Madi Flashcards

Question

Diverticular Disease

Answer 1

• Diverticulosis - weaknesses in the bowel wall lead to the formation of small (usually 5 to 10mm) pouches in the wall of the colon • More common with age - asymptomatic • Diverticulitis = inflamed / infected diverticula • Exam findings include: • Tachycardia, fever, abdominal tenderness, guarding and rebound tenderness, and presence of a palpable mass (left sided) • Treatment usually with IV antibiotics

Answer 2

1.• FEV1/FVC ratio >70% / 0.7 = restrictive • Pulmonary fibrosis / oedema / pneumoconiosis • 2. FEV1/FVC ratio <70% / 0.7 = obstructive • COPD / asthma FEV1 % predicted: 80%+ Stage 1 - Mild 50-79% Stage 2 - Moderate 30-49% Stage 3 - Severe <30% Stage 4 – Very Severe • In patients without typical symptoms, alternative diagnoses should be sought.

Answer 3

• Commonly occur after planting a foot on the ground • ‘’Popping’’ sound may be heard • Swelling immediately is common • Lachman’s test is when the tibia is pulled forward with the knee flexed to 20-30 degrees • Forward movement of more than 2mm is considered positive for an ACL injury

Answer 4

• Seizure lasting 5+ minutes or 3+ fits in 1hr • Buccal midazolam 10mg • Rectal diazepam 10-20mg • Urgent admission via ambulance if not responding promptly or high risk • Diazepam / midazolam can be repeated 10-15 minutes after its first administration • In hospital, IV lorazepam can be used if resuscitation facilities available and IV access already in place

Answer 5

• AKA Slipped Capital Femoral Epiphysis (SCFE) • More common in boys vs. girls • Overweight / obese / tall thin / aged 10-15 • Due to upper femoral epiphysis slipping with respect to the femur in a postero-inferior direction. • Symptoms include pain, stiffness and instability • X-Ray to confirm diagnosis • Surgical treatment to pin slipped head

Answer 6

Red flags / indications for urgent referral • Aged 45+: • Unexplained visible haematuria without UTI • Visible haematuria that persists or recurs after successful treatment of UTI • Aged 60+: • unexplained non-visible haematuria and either dysuria OR raised WCC

Answer 7

• Progressive, sensorineural hearing loss that occurs with age • Bilateral and symmetrical • Common after 55 years of age • Gradual loss of cochlea hair cells + degeneration in the cochlea nerve • High frequency perception is lost

Answer 8

• Acute laryngitis • Duration <3 weeks, pyrexia, sore throat, pain on speaking points • Smokers are more at risk • May have bilateral erythema of the vocal cords • Laryngeal carcinoma • >4 week history • Smoking, alcohol are risk factors • Voice initially muffled then hoarse • May have dysphagia, otalgia, torticollis, lymphadenopathy or neck masses

Answer 9

3 Vocal cord palsy • Causes - idiopathic, post-surgery or secondary to neoplasm • Weak breathy voice (not a harsh voice) • May have a bovine cough • 4 Reinke’s oedema • Collection of fluid in the lamina propria bilaterally of the vocal cords • Secondary to another process i.e. GORD or voice abuse. • Diagnoses by direct visualisation with a fine naso- endoscope.

Answer 10

• Vaginitis from candida infection may cause post-coital bleeding • Foreign bodies unlikely to cause post- coital bleeding • may cause a waxing and waning pain + discharge • NICE guidelines recommend full pelvic examination including cervical speculum examination for post coital / inter- menstrual bleeding

Answer 11

• Sudden, painless loss of vision • Pallor of the retina • Reduced direct light response • ‘cherry red spot’ (prominent red fovea) • In 90% acuity is finger counting or worse • Needs urgent ophthalmology opinion

Answer 12

• Microcytic – Iron deficiency – Haemoglobinopathies (e.g. thalassaemia) • Normocytic – Anaemia of chronic disease – Bone marrow failure – Acute blood loss • Macrocytic – B12 / folate deficiency – Haemolytic anaemias – Liver disease – Impaired red cell production

Answer 13

• Quantitative faecal immunochemical testing (FIT / qFIT) should be offered in adults: – With an abdominal mass – With a change in bowel habit – With iron-deficiency anaemia – 40+ - unexplained weight loss and abdominal pain – <50 with rectal bleeding and unexplained: • Abdominal pain OR weight loss – 50+ with unexplained rectal bleeding, abdominal pain, or weight loss – 60+ with anaemia even in absence of iron deficiency • Suspected cancer pathway: FIT 10+ micrograms / gram

Answer 14

• IgA – 10-15%- protect body surfaces that are exposed to outside foreign substances. • IgG – 75-80% - found in all body fluids. Important in fighting bacterial and viral infections. IgG can cross placenta. • IgM – 5-10% - largest antibody. Found in blood and lymph fluid. First response to an infection. • IgE - found in the lungs, skin, and mucous membranes. Cause the body to react against foreign substances. Often involved in allergic type reactions. • IgD - found in small amounts in the tissues that line the belly or chest. How they work is not clear.

Answer 15

• Carried by Aedes mosquito • Dengue fever has a biphasic fever – Phase I – 3-6 days then remittance – Phase II – 1-2 days • Classical symptoms include diffuse pain – “bone breaking fever” • Malaria not endemic to Australia

Answer 16

• AKA limited cutaneous systemic sclerosis • Variant of systemic sclerosis (SS) • Calcinosis • Raynaud’s phenomenon • Esophageal dysmotility • Sclerodactyly • Telangiectasia • Anti centromere antibody >98% specificity

Answer 17

• Male : Female ratio 3:1 • Symptoms – Haematuria – painless in early tumours – Dysuria / frequency – Abdominal pain (muscle invasive) – Weight loss • Cystoscopy + biopsy diagnostic

Answer 18

• Severe acne = deep scarring / emotional problems • Combination topical therapies +/- oral lymecycline / doxycycline used 1st line for. moderate to severe acne • Isotretinoin (Roaccutane) effective when not responding to other treatments • Teratogenic (caution with female patients) • Laser not recommended except in trials

Answer 19

• Congenital – Often presents in children – Chronic purulent discharge not responding to antibiotics • Acquired – secondary to tear or retraction of ear drum – Surgery – e.g. Grommets – Ear infection with rupture of tympanic membrane • Both types can affect the facial nerve.

Answer 20

Primary Prevention • Manage other modifiable risk factors • smoking / high blood pressure / obesity • Provide lifestyle and dietary advice • Treat if 10-year CVD risk is >10% • 20mg Atorvastatin daily 1st line Secondary Prevention • Treat all patients with CVD • Past / current history of: • MI / angina / stroke / TIA / PAD • Starting dose is Atorvastatin 80mg daily

Answer 21

Autosomal dominant Marfan, achondroplasia, neurofibromatosis, Huntington’s Autosomal recessive Albinism, cystic fibrosis, phenylketonuria, sickle cell anaemia X linked dominant Alport / Rett syndrome, Vit. D resistant rickets, Fragile X X linked recessive DMD, haemophilia, G6PD def., Hunter syndrome, colour blindness Polygenic: Neural tube defects, pyloric stenosis Chromosomal: Trisomy 21, Turners (45XO), Klinefelter’s (47 XXY

Answer 22

Analgesic Dose Notes Morphine sulphate 10mg Oral - universal opioid Morphine sulphate 5mg IM, SC, IV Oxycodone 6.6mg Suitable where morphine not tolerated Diamorphine 3mg I.M. or subcut. Hydromorphone 2mg PO Codeine, dihydrocodeine, tramadol 100mg Weaker opioids

Answer 23

Pain management: Fentanyl Only when pain is stable (72 hr patch) Morphine Salt daily Equivalent Fentanyl Patch 30mg 12 60mg 25 120mg 50 180mg 75 240mg 100 Half the 24hr oral morphine dose, then find closest patch LOWER than this

Answer 24

Oral Morphine Total 24 hour dosage Morphine (SC, IM, IV) Divide by 2 Diamorphine (SC, IM, IV) Divide by 3 30mg 15mg 10mg 60mg 30mg 20mg 90mg 45mg 30mg 120mg 60mg 40mg 180mg 90mg 60mg

Answer 25

1.• Basal cell carcinoma – Most common, least aggressive – Pearly border 2 • Squamous cell carcinoma – 2nd most common, can metastasize – Transplant patients high risk – Asymmetrical, Telangectasia / Ulceration 3 • Malignant melanoma – Less common, most aggressive – Asymmetrical, irregular, variegated pigmentation

Answer 26

Cardiac arrest • Adults – 1mg (10ml at 1:10,000) IV • Paediatric – 10 micrograms per kg IV Anaphylaxis – 1:1,000 IM preferred • Adults – 0.5mg / 500 mcg (0.5ml) • Child 12 years+: 0.5mg (0.5ml) • Child 6-12 years: 0.3mg (0.3ml) • Child 6m - 6 years: 0.15mg (0.15ml) • Child <6 months: 0.1-0.15 (0.1-0.15ml)

Answer 27

Primary Hashimoto thyroiditis Idiopathic myxoedema Radioactive iodine therapy Subtotal thyroidectomy Neck irradiation Following acute thyroiditis Cystinosis Iodine deficiency Iodine excess (>6 mg/d) Antithyroid drugs Overt hypothyroidism Secondary Hypothalamic / pituitary dysfunction due to neoplasm Pituitary surgery or irradiation Idiopathic hypopituitarism Sheehan syndrome Dopamine infusion Heatstroke Traumatic brain injury

Answer 28

• Graves’ disease • Toxic multinodular goitre • Toxic adenoma • Iodide-induced hyperthyroidism • Subacute thyroiditis • Factitious (exogenous) thyroiditis • Neonatal thyrotoxicosis (e.g., mother with Graves disease) • TSH-secreting pituitary tumor • Choriocarcinoma or hydatidiform mole • Struma ovarii • Hyperfunctioning thyroid carcinoma (usually metastatic)

Answer 29

• Postpartum thyroiditis – usually within 1 year of childbirth • De Quervain’s thyroiditis – associated with viral infection • Overt hypothyroidism – raised TSH and low T4 • Subclinical hypothyroidism – raised TSH, normal T3/T4 • Secondary hypothyroidism – low T4, normal TSH • Drug induced thyrotoxicosis - low TSH, high T3/T4 • Graves’ disease – very low TSH, high T3 / T4

Answer 30

• Amiodarone can induce hyper or hypothyroidism • Alemtuzumab (MS drug) can also cause hyperthyroidism • Drugs that can cause hypothyroidism: • Glucocorticoids • Dopamine • Lithium • Interferon

Answer 31

• Raised TSH with normal T3 / T4 • Patient usually asymptomatic • May have tiredness / weight gain • Can develop a goitre • Most common cause is chronic autoimmune thyroiditis • 2-5% go on to overt hypothyroidism

Answer 32

• Pyloric stenosis – projectile vomiting • Intususseption – sausage shaped mass, red currant jelly stool • Retinoblastoma – absent red reflex (white or pale pupil) • Leukaemias are most common childhood cancers – ALL and AML • ALL most common in childhood and young adulthood with a peak incidence at 4-5 yrs • Symptoms – fatigue, bone / joint pain, fever

Answer 33

• Triad of arthritis, conjunctivitis (or uveitis) and urethritis • Can’t see, can’t pee, can’t bend the knee! • Can be secondary to GI infection or STI • Primary may need treatment • Treat individual components

Answer 34

• First vasculitis described (Kussmaul and Maier) • Necrotising vasculitis affecting medium sized arteries • Non-specific symptoms include malaise, headache, arthralgia • 60% have renal involvement (hypertension) • Diagnostic criteria include: – weight loss >4kg, HBsAg +ve, diastolic BP >90, neuropathy amongst others.

Answer 35

• Cystic Fibrosis – sweat test / genetics • PE – Pulmonary angiography – V/Q sensitive but not specific – CTPA not as sensitive / specific • Lung cancer – bronchoscopy / biopsy • Bronchiectasis – High Res. CT Scan • Chest infection – sputum culture

Answer 36

• Localised irreversible dilatation of part of the bronchial tree • Triad of symptoms – chronic cough – excess purulent sputum production – repeated infections • Haemoptysis in 50% • CXR findings include peribronchial fibrosis • HRCT scan of the chest is used for diagnosis

Answer 37

Chronic Heart Failure Treatment • Loop diuretic – up to 80mg furosemide • Prescribe both an ACE inhibitor and a beta blocker – Only start one heart failure drug at a time • ACE inhibitor first if co-morbid diabetes or fluid overload • Beta blocker first if co-morbid angina

Answer 38

• CBT – anxiety, depression, phobias • Antidepressants (SSRI, SNRI, TCA) – depression, anxiety • ECT – severe depression resistant to medication / catatonic patients • Antipsychotics – schizophrenia, psychosis • Lithium – bipolar • Psychodynamic psychotherapy – depression, anxiety, eating disorders, personality disorders, trauma

Answer 39

• Cushing’s – Dexamethasone suppression – Cortisol levels alone not diagnostic • Addison’s – Synacthen test – No increase in cortisol with ACTH • Acromegaly – OGTT + GH measurement – Measure GH – no drop with glucose load • Diabetes Insipidus – Water deprivation • Diabetes Mellitus – OGTT, Glucose, HbA1C • Myasthenia Gravis – Tensilon test

Answer 40

• Pneumocystis jirovecii (carinii)– HIV / AIDS – Silent breathlessness, dry cough • Legionnaire’s disease - Legionella – prodrome, dry cough, confusion, diarrhoea, hyponatraemia, leucocytosis – A/c, hot water systems, spas • Psittacosis – Chlamydia psittaci – “Bird fancier’s lung” – Systemic prodrome, pneumonitis – Rising titre complement fixing antibody

Answer 41

• Acute glomerulonephritis and pulmonary alveolar haemorrhage • Goodpasture’s disease is an autoimmune cause of the syndrome • 60 - 80% have both renal and pulmonary disease. • CXR - Patchy consolidation, usually bilateral. • Treatment – plasmapharesis / immune suppression

Answer 42

• Vague and slow-onset history over a few days or weeks • Fever, headache, dry cough with tracheitic ± pleuritic pain, myalgia, malaise and sore throat. • CXR usually shows single lower lobe affected • Complications include cold agglutinin disease and haemolytic anaemia • Treatment is with macrolides

Answer 43

• Caused by Coxiella burnetii • Often transmitted from cattle, sheep, goats • Typically starts with flu like illness • Sudden onset of fever, myalgia, headache • Dry cough +/- pleuritic pain • GI symptoms • Can cause acute respiratory distress syndrome and endocarditis

Answer 44

A. Presystolic murmur – Mitral/Tricuspid stenosis B. Mitral/Tricuspid regurgitation C. Aortic ejection murmur D. Pulmonic stenosis (spilling through S2) E. Aortic/Pulm. diastolic murmur F. Mitral stenosis - opening snap G. Mid-diastolic inflow murmur H. Continuous murmur of PDA

Answer 45

I. Systolic Murmurs: 1. Aortic stenosis - ejection type 2. Mitral / tricuspid regurgitation - pansystolic 3. Mitral valve prolapse - late systole II. Diastolic Murmurs: 1. Aortic regurgitation - early diastole 2. Mitral stenosis - mid to late diastole

Answer 46

Male hb less than 130g (120)per litre or heamatocrit less than 40(36) Score 2 (Values for female) Personal history of bleeding : gi ,ic bleed ,hemorrhagic stroke Score 2 Age greater than 74 EGFR less than 60 On antiplatelet Score 1

Answer 47

A. Auditory hallucinations B. Broadcasting of thoughts C. Controlled thoughts D. Delusional perception

Answer 48

• 1 point for each of: • Active cancer • Paralysis, paresis, or recent plaster immobilization • Recently bedridden for 3+ days, or major surgery <12wks • Localized tenderness along the distribution of the deep venous system (such as the back of the calf) • Entire leg is swollen • Calf swelling >3 cm compared with other leg • Pitting oedema confined to the symptomatic leg • Collateral superficial veins (non-varicose) • Previously documented DVT • Score ≤1: DVT unlikely Score 2+: DVT more likely

Answer 49

• Reduces incidence of neural tube defects • Recommended before conception – 12 wks • Low risk patients: 400 mcg daily • High risk patients: 5mg daily – BMI 30 kg/m2 + – Previous neural tube defect / FH of NTD – On antiepileptic medication – Diabetes – Sickle-cell disease or thalassaemia (take folic acid throughout pregnancy)

Answer 50

Scoring Tool Indication / Usage CHA2DS2-VASc Stroke risk in AF ORBIT Bleeding risk in AF – current NICE recommended score HASBLED Bleeding risk in AF – less accurate ABCD2 Stroke risk in TIA QRISK CVD risk

Answer 51

• Suspect gout if typical features: – Rapid onset severe pain, redness, swelling in 1st MTP joint(s) – Tophi • Consider gout if rapid onset of symptoms in other joints • Assess differentials – septic arthritis, pseudogout, inflammatory arthritis • 1st line investigation – serum urate – If level is <360 micromol/litre with typical symptoms repeat at least 2 weeks after flare has settled • 2nd line investigation – synovial fluid microscopy

Answer 52

• 4 defects – usually present at birth – pulmonary stenosis – ventricular septal defect – right ventricular hypertrophy – an overriding aorta • May have bluish colouration, dyspnoea • Normal size heart – concavity in area of main pulmonary artery – boot shaped

Answer 53

• Typical features of UTI: – Dysuria, Frequency, Urgency, Changes in urine appearance, Nocturia, Suprapubic discomfort • Infection may spread from bladder to kidneys • Pyelonephritis should be suspected if fever, loin pain, rigors • Patients should be admitted if tachycardic, hypotension, breathless; marked signs of illness, fever over 38°C

Answer 54

• Ovarian Torsion – severe pelvic pain, nausea, abnormal bleeding, palpable mass • AAA – can lead to referred flank pain, rare • Appendicitis – right iliac fossa, unlikely to present with pain on left • Sigmoid diverticulitis – unlikely in this age range

Answer 55

• Serum potassium level < 3.5mmol/L. • Causes: – diuretics, diarrhoea and vomiting, Cushing’s disease, Conn’s syndrome, pyloric stenosis, rectal villous adenoma and renal tubular failure. • Symptoms and signs: – muscle weakness, hypotonia, hyporeflexia, cramps, palpitations and constipation.

Answer 56

Electrolyte Deficiency • Hyperkalaemia – more common in men, AKI or CKD, medications • Hypokalaemia – more common in women, result of loss of GI fluids (vomiting) • Hypernatremia – most common is hospital setting, associated with IV fluids • Hypercalcaemia – most frequently encountered in malignancy • Hypocalcaemia – common in ICU patients

Answer 57

• Common / Very common – Nausea, thrombocytopenia, vomiting • Uncommon – Diarrhoea, leukopenia • Unknown frequency – Includes: AKI, Hepatitis, Influenza, Discolouration of sputum, sweat, tears, urine, SCARS • When used IV – Bone pain, GI disorder, hyperbilirubinaemia

Answer 58

• Assess severity of obstruction – Mild – breathing, effective cough, speech – Severe – unable to breath / speak, wheezy breath sounds, cyanosis • Mild obstruction – encourage cough • Severe obstruction, conscious – back blows, abdominal thrusts • Severe obstruction, unconscious – CPR (even if pulse is present), call ambulance

Answer 59

• Red flag symptoms – dysphagia, voice change, ipsilateral otalgia, epistaxis, sensation of lump in throat • Pulsatile – vascular cause? • Hard / compressible – malignancy? branchial cyst? • Lymphadenopathy – local / general • Swallow test – does lump move? thyroid lump / thyroglossal cyst • Tongue protrusion – thyroglossal cyst moves up

Answer 60

• Vitamin A– night blindness • Vitamin B1 (thiamine) - Beriberi • Vitamin B3 (niacin) – Pellagra • Vitamin B6 (pyridoxine) – peripheral neuropathy, sideroblastic anaemia • Vitamin C (scurvy) - fragile capillaries, poor wound healing, gingivitis, gum bleeding, haematuria, malaise • Vitamin D – muscle weakness, bone pain, fatigue, depression

Answer 61

• <10 weeks– booking appointment - lifestyle, screening mother, discuss screening of foetus • 11-14 weeks (11+2 - 14+1)– dating scan • 18-20 weeks (18+0-20+6)– anomaly scan • 28 weeks– further screening, vaccinations, 1st anti-D for rhesus –ve women. • 32 weeks– repeat scan for abnormalities in anomaly scan • 36 weeks– checking foetal position, information re: delivery and early parenthood, ECV if NP • 37 weeks– ECV if not nulliparous and breech

Answer 62

• Manipulations of foetus to cephalic presentation • Success rate ~50% • Usually done at 37 weeks or later – From 36 weeks in nulliparous women • If ECV unsuccessful, very few babies spontaneously turn to cephalic presentation • If successful, unlikely to return to breech • Reduces the chance of needing C-section

Answer 63

Poison Antidote Paracetamol N-Acetylcysteine Beta blockers Glucagon, atropine Opioids Naloxone Iron Desferrioxamine Ethylene glycol, methanol Fomepizole / ethanol Warfarin Phytomenadione (Vitamin K) Oral poisons (tablets / capsules) Activated charcoal

Answer 64

l • Binds poisons to reduce absorption • Can be used for most tablets / capsules • NOT to be used for corrosive substances, alcohol, metal salts, cyanide, petroleum • Effective up to ~1 hour • Repeated doses can be give to enhance elimination after absorption for: – Carbamazepine, Dapsone, Phenobarbital, Quinine, Theophylline

Answer 65

• <10 weeks– booking appointment - lifestyle, screening mother, discuss screening of foetus • 11-14 weeks (11+2 - 14+1)– dating scan • 18-20 weeks (18+0-20+6)– anomaly scan • 28 weeks– further screening, vaccinations, 1st anti-D for rhesus –ve women. • 32 weeks– repeat scan for abnormalities in anomaly scan • 36 weeks– checking foetal position, information re: delivery and early parenthood, ECV if NP • 37 weeks– ECV if not nulliparous and breech

Answer 66

• Manipulations of foetus to cephalic presentation • Success rate ~50% • Usually done at 37 weeks or later – From 36 weeks in nulliparous women • If ECV unsuccessful, very few babies spontaneously turn to cephalic presentation • If successful, unlikely to return to breech • Reduces the chance of needing C-section

Answer 67

• >2 red cells /mm3 • >10 white cells /mm3 in an unspun sample • Red / white cell casts – suggest glomerular inflammation – Pyelonephritis – Glomerulonephritis – Interstitial nephritis • Granular casts – seen in any chronic kidney disease

Answer 68

• Squamous epithelial cells • <2 red cells /mm3 • <10 white cells /mm3 in an unspun sample • Hyaline casts • Crystals – in old or cold urine

Answer 69

Side Effect Drugs Gynaecomastia Cimetidine, spironolactone, zoladex, finasteride, CCBs Tardive dyskinesia Metoclopramide, antipsychotics Rhabdomyolysis Statins Deafness Gentamycin Erectile Dysfunction Antihypertensives, antidepressants, nicotine Jaundice Nitrofurantoin, erythromycin, isoniazid, methyldopa, indometacin, salicylates

Answer 70

• Chronic, painful, degenerative inflammatory arthritis • Primarily affects spine and sacroiliac joints • Eventual fusion of the spine • The 4 ‘A’s of AS are; – anterior uveitis – apical fibrosis – aortic regurgitation – Achilles tendonitis. • Management is medical (NSAIDs, DMARDs, TNF α) or surgical to correct flexion deformities.

Answer 71

• IM Adrenalin 1:1000 • 500 micrograms / 0.5mg / 0.5ml • IV steroids no longer recommended • Where fluids required, use crystalloids

Answer 72

• Individual CBT + anti-depressant recommended in more severe depression (moderate / severe depression) • SSRI 1st line for most patients – optimise dose • Sertraline, citalopram, fluoxetine • 2nd line / 3rd line • Alternate SSRI if no response • TCA or SNRI (avoid if high risk of overdose) • Amitriptyline, Venlafaxine • When changing antidepressants, cross taper or stop 1st drug before starting new drug

Answer 73

• Resting 12 lead ECG – chest pain, HTN, pre-op • ABPM / HBPM - hypertension • Exercise ECG – known CAD + ?stable angina • 24 hour ECG – palpitations, paroxysmal AF • Echocardiogram – suspected heart failure / structural • Spirometry - COPD • Chest X-Ray – pneumonia, lung cancer (initial) • Bronchoscopy – lung cancer • Ultrasound doppler - DVT • CT scan – stroke, lowered GCS

Answer 74

• Binds poisons to reduce absorption • Can be used for most tablets / capsules • NOT to be used for corrosive substances, alcohol, metal salts, cyanide, petroleum • Effective up to ~1 hour • Repeated doses can be give to enhance elimination after absorption for: – Carbamazepine, Dapsone, Phenobarbital, Quinine, Theophylline

Answer 75

• Vaginitis from candida infection may cause post-coital bleeding • Foreign bodies unlikely to cause post- coital bleeding • may cause a waxing and waning pain + discharge • NICE guidelines recommend full pelvic examination including cervical speculum examination for post coital / inter- menstrual bleeding