extra

Question 1

A 42-year-old Caucasian lady is referred to the gynaecology clinic as she has not had any periods in 8 months. She also complains of joint pains for the last 2 years as well as lethargy. Her past medical history is significant for diabetes diagnosed 4 months ago and early-stage liver fibrosis diagnosed 6 months ago. She has no other past medical history and has never consumed alcohol.

A hormone profile requested by the gynaecologist reveals low levels of FSH and LH.

Which of the following investigations should be performed next?

Answer 1

Iron studies

This patient has secondary amenorrhoea which is the cessation of menstruation for at least 6 months in a patient who had periods before. The symptoms of lethargy and history of recent diabetes together with liver fibrosis point towards a diagnosis of hereditary haemochromatosis. This is a primary disorder of iron overload and can cause amenorrhoea due to deposition of iron in the hypothalamus and ovaries. Iron studies would reveal elevated levels of serum iron, raised ferritin and raised transferrin saturation. Transferrin levels and total iron-binding capacity (TIBC) would be reduced

Question 2

AMH is hormone that serves as a marker of ovarian reserve.

decreased in what women

Answer 2

POI

Question 3

what is ashermans syndrome

Answer 3

Asherman’s syndrome is characterised by intrauterine adhesions commonly as a result of previous uterine surgery such as dilation and curettage. It can lead to obstruction to the menstrual outflow tract which presents as secondary amenorrhoea.

in this case, the cyclical abdominal pain may be a sign that menstruation is occurring.

Question 4

what is sheehan syndrome

Answer 4

Sheehan syndrome is hypopituitarism caused by ischaemic necrosis of the pituitary gland following excessive peri-partum blood loss. However, it is very rare in the developed world and the history is not consistent with this diagnosis

Question 5

most common type of vulvar cancer

Answer 5

squamous cell carcinomas.

Question 6

sx of vulvar cancer

Answer 6

Lump with or without lymphadenopathy
Itching
Non-healing ulcer
Vulval pain
Skin changes
Bleeding

Question 7

how long do you not need contraception for in postnatal period

Answer 7

first 3 weeks

Question 8

if you had a classic vertical. section can you have NVD after

Answer 8

no only if had LSCS

Question 9

A 76 year old man comes into the GP clinic with a complaint of erectile dysfunction. He is prescribed Viagra (sildenafil). Which of the following medications is contraindicated with concurrent use?

Answer 9

Sildenafil is a PDE5 inhibitor and leads to vasodilation of the peripheral vasculature leading to a drop in the blood pressure in a similar way to how nitrates work - cannot be taken together

Question 10

on examination of cervix in preg
a halo of red tissue around external os
blue ish tinge - increased blood flow
slit like apparance - pinpoint
is all nromal what is abnromal

Answer 10

odourless clear white watery fluid in posteriro vaginal vault - PPROm

Question 11

recognised complication of epidural

Answer 11

Maternal and foetal distress secondary to hypotension are a recognised complication

This is correct. Maternal hypotension can be a distressing complication from epidural anaesthesia. It can be treated with 1L Hartmann’s solution over 20 minutes

Question 12

how can maternal hypotension be treated in a distressing complication from epidural anaethesia

Answer 12

1L Hartmann’s solution over 20 minutes

Question 13

A 32 year old patient with a history of depression presents with four episodes of severe shooting pain on her right cheek. Cranial nerve examination is normal, but the patient complains of worsening pain on light touch in the same area.

Answer 13

trigmeninal neuralgia
treated with carbamazepine

Question 14

symptoms of local anaesthetic toxicity

Answer 14

Symptoms include the tinnitus, tremor, dizziness and paraesthesia seen in this patient

Question 15

diabetic neuropathy first line

Answer 15

duloxetine

Question 16

suxamethonium apnoea occurs in individuals who have a defect in

Answer 16

the enzymes (plasma cholinesterase) to metabolise suxamethonium leading to sustained action of the drug on the post-synaptic membrane of the neuromuscular junction

prolonged paralysis

Question 17

uterine rupture common is sudden onset abdo pain and loss of contractions especially in context of previous c section

Answer 17

emergence lapratomy

Question 18

cardiac disease - maternal, hypertension, pre-eclampsia or pre-existing renal disease can cause what in the baby

Answer 18

Due to the later onset of growth restriction, and the head circumference being reduced less than the abdominal circumference, this can be classed as asymmetrical IUGR. This is most commonly caused by maternal conditions such as hypertension, pre-eclampsia or pre-existing renal or cardiac disease. This can also be caused by maternal substance abuse.

Question 19

can a HIV positive patient have a normal vaginal delivery

Answer 19

If a patient has a viral load of <50 copies/ml and is taking multiple antiretroviral medications, they can be offered a vaginal delivery

Question 20

can a HIV positive patient have a normal vaginal delivery

Answer 20

If a patient has a viral load of <50 copies/ml and is taking multiple antiretroviral medications, they can be offered a vaginal delivery

Question 21

Intrahepatic cholestasis generally seen in third trimester. There is accumulation of bile salts in the serum. As a result it often involves pruritus in the palms and soles. Liver enzymes rarely rise above 250 u/l along with elevated bilirubin

Answer 21

Acute fatty liver of pregnancy is a rare complication of pregnancy but important to be aware of. It commonly occurs in the third trimester or immediately following delivery and is thought to be more common in nulliparous women as in the case of this patient. A typical patient will present with a few days history of general malaise, anorexia, vomiting, and jaundice. Pain in the right upper quadrant may sometimes be present. Blood results would show marked elevation of liver enzymes, prolonged PT, raised and bilirubin. Low platelets will be seen due to consumptive coagulopathy

nulliparous
follows delivery
RUQ
and raised LFTs

Question 22

iron deficiency anaemia no symtpoms what shoudl you be given

Answer 22

oral ferrosu sulpahte fumarate 200mg TDS
and checked HB in 2 weeks
remain on for at least 3 months

Question 23

B12 deficiency

Answer 23

IM cyanocobalamin 12mg

Question 24

what if fitz hugh curtis syndrome

Answer 24

Fitz–Hugh–Curtis syndrome is a complication of pelvic inflammatory disease where the liver capsule becomes inflamed, leading to the development of adhesions between the capsule and the surrounding peritoneum. This causes right upper quadrant pain, which can radiate up to the shoulder, alongside symptoms of pelvic inflammatory disease such as vaginal discharge and fever.

Question 25

The risk of malignancy (RMI) index is used to determine the risk category in a woman with suspected ovarian malignancy.

The RMI is a product of

Answer 25

ultrasound scan score, menopausal status and the serum CA125 level (IU/ml)
The ultrasound result is scored 1 point for each of the following characteristics: multilocular cysts, solid areas, metastases, ascites and bilateral lesions. U = 0 (for an ultrasound score of 0), U = 1 (for an ultrasound score of 1), U = 3 (for an ultrasound score of 2–5).

Question 26

kallmann syndrome main feature

Answer 26

no smell

lack of all secondary sex - so no breasts

Question 27

what is androgen-insensitivity syndrome

Answer 27

Androgen-insensitivity syndrome occurs when an individual has XY chromosomes (male sex), but their body does not respond to the androgen hormones that drive the development of the male body.
Hence, they have externally female characteristics but no female reproductive organs.
features - primary amenorrhoea, lack of secondary sexual characteristics (except for breast development), absence of female reproductive organs and a short vagina (sometimes described as ‘blind ending’).
Breast development still occurs because testosterone can be converted to oestrogen in the periphery to drive breast development, but it is not present in the reproductive system.

Question 28

bhcg readings

Answer 28

molar massive over 10000

When a pregnancy is not seen on an early scan, a β-hCG should be performed. If it is more than 1500 mIU/ml, the pregnancy should be treated as ectopic. If it is lower than this, the test will be repeated in 48 h and the two numbers compared. If the second reading is less than half of the first reading, it is most likely a miscarriage. If the second reading is more than double the first reading, it is most likely a viable pregnancy. If the second reading is between half and double the first reading, it should be treated as an ectopic pregnancy - which is the case for this woman.

Question 29

what contraceptive measure reduces pelvic pain in endometriosis

Answer 29

POP

Question 30

normally women do not have to take a withdrawl bleed whilst on the COCP what about with PCOS

Answer 30

Advice about the COCP has changed in recent years. While all women were initially advised not to take it continuously for more than 3 months, advice now states that it is safe to take it continuously without withdrawal bleeds. However, for patients with PCOS, they should still induce a withdrawal bleed at least once every 3 months to reduce the risk of endometrial cancer.

Question 31

what is chandlier sign

Answer 31

Chandelier sign

Chandelier sign is the informal name for cervical excitation, also known as cervical motion tenderness. Cervical excitation is a sign of inflammation of pelvic organs and/or peritoneum.
It is tested during a bimanual examination by pressing anteriorly on the cervix with one hand and on the fundus of the uterus with the other hand. This results in severe pain. It is commonly present in pelvic inflammatory disease (the most likely diagnosis here), and occasionally in ectopic pregnancy.

Question 32

what is chadwick sign

Answer 32

Chadwick’s sign refers to a blueish tinge to the cervix, which is seen in early pregnancy due to cyanosis and softening of the cervix

Question 33

A 50 year old woman presents to her GP with a 4 month history of irregular menstrual bleeding. She has not bled for 8 months prior. She is not sexually active and takes no regular medications.

What is the most appropriate first step in the management of this patient?

Answer 33

Arrange for transvaginal ultrasound

Whilst irregular menstruation is common in the perimenopausal period, women over the age of 45 with irregular bleeding should be investigated with a transvaginal ultrasound scan to assess the endometrial thickness. This may be followed up by an endometrial biopsy

Question 34

best way preg

Answer 34

urianry BHCG

Question 35

when is topical oestrogen cream used over HRT

Answer 35

for when there are only sypmoms nt systemuc such as vaginal dryness

Question 36

no diagnossi needed for menopause

Answer 36

only under 45 is FHS

Question 37

A 29-year-old woman attends for her cervical screen. She reports feeling well and denies any gynaecological symptoms. She has no significant past medical history and currently has four children. On insertion of the speculum, the GP notes four lumps around the cervical os, which contain amber mucous. They are approximately 4 mm in size each. What is the most likely diagnosis?

Answer 37

Nabothian cysts

Nabothian cysts are cysts on the cervix that occur when the squamous-cell epithelium of the cervix slightly covers the columnar epithelium. As the columnar epithelium secretes mucous, the mucous becomes trapped, and cysts form. The cysts contain yellow/amber mucous and are usually located around the os where the epitheliums transition. They are a normal finding, particularly in women who have had children. The cervical smear should still be taken.

Question 38

hiv positve cevical smear

Answer 38

very year

Question 39

how long shuld you wait after preg or termiantion for cervical smear

Answer 39

3 months

Question 40

first lien for fibrioid IX - heavy blledding and pain in premenopausal

Answer 40

TVUS

Question 41

combine HRT reduces the risk of

Answer 41

osteoporosis and fractures

Question 42

moa of clomiphene citrate

Answer 42

Clomiphene Citrate

Clomiphene Citrate is an antioestrogen which increases endogenous follicle stimulating hormone (FSH) and acts to induce ovulation. It is usually given at a dose of 50mg on days 2-6 of the menstrual cycle, with a progesterone level taken on day 21 to confirm ovulation

Question 43

What is the most appropriate management for this patient to reduce her risk of ovarian cancer?

Answer 43

Bilateral salpingooophorectomy

Hysterectomy and bilateral salpingoophorectomy

Hysterectomy is only recommended if required for other reasons e.g. fibroids or menorrhagia

Question 44

lichen sclerosis tx

Answer 44

potent topical corticosteroids such as dermovate.

Treatment helps prevent complications such as scarring and narrowing of the vaginal opening and reduces the risk of vulval cancer.

Question 45

small bartholin cysts warm compress largeer ones

Answer 45

Incision and drainage: under local anaesthetic, the swollen gland is incised and allowed to drain. A Word catheter may also be inserted to promote continued drainage
Antibiotics in cases of abscess
Salt water baths may relieve pain
Surgery may be required in recurrent cases

Marsupialisation

This is the recommended treatment for symptomatic Bartholin’s cysts. The Bartholin’s glands are two glands situated on either side of the vaginal opening. They function to secrete lubricating fluid during sexual arousal. Bartholin’s gland cysts occur when the duct of the gland becomes blocked. This leads to swelling and tenderness of the area. Marsupialisation involves cutting into the cyst and placing stitches to make a permanent opening so that the gland can drain freely. Insertion of a balloon catheter is a non-surgical alternative to marsupialisation.

Question 46

most common cause of postmenopausal bleeding

Answer 46

Vaginal atrophy

Vaginal atrophy (also known as atrophic vaginitis) is the most common cause of postmenopausal bleeding. Any postmenopausal bleeding will require thorough investigation for endometrial cancer, but only 10% of all postmenopausal bleeding is caused by malignancy.

Question 47

endometrial cancer referral pathway

Answer 47

According to NICE guidance, any woman over 55 with postmenopausal bleeding (defined as unexplained vaginal bleeding 12 months after the last menstrual period) should be referred under a 2-week wait pathway for endometrial cancer. The first-line investigation for endometrial cancer is a TVS to assess endometrial thickness.

Question 48

A 70-year-old woman attends her GP with the feeling that something is ‘coming down’ in her vagina. On examination, a uterine prolapse is noted. What is the most appropriate first-line management of this case?

Answer 48

vaginal pessary 1st line

Question 49

A 12-year-old girl is brought to her GP with a 4-day history of gradual-onset worsening abdominal pain and bloating. The pain is constant and is not associated with eating, urinating or passing stool. She has not started her periods yet and has never had sexual intercourse. Her vital signs are within normal ranges. On palpation, there is generalised abdominal pain but no masses are felt. On genital examination, breast development and pubic hair are seen. A blue and bulging membrane is overlying the vagina, with a mass protruding from behind. What is the most likely diagnosis?

Answer 49

imperforate hymen

Question 50

A 22 year old patient presents complaining of anxiety and irritability prior to her period each month, which is starting to affect her interpersonal relationships, especially at work. She also finds it difficult to concentrate and sleeps more in the week prior to her period.

She has a regular menstrual cycle, not using contraception, is not sexually active, and is not planning any pregnancies.

What is the most appropriate first line management for premenstrual syndrome?

Answer 50

Combined oral contraceptive pill with no pill-free interval

The COCP is useful for women with PMS however some suffer progestogenic side effects during the pill-free period. Therefore choosing a regime that has a shorter break, or no pill-free period may be more effective

Question 51

An 81-year-old woman attends her GP complaining of a 2-month history of itching in the vulval region. On examination, the GP notes bleeding and ulceration suspicious of vulval cancer. Which part of the vulva is most commonly affected in vulval cancer?

Answer 51

labia majora

Question 52

Transmural fibroid means what

Answer 52

Transmural fibroids are those located within the wall of the myometrium of the uterus.

Question 53

difference between tranexamic acid and mefenamic acid

Answer 53

Tranexamic acid is an antifibrinolytic that has been shown to reduce menstrual blood loss.
Mefenamic acid is a non-steroidal anti-inflammatory drug (NSAID) that has been shown to reduce menstrual pain and menstrual blood loss.

This patient does not complain of pain, and tranexamic acid is more effective than mefenamic acid at reducing menstrual blood loss.

Question 54

1st line for vaginal prolapse

Answer 54

A vaginal pessary is usually the first-line management of uterine prolapse (although sometimes, pelvic floor exercises known as Kegel exercises may be tried first in some mild cases).

Question 55

POI

how many FSH readings under 25
tx

Answer 55

This is diagnosed in women under the age of 40 who have symptoms of menopause (eg. period cessation) alongside two FSH measurements of >25 IU/l. The most appropriate management is hormone-replacement therapy.

Question 56

criteria for lactational amenorrhea

Answer 56

The woman has complete amenorrhoea.
The woman is fully, or nearly fully (>85% of feeds are breast milk) breastfeeding.
It has been six months or less since the birth of the baby

Question 57

A 40-year-old primipara with an uneventful pregnancy is in established labour and 10cm dilated, experiencing powerful regular contractions. She is about to start pushing when she suddenly becomes tachypnoeic and hypotensive, and shortly after loses consciousness.

What is the most likely cause of her symptoms?

Answer 57

Amniotic fluid embolism

Amniotic fluid embolism is an extremely rare, often fatal, obstetric emergency. A bolus of amniotic fluid escapes the uterus and becomes lodged in the pulmonary circulation causing hypoxia, respiratory and often cardiac arrest, as well as disseminated intravascular coagulation. The treatment comprises resuscitation, steroids and immediate delivery, but it often results in the mother’s demise.

palecntal abruption likely to see other sx such as vag bleed

Question 58

when does carcinoid syndroem coccur

Answer 58

when there are liver mets

Question 59

diangostic for haitus hernia

Answer 59

barium swallow

Question 60

lung cancer can cause

Answer 60

horners

Question 61

best mx for FAP

Answer 61

Total proctocolectomy

Question 62

cyclophosphoamide se

Answer 62

bladder problems - cystitis

cisplatin neohrotoxic and cx peripheral neuropathy

Question 63

cyclophosphoamide se

Answer 63

bladder problems - cystitis

cisplatin neohrotoxic and cx peripheral neuropathy

Question 64

common electrolyte imbalance seen in people with cancer mets

Answer 64

Hypercalcaemia

This is a common electrolyte imbalance in patients with cancer, especially those with bony metastases. The patient’s symptoms are acute and fit more with hypercalcaemia rather than more chronic conditions.

Question 65

headahces triggered by coughing

Answer 65

raised ICP -need CT head

Question 66

POP missed pill what should you do

Answer 66

Take the missed pill now. No further action required.

Correct. This patient takes Micronor (Norethisterone), a traditional POP. With a traditional POP, the rules are:

LESS than 3 hours late: Take the missed pill. No further action required.
MORE than 3 hours late: Take the missed pill as soon as possible. If more than one pill is missed - just take one pill. Take the next pill at its usual time even if it means taking two pills in the same day. Continue with the rest of the pack as normal but make sure to take extra precautions such as using condoms until the pill taking has re-established for 48 hours.
She is within the 3 hour window of taking her POP. Newer Desogestrel POPs are considered missed after 12 hours of being late to take them.

Question 67

1 off seixure nroaml antomoty how much off driving

Answer 67

6 months

This patient has had an isolated unprovoked seizure with a normal CT head and EEG - DVLA guidance is for 6 months off driving.

if abnmrla ct 1 month

Question 68

topical acetic acid

Answer 68

tx for ottitis externa

Question 69

another name for bacterial vaginoss

Answer 69

gardenella vaginosis

Question 70

what is lymphogranuoma venerum

Answer 70

Lymphogranuloma venereum (LGV)

Lymphogranuloma venereum (LGV) is an sexually transmitted infection (STI) caused by certain strains of Chlamydia trachomatis. LGV usually causes a painless genital ulcer at the site of inoculation and a subsequent inflammatory reaction of the inguinal nodes (buboes). LGV can also cause systemic symptoms of fever, fatigue and malaise. Given the patient’s history of unprotected sexual activity and the presence of these specific symptoms, LGV is the most likely diagnosis.

Question 71

genital herpes normally resolves without treatment

Answer 71

correct

Question 72

cervical motion tenderness

Answer 72

intense pain which examining the vagina

Question 73

PID tx

Answer 73

Intramuscular ceftriaxone, oral doxycycline and oral metronidazole.