00
Correct
00
Incorrect
00 : 00 : 0 00
Session Time
00 : 00
Average Question Time ( Secs)
  • Question 1 - A 26-year-old female is undergoing examination for an atypical cyst on her left...

    Incorrect

    • A 26-year-old female is undergoing examination for an atypical cyst on her left ovary. Her AFP levels are elevated. Upon biopsy, the following report is obtained:

      Biopsy report: Schiller-Duval bodies are present

      What type of ovarian tumor has developed in this patient?

      Your Answer: Granulosa cell tumour

      Correct Answer: Yolk sac tumour

      Explanation:

      Schiller-Duval bodies seen on histology are a characteristic feature of yolk sac tumor, making it a pathognomonic finding.

      1. Incorrect. Yolk sac tumor would not present with diffuse sheets, nests, and cords of large uniform tumor cells like testicular seminoma.

      2. Incorrect. Call-Exner bodies are not present in yolk sac tumor.

      3. Incorrect. Yolk sac tumor is not a metastasis from a diffuse-type gastric adenocarcinoma, which would have a signet cell histology appearance.

      4. Incorrect. Yolk sac tumor contains tissues from all three germ layers, including ectodermal, mesodermal, and endodermal tissues.

      5. Correct. Schiller-Duval bodies are a unique feature of yolk sac tumor, and it also secretes AFP.

      Types of Ovarian Tumours

      There are four main types of ovarian tumours, including surface derived tumours, germ cell tumours, sex cord-stromal tumours, and metastasis. Surface derived tumours are the most common, accounting for around 65% of ovarian tumours, and include the greatest number of malignant tumours. These tumours can be either benign or malignant and include serous cystadenoma, serous cystadenocarcinoma, mucinous cystadenoma, mucinous cystadenocarcinoma, and Brenner tumour. Germ cell tumours are more common in adolescent girls and account for 15-20% of tumours. These tumours are similar to cancer types seen in the testicle and can be either benign or malignant. Examples include teratoma, dysgerminoma, yolk sac tumour, and choriocarcinoma. Sex cord-stromal tumours represent around 3-5% of ovarian tumours and often produce hormones. Examples include granulosa cell tumour, Sertoli-Leydig cell tumour, and fibroma. Metastatic tumours account for around 5% of tumours and include Krukenberg tumour, which is a mucin-secreting signet-ring cell adenocarcinoma resulting from metastases from a gastrointestinal tumour.

    • This question is part of the following fields:

      • Reproductive System
      11.1
      Seconds
  • Question 2 - A 32-year-old woman, Sarah, visits her doctor to inquire about the ideal time...

    Incorrect

    • A 32-year-old woman, Sarah, visits her doctor to inquire about the ideal time to take a urine pregnancy test for accurate results.

      Urine pregnancy tests available in the market detect hCG in the urine. However, the doctor advises Sarah to wait until the first day of her missed menstrual period before taking the test to increase the likelihood of an accurate result.

      Your Answer: The ovary produces hCG immediately after fertilisation, but levels are not high enough to detect in the urine until after a few days

      Correct Answer: HCG is secreted by the syncytiotrophoblast after implantation

      Explanation:

      During the early stages of pregnancy, the syncytiotrophoblast secretes hCG to prompt the corpus luteum to produce progesterone. This process typically begins around 6-7 days after fertilization and is complete by day 9-10. To ensure accurate results, it is recommended that women wait until at least the first day of their missed period to take a pregnancy test, as testing too early can result in a false-negative.

      The role of hCG in pregnancy is crucial, as it stimulates the corpus luteum to produce progesterone, which is essential for maintaining a healthy pregnancy. In the first four weeks of pregnancy, hCG levels should double every 48-72 hours until they eventually plateau. Monitoring hCG levels through sequential blood tests can help identify potential issues such as miscarriage or ectopic pregnancy, as hCG levels may fall or plateau prematurely. It is important to note that hCG is not secreted by the blastocyst, corpus luteum, ovary, or zygote.

      Endocrine Changes During Pregnancy

      During pregnancy, there are several physiological changes that occur in the body, including endocrine changes. Progesterone, which is produced by the fallopian tubes during the first two weeks of pregnancy, stimulates the secretion of nutrients required by the zygote/blastocyst. At six weeks, the placenta takes over the production of progesterone, which inhibits uterine contractions by decreasing sensitivity to oxytocin and inhibiting the production of prostaglandins. Progesterone also stimulates the development of lobules and alveoli.

      Oestrogen, specifically oestriol, is another major hormone produced during pregnancy. It stimulates the growth of the myometrium and the ductal system of the breasts. Prolactin, which increases during pregnancy, initiates and maintains milk secretion of the mammary gland. It is essential for the expression of the mammotropic effects of oestrogen and progesterone. However, oestrogen and progesterone directly antagonize the stimulating effects of prolactin on milk synthesis.

      Human chorionic gonadotropin (hCG) is secreted by the syncitiotrophoblast and can be detected within nine days of pregnancy. It mimics LH, rescuing the corpus luteum from degenerating and ensuring early oestrogen and progesterone secretion. It also stimulates the production of relaxin and may inhibit contractions induced by oxytocin. Other hormones produced during pregnancy include relaxin, which suppresses myometrial contractions and relaxes the pelvic ligaments and pubic symphysis, and human placental lactogen (hPL), which has lactogenic actions and enhances protein metabolism while antagonizing insulin.

    • This question is part of the following fields:

      • Reproductive System
      25.4
      Seconds
  • Question 3 - A 57-year-old woman came to the breast clinic with a breast lump. During...

    Incorrect

    • A 57-year-old woman came to the breast clinic with a breast lump. During the examination, a non-tender, irregular, 3 cm lump was palpated in the left upper quadrant. The diagnosis was ductal carcinoma in situ of the left breast. The oncology team was consulted, and the patient was started on anastrozole.

      What is the mechanism of action of this medication?

      Your Answer: Binds to human epidermal growth factor receptor 2 (HER2) receptors

      Correct Answer: Reduces peripheral oestrogen synthesis

      Explanation:

      Anastrozole and letrozole are medications that inhibit the production of oestrogen in peripheral tissues through the enzyme aromatase. These drugs are commonly used to treat breast cancer in postmenopausal women.

      Trastuzumab is a monoclonal antibody that targets HER2 receptors on cancer cells, inhibiting their growth and proliferation. It is effective in treating HER2-positive breast cancer.

      Fulvestrant is a selective oestrogen receptor degrader that breaks down oestrogen receptors without activating them, unlike tamoxifen. This leads to downregulation of the receptor.

      Goserelin is an LHRH agonist that suppresses oestrogen production by the ovaries. It is often used as adjuvant therapy in premenopausal women.

      Tamoxifen is an antagonist (and partial agonist) of the oestrogen receptor. It is particularly useful in treating oestrogen-receptor positive breast cancer, especially in patients who have not yet gone through menopause.

      Anti-oestrogen drugs are used in the management of oestrogen receptor-positive breast cancer. Selective oEstrogen Receptor Modulators (SERM) such as Tamoxifen act as an oestrogen receptor antagonist and partial agonist. However, Tamoxifen may cause adverse effects such as menstrual disturbance, hot flushes, venous thromboembolism, and endometrial cancer. On the other hand, aromatase inhibitors like Anastrozole and Letrozole reduce peripheral oestrogen synthesis, which is important in postmenopausal women. Anastrozole is used for ER +ve breast cancer in this group. However, aromatase inhibitors may cause adverse effects such as osteoporosis, hot flushes, arthralgia, myalgia, and insomnia. NICE recommends a DEXA scan when initiating a patient on aromatase inhibitors for breast cancer.

    • This question is part of the following fields:

      • Reproductive System
      13.6
      Seconds
  • Question 4 - A 35-year-old primigravid woman visits the antenatal clinic for her 20-week scan. She...

    Incorrect

    • A 35-year-old primigravid woman visits the antenatal clinic for her 20-week scan. She is informed that the combined test results indicate a high probability of her fetus having Down's syndrome.

      What were the probable outcomes of her combined test?

      Your Answer: ↑ HCG, ↑ PAPP-A, increased amount of nuchal fluid

      Correct Answer: ↑ HCG, ↓ PAPP-A, increased amount of nuchal fluid

      Explanation:

      The presence of ↑ HCG, ↓ PAPP-A, and a thickened nuchal translucency is indicative of Down’s syndrome. The combined screening test, which includes an ultrasound scan and blood test, is used to assess the risk of the fetus having Down’s syndrome, Edwards’ syndrome, and Patau’s syndrome. However, a diagnostic test such as amniocentesis or chorionic villus sampling is required to confirm the diagnosis. Advanced maternal age is also a significant risk factor for Down’s syndrome. The answer choices ‘↑ HCG, ↑ PAPP-A, increased amount of nuchal fluid’, ‘↑ HCG, ↓ PAPP-A, normal amount of nuchal fluid’, and ‘↓ HCG, ↓ PAPP-A, decreased amount of nuchal fluid’ are incorrect as they do not match the typical indicators of Down’s syndrome.

      NICE updated guidelines on antenatal care in 2021, recommending the combined test for screening for Down’s syndrome between 11-13+6 weeks. The quadruple test should be offered between 15-20 weeks for women who book later in pregnancy. Results of both tests return either a ‘lower chance’ or ‘higher chance’ result. If a woman receives a ‘higher chance’ result, she will be offered a second screening test (NIPT) or a diagnostic test. NIPT analyzes cell-free fetal DNA from placental cells in the mother’s blood and has high sensitivity and specificity for detecting chromosomal abnormalities, with private companies offering screening from 10 weeks gestation.

    • This question is part of the following fields:

      • Reproductive System
      13.2
      Seconds
  • Question 5 - A midwife contacts the Obstetric Foundation Year 2 doctor to assess a 32-year-old...

    Incorrect

    • A midwife contacts the Obstetric Foundation Year 2 doctor to assess a 32-year-old patient who delivered vaginally an hour ago. The patient is experiencing continuous vaginal bleeding, and the midwife approximates a total blood loss of 600 millilitres. What is the leading cause of primary postpartum haemorrhage?

      Your Answer: Retained products of conception

      Correct Answer: Uterine atony

      Explanation:

      PPH, which is the loss of 500 millilitres or more of blood within 24 hours of delivery, is primarily caused by uterine atony. This occurs when the uterus fails to contract after the placenta is delivered. However, other potential causes must be ruled out through thorough clinical examination. To remember the causes of PPH, the acronym ‘the 4 Ts’ can be used: Tone (uterine atony), Tissue (retained products of conception), Trauma (to the genital tract or perineum), and Thrombin (coagulation abnormalities). This information is based on RCOG Green-top Guideline No. 52.

      Postpartum Haemorrhage: Causes, Risk Factors, and Management

      Postpartum haemorrhage (PPH) is a condition characterized by excessive blood loss of more than 500 ml after a vaginal delivery. It can be primary or secondary. Primary PPH occurs within 24 hours after delivery and is caused by the 4 Ts: tone, trauma, tissue, and thrombin. The most common cause is uterine atony. Risk factors for primary PPH include previous PPH, prolonged labour, pre-eclampsia, increased maternal age, emergency Caesarean section, and placenta praevia. Management of PPH is a life-threatening emergency that requires immediate involvement of senior staff. The ABC approach is used, and bloods are taken, including group and save. Medical management includes IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options are considered if medical management fails to control the bleeding. Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis.

      Understanding Postpartum Haemorrhage

      Postpartum haemorrhage is a serious condition that can occur after vaginal delivery. It is important to understand the causes, risk factors, and management of this condition to ensure prompt and effective treatment. Primary PPH is caused by the 4 Ts, with uterine atony being the most common cause. Risk factors for primary PPH include previous PPH, prolonged labour, and emergency Caesarean section. Management of PPH is a life-threatening emergency that requires immediate involvement of senior staff. Medical management includes IV oxytocin, ergometrine, carboprost, and misoprostol. Surgical options are considered if medical management fails to control the bleeding. Secondary PPH occurs between 24 hours to 6 weeks after delivery and is typically due to retained placental tissue or endometritis. It is important to be aware of the signs and symptoms of PPH and seek medical attention immediately if they occur.

    • This question is part of the following fields:

      • Reproductive System
      8.1
      Seconds
  • Question 6 - As a medical student on a surgical placement, you are observing the breast...

    Incorrect

    • As a medical student on a surgical placement, you are observing the breast clinic when a 58-year-old woman comes in with a new breast lump. During the exam, the surgeon checks for the muscles that the breast lies over. What are these muscles?

      Your Answer: Pectoralis major and deltoid

      Correct Answer: Pectoralis major and serratus anterior

      Explanation:

      The breast is positioned on the superficial fascia, resting on top of the pectoralis major muscle (2/3) and the serratus anterior muscle (1/3). The pectoralis minor muscle is located beneath the pectoralis major muscle, while the deltoid muscle forms the sleek shoulder. Therefore, neither of these muscles come into contact with the breast. The subclavius muscle is situated between the clavicle and the first rib and also does not touch the breast.

      The breast is situated on a layer of pectoral fascia and is surrounded by the pectoralis major, serratus anterior, and external oblique muscles. The nerve supply to the breast comes from branches of intercostal nerves from T4-T6, while the arterial supply comes from the internal mammary (thoracic) artery, external mammary artery (laterally), anterior intercostal arteries, and thoraco-acromial artery. The breast’s venous drainage is through a superficial venous plexus to subclavian, axillary, and intercostal veins. Lymphatic drainage occurs through the axillary nodes, internal mammary chain, and other lymphatic sites such as deep cervical and supraclavicular fossa (later in disease).

      The preparation for lactation involves the hormones oestrogen, progesterone, and human placental lactogen. Oestrogen promotes duct development in high concentrations, while high levels of progesterone stimulate the formation of lobules. Human placental lactogen prepares the mammary glands for lactation. The two hormones involved in stimulating lactation are prolactin and oxytocin. Prolactin causes milk secretion, while oxytocin causes contraction of the myoepithelial cells surrounding the mammary alveoli to result in milk ejection from the breast. Suckling of the baby stimulates the mechanoreceptors in the nipple, resulting in the release of both prolactin and oxytocin from the pituitary gland (anterior and posterior parts respectively).

    • This question is part of the following fields:

      • Reproductive System
      9.5
      Seconds
  • Question 7 - During your placement in general practice, a 35-year-old female patient expresses worry about...

    Incorrect

    • During your placement in general practice, a 35-year-old female patient expresses worry about a recent lump she discovered in her breast. Can you identify the primary region in the breast where most breast cancers develop?

      Your Answer: Lower medial

      Correct Answer: Upper lateral

      Explanation:

      The breast is divided into 5 regions, which help in describing the location of pathology and disease spread. The upper lateral area has the most mammary tissue and is where the auxiliary tail of Spence extends from, passing through an opening in the deep fascia foramen of Langer to reach the axilla. The upper lateral region is where the majority of breast tumors occur.

      Breast Cancer Treatment Options and Prognosis

      Breast cancer is more common in older individuals and the most common type is invasive ductal carcinoma. Pathological assessment involves evaluating the tumor and lymph nodes, with sentinel lymph node biopsy being a common method to minimize morbidity. Treatment options include wide local excision or mastectomy, with the final cosmetic outcome being a consideration. Reconstruction is also an option following any resectional procedure. The Nottingham Prognostic Index can be used to give an indication of survival, with factors such as tumor size, lymph node involvement, and grade being taken into account. Other factors such as vascular invasion and receptor status also impact survival. The aim of any surgical option should be to have a local recurrence rate of 5% or less at 5 years.

      Breast cancer treatment options and prognosis are important considerations for individuals diagnosed with this disease. The most common type of breast cancer is invasive ductal carcinoma, and treatment options include wide local excision or mastectomy. The final cosmetic outcome is a consideration, and reconstruction is an option following any resectional procedure. The Nottingham Prognostic Index can be used to give an indication of survival, with factors such as tumor size, lymph node involvement, and grade being taken into account. Other factors such as vascular invasion and receptor status also impact survival. The aim of any surgical option should be to have a local recurrence rate of 5% or less at 5 years.

    • This question is part of the following fields:

      • Reproductive System
      10.7
      Seconds
  • Question 8 - A 67-year-old woman presents with 6 months of gradually increasing abdominal distension, abdominal...

    Incorrect

    • A 67-year-old woman presents with 6 months of gradually increasing abdominal distension, abdominal pain and feeling full quickly. She has also experienced recent weight loss. Upon examination, her abdomen is distended with signs of ascites. Her cancer antigen 125 (CA-125) level is elevated (550 IU/mL). An abdominal ultrasound reveals a mass in the left ovary. What is the most frequent histological subtype of the mass, based on the most probable diagnosis?

      Your Answer: Endometrioid

      Correct Answer: Serous

      Explanation:

      Understanding Ovarian Cancer: Risk Factors, Symptoms, and Management

      Ovarian cancer is a type of cancer that affects women, with the peak age of incidence being 60 years. It is the fifth most common malignancy in females and carries a poor prognosis due to late diagnosis. Around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas. Interestingly, recent studies suggest that the distal end of the fallopian tube is often the site of origin of many ‘ovarian’ cancers.

      There are several risk factors associated with ovarian cancer, including a family history of mutations of the BRCA1 or the BRCA2 gene, early menarche, late menopause, and nulliparity. Clinical features of ovarian cancer are notoriously vague and can include abdominal distension and bloating, abdominal and pelvic pain, urinary symptoms, early satiety, and diarrhea.

      To diagnose ovarian cancer, a CA125 test is usually done initially. If the CA125 level is raised, an urgent ultrasound scan of the abdomen and pelvis should be ordered. However, a CA125 should not be used for screening for ovarian cancer in asymptomatic women. Diagnosis is difficult and usually involves diagnostic laparotomy.

      Management of ovarian cancer usually involves a combination of surgery and platinum-based chemotherapy. The prognosis for ovarian cancer is poor, with 80% of women having advanced disease at presentation and the all stage 5-year survival being 46%. It is traditionally taught that infertility treatment increases the risk of ovarian cancer, as it increases the number of ovulations. However, recent evidence suggests that there is not a significant link. The combined oral contraceptive pill reduces the risk (fewer ovulations) as does having many pregnancies.

    • This question is part of the following fields:

      • Reproductive System
      19
      Seconds
  • Question 9 - A female patient comes in with a history of struggling to conceive for...

    Correct

    • A female patient comes in with a history of struggling to conceive for two and a half years. Upon further examination with an ultrasound, it is discovered that fibroids are present and may be hindering embryo implantation. Where is the most probable location of these fibroids?

      Your Answer: Uterus- submucosal

      Explanation:

      When it comes to fibroids and difficulty conceiving, submucosal fibroids are the most likely culprit. These fibroids are located in the uterine cavity and can interfere with the implantation of an embryo. Intramural and subserosal fibroids are less likely to cause fertility issues, but they can cause symptoms such as increased urinary frequency and constipation due to their size and location. It’s important to note that fibroids are typically found within the uterus and not outside of it.

      Understanding Uterine Fibroids

      Uterine fibroids are non-cancerous growths that develop in the uterus. They are more common in black women and are believed to occur in around 20% of white women in their later reproductive years. Fibroids are usually asymptomatic, but they can cause menorrhagia, which can lead to iron-deficiency anaemia. Other symptoms include lower abdominal pain, bloating, and urinary symptoms. Fibroids may also cause subfertility, but this is rare.

      Diagnosis is usually done through transvaginal ultrasound. Asymptomatic fibroids do not require treatment, but periodic monitoring is necessary. For menorrhagia, treatment options include the levonorgestrel intrauterine system, NSAIDs, tranexamic acid, oral progestogen, and injectable progestogen. Medical treatment to shrink or remove fibroids includes GnRH agonists and ulipristal acetate, while surgical options include myomectomy, hysteroscopic endometrial ablation, hysterectomy, and uterine artery embolization.

      Fibroids generally regress after menopause, and complications such as subfertility and iron-deficiency anaemia have been mentioned previously. Another complication is red degeneration, which is haemorrhage into the tumour and commonly occurs during pregnancy. Understanding uterine fibroids is important for women’s health, and seeking medical attention is necessary if symptoms arise.

    • This question is part of the following fields:

      • Reproductive System
      6.5
      Seconds
  • Question 10 - A 28-year-old primigravida, at 8 weeks gestation presents for her prenatal check-up. She...

    Correct

    • A 28-year-old primigravida, at 8 weeks gestation presents for her prenatal check-up. She reports taking a daily vitamin and denies any use of tobacco, alcohol, or illicit drugs. On examination, her blood pressure is 118/66 mmHg and pulse is 78/min. Bimanual examination reveals a 10-week-sized non-tender uterus with no adnexal masses or tenderness. Ultrasound shows two 8-week intrauterine gestations with normal heartbeats, a single placenta, and no dividing intertwine membrane.

      What is the most likely diagnosis for this patient?

      Your Answer: Monochorionic monoamniotic twins

      Explanation:

      Twin Pregnancies: Incidence, Types, and Complications

      Twin pregnancies occur in approximately 1 out of 105 pregnancies, with the majority being dizygotic or non-identical twins. Monozygotic or identical twins, on the other hand, develop from a single ovum that has divided to form two embryos. However, monoamniotic monozygotic twins are associated with increased risks of spontaneous miscarriage, perinatal mortality rate, malformations, intrauterine growth restriction, prematurity, and twin-to-twin transfusions. The incidence of dizygotic twins is increasing due to infertility treatment, and predisposing factors include previous twins, family history, increasing maternal age, multigravida, induced ovulation, in-vitro fertilisation, and race, particularly Afro-Caribbean.

      Antenatal complications of twin pregnancies include polyhydramnios, pregnancy-induced hypertension, anaemia, and antepartum haemorrhage. Fetal complications include perinatal mortality, prematurity, light-for-date babies, and malformations, especially in monozygotic twins. Labour complications may also arise, such as postpartum haemorrhage, malpresentation, cord prolapse, and entanglement.

      Management of twin pregnancies involves rest, ultrasound for diagnosis and monthly checks, additional iron and folate, more antenatal care, and precautions during labour, such as having two obstetricians present. Most twins deliver by 38 weeks, and if longer, most are induced at 38-40 weeks. Overall, twin pregnancies require close monitoring and management to ensure the best possible outcomes for both mother and babies.

    • This question is part of the following fields:

      • Reproductive System
      41.2
      Seconds

SESSION STATS - PERFORMANCE PER SPECIALTY

Reproductive System (2/10) 20%
Passmed