presents with a fever and purulent vaginal discharge. On internal examination she has significant cervical motion tenderness. What is the likely diagnosis?
ANSWER: Pelvic inflammatory disease. The clinical information and examination findings are extremely suggestive.
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EMQ PAPER 2.
For each clinical scenario select the most appropriate investigation. Serum lipase Abdominal ultrasound Erect chest xray Serum amylase Non contrast CT scan of the abdomen Erect abdominal xray |
Non contrast CT scan of the abdomen IV Contrast CT scan of the abdomen Erect and supine abdominal xray IV and oral contrast CT scan of the abdomen Scrotal ultrasound No imaging is required |
1. A 55 year old man presents with severe central abdominal pain radiating through to his back. It is associated with non-bloody vomiting and came on after an alcohol binge the previous night . He has no medical history of note.
His vital signs are:
HR 98 /min
BP 136/98 mmHg
RR 18 /min
Sats 98% RA
T 37.2 oC
Answer: serum lipase. This patient has a history suggestive of acute pancreatitis. A serum lipase with a cut off of 3 times the normal limit has a sensitivity of 98% for acute pancreatitis, which is higher than that of amylase. (Ref Steinberg et al Ann Intern Med 1985; 102(5):576)
2. A 45 year old man with a history of inguinal hernia presents with cramping abdominal pain and distention. He has vomited several times, and when asked he specifically mentions that he has not passed flatus for the last twenty four hours. He also describes a painful swelling in the right testicle.
His vital signs are:
HR 109 /min
BP 122/89 mmHg
RR 17 /min
Sats 99% RA
T 37.0 oC
Answer: IV and oral contrast CT scan of the abdomen. This patient has a history suggestive of acute bowel obstruction likely due to an incarcerated inguinal hernia. In this situation a CT scan is preferable to plain films, as diagnosis of obstruction is highly likely. The incorporation of oral contrast will allow the “transition point” or site of obstruction to be evaluated radiographically.
3. A 26 year old man presents with severe generalized abdominal pain. He has had right iliac fossa pain for the previous 3 days, which has become acutely worse. On examination his abdomen is rigid.
His vital signs are:
HR 118 /min
BP 105/87 mmHg
RR 25 /min
Sats 99% RA
T 38.7 oC
Answer: IV Contrast CT scan of the abdomen. This patient has a history suggestive of an intestinal perforation, most likely an appendix. In the absence of any contraindication the addition of IV contrast to a CT scan will increase the sensitivity for the underlying pathology, and therefore highlight the likely site of perforation.
4. An 18 year old man presents with right sided abdominal pain and loss of appetite. He says the pain initially began in the periumbilical region two days prior, and gradually migrated to his right lower abdomen. He is not hungry despite having not eaten for 24 hours. On examination he is exquisitely tender in the right iliac fossa. The tenderness on the right is reproducible with palpation on the left side of the abdomen.
His vital signs are:
HR 100 /min
BP 123/81 mmHg
RR 16 /min
Sats 99% RA
T 38.1 oC
Answer: No imaging is required. This patient has a history suggestive of acute appendicitis. It is entirely reasonable to seek a surgical opinion on immediate laparoscopy versus a period of observation rather than perform a CT scan.
5. A 30 year old woman presents with right sided upper abdominal pain. The pain has been crampy for the last 2 days, but has started to increase in severity and duration. She has no medical history of note.
Her vital signs are:
HR 97 /min
BP 121/85 mmHg
RR 14 /min
Sats 99% RA
T 37.3 oC
Answer: Abdominal ultrasound. This patient has a history suggestive of early cholecystitis. An ultrasound is a sensitive and non invasive way to evaluate for this possibility.
His vital signs are:
HR 98 /min
BP 136/98 mmHg
RR 18 /min
Sats 98% RA
T 37.2 oC
Answer: serum lipase. This patient has a history suggestive of acute pancreatitis. A serum lipase with a cut off of 3 times the normal limit has a sensitivity of 98% for acute pancreatitis, which is higher than that of amylase. (Ref Steinberg et al Ann Intern Med 1985; 102(5):576)
2. A 45 year old man with a history of inguinal hernia presents with cramping abdominal pain and distention. He has vomited several times, and when asked he specifically mentions that he has not passed flatus for the last twenty four hours. He also describes a painful swelling in the right testicle.
His vital signs are:
HR 109 /min
BP 122/89 mmHg
RR 17 /min
Sats 99% RA
T 37.0 oC
Answer: IV and oral contrast CT scan of the abdomen. This patient has a history suggestive of acute bowel obstruction likely due to an incarcerated inguinal hernia. In this situation a CT scan is preferable to plain films, as diagnosis of obstruction is highly likely. The incorporation of oral contrast will allow the “transition point” or site of obstruction to be evaluated radiographically.
3. A 26 year old man presents with severe generalized abdominal pain. He has had right iliac fossa pain for the previous 3 days, which has become acutely worse. On examination his abdomen is rigid.
His vital signs are:
HR 118 /min
BP 105/87 mmHg
RR 25 /min
Sats 99% RA
T 38.7 oC
Answer: IV Contrast CT scan of the abdomen. This patient has a history suggestive of an intestinal perforation, most likely an appendix. In the absence of any contraindication the addition of IV contrast to a CT scan will increase the sensitivity for the underlying pathology, and therefore highlight the likely site of perforation.
4. An 18 year old man presents with right sided abdominal pain and loss of appetite. He says the pain initially began in the periumbilical region two days prior, and gradually migrated to his right lower abdomen. He is not hungry despite having not eaten for 24 hours. On examination he is exquisitely tender in the right iliac fossa. The tenderness on the right is reproducible with palpation on the left side of the abdomen.
His vital signs are:
HR 100 /min
BP 123/81 mmHg
RR 16 /min
Sats 99% RA
T 38.1 oC
Answer: No imaging is required. This patient has a history suggestive of acute appendicitis. It is entirely reasonable to seek a surgical opinion on immediate laparoscopy versus a period of observation rather than perform a CT scan.
5. A 30 year old woman presents with right sided upper abdominal pain. The pain has been crampy for the last 2 days, but has started to increase in severity and duration. She has no medical history of note.
Her vital signs are:
HR 97 /min
BP 121/85 mmHg
RR 14 /min
Sats 99% RA
T 37.3 oC
Answer: Abdominal ultrasound. This patient has a history suggestive of early cholecystitis. An ultrasound is a sensitive and non invasive way to evaluate for this possibility.