Friday [17/09/2021]

Question 1

At what age would the average child acquire the ability to walk unsupported?

Answer 1

13-15m

Question 2

What happens at 0-12m for the milestones gross motor babies?

Answer 2

Age Milestone
3 months Little or no head lag on being pulled to sit
Lying on abdomen, good head control
Held sitting, lumbar curve
6 months Lying on abdomen, arms extended
Lying on back, lifts and grasps feet
Pulls self to sitting
Held sitting, back straight
Rolls front to back
7-8 months Sits without support (Refer at 12 months)
9 months Pulls to standing
Crawls
12 months Cruises
Walks with one hand held

Question 3

What happens 13m-> 4 years children gross motor

Answer 3

13-15 months Walks unsupported (Refer at 18 months)
18 months Squats to pick up a toy
2 years Runs
Walks upstairs and downstairs holding on to rail
3 years Rides a tricycle using pedals
Walks up stairs without holding on to rail
4 years Hops on one leg

Question 4

Should you be concerned if the baby is bottom-shuffling?

Answer 4

the majority of children crawl on all fours before walking but some children ‘bottom-shuffle’. This is a normal variant and runs in families

Question 5

Which one of the following antibodies is most specific for limited cutaneous systemic sclerosis?

Anti-Jo 1antiobodies
Rheumatoid factor
Anti-Scl-70 antibodies
Anti-centromere antibodies
Anti-nuclear factor

Answer 5

Anti-centromere antibodies
-Limited (central) systemic sclerosis = anti-centromere antibodies

Question 6

What other test would be positive in cutaneous systemic sclerosis?

Answer 6

Although ANA is positive in 90% of patients with systemic sclerosis, anti-centromere antibodies are the most specific test for limited cutaneous systemic sclerosis

Question 7

What is systemic sclerosis?

Answer 7

Systemic sclerosis is a condition of unknown aetiology characterised by hardened, sclerotic skin and other connective tissues. It is four times more common in females.

There are three patterns of disease:

Question 8

What are the three patterns of disease in systemic sclerosis?

Answer 8

Limited cutaneous systemic sclerosis
Diffuse cutanoeus systemic scelrosis
Scleroderma [w/o organ invoovement]

Question 9

Go through limited cutaneous systemic sclerosis

Answer 9

Raynaud’s may be first sign
scleroderma affects face and distal limbs predominately
associated with anti-centromere antibodies
a subtype of limited systemic sclerosis is CREST syndrome: Calcinosis, Raynaud’s phenomenon, oEsophageal dysmotility, Sclerodactyly, Telangiectasia

Question 10

Go through diffuse cutaneous system

Answer 10

scleroderma affects trunk and proximal limbs predominately
associated with scl-70 antibodies
the most common cause of death is now respiratory involvement, which is seen in around 80%: interstitial lung disease (ILD) and pulmonary arterial hypertension (PAH)
other complications include renal disease and hypertension
poor prognosis

Question 11

Go through scleroderma

Answer 11

tightening and fibrosis of skin
may be manifest as plaques (morphoea) or linear

Question 12

Antibodies in systemic sclerosis

Answer 12

ANA positive in 90%
RF positive in 30%
anti-scl-70 antibodies associated with diffuse cutaneous systemic sclerosis
anti-centromere antibodies associated with limited cutaneous systemic sclerosis

Question 13

What are the causes of secondary amenorrhoea?

Answer 13

hypothalamic amenorrhoea (e.g. secondary stress, excessive exercise)
polycystic ovarian syndrome (PCOS)
hyperprolactinaemia
premature ovarian failure
thyrotoxicosis* [also hypothydoisim]
Sheehan’s syndrome
Asherman’s syndrome (intrauterine adhesions)

Question 14

For each of the following scenarios select the most likely diagnosis:

9. A 28-year-old woman presents because she has not had a period for the past 9 months. She also describes fluid leaking from her nipples.

Answer 14

Asherman’s syndrome
The correct answer is: Sheehan’s syndrome 82%

Sheehan syndrome describes hypopituitarism caused by ischemic necrosis due to blood loss and hypovolaemic shock.

Question 15

0. A 26-year-old woman presents 3 months after giving birth to her first child. During labour she had a large post-partum haemorrage. She did not breastfeed but has not had a period since.

Answer 15

Premature ovarian failure
The correct answer is: Asherman’s syndrome 78%

Asherman’s syndrome, or intrauterine adhesions, may occur following dilation and curettage. This may prevent the endometrium responding to oestrogen as it normally would.

Question 16

Features of Sheehan’s syndrome

Answer 16

Asherman’s syndrome
The correct answer is: Sheehan’s syndrome 82%

Sheehan syndrome describes hypopituitarism caused by ischemic necrosis due to blood loss and hypovolaemic shock.

Features may include:
agalactorrhoea
amenorrhoea
symptoms of hypothyroidism
symptoms of hypoadrenalism

Question 17

What can amenorrhoea be divided into?

Answer 17

Amenorrhoea may be divided into:

primary: defined as the failure to establish menstruation by 15 years of age in girls with normal secondary sexual characteristics (such as breast development), or by 13 years of age in girls with no secondary sexual characteristics
secondary: cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhoea

Question 18

Causes of primary amenorrhoea

Answer 18

gonadal dysgenesis (e.g. Turner’s syndrome) - the most common causes
testicular feminisation
congenital malformations of the genital tract
functional hypothalamic amenorrhoea (e.g. secondary to anorexia)
congenital adrenal hyperplasia
imperforate hymen

Question 19

Ix for amenorrhoea, what would low levels of gonadtrophins indicate?

Answer 19

Initial investigations
exclude pregnancy with urinary or serum bHCG
full blood count, urea & electrolytes, coeliac screen, thyroid function tests
gonadotrophins
low levels indicate a hypothalamic cause where as raised levels suggest an ovarian problem (e.g. Premature ovarian failure)
raised if gonadal dysgenesis (e.g. Turner’s syndrome)
prolactin
androgen levels
raised levels may be seen in PCOS
oestradiol

Question 20

Mx of primary vs secondary amenorrhoea

Answer 20

Management
primary amenorrhoea:
investigate and treat any underlying cause
with primary ovarian insufficiency due to gonadal dysgenesis (e.g. Turner’s syndrome) are likely to benefit from hormone replacement therapy (e.g. to prevent osteoporosis etC)
secondary amenorrhoea
exclude pregnancy, lactation, and menopause (in women 40 years of age or older)
treat the underlying cause

Question 21

A 42-year-old Caucasian gentleman presents to the emergency department with a burn. You assess the burn and consider the need for IV fluids. Which of the following is most likely to require IV fluids?

A superficial dermal (partial thickness; second degree) burn covering 12% body surface area
A deep dermal (partial thickness; second degree) burn covering 7% body surface area
A full thickness (third degree) burn covering 3% body surface area
A superficial dermal (partial thickness; second degree) burn covering 20% body surface area
A superficial epidermal (first degree) burn covering 65% body surface area

Answer 21

IV fluids are not required for first degree (i.e. superficial, epidermal) burns
Important for meLess important
In adults, IV fluids should be given in second or third degree burns that cover 15% body surface area or more. In children, IV fluids are recommended when burns cover 10% body surface area.

Question 22

immediate first aid for burns?

Answer 22

Immediate first aid
airway, breathing, circulation
burns caused by heat: remove the person from the source. Within 20 minutes of the injury irrigate the burn with cool (not iced) water for between 10 and 30 minutes. Cover the burn using cling film, layered, rather than wrapped around a limb
electrical burns: switch off power supply, remove the person from the source
chemical burns: brush any powder off then irrigate with water. Attempts to neutralise the chemical are not recommended

Question 23

How to assess the extent of a burn?

Answer 23

Wallace’s Rule of Nines: head + neck = 9%, each arm = 9%, each anterior part of leg = 9%, each posterior part of leg = 9%, anterior chest = 9%, posterior chest = 9%, anterior abdomen = 9%, posterior abdomen = 9%
Lund and Browder chart: the most accurate method
the palmar surface is roughly equivalent to 1% of total body surface area (TBSA). Not accurate for burns > 15% TBSA

Question 24

Initial Mx of burns

Answer 24

Initial management of burns
initial first aid as above
review referral criteria to ensure can be managed in primary care
superficial epidermal: symptomatic relief - analgesia, emollients etc
superficial dermal: cleanse wound, leave blister intact, non-adherent dressing, avoid topical creams, review in 24 hours

Question 25

When to refer to secondary care for burns?

Answer 25

all deep dermal and full-thickness burns.
superficial dermal burns of more than 3% TBSA in adults, or more than 2% TBSA in children
superficial dermal burns involving the face, hands, feet, perineum, genitalia, or any flexure, or circumferential burns of the limbs, torso, or neck
any inhalation injury
any electrical or chemical burn injury
suspicion of non-accidental injury

Question 26

PP of severe burns

Answer 26

Following the burn, there is a local response with progressive tissue loss and release of inflammatory cytokines. Systemically, there are cardiovascular effects resulting from fluid loss and sequestration of fluid into the third space. There is a marked catabolic response. Immunosupression is common with large burns and bacterial translocation from the gut lumen is a recognised event. Sepsis is a common cause of death following major burns.

Question 27

Mx of severe burns

Answer 27

The initial aim is to stop the burning process and resuscitate the patient. Intravenous fluids will be required for children with burns greater than 10% of total body surface area. Adults with burns greater than 15% of total body surface area will also require IV fluids. The fluids are calculated using the Parkland formula which is; volume of fluid= total body surface area of the burn % x weight (Kg) x4. Half of the fluid is administered in the first 8 hours. A urinary catheter should be inserted. Analgesia should be given. Complex burns, burns involving the hand perineum and face and burns >10% in adults and >5% in children should be transferred to a burns unit.

Circumferential burns affecting a limb or severe torso burns impeding respiration may require escharotomy to divide the burnt tissue.

Conservative management is appropriate for superficial burns and mixed superficial burns that will heal in 2 weeks. More complex burns may require excision and skin grafting. Excision and primary closure is not generally practised as there is a high risk of infection.

There is no evidence to support the use of anti microbial prophylaxis or topical antibiotics in burn patients.

Question 28

When are escharotomies indicated?

Answer 28

Indicated in circumferential full thickness burns to the torso or limbs.
Careful division of the encasing band of burn tissue will potentially improve ventilation (if the burn involves the torso), or relieve compartment syndrome and oedema (where a limb is involved)

Question 29

As a general rule, what is it safer to asusme if there is growth plate tenderness in a child?

Answer 29

As a general rule it is safer to assume that growth plate tenderness is indicative of an underlying fracture even if the x-ray appears normal. Injuries of Types III, IV and V will usually require surgery. Type V injuries are often associated with disruption to growth.

Question 30

Signs of NAI?

Answer 30

Non accidental injury
Delayed presentation
Delay in attaining milestones
Lack of concordance between proposed and actual mechanism of injury
Multiple injuries
Injuries at sites not commonly exposed to trauma
Children on the at risk register

Question 31

Which particualr condition may cause pathological fractures?

Answer 31

Genetic conditions, such as osteogenesis imperfecta, may cause pathological fractures.

Question 32

What is osteogenesis imperfecta?

Answer 32

Defective osteoid formation due to congenital inability to produce adequate intercellular substances like osteoid, collagen and dentine.
Failure of maturation of collagen in all the connective tissues.
Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.

Question 33

Subtypes of osteogenesis imperfecta

Answer 33

Type I - The collagen is normal quality but insufficient quantity.
Type II - Poor collagen quantity and quality.
Type III - Collagen poorly formed. Normal quantity.
Type IV - Sufficient collagen quantity but poor quality.

Question 34

What is osteopetrosis?

Answer 34

Bones become harder and more dense.
Autosomal recessive condition.
It is commonest in young adults.
Radiology reveals a lack of differentiation between the cortex and the medulla described as marble bone.

Question 35

A 22-year-old woman is brought to the emergency department after ingesting approximately 40 paracetamol tablets in a suicide attempt 36 hours previously. She denies taking any other drugs or alcohol and has no known medical conditions. She had epigastric pain and nausea without vomiting ingestion but is now complaining of severe right upper quadrant pain. On examination, she is slightly diaphoretic and pale.

Some investigations are sent to the lab, the results of which are below:
Arterial pH 7.2 (7.35 - 7.45)
Bilirubin 19 µmol/L (3 - 17)
AST 1330 u/L (30 - 100)
ALT 1440 u/L (3 - 40)
Creatinine 167 µmol/L (55 - 120)
Prothrombin time (PT) 76 secs (10 - 14)

Which of the following prognostic factors in this patient’s condition are the most important?

Answer 35

Arterial pH is the single most important factor in paracetamol OD

‘Arterial pH’ is the correct answer. Paracetamol overdose produces metabolic acidosis and arterial pH is the most important prognostic factor. This patient has a pH of 7.2 and needs a liver transplant as the King’s college criteria for liver transplantation in paracetamol overdose only requires a patient to have an arterial pH < 7.3 more than 24 hours after ingestion for liver transplantation to be indicated.

Question 36

What’s the King’s college criteria for liver transplantation?

Answer 36

While these are all poor prognostic factors, arterial pH is the single most important one. The King’s college criteria for liver transplantation in paracetamol overdose requires a patient to have ‘an arterial pH < 7.3 more than 24 hours after ingestion’ OR for a patient to HAVE ALL 3 OF: ‘grade III/IV hepatic encephalopathy’, ‘creatinine > 300 µmol/L’ and ‘prothrombin time > 100 seconds’ to require a liver transplant. This demonstrates how arterial pH is the most important prognostic factor

Question 37

When is activated charcoal indicated?

Answer 37

The minority of patients who present within 1 hour may benefit from activated charcoal to reduce absorption of the drug.

Question 38

When should acetylcysteine be given to a patient?

Answer 38

Acetylcysteine should be given if:
there is a staggered overdose* or there is doubt over the time of paracetamol ingestion, regardless of the plasma paracetamol concentration; or
the plasma paracetamol concentration is on or above a single treatment line joining points of 100 mg/L at 4 hours and 15 mg/L at 15 hours, regardless of risk factors of hepatotoxicity

Question 39

How is acetylcysteine given?

Answer 39

Acetylcysteine is now infused over 1 hour (rather than the previous 15 minutes) to reduce the number of adverse effects. Acetylcysteine commonly causes an anaphylactoid reaction (non-IgE mediated mast cell release). Anaphylactoid reactions to IV acetylcysteine are generally treated by stopping the infusion, then restarting at a slower rate.

Question 40

A 28-year-old woman presents the Emergency Department at 35-weeks gestation with lower abdominal pain and vaginal bleeding. She is alert and responsive. Physical examination revealed a heart rate of 115 bpm, blood pressure of 90/60 mmHg and O2 saturation of 99%. On neurological exam, her pupils were dilated and her reflexes were brisk.

Hb 115 g/l
Platelets 250 * 109/l
WBC 5 * 109/l
PT 12 seconds
APTT 30 seconds

Which of the following underlying conditions would most likely explain the findings on physical exam?

Answer 40

Cocaine abuse

The scenario described in this question is consistent with that of placental abruption. Cocaine abuse, pre-eclampsia and HELLP syndrome are known causes of placental abruption, which typically presents with hyperreflexia. HELLP syndrome can be ruled out since the full blood count shows no indication of anaemia or low platelets as would be expected in this condition. Dilated pupils + hyperreflexia seen on physical examination point towards cocaine abuse. Heroin abuse would often present with pinpointed pupils and has not been associated with an increased risk of placental abruption. Although pre-eclampsia in pregnancy is associated with an increased risk of placental abruption, the findings on physical exam are more consistent with that of cocaine abuse. Disseminated intravascular coagulopathy is a complication placental abruption, not an underlying cause. Additionally, the normal partial thromboplastin time (PTT) and activated partial thromboplastintime (APTT) decrease the likelihood of underlying DIC.

Question 41

How much does smoking increase the risk of miscarriage?

Answer 41

47%

Question 42

What does drinking increase the risk?

Answer 42

FAS

Question 43

Maternal and fetal risk of cocaine during pregnancy?

Answer 43

Maternal risks
hypertension in pregnancy including pre-eclampsia
placental abruption

Fetal risk
prematurity
neonatal abstinence syndrome

Question 44

A 60-year-old man with benign prostatic hyperplasia presented with lower abdominal pain and inability to urinate. After inserting a catheter, >2L of clear urine drained, with immediate relief of the pain.

Three hours later you are asked to review the patient as his urine is now a pale pink colour. The patient feels well in himself, and his observations are stable.

What is the most appropriate management?

Answer 44

Monitor - no immedate action is required

Decompression haematuria doe snot require further management if the patient is haemodynamically stable

Question 45

What is decompression haematuria?

Answer 45

This patient has decompression haematuria. Decompression haematuria occurs commonly after catheterisation for chronic urinary retention due to the rapid decrease in the pressure in the bladder. It usually does not require further treatment and resolves spontaneously over a few days. Patients should be monitored to ensure the bleeding does not become severe.

Question 46

When are bladder washouts indicated?

Answer 46

Bladder washouts are indicated for moderate or severe haematuria, but are not needed in this case as the bleeding from decompression haematuria is likely to settle on its own. [bladder irrigation helpful to control haematuria also]

Question 47

SHould you use tranexamic acid for haematuria?

Answer 47

Tranexamic acid is generally contra-indicated in haematuria as it causes clots to form in the bladder, leading to bladder outflow obstruction. Therefore, this is an incorrect answer.

Question 48

Characterisitics of chronic urinary retnetion?

Answer 48

Painless and insidious

Question 49

Compare low vs high pressure retention

Answer 49

Chronic urinary retention is characterised by being painless and insidious.

High pressure retention
impaired renal function and bilateral hydronephrosis
typically due to bladder outflow obstruction

Low pressure retention
normal renal function and no hydronephrosis

Question 50

A 65-year-old male presents to the GP following 6 months of hearing loss as a result of ototoxicity due to furosemide. On examination, he has bilateral severe sensorineural hearing loss and can only hear spoken words if the source is less than 10 cm away. He has been using hearing aids for 4 months, although he doesn’t find them particularly helpful.

What feature of the history suggests that management with a cochlear implant is appropriate?

Answer 50

Duration of hearing aid use
-Adults are generally required to have had a failed trial of hearing aids before having a cochlear implant

The feature of the history that most suggests that a cochlear implant is an appropriate management strategy is the duration of his hearing aid use. A cochlear implant is appropriate in the management of a patient who has failed a trial of hearing aids for at least 3 months.

Question 51

What is a cochlear implant?

Answer 51

A cochlear implant is an electronic device that may be offered to patients with severe-to-profound hearing loss.

The device has both internal and external components.

Externally, the microphone recognises the environmental sound and sends it to the sound processor. This, in turn, transforms the impulses received into a digital signal that which is then transferred to the transmitter coil. The transmitter coil conveys the signal to the internal components. Internally, a receiver, which magnetically connected to, and sits directly above the transmitter coil, and receives the impulses from the external apparatus which are then processed by a set of electrodes. The electrodes do the work that would be performed by the inner ear hair cells in a ‘normal’ ear. The brain can then process these signals to comprehend sound. Rechargeable batteries can be used to power the apparatus and life span depends upon usage and the individual device.

Hearing link describes cochlear implants as ‘…the world’s most successful medical prostheses in that less than 0.2% of recipients reject it or do not use it and the failure rate needing reimplantation is around 0.5%.’

Question 52

Sustainablility of cochlear implant determined by what?

Answer 52

In children, audiological assessment and/or difficulty developing basic auditory skills.
In adults, patients should have completed a trial of appropriate hearing aids for at least 3 months which they have been objectively demonstrated to receive limited or no benefit from.

Question 53

Causes of severe-t-profound hearing loss in children

Answer 53

Genetic (accounts for up to 50% of cases).
Congenital e.g. following maternal cytomegalovirus, rubella or varicella infection.
idiopathic (accounts for up to 30% of childhood deafness).
Infectious e.g. post meningitis.

Question 54

Causes of severe-t-profound hearing loss in adults

Answer 54

Viral-induced sudden hearing loss.
Ototoxicity e.g. following administration of aminoglycoside antibiotics or loop diuretics.
Otosclerosis
Ménière disease
Trauma

Question 55

Common drugs that can cause ototoxicity?

Answer 55

Aminoglycoside antibiotics, or loop diuretics

Question 56

What should happen prior to the assessment for a cochlear implant?

Answer 56

Prior to an assessment for the cochlear implant, patients should have exhausted all medical therapies aimed at targeting any underlying pathological process contributing to the loss of hearing. In addition, they should have explored ‘conventional’ amplification strategies i.e. hearing aids and found the devices insufficient to allow functioning within daily life and/or support language development/maintenance.

Question 57

What are implants neccessated by?

Answer 57

Whilst implants are necessitated by the destruction or degeneration of the organ of Corti, it is essential that there are surviving spiral ganglion neurons to ensure the success of the implant. An assessment of the patient anatomy should be undertaken by an experienced otolaryngologist/skull base surgeon.

Question 58

What may surgical implantation be complicated by?

Answer 58

Surgical implantation may be complicated by infection, facial paralysis due to nerve injury intra-operatively, cerebrospinal fluid (CSF) leakage, and meningitis. To reduce the risk of meningitis as far as possible, it is recommended that all patients should have up-to-date vaccinations against Streptococcus and Haemophilus.

Question 59

Complete and relative CI for cohlear implant?

Answer 59

Contraindications to consideration for cochlear implant:
Lesions of cranial nerve VIII or in the brain stem causing deafness
Chronic infective otitis media, mastoid cavity or tympanic membrane perforation
Cochlear aplasia

Relative contraindications:
Chronic infective otitis media or mastoid cavity infections
Tympanic membrane perforation
Patients that may be seen to demonstrate a lack of interest in using the implant to develop enhanced oral communication skills.

Question 60

A 35-year-old woman presents with a variety of symptoms including generalised skin tingling and headache. She is concerned she may have multiple sclerosis. What is the most common presentation of multiple sclerosis?

Answer 60

Optic neuritis
- can be a feature of MS

Question 61

75% of patients present how with MS?

Answer 61

Significant lethargy

Question 62

How is diagnosis of MS made?

Answer 62

Diagnosis can be made on the basis of two or more relapses and either objective clinical evidence of two or more lesions or objective clinical evidence of one lesion together with reasonable historical evidence of a previous relapse.

Question 63

Visual, sensory, motor and cerebellar signs of MS

Answer 63

Visual
optic neuritis: common presenting feature
optic atrophy
Uhthoff’s phenomenon: worsening of vision following rise in body temperature
internuclear ophthalmoplegia

Sensory
pins/needles
numbness
trigeminal neuralgia
Lhermitte’s syndrome: paraesthesiae in limbs on neck flexion

Motor
spastic weakness: most commonly seen in the legs

Cerebellar
ataxia: more often seen during an acute relapse than as a presenting symptom
tremor

Question 64

Other Sx of MS

Answer 64

Others
urinary incontinence
sexual dysfunction
intellectual deterioration

Question 65

A 36-year-old woman presents with increasing fatigue, arthralgia and weight loss. She has recently noticed a rash on the bridge of her nose and cheeks, which she believes has worsened in the sun.

Given the likely diagnosis, what medication would be prescribed with NSAIDs as first-line treatment?

Answer 65

Hydroxychloroquine
- first-line Tx for SLE

Question 66

What is SLE?

Answer 66

This vignette describes a patient with systemic lupus erythematosus (SLE). SLE is a systemic inflammatory autoimmune connective tissue disease that takes a relapsing-remitting course and results in chronic inflammation. ‘Erythematosus’ in the name refers to the red malar ‘butterfly’ rash that typically forms across the cheeks and bridge of the nose. SLE presents with non-specific symptoms such as fatigue, weight loss, arthralgia and myalgia along with the characteristic photosensitive ‘butterfly’ rash.

Question 67

Basic, long-term and internal organ involvement treatment choice for SLE

Answer 67

Basics
NSAIDs
sun-block

Hydroxychloroquine
the treatment of choice for SLE

If internal organ involvement e.g. renal, neuro, eye then consider prednisolone, cyclophosphamide

Question 68

How does the combined oral contraceptive pill work? MoA

Answer 68

Inhibits ovulation 88%

The questions asks for the primary mode of action.

The Faculty for Sexual and Reproductive Health (FSRH) state Combined Hormonal Contraception (CHC) works primarily by inhibiting ovulation via action on the hypothalamo-pituitary-ovarian axis to reduce luteinising hormone and follicle-stimulating hormone. Alterations to cervical mucus and the endometrium may also contribute to the efficacy of CHC.

Question 69

MoA of implantable contraceptive

Answer 69

. Implantable contraceptive (etonogestrel)
Thickens cervical mucus only
The correct answer is: Inhibits ovulation 54%

The Faculty for Sexual and Reproductive Health (FSRH) state The progestogen-only implant is a long-acting reversible method of contraception (LARC). The primary mode of action is to prevent ovulation. Implants also prevent sperm penetration by altering the cervical mucus and possibly prevent implantation by thinning the endometrium.

Question 70

MoA of copper IU contraceptive device

Answer 70

. Copper intrauterine contraceptive device (used as a standard contraceptive)
Inhibits implantation of the conceptus
The correct answer is: Decreases sperm motility and survival 67%

Question 71

Match each scenario with the most likely diagnosis.

23. Brad is a 48-year-old builder who calls you on a Monday morning complaining of severe epigastric pain, which started over the weekend and worsens by lying down. The pain radiates into his back. He has vomited several times over the last few days. He has no known medical history and takes no regular medication. He reports that the pain started following a takeaway meal on Friday night.

Answer 71

Gastroenteritis
The correct answer is: Pancreatitis 65%

Epigastric pain that worsens on lying down and radiates into the back is typical of a pancreatitis picture.

Acute gastritis is also a possible differential, particularly following a potentially heavy meal. However, the nature of the pain makes pancreatitis more likely.

Gastroenteritis following a takeaway is another possible differential, however, the overarching symptoms tend to be vomiting and diarrhoea with generalised abdominal pain, rather than focal epigastric pain.

Appendicitis typically starts with pain in the umbilical region which then localises to the right iliac fossa. It is usually associated with a fever.

In this case, pancreatitis is the single most likely cause.

Question 72

Gloria is a 28-year-old city worker who attends your surgery complaining of a 7-month history of intermittent abdominal pain and diarrhoea. She has a busy job and her constant need for the toilet is starting to affect her. She describes the symptoms as more constant over the last 3 months, occurring almost daily. She denies any bleeding and is otherwise well in herself. She denies any weight loss. Her father suffers from Crohn’s disease and she is concerned this is the case.

Answer 72

Inflammatory bowel disease (IBD)
The correct answer is: Irritable bowel syndrome (IBS) 64%

In a busy city worker, stress is likely the trigger of this patient’s abdominal symptoms, which are most likely caused by IBS. In patients with IBS, their symptoms can comprise abdominal pain, bloating, diarrhoea or constipation. IBS is normally a diagnosis of exclusion in patients who have experienced symptoms for at least 6 months, as in this case.

IBD would also be a differential that needs to be ruled out, however, IBD tends to occur in acute flares rather than daily symptoms over a three-month period. In addition, IBD is more commonly associated with rectal bleeding and weight loss.

Bowel cancer should also be ruled out with a faecal immunochemical test however, it is less likely given the intermittent nature of the symptoms and lack of systemic symptoms such as weight loss.

Question 73

A mother brings her 6-year-old son to the surgery as he has been complaining of abdominal pain for the last few days. He points to the left lower quadrant when questioned on the location of the pain. This has been constant. There is no history of any recent infections. His mother denies any fevers and reports he has been drinking well but reports he has had a reduced appetite over the last few days. He last opened his bowels three days ago. On examination, his abdomen is soft with mild tenderness in the left iliac fossa. His observations are within the normal range.

Answer 73

Appendicitis
The correct answer is: Constipation 70%

In this scenario, the young child is complaining of localised pain and so several differentials must be excluded.

His abdomen is soft with only mild tenderness and no guarding. This, coupled with the absence of a fever, vomiting and normal observations make appendicitis less likely. Furthermore, appendicitis pain occurs most commonly in the right iliac fossa.

He has not been recently unwell and therefore mesenteric adenitis is also unlikely.

He last opened his bowels three days ago. The most likely option, therefore, is constipation and his recent lack of eating may be

Question 74

unusual and medical causes of abdominal pain that should be remembered

Answer 74

acute coronary syndrome
diabetic ketoacidosis
pneumonia
acute intermittent porphyria
lead poisoning

Question 75

A 27-year-old woman presents to the GP with lethargy and tiredness since moving out of her parents home 1 year ago. She also complains of aches and pains in her joints as well as easy bruising. She mentions that she has an appointment arranged with the dentist the next day for some bleeding from her gums. After further questioning, she is found to smoke 5 cigarettes per day and drink 1 bottle of wine per week.

Given her presentation, which of the following is the most likely cause of her symptoms?

Answer 75

Vitamin C defiency:
- bleeding gums, think scurvy

This question is asking about a woman presenting with lethargy, arthralgia, easy bruising and bleeding gums. While there are many differentials for this presentation it is quite classic of a vitamin C deficiency (also known as scurvy). Scurvy is more common in people from low-income backgrounds, the elderly, alcoholics or those with a poor diet (as indicated in this case with the patient recently moving away from home). Bleeding gums is a characteristic symptom.

Question 76

Where is vitmain C found in?

Answer 76

Vitamin C (ascorbic acid) is found in citrus fruits, tomatoes, potatoes, Brussel sprouts, cauliflower, broccoli, cabbage and spinach.

Question 77

What does low vitamin C lead to PP?

Answer 77

Deficiency (commonly called scurvy) leads to impaired collagen synthesis and disordered connective tissue as ascorbic acid is a cofactor for enzymes used in the production of proline and lysine.

Question 78

RFs for low vit C

Answer 78

It is associated with severe malnutrition as well as drug and alcohol abuse, and those living in poverty with limited access to fruits and vegetables.

Question 79

Sx and Sx of scurvy

Answer 79

Symptoms and signs include:
Follicular hyperkeratosis and perifollicular haemorrhage
Ecchymosis, easy bruising
Poor wound healing
Gingivitis with bleeding and receding gums
Sjogren’s syndrome
Arthralgia
Oedema
Impaired wound healing
Generalised symptoms such as weakness, malaise, anorexia and depression

Question 80

A 12-year-old boy attends his general practice with his mum and dad. His parents say that he has had trouble with his speech recently, has been behaving unusually, and they have noticed some strange colours in his eyes. The GP thinks that this may be the rare disease, Wilson’s, so sends off a variety of blood tests including iron studies and copper studies.

Which of the following blood results would the GP expect, if this is indeed Wilson’s disease?

Answer 80

Reduced total serum copper.

Wilson’s disease is a problem with copper, in which excess copper is deposited in tissues, causing a low serum copper. It has many unusual manifestations, the most common of which are behavioural or speech changes.

Question 81

Tell-tale sigsn see in exams for Wilson’s disease

Answer 81

Some tell-tale signs that you might see in exam questions include brown rings in the eyes (Kayser-Fleischer rings), blue nails, and a reduced serum copper and reduced caeruloplasmin.

Question 82

What is Wilson’s disease

Answer 82

Wilson’s disease is an autosomal recessive disorder characterised by excessive copper deposition in the tissues. Metabolic abnormalities include increased copper absorption from the small intestine and decreased hepatic copper excretion. Wilson’s disease is caused by a defect in the ATP7B gene located on chromosome 13.

Question 83

Usual onset time Wilson’s disease?

Answer 83

The onset of symptoms is usually between 10 - 25 years. Children usually present with liver disease whereas the first sign of disease in young adults is often neurological disease

Question 84

Features of Wilson’s disease

Answer 84

Features result from excessive copper deposition in the tissues, especially the brain, liver and cornea:
liver: hepatitis, cirrhosis
neurological:
basal ganglia degeneration: in the brain, most copper is deposited in the basal ganglia, particularly in the putamen and globus pallidus
speech, behavioural and psychiatric problems are often the first manifestations
also: asterixis, chorea, dementia, parkinsonism
Kayser-Fleischer rings
green-brown rings in the periphery of the iris
due to copper accumulation in Descemet membrane
present in around 50% of patients with isolated hepatic Wilson’s disease and 90% who have neurological involvement
renal tubular acidosis (esp. Fanconi syndrome)
haemolysis
blue nails

Question 85

Diagnosis Wilson’s disease made how?

Answer 85

slit lamp examination for Kayser-Fleischer rings
reduced serum caeruloplasmin
reduced total serum copper (counter-intuitive, but 95% of plasma copper is carried by ceruloplasmin)
free (non-ceruloplasmin-bound) serum copper is increased
increased 24hr urinary copper excretion

Question 86

Mx of Wilson’s disease

Answer 86

penicillamine (chelates copper) has been the traditional first-line treatment
trientine hydrochloride is an alternative chelating agent which may become first-line treatment in the future
tetrathiomolybdate is a newer agent that is currently under investigation

Question 87

A 22-year-old woman has just had an artificial rupture of membranes in order to augment a slowly progressing labour. Her partner is helping her move into a more comfortable position when she suddenly becomes breathless and collapses from the bed. She is unconscious and unresponsive with a blood pressure of 82/50 mmHg and a heart rate of 134 beats per minute. What is the most likely diagnosis?

Answer 87

Amniotic fluid embolism:
-A history of sudden collapse occurring soon after a rupture of membranes is suggestive of amniotic fluid embolism. The patient is clearly too unwell for this to be a simple vasovagal event. Amniotic fluid emboli can indirectly lead to myocardial infarcts, but It is hard to arrive at a primary diagnosis of myocardial infarction without mention of preceding chest pain. Occult bleeding and hypovolaemic shock would also typically evolve at a slower pace. Postural orthostatic tachycardia syndrome is more common in women of a reproductive age but would not be associated with marked hypotension as present here.

Question 88

Define amniotic fluid embolism

Answer 88

This is when fetal cells/ amniotic fluid enters the mothers bloodstream and stimulates a reaction which results in the signs and symptoms described below.

Question 89

Epidemiology, aetiology of amniotic fluid embolism

Answer 89

Epidemiology:
Rare complication of pregnancy associated with a high mortality rate.Incidence 2/ 100,000 in the U.K .

Aetiology:
Many risk factors have been associated with amniotic fluid embolism but a clear cause has not been proven. A consistent link has been demonstrated with maternal age and induction of labour. It is widely accepted that maternal circulation must be exposed to fetal cells/ amniotic fluid in order for an amniotic fluid embolism to occur. However the precise underlying pathology of this process which leads to the embolism is not well understood, though suggestions have been made about an immune mediated process.

Question 90

Clinical presentation, diagnosis and Mx of amniotic fluid embolism

Answer 90

Clinical presentation:
The majority of cases occur in labour , though they can also occur during caesarean section and after delivery in the immediate postpartum.
Symptoms include: chills, shivering, sweating, anxiety and coughing.
Signs include: cyanosis, hypotension, bronchospasms, tachycardia. arrhythmia and myocardial infarction.

Diagnosis:
Clinical diagnosis of exclusion, as there are not definitive diagnostic tests.

Management:
Critical care unit by a multidisciplinary team, management is predominantly supportive

Question 91

What signsa are these of?

Answer 91

Systemic sclerosis

Question 92

What is this a sign of?

Answer 92

SS

Question 93

How to assess the depth of a burn?

Answer 93

Question 94

Question

Answer 94

Question 95

Paediatric type fractures

Answer 95

Question 96

Go htrough growth plate fractures

Answer 96

Question 97

Salter-Hasrris fracture types

Answer 97

Question 98

Go through effect on baby for smoking, alcohol, cannabis, cocaine, heroin

Answer 98

Question 99

Standard contraceptive MoA: COCP, POP, DOP, injectable, implantable, IUCD, IUS

Answer 99

Question 100

Methods of emergency contraception MoA: Levnorgestel, Uliristal, IUCD

Answer 100