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EDUCATION Clinical Challenge EDUCATION Questions for this month’s clinical challenge are based on articles in this issue. The style and scope of questions is in keeping with the MCQ of the College Fellowship exam. The quiz is endorsed by the RACGP Quality Assurance and Clinical challenge Continuing Professional Development Program and has been allocated 4 CPD points per issue. Answers to this clinical challenge will be published next month, and are available immediately following successful completion online at: www.racgp.org.au/clinicalchallenge. Jenni Parsons SINGLE COMPLETION ITEMS DIRECTIONS Each of the questions or incomplete statements below is followed by five suggested answers or completions. Select the most appropriate statement as your answer. Case 1 – Donna Watson A. have no treatment until the results of the A. abdominal ultrasound Donna, 23 years of age, has been taking tests come back so that the appropriate B. transvaginal ultrasound the combined oral contraceptive pill antibiotic can be given C. a qualitative urine BHCG (COCP) for many years without problems. B. be treated with azithromycin 1 g stat, doxy- D. a quantitative serum BHCG Over the past 6 weeks she has had cycline 100 mg twice daily for 14 days and E. full blood examination and C reactive protein. intermittent vaginal bleeding on several metronidazole 400 mg twice daily for 14 days days per week despite no missed pills. She Question 6 also noted pain on intercourse during that C. be treated with amoxycillin 500 mg and met- You confirm that Sarah is pregnant. She is time and over the past 2 weeks has had ronidazole 400 mg three times daily haemodynamically stable. Sarah now needs: vague lower abdominal pain. She has had D. be treated with azithromycin 1 g stat and one sexual partner over the past 6 months then await investigation results A. an urgent laparoscopy and they do not use condoms. She has not E. be treated with ceftriaxone 250 mg IM stat B. an abdominal ultrasound to check to see if had any recent gynaecological procedures. and then await investigation results. there is a gestational sac in the uterus Question 1 C. a laparoscopy if the abdominal ultrasound Question 4 You consider the possibility of pelvic inflam- reveals an empty uterus Donna comes back for review 4 days later. matory disease (PID). Choose the correct D. a transvaginal ultrasound to locate an intra- Her symptoms are improving on the treatment statement regarding examination features uterine pregnancy or an adnexial mass you initiated. Her tests revealed no STIs and in PID: E. routine antenatal care if she wishes to con- her vaginal swab revealed organisms asso- tinue with the pregnancy. A. clinical examination is not worth doing ciated with bacterial vaginosis. Choose the because signs for PID have low sensitivity correct statement: Question 7 and specificity Sarah asks what will happen if she is diag- A. bacterial vaginosis does not cause PID so B. adnexial tenderness is both highly sensitive nosed with an ectopic pregnancy. You tell her: Donna requires a pelvic ultrasound to check and highly specific for endometritis for endometriosis A. all ectopic pregnancies require surgical C. cervical motion tenderness would add B. Donna does not have PID as she does not intervention with laparotomy weight to the clinical suspicion of PID in have a STI B. laparoscopic surgery may involve either sal- Donna’s case C. this result is surprising as over 90% of cases pingectomy or salpingotomy D. absence of vaginal discharge excludes PID of PID are caused by STIs C. all early ectopic pregnancies can be man- E. PID does not cause systemic symptoms. D. you tell Donna to stop all antibiotics as no aged with systemic methotrexate Question 2 pathogens were isolated D. medically managed ectopic pregnancies On examination Donna is afebrile. She has a E. Donna should complete a 14 day course of have a subsequent ectopic pregnancy rate cervical ectropion, a small amount of yellowish doxycycline 100 mg twice daily and metroni- of over 50% cervical mucous, cervical motion tenderness dazole 400 mg three times daily. E. after treatment her best contraceptive and adnexial tenderness but no abdominal ten- option would be an intrauterine contracep- derness or guarding. Donna requires: Case 2 – Sarah McMillan tive device (IUCD). A. urine sample or cervical swabs for chla- Sarah, 31 years of age, has a past history Question 8 of appendicectomy at age 13 years and mydia and gonorrhoea PCR Sarah asks you about risk factors for ectopic PID at age 22 years. She has irregular B. bacterial cervical culture for gonorrhoea pregnancy. You tell her: and other organisms and high vaginal swab cycles of 28–42 days and uses condoms for contraception. She presents with a A. women with previous PID are at vastly and wet prep or gram stain 2 day history of left lower abdominal elevated risk of ectopic pregnancy C. a pregnancy test pain. Her last menstrual period started 37 B. previous ectopic pregnancy does not neces- D. A and B are correct days ago. She has no vaginal bleeding sarily increase subsequent risk E. A, B and C are correct. or discharge and no cervical or adnexial C. IUCD use is associated with increased risk tenderness. Question 3 that continues even after discontinuation of You tell Donna you think she may have PID. Question 5 IUCD You discuss treatment with her. Donna has no Of the following tests, the first investigation D. COCP use is associate with a small allergies. She should: that should be done is: increased risk 896 Reprinted from Australian Family Physician Vol. 35, No. 11, November 2006 Clinical challenge EDUCATION E. if she is treated with methotrexate, the likeli- further assessment at this stage involves: D. a tender fixed adnexial mass or fixed retro- hood of a subsequent ectopic pregnancy is A. ascertaining the effect of Casey’s symptoms verted uterus approximately 30%. on her sporting and social activities and E. any of the above. study Question 14 Case 3 – Casey O’Brien B. establishing rapport and undertaking a psy- You consider what investigations to arrange Casey, 15 years of age, is brought in by chosocial history using a HEADSS framework for Simone. Choose the correct statement: her mother, Amanda, to discuss problems C. seeing Casey on her own to assess her Casey is having with period pain. need for contraception and sexually trans- A. a normal transvaginal scan would exclude mitted infection risk the diagnosis of endometriosis Question 9 B. peritoneal implants and adhesions are read- Which of the following strategies is likely to be D. all of the above ily detected on ultrasound the most helpful: E. all of the above plus pelvic examination and transvaginal ultrasound to exclude pelvic C. ovarian endometriomas are detectable A. establishing with Amanda that it is your pathology. on ultrasound and have a 'ground glass' usual practice to spend some of the con- appearance sultation with the young person without the Question 12 D. haemorrhagic corpus luteum cysts have a parent present Casey has not yet commenced sexual completely different appearance to ovarian B. only asking Amanda to leave if it becomes intercourse. Her main concern is that she endometriomas obvious there are questions Casey does not sometimes misses netball games or school E. transvaginal ultrasound is not indicated as it want to answer in front of her mother because of period pain and headaches. will not detect endometriosis. C. asking Amanda to remain in the consulting Appropriate initial management room throughout the interview and examina- A. is to reassure Casey that her pain is normal Question 15 tion to reduce Casey’s anxiety and requires no treatment Simone has a laparoscopy. Choose the D. asking Casey to leave the room so that you B. is to reassure Casey that there are many correct statement: can discuss her problem with her mother in effective management options to address A. laparoscopy is used to diagnose endome- private her symptoms triosis by visual recognition alone E. telling Casey and Amanda that period pain C. is to advise Casey that her symptoms may B. laparoscopy is used to diagnose endome- is normal and Casey needs to just get be from endometriosis and that she is likely triosis by visual recognition and histological used to it. to have long term difficulties with pain and confirmation Question 10 infertility C. peritoneal implants should not be excised at Choose the correct statement about confiden- D. is to investigate Casey fully for secondary laparoscopy as these are better treated by tiality and consent in teenagers: dysmenorrhoea before embarking on treat- medical means ments such as NSAIDs, tranexamic acid or D. endometriomas are better treated by drain- A. discussing confidentiality is not necessary the OCP age and ablation than excision because of as teenagers are familiar with the concept E. with an OCP is contraindicated as it would the risk of loss of ovarian tissue of doctor-patient confidentiality encourage Casey to commence sexual E. surgical treatment of endometriosis is only B. teenagers are more likely to be open and experimentation. used when medical treatment has failed. disclose information if you outline the prin- ciples of confidentiality Case 4 – Simone Di Peitro Question 16 C. you tell Casey that doctor-patient confidenti- You discuss various hormone treatments ality is absolute and will not be broken under Simone, 29 years of age, has had painful periods since a year or two after menarche for endometriosis with Simone. Choose the any circumstances at age 14 years. Her symptoms were quite correct statement: D. as Casey is under 16 years of age her moth- well controlled as a teenager with NSAID A.
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