general specilaties

Question 1

how to manage gestational trophoblastic disease

Answer 1

treated via a surgical procedure known as a suction curettage where the cervix is dilated and the trophoblastic tissue is extracted under general anaesthesia. Some of the tissue will be sampled and sent for analysis to determine the type of molar pregnancy

Question 2

depending on different CIN grades how do you manage ?

Answer 2

CIN 1 - observation and follow up smear in 12 months

CIN 2 / CIN 3 - Large Loop Excision of Transformation Zone (LLETZ)

Question 3

chest pain, sudden-onset dyspnoea, seizures and cardiac arrest in woman in labour ?

Answer 3

amniotic fluid embolism

The clinical features of AFE include chest pain, sudden-onset dyspnoea, seizures and cardiac arrest. Due to the disseminated intravascular coagulation that ensues, women also suffer from massive postpartum haemorrhage. It is often mistaken for a pulmonary embolism, collapse or eclampsia due to similarities in the presentation and due to how rare AFE is

Question 4

difference types of prolapse in old women ?

Answer 4

prolapse of anterior vag wall = cystocele (bladder)/ urethrocele (urethra)/ cystourethrocele (both)

prolapse of posterior vag wall =
rectocele / enterocele
—– A digital rectal examination enables differentiation between the two on examination; a finger in the rectum will be seen to bulge into a rectocele but not into an enterocoele, which does not contain rectum

Question 5

what scoring system for pharingitis/tonsilitis and how is it used ?

Answer 5

Fever Pain score

Fever in past 24 hoursYes +1
Absence of cough or coryzaYes +1
Symptom onset≤3 daysYes +1
Purulent tonsilsYes +1
Severe tonsil inflammationYes +1

A score of < 2 is likely not bacterial thus no antibiotics are needed.

A score of 2-3 is potentially bacterial thus a delayed antibiotic prescription should be considered.

A score of 4-5 is likely a bacterial infection and antibiotics should be considered now

Abx = o Phenoxymethylpenicillin

Question 6

how to manage neonatal necrotising enterocolitis ?

Answer 6

if not perforation,
1. stop enteral feeding
2. drip and suck
3. parental feeding
4. Abx cefotaxime and vancomycin

Question 7

types of artificial feeding what are they ?

Answer 7

enteral feeding (through a tube placed into the stomach or small intestine; parenteral feeding (through a tube inserted into a vein whereby nutrients enter the bloodstream directly

Question 8

gastroschisis vs omphalocele

Answer 8

Gastroschisis is a birth defect in which the newborn’s intestines herniate through a large defect in the anterior abdominal wall that isusually lateral to the umbilicus.

Unlike an omphalocele, the herniated contents in gastroschisis are not covered by a peritoneal membrane. This means that the infants are usually at significant risk of insensible fluid and protein loss

Question 9

An 8-year-old child is brought to the paediatric urgent care centre by her mother after noticing a rash on her left arm and back. The child explains that the rash is slightly itchy but is not otherwise troubling her. On examination, there is a widespread, mildly erythematous maculopapular rash with one particularly large oval shaped macule on her left arm

what and how to manage ?

Answer 9

Pityriasis rosea

tx = reassurance

Question 10

quadraplestic/ hemiplegic / diplegic cerebral palsy??

Answer 10

According to the vignette, it is only the patient’s lower limbs thatare affected which is, therefore, described as diplegic cerebral palsy.

Hemiplegia is when one upper limb and one lower limb is affected. Quadriplegia is when all four limbs are affected

Question 11

pregnant lady infected with parvovirus b19 - what does this mean and how do you manage ?

Answer 11

Erythema infectosum

Foetal anaemia is investigated using Doppler ultrasound imaging of the middle cerebral artery. This should be performed fortnightly for the remainder of the pregnancy, to detect manifestations of foetal anaemia, including hydrops foetalis.

Anaemia cannot be detected by ultrasound imaging alone. Foetal monitoring enables clinicians to determine whether in utero blood transfusions will be required to support the developing foetus. In 50% of cases, there is spontaneous resolution of foetal anaemia; therefore, in utero blood transfusionsare reserved for only a proportion of cases in which foetal anaemia is severe

Question 12

abdmoinal distention (bloating), early satiety, loss of appetite - what is diagnosis ?

Answer 12

ovarian cancer

Question 13

what is blood like in ruptured ectopic ?

Answer 13

It usually presents with abnormal vaginal bleeding that is dark and scanty in nature, and abdominal pain

Question 14

if a type 2 diabetic is taking her meds and wants to get pregnant/ is pregnant what happens to her meds?

Answer 14

Diabetes medications that are not metformin or insulin should be stopped prior to conceiving`

Question 15

if a lady with hypertension wants to get pregnant / is pregnant what should happen to her meds ?

Answer 15

Women taking statins, ACE inhibitors or angiotensin receptor blockers should be advised to stop.

In women with hypertension, suitable antihypertensives include labetalol, nifedipine or methyldopa

Question 16

how to prevent pre eclampsia in high risk groups… who are these groups?

Answer 16

Offer aspirin 75-150mg OD from 12 weeks gestation until delivery in women with 1 high-risk right factor or ≥2 moderate-risk risk factors:

o High-risk risk factors:
 Hypertensive disease in a previous pregnancy
 Pre-existing maternal disease (chronic hypertension, renal disease, diabetes, autoimmune disease [SLE, antiphospholipid syndrome])

o Moderate-risk risk factors:
 First pregnancy (primigravid)
 Age >40 years
 Pregnancy interval of >10 years
 BMI >35 at booking visit
 FH of pre-eclampsia
 Multiple pregnancy

Question 17

The severity of NVP can be assessed using the ….

Answer 17

Pregnancy-Unique Quantification of Emesis (PUQE) score

Question 18

in pregnancy Hypothyroidism is associated with an increased risk of…..

Answer 18

pre-eclampsia

Question 19

what liquid can come out the vagina at the start of labour ?

Answer 19

a “show”, when the plug of mucus from your cervix (entrance to your womb, or uterus) comes away

waters breaking - rupture of membranes

Question 20

how to know if pregnant woman has ruptured her membranes ? is there a more speciifc test you can use as well… ?

Answer 20

Pooling of amniotic fluid in the posterior vaginal fluid is diagnostic, but not always present

ROM plus test gives a positive result if it detects insulin-like growth factor binding protein-1.

Question 21

Ix for small for gestational age fetus which can be picked up with small for dates symphasis fundal height…?

Answer 21

Umbilical artery Doppler is the most important surveillance for monitoring SGA foetuses.

It is able to predict foetal acidaemia which enables prompt delivery of the baby to avoid intrauterine death and other irreversible end-organ damage

Question 22

woody uterus ?

Answer 22

placental abruption

Question 23

how do you describe the uterus in placental abruption?

Answer 23

woody uterus

Question 24

in paeds what is Bronchopulmonary dysplasia

Answer 24

refers to the lung damage that occurs following mechanical ventilation in neonates

Question 25

cyanotic heart defect resulting in left axis deviation

Answer 25

tricuspid atresia

Question 26

child finding is harder to walk and falls over. used his arms to push himself off the floor - diagnosis ?

Answer 26

duchenne muscular dystrophy

the arm thing is Gower’s sign

Question 27

what kind of time frame do babies get GORD ?

Answer 27

Gastro-oesophageal reflux typically presents before 8 weeks of age with regular vomiting.

It occurs due to immaturity of the lower oesophageal sphincter and most cases will resolve spontaneously by 12 months of age

Posseting is basically the same thing as GORD

Question 28

section 135 vs 136?

Answer 28

135 = enter a private place (patients home if required)

136 = public place

both used to take a patient to a place of safety (this can be A&E)

Question 29

how does neurosyphyalis present and tx ?

Answer 29

present:
confusion and a change in personality. He has also complained of persistent headaches and a change in his vision

tx = benzathine penicillin

Question 30

what do you need to bare in mind with past medical history and prescribing drugs in scizophrenia ?

Answer 30

if patients has obesity, t2dm, hypertension you want to avoid atypicals because they have lots of metabolic side effects

you can give a typical like haloperidol

Question 31

how to manage kawasaki and what is interesting ab0ut this managemnt ?

Answer 31

Aspirin is usually contraindicated in children due to the risk of developing Reye’s syndrome (a rapidly progressive encephalopathy)

Question 32

woman with signs of infection post partum (smelly discharge, painful uterus… ) - what is it ?

Answer 32

endometritis

Postpartum endometritis is the most common cause of postpartum infection. Most cases of postpartum endometritis are polymicrobial, involving aerobic and anaerobic bacteria, and are due to the translocation of normal vaginal flora into the uterine cavity during labor and delivery.[4] Endometritis is 5 to 20 times more common in patients undergoing cesarean delivery than vaginal delivery.[4]

Question 33

consequences of maternal parvovirus b19 infection?

Answer 33

Effects include foetal anaemia, cardiac failure and hydrops foetalis

Question 34

Risk factors for cord prolapse include:

Answer 34

prematurity
multiparity
polyhydramnios
twin pregnancy
cephalopelvic disproportion
abnormal presentations e.g. Breech, transverse lie

Question 35

Severe abdominal pain in a postpartum patient that is not responsive to conventional pain relief is a relatively common presentation of ….

give most common cause

Answer 35

puerperal sepsis originating in the urogenital tract.

Group A Strep (Strep Pyogenes) is the most commonF

Question 36

first ultrasound scan for mum…

when is it and what does it aim to do ?

Answer 36

10 - 13+6 weeks

It aims to detect multiple pregnancies, determine gestational age and measure nuchal translucency.

It estimates the gestational age based on the crown-rump length ofthe foetus

Question 37

if previous Gestational diabetes how should you appraoch testing for it in upcoming pregnancy ?

what would you screen for ?

Answer 37

if women have previously had GDM then offer OGTT as soon as possible after booking.

If no previous GDM, but other risk factors then offer OGTT at 24-28 weeks

Risk factors:
BMI over 30 kg/m2, previous macrosomic baby weighing over 4.5 kg, previous GDM, family history of diabetes and an ethnicity with a high prevalence of diabetes

Question 38

explain induction of labour and when you would do what

Answer 38

Bishop’s score (how progressed the woman is)

for all women you do…

1. Membrane sweep to stimulate physiological prostaglandins

Bishops < 6 means not that progressed…. therefore you would give:

• prostaglandin E1
  ((Tablet or Gel (Prostin®) or Pessary (Propess®) ((Risk of uterine hyperstimulation with dinoprostone and misoprostol))
• if don’t want prostaglandin can offer mechanical induction to break waters… (cervical ripening balloon(CRB)),

Bishops > 6 this means that decently advanced so you can jumpt straight to….

Artificial rupture of membranes (ARM) Amniotomy (* Only possible if the cervix is beginning to dilate and efface) use an amnihook

do this followed by IV Syntocinon (synthetic oxytocin) which promotes contractions

Question 38

if combined test results in high suspicuous of Downs what Ix do you do

Answer 38

amniocentesis (15-20 weeks) or chorionic villus sampling (11- 14 weeks)

check gestational of mother to see which one is best to offer

Question 39

most common cause + 2nd most common of secondary post partum haemorrhage

Answer 39

endometritis

retained products of conception

Question 40

26 y/o female non painful lump, 2 weeks, unconfortbale to sit down, soft lump less than 1 cm in size, just left of the vaginal introitus. There is slight tenderness on palpation

Answer 40

bartholin’s cyst

Question 40

gold standard for cerebral palsy

Answer 40

An MRI head is the gold standard investigation for suspected cerebral palsy

Question 41

duchenne vs becker musclar dystrophy ?

Answer 41

duchenne is much more severe and present < 5 y/o
- calf pseudohypertrophy
- Gower’s sign: child uses arms to stand up from a squatted position

Becker’s less severe, develops after the age of 10 years

Question 42

name of the surgery for hirschprung’s

Answer 42

The treatment procedure is called an anorectal pull-through, and involves an initial colostomy followed by anastomosis of normally innervated bowel to the anus.

Question 42

neonatal jaundice how do you investigate ?

Answer 42

depends on when it develops

< 24 hours of life - serum measurement is appropriate (or when the baby was born before 35 weeks’ gestation)

> 24 hours of life - transcutaneous bilirubinometery (or the gestational age is more than 35 weeks)

• Transcutaneous bilirubin is a Non-invasive method of measuring bilirubin which is more pleasant for the neonate

Question 43

opthalmia neonatorum - which pathogen is most likely and how does this effect management ?

Answer 43

Chlamydia is more common and presents between 5 days and 2 weeks after birth
= The first-line treatment is oral erythromycin for 14 days

Gonococcal conjunctivitis presents within the first 24 hours and up to 5 days after birth.
= IV cefotaxime

Before receiving the culture results, topical chloramphenicol eye ointment may be applied to the eyes if there is evidence of inflammation or purulent discharge.

Question 44

tonic-clonic or myoclonic generalised seizures what is first line ?

Answer 44

sodium valproate

Question 45

focal seizure management ?

Answer 45

Focal seizures are treated with carbamazepine or lamotrigine.

Question 46

how does bronchiolitis present ? signs sx ix

Answer 46

The clinical features include a dry cough and increasing breathlessness. This episode is often preceded by a coryzal illness, and parents may report a recent history of rhinitis, nasal obstruction, sneezing and/or sore throat. As the infant becomes dyspnoeic, feeds become increasingly difficult.

On examination, the infant is likely to be tachypnoeic and tachycardic. Subcostal and intercostal recession may be observed, as well as hyperinflation of the chest.

Fine end-inspiratory crackles may be auscultated, and a high-pitched expiratory wheeze may be present

Question 47

how to manage catatonia ?

Answer 47

The first-line treatment option for catatonia is a benzodiazepine such as lorazepam. If the benzodiazepines are ineffective, electroconvulsive therapy should be considered.

Question 48

post delivery, woman bleeds + maternal shock + lump protruding at vaginal introitus - what is it ?

Answer 48

uterine inversion

a serious complication of the third stage of labour, where the uterine fundus prolapses

uterus should be manually reduced and if this is ineffective then surgery

this must not be confused with uterine involution where uertus shrinks during the first month after delivery. The trend of involution in primiparous and multiparous women is similar; however, in multiparous women, it lasts longer than 6–8 weeks

Question 49

rate of cervix dilation for multiparous woman?

Answer 49

cervix of a multiparous woman to dilate at around 1 cm per hour

Question 50

time periods where IUS can be inserted post delivery

Answer 50

The levonorgestrel intrauterine system (LNG-IUS) can be inserted within 48 hours of birth or after 4 weeks. It is effective immediately and is not contraindicated whilst breastfeeding

Question 51

next step once mother has perineal tear ?

Answer 51

Once identified, the next most appropriate step in assessing a perineal tear is to perform a digitalrectal examination (DRE) to assess the extent of involvement of the anal canal

Question 52

neonatal vesicles and pustules often involving the face and mouth (+ milia) - what disease ?

Answer 52

herpes simplex virus

Neonatal herpes simplex infection can manifest in three main forms: localised to the skin, eyes and mouth (SEM), localised to the central nervous system (i.e. encephalitis) and disseminated infection

Question 52

perineal tear degree classifications

Answer 52

First
Perineal skin and/or vaginal mucosa

Second
Perineal muscles, no involvement of anal sphincter

Third
Involvement of anal sphincter
●3A<50% of external anal sphincter
●3B>50% external anal sphincter
●3CExternal and internal anal sphincter

Fourth
Involvement of anal sphincter and anorectal mucosa

Question 53

cutaneous scarring, microcephaly and limb hypoplasia of neonate

Answer 53

congenital varicella zoster infection

Question 54

what is A boggy uterus

Answer 54

A boggy uterus refers to an enlarged, soft, and tender uterus identified during physical examination. It is most commonly caused by uterine atony or adenomyosis.

Question 55

explain the basis of the staining during colpsoscopy when looking for CIN

Answer 55

During colposcopy insert speculum

add acetic acid - presence of ‘egg-white’ (aceto-white) lesions indicates the presence of an abnormal nuclear: protein ratio within cells.

Lugol’s iodine is then used to stain the cervix. The Iodine binds to glycogen (which is present in normal cells), resulting in a chemical reaction that turns cells brown.

However, abnormal cells lack glycogen, so these cells remain yellow.

A cervical biopsy will be taken simultaneously for histological analysis, to determine the grade of CIN

Question 56

how does roseola infantum present ?

Answer 56

recent febrile illness

macular rash which appears as the child starts to recover. The rash begins on the chest and abdomen, and spreads to the limbs over days.

caused by human herpes viruses 6 and 7 (HHV6 and HHV7)

Question 57

roseola infantum vs measles/rubella

Answer 57

Roseola infantum is often misdiagnosed as measles or rubella. These are unlikely diagnoses, given that in both diseases, the rash typically begins on the face and appears simultaneously with the fever, not afterwards.

Furthermore, the child is vaccinated, making these differentials less likely

Question 58

mx sickle cell crisis ?

Answer 58

1. ANALGESIA (Opioids)
2. fluids
3. oxygen

Question 59

ix for perthes with findings

Answer 59

If Perthes disease is suspected, an X-ray of both hips should be requested (including anteroposterior and frog leg lateral views). This characteristically shows increased density of the femoral head, which may be fragmented as a result of necrosis

Question 60

safety netting with mumps diagnosis ?

Answer 60

It is recommended that patients stay away from school or work for 5 days following the onset of parotitis.

Key red flags that parents should be warned about include signs of meningism and epididymo-orchitis in males

Question 61

outline section 5(2) and 5(4)

Answer 61

Section 5(2) can be used by a doctor for patients under their care. It lasts for 72 hours, allowing time for assessment.

Section 5(4) is used by nurses to detain patients for up to 6 hours to allow time for further assessment, and further sections to be implemented by the relevant staff

Question 62

mx = neuroleptic malignant syndrome

Answer 62

Neuroleptic malignant syndrome (NMS) is characterised by hyperthermia, confusion, muscle rigidity and autonomic instability. It usually occurs after treatment with dopamine antagonists (e.g. haloperidol). NMS can lead to a number of life-threatening consequences -for example, the muscle rigidity can lead to rhabdomyolysis, acute kidney injury and hyperkalaemia.

The first-step in the management of NMS involves stopping the offending drug.

The remainder of treatment is largely supportive with the use of external cooling devices and rehydration with IV fluids

Question 63

drug for dementia with lewy bodies

Answer 63

rivastigmine

Question 64

scizoaffective disorder vs scizophrenia

Answer 64

schizoaffective - they have mood sx (e.g. depression, mania, etc… as well as psychosis)

In schizophrenia, there may be negative mood symptoms such as flat affect, social withdrawal, lack of motivation or catatonic behaviour. However, these features are usually less prominent than the psychotic features

Question 65

mx schizoaffective disorder

Answer 65

Schizoaffective disorder is usually initially treated with an antipsychotic (e.g. risperidone) with a mood stabiliser (e.g. lithium). Other examples of mood stabilisers that may be considered include sodium valproate, lamotrigine and carbamazepine

Question 66

important complication of eczema and how to treat?

Answer 66

eczema herpeticum

tx = aciclovir

Question 67

how to investigate underlying cause of someone presenting with bronchiectasis

Answer 67

Investigating the underlying cause
* Sweat chloride test or genetic testing for CF
o Should be offered to all children
* Screen for antibody deficiency
o IgG/ IgA/ IgM
o Done for all patients with confirmed diagnosis
* Test for primary ciliary dyskinesia in children
o Only if no other cause for bronchiectasis is found and if there is a history of continuous rhinitis, neonatal respiratory distress, and/or dextrocardia

Question 68

what congenital heart defect in turners

Answer 68

bicuspid aorta

Question 69

what is Henoch Schonlein Purpura**
and how does it present ?

Answer 69

IgA mediated vasculitis
In children 3-15 yrs
Preceding URTI → glomerulonephritis
Triad of:
* Purpuric rash on lower limb extensors + buttocks
* Abdo pain
* Arthralgia

Question 69

nasal polyps ?

Answer 69

cystic fibrosis

Question 69

when does puberty start ?

Answer 69

Puberty starts age 8 – 14 in girls and 9 – 15 in boys

Question 69

physiological abnormalities in anorexia

Answer 69

Physiological abnormalities:
* hypokalaemia
* low FSH, LH, oestrogens and testosterone
* raised cortisol and growth hormone
* impaired glucose tolerance
* hypercholesterolaemia
* hypercarotinaemia
* low T3

Question 70

week old baby is seen for his routine baby check in General Practice with his mother. She has no concerns. A soft systolic murmur is heard on examination. It varies with posture and does not radiate

Answer 70

innocent murmur

Question 70

what is important to bear in mind when switching some antidepressants

Answer 70

• Be especially cautious when switching the following antidepressants:

o From fluoxetine to other antidepressants (as fluoxetine has a long half-life). NICE recommends a washout period of 4-7 days with NO antidepressant before starting a low dose of another SSRI

o From fluoxetine or paroxetine to a TCA (both drugs inhibit TCA metabolism so a lower starting dose may be needed to reduce risk of serotonin syndrome)

o To a new serotoninergic antidepressant or MAOI (because of risk of serotonin syndrome)

o From non-reversible MAOI: a 2-week washout period is required (other antidepressants should not be prescribed during this period)

Question 70

can you just stop an antidepressant drug immediately ?

Answer 70

Discontinuation syndrome is a collection of unpleasant symptoms that occur from suddenly discontinuing an antidepressant. Such symptoms include flu-like symptoms, insomnia, tremors, vertigo, and irritability. This can be prevented by reducing the dose over a 4-
week period. Discontinuation syndrome is more common with paroxetine and venlafaxine.

Question 71

what is this thought disorder

‘Doctor, that’s a difficult question. When I woke up at 7am, I thought about how much I’d like to make myself a boiled egg. I watched the news for a bit, and then found my favourite leather shoes. Later on I popped over to Tesco to get some fruit, and after that I came here to discuss a change in my medication’

Answer 71

circumstantiality

long winded but eventually you answer the question

Question 72

I’m really hungry I want fish, you know fish swim in the sea, the sea is blue, blue sky

Answer 72

flight of ideas

common in mania

Question 73

pressure of speech

Answer 73

Pressured speech is when you talk faster than usual. You may feel like you can’t stop. It’s different than talking fast because you’re excited or you naturally speak that way. You might jump from one idea to the next. People could have trouble following the conversation

common in mania

Question 74

Derailment (loosening of associations)

Answer 74

the phrases don’t have connection - it doesn’t make sence

schizophrenia

Question 75

forceps vs ventouse delivery

Answer 75

this is about position. you want to delvier occiput anterior (OA)

ventouse delivery allows rotation - this involves attaching a suction cup to the head and applying traction to rotate the foetus.

Neville Barnes forceps do not allow rotation and can only be used for occipito-anterior positions.

The requirements for delivery with Neville Barnes forceps can be remembered with the mnemonic
FORCEPS: Fully dilated, Occipito-anterior position, Ruptured membranes, Cephalic presentation, Engaged presenting part, adequate Pain relief, and Sphincter (empty bladder).

NB: Kielland forceps are rotational forceps that can turn the baby to an occipito-anterior position but are rarely used due to the risk of perineal tears and need for episiotomy

Question 75

what is the most sensitive screening test for genetic abnormalities like downs syndrome in a fetus ?

Answer 75

non invasive pre natal testing

Question 76

outline post dural tap headache

Answer 76

Postdural puncture headache is a potential complication of a lumbar puncture, with symptoms caused by traction on pain-sensitive structures from low cerebrospinal fluid pressure (intracranial hypotension) following a leak of cerebrospinal fluid at the puncture site.

Symptoms of this condition include a bilateral frontal or occipital headache that is worse in the upright position, along with nausea, neck pain, dizziness, visual changes, tinnitius, hearing loss, or radicular symptoms in the arms

Question 77

stress incontinuence mx

Answer 77

• 1st line: Pelvic floor muscle training
• Supervised training involving least 8 contractions performed 3 times per day for a minimum of 3 months (continue for longer if beneficial)
• 2nd line: Surgical procedures (only initiated by 2° services)
   Colposuspension - sutures are used to lift the neck of the bladder and fix in place to Cooper’s ligaments
   Autologous rectus fascial sling - elevate the urethra
   Retropubic mid-urethral mesh sling - elevate the urethra
   Intramural urethral bulking agents - injection of a bulking agent around the urethra
  F/U for all surgeries should happen within 6 months
• 3rd line: Duloxetine (enhances sphincter contraction) then r/v in 2-4 weeks if unsuitable for surgery/prefer pharmacological to surgical Rx

Question 77

when should oxytocin be admiintereed in active third stage of labour ?

Answer 77

after delivery of the baby’s anterior shoudler

Question 78

A 34 year old woman has an evacuation of retained products of conception, which are sent for cytogenetics. She is told she had a molar pregnancy. Which is the most appropriate follow up?

Answer 78

serial quantitative hBCG measurements

Question 79

A 5 month old baby who is unvaccinated is in the Paediatric Emergency Department following apnoeic episodes with coughing at home. What is the most likely causative organism?

Answer 79

Bordetella pertussis

Question 80

threadworm mx

Answer 80

mebendazole to household

Question 80

mx for milia

Answer 80

nothing

Question 81

asymptoatmic nappy rash if conservative measures have been tried ?

Answer 81

Zinc and Castor oil ointment BP

Question 82

A 28 year old woman with a twin IVF pregnancy has a scan at 18 weeks gestation. This shows a marked difference in foetal size with oligohydramnios in one twin and polyhydramnios in the other twin. What is the most likely diagnosis?

Answer 82

Twin-twin transfusion syndrome

Twin-twin transfusion syndrome (also called TTTS or twin to twin transfusion syndrome) is a condition in which the blood flows unequally between twins that share a placenta (monochorionic twins). TTTS occurs in about 10 to 15 percent of monochorionic, diamniotic (two amniotic sacs) twins.

Question 82

A 30 year old woman in the third trimester of her first pregnancy develops an itchy, bumpy rash on her abdomen, with sparing of the periumbilical area. She is usually fit and well and has had an uneventful pregnancy so far. What is the most likely diagnosis?

Answer 82

Pruritic urticarial papules and plaques of pregnancy occur most often during the last month of pregnancy and only rarely appear in the postpartum period. The rash consists of itchy small erythematous and edematous papules and plaques usually first start in the stretch marks, typically with periumbilical sparing.

Question 82

child presents with lump behind ear - what is it ?

Answer 82

mastoiditis

complication of acute otitis media –> treat with abx

Question 83

lymph nodes in infection vs lymphoma ?

Answer 83

lymphoma is painless lymph nodes (Hodkins can be painful when drinkning alcohol)

Question 84

Kid with 2cm mass (inframandibular) on left side, painful – blood film shows: toxic left shift with reactive neutrophilia.

lymphoma or lymphadenitis

Answer 84

lymphadenitis

Question 85

child has 5 min seizure, stopped when ambulance arrived so they didn’t do anything - he comes to hospital - now what can you do for him ?

Answer 85

Children with prolonged epileptic seizures (convulsive seizures with loss of consciousness > 5 mins) are given rescue therapy to keep with them

 This is usually buccal midazolam

then you can just discharge them after this…

Question 86

status epilepticus pathway

Answer 86

• Step 1: (0 min)
  o Secure airway
  o Check ABC, high flow Oxygen2 if available
  o Check blood glucose
  o Confirm clinically that it is an epileptic seizure
• Step 2: (5 min)
  o If IV access, IV lorazepam
  o If NO immediate IV access:
   Buccal midazolam
   Rectal diazepam
• Step 3: (15 min)
  o if no response, give a second dose of IV lorazepam
  o Call for senior help
  o Start to prepare phenytoin for step 4
  o Re-confirm it is an epileptic seizure
• Step 4: (25 min)
  o Seek senior anaesthetist / inform ICU
  o Phenytoin 20 mg/kg by intravenous infusion over 20 mins
   or (if on regular phenytoin): Phenobarbital 20 mg/kg intravenously over 5 mins
  o Consider rectal paraldehyde 0.8 ml/kg
• Step 4: (45 min)
  o Rapid sequence induction of anaesthesia using thiopental sodium
• Consider dexamethasone if vasculitis/cerebral oedema is possible
• NOTE: treat reversible causes if identified (e.g. thiamine if malnourished or glucose if hypoglycaemic)

Question 87

precocious puberty differential

Answer 87

Central Precocious Puberty (CPP):

Idiopathic (most common, especially in girls)
Brain tumors or lesions (e.g., hypothalamic hamartoma)
Central nervous system abnormalities (e.g., hydrocephalus, radiation therapy)
Genetic mutations
Peripheral Precocious

Puberty (PPP):

Hormone-secreting tumors (e.g., adrenal or gonadal tumors)
Congenital adrenal hyperplasia
McCune-Albright syndrome
Exogenous hormone exposure (e.g., estrogen or testosterone creams)

Other Causes:

Hypothyroidism
Genetic factors
Obesity

Question 88

factors associated with poor prognosis in schizophrenia

Answer 88

strong family history
gradual onset
low IQ
prodromal phase of social withdrawal
lack of obvious precipitant

Question 89

how long to take antidepressant for ? when do you start feeling effects ?

Answer 89

It usually takes around 7 days before you begin to notice the effects of antidepressants.

Contact your doctor if you have not noticed any improvement after 4 weeks, as they may recommend increasing your dose or trying a different antidepressant.

It’s usually recommended that a course of antidepressants continues for at least 6 months after you feel better, to prevent your condition recurring when you stop.

Some people with recurrent illness are advised to carry on taking medicine indefinitely.

Question 90

Pregnant lady with bullous rash on R forearm, started at umbilicus and spread from there

Answer 90

Pemphigoid gestationis

Question 91

aftercare following vaginal hysterectomy

Answer 91

Recovery after vaginal hysterectomy is shorter and less painful than it is after an abdominal hysterectomy. A full recovery might take three to four weeks. Even if you feel recovered, don’t lift anything heavy — more than 20 pounds (9.1 kilograms) — or have vaginal intercourse until six weeks after surgery

Question 92

Woman with controlled hypothyroidism presents to GP as just fell pregnant, what should be done about her levothyroxine during pregnancy?

Answer 92

continue dose and check TFTs to see how much to change to …

 Continue thyroid replacement therapy
 Adjust dose throughout pregnancy according to TFTs
* It is typical to increase the dose of thyroxine by 25 micrograms.

Question 93

what is follow up for is you have CIN and get LLETZ ?

Answer 93

Requires a test of cure 6mo later (smear)

Question 94

pregnant woman falls over but she’s completely fine - what should you also be thinking about ?

Answer 94

what is her rhesus status - do I need to give anti-D

Question 95

best test for predicting pre term labour ?

Answer 95

Fetal fibronectin (FFN) acts as a ‘glue’ between the pregnancy and the uterus. Normally very low levels of FFN can be found in secretions of the vagina and cervix. Raised levels at or after 22 weeks have been associated with an increased risk of spontaneous preterm birth.

Question 96

molluscum contagiosum mx

Answer 96

• Does not require treatment if immunocompetent (it is self-limiting), with spontaneous resolution usually occurs within 18 months

Question 97

Small child with UTI, name test where dye is injected into urinary tracts to visualise them

Answer 97

Micturating cystourethrogram

Question 98

scoting system for croup ?

Answer 98

Westley Croup Score

Question 99

persistent delusions that are not related to any other psychiatric condition. Psychotic symptoms such as hallucinations are not typically present in this diagnosis.

Answer 99

Delusional Disorder: Delusional disorder is a rare mental illness characterized by persistent delusions that are not related to any other psychiatric condition. Psychotic symptoms such as hallucinations are not typically present in this diagnosis.

Question 100

Best opiate replacement (OST) for 6 week pregnant lady on a menagerie of other drugs?

Answer 100

methadone or buprenorphine

Question 101

on baby’s head what are suture lines like on the front and back ?

Answer 101

anterior = 4 suture lines

posterior = 3 suture lines

Question 102

ovarian multi loculated cyst seen on USS - what do you do ?

Answer 102

Complex (i.e. multi-loculated) ovarian cysts should be biopsied to exclude malignancy.

Question 103

Androgen insensitivity syndrome

Answer 103

Androgen insensitivity syndrome is an X-linked recessive condition due to end-organ resistance to testosterone causing genotypically male children (46XY) to have a female phenotype. Complete androgen insensitivity syndrome is the new term for testicular feminisation syndrome

Features
‘primary amenorrhoea’
little or no axillary and pubic hair
undescended testes causing groin swellings
breast development may occur as a result of the conversion of testosterone to oestradiol

Question 104

what to give in severe croup?

Answer 104

nebulised adrenaline

+ oxygen

Question 105

define personality disorder

Answer 105

Personality disorders may be defined as a series of maladaptive personality traits that interfere with normal function in life

Question 106

how long is normal grief reaction ?

Answer 106

can be many months - year

prolonged grief: difficult to define. Normal grief reactions may take up to and beyond 12 months

Question 107

PHQ-9 = 6, what does this mean ?

Answer 107

less severe depression - probs just CBT but can consider SSRIs as welll

Question 108

how to manage fibroid in preganncy ?

Answer 108

Uterine fibroids are sensitive to oestrogen and can therefore grow during pregnancy. If growth outstrips their blood supply, they can undergo red or ‘carneous’ degeneration.

This usually presents with low-grade fever, pain and vomiting. The condition is usually managed conservatively with rest and analgesia and should resolve within 4-7 days.

Question 109

how long until you can conceive again after having tx for ectopic - and what is this medical treatment ?

Answer 109

methotrexate

can’t conceieve for 3 months !!!

Question 110

if suspecting endometrial cancer and Outpatient endometrial sampling fails because of cervical stenosis - what do you do?

Answer 110

bring them into hospital

hysteroscopy with dilatation and curettage

Question 111

options for hyperemessi gradivdarum ?

Answer 111

• antihistamines: oral cyclizine or promethazine
• phenothiazines: oral prochlorperazine or chlorpromazine
• ondansetron

Question 112

82. 29 y/o woman with past history of cocaine and cannabis use denies using for the past 3 years. Which additional test should be done for this patient at booking?

Answer 112

Hep C

Question 113

22. A 3 y/o boy in GP has left-sided neck lump on a background of 6 days of coryza, cough, and mild fever, but no systemic symptoms. Temperature 37.0, HR 105, capillary refill <1s, RR 26, O2 sats 99% on room air. ENT exam is normal and chest is clear. He has a single enlarged lymph node in the left posterior chain. What is the most appropriate next step in management?

Answer 113

lymphadenitis

wathcful waiting

Question 114

92. 25 y/o woman who is 38 weeks pregnant is seen in triage for irregular painful contractions lasting 6 hours. She took paracetamol 6 hours ago. She is examined and found to be 2cm dilated. Which analgesia is most appropriate?
    a. Co-dydramol
    b. Epidural analgesia
    c. Nitrous oxide
    d. NSAID
    e. Warm bath

Answer 114

a. Co-dydramol

Question 115

what congenital heart defect in turners ?

Answer 115

bicuspid aortic valve

Question 116

5. 5 y/o boy has a systolic murmur which is soft and audible at the left sternal edge. The boy is asymptomatic. What is the most likely diagnosis?

Answer 116

Innocent murmur

Question 117

Child has symptoms of perennial rhinitis (blocked nose, nasal voice, running eyes). What is the most likely causative allergen in this scenario?

Answer 117

perennial = dust mites

also seasonal and occupational

seasonal = hay fever (pollen)

Question 118

8. 2 y/o girl has a fever of 39.7 and a painful, swollen right eye with preserved eye movements (see picture below). What is the most appropriate first-line treatment?

Answer 118

oral co amoxiclav

Question 119

11. A ‘clunk’ is felt when examining the hips of a 48 hour old baby at the routine check. Which investigation should now be requested?

Answer 119

USS of the hip

Question 120

14. Mother with SLE has a baby who is born with a slow heartbeat. What is the most likely diagnosis?

Answer 120

Congenital heart block

Question 121

24. 97 y/o woman has dementia and frequently tries to leave her nursing home an 03:00 in her nightgown to feed the swans. What legal framework may be considered in order to prevent her from leaving?

Answer 121

Deprivation of Liberty Safeguards

Question 122

what is it called when you think you aren’t real ?

Answer 122

Depersonalization-derealization disorder

Question 123

36. 78 y/o woman has 2 weeks of progressive lethargy, nausea, and dizziness. She has depression and has recently increased her dose of Citalopram. What is the most likely biochemical abnormality?

Answer 123

Hyponatraemia

Question 124

40. 16 y/o attends GP with difficulties at college: she fears sitting on public transport and feels scared to leave her house. She avoids the supermarket and now does her grocery shopping online. What is the most likely diagnosis?

Answer 124

Agoraphobia

Question 125

45. 35 y/o woman has frothy and thin offensive yellow vaginal discharge. She is afebrile and last has sexual intercourse 3 weeks ago. She describes dysuria for the last few days and soreness and itchiness of her vulva. What is the most likely diagnosis?

Answer 125

Trichomonas vaginalis infection

Question 126

48. 8 y/o girl brought to gynaecology clinic with offensive vaginal discharge, but is otherwise well. What is the most likely cause?

Answer 126

Vaginal foreign body

Question 127

how to calc due date for pregancy from last menstrual period

Answer 127

add 9 months + 7 days from the last menstrual period if 28 day cycle

+ 14 days if its a 35 day cycle

Question 128

52. 32 y/o with mild asthma has unexplained intra-uterine death at 37 weeks gestation. She is induced and has epidural analgesia and a spontaneous vaginal delivery. She is very distressed and would like to go home. What should be given to prevent her from expressing breast milk in this scenario?

Answer 128

Cabergoline

Question 129

57. 19 y/o woman with intra uterine device in situ presents to GP with new onset low abdominal pain and spotting. Temperature 36.3, HR 83, BP 110/90, RR 18, O2 sats 98% on room air. What is the most appropriate initial investigation?

Answer 129

Urinary beta-hCG

Question 131

what can be offered for short cervix / mid trimester pregnancy loss?

Answer 131

This patient has a background of mid-trimester pregnancy loss and the ultrasound scan reveals a short cervix (< 25 mm at 16-24 weeks’ gestation).

The most appropriate option in this case would be cervical cerclage -this involves placing a band around the cervix to maintain its integrity.

A plan should be in place to remove the suture. The patient should be advised to present to labour ward immediately if she begins to experience contractions, as they are at risk of developing a cervical tear.

Vaginal progesterone is another option that can be offered to patients with a short cervix and a history of mid-trimester pregnancy loss

Question 132

cyclical vs continuous HRT ?

Answer 132

Cyclical combined HRT is recommended in peri-menopausal women. Since this patient has not had periodsfor the past 18 months, she is now post-menopausal and should receive continuous combined HRT

Question 133

A transvaginal ultrasound scan indicates an endometrial thickness of 9 mm and, following a biopsy, she is diagnosed with endometrial hyperplasia with no atypia.

mx?

Answer 133

IUS

Question 134

how to manage urge incontinence in frail elderly women ?

Answer 134

Often, the first bladder-stabilising drugs to be offered at antimuscarinics such as tolterodine, darifenacin and oxybutynin, however, these are generally avoided in frail and elderly women as it can increase their risk of falls. Mirabegron, a beta-3 agonist, is a suitable alternative. If symptoms fail to resolve with medical treatment, interventions such as botox injections and percutaneous tibial nerve stimulation should be considered

Question 135

pregnant women with UTI - what do you give and how long ?

Answer 135

nitrofurantoin 7 days

Question 136

what hapens if mum gets herpes during pregnancy ?

Answer 136

For patients presenting with a primary infection in the 1stor 2ndtrimester, oral aciclovir is recommended from 36 weeks’ gestation until delivery with a vaginal delivery anticipated. For patients presenting in the 3rdtrimester, oral aciclovir should be commenced
Distributing this file can amount to a criminal offence©Make a Medic. Reg: 1192343immediately until delivery. For all patients developing a first episode of genital herpes in the 3rdtrimester (especially if within 6 weeks of delivery), C-section is the recommended mode of delivery to reduce the risk of transmission to the foetus. Invasive procedures such as instrumental delivery should be avoided if there are genital lesions. Recurrent episodes of genital herpes do not require a C-section delivery however oral acyclovir should be considered from 36 weeks onwards

Question 137

if pregnant woman gets PE/DVT what ix do you do ?

Answer 137

This patient has developed features of both a DVT and a PE. There are considerable risks associated with both CTPAs and VQ scans in pregnancy. CTPAs are associated with an increased risk of breast cancer in the mother and VQ scans are associated with an increased risk of childhood cancer. If the patient has features of DVT, they should undergo a duplex ultrasound scan to confirm the presence of a DVT as this does not involve exposing the patient to radiation

Question 138

new name for hypochondriasis disorder ?

Answer 138

Illness anxiety disorder (previously known as hypochondriacal disorder

Question 139

vaginal candidiasis in pregnant lady tx ?

Answer 139

intravaginal clotrimazole

This patient has features suggestive of vulvovaginal candidiasis (thick white vaginal discharge and vulvar itching). As the patient is also pregnant, intravaginal antifungal treatments are preferred over oral options.

Question 140

mastitis mx ?

Answer 140

This patient has likely developed mastitis due to milk stasis. The most effective treatment is to continue breastfeeding to encourage the passage of milk and relieve milk duct obstruction. This will not harm the baby.

As the symptoms have persisted for over hours despite adequate milk expression, oral antibiotics are indicated. Flucloxacillin is usually used in the first instance.

Question 141

tx for balanitis ?

Answer 141

hydrocortisone
topical clotrimazole