Misc.

Question 1

Down’s AFP

Answer 1

low

Question 2

Down’s bHCG

Answer 2

high

Question 3

Downs Nuchal Translucency

Answer 3

Thickened

Question 4

Down’s Oestradiol

Answer 4

low

Question 5

Down’s PAPPA

Answer 5

low

Question 6

You review a 3-year-old girl who is being treated for idiopathic constipation with Movicol Paediatric Plain. Her mother has increased the dose but unfortunately there has been no response. She remains well and examination of the abdomen is normal. What is the most appropriate next step?

Answer 6

Add Senna (Stimulant laxtive)

Question 7

DDH

Answer 7

Most stabilise 3-6w
Pavlik harness (flexion-abduction orthosis) in children younger than 4-5 months

Question 8

COCP and surgery

Answer 8

stop 4 weeks prior, restart 2 weeks after

Question 9

Avoid whilst breasfeeding

Answer 9

antibiotics: ciprofloxacin, tetracycline, chloramphenicol, sulphonamides
psychiatric drugs: lithium, benzodiazepines
aspirin
carbimazole
sulphonylureas
cytotoxic drugs
amiodarone

Question 10

A 2 day old baby born by a ventouse delivery- swelling on the left side of his head in the parietal region. His head appeared normal immediately after delivery. On examination, the baby is well and the swelling does not cross suture lines. The fontanelles and sutures appear normal. What is the most likely diagnosis?

Answer 10

Cephalohaematoma

Question 11

A 9-day-old pre-term neonate stops tolerating his cow’s milk feeds given by the nurses in the special care baby unit. He vomited after the most recent feed and the nurse noticed bile in the vomit. Stools are normal consistency but the last stool contained fresh red blood. On examination he is well hydrated but his abdomen is grossly distended and an urgent abdominal x-ray is requested. X-ray shows distended loops of bowel with thickening of the bowel wall. What is the next best step in management?

	Continue oral feeds, switching to breast milk
	Commence broad spectrum antibiotics
	Commence IV fluids
	Commence IV hydrocortisone
	Commence erythromycin

Answer 11

Commence broad spectrum antibiotics

This scenario describes a case of necrotising enterocolitis. Given the history and examination along with the age and prematurity of the infant, bacterial necrotising enterocolitis is the most likely diagnosis. Due to the seriousness of this, broad spectrum antibiotics must be commenced immediately. For this reason, answer 2 is the correct answer.

Although necrotising enterocolitis is seen more often in bottle fed infants, changing feeds at this stage is futile.

IV fluids are important to maintain hydration but not as urgently needed in this case as antibiotics.

Erythromycin is given antenatally to prevent necrotising enterocolitis but is not useful in treatment.

Question 12

Impetigo Treatement

Answer 12

Topical Fusidic Acid

topical retapamulin is used second-line if fusidic acid has been ineffective or is not tolerated

Question 13

Contraceptives - time until effective (if not first day period):

Answer 13

instant: IUD
2 days: POP
7 days: COC, injection, implant, IUS

Question 14

A 31-year-old man and 30-year-old woman attend clinic after struggling to conceive for 12 months. Testing reveals mild endometriosis. What is the most appropriate management?

Answer 14

Continue trying to conceive naturally for another 12 months

Question 15

Pre Eclampsia RF

Answer 15

Aged 40 years or older
Nulliparity
Pregnancy interval of more than 10 years
Family history of pre-eclampsia
Previous history of pre-eclampsia
Body mass index of 30kg/m^2 or above
Pre-existing vascular disease such as hypertension
Pre-existing renal disease
Multiple pregnancy

Question 16

Placenta Praevia

Answer 16

5% will have low-lying placenta when scanned at 16-20 weeks gestation
incidence at delivery is only 0.5%, therefore most placentas rise away from cervix

Rescan at 34w

Question 17

Neuroleptic Malignant Syndrome

Answer 17

more common in young male patients
onset usually in first 10 days of treatment or after increasing dose
pyrexia
rigidity
tachycardia

Mx
stop antipsychotic
IV fluids to prevent renal failure
dantrolene* may be useful in selected cases
bromocriptine, dopamine agonist, may also be used

Question 18

A 72 year-old woman presents to the GP with an itchy, sore white plaque on her vulva. The patient has a past medical history of type 1 diabetes and no personal or family history of cancer. Which of the following is the most likely diagnosis?

Answer 18

Lichen sclerosus

Management
topical steroids and emollients

Question 19

Contraindications to MMR

Answer 19

severe immunosuppression
allergy to neomycin
children who have received another live vaccine by injection within 4 weeks
pregnancy should be avoided for at least 1 month following vaccination
immunoglobulin therapy within the past 3 months (there may be no immune response to the measles vaccine if antibodies are present)

Question 20

A 5-year-old girl is seen in the emergency department following her first seizure. lasted 5 minutes. falling to the floor suddenly and jerking her arms. now feels well in herself and does not remember the incident. She is otherwise well.

Neurological examination is normal. General examination reveals four de-pigmented patches of skin over her torso and areas of thickened leathery skin over her lumbar region.

What is the most likely diagnosis?

Answer 20

Tuberous sclerosis

Cutaneous features
depigmented ‘ash-leaf’ spots which fluoresce under UV light
roughened patches of skin over lumbar spine (Shagreen patches)
adenoma sebaceum (angiofibromas): butterfly distribution over nose
fibromata beneath nails (subungual fibromata)
café-au-lait spots* may be seen

Neurological features
developmental delay
epilepsy (infantile spasms or partial)
intellectual impairment

Also
retinal hamartomas: dense white areas on retina (phakomata)
rhabdomyomas of the heart
gliomatous changes can occur in the brain lesions
polycystic kidneys, renal angiomyolipomata
lymphangioleiomyomatosis: multiple lung cysts

Question 21

A 2-year-old child with a history of atopic eczema is brought to the local GP surgery. Her eczema is usually well controlled with emollients but her parents are concerned as the facial eczema has got significantly worse overnight. She now has painful clustered blisters on both cheeks, around her mouth on her neck. Her temperature is 37.9ºC. What is the most appropriate management?

Answer 21

Admit

Eczema herpeticum is a serious condition that requires IV antivirals

Question 22

Bishop Score

Answer 22

0 1 2 3
Cervical position Posterior Intermediate Anterior -
Cervical consistency Firm Intermediate Soft -
Cervical effacement 0-30% 40-50% 60-70% 80%
Cervical dilation <1 cm 1-2 cm 3-4 cm >5 cm
Fetal station -3 -2 -1, 0 +1,+2

Question 23

You are asked to see a 31-year-old woman on the labour ward who has developed a high fever (39.1ºC) 2 days post-partum. She complains of dysuria, and frequency, you suspect a urinary tract infection. She is choosing to breast feed, has severe anaphylactic reactions to penicillins. Which antibiotic would be appropriate?

	Nitrofurantoin
	Trimethoprim
	Cefaclor (a cephalosporin)
	Ciprofloxacin
	Fosfomycin

Answer 23

Trimethoprim is present in milk but is not known to be harmful for short term use. This would be an appropriate choice.

Nitrofurantoin should be avoided when breastfeeding - small amounts in milk but can cause haemolysis in G6PD infants.

Cefaclor is safe to use when breastfeeding but should be avoided in this instance due to history of anaphylaxis with penicillins as cephalosporins have cross-sensitivity with beta-lactams (penicillin).

Ciprofloxacin should be avoided when breast feeding.

Fosfomycin may be used for uncomplicated lower urinary tract infections caused by multiple resistant bacteria when other antibacterials cannot be used, but this is an unlicensed use.

Question 24

A 7-year-old boy is admitted to your ward after being struck by car.

patient also has type-1 Von Willebrand disease

Which of the following agents can be administered to reduce bleeding while awaiting theatre?

Answer 24

Desmopressin

is a synthetic analogue of vasopressin a.k.a antidiuretic hormone (ADH). It stimulates the release of Von Willebrand factor from Weibel-Palade bodies in endothelial cells.

Question 25

SSRI Discontinuation symptoms

Answer 25

increased mood change
restlessness
difficulty sleeping
unsteadiness
sweating
gastrointestinal symptoms: pain, cramping, diarrhoea, vomiting
paraesthesia

Question 26

Which one of the following contraceptives do the Faculty of Sexual and Reproductive Healthcare (FSRH) recommend should be discontinued after the age of 50 years?

Answer 26

Injectable contraceptives (e.g. Depo-Provera)

Question 27

A 69-year-old man is diagnosed as having Parkinson’s disease. Which one of the following psychiatric problems is most likely to occur in this patient?

Answer 27

Depression

Whilst dementia is common in patients with Parkinson’s disease depression is known to exist in around 40%

Question 28

Diagnose Hirschsprung’s disease

Answer 28

Rectal Biopsy

Question 29

A 6-year-old boy weighing 28kg is admitted to the paediatric intensive care unit with severe meningococcal meningitis. Due to his level of consciousness he is intubated and receives ventilation via an endotrachael tube. As he is nil by mouth, the consultant asks you to prescribe his maintenance fluids for the following 24 hours. How much maintenance fluid should he be given over the next 24 hours?

Answer 29

1000 + 500 + 160 = 1660ml

Question 30

At her booking visit, a woman mentions to her midwife that she has been previously diagnosed with immune thrombocytopenic purpura (ITP). Which procedure carries the greatest risk of haemorrhage in the newborn?

Answer 30

Prolonged ventouse delivery

Question 31

A 14-year-old male being investigated for iron-deficiency anaemia is found to have numerous polyps in his jejunum. On examination he is also noted to have pigmented lesions on his palms and soles. What is the likely diagnosis?

Answer 31

Peutz-Jeghers syndrome

Genetics
autosomal dominant
responsible gene encodes serine threonine kinase LKB1 or STK11

Features
hamartomatous polyps in GI tract (mainly small bowel)
pigmented lesions on lips, oral mucosa, face, palms and soles
intestinal obstruction e.g. intussusception
gastrointestinal bleeding

Management
conservative unless complications develop

Question 32

A hepatitis B serology positive woman gives birth to a healthy baby girl. She is surface antigen positive. What treatment should be given to the baby?

Answer 32

Hep B vaccine

0.5 millilitres of HBIG within 12 hours of birth with a

further hepatitis vaccine at 1-2 months and a further vaccine at 6 months

Question 33

A 24-year-old female has an abdominal ultrasound performed as she has had repeat urinary tract infections in the past 12 months. It is reported as follows:

4cm simple ovarian cyst noted on left ovary

Answer 33

Repeat ultrasound in 12 weeks

Premenopausal women
a conservative approach may be taken for younger women (especially if < 35 years) as malignancy is less common. If the cyst is small (e.g. < 5 cm) and reported as ‘simple’ then it is highly likely to be benign. A repeat ultrasound should be arranged for 8-12 weeks and referral considered if it persists.

Postmenopausal women
by definition physiological cysts are unlikely
any postmenopausal woman with an ovarian cyst regardless of nature or size should be referred to gynaecology for assessment

Question 34

A 64-year-old woman presents as she is feeling down and sleeping poorly. she has moderate depression. She has a past history of ischaemic heart disease and currently takes aspirin, ramipril and simvastatin. What is the most appropriate course of action?

Answer 34

Start sertraline + lansoprazole

SSRI + NSAID = GI bleeding risk - give a PPI

Question 35

Barlow and Ortolani tests

Answer 35

Barlow test: attempts to dislocate an articulated femoral head
Ortolani test: attempts to relocate a dislocated femoral head

Question 36

Which condition may be significantly worsened if haloperidol is prescribed for sedation?

Answer 36

All antipsychotics may worsen the symptoms of Parkinson’s disease and should be avoided if possible.

A small dose of oral lorazepam may be an alternative in such a situation.

Question 37

A 31-year-old female with a history of epilepsy consults you following an uneventful pregnancy. Which one of the following drugs would it be safe to continue during breast feeding?

	Phenytoin
	Carbamazepine
	Lamotrigine
	Sodium valproate
	All of the above

Answer 37

All

Question 38

A 27 year-old lady is day 1 post emergency caesarean section for failure to progress in the first stage. She has been complaining of pain and heavy vaginal bleeding since delivery and in the morning was noted to have heavy, offensive lochia and a boggy poorly contracted uterus above the umbilicus.

What is the most appropriate treatment?

Answer 38

Examination under anaesthesia

Question 39

A 3-year-old girl presented to the general practitioners 1 week ago for recurrent epistaxis and bruising on her flanks. Clotting has also been assessed and revealed a prolonged prothrombin time.

Results (with normal ranges for a 3-year-old)

Hb 80g/l (115-135)
Platelets 100 * 109/l (150-450)
WBC 10.0 * 109/l (5.0-17.0)
Neutrophils 1.0 * 109/l (1.5-8.5)

What is the most likely diagnosis?

Answer 39

With the symptoms of epistaxis and bruising leukaemia is the most likely choice out of the options given. This is compounded by the anaemia associated with low platelets. Disseminated intravascular coagulation is also hinted at by the low platelets and prolonged prothrombin time. This would also fit with acute lymphoblastic leukaemia. Acute myeloid leukaemia is unlikely due to the age group. White blood cells are normal which would point away from a long standing infection. Although aplastic anaemia and myelodysplasia would give lowered erythrocytes and platelets, they would not produce the symptoms of epistaxis and bruising.

anaemia: lethargy and pallor
neutropaenia: frequent or severe infections
thrombocytopenia: easy bruising, petechiae

Question 40

Turner’s Likely Heart Murmur

Answer 40

Systolic, loudest over the aortic valve

Turner’s syndrome are prone to have bicuspid aortic valve, aortic valve stenosis and/or aortic coarctation

Question 41

You review the blood results taken from a pregnant woman at her booking visit. She is now 11 weeks pregnant, currently well and has no past medical history of note.

Rubella IgG NOT detected

What is the most appropriate course of action?

Answer 41

Advise her of the risks and the need to keep away from anyone who has rubella

women normally have their immunity checked before becoming pregnant
rubella immunity is routinely checked at the booking visit. If the no immunity is demonstrated pregnant women need to keep away from people who might have rubella
non-immune mothers should be offered the MMR vaccination in the post-natal period
Next question

Question 42

An 18-month-old boy is brought to the GP by his mother as she is concerned about his breathing. Three days ago he started with fever, cough and rhinorrhoea. For the past 24 hours his mother reports that he has been ‘wheezy’. On examination his temperature is 37.9ºC, heart rate 126/min, respiratory rate 42/min and a bilateral expiratory wheeze is noted. You prescribe a salbutamol inhaler along with a spacer. Two days later the mother represents noting the inhaler has made little difference to the wheeze. Clinical findings are similar, although his temperature today is 37.4ºC. What is the most appropriate next step in management?

Answer 42

Oral montelukast or inhaled corticosteroid

This child is likely to have a viral-induced wheeze, also known as episodic viral wheeze. First-line treatment is short-acting bronchodilator therapy. If this is not successful then either oral montelukast or inhaled corticosteroids should be tried.

Question 43

Viral Induced Wheeze Mx

Answer 43

Episodic viral wheeze
treatment is symptomatic only
first-line is treatment with short acting beta 2 agonists (e.g. salbutamol) or anticholinergic via a spacer

next step is intermittent leukotriene receptor antagonist (montelukast), intermittent inhaled corticosteroids, or both

there is now thought to be little role for oral prednisolone in children who do not require hospital treatment

Multiple trigger wheeze
trial of either inhaled corticosteroids or a leukotriene receptor antagonist (montelukast), typically for 4-8 weeks

Question 44

Squint (strabismus) is characterised by misalignment of the visual axes. Squints may be divided into

Answer 44

concomitant (common)
Due to imbalance in extraocular muscles
Convergent is more common than divergent

and paralytic (rare)
Due to paralysis of extraocular muscles

Question 45

Detection of a squint

Answer 45

Detection of a squint may be made by the corneal light reflection test - holding a light source 30cm from the child’s face to see if the light reflects symmetrically on the pupils

Question 46

Testing nature of a squint

Answer 46

The cover test is used to identify the nature of the squint
ask the child to focus on a object
cover one eye
observe movement of uncovered eye
cover other eye and repeat test

Question 47

Mx of Squint

Answer 47

Management
eye patches may help prevent amblyopia
referral to secondary care is appropriate

Question 48

Endometriosis Mx

Answer 48

The COCP is the first line option, and can be used back-to-back with no pill-free interval.

Second line treatments include progesterone only methods, such as POP, implant or injection (again they work by inhibiting ovulation). In addition, the mirena coil can be used as it will reduce bleeding, resulting in less retrograde menstruation.

The copper intra-uterine device can make menstrual cycles longer and more painful and would not be a suitable option.

If the above methods fail to improve a patient’s symptoms, then GnRH analogues may be used.

Question 49

Partial Mole

Answer 49

69XXY 69XXX

Question 50

What is the investigation of choice to look for renal scarring in a child with vesicoureteric reflux?

Answer 50

DMSA

Question 51

RF for SIDS

Answer 51

Risk factors
prematurity
parental smoking
hyperthermia (e.g. over-wrapping)
putting the baby to sleep prone
male sex
multiple births
bottle feeding
social classes IV and V
maternal drug use
incidence increases in winter

Question 52

Cerebral Palsy Mx

Answer 52

Management

multidisciplinary

treatments for spasticity include 
oral diazepam, 
oral and intrathecal baclofen, 
botulinum toxin type A, 
orthopaedic surgery 
selective dorsal rhizotomy
anticonvulsants,
 analgesia as required

Question 53

fetal macrosomia. An infant weighing 4.4kg is born who has a noticeably large tongue which obstructs his airway. Shortly after intervention, he becomes hypoglycemic

Answer 53

Beckwith-Wiedemann syndrome

Question 54

An 80 year-old woman presents to her GP with a 1.5cm ulcerated lesion on her left labium majus. Her history includes a two year history of vulval itching and soreness, which has failed to respond to topical steroid treatment. What is the most likely diagnosis?

Answer 54

Vulval carcinoma

Vulval carcinomas are commonly ulcerated and can present on the labium majora. Melanomas are usually pigmented. Vulval intraepithelial neoplasia tend to be white or plaque like and don’t tend to ulcerate. Herpes simplex tend to be smaller vesicles and chancre tends to be painless and is seen in the first phase of syphilis.

Question 55

Inactivated preparations

vaccines

Answer 55

rabies
influenza (intramuscular) - Intranasal is live attenuated

Question 56

Pertussis Mx

Answer 56

an oral macrolide (e.g. clarithromycin, azithromycin or erythromycin) is indicated if the onset of the cough is within the previous 21 days to eradicate the organism and reduce the spread
antibiotic therapy has not been shown to alter the course of the illness

Question 57

A 29-year-old primiparous woman is in a prolonged labour following an induction at 41 weeks gestation. She is 6 cm dilated and the fetal head is 1 cm above the ischial spines. The midwife calls you to look at her CTG. The fetal heart rate is progressively dropping, it is now below 100 beats per minute, and it has not recovered for more than 3 minutes.

Answer 57

Category 1 Caesarean section

Question 58

An antenatal ultrasound scan demonstrates a hyperechogenic bowel. Which conditions are this finding most associated with?

Answer 58

cystic fibrosis
Down’s syndrome
cytomegalovirus infection

Question 59

A nuchal scan is performed at 11-13 weeks. Causes of an increased nuchal translucency include:

Answer 59

Down’s syndrome
congenital heart defects
abdominal wall defects

Question 60

Bronchiolitis Peak incidence

Answer 60

Peak incidence is 3-6 months of age

Management is largely supportive
humidified oxygen is given via a head box
Next question

Question 61

A 20 year old woman who is 16 weeks pregnant presents with pain passing urine and an irritating rash. On examination she has a tender, red, vesicular rash on her vulva. A urine dipstick shows both blood and white cells. What is the best treatment?

Answer 61

Oral aciclovir

The primary purpose of treatment is to reduce the risk of transmission to the neonate at birth. The risk is much more considerable with primary genital herpes simplex within the final six weeks of pregnancy. Caesarian section should be the recommended mode of delivery for all women developing the first episode of genital HSV in the third trimester.

Question 62

benzodiazepine withdrawal syndrome

Answer 62

insomnia
irritability
anxiety
tremor
loss of appetite
tinnitus
perspiration
perceptual disturbances
seizures

Question 63

An 82-year-old lady presents with urinary straining, poor flow, incomplete emptying of the bladder, and urinary incontinence. Urodynamics demonstrates a voiding detrusor pressure of 90 cm H20 (normal value < 70 cm H2O) and peak flow rate of 5 mL/second (normal value > 15 mL/second). What is the most likely diagnosis?

Answer 63

overflow incontinence

Normal bladder function should have a voiding detrusor pressure rise of < 70 cm H20 with a peak flow rate of > 15 ml/second A high voiding detrusor pressure with a low peak flow rate is indicative of bladder outlet obstruction. Therefore the most likely answer is overflow incontinence. Voiding symptoms (e.g. straining, poor flow, and incomplete emptying of the bladder) are also suggestive of bladder outlet obstruction.

Question 64

PPH Mx

Answer 64

Management
ABC
IV syntocinon (oxytocin) 10 units or IV ergometrine 500 micrograms
IM carboprost
other options include: B-Lynch suture, ligation of the uterine arteries or internal iliac arteries
if severe, uncontrolled haemorrhage then a hysterectomy is sometimes performed as a life-saving procedure

Question 65

Section 5(4)

Section 17a

Answer 65

Section 5(4)
similar to section 5(2), allows a nurse to detain a patient who is voluntarily in hospital for 6 hours

Section 17a
Supervised Community Treatment (Community Treatment Order)

Question 66

Pre-eclampsia and gestational hypertension would only occur after

Answer 66

20 weeks gestation. Pre-eclampsia with significant proteinuria, gestational hypertension without.

Question 67

GBS

Answer 67

Intrapartum benzylpenicillin

Question 68

A 4-year-old boy is brought to the clinic by his mother who has noticed a small lesion at the external angle of his eye. On examination there is a small cystic structure which has obviously been recently infected. On removal of the scab, there is hair visible within the lesion. What is the most likely diagnosis?

Answer 68

Dermoid cysts occur at sites of embryonic fusion and may contain multiple cell types. They occur most often in children.

Question 69

Menorrhagia: management

Answer 69

Investigations
a full blood count should be performed in all women
further investigations are based upon the history and examination findings

Does not require contraception
either mefenamic acid 500 mg tds (particularly if there is dysmenorrhoea as well) or tranexamic acid 1 g tds. Both are started on the first day of the period
if no improvement then try other drug whilst awaiting referral

Requires contraception, options include
intrauterine system (Mirena) should be considered first-line
combined oral contraceptive pill
long-acting progestogens

Question 70

A baby is born by normal vaginal delivery at 39 weeks gestation. Initially all appears well and then the clinical staff become concerned because the baby develops recurrent episodes of cyanosis. These are worse during feeding and improve dramatically when the baby cries.

Answer 70

Choanal atresia

Question 71

ECT Side Effects

Answer 71

Short-term side-effects
headache
nausea
short term memory impairment
memory loss of events prior to ECT
cardiac arrhythmia

Long-term side-effects
some patients report impaired memory
Next question

Question 72

4: Vaginal investigations should always be avoided in a pregnant woman with unexplained vaginal bleeding

Answer 72

good

Question 73

A 3-year-old male cold becoming worse’.cough he has had for 4 days has become louder and more frequent and he hasn’t eaten 24 hours. On examination he is febrile (38.4ºC) and mildly agitated with overt coryzal symptoms. There is mild retraction of the skin around the sternal wall and a gentle, soft inspiratory high pitched noise heard between fits of coughing. What is the most appropriate management in this case?

Answer 73

Croup

Soft inspiratory high pitched noise heard is stridor

Oral dexamethasone

Question 74

Features of growing pains

Answer 74

never present at the start of the day after the child has woken
no limp
no limitation of physical activity
systemically well
normal physical examination
motor milestones normal
symptoms are often intermittent and worse after a day of vigorous activity

Question 75

A 34-year old pregnant female at 12 weeks gestation presents with a two week history of severe nausea and vomiting. On examination the pulse is 110 beats/min and blood pressure 110/80 mmHg. It is also noted that the patient is experiencing diplopia and ataxia. Urinalysis demonstrates an increased specific gravity and 3+ ketones. A diagnosis of hyperemesis gravidarum is made. The patient responds suitably to fluid resuscitation with 0.9% saline. What other treatment should this patient receive?

	Nasogastric tube feeding
	Vitamin B12
	Insulin
	Intravenous vitamins B and C (Pabrinex)
	Low molecular weight heparin

Answer 75

In this case the patient has presented with diplopia and ataxia suggestive of Wernicke’s encephalopathy. Therefore, supplementation of thiamine (Vitamin B1) with a vitamin B and C complex (e.g. Pabrinex) is indicated.

Question 76

PPH medical failed What is the most appropriate initial surgical intervention?

Answer 76

Intrauterine balloon tamponade

Question 77

Missed ‘Traditional’ POPs (Micronor, Noriday, Nogeston, Femulen)

Answer 77

If less than 3 hours late
no action required, continue as normal

If more than 3 hours late (i.e. more than 27 hours since the last pill was taken)
action needed - see below

Action required, if needed:
take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
continue with rest of pack
extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours

Question 78

Missed Cerazette (desogestrel)

Answer 78

If less than 12 hours late
no action required, continue as normal

If more than 12 hours late (i.e. more than 36 hours since the last pill was taken)
action needed - see below

Action required, if needed:
take the missed pill as soon as possible. If more than one pill has been missed just take one pill. Take the next pill at the usual time, which may mean taking two pills in one day
continue with rest of pack
extra precautions (e.g. condoms) should be used until pill taking has been re-established for 48 hours

Question 79

You are asked to see a baby on the post-natal ward 10 hours post vaginal delivery. The midwife informs you that the mother was positive for group B streptococcus. On examination you note a yellow discolouration to the skin. What is the next most appropriate action to take?

	Measure serum bilirubin within 2 hours
	Measure serum bilirubin within 6 hours
	Measure bilirubin via transcutaneous bilirubinometer
	Start empirical phototherapy
	Reassess after 24 hours of age

Answer 79

As this baby is less than 24 hours old they are high risk for developing severe hyperbilirubinaemia and must have their serum bilirubin urgently (within 2 hours). As this baby is less than 24 hours old the use of a transcutaneous bilirubinometer is inappropriate. Phototherapy is a treatment option for jaundice, but a serum bilirubin should be measured in case it is beyond the threshold for exchange transfusion.