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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 degrees deg, 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 degrees deg, 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.
Select the most appropriate diagnosis for each clinical scenario. Acute appendicitis Incomplete miscarriage Ovarian hyperstimulation syndrome Indeterminate ultrasound/pregnancy of unknown location Ovarian teratoma Threatened miscarriage Molar pregnancy |
Ruptured Ovarian Cyst Ectopic Pregnancy Septic miscarriage Heterotropic Pregnancy Missed miscarriage Complete miscarriage |
1. A 42 year old primigravid female on clomiphene presents with severe left sided lower abdominal pain and bleeding per vaginum. Her bHCG is measured at 13000 IU/L.
Her vital signs are:
BP 80/60 mmHg
HR 116 /min
RR 22 /min
Sats 99% RA
T 37.1 oC
A transvaginal ultrasound shows a live intrauterine pregnancy, as well as a large volume of free pelvic fluid.
Answer: Heterotropic Pregnancy. The history of assisted reproduction raises the risk of this, and the clinical scenario is highly suggestive of an ectopic pregnancy despite the presence of a live intrauterine foetus. Thus multiple gestations should be suspected, ie a heterotropic pregnancy.
2. A 28 year old woman presents to the emergency department with cramping lower abdominal pain and PV spotting. Her serum bHCG is measured at 2800 IU/L. A transabdominal ultrasound does not show a gestational sac in the uterus, and the findings are otherwise unremarkable.
Her vital signs are:
BP 115/80 mmHg
HR 91 /min
RR 18 /min
Sats 99% RA
T 37.0 oC
Answer: indeterminate ultrasound. The bHCG is below the zone of discrimination for a transabdominal scan (approximately 5000IU/L), thus the absence of a yolk sac is difficult to interpret.
3. A 26 year old woman presents with significant lower abdominal pain and mild PV spotting at 7/40. She denies a significant vaginal bleed. Her bHCG is 1900 IU/L.
BP 105/71 mmHg
HR 101 /min
RR 18 /min
Sats 99% RA
T 37.0 oC
A transvaginal ultrasound shows an empty uterus and a small amount of free pelvic fluid.
Answer: Ectopic pregnancy. This bHCG is above the zone of discrimination and the absence of either a passed yolk sac, or intrauterine yolk sac strongly implies an ectopic pregnancy.
4. A 22 year old woman presents with lower abdominal cramping and PV spotting at 9/40. Her bHCG is 2800 IU/L. A transvaginal ultrasound shows an intrauterine pregnancy with a heart rate seen at 140 bpm. There is no pelvic free fluid.
Her vital signs are:
BP 119/81 mmHg
HR 81 /min
RR 16 /min
Sats 99% RA
T 37.0 oC
Answer: threatened miscarriage. This bHCG is above the discrimination threshold for a transvaginal ultrasound (1500IU/L). The presence of a live intrauterine gestation designates this as a threatened miscarriage.
5. A 29 year old woman presents after a large PV bleed at home. She is 10 weeks pregnant with her first child. A serum bHCG is 2100 IU/L. The bleeding has now ceased.
Her vital signs are:
BP 124/86 mmHg
HR 88 /min
RR 16 /min
Sats 99% RA
T 37.0 oC
A transvaginal ultrasound is performed, which shows an empty uterus with no other abnormal findings in the pelvis.
Answer: complete miscarriage. This bHCG is above the discrimination threshold, which means that a gestational sac should be able to visualized if present. The large (complete) bleed and ultrasound findings suggest this patient has had a complete miscarriage.
Her vital signs are:
BP 80/60 mmHg
HR 116 /min
RR 22 /min
Sats 99% RA
T 37.1 oC
A transvaginal ultrasound shows a live intrauterine pregnancy, as well as a large volume of free pelvic fluid.
Answer: Heterotropic Pregnancy. The history of assisted reproduction raises the risk of this, and the clinical scenario is highly suggestive of an ectopic pregnancy despite the presence of a live intrauterine foetus. Thus multiple gestations should be suspected, ie a heterotropic pregnancy.
2. A 28 year old woman presents to the emergency department with cramping lower abdominal pain and PV spotting. Her serum bHCG is measured at 2800 IU/L. A transabdominal ultrasound does not show a gestational sac in the uterus, and the findings are otherwise unremarkable.
Her vital signs are:
BP 115/80 mmHg
HR 91 /min
RR 18 /min
Sats 99% RA
T 37.0 oC
Answer: indeterminate ultrasound. The bHCG is below the zone of discrimination for a transabdominal scan (approximately 5000IU/L), thus the absence of a yolk sac is difficult to interpret.
3. A 26 year old woman presents with significant lower abdominal pain and mild PV spotting at 7/40. She denies a significant vaginal bleed. Her bHCG is 1900 IU/L.
BP 105/71 mmHg
HR 101 /min
RR 18 /min
Sats 99% RA
T 37.0 oC
A transvaginal ultrasound shows an empty uterus and a small amount of free pelvic fluid.
Answer: Ectopic pregnancy. This bHCG is above the zone of discrimination and the absence of either a passed yolk sac, or intrauterine yolk sac strongly implies an ectopic pregnancy.
4. A 22 year old woman presents with lower abdominal cramping and PV spotting at 9/40. Her bHCG is 2800 IU/L. A transvaginal ultrasound shows an intrauterine pregnancy with a heart rate seen at 140 bpm. There is no pelvic free fluid.
Her vital signs are:
BP 119/81 mmHg
HR 81 /min
RR 16 /min
Sats 99% RA
T 37.0 oC
Answer: threatened miscarriage. This bHCG is above the discrimination threshold for a transvaginal ultrasound (1500IU/L). The presence of a live intrauterine gestation designates this as a threatened miscarriage.
5. A 29 year old woman presents after a large PV bleed at home. She is 10 weeks pregnant with her first child. A serum bHCG is 2100 IU/L. The bleeding has now ceased.
Her vital signs are:
BP 124/86 mmHg
HR 88 /min
RR 16 /min
Sats 99% RA
T 37.0 oC
A transvaginal ultrasound is performed, which shows an empty uterus with no other abnormal findings in the pelvis.
Answer: complete miscarriage. This bHCG is above the discrimination threshold, which means that a gestational sac should be able to visualized if present. The large (complete) bleed and ultrasound findings suggest this patient has had a complete miscarriage.