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MRCOG PART 2 SBAs and EMQs

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EMQ1470
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essay 363

essay 363 Posted by Shradha G.

sorry Paul,

The answer to essay 363, you marked  in forum is not mine.And essay 360 also was submitted by me in time, but not marked.Please look into the matter

essay 363 Posted by Shradha G.

A) Clinical assessment include thorough history regarding any previous episode of blood stained vaginal discharge since menopause, anorexia, weight loss. Ask if early menarche and late menopause, PCOS (unopposed estrogen exposure)were present or not which are risk factors for endometrial cancer and also of diabetes, hypertension, obesity, nulliparity, family history of endometrial, breast cancer.

Drug history is of paramount importance;if on HRT( unopposed estrogen) due to menopausal symptoms, tamoxifen for breast cancer which may lead to endometrial hyperplasia and anticoagulants( lead to increased APTT). Ask if this is post-coital bleeding,(cervicitis/Ca Cx) or associated with itching in vagina, dyspareunia (atrophic vaginitis). h/o purulent discharge( senile endometritis), coagulopathy has to be asked.

Associated features of bladder pain, hematuria, dysuria has to be asked to rule out pathology of bladder and constipation , rectal bleeding should be enquired to rule out piles,rectal carcinoma. H/o of previous smears and their report has to be asked. Past treatment history has to be asked of cervical cauterisation,LLETZ,LEEP, cervical/endometrial polypectomy, hysterectomy( granulation tissue at vault leads to bleeding) as there may be recurrence of those lesions.

Examination include general examination ; BMI, BP measurement, pallor(estimation of blood loss), icterus(any metastasis to liver), supraclavicular and inguinal lymphadenopathy( advanced stage of endometrial cancer) Abdominopelvic examination has to be done, to look for any palpable abdominal mass, its consistency (hard s/o malignant and cystic s/o benign pathology),mobility, margins, tenderness.(fixed,irregular margins, s/o malignancy) and associated ascites .

Local genitalia examination – look for urethral caruncle ,piles ( Bladder and bowel origin of bleeding needs to be ruled out).Sterile per speculum examination has to be done to look for the atrophic changes in vagina, cervicitis, erosion,cervical polyp. Take endometrial sample with Vibra aspirator during clinical assessment. Bimanual pelvic examination has to be done to assess the size of uterus, consistency, adnexal mass and its mobility.

 

B) On diagnosis of endometrial adenocarcinoma,if surgical fitness is there; definitive treatment is Staging laparotomy followed by TAH + BSO, pelvic and paraortic lymphnode sampling, peritoneal washing and peritoneal biopsy.

On frozen section if cervical stromal(stage II) involvement is present, do paraortic and pelvic lymphadenectomy. Post-op adjuvant radiotherapy is given in form of intracavitary and external radiotherapy to decrese regional recurrence . For Stage Ia i.e, no or < 50% myometrial involvement, no post-op radiotherapy is required. Patient has to be kept in close follow-up regarding recurrence of any metastasis.

For stage III- inoperable cases due to extension of tumour to pelvic wall, intracavitary and external radiotherapy is given. Chemotherapy with doxorubicin+ cisplatin or granulocyte colony stimulating factor can also be used if not fit for radiotherapy. If the patient is not fit for surgery and stage IVB(distant metastasis) start her on high dose progestogen- 100-200mg medroxyprogesterone in divided doses. For stage IVA palliative treatment by radiotherapy is given.

Social support by local authorities and written information leaflets should be provided to the patient.

   

This is my answer to essay 363, by mistake you marked sombody's else. Please mark iit!!