Oppgave: MED5600_OPPGAVE04_V18_ORD

Transcription

1 Side 23 av 63 Oppgave: MED5600_OPPGAVE04_V18_ORD Del 1: Sofie, 38 years, para1, comes to your office complaining about dyspareunia and spotting she has recently observed on several occasions, unrelated to menstruation. She also had malodorous vaginal discharge in recent weeks. She has not been to a gynecologist in 3 years. When you ask about cervical smears or HPV testing she cannot recall the last time she was tested. You perform a gynecological examination and find a uterine cervix which bleeds easily, is firm and irregular at palpation and has partly a verrucous surface. What do you do? (Two correct answers) Order a genetic test for BRCA1/2 to rule out hereditary ovarian cancer. Take a pipelle biopsy. Refer the patient to a gynecologist for further assessment. Obtain a urine culture. Take a cervical smear. Refer the patient to a gynecologist for further assessment. Take a cervical smear. Del 2: Sofie, 38 years, para1, comes to your office complaining about dyspareunia and spotting she has recently observed on several occasions, unrelated to menstruation. She also had malodorous vaginal discharge in recent weeks. She has not been to a gynecologist in 3 years. When you ask about cervical smears or HPV testing she cannot recall the last time she was tested. You perform a gynecological examination and find a uterine cervix which bleeds easily, is firm and irregular at palpation and has partly a verrucous surface. You take a cervical smear and at the same time refer Sofie to the next gynecology department. Following colposcopy and biopsy, she undergoes conization. A section from this specimen is shown.

2 Side 24 av 63 When looking at the microscopic pictures, which two of the following statements are true? The tumor shown is trophoblastic The tumor has its origin in the endocervical columnar epithelium An in situ component can be seen Horn pearls, suggesting squamous differentiation, can be seen Evidence of serous differentiation in the form of concentric calcifications (psammoma bodies) is evident An in situ component can be seen Horn pearls, suggesting squamous differentiation, can be seen

3 Side 25 av 63 Del 3: Sofie, 38 years, para1, comes to your office complaining about dyspareunia and spotting she has recently observed on several occasions, unrelated to menstruation. She also had malodorous vaginal discharge in recent weeks. She has not been to a gynecologist in 3 years. When you ask about cervical smears or HPV testing she cannot recall the last time she was tested. You perform a gynecological examination and find a uterine cervix which bleeds easily, is firm and irregular at palpation and has partly a verrucous surface. You take a cervical smear and at the same time refer Sofie to the next gynecology department. Following colposcopy and biopsy, she undergoes conization. A section from this specimen is shown. An in situ component (HSIL) can be seen and the tumor contains elements of squamous differentiation. What is the diagnosis? Choriocarcinoma. Squamous cell carcinoma. Adenocarcinoma of endocervical (usual) type. High-grade serous carcinoma Endometrioid adenocarcinoma. Squamous cell carcinoma. Del 4: Sofie, 38 years, para1, comes to your office complaining about dyspareunia and spotting she has recently observed on several occasions, unrelated to menstruation. She also had malodorous vaginal discharge in recent weeks. She has not been to a gynecologist in 3 years. When you ask about cervical smears or HPV testing she cannot recall the last time she was tested. You perform a gynecological examination and find a uterine cervix which bleeds easily, is firm and irregular at palpation and has partly a verrucous surface. You take a cervical smear and at the same time refer Sofie to the next gynecology department. Following colposcopy and biopsy, she undergoes conization. A section from this specimen is shown. An in situ component (HSIL) can be seen and the tumor contains elements of squamous differentiation. Sofie is diagnosed with a squamous cell carcinoma. Which three statements are true regarding this condition? The tumor is related to HPV infection in 50% of cases. Tumor risk is unrelated to smoking Tumor risk is increased in patients with HIV infection. Screening has reduced the incidence of this tumor in developed countries. Prognosis is excellent irrespective of disease stage. Tumor risk is related to the number of sexual partners. Surgery is the only treatment approach. Tumor risk is increased in patients with HIV infection. Screening has reduced the incidence of this tumor in developed countries. Tumor risk is related to the number of sexual partners.

4 Side 26 av 63 Del 5: Sofie, 38 years, para1, comes to your office complaining about dyspareunia and spotting she has recently observed on several occasions, unrelated to menstruation. She also had malodorous vaginal discharge in recent weeks. She has not been to a gynecologist in 3 years. When you ask about cervical smears or HPV testing she cannot recall the last time she was tested. You perform a gynecological examination and find a uterine cervix which bleeds easily, is firm and irregular at palpation and has partly a verrucous surface. You take a cervical smear and at the same time refer Sofie to the next gynecology department. Following colposcopy and biopsy, she undergoes conization. A section from this specimen is shown. An in situ component (HSIL) can be seen and the tumor contains elements of squamous differentiation. Sofie is diagnosed with a squamous cell carcinoma. Tumor risk is increased in patients with HIV infection, screening has reduced the incidence and tumor risk is related to the number of sexual partners. The diagnosis of a squamous cell carcinoma of the cervix was unexpected and the resection margins of the cone were not free. Sofie is referred to a gynoncologist. Which three are the next steps in the assessment of the patient? General examination in general anesthesia, cystocopy and rectoscopy if necessary MR examination of the pelvis Resection of the tumor in general anesthesia Whole body PET CT chest/abdomen/pelvis General examination in general anesthesia, cystocopy and rectoscopy if necessary MR examination of the pelvis CT chest/abdomen/pelvis Del 6: Sofie, 38 years, para1, comes to your office complaining about dyspareunia and spotting she has recently observed on several occasions, unrelated to menstruation. She also had malodorous vaginal discharge in recent weeks. She has not been to a gynecologist in 3 years. When you ask about cervical smears or HPV testing she cannot recall the last time she was tested. You perform a gynecological examination and find a uterine cervix which bleeds easily, is firm and irregular at palpation and has partly a verrucous surface. You take a cervical smear and at the same time refer Sofie to the next gynecology department. Following colposcopy and biopsy, she undergoes conization. A section from this specimen is shown. An in situ component (HSIL) can be seen and the tumor contains elements of squamous differentiation. Sofie is diagnosed with a squamous cell carcinoma. Tumor risk is increased in patients with HIV infection, screening has reduced the incidence and tumor risk is related to the number of sexual partners. A general examination in anesthesia, an MR of the pelvis and a CT -scan of the thorax is performed, but with no signs of metastatic disease. As a result of these examinations, a small residual tumor in the cervix is identified, but no tumor extension outside the uterus or any sign of metastatic disease is found. Which treatment would you suggest in this situation? Radiation therapy of the cervix. Extended hysterectomy with parametria and removal of fallopian tubes. Extended hysterectomy with parametria, fallopian tubes and lymph nodes in the small pelvis. Trachelectomy Radiation therapy of the cervix with adjuvant cytostatic treatment. Extended hysterectomy with parametria, fallopian tubes and lymph nodes in the small pelvis.

5 Side 27 av 63 Del 7: Maria, 52 years, para2, comes to your office for regular cervical screening and removal of an IUD. She complains about irregular menstrual bleeding. She feels constipated and complains about fatigue, but thinks her problems may be related to menopause and to the fact that her older sister recently was diagnosed with cancer of the breast. Upon genitourinary examination you palpate a mass on the right side of the pelvis. What do you do? (two correct answers) Refer her to a gynecologist for further assessment. Check serum levels of CA 125 Take anamnesis with focus on family history of cancer Take a biopsy from the endometrium (pipelle) and a blood sample for biomarkers in regard to ovarian cancer, and refer her to a gynecologist for further assessment. Remove the IUD and initiate antibiotic treatment against suspicion of salpingitis. Take a cytology-sample from the cervix, remove the IUD, take a blood sample for serum CA 125 levels. Refer her to a gynecologist for further assessment. Take a biopsy from the endometrium (pipelle) and a blood sample for biomarkers in regard to ovarian cancer, and refer her to a gynecologist for further assessment. Del 8: Maria, 52 years, para2, comes to your office for regular cervical screening and removal of an IUD. She complains about irregular menstrual bleeding. She feels constipated and complains about fatigue, but thinks her problems may be related to menopause and to the fact that her older sister recently was diagnosed with cancer of the breast. Upon genitourinary examination you palpate a mass on the right side of the pelvis. Maria is referred to a gynecology department with clinical suspicion of ovarian cancer. She has increased levels of CA 125 and HE4, and normal CEA level. The pelvis mass is found to be a partially cystic ovarian tumor, with tumor growth shown on the ovarian surface. A section from the tumor is submitted to microscopy.

6 Side 28 av 63 When looking at the microscopic pictures, which two of the following statements are true? The tumor cells look typically mucinous The tumor cells are highly pleomorphic The tumor cells are highly atypical The tumor cells grow highly differentiated, with minor atypia The tumor cell appearance indicate a seminoma (dysgerminoma) in the ovary The tumor cells are highly pleomorphic The tumor cells are highly atypical Del 9: Maria, 52 years, para2, comes to your office for regular cervical screening and removal of an IUD. She complains about irregular menstrual bleeding. She feels constipated and complains about fatigue, but thinks her problems may be related to menopause and to the fact that her older sister recently was diagnosed with cancer of the breast. Upon genitourinary examination you palpate a mass on the right side of the pelvis. Maria is referred to a gynecology department with clinical suspicion of ovarian cancer. She has increased levels of CA 125 and HE4, and normal CEA level. The pelvis mass is found to be a partially cystic ovarian tumor, with tumor growth shown on the ovarian surface. A section from the tumor is submitted to microscopy. The tumor cells are highly pleomorphic and atypical.

7 Side 29 av 63 What is the diagnosis? Mucinous cystadenoma. Serous cystadenoma. Serous adenocarcinoma, high-grade. Mature teratoma Malignant granulosa cell tumor. Seminoma of the ovary (dysgerminoma) Serous adenocarcinoma, high-grade.

8 Side 30 av 63 Del 10: Maria, 52 years, para2, comes to your office for regular cervical screening and removal of an IUD. She complains about irregular menstrual bleeding. She feels constipated and complains about fatigue, but thinks her problems may be related to menopause and to the fact that her older sister recently was diagnosed with cancer of the breast. Upon genitourinary examination you palpate a mass on the right side of the pelvis. Maria is referred to a gynecology department with clinical suspicion of ovarian cancer. She has increased levels of CA 125 and HE4, and normal CEA level. The pelvis mass is found to be a partially cystic ovarian tumor, with tumor growth shown on the ovarian surface. A section from the tumor is submitted to microscopy. The tumor cells are highly pleomorphic and atypical. Maria has a high-grade serous adenocarcinoma. Which two statements are true regarding serous carcinomas of the ovaries? High-grade serous adenocarcinomas all have their origin in the ovarian surface epithelium. High-grade serous adenocarcinomas may have their origin in atypical epithelial cells in the tubal fimbria. The risk for developing high-grade serous adenocarcinoma is lower for women who have many ovulations. Women with germline BRCA1 or BRCA2 mutations have increased risk for developing high-grade serous adenocarcinoma. The prognosis is not altered if the tumor grows on the ovarian surface. High-grade serous adenocarcinomas may have their origin in atypical epithelial cells in the tubal fimbria. Women with germline BRCA1 or BRCA2 mutations have increased risk for developing high-grade serous adenocarcinoma. Del 11: Maria, 52 years, para2, comes to your office for regular cervical screening and removal of an IUD. She complains about irregular menstrual bleeding. She feels constipated and complains about fatigue, but thinks her problems may be related to menopause and to the fact that her older sister recently was diagnosed with cancer of the breast. Upon genitourinary examination you palpate a mass on the right side of the pelvis. Maria is referred to a gynecology department with clinical suspicion of ovarian cancer. She has increased levels of CA 125 and HE4, and normal CEA level. The pelvis mass is found to be a partially cystic ovarian tumor, with tumor growth shown on the ovarian surface. A section from the tumor is submitted to microscopy. The tumor cells are highly pleomorphic and atypical. Maria has a high-grade serous adenocarcinoma. High-grade serous adenocarcinomas have their origin in atypical epithelial cells in the tubal fimbria and women with germline BRCA1 or BRCA2 mutations have increased risk for developing this tumor. An ascites is suspected. Which are the most likely reasons for ascites in this case? Consider each symptom. Production of fluid by tumor cells [Nedtrekkliste] Increased production of fluid by serosal cells [Nedtrekkliste] Metastases to the liver [Nedtrekkliste] Tumor plugging of vessels in the hilar region of the liver [Nedtrekkliste] Carcinomatosis in the abdomen [Nedtrekkliste] Nedtrekkliste: Correct Incorrect Production of fluid by tumor cells = Correct

9 Side 31 av 63 Increased production of fluid by serosal cells = Correct Metastases to the liver = Incorrect Tumor plugging of vessels in the hilar region of the liver = Carcinomatosis in the abdomen = Correct Incorrect Del 12: Maria, 52 years, para2, comes to your office for regular cervical screening and removal of an IUD. She complains about irregular menstrual bleeding. She feels constipated and complains about fatigue, but thinks her problems may be related to menopause and to the fact that her older sister recently was diagnosed with cancer of the breast. Upon genitourinary examination you palpate a mass on the right side of the pelvis. Maria is referred to a gynecology department with clinical suspicion of ovarian cancer. She has increased levels of CA 125 and HE4, and normal CEA level. The pelvis mass is found to be a partially cystic ovarian tumor, with tumor growth shown on the ovarian surface. A section from the tumor is submitted to microscopy. The tumor cells are highly pleomorphic and atypical. Maria has a high-grade serous adenocarcinoma. High-grade serous adenocarcinomas have their origin in atypical epithelial cells in the tubal fimbria and women with germline BRCA1 or BRCA2 mutations have increased risk for developing this tumor. An ascites is suspected. Increased production of fluid by tumor cells and serosal cells, and a diagnosis of carcinomatosis are likely causes of ascites. Which group of tumors does the high-grade serous carcinoma belongs to? Germ cell tumors Non-seminomas (dysgerminoma) Sex-cord stromal tumors Epithelial stromal tumors Sarcomas Primitive, blue cell tumors Epithelial stromal tumors

10 Side 61 av 63 Oppgave: MED5600_OPPGAVE11_V18_ORD Del 1: Medical ethics, non-sequential questions Within the context of global research, choose the two correct statements: Informed consent is primarily meant to protect the researcher and the institution from a lawsuit; Informed consent is a tool meant to respect the participant's autonomy. Informed consent may be justifiably waived (given up) due to reasons of social value. Informed consent must be guided by respect for the knowledge and voluntariness of the research participants. For reasons related to cultural differences between countries, it may be acceptable to waive (give up) individual informed consent. Informed consent is a tool meant to respect the participant's autonomy. Informed consent must be guided by respect for the knowledge and voluntariness of the research participants. Spørsmål 2: Within the context of global research, choose the two correct statements: The Fair Benefits approach ensures post-trial access to drugs and takes into account the powerdifferential between the contracting partners. Responsiveness refers to the principle that, prior to a clinical trial, the sponsor/principal investigator must ensure that potential benefits are shared to the research participants after the study. Post-trial access requires the pre-trial consideration and planning of how potential benefits may be shared with trial participants/population. Responsiveness requires the sponsor/clinical investigator to know the national need for an intervention in a country prior to performing the clinical trial there. The TRIPS Agreement, which sets out requirements for Intellectual Property rights, ensures post-trial access to study drugs in low and middle-income countries. Post-trial access requires the pre-trial consideration and planning of how potential benefits may be shared with trial participants/population. Responsiveness requires the sponsor/clinical investigator to know the national need for an intervention in a country prior to performing the clinical trial there. Spørsmål 3: Empathy is an important capacity in clinical medicine. Why is this so? Choose the two most correct answers. Empathy connects the physician and the patient. Empathy is crucial in creating a therapeutic relationship. Empathy provides an access to the experiences and personal perspectives of the patient. Empathy consists of affective and cognitive components and facilitates moral motivation. Empathy is to put oneself in the shoes of another person Empathy enforces moral responsibility in the clinical encounter Empathy provides an access to the experiences and personal perspectives of the patient. Empathy consists of affective and cognitive components and facilitates moral motivation.

11 Side 62 av 63 Del 2: General practice, non-sequential questions about breastfeeding. What is the name of the milk produced the first 3 days postpartum? Hindmilk Colostrum Foremilk Premilk Colostrum Spørsmål 2: How often is it recommended that the baby feeds the first days and weeks of life? Every 3 hours Every 2 hours 8-12 times a day Whenever the child cries 8-12 times a day Spørsmål 3: Which two statements are correct? Breastfeeding is not compatible with the mother taking antibiotics treating mastitis. The baby may suck from the breast even if the mother has mastitis caused by MRSA. Amoxicillin is the first-choice antibiotic for treatment of mastitis. Ibuprofen may not be used as a painkiller while breastfeeding. Dicloxacillin is the first-choice antibiotic for treatment of mastitis. The baby may suck from the breast even if the mother has mastitis caused by MRSA. Dicloxacillin is the first-choice antibiotic for treatment of mastitis. Spørsmål 4: 3-4 days postpartum most mothers experience painful swelling of the breasts. This is called lactogenesis 2 and happens when the production of mature milk starts. What causes the swelling of the breasts? Infection. Excessive milk in the breasts and milk stasis. Venous and lymphatic stasis. Growth of the milk ducts Venous and lymphatic stasis. Spørsmål 5: How do you differentiate between an inflammatory and an infectious mastitis? Infectious mastitis is usually preceded by other breastfeeding problems. In infectious mastitis the CRP is more than 100.

12 Side 63 av 63 In infectious mastitis there is always pus in the milk. In infectious mastitis the CRP is more than 50. Infectious mastitis is usually preceded by other breastfeeding problems. Spørsmål 6: What is the primary treatment of a lactational mastitis? Antibiotics Emptying of the breast every second hour Painkillers and avoid touching the breast Stop breastfeeding Emptying of the breast every second hour