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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3017_Библиотеки_им_академика_М_И_Перельмана
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142 Diagnostic EMQs
2. C. Ectopic pregnancy
This patient presents with a positive urine HCG and an empty uterus. She also
has severe abdominal pain and evidence of internal bleeding (hypotension and
tachycardia).
3. G. Postpartum haemorrhage
This is a serious, life-threatening complication of child birth. This patient has
presented with evidence of an atonic uterus, a major contributing factor to post-
partum haemorrhage.
4. F. Placenta praevia
This is where the placenta implants itself at the base of the uterus above the cer-
vix, preventing vaginal delivery. Patients typically present with painless vaginal
bleeding in the third trimester.
5. J. Prolapsed umbilical cord
When the cord is prolapsed, it may be squeezed between the baby and the womb
during contractions, this reduces oxygen supply to the fetus and is an obstetric
emergency. The heart rate of child will typically slow after the waters break.
Dysmenorrhoea
1. F. Fibroid
Also known as leiomyomas this patient has a typical ultrasound ndings of a
uterine broid. They are a common cause of menorrhagia.
2. E. Endometriosis
This occurs when tissue similar to that which lines the uterus is found growing
outside of the uterus. Patients typically complain of pain with menses. Diagno-
sis is conrmed with laparoscopy.
3. C. Cervical stenosis
This is a possible complication of LLETZ procedure.
4. J. Pelvic inammatory disease
This occurs when a vaginal infection passes to the cervix, the uterus and fal-
lopian tubes. The most common causes of this presentation are chlamydia and
gonorrhoea.
6. D. Ectopic pregnancy
This patient presents with a positive urine HCG and an empty uterus. She also
has severe abdominal pain and vaginal bleeding.
Sexually Transmitted Infection 1
1. C. Chlamydia trachomatis
This is a common sexually transmitted infection which in women can cause
damage to the reproductive system and cause difculties with fertility.
2. A. Bacterial vaginosis
This condition results in inammatory changes of the vagina as a result of over-
growth of bacteria, which is normally found within the vagina. Typical features
include vaginal irritation, dysuria and foul-smelling discharge.
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Women’s and Sexual Health 143
3. G. Human papillomavirus
This is a very common sexually transmitted infection which can be asymptom-
atic. Human papillomavirus results in genital warts and can cause cervical cancer.
4. E. Genital herpes
This is a sexually transmitted infection which results in painful vesicular
lesions. It is caused by the herpes simplex virus.
Sexually Transmitted Infection 2
1. J. Trichomoniasis
This is a common sexually transmitted infection caused by Trichomonas vag-
inalis, a protozoan parasite. This patient presents with vaginal itch and dis-
charge. Speculum examination reveals a strawberry cervix which is a sign that
is very common with this infection.
2. F. Gonorrhoea
This is a sexually transmitted infection caused by the bacterium Neisseria gon-
orrhoea. This patient has presented with classic symptoms of gonorrhoea infec-
tion including penile discharge, dysuria and testicular pain.
3. B. Candidiasis
This is a condition in which there is overgrowth of yeast within the vagina.
Women present with symptoms including itch, burning sensations and vaginal
discharge which is typically described as being of a cottage cheese appearance.
4. I. Syphilis
This is a sexually transmitted infection caused by a bacteria called Treponema
pallidum. This patient has presented with symptoms consistent with syphilis,
including primary chancre on his penis and lymph node enlargement.
Genetic disorders 1
1. F. Marfan syndrome
This condition is inherited as an autosomal dominant trait.
2. B. Down syndrome (Trisomy 21)
This is a genetic condition in which a child is born with an additional copy of
chromosome 21.
3. J. Williams syndrome
This is a genetic condition caused by deletion of genes on chromosome 7.
4. D. Fragile X syndrome
This is a genetic condition caused by a change to one of the genes on the X
chromosome. Patients with this condition typically present with intellectual
disabilities.
Genetic disorders 2
1. G. Noonan syndrome
This is a genetic condition caused by mutation in the PTPN11 gene on chromo-
some 12.
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144 Diagnostic EMQs
2. E. Klinefelter syndrome (XXY)
This is a genetic condition in which males are born with an additional copy of
the X chromosome.
3. I. Turner’s syndrome
This is a genetic condition in females in which an X chromosome is completely
or partially absent.
4. A. Angelman syndrome
This is a genetic condition caused by a defect with chromosome 15.
Pelvic-Abdominal pain 1
1. K. Ruptured ectopic pregnancy
This patient presents with a positive urine HCG and an empty uterus. She also
has severe abdominal pain and evidence of internal bleeding (hypotension and
tachycardia).
2. E. Mittelschmerz
Also known as ovulation pain this occurs midway through a woman’s men-
strual cycle.
3. L. Ruptured ovarian cyst
These are a common cause of acute pelvic pain in pre-menopausal women.
Cysts usually do not cause patients to become symptomatic but can rupture
after strenuous physical activity or sexual intercourse.
4. A. Appendicitis
The pain of appendicitis commences around the umbilicus and eventually radi-
ates to the right iliac fossa as a result of peritoneal irritation.
5. D. Endometritis
This condition results from inammation of the lining of the uterus. This con-
dition can be associated with retained products of conception after surgical
termination of pregnancy.
Pelvic-Abdominal pain 2
1. F. Ovarian hyperstimulation syndrome
This is a complication of assisted reproduction treatment. As a result of hor-
mone therapy, the ovaries swell and become painful.
2. C. Endometriosis
In this condition the tissue which normally lines the uterus, known as the
endometrium, grows outside of the uterus. This can cause signicantly painful
menstrual cycles as a result of peritoneal irritation. Endometrial nodules in the
pouch of Douglas are a common nding.
3. G. Ovarian torsion
Common ultrasound ndings are ovarian swelling, decreased or absent venous
ow, free pelvic uid and there may be a positive follicular ring sign.
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Women’s and Sexual Health 145
4. J. Renal calculus
Renal calculi are hard deposits that form within the kidney. Passage of stones
can be quite painful; the pain is usually described as being in loin to groin
distribution.
5. H. Pelvic inammatory disease
This occurs when a vaginal infection passes to the cervix, the uterus and fal-
lopian tubes. The most common causes of this presentation are chlamydia and
gonorrhoea.
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146 DOI: 10.1201/9781003459941-6
6
Urology
PENIS DISORDERS
A. Balanitis xerotica obliterans
B. Epispadias
C. Hirsutoid papillomas
D. Hypospadias
E. Lichen planus
F. Paraphimosis
G. Penile fracture
H. Penile Mondor’s disease
I. Penile wart
J. Peyronie’s disease
K. Phimosis
L. Priapism
For each of the following, what is the MOST likely diagnosis?
1. A 37-year-old male presents to your emergency department with acute onset
severe pain in his penis for the past two hours. During a particularly rough epi-
sode of coitus his penis withdrew and on trying to attempt vaginal penetration
he heard a cracking sound as his partner pushed up against it, this was followed
by detumescence.
2. A 3-year-old boy is brought into your emergency department with painful
swelling in his glans for the past six hours. His mother tells you that she has
been unable to protract his foreskin after he pulled it back while playing in the
bath at home. On examination the glans is congested and enlarged with a collar
of swollen foreskin at the base of the glans.
3. A 3-year-old is brought by his mother. She is concerned as she has not been able
to retract his foreskin while showering him. When he urinates, she has noticed
ballooning of his foreskin.
4. A mother brings in a 6-month-old who has been urinating irregularly. There seems
to be urine exiting from the underside of his penis. On examination you note an
opening in the ventral surface of the penis between the glans and the scrotum.
5. A woman has just given birth to a male child who you are asked to review. On
examination you nd an opening in the ventral surface of the penis, shortly
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Urology 147
after observing this the child begins to passage urine through it. The remainder
of the examination is unremarkable.
6. A 21-year-old man presents with a one-week history of dorsal induration. He
reports that he has had a constant ache and throbbing sensation in the penis for
the duration. He has no systemic symptoms and reports he has been otherwise
well. On examination there is a rope like cord which is palpable on the dorsum
of the penis proximally.
7. A 36-year-old uncircumcised male presents to your clinic complaining of dif-
culty urinating. He reports that his stream is crooked and he has also noted
changes on his penis. On examination the glans of the penis appears white
in color, rm and scarred, particularly around the meatus which appears
stenosed.
See page 154 for answers.
TESTICULAR AND SCROTAL
DISORDERS 1
A. Alcock canal syndrome
B. Angiokeratoma of Fordyce
C. Candidal intertrigo
D. Fournier’s gangrene
E. Gumma of the testis
F. Henoch–Schönlein purpura
G. Hydrocele
H. Epididymo-Orchitis
I. Male genital dysaesthesia
J. Retractile testicle
K. Scrotal abscess
L. Scrotal calcinosis
M. Seminoma
N. Sperm granuloma
O. Spermatocele
P. Teratoma
Q. Testicular torsion
R. Tinea cruris
S. Torsion of hydatid of Morgagni
T. Undescended testicle
U. Varicocele
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148 Diagnostic EMQs
For each of the following, what is the MOST likely diagnosis?
1. A 6-year-old boy presents to your emergency department with acute swelling
and pain in the left hemi-scrotum associated with macroscopic haematuria. On
examination there is scrotal swelling and the testicles are easily palpable, non-
tender and of normal size. You note that he has a non-blanching rash over his
left scrotum, buttocks and extensor surfaces of the lower limbs.
2. A 42-year-old man presents to your GP clinic concerned about a lump above
his left testicle. He has no recent illness and has no signicant medical history.
On examination there is a non-tender uctuant swelling in the upper part of the
posterior left testicle. The right and left testes are easily palpable.
3. A 28-year-old male presents to your clinic complaining of a two-day history of
scrotal pain and swelling. On examination he has a temperature of 38.1°C and
there is an erythematous, tender, uctuant mass measuring 3cm on the right
hemi-scrotum.
4. A mother brings a 3-month-old infant to your clinic. She is concerned as she
could not palpate his testicles when she was changing his nappy the day prior to
attendance. On examination you palpate a single testicle in the scrotum, you are
able to coax the second testicle into the scrotum with gentle palpation.
5. A 26-year-old male presents with a painless swollen right testicle. He explains
that it has progressively enlarged over the past month and he is concerned. On
examination there is uctuation, the testicle is not palpable and there is positive
transillumination.
6. A 13-year-old male presents to your emergency department with severe pain in
his right scrotum which radiates to right lower quadrant abdomen. His symp-
toms started suddenly 45 minutes prior; he has vomited twice in your assess-
ment bay. His mother reports that he was born with a bell clapper deformity
affecting both testicles. On examination Prehn’s sign is negative and the crem-
asteric reex is absent.
See pages 154–155 for answers.
TESTICULAR AND SCROTAL DISORDERS 2
A. Alcock canal syndrome
B. Angiokeratoma of Fordyce
C. Candidal intertrigo
D. Fournier’s gangrene
E. Gumma of the testis
F. Henoch–Schönlein purpura
G. Hydrocele
H. Epididymo-Orchitis
I. Male genital dysaesthesia
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Urology 149
J. Retractile testicle
K. Scrotal abscess
L. Scrotal calcinosis
M. Seminoma
N. Sperm granuloma
O. Spermatocele
P. Teratoma
Q. Testicular torsion
R. Tinea cruris
S. Torsion of hydatid of Morgagni
T. Undescended testicle
U. Varicocele
For each of the following, what is the MOST likely diagnosis?
1. A 42-year-old man presents with a two-week history of swelling and pain in
the left testicle. The pain commenced ve days ago. On questioning he reports
that he has had multiple male partners over the past 12 months. Examination
reveals a left testicle which has a “billiard ball” like hard consistency and ingui-
nal lymph node enlargement in bilateral groins. An EIA is initially requested
and this returns reactive, a diagnosis is subsequently conrmed with a positive
RPR.
2. A 39-year-old male presents to your clinic complaining of non-painful nodules
in the left side of his scrotum. The lumps started as small nodules but have pro-
gressively enlarged over the past eight months. He has no history of trauma and
has been with the same sexual partner for ve years. On examination he has a
temperature of 36.7°C, you observe two nodules in the left hemi-scrotum which
are yellow in color and measure 0.3cm and 0.2cm. The nodules are hard, rm
and there is no surrounding erythema.
3. A 10-year-old boy presents with a 12-hour history of pain in the left testicle. He
has no history of trauma or recent illness. On examination there is a blue tender
lump at the upper pole of the left testicle.
4. A 27-year-old male presents to your clinic with a three-month history of rash
on his left hemi-scrotum and groin which is very itchy. It started off as a small
area but has progressively increased. On examination there is a well demarcated
scaly plaque with raised borders and central clearing which extends from the
left groin into the scrotum.
5. A 38-year-old male presents to your clinic concerned about a lump he has
noticed in his right testicle. He has had a loss of appetite and has lost 5 kg in the
past three months. He had an undescended testicle as a child and had surgery
to correct this, otherwise he has no signicant medical history. On examination
you can palpate a hard painless lump in the right testicle. You arrange for labo-
ratory investigations which reveal a normal AFP and a slightly elevated HCG.
See page 155 for answers.
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150 Diagnostic EMQs
TESTICULAR AND SCROTAL
DISORDERS 3
A. Alcock canal syndrome
B. Angiokeratoma of Fordyce
C. Candidal intertrigo
D. Fournier’s gangrene
E. Gumma of the testis
F. Henoch–Schönlein purpura
G. Hydrocele
H. Epididymo-Orchitis
I. Male genital dysaesthesia
J. Retractile testicle
K. Scrotal abscess
L. Scrotal calcinosis
M. Seminoma
N. Sperm granuloma
O. Spermatocele
P. Teratoma
Q. Testicular torsion
R. Tinea cruris
S. Torsion of hydatid of Morgagni
T. Undescended testicle
U. Varicocele
For each of the following, what is the MOST likely diagnosis?
1. A 54-year-old obese, diabetic male presents to your clinic complaining of a
four-week history of itch in his right groin extending onto his scrotum. On
examination there are multiple erythematous and macerated plaques in the right
groin extending to the right hemi-scrotum. You also note peripheral scaling and
satellite papules.
2. A 39-year-old man presents with swelling in his left hemi-scrotum. On exami-
nation there is swelling on the left side which on palpation feels like a “bag of
worms”; the swelling decreases in size when he is supine.
3. A 37-year-old male attends your clinic as he is concerned about some spots
which he has noticed on his scrotum which are bumpy and rough to touch. On
examination of his scrotum, you note three dark purple papules, measuring
3mm at most, with a rough surface.
4. A 65-year-old obese, type 2 diabetic presents to your emergency department
complaining of a three-hour history of severe pain in the left hemi-scrotum. On
examination he has a temperature of 38.6°C and you note an area of dark red
skin measuring 2cm in diameter in the left hemi-scrotum. The area of concern
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Urology 151
is extremely tender to palpation and the tenderness extends beyond the border
of the demarcated erythema; you also note crepitus.
5. A 21-year-old male presents with a left sided testicular lump. He noticed it yes-
terday while showering and reports that he is otherwise well. He is concerned
as his father had testicular cancer. He had an undescended testicle as a child. On
examination you note an irregular hard painless lump in the left testicle. You
arrange for laboratory investigations which reveal elevated AFP and HCG.
6. A 35-year-old competitive long-distance cyclist presents to your clinic com-
plaining of recurrent and prolonged pain in the penis and scrotum while sitting
down. He reports that his symptoms are relieved by standing. He also reports
that he has been experiencing similar pain during intercourse.
See pages 155–156 for answers.
UROLOGY 1
A. Acute interstitial nephritis
B. Acute post-streptococcal glomerulonephritis
C. Acute prostatitis
D. Acute tubular necrosis
E. Benign prostatic hyperplasia
F. Chronic prostatitis
G. Cystitis
H. IgA nephropathy
I. Polycystic kidney disease
J. Prostate cancer
K. Pyelonephritis
L. Renal calculus
M. Renal cell carcinoma
N. Wilms tumor
For each of the following, what is the MOST likely diagnosis?
1. A 39-year-old man presents with worsening right ank pain for the past three
months. He explains that he also suffers from night sweats and has lost 8 kg
during this time. He has no signicant medical history and is not using any
medication. On examination he has a palpable mass in the right ank. Urine
dipstick reveals microscopic haematuria.
2. A 67-year-old male attends your clinic complaining of a three-month history
of difculty with initiation of micturition, when it does get started, he reports
dribbling and a feeling of incomplete emptying of the bladder. He noticed some
blood in his urine the other day. He denies any associated pain and has no loss
of appetite or weight.
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