Getting the best marks
Read the whole question – a latter section may give you a
clue about an earlier one.
To see how many points you need look at the marks
allocated – for example a 3 point question is generally looking for 3 salient points
If giving a list answer put the best answers first – examiners will not usually mark answers too
far down a list
Always write something – it may get you part of a mark and is anonymised so
no one will think you are stupid!
If you genuinely have no clue then re-write the question to see if this sparks
some ideas.
If not then move on and come back at the end. And remember – always
write something.
Good luck!
Question 8
Andrea, a 19 year old girl presents with right iliac fossa pain.
Q8.1• List 3 differentials (3)
Question 8
Your SHO tells you not to forget to
palpate McBurneys point in the exam.
Q8.2• Where is McBurneys
point? (2)
Q8.3• What is it’s
significance? (1)
Question 7
Andrea has missed her last period.
Q8.4• Illustrate the hormonal
changes of the menstrual cycle showing the four main hormones (8)
Question 7
A pregnancy test is performed
Q8.5• What is the molecule
detected by this test (3)
Q8.6• What is this molecules
physiological purpose? (1)
Question 7
The test is positive - it is a reliable test
with a good sensitivity and
specificity.
Q8.7• Define the statistical
terms sensitivity and specificity (2+2)
Question 8
Ultrasound shows no foetus in the uterus
and an ectopic pregnancy is diagnosed
Q8.8• What is the commonest
site for an ectopic pregnancy to implant? (1)
Q8.9• List two other sites of
ectopic implant (2)
Question 8
After successful treatment, Andrea
reveals she is sexually active with
multiple partners and does not use
contraception.
Q8.10• Compare the
combined oral contraceptive pill and the condom for mode of action, advantages and disadvantages (6)
Question 8
Andrea’s chaotic lifestyle lead you to believe that a long term contraceptive
option may be best.
Q8.11• List a long term mode
of contraception (lasts at least 3 months) and its mode of operation. (2)
The Answers
View these on ‘note view’ rather than on full screen – additional
notes are provided for some slides
Abdo Pain?
I Infectious/inflammatory Appendicitis, gastroenteritis, food poisoning
G Genetic / Ideopathic
E Endrocrine Diabetic ketoacidosis (mainly in children)
T Trauma
V Vascular / blood
I Iatrogenic / ingested Surgical adhesions
N Neoplastic
O Organs / other LOTS and LOTs…
Abdominal Organs
Right Hypochondrial:LiverGall bladderColon (hepatic flexure)
Epigastric:StomachDuodenum r
Colon (transverse)Pancreas r
Aorta R
Left Hypochondrial:StomachSpleen Pancreas (tail) r
Colon (splenic flexure)
Right Lumbar:Colon (ascending) r
Kidney R
Umbilical:Small bowelColon (transverse)Aortic bifurcation R
Left Lumbar:Colon (descending) r
Kidney R
Right Iliac FossaCaecumAppendixOvary / ovarian tubeUreter
Suprapubic:Rectum Urinary bladder R
Left Iliac FossaColon (descending)Colon (sigmoid)Ovary / ovarian tubeUreter
Abdominal Organs
Embryology Arterial supply Visceral pain in
Red Foregut Coeliac trunk Epigastrium
Green Midgut superior mesenteric Umbilical quadr
Blue Hindgut Inferior Mesenteric Suprapubic quadr.
Junction Points:
Foregut becomes Midgut: Ampulla of Vater – halfway along second section of duodenum
Midgut becomes Hindgut: approximately at the splenic flexure
R= primary retroperitoneal structurer= secondary retroperitoneal structure
Right Iliac Fossa Pain
Gut Gynae Other Appendicitis Mesenteric
adenitis
Ectopic Pregnancy
Ovarian cyst torsion
Salpingitis Ureteric stone
McBurney’s Point
Umbilicus
Rt ASIS
Basis of Pregnancy Test
• Implanting embryo produces human chorionic gonadotrophin (hCG)
• This stabilises the corpus luteum allowing continued progesterone production and pregnancy to continue
• hCG has 2 chains – alpha and beta
• Pregnancy test detects the beta-chain of the hCG molecule.
• Levels peak at 9-11 weeks
• Detectable 14 days post ovulation in urine and 6-7 days in plasma
Menstruation
Follicular phase
• Reducing oestrogen and progesterone – reduction of neg feedback on pituitary
• Pituitary releases FSH/LH
Within the follicle
• LH + Thecal cells gives choleterol androgens
• FSH causes proliferation of granulosa cells
• FSH + Granulosa gives androgens oestrogens
Little Tiny Follicles Grow: LH + Thecal cells; FSH + Granulosa
Menstruation
• Follicular phase (cont…)
• Selection of dominant follicle – produces oestrogen
• Oestrogen levels rise until passing level for inducing positive feedback on LH
• FSH + oestrogen induce LH receptors
• LH receptor levels rise
• Luteinisation of follicle occurs– Progesterone produced
• Progesterone potentiates positive feedback of oestrogen
• LH Surge
Menstruation
Ovulation• Occurs 36 hours after
LH surge• Meiosis restarts within
the oocyte• Follicle wall breaks
down release of oocyte
Luteal phase• Corpus luteum
produces progesterone
• Induced by LH• Continued production
needed for pregnancy• LH levels falling…
Sensitivity and Specificity Or: The Spinning Snout Test
• SPPIN = Sp+P+In
If a test has a high • Specificity then a• Positive result rules
the diagnosis• In
• SNNOUT = Sn+N+Out
If a test has a high • Sensitivity then a• Negative result rules
the diagnosis• Out
Combined Oral Contraceptive
Effectiveness• Pearl index: 0.3 – 4
Main Mode of action• Suppress synthesis
and secretion of FSH and the mid-cycle surge of LH.
Other actions• Endometrium: Results
in inadequte proliferation and secretory phases – preventing implantation.
• Cervical mucus: inhibits sperm penetration
Combined Oral Contraceptive
Advantages• Usually results in pain-free,
moderate periods
• Less PID / ectopics
• Less ovarian / endometrial cancer
• Less iron defic anaemia
• Less benign breast disease
• Less symptoms of the menopause
• Fewer ovarian cysts
Disadvantages:• No STI protection• Breast tenderness• Nausea• Headaches• Leg cramps• Depression• Acne• Alopecia• Hirsutism• Weight gain
Condom
Advantages:• Protection from STI’s
e.g. Chlamidia, HIV. Limited protection against HPV.
• Easy to use.• Non-hormonal.• Available free from
family planning clinics and similar sites.
• Disadvantages:• Interfere with sex.• Allergy.• Can be damaged by
oil-based products e.g. baby oil, some thrush treatments.
Condom
Effectiveness:• Pearl index 2-15
dependent on care in useage.
Mode of action:• A physical barrier that
prevents entry of the sperm into the vagina or cervix. Barrier methods need to be put in place before genital contact as the pre-ejaculate contains sperm.
Long term contraception
Male sterilisation• Ads: Very low failure rate (0 – 0.05% over lifetime), does
not interfere with sex. Nothing to remember.• Disads: should be considered permanent, no protection
vs STIs
Female sterilisation• Ads: Does not interfere with sex. Nothing to remember.• Disads: Relatively high failure rate (0 – 0.5% over
lifetime) – recanalisation not uncommon. Should be considered permanent, no protection vs STIs
Long term contraception
Implanon device• Action: Slow release of a progestogen - inhibits
ovulation, thickens the cervical mucus, inhibiting the passage of sperm to the uterus, and thins the endometrium, preventing implantation.
• Ads: Virtually no failure chance, Lasts years, reversible• Disads: May cause Irregular bleed, acne, ‘wt gain’
Long term contraception
IUCD ‘coil’• Action: induces an inflammatory response in the uterus
which affects the viability of sperm and ova. Prevent fertilisation and implantation
• Ads: Low failure (Pearl index 0.2 - 1), reversible.• Disads: Often causes menorrhagia