Get ahead! Specialties questions Flashcards
A 26-year-old multigravid woman is in spontaneous labour at 41 weeks. She has no antenatal risk factors with normal ultrasound scans. On examination, the head is 2/5th palpable per abdomen. She has a spontaneous rupture of membranes at 3 cm with heavily blood-stained liquor. The CTG shows significant abnormalities. The midwife performs a vaginal examination and there is no cord protruding through the cervix which is now 4 cm dilated. The mother feels no pain. What is the most likely diagnosis? A. Bloody show B. Placental abruption C. Placenta praevia D. Uterine rupture E. Vasa praevia
Vasa praevia -
The risk of vessels tearing is greatest when cervical dilation occurs and at rupture of membranes. A severely abnormal cardiotocograph (CTG) is seen with a small amount (,500mL) of painless vaginal blood loss. Because it is fetal blood that is lost in vasa praevia, fetal mortality is very high (35–95%) while there is little risk to the mother. A Caesarean section must be performed immediately and the neonate transfused. There is no specific investigation for vasa praevia, so the diagnosis is clinical and only confirmed when the placenta and membranes are examined after Caesarean section.
Which of the following conditions is an indication for routine delivery by Caesarean section?
A. Hepatitis C virus
B. Maternal request
C. Preterm birth
D. Previous Caesarean section
E. Twin pregnancy with first twin breech and second twin cephalic
Twin pregnancy with first twin breech and second twin cephalic -
A Caesarean section should be routinely offered to the following women:
† HIV with or without other concurrent infections
† Primary genital herpes in the third trimester (NB not a secondary attack)
† Placenta praevia major, i.e. grade 3 or 4
† Twin pregnancy where the first baby is breech
† Singleton breech at term but only after external cephalic version has been
offered and failed or contraindicated
These women should not routinely be offered a Caesarean section:
† Twin pregnancy where the first twin is cephalic
† Preterm birth
† Small for gestational age baby
† Hepatitis B virus without HIV
† Hepatitis C virus without HIV
† Recurrent genital herpes at term
A 25-year-old woman attends the GUM clinic complaining of increased vaginal discharge which has an unpleasant odour. She says sexual intercourse with her partner is uncomfortable. A swab is taken and sent to the lab. On direct microscopy a flagellated protozoan is seen. Which is the most likely pathogen? A. Candida albicans B. Chlamydia trachomatis C. Gardnerella vaginalis D. Neisseria gonorrhoeae E. Trichomonas vaginalis
Trichomonas vaginalis -
Trichomoniasis is a sexually transmitted infection caused by the flagellated protozoan Trichomonas vaginalis, which invades superficial epithelial cells of the vagina, urethra, glans penis, prostate and seminal vesicles. Affected females present with an offensive frothy greeny-grey discharge, vulval soreness, dyspareunia, dysuria, vaginitis and vulvitis, although some are asymptomatic. On examination, the cervix may have a punctate erythematous (strawberry) appearance. Males are mostly asymptomatic. Diagnosis is by direct microscopy or culture of vaginal exudate. Treatment is with metronidazole.
A 57-year-old woman presents with a history of having to run to the toilet and occasionally not getting there in time. She needs to wear pads every day and this is negatively impacting on her life. She also complains of waking up two or three times per night to pass urine. She has had two children by normal delivery and has never had any surgery on her bladder. She says she has been doing occasional pelvic floor exercises with little success.
Considering her diagnosis, what is the first-line treatment?
A. Bladder training
B. Botulinum toxin
C. Oxybutynin
D. Pelvic floor exercises with a trained physiotherapist
E. Tolteridone
Bladder training -
This lady is suffering from an overactive bladder (OAB), also known as detrusor instability, unstable bladder or hyperactive bladder. First-line treatment is bladder training for 6 weeks.
You are looking at a CTG of a woman of 39 weeks gestation who has come to the antenatal day unit as she has had reduced fetal movements. There is a baseline rate of 170. There are four accelerations in a 20-minute section. The variability is over 10 beats. There are no decelerations.
What could explain the features of this trace?
A. Maternal pyrexia
B. Normal trace
C. Pre-terminal trace
D. Sleep pattern of fetus
E. Thumb sucking of fetus
Maternal pyrexia
You are examining a woman in established labour with the midwife and she asks you to tell her how you would describe the examination. The cervix is fully dilated. Anteriorly you feel a diamond-shaped fontanelle and if you follow a line posteriorly you can then feel a Y-shaped depression in the skull bones. How is the position best described? A. Brow B. Left occipitotransverse C. Occipitoanterior D. Occipitoposterior E. Right occipitotransverse
Occipitoposterior
In which anatomical location does fertilization normally occur?
A. Ampulla of fallopian tube
B. Cervix
C. Fimbriae of fallopian tube
D. Infundibulum of fallopian tube E. Uterus
Ampulla of fallopian tube
A 21-year-old lady at 40 weeks þ 12 days is being induced. She has received two doses of prostaglandins after examination revealed a low Bishop score. She is experiencing mild contractions with good fetal movements. Her CTG trace is reactive. She is fed up, tired and is becoming angry with the midwives as she thought she would have delivered sooner. On abdominal palpation there is cephalic presentation with two-fifths palpable. On vaginal examination after the second dose of progesterone she is 3 cm dilated with a partially effaced cervix. What would be the next course of action? A. Artificial rupture of membranes B. Caesarean section C. Further prostaglandin D. Observation alone E. Oxytocin
Artificial rupture of membranes -
Induction of labour is offered if pregnancy continues past 40 weeks þ 12 days. The process involves vaginal prostaglandins with artificial rupture of membranes (ARM) and use of oxytocin. This lady has received two doses of vaginal prostaglandins (PGE2) to initiate contractions and encourage cervical ripening. The tablets are 3 mg and are given 6–8 hourly with a maximum dose of 6mg/day. They have clearly worked as she has progressed from a low Bishop score to a cervical dilation of 3 cm. If women are progressing well with strong contractions no other action is needed, however if there is slow progress with minimal contractions (in this case) an ARM can be performed and an oxytocin infusion is used to maintain the contractions after membrane rupture. Further prostaglandins are contraindi- cated due to the risk of hyperstimulation as she already feels some uterine activity.
Which measurement is the most reliable indicator of gestational age in the first trimester? A. Biophysical profile B. Biparietal diameter C. Crown–rump length D. Femur length E. Nuchal translucency
Crown–rump length
A 32-year-old lady returns to the gynaecology clinic to find out the results of her cervical screening test. You see her report says moderate dyskaryosis.
What would be the next stage in her management?
A. Colposcopy
B. Recall in 6 months
C. Recall in 1 year
D. Recall in 3 years
E. Repeat the test today
Colposcopy -
If a woman aged 25 to 49 years has a normal smear they are called back in 3 years. A woman may be recalled if there are inadequate cells for the study – this would normally be in 6 months. If a diagnosis of mild dyskaryosis is made a repeat is needed in 6 months as these cells often revert to normal without any treatment. If on the repeat test at 6 months the cells still show mild dyskar- yosis, colposcopy will be required. A single diagnosis of moderate or severe dyskaryosis indicates referral to colposcopy. Obviously a diagnosis of invasive carcinoma would require immediate specialist referral. Immunocompromised patients require annual screening.
Which one of the following factors increases your risk of developing ovarian cancer? A. Early menopause B. Late menarche C. Multiparity D. Nulliparity E. Oral contraceptive pill
Nulliparity -
Like all cancers there are numerous risk factors for its development. It may be related to ovulation, due to the repair of the ovarian epithelium required follow- ing each ovulation. This means the more you ovulate the more you increase your risk of developing cancer of the ovary. Hence nulliparity, infertility, late meno- pause and early menarche all increase your risk, whereas risk is lowered by the contraceptive pill, breastfeeding and pregnancy. Pelvic surgery decreases the risk (including hysterectomy, unilateral oophorectomy and sterilization) for reasons that are not fully understood.
The risk of ovarian cancer is slightly increased with a positive family history and this much more significant if there was early onset and more than one primary relative affected. Around 5 to 10% of ovarian cancers have a direct genetic link with the most significant being BRCA1 and BRCA2. Affected women have a life- time risk of up to 50% of developing ovarian cancer, hence close monitoring is needed using CA125 and pelvic ultrasounds.
A 22-year-old woman attends the labour ward for induction of labour as she is 40 weeks þ 12 days. She has had an uncomplicated pregnancy. She has no pain in her abdomen and says that the baby is moving but less than normal. A CTG is performed and the baseline is 135, variability is over 10, accelerations are present and there are no decelerations. You examine her and find a cephalic presentation and a long and closed cervix. What would you like to do next? A. Artificial rupture of membranes B. Elective Caesarean section C. Emergency Caesarean section D. Oxytocin E. Prostaglandin
Prostaglandin -
Prior to IOL the woman’s cervix should be assessed using the Bishop score. If the Bishop score is very low, like this case, IOL involves vaginal prostaglandins (PGE2) as either tablets or gels to initiate contractions and encourage cervical ripening. The tablets are 3 mg and are given 6 to 8 hourly with a maximum dose of 6 mg. The CTG has to be reassuring for prostaglandins to be given and there should be no pain or evidence of contractions otherwise you increase the risk of uterine hyperstimulation.
If women are progressing well they can be left to labour; however, if there is slow progress or the cervix is already dilated on initial examination an artificial rupture of membranes can be performed along with an oxytocin infusion to maintain the contractions. If there has been pre-labour rupture of membranes, the oxytocin can be started regardless of the state of the cervix.
A 27-year-old woman is of 19 weeks gestation. She has a 3-day history of flu-like symptoms with a macular rash over her body. Her doctor takes serological testing. When he has the results he tells her that her baby is at increased risk of sensorineural deafness, cataracts, congenital heart disease, learning difficulties, hepatosplenomegaly and microcephaly. What is the underlying causative agent? A. Chickenpox B. Cytomegalovirus C. Listeria D. Parvovirus E. Rubella
Rubella -
Women develop a non-specific flu-like illness with a macular rash covering their trunk (20 to 50% infections are asymptomatic). Diagnosis is confirmed by serological anti- body testing. Rubella antibodies are checked at booking and postnatal vacci- nation is offered to those with low titres. There is an 80% risk of infection to the fetus if rubella develops in the first trimester, dropping to 25% at the end of the second trimester. Teratogenic effects are worse at earlier gestations, with a 50% risk of abnormalities if the fetus is under 4 weeks, 25% at 5 – 8 weeks, 10% at 9–12 weeks and 1% over 13 weeks. The characteristic abnormalities from maternal rubella infection are sensorineural deafness, cataracts, congenital heart disease, learning difficulties, hepatosplenomegaly, jaundice, microcephaly and spontaneous miscarriage.
The midwife is delivering a term baby. The head has been delivered. Which movement should the midwife wait for before delivering the shoulders? A. Descent B. Extension C. External rotation D. Flexion E. Internal rotation
External rotation -
Stages of labour: Descent – literally descent of the head into the pelvis which usually occurs in the last few weeks of pregnancy in a nulliparous woman but much later in multiparous women
† Engagement – when the maximum transverse diameter of the head has passed below the pelvic inlet. Engagement is when less than two-fifths of the head can be palpated above the pelvic brim abdominally
† Flexion – as the head descends through the pelvis it flexes to give the smallest diameter for easy passage through the pelvis. The posterior fonta- nelle should be palpable vaginally with maximum flexion
† Internal rotation – this is the rotation of the head that occurs in the mid-pelvis from the left occiput transverse (LOT) position it enters the pelvic inlet to the OA position required for easy delivery
† Extension–the head only extends as it reaches the perineum and ‘crowns’ as delivery is imminent
† External rotation (restitution) – on delivery the fetal head reverts back to its earlier transverse position
† Lateral flexion – this is the movement needed for the shoulders and trunk to be delivered
Which of the following hormones stimulate the growth of primary follicles? A. Activin B. Follicle-stimulating hormone C. Inhibin D. Oestrogen E. Progesterone
Follicle-stimulating hormone -
The action of FSH along with LH is to stimulate the growth of 6–12 primary follicles each month during the follicular phase of the cycle (days 1 to 14). As the follicles mature there is a rise in oestrogen due to increased production from the granulosa cells of the developing follicles and this increase in oestrogen inhibits the release of FSH and LH (negative feedback). This mechanism avoids hyperstimulation of the ovary and the resultant maturation of multiple follicles. Thus only one of these follicles will reach full maturation at the mid-follicular phase with the others undergoing atresia.
A 31-year-old primigravid woman with a body mass index of 31 had a positive glucose tolerance test at 28 weeks consistent with gestational diabetes mellitus. Although she was advised to change her diet she did not do this and her glucose control has been suboptimal. An ultrasound scan demonstrated macrosomia.
Which emergency condition does this put her at a greater risk of?
A. Amniotic fluid embolisation
B. Disseminated intravascular coagulation
C. Shoulder dystocia
D. Uterine inversion
E. Uterine rupture
Shoulder dystocia -
Other risk factors for shoulder dystocia include a past history of dystocia, maternal obesity, prolonged first stage of labour, secondary arrest >8 cm cervical dilation, mid-cavity arrest and forceps/ventouse delivery. Consider shoulder dystocia if the head delivers slowly or with difficulty and the neck does not appear, or if the chin retracts against the perineum (the turtle sign).
A 32-year-old woman complains of longstanding painful, heavy periods. She has had two normal vaginal deliveries after difficulty conceiving with both pregnancies. She suffers from significant pain on intercourse. On further questioning she also states she has had occasional rectal bleeding during her menstrual cycle throughout her life. Her past history includes an appendicectomy aged 10. Pelvic examination reveals a fixed retroverted uterus that is tender.
What is the most likely explanation for her pain?
A. Adhesions from surgery
B. Chronic pelvic inflammatory disease
C. Endometriosis
D. Fibroid degeneration
E. Ovarian cyst
Endometriosis -
Endometriosis is the most likely diagnosis, with the typical symptoms of abdomi- nal pain, dyspareunia, secondary dysmenorrhoea and subfertility. Bimanual palpation in this case has revealed a tender fixed uterus but there can also be uterosacral nodules, endometriomas, uterine or ovarian enlargement or adnexal tenderness.
A 43-year-old woman has conceived naturally for the first time despite two failed IVF attempts. She is very concerned about Down’s syndrome and would like a test performed as soon as possible that would give a firm diagnosis. She is currently at 11 weeks gestation. What test would be most appropriate? A. Amniocentesis B. Chorionic villus sampling C. First trimester ultrasound scan D. Nuchal translucency test E. Serum triple test
Chorionic villus sampling
A 26-year-old woman with a twin pregnancy has developed twin-to-twin transfusion syndrome at 34 weeks gestation.
What type of twins is she likely to have?
A. Dizygotic dichorionic diamniotic
B. Dizygotic dichorionic monoamniotic
C. Dizygotic monochorionic monoamniotic
D. Monozygotic dichorionic diamniotic
E. Monozygotic monochorionic diamniotic
Monozygotic monochorionic diamniotic - Twin-to-twin transfusion is where, due to anastomosis of vessels in the single placental mass of a monochorionic twin pregnancy, one twin gains at the other’s expense. One twin becomes anaemic, hypovolaemic, oligohydramniotic and growth-restricted while the other one develops polycythaemia, hypervolae- mia, polyuria and polyhydramnios. It occurs in varying degrees in up to 35% of monochorionic twins and accounts for 15% of perinatal mortality. Ultrasound scan is used to look at fetal wellbeing and to identify any abnormalities such as liquor volume that may suggest twin-to-twin transfusion. Therapeutic amnio- centesis may be used to reduce the amniotic fluid pressure. Laser ablation of placental vessels can be useful although there are risks of fetal demise or con- genital abnormalities. Vanishing twin syndrome is where a fetus in a multiple- gestation pregnancy dies in utero and is subsequently reabsorbed by the mother (either partially or completely).
A 32-year-old woman is 40 weeks þ 6 days and is having induction of labour for mild pre-eclampsia. She has had a total of 6 mg prostaglandin tablets per vagina. On abdominal examination the head is 5/5 palpable and on vaginal examination she is 3 cm dilated with intact membranes and a station of –3. She has mild contractions. The plan is to undertake an artificial rupture of membranes.
Which emergency condition does this put her at a greater risk of?
A. Cervical shock
B. Cord prolapse
C. Shoulder dystocia
D. Uterine inversion
E. Uterine rupture
Cord prolapse -
As seen in this case, cord prolapse is more likely in cases where there is not a close fit between the presenting part and the pelvic inlet such as a high head, malpresentation such as transverse or oblique lie, breech presentation parti- cularly footling breech, prematurity, polyhydramnios and fetal growth restri- ction. It is also seen where there is a long umbilical cord or in a 2nd twin. Of course it can occur without risk factors and a vaginal examination should be done if there are CTG abnormalities after spontaneous rupture of membranes to rule out a cord prolapse.
You are asked to examine a woman’s perineum after she has delivered vaginally. You see that the perineal skin and muscles are torn. On examination of the anus, the external anal sphincter is torn but less than 50% so.
What degree of perineal tear has this woman sustained?
A. 1st degree tear
B. 2nd degree tear
C. 3rd degree tear 3a
D. 3rd degree tear 3c
E. 4th degree tear
3rd degree tear 3a -
First degree – injury to perineal skin only. There is no need for routine suturing unless haemostasis is a problem
† Second degree – injury to perineum involving perineal muscles only without involvement of the anal sphincter. These should be sutured to ensure correct apposition of the perineal muscles and skin and to secure haemostasis. Many midwives will suture second degree tears
† Third degree – injury to perineum involving the anal sphincter complex. These must be sutured in theatre with adequate analgesia, spinal or epi- dural top-up, by a trained surgeon normally the obstetric registrar or con- sultant. The anal sphincter must be repaired to avoid incontinence
W 3a – less than 50% external anal sphincter (EAS) thickness torn W 3b – more than 50% EAS thickness torn
W 3c – both EAS and internal anal sphincter (IAS) torn
† Fourth degree – injury to perineum involving the anal sphincter complex and anal epithelium. These must be repaired in theatre by a trained obste- trician with the assistance of a general surgeon if required
Which hormone, produced by the corpus luteum, is low in the follicular phase and maximal in the luteal phase? A. Follicle-stimulating hormone B. Inhibin C. Luteinizng hormone D. Oestradiol E. Progesterone
Progesterone-
Progesterone is a steroid hormone produced by the corpus luteum. The corpus luteum is the remnant of the Graafian (ovarian) follicle after the oocyte and cumulus oophorus have been expelled. After ovulation the remnants are penetrated by capillaries and fibroblasts while the granulosa cells undergo luteinization to collectively form the corpus luteum (yellow body).
A 29-year-old woman is in spontaneous labour at 40 weeks. The CTG is reactive. She has had one previous lower segment Caesarean section. On abdominal examination, the head is 0/5 palpable. On vaginal examination, she has been 10 cm dilated for 20 minutes. There is an occipitoanterior presentation with a flexed head. The head is at station þ1 and there is no caput and no moulding. How should the baby be delivered? A. Elective Caesarean section B. Emergency Caesarean section C. Kielland’s forceps D. Normal delivery E. Neville Barnes forceps
Normal delivery -
This case describes very good conditions for a normal delivery. Most importantly the cardiotocograph is normal so labour can continue without intervention.
A 31-year-old pregnant woman was involved in a minor road traffic collision where she banged her abdomen on the steering wheel. Serious injury has been excluded but she is concerned about the baby. She has good fetal movements and has had no bleeding per vagina. The fetal heart is heard and is regular. She is 25 weeks gestation and is RhD negative. She has had no previous children.
What action needs to be taken with regards to anti-D prophylaxis?
A. Give antenatal anti-D prophylaxis 250 iu
B. Give antenatal anti-D prophylaxis 500 iu
C. Give postnatal anti-D
D. Give routine antenatal anti-D prophylaxis at 28 weeks
E. No action needed at present
Give antenatal anti-D prophylaxis 500iu -
The RCOG guidelines describe when anti-D prophylaxis must be given. All women who are RhD –ve are offered anti-D prophylaxis 500 iu at 28 and 34 weeks regardless of sensitizing events or previous administration of anti-D.
RhD –ve women are offered antenatal anti-D prophylaxis at the time of any possible sensitizing event (as described above) where fetal blood could enter the maternal circulation such as antepartum haemorrhage, closed abdominal injury, external cephalic version of the fetus, invasive prenatal diagnosis (amnio- centesis, chorionic villus sampling, fetal blood sampling), other intrauterine pro- cedures (insertion of shunts, embryo reduction) or intrauterine death. The dose is 250 iu before 20 weeks and 500 iu after 20 weeks gestation.
You examine a lady who has attended a labour ward for induction of labour at term þ 12 days. She has a cephalic presentation which is three-fifths palpable. The cervix is not dilated at all, is 3 cm long, of average consistency and is in a mid-position. The station is –2. What is her Bishop score? A. 0 B. 2 C. 4 D. 6 E. 8
4 -
The Bishop score is a classification system used to describe the ‘favourability’ of the cervix. A higher score is associated with an easier, shorter labour that is less likely to fail. Although it is a universal system it is subject to examiner variation. Therefore the same person should examine the woman to assess progress.
A 43-year-old woman has recently been diagnosed with cervical cancer.
Which of the following are risk factors for the development of cervical cancer?
A. Early menarche
B. Early menopause
C. Increased number of sexual partners
D. Nulliparity
E. Progesterone-only pill
Increased number of sexual partners -
Other risks include smoking and the oral contraceptive pill
A 39-year-old primigravid woman who has had no antenatal care attends a labour ward at 39 weeks gestation. She complains of heavy, unprovoked, painless vaginal bleeding. On examination, she has a soft non-tender abdomen and the head is not engaged. She is passing clots per vagina. She has a pulse rate of 112/min and her blood pressure is 96/56 mmHg. The CTG is non-reassuring. What is the most likely diagnosis? A. Cervical ectropion B. Placental abruption C. Placenta praevia D. Uterine rupture E. Vasa praevia
Placenta praevia -
Clinically, there is sudden-onset painless unprovoked or postcoital fresh red blood per vagina in the second or third trimester. On abdominal examination there is a soft non-tender uterus with a high head or malpresentation as the placenta blocks the passage of the presenting part into the pelvis. The clinical condition of the mother correlates with the visible blood loss (unlike uterine abruption). Maternal blood is lost so there is little risk to the fetus unless the mother becomes hypovolaemic.
A 23-year-old woman with a positive pregnancy test complains of lower abdominal cramping with what she describes as a period-type bleed at home. On abdominal palpation there is mild suprapubic discomfort. On speculum examination a small amount of blood is seen in the vagina and the cervical os is closed. Urine dipstick is unremarkable. What is the most likely diagnosis? A. Complete miscarriage B. Incomplete miscarriage C. Inevitable miscarriage D. Menstruation E. Threatened miscarriage
Threatened miscarriage -
This scenario describes a threatened miscarriage. There can be cramping lower abdominal pain with vaginal bleeding. On examination the cervical os is closed. Only 25% of threatened miscarriages eventually miscarry. A scan should be arranged to investigate the bleeding and to confirm the viability of the pregnancy. This can be done in an early pregnancy assessment unit.
A 34-year-old woman who has had four previous normal deliveries attends the antenatal day unit at 40 weeks complaining of abdominal pain asso- ciated with fevers and sweating. Initially she thought she was in labour as she had spontaneous rupture of membranes four days ago, but she says the pain has become increasingly worse. On examination, her uterus is very tender and the cervix is long and closed with an associated yellow– green discharge. Her temperature is 39.78C. She has raised white cell count and C-reactive protein. What is the likely diagnosis? A. Abruption B. Acute pyelonephritis C. Chorioamnionitis D. Uterine rupture E. Urinary tract infection
Chorioamnionitis - Chorioamnionitis is infection of the amniotic cavity and the chorioamniotic membranes. Causative pathogens include Escherichia coli, Streptococcus and Enterococcus faecalis. Both mother and fetus can develop potentially life- threatening septicaemia. It is normally seen after rupture of membranes parti- cularly if this has been over a prolonged period of time, although it can occur with intact membranes. Other risk factors include prolonged labour, preterm labour, internal fetal monitoring, cervical examinations or urinary tract or vaginal infection.
A woman with chorioamnionitis presents with abdominal pain, uterine tender- ness, maternal pyrexia and tachycardia, raised C-reactive protein and white cell count, meconium or foul smelling liquor. There could be fetal tachycardia or a non-reassuring cardiotocograph. If there is any suspicion of chorioamnionitis the baby must be delivered without delay (ideally by Caesarean section unless labour is well-established). Antibiotics are needed for the mother and baby and the paediatricians should be present at the delivery.
A 33-year-old woman attends the emergency department complaining of an aching pain in her left iliac fossa. This has been present intermittently for a few months. She says the pain is significantly worse today but remains focused in the left iliac fossa. She has vomited four times. She denies being sexually active. On examination, she is tender in the left iliac fossa with some voluntary guarding. Speculum examination revealed no abnormalities. There is left adnexal tenderness on vaginal examination but no cervical excitation. Her observations show heart rate 112/min, blood pressure 98/62 mmHg and temperature 36.88C. A urine result is awaited. What is the most likely diagnosis? A. Appendicitis B. Mittelschmerz C. Ovarian cyst torsion D. Pelvic inflammatory disease E. Renal colic
Ovarian cyst torsion -
This case describes an intermittent ovarian cyst torsion which has become an acute problem. Torsion of an ovarian cyst results in a sudden-onset severe, unilateral, colicky or twisting pain with intermittent pain if torsion is incomplete. Vomiting is common and tachycardia, hypotension and pyrexia are found on examination. This must not be missed as delay can lead to irreversible ischaemia of the ovary. An urgent laparoscopy is needed where a cystectomy may be com- pleted, but signs of ischaemia or necrosis warrant oophorectomy.
A 31-year-old woman, who has recently had a positive pregnancy test, has an early pregnancy transvaginal scan which showed no intrauterine pregnancy. She subsequently has two bhCG samples taken, the first on the day of the scan and the second 48 hours later. The first result was 578 iu and the second result was 1126 iu. What is the most likely diagnosis? A. Ectopic pregnancy B. Early intrauterine pregnancy C. Inevitable miscarriage D. Missed miscarriage E. Threatened miscarriage
Early intrauterine pregnancy -
The fact that the bhCG was below 1000 iu on the day of the transvaginal scan explains the reason why an intrauterine pregnancy was not seen. Generally a level of 1000 iu or more is associated with being able to visualize the gestational sac. The bhCG was therefore repeated 48 hours later and doubled, suggesting a healthy intrauterine pregnancy. An ultrasound scan can be repeated in a week to confirm viability of the pregnancy.
A 23-year-old woman complains of intense cramping pains that start on the second day of her period and last for 2 days. She has experienced these since menarche. She is otherwise fit and well. What is the diagnosis? A. Primary amenorrhea B. Primary dysmenorrhoea C. Primary menorrhagia D. Secondary dysmenorrhoea E. Secondary menorrhagia
Primary dysmenorrhoea -
Dysmenorrhoea describes cyclical cramping pains occurring before or during menstruation, which may be associated with malaise and gastrointestinal symptoms. Fifty percent of women have some pain during periods, with 10% describing it as severe. Primary dysmenorrhoea occurs from menarche and there is often no cause found. Secondary dysmenorrhoea has an onset after menarche and is often associated with pathology such as endometriosis, pelvic inflam- matory disease, fibroids or iatrogenic causes including intrauterine devices or cervical stenosis after large loop excision of the transformation zone (LLETZ).
Which term describes the transition from a left occipitotransverse position to an occipitoanterior position as the head passes through the pelvis? A. Effacement B. Extension C. External rotation D. Flexion E. Internal rotation
Internal rotation
A 25-year-old woman is brought into the resuscitation area having collapsed. She is maintaining her airway, is breathing with a non-rebreathe bag and has a weak pulse. The nurse informs you her observations are: heart rate 125/min, blood pressure 86/48 mmHg, saturations 98%, temperature 37.28C. After fluid resuscitation the patient is responsive enough to tell you she had some right-sided lower abdominal pain earlier in the day but cannot remember anything else. She says she uses the copper coil for contraception. On examination, she is tender with guarding in the right iliac fossa. On speculum examination there is brown discharge seen in the vagina. Threads from the coil are seen and cervical excitation is present. A urine result is awaited. What is the most likely diagnosis? A. Appendicitis B. Dislodged coil to a cervical location C. Ectopic pregnancy D. Ovarian cyst torsion E. Pelvic inflammatory disease
Ectopic pregnancy -
This is most likely to be an ectopic pregnancy which may have ruptured leading to bleeding into the abdominal cavity causing the woman to collapse and become clinically shocked. Presentation is variable and ectopic must always be considered in a woman of childbearing age with amenorrhoea, lower abdominal pain, abnormal vaginal bleeding associated with dizziness, fainting, shoulder pain or collapse. On examination there is abdominal tender- ness with cervical excitation, tender adnexae or an adnexal mass in a shocked patient. If the patient is shocked, fluid resuscitation is required followed by urgent laparoscopy or laparotomy to remove the ectopic and stop the bleeding. In a stable patient transvaginal and abdominal ultrasound scans are needed. Depending on the scan result, management can be medical (methotrexate) with serial bhCG measurements, or surgical. Rhesus D negative women should be given anti-D.
A 29-year-old primigravid woman of 38 weeks þ 5 days gestation attends the antenatal day unit after suddenly feeling unwell. She has vomited five times and complains of severe right upper quadrant pain. On examination, she is tender in the right upper quadrant only. Her blood results show mild anaemia, low platelets, deranged liver enzymes, and a normal white cell count. Observations reveal temperature 36.78C, blood pressure 168/96 mmHg and pulse rate 76/min. Her blood glucose level is 5 mmol/L. What is the most likely diagnosis? A. Acute fatty liver of pregnancy B. Acute pyelonephritis C. Cholecystitis D. HELLP syndrome E. Obstetric cholestasis
HELLP syndrome -
HELLP syndrome is the hepatic manifestation of pregnancy-induced hyperten- sion, characterized by hepatic and haematological dysfunctions. The name is an acronym of the biochemical findings: Haemolysis, Elevated Liver enzymes and Low Platelets. The patient presents with nausea, vomiting and epigastric/ right upper quadrant pain due to haemorrhage or distension of the liver capsule. There is often a sudden onset and, despite the normal association with pre-eclampsia, 10–20% of women with HELLP have no high blood pressure and therefore no warning that they will develop the condition. Delivery is the only cure but deterioration can occur 48 hours after delivery. The woman must be counselled that the recurrence rate in subsequent pregnancies is 20%.
A 38-year-old woman is seen at 29 weeks gestation. She has had one normal delivery at 41 weeks, one emergency C-section at 30 weeks, two miscar- riages at 10 and 12 weeks and also a termination of pregnancy at 13 weeks with a different partner when she was 16 years old.
How would you describe her gravidity and parity?
A. G2 P6þ3
B. G5 P2þ3
C. G6 P2þ3
D. P3 G5þ2
E. P6 G2þ3
G6 P2þ3
A 25-year-old woman has an early transvaginal ultrasound scan due to some per vagina brown spotting with a positive pregnancy test. The scan showed no intrauterine pregnancy. She had two bhCG serum tests taken, the first on the day of her scan showed a result of 653 and the second 48 hours later had a result of 623. What is the most likely diagnosis? A. Early intrauterine pregnancy B. Ectopic pregnancy C. Inevitable miscarriage D. Missed miscarriage E. Threatened miscarriage
Ectopic pregnancy -
In the early stages of a normal pregnancy the bhCG level should double every 48 hours. If the bhCG plateaus an ectopic must be ruled out. If the bhCG is falling it is likely to represent a miscarriage. A gestational sac should generally be seen on transvaginal scan if the bhCG level is above 1000 iu (or .6500 iu for transabdominal scans).
A 42-year-old woman was seen by the general practitioner after she complained of fatigue, weight loss and more recently a change in bowel habit. On examination, her abdomen was distended and the doctor elicited a positive fluid thrill test. She was urgently referred to the bowel surgeons; however, on CT bilateral ovarian cysts were seen. After referral to the gynae- cology oncologists she had an operation and the histological findings were of psammoma bodies. Her diagnosis is the most common ovarian carcinoma.
Which type of ovarian cancer did she have?
A. Clear cell tumour
B. Endometrioid tumour
C. Mucinous tumour
D. Serous tumour
E. Urothelial-like tumour
Serous tumour -
The presentation of ovarian cancer is non-specific and varied, and most present late. The most common symptoms are pain, which can be caused by bleeding or torsion, and abdominal swelling. Other symptoms include anorexia, nausea and vomiting, change in bowel habit, weight loss, abnormal vaginal bleeding, urinary symptoms, malaise, deep vein thrombosis, and rarely hormonal effects such as virilization and precocious puberty. Signs include an abdominal/pelvic mass, ascites, pleural effusion, cervical lymphadenopathy and hepatomegaly.
Epithelial tumours are the most common of the ovarian tumours and are divided into serous, mucinous, endometrioid, clear cell and urothelial-like (Brenner) tumours. Serous tumours comprise approximately half of all ovarian cancers and are the most common ovarian neoplasm.
A B-lynch brace suture is used in management of this cause of postpartum haemorrhage. A. 3rd degree perineal tear B. 4th degree perineal tear C. Atonic uterus D. Cervical tear E. High vaginal tear
Atonic uterus -
If medical options are not controlling the bleeding, surgical options must be exe- cuted. A laparotomy is performed for better access to the uterus. The uterus is massaged directly to attempt to initiate contraction of the uterine muscles. Carbo- prost (15-methylprostaglandin/Haemobate) can be given directly into the myo- metrium to encourage it to contract. If this does not work a B-lynch suture can be used, which is a uterine compression stitch that opposes the anterior and posterior walls to apply continuing compression. Other surgical approaches include under- sewing the placental bed, the tamponade test using a Rusch balloon, uterine artery or internal iliac artery ligation or hysterectomy as a last resort.
A 59-year-old woman who has had three previous vaginal deliveries complains of a feeling of ‘something coming down’ at the front of her vagina and increased urinary frequency. On examination, there is a bulge at the front of her vagina which is easily visible with a Sims’ speculum. It is worse when she coughs. What is the most likely diagnosis? A. Cystocele B. Enterocele C. Procidentia D. Rectocele E. Vault prolapse
Cystocele -
Cystocele describes descent of the bladder through the superior anterior vaginal wall. This can occur in conjunction with an urethrocele (descent of the first 3 to 4 cm of the vaginal wall which overlies the urethra). Urinary symptoms occur due to alteration of the urethrovesical angle which can lead to genuine stress incontinence, urinary frequency or urgency and difficulties in emptying the bladder which can lead to overflow incontinence. Patients with large cystoceles are predisposed to urinary tract infections due to incomplete emptying of bladder.
A 26-year-old female student is seen in the emergency department with postcoital bleeding which she has experienced for 2 weeks. She has no other abnormal discharge. She uses the oral contraceptive pill and has a long-term partner with whom she always uses barrier contraception. Her last smear was a year ago and was normal. On examination you see an abnormal area of skin surrounding the os. It is flat with a florid appearance. There is contact bleeding when a swab is taken. What is the most likely diagnosis? A. Cervical cancer B. Cervical ectropion C. Cervical polyps D. Endometrial carcinoma E. Endometrial polyps
Cervical ectropion -
Cervical ectropion is an entirely benign change in the area of mucosa surround- ing the lower cervical canal. A florid appearance is described (signifying secretory glandular mucosa). It is often asymptomatic, but may cause postcoital bleeding or persistent vaginal discharge. There may be no obvious cause but it is associated with hormonal changes during puberty, pregnancy or the oral contraceptive pill. Sexually transmitted infections must be ruled out and a normal smear test must be seen. If there is no reason to suspect anything more sinister then it can be treated with diathermy or cryocautery.
A 30-year-old primigravid woman who is 34 weeks pregnant attends the antenatal clinic. She has persistent hypertension of 164/112 mmHg and some protein in her urine on dipstick testing. She has no visual disturbances, no epigastric pain and complains of mild headaches which are generally relieved with paracetamol. On examination, her abdomen is soft and non-tender, she has mild pedal oedema, normal reflexes and one beat of clonus. Her bloods are all normal. She has asthma for which she uses a salbutamol inhaler when required.
Which antihypertensive should you use to manage her hypertension?
A. Furosemide
B. Labetalol
C. Magnesium sulphate
D. Nifedipine
E. Ramipril
Nifedipine-
Although labetalol is the first drug of choice in pre-eclampsia it is not suitable in this case due to the history of asthma. Nifedipine is given orally. It is a calcium channel blocker and vasodilator. Side-
effects include flushing, headache, ankle swelling. This is the most suitable drug in this case.
A 31-year-old nulliparous woman is requesting the combined oral contraceptive pill. She says she would like to consider trying to conceive in 2 years time. On further questioning she reveals she smokes 15 cigarettes per day, she occasionally suffers from migraines with typical focal aura and her mother had a pulmonary embolism when aged 50 associated with abdominal surgery. She has a body mass index of 26. There is no other relevant history.
Can you safely prescribe her the pill and if not, why not?
A. No – family history of thromboembolic disease
B. No – intends on having children in future
C. No – migraines
D. No – smoker
E. Yes
No – migraines -
Migraines with typical focal aura are a contraindication to the combined oral contraceptive pill (COCP).
A 27-year-old para 1þ0 woman attends the labour ward with regular painful contractions at 31 weeks gestation. On abdominal examination, a cephalic presentation is felt with the head 3/5 palpable. The contractions are palpable and regular every 3 minutes lasting 30 seconds.
What drug would you give to reduce the risk of respiratory distress syndrome if the baby is born prematurely?
A. Amoxicillin
B. Betamethasone
C. Nifedipine
D. Salbutamol
E. Theophylline
Betamethasone
A 24-year-old woman, who has been with her current partner for 5 years, has been trying to conceive for 2 years. They are now being investigated for subfertility. The woman is being investigated for tubal patency.
What is the gold standard test for tubal patency?
A. Laparoscopy and dye
B. Hysterosalpingo-contrast sonography
C. Hysterosalpingogram
D. Hysteroscopy
E. Salpingoscopy
Laparoscopy and dye -
Diagnostic laparoscopy and dye is the gold standard test for tubal patency. A laparoscopy is performed, under general anaesthetic, to give a direct view of pelvic organs to assess abnormalities, damage or significant adhesions. During the operation, methylene blue dye is inserted into the uterus using a syringe via the cervix. If blue dye is seen coming from the fimbrial ends of the fallopian tubes they are deemed patent. Hysteroscopy is often done at the same time.
A 32-year-old pregnant woman attends the emergency department with a history of bleeding per vagina. She says the bleeding is lighter than her normal period and has lasted for 2 days. She is 9 weeks gestation and this is her first pregnancy. She says she knows she is rhesus D negative as she gives blood regularly.
What needs to be done today with regards to anti-D prophylaxis?
A. Give antenatal anti-D prophylaxis 250 iu
B. Give antenatal anti-D prophylaxis 500 iu
C. Give postnatal anti-D
D. Give routine antenatal anti-D prophylaxis at 28 weeks
E. No action needed at present
No action needed at present -
It sounds like this woman has had a threatened miscarriage. The guidelines state that only those women with per vagina bleeding after 12 weeks require anti-D. As long as the bleeding is not heavy this woman could be sent home after arran- ging a pelvic scan to assess the bleeding and viability of the pregnancy.
RCOG guidelines: Threatened miscarriage: Anti-D prophylaxis should be given to all RhD –ve women after 12 weeks in the event of a threa- tened miscarriage but not given before 12 weeks as is seen in this case.
A 29-year-old woman who is 38 weeks þ 3 days attends the antenatal clinic after being referred by the midwife for measuring smaller than her dates. The baby is on the 25th centile for all measurements and there is a normal liquor volume. The placental site is fundal.
Which emergency does this make her more at risk of when she is in labour?
A. Cord prolapse
B. Fetal distress
C. Stillbirth
D. Uterine inversion
E. Uterine rupture
Uterine inversion -
Uterine inversion is rare and describes the passage of the uterine fundus through the cervix into the vagina. The resultant stretch on the round ligament can cause profound shock due to vagal stimulation. The shock seen is out of proportion to blood loss and this increases suspicion of uterine inversion rather than haemor- rhage.
Which of the following is the most common cause of primary postpartum haemorrhage?
A. Atonic uterus
B. Disseminated intravascular coagulation
C. Infection
D. Perineal trauma
E. Retained placental fragments
Atonic uterus -
Ninety percent of primary postpartum haemorrhages (PPHs) are caused by an atonic uterus. Other causes include cervical tear, high vaginal tear, perineal trauma, retained placenta or placental fragments, clotting disorders, uterine inversion and uterine rupture. Risk factors include antepartum haemorrhage, previous history of PPH, over-enlarged uterus due to multiple pregnancy, poly- hydramnios or macrosomic fetus, uterine fibroids, placenta praevia, prolonged labour, grand multiparity, chorioamnionitis and bleeding diathesis.
Which of the following is the by-product of female gametogenesis? A. Mature oocyte B. Oogonia C. Polar body D. Primary oocyte E. Secondary oocyte
Polar body -
Primary oocytes contain 46 double-structured chromosomes and enter prophase of meiosis I. Division is arrested at the dictyotene phase of meiosis I, and the first meiotic division is completed only with the pre-ovulatory leutenizing hormone/follicle-stimulating hormone (LH/FSH) surge to give a secondary oocyte and a polar body. The polar body is merely a useless by-product which subsequently degenerates.
You are called acutely to the postnatal ward to see a 48-hour-old baby girl. She was seen the day before by your colleague who performed her baby-check and found no abnormalities. On arrival you find a baby who is grunting and cyanotic. All pulses are palpable and there is no murmur on auscultation of the chest. You transfer her to the neonatal unit where you find her oxygen saturations are 55% in air.
Which of the following congenital cardiac lesions would be consistent with these findings?
A. Coarctation of the aorta
B. Eisenmenger’s syndrome
C. Patent ductus arteriosus
D. Tetralogy of Fallot
E. Transposition of the great arteries
Transposition of the great arteries -
These features are also suspicious of a cardiac lesion. Tetralogy of Fallot would usually not present so early in life and would usually be associated with a pul- monary stenosis murmur. In transposition of the great arteries the great vessels are reversed (transposed) with the aorta coming off the right ventricle and the pulmonary artery off the left ventricle. Affected children are therefore dependent on the ductus arteriosus to supply oxygenated blood to the systemic circulation (‘duct dependent’). As the duct closes after birth the baby will become profoundly cyanotic and acidotic. Chest X-ray shows a characteristic narrow mediastinum with an egg-on-side appearance of the heart shadow. The ‘switch operation’ (surgical swapping of the pulmonary artery and aorta) is required as definitive management.
A 12-year-old boy with a history of type-1 diabetes is seen in the emergency department. His blood sugar is high and he is breathing much harder than usual. An arterial blood gas is taken (on air): pH - 7.19 PaCO2 - 2.8 kPa Base excess - –9 PaO2 - 14.6 kPa
Normal reference ranges for arterial blood gases: pH - 7.36 – 7.44 PaCO2 - 4.7–6.0 kPa, 35–45 mmHg Base excess - ±2 PaO2 - >10.6 kPa, >80 mmHg (in air)
Which of the following is your interpretation of this blood gas?
A. Metabolic acidosis (uncompensated)
B. Metabolic acidosis with some respiratory compensation
C. Mixed metabolic and respiratory acidosis
D. Respiratory acidosis (uncompensated)
E. Respiratory acidosis with some metabolic compensation
Metabolic acidosis with some respiratory compensation
A 7-year-old girl is referred to the paediatrician as she has started showing signs of puberty. On examination, she has some breast tissue and sparse pubic hair, as well as axillary hair. She is growing well and appears to be starting a growth spurt. Her mother is worried as no one else in her class has any signs of puberty and she is being teased. She has not started to menstruate yet. She has no other symptoms and there is nothing else of note on examination.
What is the most likely cause of her precocious puberty?
A. Congenital adrenal hyperplasia
B. Hypothyroidism
C. Idiopathic
D. McCune–Albright syndrome
E. Pituitary tumour
Idiopathic -
In true precocious puberty the course of puberty occurs in a normal synchro- nous manner, as in this case, suggesting an intact hypothalamic–pituitary axis. It is more common in girls and is idiopathic in 80–90% of cases. Other causes of true precocious puberty include: intracranial pathology such as tumours (although pituitary tumours are more likely to be associated with delayed puberty), haemorrhage, hydrocephalus, neurofibromatosis, cerebral palsy and primary hypothyroidism. Although true precocious puberty is less common in boys, if it does occur there is more likely to be a central cause and therefore should be investigated. This would normally involve a brain MRI, gonadotrophin levels and sex steroid levels.
A 9-month-old boy has gastroenteritis. He is febrile and tachycardic. On examination, he has a normal capillary refill time, a slight reduction in skin turgor and dry mucous membranes. He is not wetting his nappies as much as usual.
What percentage of weight do you expect to be lost from dehydration in this case?
A. 0%
B. 5%
C. 10%
D. 15%
E. 20%
10%
A 3-year-old is in clinic and your consultant asks you to assess his development. You find he demonstrates normal development in all areas.
Which of the following would you expect him not to be able to do?
A. Build a tower of five bricks
B. Copy a circle
C. Feed with a fork
D. Hop on one leg
E. Know his first and last name
Hop on one leg -
A 3-year-old would be expected to be able to pedal a tricycle but not be able to hop until they are 4 years old. In fine motor and vision development, a 3-year- old should be able to copy a circle and build a tower of nine bricks. Language- wise they would be speaking in at least three-word sentences and would know their first and last names. They would not be expected to be able to count until they were 4. Socially 3-year-olds play make-believe, can eat with a fork and can brush their teeth. They should be being potty-trained and be dry during the day.
A 4-year-old boy presents to the emergency department with tachypnoea and a fever. He has been vomiting and is passing only small amounts of dark urine. On examination he is not clinically dehydrated and may even be a little oedematous around his eyes. He is unable to tolerate oral antibiotics so you insert a peripheral cannula. Because he is vomiting you perform routine electrolyte studies while inserting the cannula. A chest X-ray shows right lower lobe consolidation. You receive the following blood results: Na 129 (135 – 145 mmol/L) K 4.2 (3.5 – 5.0 mmol/L) Urea 3.2 (1.5 – 4.5 mmol/L) Creatinine 83 (40 – 110 mmol/L) pH 7.37 (7.35 – 7.45) Glucose 4.2 (3.4 – 5.5 mmol/L) Which of the following is the most likely cause of the electrolyte disturbance? A. Conn’s syndrome B. Diabetes insipidus C. Hypovolaemic hypernatraemia D. Hypovolaemic hyponatraemia E. Syndrome of inappropriate ADH secretion
SIADH -
This child has pneumonia associated with syndrome of inappropriate anti- diuretic hormone (SIADH). Though he is producing small volumes of concen- trated urine this is because of water retention rather than hypovolaemia. In addition, if he was dehydrated, we may expect a raised urea.
SIADH secretion should always be considered if a child is hyponatraemic. Causes of SIADH include lung disease (pneumonia, ventilation, acute asthma), central nervous system disease (trauma, meningitis, tumour), postoperative pain and drugs (carbamazepine, morphine). In order to make the diagnosis it is important to rule out hypovolaemia. Typically a small amount of concentrated urine is produced. Treatment involves restricting the amount of fluid given to the child to approximately 2/3 of their normal maintenance input.
You are at a wedding next to your 4-year-old nephew. He is eating a sausage and suddenly starts coughing vigorously. He is very agitated and continues to cough. He has been coughing for over a minute and he is now crying between coughs.
You suspect an inhaled foreign body, which of the following would be your next course of action?
A. Encourage coughing
B. Five back blows
C. Five chest thrusts
D. Heimlich manoeuvre
E. Rescue breaths
Encourage coughing -
If a child is coughing, such as in this case, then they should be encouraged as a spontaneous cough is more likely to be effective than externally imposed manoeuvres at relieving the obstruction. No further intervention should be made unless the cough becomes ineffective. An effective breath is defined as one in which the child is able to speak, cry or take breaths between coughs.
A 6-month-old girl born in India is referred to you by her general practitioner as she is not growing along the centiles. She was born on the 50th centile and has now dropped below the 2nd centile despite a good intake. She has had two chest infections but has never needed to be hospitalized. On examination, she looks thin but is not pale. Her abdomen is not distended and is soft on palpation.
What investigation is most likely to give you a cause for her failure to thrive?
A. Full blood count
B. IgA
C. No investigation necessary
D. Sweat test
E. Thyroid function test
Sweat test -
This girl is likely to have cystic fibrosis, which is diagnosed with a sweat test. She was not born in the UK and so would have missed out on the neonatal screen- ing. A common presentation of cystic fibrosis is failure to thrive (FTT) along with a history of chest infections.
A 28-year-old woman has asked the community midwife if it is appropriate for her to breastfeed.
Which of the following is a contraindication to breastfeeding?
A. Cosmetic breast surgery
B. Mastitis
C. Maternal digoxin therapy
D. Maternal HIV in a developed country
E. Maternal HIV in a developing country
Maternal HIV in a developed country - The contraindications to breastfeeding are: † Breast cancer † Maternal infection † HIV in developed country † Active tuberculosis † Hepatitis B † Hepatitis C † Active herpes infection of the breast † Infantile galactosaemia † Maternal medication, e.g. lithium, antimetabolite chemotherapies (not digoxin) † Maternal intravenous drug user
A 12-year-old boy presents to the emergency department with worsening shortness of breath and a wheeze. You suspect an acute exacerbation of asthma.
Which of the following peak expiratory flow rates (best or predicted) would suggest a severe exacerbation of asthma?
A. 75 – 100%
B. 50–75%
C. 33–50%
D. <33%
E. <20%
33–50%
A 4-year-old boy, who was previously fit and well, developed some petechial spots on his legs after climbing a tree. A few days later, the rash had spread over his entire body. He had not been any more lethargic than normal and was eating well. On examination, you note a large bruise on his hip and a black eye which his mother could not give any explanation for.
Which of the following investigation would be likely to confirm the diagnosis?
A. Bone marrow biopsy
B. Clotting screen
C. Full blood count
D. Skeletal survey
E. No investigation required
Full blood count -
This boy most likely has idiopathic thrombocytopenia (ITP) which is diagnosed by a very low platelet count (,40 109/L) with no evidence of anaemia and a normal white cell count. Unexplained or extensive bruising in any child is worrying.
A 5-year-old girl has suffered from arthritis for the last 6 months. It only affects her knees and elbows, and she has never had sacroiliac tenderness or nail problems. She has no rash or fever, but she does have regular oph- thalmology follow-up due to her increase risk of developing uveitis. Blood tests reveal that she is antinuclear antibody positive but rheumatoid factor negative.
What type of arthritis is she most likely to have?
A. Enthesitis
B. Oligoarticular juvenile idiopathic arthritis
C. Polyarticular juvenile idiopathic arthritis
D. Psoriatic arthritis
E. Systemic juvenile idiopathic arthritis
Oligoarticular juvenile idiopathic arthritis
An 8-year-old boy presents to the emergency department with abdominal pain, fever, nausea and some diarrhoea. The pain is poorly localized, although on palpation you feel he is most tender in the right lower quadrant and he demonstrates guarding over this area. There are no obvious swellings.
What is the most likely cause for his abdominal pain?
A. Appendicitis
B. Gastroenteritis
C. Inguinal hernia
D. Mesenteric adenitis
E. Torsion of the testis
Appendicitis -
Appendicitis is common in children and is caused by inflammation and swelling of the appendix. The lumen to the appendix becomes blocked and the appen- diceal wall subsequently becomes oedematous and inflamed. Initially, the pain is poorly defined and periumbilical, but moves to the right iliac fossa (RIF) due to inflammation of the peritoneum over the appendix. Nausea, anorexia, vomiting and a low grade fever may also be present. The child with appendicitis typically lies still and there is usually tenderness and guarding over the McBurney’s point (one-third of the way between the anterior superior iliac spine and the umbili- cus). There are a number of other signs suggesting peritoneal irritation in the RIF:
Rovsing’s sign - pain in the RIF in response to left-sided palpation
Cough sign - pain in the RIF after a voluntary cough
Obturator sign - pain on internal rotation of the flexed right thigh caused by an inflammatory mass overlying the psoas muscle
A 3-year-old girl presents to the emergency department with a 3-day history of diarrhoea and vomiting. Her mother is worried as she has blood in her stool. On examination, she appears mildly dehydrated and pale but is otherwise well. You perform some blood tests and a urine dipstick. Bloods: Hb - 7.2 g/dL WCC - 8.0 g/dL Platelets - 69x10^9/L Na - 145 mmol/L K - 6.1 mmol/L Urea - 32 mmol/L Creatinine - 219 mmol/L Urine dipstick: Protein - 3+ Blood - -ve Leucocytes - -ve Nitrites - -ve
What is the most likely diagnosis? A. Glomerulonephritis B. Haemolytic uraemic syndrome C. Henoch–Schonlein purpura D. Leukaemia E. Pyelonephritis
Haemolytic uraemic syndrome -
This girl is anaemic, thrombocytopenic and is in acute renal failure. The most likely diagnosis is haemolytic uraemic syndrome (HUS).
HUS is characterized by acute renal failure, microangiopathic anaemia and thrombocytopenia (with a normal clotting time). It is commonly seen after gas- troenteritis caused by Escherichia coli (the verotoxin-producing O157:H7 strain), Salmonella, Shigella or Campylobacter. Children present with vomiting and diar- rhoea (which is often bloody) and acute renal failure occurs soon after. This form of HUS is known as the epidemic/typical version and is seen more commonly in younger children and in the summer months. It usually has a good outcome and permanent renal damage is uncommon. However the rarer type (‘sporadic type’) is seen in older children and renal damage is more severe. Drugs and malignancy can also all cause HUS, and there is a hereditary form. A blood film is diagnostic, showing a microangiopathic haemolytic anaemia.
A newborn baby has a heel-prick blood test taken for Guthrie card screening.
Which of the following is not screened for on the newborn Guthrie card?
A. Congenital hypothyroidism
B. Cystic fibrosis
C. Diabetes mellitus
D. Phenylketonuria
E. Sickle cell disease
Diabetes mellitus
A 10-year-old boy falls from a lower branch of a tree while playing with his brother at home. There was no loss of consciousness at the time but he now has a headache and is feeling sick. He is brought to the emergency department 20 minutes later. On examination there is no focal neurology.
Which of the following is an indication for an immediate CT scan?
A. Amnesia of the event and the preceding 4 hours
B. Glasgow Coma Score of 14 on admission
C. Obvious tender swelling to the side of the head
D. One episode of vomiting in the department
E. Previous head injury 2 years previously
Amnesia of the event and the preceding 4 hours -
Indications for CT head scanning in patients under 16 years are as follows:
† Witnessed loss of consciousness lasting >5 minutes
† Amnesia (anterograde or retrograde) lasting >5 minutes
† Abnormal drowsiness
† Three or more discrete episodes of vomiting
† Clinical suspicion of non-accidental injury
† Post-traumatic seizure but no history of epilepsy
† Age >1 year: GCS <14 on assessment in the emergency department
† Age >1 year: GCS (paediatric) <15 on assessment in the emergency
department
† Suspicion of open or depressed skull injury or tense fontanelle
† Sign of basal skull fracture
- Haemotympanum (blood behind the tympanic membrane)
- Raccooneyes
- Cerebrospinal fluid otorrhoea /rhinorrhoea
- Battle’s sign (blood at the mastoid)
† Focal neurological deficit
†Age <1 year: presence of bruise, swelling or laceration <5cm on the head
† Dangerous mechanism of injury (high-speed road traffic accident either as a pedestrian, cyclist or vehicle occupant, fall from >3 m, high-speed injury)
A 13-month-old boy presents to the general practitioner. He has a 24-hour history of irritability. His mother reports he has been ‘tugging’ at his left ear. His temperature is 38.28C. On examination of the left ear, there is a bulging red tympanic membrane.
Which of the following describes the appropriate management of this case?
A. Five-day course of oral antibiotics
B. Insertion of oil to the external ear canal
C. No action required
D. Oral analgesia
E. Oral antihistamine
Oral analgesia -
Acute otitis media (AOM) is a purulent middle ear process. Earache is the single most important symptom. Other ear-related symptoms include tugging and rubbing of the ear, irritability, restless sleep and fever. Non-specific symptoms such as cough and rhinorrhoea may also be present. Examination with an oto- scope may reveal a bulging tympanic membrane with loss of the normal land- marks, a change in colour (red or yellow) and poor mobility.
In this case it would be entirely reasonable to use paracetamol for control of dis- comfort and as an antipyretic.
A 4-year-old boy presents with a 10-month history of cough. This occurs most nights and he is usually symptom-free during the day. He has had two episodes of wheeze, the first at 9 months of age associated with bronchiolitis, the second when he was 3 years old when he had a viral upper respiratory tract infection.
Which of the following would you like to perform?
A. Chest X-ray
B. Peak expiratory flow rate before and after bronchodilator
C. pH study
D. Sweat test
E. Trial of therapeutic bronchodilators
Trial of therapeutic bronchodilators -
Peak expiratory flow rate (PEFR) is very useful in asthma as it is easy to perform. PEFR becomes even more useful if a diary is maintained docu- menting morning, evening and pre/post bronchodilator PEFRs. However, most children under 5 years are unable to perform this coordinated test, so a trial of bronchodilators would be the most useful diagnostic test. If the cough persisted despite this, further investigation is warranted.
A 5-year-old boy presents to the emergency department with a red, non- blanching rash over his trunk and peripheries. His mother says that he has been complaining of a headache. He is crying but is limp in his mother’s arms. He is cool to touch and has a central capillary refill time of 4 seconds.
The child has an oxygen mask before you arrive. Which of the following would be your first course of action?
A. Give a bolus of antibiotic
B. Give a fluid bolus of 10 mL/kg
C. Give a fluid bolus of 20 mL/kg
D. Intubation and ventilation
E. Perform a lumbar puncture
Give a fluid bolus of 20mL/kg -
In this case, as the perfusion is poor, your first action would be to site a peripheral cannula (taking a blood sugar, blood culture, full blood count, C-reactive protein, venous blood gas and polymerase chain reaction for organisms) and then give a fluid bolus (20 mL/kg is the recommended first bolus). This is to improve the perfusion to maximize the distribution of anti- biotics which should be given immediately after the fluid bolus. Antibiotics should not be delayed for a lumbar puncture.
A 4-month-old boy presents to the emergency department with vomiting, poor feeding and excessive crying for the last 8 hours. He has previously been a well boy with normal development and growth, but was born prematurely. On examination, he looks unwell and appears in pain particularly when you press in the lower right quadrant. He is chubby but you think you can feel a mass in his groin. What is the most likely diagnosis? A. Appendicitis B. Inguinal hernia C. Intussusception D. Pyloric stenosis E. Volvulus
Inguinal hernia -
This child presents with an inguinal hernia. Inguinal hernias in children are most commonly indirect (pass down the inguinal canal into the scrotum, lateral to the inferior epigastric vessels) and are the result of a patent processus vaginalis. Indirect inguinal hernias have an incidence of 5% and are more common in pre- mature babies, males and on the right-hand side (due to delayed descent of the right testis). Children often present with an intermittent swelling in the groin which is more prominent after crying. An incarcerated hernia (this case) presents with poor feeding, vomiting, crying and a painful lump. Incarcerated hernias are a medical emergency as they can quickly lead to bowel strangulation and per- foration. All uncomplicated inguinal hernias should have an elective herniorrha- phy to prevent incarceration.
You review a baby boy on the postnatal ward as the midwives are worried the child is hypotonic. The baby is indeed hypotonic and you also notice he has an unusual looking face. He has a flat nasal bridge, almond-shaped eyes with prominent epicanthic folds and low set ears. His genitalia are normal.
What is the most likely cause of this child’s signs?
A. Down’s syndrome
B. Fetal alcohol syndrome
C. Hypothyroidism
D. Prader–Willi syndrome
E. Turner syndrome
Down’s syndrome
A 3-year-old girl has increased tone of her lower and upper limbs. Her legs are affected more than her arms and she has exaggerated reflexes in both her legs. You note that she has an abnormal gait, walking on her tiptoes with her knees and hips both flexed. She was born at 25 weeks gestation and she had a stormy course during the neonatal period.
What type of cerebral palsy is this girl most likely to have?
A. Ataxic cerebral palsy
B. Athetoid cerebral palsy
C. Diplegic cerebral palsy
D. Hemiplegic cerebral palsy
E. Quadriplegic cerebral palsy
Diplegic cerebral palsy -
The girl in this scenario most likely has diplegia as both her legs and arms are involved but the upper limbs are less severely affected. These children often demonstrate scissoring of the legs due to excessive adduction of the hips, and have a characteristic gait: the feet are equinovarus (plantarflexed and turned inward), the hips and knees are flexed, and they walk on tiptoes. This form of CP is seen in association with periventricular leukomalacia (white-matter injury near the cerebral ventricles, seen on ultrasound or MRI) often found in ex-premature babies. Affected children often do not have severe learning diffi- culties or epilepsy.
A 4-year-old girl is referred to the paediatric clinic due to poor growth. She weighed 3.5 kg at birth and initially grew along the 50th centile for weight, length and head circumference. Since her first birthday her growth has tailed off and her height is now well below the 0.4th centile with her weight on the 9th centile. The only other history of note was she was admitted to the neonatal unit when she was born because of low blood sugars and jaundice.
What investigation is most likely to reveal her underlying problem?
A. Bone age
B. Chromosomal analysis
C. Growth hormone test
D. Mid-parental centile
E. Thyroid function tests
Growth hormone tests -
This child is most likely to have growth hormone deficiency. This leads to short stature (about half the normal growth velocity) associated with a markedly delayed bone age. There is a normal rate of growth until 6–12 months of age, then the growth velocity tails off. It is also associated with neonatal hypoglycaemia, jaundice and a doll-like face. Hypothyroidism is also associated with short stature but there is often weight gain and other signs of thyroid disease such as dry skin, constipation and bradycardia. Routine Guthrie testing assesses for thyroid function and would rule out the majority of cases of hypothyroidism
You see a 7-year-old boy in the emergency department who has a history of asthma. He says he had a cold yesterday and now presents with a 6-hour history of ‘feeling tight’. On arriving he tells you his name is Jonny and that he’s disappointed to be here as he was going to see Leeds United this afternoon. On examination, he has equal air entry bilaterally associated with a loud polyphonic wheeze. His saturations are 93% in air and his peak expiratory flow rate is 60% of his best in clinic. His heart rate is 110/ min and his respiratory rate is 28/min.
Which of the following would be your most immediate step?
A. Give a b-agonist via a nebulizer
B. Give a b-agonist via a spacer
C. Give oral steroids
D. Start oxygen via a face mask
E. Take no action
Give a b-agonist via a spacer -
In this case using a b-agonist (such as salbutamol) should help open up the airways. This boy will also need a course of oral steroids, but that would not be your first step. It is difficult to know how to administer b-agonists during an acute exacerbation; especially as using a nebulizer is practically a lot easier. However, a recent Cochrane review did show that children using a spacer would spend less time in A&E than if a nebulizer was used.
A term baby is born by elective Caesarean section as the baby is in a breech presentation. The mother has been well during the pregnancy and a vaginal swab from a previous pregnancy was clear. A few hours after birth you are called to see the baby as he is ‘working hard’. On examination he has a respiratory rate of 100/min, is afebrile and well perfused. The chest is clear with equal air entry.
Which of the following is the most likely diagnosis?
A. Congenital pneumonia
B. Pneumothorax
C. Respiratory distress syndrome
D. Sepsis
E. Transient tachypnoea of the newborn
Transient tachypnoea of the newborn -
Transient tachypnoea of the newborn (TTN) is due to a delayed clearance of fluid from the fetal lungs. This makes TTN much more common in babies born by elective Caesarean section. During vaginal delivery, adrenaline levels rise in the baby due to stress which causes active uptake of fetal lung fluid via sodium channels. As there is no stress during an elective Caesarean, the adrenaline-mediated response does not occur, leaving fluid in the newborn’s lungs. Babies with TTN can have respiratory rates as high as 100 to 120/min. A chest X-ray should be performed to rule out congenital pneumonia. In TTN the chest X-ray will show hyperinflation, oedema and fluid in the fissures. Most infants with TTN will not require any treatment other than oxygen.
A 2-year-old girl presents with a 6-week history of foul smelling diarrhoea. She has also lost some weight. On examination, her abdomen looks full and slightly distended.
Which of the following is the most appropriate first-line investigation that would identify the cause?
A. Antigliadin IgA
B. Large bowel biopsy
C. Small bowel biopsy
D. Stool sample
E. Tissue transglutaminase IgA
Tissue transglutaminase IgA -
Guidelines at present recommend using IgA tTGA as the initial screening test and, if this is positive, to add EMA to further increase the speci- ficity. It must be remembered that those who are IgA-deficient may have a falsely negative test and therefore should have IgA levels measured at the same time as the tTGA. The gold standard diagnostic technique is duodenal or jejunal biopsy taken during endoscopy.
A 4-year-old boy is brought to the general practitioner with a cold. On auscultating the chest, a loud murmur is heard. The murmur occurs at the beginning of systole and is heard loudest at the upper left sternal edge. It radiates to the back and is associated with a thrill.
Which of the following is the most likely diagnosis?
A. Aortic stenosis
B. Coarctation of the aorta
C. Mitral regurgitation
D. Pulmonary stenosis
E. Ventricular septal defect
Pulmonary stenosis -
An 18-month-old girl presents to the general practitioner with fever and a runny nose. On examination, there are no signs of a serious illness, though she has a temperature of 38oC. The mother is concerned as she had a febrile convulsion 4 months ago.
Which of the following statements is true regarding this febrile child?
A. Do not routinely give antipyretics to solely reduce body temperature
B. Give ibuprofen and paracetamol simultaneously to maximize effect
C. Strip the child to her nappies
D. Tepid sponging is recommended
E. Use antipyretics to prevent febrile convulsions
Do not routinely give antipyretics to solely reduce body temperature -
The NICE guidelines for feverish illness in young children recommend the following for antipyretic interventions:
† Tepid sponging is not recommended
† Do not over- or under-dress a child with fever
† Consider either paracetamol or ibuprofen as an option if the child appears distressed or is unwell
† Take the views and wishes of parents and carers into account when considering the use of antipyretic agents
† Do not routinely give antipyretic drugs to a child with fever with the sole
aim of reducing body temperature
† Do not administer paracetamol and ibuprofen at the same time, but
consider using the alternative agent if the child does not respond to the
first drug
† Do not use antipyretic agents with the sole aim of preventing febrile
convulsions
A 14-year-old girl is referred to paediatric outpatient as she has not entered puberty yet. She has no breast development or pubic hair. On examination, she is well and a full neurological examination is normal. She is short for her age but has no dysmorphic features. Her mother says that she herself ‘developed late’ but cannot remember exactly when she went through puberty.
Which investigation should be done initially?
A. Gonadotrophin levels
B. Karyotyping
C. Ovarian ultrasound
D. Pituitary CT
E. No investigation required
Gonadotrophin levels -
Gonadotrophins are a useful first-line investigation to determine which further investigations are needed, as delayed puberty can either be associated with low or high gonadotrophin secretion.
You are called to the emergency department where a 4-year-old boy is having a seizure. He is known to have epilepsy and is on regular phenytoin. He was brought in by ambulance and the paramedic has given buccal midazolam en route. The emergency doctor has cited a cannula from which a sample of blood has revealed a blood sugar of 4.8 mmol/L. He is still fitting 10 minutes after the buccal midazolam.
Which of the following would be your next step in management?
A. Bolus 10% dextrose
B. Intravenous lorazepam
C. Intravenous phenytoin
D. Intubation and ventilation
E. Rectal paraldehyde
Intravenous lorazepam -
If a patient has intravenous access, the order of management is:
1. ABC (DEFG)
2. Lorazepam intravenously (2 doses)
3. Paraldehyde rectually. Draw up and give phenytoin intravenously while giving the paraldehyde (unless already on phenytoin in which case give phenobarbitone)
4. Intubation and ventilation with thiopental
You are working in the emergency department when you are called to an ambulance. A mother has just delivered her baby a few seconds before arriving. As you enter the ambulance the paramedic is clamping the cord. The baby is not breathing and looks floppy and pale.
Which of the following would be your most immediate action?
A. Administer five rescue breaths
B. Cardiac compressions
C. Evaluate breathing
D. Manage airway
E. Warm and dry the baby
Warm and dry the baby - In practice, warming and drying the baby, opening the airway and assessing the newborn all form one swift movement for an experienced paediatrician. The steps in neonatal resuscitation can be summarized as: † Clamp the cord † Warm and dry the baby † Open and clear the airway † Evaluate breathing, heart rate, colour and tone † Five inflation breaths † Continuing ventilation † Cardiac compressions
An 8-year-old boy presents with a 3-hour history of a painful, swollen testicle. The pain started gradually overnight and he now scores it as 6/10. He has no nausea and has not vomited. On examination, his abdomen is soft but there is an obvious swelling and redness of the left scrotum. There is mild tenderness in the upper area of the testicle. His cremasteric reflex is present. What is the most likely diagnosis? A. Epididymitis B. Hydrocele C. Inguinal hernia D. Torsion of the hydatid of Morgagni E. Torsion of the testicle
Torsion of the hydatid of Morgagni
A 3-year-old girl is brought to her general practitioner. She has been treated for a chest infection for 10 days with antibiotics but is still no better. Her mum has noticed that she is pale and lethargic. On examination, the girl appears unwell and the doctor is able to palpate the spleen. He also notices a number of bruises over her arms and body which mum is unable to account for. What is the most likely diagnosis? A. Acute lymphoblastic leukaemia B. Acute myeloid leukaemia C. Cystic fibrosis D. Glandular fever E. Neglect and physical abuse
Acute lymphoblastic leukaemia -
This child is most likely to have leukaemia with a combination of splenomegaly, bruises, lethargy and pallor. Acute lymphoblastic leukaemia (ALL) accounts for 80% of childhood leukaemias and is therefore the most likely answer. ALL has a peak incidence at around 5 years and slowly decreases in adolescence. It is slightly more common in boys and a higher incidence is seen in Caucasians.
A 9-year-old boy suffers from epilepsy. His mother describes his seizures as infrequent. She normally hears a strange noise in the night from her son’s room and then finds him twitching the right-hand side of his mouth and face. He is usually drooling and is unrousable. This lasts for a few minutes and the child has no recollection of the event. A subsequent EEG shows high amplitude spikes in the left centrotemporal region.
What is the most likely type of epilepsy this boy has?
A. Absence seizures
B. Benign rolandic epilepsy
C. Juvenile myoclonic epilepsy
D. Lennox–Gastaut type epilepsy
E. Tonic – clonic epilepsy
Benign rolandic epilepsy -
Seven to 10-year-olds are most likely to be affected (but it can be seen from 3 to 13 years of age) and there is a male pre- ponderance. Rolandic seizures are usually nocturnal involving the mouth and face. They often begin with an odd sensation at the corner of the mouth which leads to twitching of the mouth and then the rest of the ipsilateral face. Excessive salivation, grunting and slurred speech can occur, and they can progress to generalized seizures. The EEG often shows high amplitude spikes in the left centrotemporal region. This area of the brain is near the motor strip (the Rolandic fissure, hence the name of the epilepsy). It is a benign condition and children often grow out of it by adolescence.
A 2-month-old boy is brought to the general practitioner by his mother for routine immunizations.
Which of the following immunizations should not routinely be given at 2 months of age?
A. Diphtheria
B. Haemophilus influenzae
C. Meningitis C
D. Pneumococcus
E. Tetanus
Meningitis C
A 5-month-old infant was found to be failing to thrive. On examination, a quiet murmur is heard at the lower left sternal edge throughout systole. Over the past 2 months he has become short of breath during feeding. His weight has now fallen down two centile lines.
Which of the following would be your first step in management?
A. ACE inhibitor
B. Digoxin
C. Diuretics
D. Insertion of a feeding nasogastric tube
E. Surgical correction
Insertion of a feeding NG tube -
The management of heart failure starts with supportive steps to maximize the provision of metabolic requirements to the body. Therefore inserting a nasogastric tube and starting high caloric feeds will reduce the associated growth retardation. Growth retar- dation is caused by a failure to take adequate feeds due to breathlessness and secondly due to a high metabolic rate in the symptomatic child. Commencing oxygen therapy will also aid in the provision of oxygen to the tissues.
It is likely that this child will need pharmacological management. Diuretics (thia- zide or loop) will reduce the load on the heart. ACE inhibitors are frequently used in conjunction with diuretics.
An anxious mother attends the general practice as her 7-day-old newborn has sticky eyes. Both eyes have a mucopurulent exudate. You take swabs including a scraping and advise the mother to clean the eyes four times a day with cooled, boiled tap water. Three days later you are informed that an intracellular organism has grown from the samples you sent.
Which of the following organisms is responsible for the infection?
A. Chlamydia trachomatis
B. Neisseria gonorrhoeae
C. Pseudomonas aeruginosa
D. Staphylococcus aureus
E. Streptococcus pneumoniae
Chlamydia trachomatis-
Ophthalmia neonatorum is the term used for conjunctivitis occurring in the first few weeks of life. A standard swab for microscopy and culture should be per- formed along with a conjunctival scraping. The aim of the scraping is to gain cells within which chlamydial organisms can be found.
A 3-year-old boy presents to the general practitioner with a 2-month history of cough. It started with a cold, but that has since resolved. Currently, he has severe bouts of coughing, occasionally followed by vomiting. On exam- ination, he has bilateral equal air entry and no crepitations.
Which of the following is the most likely diagnosis?
A. Asthma
B. Bronchiolitis
C. Inhaled foreign body
D. Pneumonia
E. Whooping cough
Whooping cough -
A 7-year-old boy is brought to the emergency department by ambulance following a 10-minute seizure. He has now stopped fitting but remains drowsy. He has a 3-year history of headaches, nausea and lethargy which is present only in the winter months. He lives with his family in a poorly maintained council flat with gas heating.
Which of the following would confirm your diagnosis?
A. Arterial pO2
B. Carboxyhaemoglobin levels
C. Chest X-ray
D. ECG
E. Oxygen saturations
Carboxyhaemoglobin levels - Carbon monoxide (CO) can be produced by natural gas combustion devices, (especially if poorly ventilated), motor vehicle exhausts and burning charcoal or kerosene. It is therefore more likely that you will come into contact with CO poisoning in the winter months when heating devices are used. CO has a very high affinity for binding with haemoglobin (250 times greater than oxygen), although binding is reversible. Poisoning causes acute symptoms associated with hypoxia, such as headaches, dizziness and nausea. Cyanosis does not occur and the skin remains pink. Syncope and seizures can occur and this may be followed by coma and death.
Below is a list of genetic conditions. Which of the following has an autosomal dominant inheritance pattern? A. Haemophilia A B. Incontinentia pigmenti C. Klinefelter’s syndrome D. Oculocutaneous albinism E. Tuberous sclerosis
Tuberous sclerosis -
A 12-year-old boy has a prolonged history of atopic eczema. The extensor surfaces of his limbs are dry, excoriated and inflamed. He says that the rash is incessantly itchy.
Which of the following would be appropriate adjuncts to his topical emollient and steroids?
A. Bandages
B. Phototherapy
C. Systemic steroids
D. Tacrolimus
E. All of the above
All of the above
A 2-year-old girl is bought into the emergency department by her mother following a fit. She had been playing with her brother when mum heard her cry briefly. She then went quiet, looked extremely pale and then fell to the ground and was unrousable. Mum noticed her body shake for about 10 seconds before she then came round and was back to her normal self, playing within minutes. Her brother says she had trapped her finger in the door just prior to the event.
What is the most likely cause for her loss of consciousness?
A. Absence seizure
B. Breath-holding attack
C. Cardiac arrhythmia
D. Epileptic fit
E. Reflex anoxic seizure
Reflex anoxic seizure -
This little girl has had a reflex anoxic seizure. These often occur after pain, dis- comfort or minor head injuries, with other triggers including fever, cold drinks or a fright. The child (usually an infant or toddler) becomes very pale and can fall to the ground. Episodes occur due to a reflex cardiac asystole secondary to increased vagal response. They can occasionally be associated with tonic– clonic movements, as in this case, but the child recovers rapidly and is its usual self soon after the event (unlike after an epileptic seizure).
You see a 3-week-old baby in the community who is being exclusively breastfed. He has gained weight and is generally well. You have been asked to see him by the health visitor who is concerned he is yellow. On examination, you confirm that he is jaundiced but other than this there is no abnormality to be found.
Which of the following is the most important investigation to perform at this point?
A. Direct antibody test
B. Split bilirubin
C. TORCH screen
D. Unconjugated bilirubin
E. No investigation required
Split bilirubin -
Any baby who is jaundiced after 14 days (21 days if premature) needs to have a split bilirubin assay performed. A split bilirubin assay measures conjugated and total bilirubin levels. If the conjugated fraction is greater than 20% (and .18 mmol/L) then the baby should be seen in a specialist paediatric liver centre. Examining the stool of a jaundiced neonate is very important as acholic stool (pale stools due to the absence of bilirubin) suggests an obstruction in the biliary tree. Detailed investigation is warranted in children with prolonged con- jugated hyperbilirubinaemia. The most important diagnosis to rule out is biliary atresia. Investigations should also be directed at ruling out infection, metabolic disorders, hypothyroidism and familial cholestatic syndromes.
A 4-year-old girl presents with a fever, lethargy and vomiting. She complains of dysuria and has 2++ leucocytes and nitrites on urine dipstick. There are no signs to find on examination and she is alert and well hydrated. You make the diagnosis of a urinary tract infection and send her urine for culture.
What treatment should she receive?
A. A 3-day course of oral antibiotics
B. A 7-day course of oral antibiotics
C. Intravenous antibiotics
D. No treatment required
E. No treatment until microscopy and culture result is obtained
A 3-day course of oral antibiotics
A 4-year-old girl attends the emergency department with a 2-day history of a palpable purpuric rash over her lower limbs and buttocks. She is systemically well but recently had a cold.
Which of the following is not a complication of this condition?
A. Abdominal pain
B. Arthritis
C. Conjunctivitis
D. Recurrence
E. Renal failure
Conjunctivitis -
This girl has Henoch–Scho ̈nlein purpura (HSP). HSP is an immunologically mediated diffuse vasculitis, especially of the small blood vessels, often preceded by an upper respiratory tract infection (especially b-haemolytic streptococci). It usually occurs between 3 and 10 years of age and is twice as common in boys. The characteristic finding is a palpable purpuric rash which can occur anywhere, but is most commonly seen on the buttocks and lower extremities.
A 13-year-old boy has been unwell for a number of days with a sore throat. Three days after the onset of the illness he developed a widespread rash over his torso and proximal extremities. The rash is made up of numerous scaly papules, each 0.5 to 2 cm in size. On examination of his oropharynx you note bilaterally inflamed tonsils with exudates.
Which of the following is the most likely diagnosis?
A. Atopic eczema
B. Measles
C. Meningococcal sepsis
D. Psoriasis
E. Scarlet fever
Psoriasis -
Guttate psoriasis occurs almost exclusively in children and young adults. The lesions found are 0.5 to 2 cm oval scaling red papules and small plaques. The lesions are numerous and distributed over the torso and proximal extremities. Guttate psoriasis is often preceded by streptococcal infections (as in this case). The possibility of a concurrent streptococcal infection should be investigated in any new cases of guttate psoriasis.
A 14-year-old girl presents with a one-day history of severe throbbing headache. She is feeling nauseated but has not vomited. There is no blurring of vision or flashing lights but she has some photophobia. She had a similar headache which lasted a day about 3 months ago. She is on the oral contraceptive pill. Neurological examination is unremarkable and there is no papilloedema on fundoscopy.
What is the most likely explanation for her headache?
A. Cluster headache
B. Idiopathic intracranial hypertension
C. Intracranial tumour
D. Migraine
E. Tension headache
Migraine
A 3-year-old girl is seen in the outpatient clinic due to her longstanding history of constipation. For the last 6 months she has not passed a normal stool. She is straining, in pain and only passing very small ‘rabbit- like droppings’. Her mum is also worried as she is continually soiling her pants and has not managed to take her out of nappies.
What is the most important initial step in treating this child’s constipation?
A. Encourage increased dietary fibre
B. Enema disimpaction regimen
C. Lactulose twice a day
D. Make sure child is placed on the toilet after every meal
E. Movicol disimpaction regimen
Movicol disimpaction regimen -
This child has chronic constipation and has secondary soiling. Incontinence occurs in chronic constipation due to the leakage of liquid stool from above the impacted stool. Until full disimpaction has been achieved, the soiling is likely to remain. The objectives of treatment are to firstly remove faecal impaction, restore a bowel habit where soft stools are passed without discomfort, and then to ensure self-toileting and passing stools in appropriate places (in younger children). It is essential to establish a good rapport with both parents and the child as there may be feelings of guilt, blame and shame that all need to be recognized and dealt with sensitively.
You examine a woman’s abdomen who has attended for induction of labour at 40 weeks þ 12 days. The abdomen is soft and non-tender. It is difficult to feel any definite presenting part in the pelvis. The baby is longitudinal lie, you can feel a smooth part on the patient’s left side and the right side feels more irregular. The fundus has a ballottable object. You find the fetal heart above the umbilicus. How is the position best described? A. Breech B. Occipitoposterior C. Occipitotransverse D. Occipitoposterior fully engaged E. Transverse lie
Breech
