ISCE revision station

You are working in gynae outpatients and your next patient is Maryam Alzetani, a 28-year-old female
coming in due to pelvic pain. Please take a history, you have 7 minutes. The examiner will then stop
you and ask some questions.

History

 I’ve got really bad period pains

 Always had it but has been getting worse, paracetamol doesn’t help
 In lower tummy, comes on a few days before my period and stops a few days after,
cramping pain, no where else, nothing helps, worse with sex (deep), there all the time but
gets worse, periods are fine 7 days long, gets quite bloated can be 8/ 10 severity
 Also ask about: bowel and bladder habit (fine)
 No children no pregnancies, up to date with smears, sexually active using condoms, no STIs
 PMHx: appendicitis as a child, no allergies, no medications
 FHx: My mum has a similar pain but not as bad, hasn’t seen a doctor
 SHx: doesn’t smoke or drink, lives with husband, works in an office
 ICEE: this is really impacting me, I have to miss work sometimes due to the pain and find it
hard to enjoy sex, really want some help
Questions

 Please can you summarise

 What are your differential diagnoses
o Endometriosis, adenomyosis, PID, IBS, ovarian Ca?
 What investigations would you like to do?
o Abdo & pelvis exam, TVUSS, MSU, Swabs, MRI, Laproscopy
 Mrs Alzetani has some investigations done, this is her latest one. Please can you state what
type of investigation it is and what it shows
o Endometriosis
 How is this condition managed?
o Medical= nsaids, hormones (COCP, progesterone, GnRH analogues with HRT, IUS)
o Surgical- laprascopic laser ablation/ bipolar diathermy or scissors and adhesiolysis or
hysterectomy with bilateral salphino-oophrectomy
 6 months later, Mrs Alzetani comes in to A & E with vaginal bleeding, abdominal pain and
collapse. A Pregnancy test is positive. Examination reveals tachycardia, hypotension,
abdominal tenderness and cervical excitation. What is your top diagnosis?
o Ectopic
 How would you manage this?
o Ix= USS, serum hCG
o NBM, FBC, cross-match, pregnancy test, USS, IV access, anti-D
o Surgery if acute or subacute- salphingectomy (or salphinostomy)
o Medical-methotrexate
 What are the indications for medical over surgical treatments in this case?
o Unable to return for follow up, significant pain, adnexal mass > 35mm, visible foetal
heart, hCG>5000
 If medical treatment is chosen, what is the main follow up investigation required?
o Serial hCG until <20
28/04/2019

10:00

Maryam Alzetani, 22/03/1991