Clinical Flashcards
60 years old,female, smoker patient in the ward for preoperative preparation for abdominal hysterectomy due to endometrial carcinoma. Which investigation of the following you don’t require?
-Chest X ray
-Complete blood film
-Coagulation profile
-Cross match and saving
-ECG
Coagulation profile
What recreational drug may cause an MI?
Cocaine
Management of Hb 6.2
O neg blood immediately
/ vs crossmatch 2 units
Patient with an old MI Infarct - ECG finding
Pathological Q wave
4 year history of infertility, severe dysmenorrhea and increasing pain with sexual intercourse. O/E: adnexal mass is felt and nodules are palpated along the uterosacral ligaments. Diagnosis?
Endometriosis
Superficial burn; severely painful and blistered. Which layer is involved?
Superficial layer of the dermis
Uterus is empty on scan and the level of beta hcg decreases
Complete miscarriage
Complete - all products expelled
Inevitable - cramping + open cx
Missed - non viable foetus, products inside still
How can you monitor opioid toxicity?
Respiratory rate
Pregnant patient (with sickle cell) presents with generalised pruritus, LFTs normal, Serum bile acids elevated. Dx?
Obstetric cholestasis
Megaloblastic anaemia is caused by which vitamin deficiency?
Folic Acid and B12
BIG B12 and Folate (macrocytic)
A patient with primary infertility, presents with 3 months amenorrhea, elevated FSH and prolactin, Bhcg positive
Pregnant
In a pregnant woman suspected to have pulmonary embolism. Investigation of choice?
VQ scan
(CT not on the list)
Best screening method for hemolytic anaemia
FBC
What is the clinical finding in an incomplete miscarriage
Cervix with open os
in a 25 years old lady with 4 previous miscarriages , the most useful investigation would be:
Thrombophilia screen
a pregnant women in first trimester has nausea and vomiting with 4+ ketone in urine, the correct management
IV fluids and antiemetic as inpatient
FBS
Normal
Borderline
Abnormal
In exam example e.g. FBS is 7.23
Normal >7.25
Repeat FBS in 1h if CTG still abnormal
*Borderline [in between]
Repeat FBS in 30 mins
Abnormal <7.2
Consider delivery
Recommended method for delivery of placenta
Controlled cord contraction
Patient post date admitted for induction of labour with PG, ARM + oxytocin
Oxytocin given for 6 hrs
Then she developed hyponatraemia what is cause?
Excess oxytocin
Stimulates ADH receptor on kidney
Water retention and hyponatraemia
(iatrogenic)
Obstetric cholestasis - what vitamin treatment?
Vitamin K
~Prevents bleeding
On USS:
Hypoechoic area in the uterus
Bilateral adnexa clear
What is this caused by?
Fibroid?
Patient with fever on 2nd post operative day with increased pulmonary vascular markings and pleural effusions. Dx?
Pulmonary oedema
Cause of acute haemolytic reaction in blood transfusion
ABO incompatability
36/40 describes gush of fluid, not in labour. What should NOT be part of the examination
PV exam
(risk infection)
Perimenopausal, 44y/o with no periods. Wants to stop taking contraception (POP). FSH is 20. When should the FSH be repeated?
Internet says about 6 weeks
First investigation in pleuritic chest pain, SOB
CXR
Which is not a recognised sign of imminent eclampsia:
a. Headache
b. Epigastric pain
c. Blurred vision
d. Decreased fetal movement
e. Hypertension
HTN (?)
Complete mole on USS initial management
Suction curettage and bhcg in 48h
Risk of miscarriage at 30y/o
10%
What is normal variability
5-25bpm
Which test predicts preterm birth between 22 and 35 weeks of gestation
foetal fibronectin
What constitutes normal semen analysis
Vol
pH:
Sperm concentration: million/ml
Total sperm/ejaculate: million
Total motility: %
Progressive motility: %
Vitality: %
Morphology: %
Vol 1.5 ml
pH: 7.2
Sperm concentration: 15 million/ml
Total sperm/ejaculate: 39 million
Total motility: 40%
Progressive motility: 32%
Vitality: 58%
Morphology: 4%
Fraser’s Law - describe
Dr should encourage girl age 16 or less to tell her parents she is starting contraception.
Patient seen after hysterectomy with Hb 6.2g/dl, hematocrit 29%, Blood pressure 80/90, pulse 109 bpm. Cause?
Internal bleeding
5 weeks since last menses. Patient presents with mild vaginal bleeding. US shows no evidence of intrauterine pregnancy. beta Hcg is 400 IU and after 48hrs beta Hcg is 700 IU . What is the most likely diagnosis?
Normal pregnancy (?)
HCG has increased by >63% in 48h
Repeat scan when HCG >1500
(If it falls by 50% then likely failing)
Patient with 9cm dilated cervix and intact membranes. CTG is reactive since the last exam 2hrs ago. What is the next action?
Leave for another 2hr
(4h between assessments)
Postpartum haemorrage after vaginal delivery. pharmaceutically failed to stop bleed. What is the first surgical step to stop bleeding?
Intrauterine balloon tamponade
Medical treatment of ectopic pregnancy
Methotrexate
Early pregnancy with irregular cycle with vaginal bleeding. Urine pregnancy test is positive. Her LMP 5 weeks ago. Transvaginal ultrasound shows CRL 6 mm and lntrauetrine gestational sac with fetal pole. There is no fetal heart beat. What is the next appropriate step?
Repeat U/S after 7-10 days
When no FH found, CRL must be >7mm
To diagnose miscarriage
CRL >7mm + no FH
Gestation sac > 25mm (with no yolk sac)
Kleihauer test is used to determine ?
Fetomaternal haemorrhage
How do you calculate Apgar score?
(score is 0-10)
Appearance: 1 peripheral cyanosis
*Pulse: 1<100 / 2 >100
Grimace: 1 weak cry
Activity/tone: 1 some flexion
Respiration: 1slow irregular breath
Semen analysis
Vol 2.5ml
pH: 7.3
Sperm concentration: 32 million/ml
Progressive motility: 60%
Morphology: 5%
Liquefaction time 30 minutes
Interpretation?
Normal semen analysis
Minimum parameters:
Vol 1.5 ml
pH: 7.2
Sperm concentration: 15 million/ml
Progressive motility: 32%
Morphology: 4%
Where is cell-free fetal DNA in NIPT derived from
The placenta - trophoblast
CTG
Baseline 120-130
Normal variability
Few accelerations
Typical variable decelerations for >90 mins
Classification and management?
Suspicious CTG - observe closely
Teenager wants abortion without parents’ knowledge - which law/principle should be followed?
Fraser’s Law
Wernicke-Korsakoff syndrome Deficiency disease of vitamin?
Vitamin B1
What is affected in Horner syndrome?
Loss of sympathetic supply
Urodynamics interpretation
Increase in PVES and PDET
PABD stays same
Detrusor overactivity
(increased detrusor pressure)
Contrast with stress incontinence
Increased abdominal pressure (no detrusor activity)
Placement of cup during ventose delivery when the neck is flexed
Saggital
Pregnancy related nausea and vomiting uses PUQE index. What is the maximum score?
15
The most common dermatitis in pregnancy
Polymorphic (PUPP)
+ Obstetric Cholestasis
Vitamin E toxicity causes?
Haemorrhage
RTA with abdominal pain at term Rh negative. Management (specific)?
Anti D 500 iu
Incomplete early miscarriage, bleeding PV, refuse surgical intervention. Alternative main drug for medical management?
misoprostol
How long should patients with hyperemesis gravidarum have LMWH for?
Until discharge only
CTG normal, then changes to variability <5bpm Next management?
FBS
What depression screening questionnaire is frequently used during pregnancy?
Edinburgh Postnatal Depression Scale
CT KUB with blocked ureter in patient with history of cervical cancer
Ureteric obstruction
A 25-year-old woman presented to an early pregnancy unit with mild vaginal bleeding after 5 week’s amenorrhea. There is history of irregular menses. Ultrasound shows no evidence of intrauterine pregnancy. Beta hCG is 400 IU/l and beta hCG after 48hrs later is 700 IU/l. What is the most likely diagnosis?
Early normal pregnancy
HCG <700 can’t see on USS
Which is the most common cause of the premature ovarian failure?
Idiopathic
Telogen Effluvium (hair loss) is more pronounced in what stage of pregnancy?
After delivery
absent clitoris and normal labia majora. What type of FGM is this?
Type 1 FGM
1 - clitoris removed
2 - clitoris + labia minora +/- majora
3 - infibulation (narrowed Introitus)
4 - everything else (e.g. a nick/burn)
You see a patient who is 35 weeks pregnant in your day assessment unit. She presents with itching… more on the area of the abdominal striae. Lab results given which showed normal ALP, normal bilirubin levels. Diagnosis?
Polymorphic eruption of pregnancy
What part of the uterus is destroyed in ablation for menorrhagia?
Basal layer of the endometrium
What is the new non invasive prenatal diagnostic test of cell-free fetal DNA of maternal blood derived from?
Placental trophoblast
What is the most common site of endometriosis
Ovary
What is the most common form of fibroid degeneration?
Hyaline
31 yr old c/o subfertility for 2yrs , no medical problem , BMI 38kg/m2 , hormone result : FSH 8
LH 18
progesterone 4 nm m/l
E2 198
Most appropriate management
Weight loss
25 y/o had lscs at term for breech presentation with spinal anesthesia After what time you start low dose molecular heparin(LMWH)
?6 hours
Patient has a renal calculus, where is referred pain often felt?
Lumbar region
What is the process for a direct Coombs test?
Who gets this test?
Patient RBCs + anti-human globulin –> agglutination
Done on a newborn with jaundice
?haemolytic anaemia
What is the process for indirect Coombs test?
Who gets this test?
Patient serum + add test RBCs & anti-human globulin –> agglutination
Identifies free floating antibodies
Shows mother has antibodies to foetal RBCs and is sensitised
Woman with 3 previous children that had jaundice. She is O neg and her new partner in this pregnancy is A + with phenotype: CDe/cde.
? I think A pos or A negative
as ‘CDe’ is small chance of recessive
What is the risk of repeat ectopic after laparoscopy for ectopic?
18%
Pregnant patient develops a goitre, which nerve has been injured or compressed?
Recurrent laryngeal nerve
A patient with pre-eclampsia has an intracranial haemorrhage, which artery is affected?
Middle cerebral artery
ECG long QT
spasms
paraesthesia
Dx
Hypocalcaemia
Blood group O+
What antibodies do they have
AB antibodies
What is CRISPR
enzyme that cleaves DNA sequences
What gestational age are the two doses of anti D given at?
28 + 34 weeks
Lack of which vitamin causes pellagra?
Niacin (B3)
CtG picture G2P1 , term , mid wife noticed ctg showing variable deceleration for last 20 minutes rest ctg was reactive normal , p/v exm os 6 cm. Next step?
This may be a suspicious CTG
BUT doesn’t say whether there are ‘concerning characteristics’ of decels or whether with >/< 50% of contractions
Indications for FBS
1. Pathological CTG in labour (cervix dilated >3 cm)
2. Suspected acidosis in labour (cervix dilated >3 cm)
What is a good source of vitamin K
Green leafy vegetables
Intraoperative cell salavage blood loss during cesarean section (%)
20%
36h post op TAH, patient has a fever of 38 degrees. Why?
Physiological cytokine release
What is the shelf life of whole blood
7 weeks
What bile acid level is considered harmful to foetus and indication for delivery
> 40
What causes hypotension after an anaesthesia?
Blockade of preganglionic sympathetic nerves
HbAS identified at booking - what is the diagnosis?
Sickle cell trait
Baby born with intestines extending uncovered through a hole which is next to the umbilicus
Gastroschisis
Baby born with intestines extending covered through a hole in the umbilicus
Omphalocele
What are the two diagonal lines on a partograph?
Alert line
Action line
Vulval ulcers in someone who has not been sexually active?
Behchets
Oral, genital ulcers, anterior uveitis
An autoimmune vasculitis
DVT in previous pregnancy
Now 18/40 pregnant
Mx?
Start LMWH now
In an ongoing PPH, what should the fibrinogen level be maintained above?
2-4 micro L
What is an elevated FFN
> 50
FFN can be done between 22 - 35 weeks gestation
How many ml lidocaine can be given with adrenaline?
7mg / kg
What deficiency in hyperemesis gravidarum is dangerous?
B1 (thiamine) causes wercicke’s encephalopathy
Which vitamins break down homocysteine (an amino acid).
Without the vitamin you get high homocysteine
Folic acid
B12
B6
Caput medusi are due to engorgement of what vessel?
Umbilical vein
What speed is a CTG print out?
1cm per minute
Young girl with history of dysfunctional uterine bleeding. FBC + which other test?
Clotting profile
What is a normal post void bladder scan ?
<200mls
Missed COCP on day 12. What is your advice?
You need 7 active pills to be taken
1st week - emergency contraception
*2nd week (D8-14) - take extra pill only
3rd week - omit pill free interval
What are Filshie clips, used in tubal ligation, made of?
titanium
1 miscarriage, 1 still birth, 1 twin gest live birth at 36 weeks. How do you describe their gravidity and parity
G3P3 (?)
3 pregnancies
3 births / stillbirths
HCG measured 48h apart
What change indicates
1 - pregnancy unlikely to continue
2 - need for repeat review
3 - Likely intrauterine pregnancy
1 fail - decrease 50% - UPT in 14 days
2 - in between
3 ok - Increase by 63% - Scan when HCG >1500
According to RCOG, which progesterone levels suggest:
failing
intrauterine pregnancy
failing <20
intrauterine >60
Describe
Septate
Bicornuate
Didelphus
Septate - septum middle, convex outer
Bicornuate - two horns of uterus, heart shaped outer
Didelphus - complete duplication of uterine horns AND cervix
Describe Placenta
Succentiurate
Velamentous
Battledore
Succentiurate LOBE (extra lobe)
Velamentous - in the membranes
Battledore - insertion at the outer edge
What is the definition of a minor PPH
500-1000ml with no signs of shock
What drug is given to treat severe pre eclampsia in an asthmatic patient
Hydralazine
Below which centile of symphysis fundal height should women be referred for serial growth scans ?SGA
Below 10th centile
Prior to hysterectomy, patient is on POP, what additional contraception will you advise?
Barrier
(not sure why)
At what point can someone who had gestational trophoblastic disease begin taking COCP?
When the BHCG returns to normal and is not rising
How many weeks after a complete miscarriage should a pregnancy test be completed?
3 weeks (NHS website)
What does fibronectin bind to?
Integrins
(which are membrane receptors)
Deficiency of which electrolyte can cause paralytic ileus?
Potassium
At what gestation can placenta praaevia diagnosis be confirmed
32 weeks (?)
A patient has been on oestrogen only HRT for 5 years. What is their breast cancer risk?
Low risk or no risk (?)
