MSK, Reproduction and Psychiatry Summary COPY

Question 1

What is the management of ectopic pregnancies?

Answer 1

• medical: methotrexate
• surgical: laparoscopic salpingectomy/ salpinotomy for few indications

conservative

+ USS in following pregnancies

Question 2

What infections might cause reactive arthritis?

Answer 2

Infections include- Salmonella, Shigella, Yersinia, Campylobacter, Chlamydia trachomatis or pneumoniae, Borrelia, Neisseria and streptococci

Infections- throat, urogenital & GI

Question 3

Gout vs Pseudogout comparison

Answer 3

Question 4

What is the management of bacterial vaginosis?

Answer 4

Amsel’s criteria for diagnosis of BV - 3 of the following 4 points should be present

thin, white homogenous discharge

clue cells on microscopy: stippled vaginal epithelial cells

vaginal pH > 4.5

positive whiff test (addition of potassium hydroxide results in fishy odour)

Management

oral metronidazole for 5-7 days

70-80% initial cure rate

relapse rate > 50% within 3 months

the BNF suggests topical metronidazole or topical clindamycin as alternatives

Question 5

What are risk factrors for stress incontinence?

Answer 5

Age

Parity

Menopause

Smoking

Medical problems

Increased intra abdominal pressure

Pelvic floor trauma

Denervation

Connective tissue disease

Surgery

Question 6

What is the presentation of breast cancer?

Answer 6

hard lump, fixed mass, tethering to skin, dimpling of skin, often painless lump or thickening in breast, discharge or bleeding, change in size or contours of breast, change in colour of areola, redness or pitting of skin over the breast like the skin of an orange

Question 7

What are the two ways of assessing osteoporosis fracture risk?

Answer 7

FRAX

Qfracture

Question 8

How is the diagnosis of PCOS made?

Answer 8

2 of the three

• Polycystic ovaries on USS
• Oligo ovulation or anovulation
• Clinical hirsuitism, acne or biochemical signs of hyperandrogenism

Question 9

What is the presentation of SLE?

Answer 9

classification criteria (any 4 “ORDER HIS ANA):

Oral ulcers

malar Rash

Discoid rash (raised, scarring, permanent marks, alopecia)

Exaggerated photosensitivity

Renal disorders (significant proteinuria or cellular casts in urine)

Haematological (low WCC, platelets, lymphocytes, haemolytic anaemia)

Immunological (anti ds-DNA, SM ( I think this is anti-smith, cardiolipin, lupus anticoagulant, low complement)

Serositis (pleurisy or pericarditis)

Arthritis/arthralgia (2 joints at least)

Neuro (unexplained seizures or psychosis)

ANA (anti-nuclear Ab)

Also has fever

Question 10

What is the triad of granulomatosis with polyangitis?

Answer 10

Focal necrotising vasculitis

Necrotizing granulomas in the upper airway, lungs

Necrotizing glomerulonephritis (renal vasculitis)

Question 11

What are the casues of male infertility?

Answer 11

CF, testicular maldescent, testicular problem, pre-testicular (hypothalamus) or post-testicular. Previously mentioned that there can also be absence of vas deferens

failure of production (35%)

Klinfelter’s syndrome

previous mumps or TB

failure of transport

sterilisation

CF

impotence

Question 12

What is a bone biopsy finding of pagets disease of the bone?

Answer 12

Mosaic pattern of lamellar bone

Large numerous osteclasts with up to 100 nuclei normal is 5-10)

Affected bone marrow field is filled with highly vascular stroma

Question 13

What are X ray findings of Paget’s disease of the bone?

Answer 13

Osteoporisis circumscripta (well defined osteolytic lesions of the skull in early course)

Cotton wool appearance

Squaring of vertebrae seen on lateral X-ray

Tam O’shanter sign (enlarged overriding frontal bone)

Bone scan scintigraphy is a potential investigation (focal increased radionuclide uptake)

Question 14

What medications might predispose you to osteoporosis?

Answer 14

Steroids

PPI - reduced calclium absorption

Enzyme inducting antiepileptic mediations

Aromatase inhibitors

GnRH inhibitors

Warfarin - Vitamin K is an essential factor for carboxylation of bone matrix protein. Low vitamin K may be associated with reduced bone mineral density (BMD)

Question 15

What are the features of endometrial cancer?

Answer 15

post-menopausal bleeding is most common feature, abnormal vaginal bleeding (change in pre-menstrual bleeding)

Question 16

How does dupuytrens disease progress?

Answer 16

Starts in the palms causing puckering of the skin. Metacarpophalangeal (MCP) joints affected before the proximal interphalangeal (PIP) joints.

Question 17

What are the relevant investigations for menopause?

Answer 17

DEXA scan for bone density

LH (Increases)

FSH (increases)

Oestrogen (decreases)

Progesterone (decreases)

Question 18

What is the management for placental abruption?

Answer 18

May have to do immediate C section in worst cases but vaginal delivery may be achieved

Question 19

What is the presentation of osteoarthritis?

Answer 19

patient over 45 and activity-related joint pain (pain after exertion) plus either morning stiffness < 30 minutes, reduced ROM, deformity

pain after exertion,

IF linked to trauma, prolonged morning-related stiffness, rapid deterioration of symptoms, hot swollen joint then -> gout, other inflammatory arthrides, septic arthritis, malignancy

Question 20

What would you find in a salivary gland biopsy in sjogren’s?

Answer 20

Focal lymphocyte foci (collections of tightly aggregated lymphocytes)

Question 21

What is FIGO staging?

Answer 21

Endometrial cancer staging

(FIGO stage 1-4 according to depth of myometrial invasion, cervical involvement and lymph node involvement) and type (1 or 2)

stage 1 (carcinoma strictly confined to the uterus)

stage 2 (carcinoma extended to the endocervix (2A) or cervical stoma (2B))

stage 3 (spread to serosa of uterus, pelvic peritoneum or pelvic lymph nodes)

stage 4 (local metastasis to bladder/bowel (4A) or distant metastasis (4B))

Question 22

What is the disease mechanism of granulomatosis with polyangitis (wegners)?

Answer 22

B cell mediated release of free radicals from neutrophils

Free radicals damage neighbouring endothelial cells - vasculitits

granulomatosis with polyangitis only affects small vessels (nasopharynx, kidneys and lungs)

Question 23

What are the causes of pseudogout?

Answer 23

Sporadic

Hereditary component

Secondary to previous joint damage, hyperparathyroidism, haemachromatosis, hypothyroidism, ochronosis, diabetes

Question 24

What is presentation of RA?

Answer 24

Morning stiffness, improves with use
Bilateral symptoms
Systemic upset

Joint swelling (joints are swollen and warm, limitation of movement

Lymphadenopathy

Splenomegaly

Systemic - fatigue/lethargy, weight loss, anaemia

swollen, painful joints in hands and feet

stiffness worse in the morning

gradually gets worse with larger joints becoming involved

presentation usually insidiously develops over a few months

positive ‘squeeze test’ - discomfort on squeezing across the metacarpal or metatarsal joints

Swan neck and boutonnière deformities are late features of rheumatoid arthritis and unlikely to be present in a recently diagnosed patient.

Question 25

What is the definition of primary amenorrhoea?

Answer 25

never had period, either \>14 and no secondary sexual characteristics or \>16 and sexual characteristics

Question 26

What is the managment of hallux rigidus?

Answer 26

Non-operative: - Activity modification, shoe wear with rigid sole, analgesia Operative: cheilectomy (remove dorsal bone impingement) arthrodesis = 1st MTPJ fusion (gold standard, permanent) arthroplasty

Question 27

What are the features of dyskariosis?

Answer 27

dyskariosis (abnormal cells may be few, nucleus is increased in size and nuclear/cytoplasmic ratio, variation in size, shape, outline, coarse, irregular chromatin, nucleoli)

Question 28

Where do ganglia arise from ?

Answer 28

Joint capsule, tendon sheath or ligament

Question 29

What are the tests for achilles tendon rupture?

Answer 29

Simmonds - squeeze test Matles test - angle of dangle

Question 30

What are the investigations for endometriosis?

Answer 30

laparoscopy (gold standard) look for clear, red, bluish lack or with lesions, pelvic MRI for deep endometriosis, if severe disease is suspected and surgical planning necessary pelvic USS can diagnose endometrioma (chocolat cyst) or large nodules

Question 31

What are the stages of cervical cancer?

Answer 31

stage 1 (carcinoma strictly confined to the cervix) stage 2 (carcinoma that extends into the parametrium or upper 2/3 of vagina) stage 3 (carcinoma has extended to pelvic side wall, lower 1/3 of vagina or causes hydronephrosis) stage 4 (carcinoma that has extended beyond the pelvis)

Question 32

What percentage of CIN 3 progresses to cervical carcinoma?

Answer 32

30-80%

Question 33

What is the diagnostic criteria for pre-eclampsia?

Answer 33

creatinine ratio \>30mg/mmol, 24h urine protein collection \>300mg/day, mild HT on two occasions or more, more than 4 hours apart or moderate to severe HT

Question 34

What is the presentation for hallux valgus (forefoot problems)

Answer 34

**bunions**, pressure symptoms from shoe wear, pain from crossing over of toes, **metatarsalgia**

Question 35

What is the investigation for vulvovaginal candidosis?

Answer 35

Gram stained preparation, culture

Question 36

What is the disease process of septic arthritis?

Answer 36

Articular cartilage is attacked by abcterial toxin and cellular enzyme Complete destruction of the articular cartilage source of infection can be from blood, adjacent sites (osteomyelitis, bone abscess) or it can be through direct introduction of the organism via trauma / instrumentation

Question 37

What are the causes of menorrhoagia?

Answer 37

Uterine fibroids Dysfunctional uterine bleeding Coagulopathies Pelvic malignancies

Question 38

What is the treatment of DDH?

Answer 38

Pavlik harness Surgery may be needed if your baby is diagnosed with DDH after they're 6 months old, or if the Pavlik harness has not worked Surgical options include: closed reduction – the ball is placed in the socket without making any large cuts (incisions) open reduction – an incision is made in the groin to allow the surgeon to place the ball in the socket

Question 39

What are the functions of progesterone?

Answer 39

* Maintenance of endometrium and pregnancy * Thickens cervical mucous * Decreases myometrial excitability * Increases body temperature * Responsible for spiral artery development

Question 40

What are the three different types of idiopathic juvenile arthritis?

Answer 40

Polyarticular (5 joints or more) Pauci articular (4 joints or less) Stills disease which is systemic onset

Question 41

What are investigations for polymyalgia rheumatica?

Answer 41

ESR \> 40 mm/hr Increased CRP note CK and EMG normal reduced CD8+ T You tend to find that there is a dramatic response to steroids

Question 42

What is acute flare therapy for gout?

Answer 42

Anti-inflammatory treatment ASAP GLucocorticoids (oral and or intraarticular injections) NSAIDs (naproxen, indomethacin) Colchicine (inhibits leukocyte migration) Biological agents (IL-1 inhibitors)

Question 43

What is stage 2 of labour?

Answer 43

Full cervical dilation to the birth of the baby Passive second stage of labour - Full dilation of the cervix with or without expulsive contractions Active second stage - Presenting part is visible, expulsive contractions with full dilatation of the cervix, active maternal effort following confirmation of full dilatation of the cervix in the absence of expulsive contractions. Primagravida = birth would be expected within two hours of active second stage commencing Multigravida = 1 hour

Question 44

What is the screening programme for breast cancer in Scotland?

Answer 44

he Scottish Breast Screening Programme invites women aged between 50 and 70 years old for screening every three years. Women over 70 years old are able to attend through self-referral.

Question 45

What is placental abruption?

Answer 45

Premature separation of the placenta from the uterine wall

Question 46

What is the presentation of pre-eclampsia?

Answer 46

asymtomatic or headache, blurry vision, epigastric pain, pain below ribs, vomiting, sudden swelling of hands, face and legs, clonus, brisk reflexes, papilloedema, reduced urine output, convulsions, epigastric pain, right upper quadrant pain, visual disturbance, leg swelling Eclampsia is characterised by tonic clonic seizures Can also cause pulmonary oedema, cerebral haemorrhage, HELLP syndrome, placental abruption HELLP syndrome is haemolysis, elevated liver enzymes and low platelets

Question 47

What causes klumpkes palsy?

Answer 47

breech delivery, T1 damage (upward traction): occurs with shoulder disclocation or cervical rib

Question 48

What type of HPV virus is most assocaited with cervical cancer?

Answer 48

HPV 16 and 18 are highr risk subtypes

Question 49

What are investigations for fibroids?

Answer 49

large fibroids are palpable abdominally, uterus may be enlarged on pelvic examination Transvaginal USS, Pelvic USS, hysteroscopy?

Question 50

What are potential complications of PID?

Answer 50

infertility (10-20% after first episode), ectopic pregnancies, chronic pelvic pain, Fitz-Hugh-Curtis syndrome (in 10% cases)

Question 51

What changes would you see in the blood in pre-eclampsia?

Answer 51

High Bp Raised liver enzymes Bilirubin Raised urea and creatinine Raised urate Low platelets Low haemoglobin Signs of haemolysis Features of DIC

Question 52

What is the cause of pathophysiology of osteogenesis imperfecta?

Answer 52

abnormality in type 1 collagen due to decreased synthesis of pro-alpha 1 or pro-alpha 2 collagen polypeptides

Question 53

What are potential ectopic sites for ectopic pregnancy?

Answer 53

Fallopian tube is the most common (especially ampullary region) Cervical Abdominal Ovarian Uterine cesarean scar

Question 54

What is managment of endometriosis?

Answer 54

medical: NSAIDs, COCP, danazol/gestrinone, mirena IUS, GnRH agonist (leuprorelin), progesterone, levonorgestrel (LNG), GnRH analogues surgical: remove endometriosis, goes from laparoscopic ablation of lesions to hysterectomy and bilateral salpingo-oophorectomy pain management

Question 55

What are the characteristic features of Ewings sarcoma on x-ray?

Answer 55

Ewings sarcoma - forms lytic bone lesions that look like an onion ring appearance

Question 56

What is the presentation of hallux rigidus?

Answer 56

Stiff big toe Asymptomatic Pain (often at extreme of dorsiflexion) Limited ROM

Question 57

What is operative treatment of lesser toe deformities?

Answer 57

flexor to extensor transfer **fusion** of interphalageal joint release of metatarsophalangeal joint shortening **osteotomy** of metatarsal

Question 58

What are potential causes for raised CA125?

Answer 58

CA 125 (glyco-protein antigen) can indicate malignancies (ovary, colon/pancreas and breast) and benign conditions such as menstruation, PID, endometriosis, liver disease, recent surgery, effusions

Question 59

What are risk factors fordupuytrens disease?

Answer 59

Male Old age Alcohol Diabetes Tobacco HIV Epilepsey

Question 60

Which fingers are most commonly affected by dupuytrens diusease?

Answer 60

Ring finger follwed by little and middle fingers

Question 61

What are risk factors for ovarian cancer?

Answer 61

Passmedicine: family history: mutations of the BRCA1 or the BRCA2 gene many ovulations\*: early menarche, late menopause, nulliparity FH, \>30 y/o, FH (2 or more relatives), cancer gene mutation carriers) for risk (combines menopausal status, ultrasound score and CA 125) use RMI I score (if 250 or greater then referral to specialist team)

Question 62

What are the complications of scaphoid fracture?

Answer 62

avascular necrosis in proximal part of scaphoid (AVN) (because blood supply is distal to proximal), non-union

Question 63

What is the presentation of base of thumb OA?

Answer 63

pain (opening jars, pinching), stiffness, swelling, deformity, loss of function

Question 64

What is Amsel's diagnostic criteria for diagnosing bacterial vaginosis?

Answer 64

Amsel's criteria for diagnosis of BV - 3 of the following 4 points should be present ## Footnote thin, white homogenous discharge clue cells on microscopy: stippled vaginal epithelial cells vaginal pH \> 4.5 positive whiff test (addition of potassium hydroxide results in fishy odour)

Question 65

What are the complications of gout?

Answer 65

Stone passage causing renal colic Renal failure - death in 20% of individuals with chronic gout

Question 66

What drug can be used to treat HER 2 positive breast cancer?

Answer 66

Some breast cancers have high numbers of receptors for the protein HER2 (human epidermal growth factor 2). They are called HER2 positive breast cancers. About 1 in 7 women (15%) with early breast cancer have HER2 positive cancer. A drug called trastuzumab (Herceptin®) is an effective treatment for this type of breast cancer.

Question 67

What is the largest cause of mortality in pregnancy women?

Answer 67

VTE/PE

Question 68

What is the difference between a complete and an incomplete hydatiform mole?

Answer 68

Complete = single sperm fertalises enucleate egg, this means that the moile only contains paternal DNA. There are no fetal cells and there is a risk of GTN (gestational trophoblastic neoplasia) - this includes invasive mole, choriocarcinoma and placental site trophoblastic tumour. Partial = One normal egg cell fertilised by two normal sperm cells, usually triploid. Some fetal cells are evident such as amnion and RBC,s there isn't really an association with choriocarcinoma.

Question 69

What type of autoantibody may be present in JIA?

Answer 69

ANA

Question 70

What are the complications of pre-eclampsia on the fetus?

Answer 70

IUGR Intrauterine death Iatrogenic preterm delivery

Question 71

What is a complication of chlamydia?

Answer 71

Peri-hepatitis (fitz hugh-curtis syndrome)

Question 72

How long is a cast recquired for the following tpes of fractures? Buckle Green stick Complete

Answer 72

Buckle = 3/4 weeks Greenstick = 4-6 weeks Complete = 6 weeks

Question 73

What are the symptoms of PID?

Answer 73

constant lower abdominal pain, purulent vaginal discharge, deep dyspareunia, pyrexia, irregular PV bleeding, adnexal tenderness dysuria, irregular periods

Question 74

What diseases might predispose you to enteropathic arthritis?

Answer 74

Commonly associated with inflammatory bowel disease (Crohn’s or UC) Rarely seen with infectious enteritis, Whipple’s disease and Coeliac disease

Question 75

What are risk factors for breast cancer?

Answer 75

Female sex Age Family history (BRCA1 and BRCA2) Early menarche late menopause Nullparity, higher age at first pregnancy Higher socioeconomic group HRT

Question 76

Why can hyperprolactinaemia cause infertility|?

Answer 76

Becasue prolactin inhibits GnRH

Question 77

What are complications of perthes disease?

Answer 77

Premature fusion of growth plates OA Phases = Avascular necrosis Fragmentation - revascularisation (pain) Reossification - bony healing Residual deformity

Question 78

What is the most common benign bone tumour?

Answer 78

Osteochondroma

Question 79

What are findings on imaging of gout? (US, radiographical, CT)

Answer 79

Joint destruction, bony erosions (rarely present on the first acute episode) Imaging findings tend to become more likely with disease duration X-Ray - radiolucent uric acid nephrolithiasis

Question 80

Which disc when prolapsed would cause : sensory loss on the little toe and sole of foot Motor weakness in plantar felxion of the foot Reflex change in ankle jerk

Answer 80

Disc = L5/S1 Actual root value = S1

Question 81

What is management for urge incontinence and overactive bladder?

Answer 81

conversative: physiotherapy, bladder retaining, lifestyle modifications, normalise fluid intake, reduce caffeine, fizzy drinks, chocolate, stop smoking, weight loss, medical: anticholinergics (oral or transdermal antimuscarinic), tri-cyclic antidepressants, surgical: Botox injections, clam cystoplasty, urinary diversion

Question 82

What are the complications of placental abruption?

Answer 82

complications include maternal shock, collapse, fetal death, maternal DIC (disseminated intravascular coagulation), renal failure, postpartum haemorrhage, ‘couvelaire uterus’

Question 83

How is histological diagnosis of CIN achieved?

Answer 83

Histological diagnosis is achieved with biopsies of abnormal area

Question 84

What are the features of osteogenesis imperfecta?

Answer 84

fragile bones from mild trauma or even daily acts of life other non-bone clinical features growth deficiency defective tooth formation (dentigenesis imperfecta) hearing loss blue sclera scoliosis/barrel chest ligamentous laxity (Beighton score) easy bruising

Question 85

What are genes associated with ovarian cancer?

Answer 85

genes associated: BRAC1, BRAC2, HNPCC/Lynch type 2 familial cancer syndrome

Question 86

Which nerve is likely to be affected in fracture of humeral condyles?

Answer 86

Ulnar nerve

Question 87

What are the findings in the urine for sjogren's?

Answer 87

Proteinuria/haematuria reflecting glomerulonephritis

Question 88

What is the management for psoriatic arthritis?

Answer 88

sulfasalazine, methotrexate, leflunomide, cyclosporine, anti-TNF therapy, anti-IL-17 and IL-23, steroids, physiotherapy and occupational therapy, axial disease treated similar to ankylosing spondylitis NSAIDs, DMARD

Question 89

What is the definition of primary and secondary postpartum haemorrhage?

Answer 89

primary PPH :\>500 mL blood loss within first 24h delivery secondary PPH: \>500 mL blood loss after 24h of delivery

Question 90

What are the mechanisms of labour?

Answer 90

Descent Flexion Internal rotation of the head Crowning and extension of the head Restitution Internal rotation of the shoulders External rotation of the head Lateral flexion

Question 91

What are the causes of sjogrens?

Answer 91

Primary = sicca syndrome Secondary (to other autoimmune diseases, RA is the most common)

Question 92

What is the management for stress incontinence?

Answer 92

conservative: pelvic floor exercises, lifestyle changes (smoking cessation, lose weight, eat more healthily to avoid constipation, stop drinking alcohol or caffeine) tension free vaginal tape (for suburethral hammock theory) (TVT) or colposuspension but TVT is now 1st choice, physiotherapy (pelvic floor muscle training), medical: duloxetine surgery: tension-free vaginal tape, colposuspension, urethral bulking agents

Question 93

What is the tool which calculates prognosis for breast cancer?

Answer 93

Nottingham prognosis index This accounts for tumour size, lymph node score and grade score

Question 94

What is the investigation for osteomyelitis?

Answer 94

MRI Others include: US, aspiration (swelling?), isotope bone scan, labelled white cell scan, MRI, FBC + WBC, ESR, CRP, CK, 3x blood cultures at peak of temperature, U&Es if ill dehydrated, bone biopsy, tissue swabs from up to 5 sites around implant at debridement in prosthetic infections but sinus tract and superficial swab results may be misleading (skin contaminants)

Question 95

What is the gene assocaited with Ewings sarcoma?

Answer 95

associated with t(11;22) translocation which results in an EWS-FLI1 gene product

Question 96

What are the differences between acute slip and chronic slip?

Answer 96

_Acute Slip:_ In an acute slip, pain in the hip is so severe that your child is unable to walk or stand. You may notice that one leg seems shorter than the other. They won't want to move their hip because it is painful. You may notice that their leg is turned outwards. _Chronic Slip:_ Limping Walking may be painful Pain worse on excersize Stiffness Leg on affected side may be shorter Muscle wasting on affected side

Question 97

What are the features of Pelvic Inflammatory Disease?

Answer 97

lower abdominal pain fever deep dyspareunia dysuria and menstrual irregularities may occur vaginal or cervical discharge cervical excitation perihepatitis (Fitz-Hugh Curtis Syndrome) occurs in around 10% of cases. It is characterised by right upper quadrant pain and may be confused with cholecystitis

Question 98

What is managment for male infertility?

Answer 98

surgical sperm retrieval, reversal of vasectomy, donor insemination, intra-uterine insemination, IVF/ICSI (intracytoplasmic sperm injection, injection of mature egg with single sperm, overnight incubation), DI (?) sperm donation

Question 99

What is the definition of adenomyosis?

Answer 99

Presence of endometrial tissue in the myometrium

Question 100

What is the blood marker for granulomatosis with polyangitis?

Answer 100

c-ANCA

Question 101

What is the managment for adenomyosis?

Answer 101

Hormonal contraception for heavy/painful periods (mirena US, progestogens, combined OCP)

Question 102

What would separate transient synovitis from septic arthritis?

Answer 102

apyrexial, allowing joint to be examined, low CRP, normal WCC, not that unwell (as opposed to septic artheritis and osteomyelitis)

Question 103

What is the management of tibialis posterior tendon dysfunction?

Answer 103

orthoses or surgery (reconstruction of tendon (tendon transfer), triple fusion (subtalar, talonavicular and calcaneocuboid)

Question 104

How do anti-psychotics work?

Answer 104

Antipsychotics act as dopamine D2 receptor antagonists, blocking dopaminergic transmission in the mesolimbic pathways

Question 105

What is the sign for tibialis posterior tendon dysfunction?

Answer 105

clinical diagnosis (double & single heel raise; heel should swing for valgus to varus as heel rises)

Question 106

What are the extrapyramidal side effects caused by traditional anti-psychotics?

Answer 106

Extrapyramidal side-effects ## Footnote Parkinsonism acute dystonia (e.g. torticollis, oculogyric crisis) akathisia (severe restlessness) tardive dyskinesia (late onset of choreoathetoid movements, abnormal, involuntary, may occur in 40% of patients, may be irreversible, most common is chewing and pouting of jaw)

Question 107

What are serological tests for Sjogren's?

Answer 107

rheumatoid factor (RF) positive in nearly 100% of patients ANA positive in 70% anti-Ro (SSA) antibodies in 70% of patients with PSS anti-La (SSB) antibodies in 30% of patients with PSS also: hypergammaglobulinaemia, low C4

Question 108

What is the aetiology of hallux valgus?

Answer 108

Genetic foot wear

Question 109

What is the presentation of septic arthritis?

Answer 109

fever, warm, red, swollen, painful joint, may also be an erythematous rash in adults: acute pain in single large joint, limping, swollen red joint, refusal to move joint (knee, ankle, wrist) (reluctancy to make any movement, increase T° and pulse, increase tenderness)

Question 110

What are the characteristic features of osteosarcoma on x-ray?

Answer 110

Lytic bone lesions which form a sunburts effect Osteosarcomas often cause the periosteum to lift and this is called codman's triangle

Question 111

What are imaging findings in psoriatic arthritis?

Answer 111

imaging: XR (para-marginal erosions, fluffy periosteal bone formation, **bony ankylosis, asymmetrical sacroiliitis**

Question 112

What is the presentation of radial nerve palsy?

Answer 112

Motor wasting (wrist drop - extensors) Sensory deficit - 1st web space dorsally

Question 113

What is the investigation / diagnosis for ectopic pregnancy?

Answer 113

US scan (no intrauterine gestational sac, may see adnexal masses, fluid in pouch of Douglas), serum Beta HCG levels, serum progesterone levels, FBC, diagnostic laparoscopy

Question 114

What are the investigations for hallux valgus?

Answer 114

clinical, XR (determine severity of underlying bony deformity, exclude associated degenerate change)

Question 115

When are posterior disocations more likely to happen?

Answer 115

Secondary to epileptic seizures

Question 116

What is SICCA syndrome?

Answer 116

Sicca syndrome is a variant of Sjögren syndrome characterized by xerostomia and keratoconjunctivitis without previous rheumatoid arthritis. (dry mouth, dry eyes and RA)

Question 117

What is the disease mechanism for trigger finger?

Answer 117

Trigger finger occurs if there's a problem with the tendon or sheath, such as inflammation and swelling. The tendon can no longer slide easily through the sheath and can bunch up to form a small lump (nodule). This makes bending the affected finger or thumb difficult. If the tendon gets caught in the sheath, the finger can click painfully as it's straightened.

Question 118

What are the risk factors for breast cancer?

Answer 118

BRCA1, BRCA2 genes - 40% lifetime risk of breast/ovarian cancer 1st degree relative premenopausal relative with breast cancer (e.g. mother) nulliparity, 1st pregnancy \> 30 yrs (twice risk of women having 1st child \< 25 yrs) early menarche, late menopause combined hormone replacement therapy (relative risk increase \* 1.023/year of use), combined oral contraceptive use past breast cancer not breastfeeding ionising radiation p53 gene mutations obesity previous surgery for benign disease (?more follow-up, scar hides lump)

Question 119

What are signs and symptoms of Pagets diseas of the bone?

Answer 119

Affects femur, lumbar vertebrae and the skull Bone pain Pathological fractures Bony malformations (enlarged skull, bowing of long bones) Increased temperature (hypervascularity) Arthritis in assocaited joints Hearing impairment (sclerosis of the skull bones, cranial nerve compression) Decreased ROM

Question 120

Where does primary bone cancer often spread to?

Answer 120

primary bone cancer spreads to breast, bronchus, prostate, kidney, thyroid

Question 121

What are the investigations for Pelvic Inflammatory Disease?

Answer 121

FBC, CRP, hCG (ensure negative), MSU, high vaginal swab, endocervical swabs, blood cultures if febrile, pelvic USS, screen for chlamydia and gonorrhoea (low vaginal swabs)

Question 122

When would you refer someone to colposcopy?

Answer 122

Three consecutive inadequate smear samples Three borderline dmears (squamous) Mild, moderate or severe dyskariosis Suspected invasive disease Dyskariosis (this is when the squamous epithelial cells have abnormal cytologic changes as well as charactersitic hyperchromatic nuclei and/or irregular nuclear chromatin). Another word for dyskariosis is dysplasia

Question 123

What is the presentation for shoulder dyslocation?

Answer 123

Pain Decreased movement Loss of deltoid coutour Arm held internally rotated and adducted

Question 124

What is the disease process of Perthes disease?

Answer 124

Part or all of the femoral head (top of the thigh bone: the ball part of the ball-and-socket hip joint) loses its blood supply and may become misshapen. This may lead to arthritis of the hip in later years.

Question 125

How is colposcopy carried out?

Answer 125

colposcopy involves inspection of ectocervix under magnification. Acetic acid and Lugol’s iodine is applied to identify abnormality.

Question 126

What is management of chronic osteomyelitits?

Answer 126

long term AB (local: gentamicin cement, systemic: IV AB) surgery (mutliple ops to eradicate) deformity correction, massive reconstruction, amputation

Question 127

What is the management for shoulder dyslocation?

Answer 127

Firstly consider anaesthesia / sedation Closed reduction (e.g Kocher's) Open reduction if closed reduction techniques fail Immobalise the arm for 3 weeks Physiotherapy Surgery

Question 128

What is the difference in crystal histology for gout and pseudogout?

Answer 128

Gout = needle shaped, negatively birefringent Pseudogout = Rhomboid, positively birefringent

Question 129

What causes female pelvico organ prolapse?

Answer 129

Caused by weakening of pelvic floor normally secondary to child birth

Question 130

What are X-ray findings in osteoarthritis?

Answer 130

Loss of joint space Subchondral sclerosis Subchondral cysts Osteophytes forming at joint margins

Question 131

What are the investigations for pre-eclampsia?

Answer 131

Serial blood pressure Urinalysis Urine protein/creatinine ratio FBC U and E LFT Coagualtion Group and save if delivery thought to be likely CTG to assess fetal well-being

Question 132

What are different types of cephalic presentation?

Answer 132

Vertex Sinciput (forehead) Brow Face Chin

Question 133

How is diagnosis of perthes disease achieved?

Answer 133

plain x-ray technetium bone scan or magnetic resonance imaging if normal x-ray and symptoms persist

Question 134

What is the potential complication assocaited with placenta praevia?

Answer 134

Post-partum haemorrhage

Question 135

What condition is polymyalgia rheumatic closely related to?

Answer 135

Giant cell arteritis

Question 136

What are the types of osteomalacia?

Answer 136

vitamin D deficiency e.g. malabsorption, lack of sunlight, diet renal failure drug induced e.g. anticonvulsants vitamin D resistant; inherited liver disease, e.g. cirrhosis

Question 137

What is the crystal in both gout and pseudogout?

Answer 137

Gout = monosodium urate Pseudogout = Calcium pyrophosphate

Question 138

What mood stabilsing agent can cause hypothyroidism?

Answer 138

Lithium

Question 139

What are risk factors for ectopic pregnancy?

Answer 139

Pelvic inflammatory disease Chlamydia Gonorrhoea Previous tubal surgery Previous ectopic Assisted conception

Question 140

What muscles are contained in the sheath which is inflamed in de quervain's tenosynovitis?

Answer 140

extensor pollicis brevis and abductor pollicis longus tendons

Question 141

What does CIN grading measure?

Answer 141

Grading is determined by how abnormal the cells look under a microscope as well as how much of the cervical tissue is affected. Epithelial lining of the transdformation zone of the cervix is the part that is affected

Question 142

What are the complications of fibroids?

Answer 142

Pain Malpresentation/obstruction of labour Menorrhagia Subfertility Red degeneration - haemorrhage into the tumour - commonly happens as a result of pregnancy

Question 143

What are risk factors for DVT/PE?

Answer 143

older mothers, increasing parity, increased BMI, smokers, IV drug users, PET, dehydration (due to hyperemesis), decreased mobility, infections, operative delivery, prolonged labour, haemorrhage, blood loss \>2L, previous VTE, FH of VTE, sickle cell disease

Question 144

What is the presentation of menopause?

Answer 144

lack of menstruation for \>1 year hot flushes and night sweats (vasomotor symptoms) vaginal dryness/soreness (vasomotor symptoms) dyspareunia (vasomotor symptoms) atrophy and thinning of vaginal epithelium overactive bladder symptoms (urgency, frequency) mood changes, loss of libido osteoporosis increase in cardiovascular risk

Question 145

What is management of osteogenesis imperfecta?

Answer 145

surgical: treat fractures medical: IV bisphosphonates (to prevent fractures) social: education and social adaptations genetic: genetic counselling for parents and next generation

Question 146

What is the managment of dupytrens disease?

Answer 146

non-operative: radiotherapy operative: partial fasciectomy (+ physio), dermo-fasciectomy (+ intense physio, no recurrence), arthodesis, amputation, percutaneous needle fasciotomy (potential recurrence, risk of nerve injury), collagenase (30% recurrence, radical, cost)

Question 147

What might be in a males history for pirmary infertility?

Answer 147

change in shaving frequency (testosterone), mumps infection, STI (chlamydia/gonorrhoea), history of varicoceal repair, vasectomy, Klinfelter’s

Question 148

What is the presentation of chlamydia?

Answer 148

female: usually none, sometime cervicitis/cystitis, lower abdominal pain, intermenstrual bleeding male: often asymptomatic discharge, dysuria asymptomatic in around 70% of women and 50% of men women: cervicitis (discharge, bleeding), dysuria men: urethral discharge, dysuria

Question 149

What are the risk factors for vulvovaginal candidosis?

Answer 149

risk factors: diabetes, oral steroids, immune suppression including HIV, pregnancy, reproductive age group

Question 150

What is the managment of preterm labour?

Answer 150

The mother should deliver the baby in a unit where adequate facilities to care for the neonate are available Medical = corticosteroids associated with significant reduction in neonatal death, respiratory distress syndrome and intraventricular haemorrhage in the newborn Tocolytics = atosiban, nifedipine Surgical = cervical cerclage for those at risk or identified as having a short cervix

Question 151

Which is more common, primary or secondary bone tumour?

Answer 151

secondary bone tumour 25x commoner than primary

Question 152

What is the bacterial change assocaited with bacterial vaginosis?

Answer 152

increased gardnerella, ureaplasma, mycoplasma, anaerobes, reduced lactobacilli Bacterial vaginosis (BV) describes an overgrowth of predominately anaerobic organisms such as Gardnerella vaginalis. This leads to a consequent fall in lactic acid producing aerobic lactobacilli resulting in a raised vaginal pH

Question 153

What is low does amitryptiline used for?

Answer 153

low-dose amitriptyline is commonly used in the management of neuropathic pain and the prophylaxis of headache (both tension and migraine)

Question 154

What is the presentation of ovarian cancer?

Answer 154

Pass Medicine: abdominal distension and bloating abdominal and pelvic pain urinary symptoms e.g. Urgency early satiety diarrhoea non-speciifc bowel symptoms (indigestion, early satiety, loss of appetite, altered bowel habit/pain, bloating, discomfort, weight loss) overlap with IBS symptoms pelvic mass (asymptomatic or pressure symptoms), adnexal mass on pelvic examination, late-stage disease may present as a large pelvic mass, ascites, palpable lymph nodes and pleural effusion

Question 155

What is the definition of menorrhagia?

Answer 155

Heavy menstrual bleeding (more than 80ml per cycle)

Question 156

What are the subtypes of breats cancer?

Answer 156

Non-invasive = Ductal carcinoma in situ, lobular carcinoma in situ Invasive = Invasive ductal carcinoma (most common) Invasive lobular carcinoma and its variants

Question 157

What causes erbs palsy?

Answer 157

birth injury or fall on side of neck (downward traction): forced contralateral neck adbuction Shoulder dystocia

Question 158

What is the management of PID?

Answer 158

medical: - mild: oral ofloxacin + metronidazole for 14 days - moderate: intramuscular ceftriaxone + oral doxycycline + metronidazole for 14 days severe: inpatient IV therapy if clinically unwell and severe surgical: may be indicated in severe cases with evidence of pelvic abscess prevention: contact tracing for sexual partners

Question 159

What does HRT increase the risk of?

Answer 159

VTE Breast cancer Endometrial cancer Gall bladder disease Vascular disease

Question 160

What are investigations for Traumatic subarachnoid haemorrhae?

Answer 160

CT Cerebral angiogram

Question 161

What is the pathogenesis of osteosarcoma?

Answer 161

assocaited mutations include abnormal pRB protein which is associated with retinoblastoma, also the p53 protein which is associated with li-fraumeni syndrome which is a multi - system cancer syndrome. Osteosarcoma is caused by osteoblast cells which are pleomorphic and produce too much osteoid tissue

Question 162

What is the management of plantar fasciitis/fasciosis?

Answer 162

rest, change training, streching of Achilles, ice, NSAIDs, orthoses (heel pads), physiotherapy, weight loss, injections (corticosteroid (good in short term but may make conditon worse long term), night splinting newer/3rd line treatment: extracorporeal shockwave therapy topaz plasma coblation nitric oxide platelet rich plasma endoscopic/open surgery

Question 163

What causes fibroids?

Answer 163

Benign tumour arising from the myometrium

Question 164

What are the complications of pre-exiswting diabetes in pregnancy?

Answer 164

increased risk of congenital fetal abnormalities (especially if blood sugars high peri-conception), miscarriage, pre-eclampsia, fetal macrosomia, polyhydramnios, operative delivery, shoulder dystocia, worsening of maternal nephropathy, retinopathy, hypoglycaemia, reduced awareness of hypoglycaemia, infections, stillbirth, increased perinatal mortality, neonatal death (impaired lung activity, neonatal hypoglycaemia, jaundice, obstruction of labour)

Question 165

What are the causes of antepartum haemorrhage?

Answer 165

Placenta praevia Placental abruption APH of unknown origin Local lesions of the genital tract Vasa praevia (very rare)

Question 166

What is the mean age of osteomyelitis?

Answer 166

6 years old

Question 167

What are the effects of gestational diabetes on the mother?

Answer 167

on mother: diabetic nephropathy and retinopathy may deteriorate. Increased risk of miscarriage, pre-eclampsia and operative delivery

Question 168

What is the management of septic arthritis?

Answer 168

fluid and pain control, AB, surgical drainage lavage, infected joint replacement, arthroscopy (knee, shoulder, ankle), arthrotomy, physiotherapy Passmedicine: synovial fluid should be obtained before starting treatment intravenous antibiotics which cover Gram-positive cocci are indicated. The BNF currently recommends flucloxacillin or clindamycin if penicillin allergic antibiotic treatment is normally be given for several weeks (BNF states 6-12 weeks) needle aspiration should be used to decompress the joint arthroscopic lavage may be required

Question 169

What is the treatment of Paget's disease?

Answer 169

don’t treat if asymptomatic uness in skull or area needing surgery do not treat based on raised alkaline phosphatase alone use **IV bisphosphonate therapy** and one-off **zoledronic acid infusion** **calcitonin** for severe pain/extensive lytic disease

Question 170

Who usually receives chemotherapy for breast cancer?

Answer 170

Node posistive Stage 3

Question 171

What are diseases that increase the chances of osteoporosis?

Answer 171

Endocrine: glucocorticoid excess (e.g. Cushing's, steroid therapy), hyperthyroidism, hypogonadism (e.g. Turner's, testosterone deficiency), growth hormone deficiency, hyperparathyroidism, diabetes mellitus Multiple myeloma, lymphoma Gastrointestinal problems: inflammatory bowel disease, malabsorption (e.g. Coeliacs), gastrectomy, liver disease Rheumatoid arthritis Long term heparin therapy Chronic renal failure Osteogenesis imperfecta, homocystinuria Another list from Laszlo's table: risk factor endocrine: thyrotoxicosis, hyper and hypoparathyroidism, Cushings, hyperprolactinaemia, hypopituitarism, low sex hormone levels ( rheumatic: rheumatoid arthritis, ankylosing spondylitis, polymyalgia rheumatica, osteomalacia GI: inflammatory- UC and Crohns liver- PBC, CAH, alcoholic cirrhosis, viral cirrhosis (hepC) malabsorption- CF, chronic pancreatitis, coeliac disease, Whipple’s disease, short gut syndromes, ischaemic bowel medication, chronic renal failure medications, steroids, PPI, enzyme inducting antiepileptic medications, aromatase inhibitors, GnRH inhibitors, warfarin

Question 172

What are the investigations for adenomyosis?

Answer 172

MRI, hysterectomy and histological diagnosis as diagnostic is often flawed

Question 173

What is the presentation of syphillis?

Answer 173

primary: **chancre lesion**, raised painless papule with ulcerated centre, usually found at the site of inoculation; **lymphadenopathy** secondary: widepsread mucocutaneous lesions, fever, malaise, headache, lymphadenopathy, sore throat tertiary: characteised by gumma, usually found in liver, bone and testes

Question 174

What is the mechanism of osteoporosis?

Answer 174

metabolic bone disease characterised by low bone mass and micro architectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk

Question 175

Mastectomy vs wide local excision?

Answer 175

Question 176

What are the different forms of hormone replacement therapy?

Answer 176

Combined (oestrogen and progestogen) for a women with a uterus Oestrogen alone for those with hysterectomy Can be given sequentially (monthly withdrawal bleeding) or can be given continuously (period free)

Question 177

What can predispose you to osteomyelitis?

Answer 177

Pathogenesis: Haematogenous spread in children and elderly Local spread from site of infection (trauma in open fracture, bone surgery or joint replacement) Secondary to vascular insufficiency Predisposing conditions diabetes mellitus sickle cell anaemia intravenous drug user immunosuppression due to either medication or HIV alcohol excess

Question 178

How do we diagnose giant cell arteritis?

Answer 178

Extremely elevated ESR (over 100mm/hr) Temporal artery biopsy

Question 179

What is the effect of gestational diabetes on a baby?

Answer 179

on fetus: increased risk of congenital anomalies, perinatal mortality, macrosomial, shoulder dystocia, polyhydramnios

Question 180

What are other side-effects of anti-psychotics?

Answer 180

antimuscarinic: dry mouth, blurred vision, urinary retention, constipation sedation, weight gain raised prolactin: galactorrhoea, impaired glucose tolerance neuroleptic malignant syndrome: pyrexia, muscle stiffness reduced seizure threshold (greater with atypicals) sprolonged QT interval (particularly haloperidol)

Question 181

What is the most common type of dislocatation?

Answer 181

Antero-inferiorly

Question 182

What are casues of amenorrhoea?

Answer 182

Pregnancy PCOS Hypothalamic disorders Hyperprolactinaemia Ovarian failure / menopause Thyroid disease Anatomical disorders of outflow

Question 183

What causes OA?

Answer 183

Inflamatory process Progressive cartilage loss Subchondral bone formation and bony osteophytes May be secondary to trauma, infection or ceongenital conditions such as developmental dysplasia of the hip.

Question 184

What are risk factors for osteoporosis?

Answer 184

Family history Female sex Increasing age Deficient diet Sedentary lifestyle Smoking Premature menopause Low body weight Caucasians and Asians

Question 185

What are the sypmtoms of ectopic pregnancy rupture?

Answer 185

Severe abdominal pain (may refer to shoulder with phrenic nerve irritation) Rebound tenderness Guarding indicates peritoneal irritation Haemodynamic instability (feeling faint, syncope, tachycardia, hypotension, diaphoresis)

Question 186

What is the cause of plantar fibromatosis?

Answer 186

Progressive connsctive tissue build up

Question 187

What is the management of molar pregnancy?

Answer 187

remove tissue by curretage, if beta hCG returns to normal then no further treatment, if beta hCG stays high (persistent disease) then cure by methotrexate

Question 188

What are blood findings in psoriatic arthritis?

Answer 188

Raised ESR RhF negative ANA negative

Question 189

What is the presenation of ulnar nerve palsy?

Answer 189

•motor deficit - claw hand, hypothenar & 1st dorsal interosseous wasting Sendory deficit is in little finger

Question 190

What are the risk factors for plantar fasciitis/fasciosis?

Answer 190

athletes associated with high intensity or rapid increase in training, running with poorly padded shoes or hard surfaces, obesity, occupations involving prolonged standing, foot/lower limb rotational deformities, tight gastro-soleus complex

Question 191

What are investigations for SCFE?

Answer 191

Physical examination X-Ray CT scan If avascular necrosis is suspected then an MRI or a bone scan may be necessary

Question 192

What is the presentation of erb's palsy?

Answer 192

waiter’s tip position, arm is adducted and IR, elbow is extended and pronated, wrist is flexed, decreased sensation over C5, C6 dermatomes

Question 193

What is the outcome of congenital syphillis?

Answer 193

Spontaneous abortion, birth defects

Question 194

What are potential complications of fractures?

Answer 194

Compartment syndrome Refracture Non-union Superficial radial nerve injury Posterior interosseous nerve injury

Question 195

What is the management of PPH?

Answer 195

obstetric emergency, resuscitation and treat cause (fluids, uterine massage, drugs to stimulate contractility (oxytocin, ergometrine) if still bleeding then insertion of intrauterine balloon, uterine artery embolisation, uterine artery ligation, hysterectomy

Question 196

What is management of primary amenorrhoea?

Answer 196

Gradual build up with estrogen Effect on breast development Add progesterone Once maximum height potential is reached At least 20 mg of estrogen dose

Question 197

What is the management of osteomyelitis?

Answer 197

hydration and analgesia, rest & splintage, AB (choice depends on microbiology), IV AB for children, surgery is indicated for abscess drainage, debridement of dead/infected tissue, drainage of subperiosteal abscess, drainage of joint sepsis, Antibiotic therapy is usually: flucloxacillin for 6 weeks clindamycin if penicillin-allergic

Question 198

What is a classical presentation of ankylosing spondylitis?

Answer 198

typically a young man who presents with lower back pain and stiffness of insidious onset stiffness is usually worse in the morning and improves with exercise the patient may experience pain at night which improves on getting up

Question 199

What clinical test could be used to show reduced forward flexion in ankylosing spondylitis?

Answer 199

Schober's test

Question 200

OA and RA comparison

Answer 200

Question 201

What are the signs and symptoms of scleroderma?

Answer 201

Raynaud phenomenon Cutaneous changes of face, extremities: Skin thickening, tightening, sclerosis (most common); edema, erythema (precede sclerosis) GI involvement ▫ Esophageal fibrosis → dysphagia, GI reflux Small intestine involvement → abdominal pain, obstructions, constipation, diarrhea, malabsorption syndrome (weight loss, anemia) ▪ Pulmonary involvement with interstitial fibrosis Right-sided cardiac dysfunction/ pulmonary hypertension ▪ Cardiac involvement ▫ Pericardial effusions, myocardial fibrosis → congestive heart failure, arrhythmias Renal involvement (diffuse disease) → fatal hypertensive crisis (rare)

Question 202

What are the risk factors for endometrial cancer?

Answer 202

obesity nulliparity early menarche late menopause unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously diabetes mellitus tamoxifen polycystic ovarian syndrome hereditary non-polyposis colorectal carcinoma

Question 203

What is the most common type of fracture in a child?

Answer 203

Forearm fracture - 80% of which occur in the distal third

Question 204

What is the treatment for chlamydia?

Answer 204

The two most commonly prescribed antibiotics for chlamydia are: azithromycin – given as 2 or 4 tablets at once doxycycline – given as 2 capsules a day for a week Your doctor may give you different antibiotics, such as amoxicillin or erythromycin, if you have an allergy or are pregnant or breastfeeding. A longer course of antibiotics may be used if your doctor is concerned about complications of chlamydia.

Question 205

What is the pathophysiology associated with lupus?

Answer 205

There is environmental damage of DNA - release of nuclear antibodies. Antinuclear antibodies and antigens form immune complexes (this is a type 3 hypersensitivity reaction, these immune complexes deposit themselves in tissues) Organs affected = kidneys, skin, joints and heart Individuals may develop antibodies which target certain molecules such as phosphilipids on red or white blood cells marking them for phagocytosis (this is a type 2 hypersensitivity reaction)

Question 206

What are the symptoms of plantar fasciitis/fasciosis?

Answer 206

pain first thing in the morning, pain on weight bearing after rest (post-static dyskinesia), pain located at origin of plantar fascia, frequently long-lasting (2 years or more)

Question 207

What is the 3rd stage of labour?

Answer 207

Birth of the baby to the expulsion of the placenta and membranes Active management management includes: Routine use of **uterotonic** drugs Deferred **clamping and cutting of the cord** Controlled **cord traction** after signs of separation of the placenta. Physiological management includes: No routine use of uterotonic drugs No clamping of the cord until pulsation has stopped Delivery of the placenta by maternal effort. Prolonged in: Active management over 30 mins Physiological management after 60 mins

Question 208

What is a monteggia fracture?

Answer 208

Fracture of proximal ulna with dislocation of radial head

Question 209

What is the presentation of rheumatoid arthritis?

Answer 209

joint pain exacerbated by movement, morning stiffness, immobility, poor function, , joint swelling, affects various joints, systemic symptoms, non-specific: fatigue/lethargy (secondary fibromyalgia due to dysregulation of the HPA axis), weight loss, anaemia, anorexia, mild fever specific: eyes, lungs (interstitial lung disease, fibrosis), nerves, skin, kidneys, muscles (sarcopenia), bones (osteoporosis), secondary Sjogren’s syndrome, liver (elevated acute-phase response, anaemia of chronic disease (IL6 increases hepatocyte production of hepcidin, an iron-regulatory hormone) long term: CVS (altered lipid metabolism, elevated acute-phase reactants, increased endothelial activation), malignancy 2010 EULAR/ACR RA classification depends on joint involvement, serology, acute-phase reactants, duration of symptoms disease activity score: DAS 2,4 represents clinical remission DAS \>5,1 represents eligibility for biologic therapy joints: swollen, warm, tender joints, limitation of movement joint deformities: swan neck, boutonniere, subluxation lymphadenopathy, splenomegaly, rheumatoid nodules, muscle weakness, evidence of amyloidosis and vasculitis diagnosis criteria: need 4 out of 7 (RF RISES) Rheumatoid factor Finger/hand joint involvement Rheumatoid nodules Involvement of 3 or more joints Stiffness - early morning Erosions/decalcification on XR Symmetrical arthritis

Question 210

What is the cassical sign of PID?

Answer 210

Cervical excitation

Question 211

What is the management of base of thumb OA?

Answer 211

non op: NSAIDs, splint, steroid injection op: trapeziectomy (gold standard), fusion, replacement

Question 212

What are investigations for septic arthritis?

Answer 212

bloods: FBC, WCC, ESR, CRP, blood cultures, XR, US, uric acid (exclude gout), Ab (exclude RA), synovial fluid: aspiration, culture (cloudy?), increased leucocytes urine: MC&S (microscopy, culture, sensitivity) microbiology: urethral, cervical and anorectal swabs XR: soft tissue swelling, joint distension, later juxta-articular osteoporosis, periosteal elevation, joint space narrowing, bony erosions and possible osteomyelitis

Question 213

What is the cause of sjogren's syndrome?

Answer 213

Chronic autoimmuned infalmmatory disease Lymphocytic infiltration Destruction of exocrine glandsof eyes and mouth

Question 214

What are risk factors for pseudogout?

Answer 214

Usually affects individuals over 50 years Decreased magnesium levels

Question 215

What are the features of de quervains tenosynovitis?

Answer 215

* pain on the radial side of the wrist * tenderness over the radial styloid process * abduction of the thumb against resistance is painful * Finkelstein's test: with the thumb is flexed across the palm of the hand, pain is reproduced by movement of the wrist into flexion and ulnar deviation

Question 216

What is the diagnosis if there is tenderness in the anotomical snuff box?

Answer 216

Scaphoid fracture

Question 217

What is the most common type of ovarian cancer?

Answer 217

around 90% of ovarian cancers are epithelial in origin, with 70-80% of cases being due to serous carcinomas

Question 218

What is a galeazzi fracture?

Answer 218

fracture of radial shaft with dislocation of the distal radio-ulna joint

Question 219

What is the aetiology of dupytrens disease?

Answer 219

Autosomal dominant but onset may be sex linked, white people disease

Question 220

What are clinical features of psoriatic arthritis?

Answer 220

Asymmetric large joint arthritis, axial arthritis, asymmetric sacroiliitis, peripheral small joint arthritis, DIP joint arthritis, and arthritis mutilans Enthesitis Dactylitis

Question 221

What are potential causative organisms for PID?

Answer 221

Causative organisms ## Footnote Chlamydia trachomatis - the most common cause Neisseria gonorrhoeae Mycoplasma genitalium Mycoplasma hominis

Question 222

What is the specific antibody for polymyositis?

Answer 222

Jo-1 (this is a specific ANA profile)

Question 223

What causes hallux rigidus?

Answer 223

unknown, possibly genetic (typical shape of metatarsal head is slightly pointed rather than rounded), possible multiple microtrauma O/A of the first MTP?

Question 224

What are the two common types of endometrial cancer?

Answer 224

type 1 (commonest): endometrioid adenocarcinoma, linked to excess oestrogen, hyperplasia with atypia precursor type 2: uterine serous & clear cell carcinoma, high grade, more aggressive, worse prognosis, generally older ladies, serous intraepithelial carcinoma precursor 95% is adenocarcinoma

Question 225

What are the advantages and limitations of qFracture?

Answer 225

qfracture only uses data from the UK Can be used for patients aged 30-99 which is better than FRAX (40-90)

Question 226

What is an incomplete miscarriage?

Answer 226

When there is only partial expulsion of the products of conception

Question 227

What is the general treatment for multi-system autoimmune diseases?

Answer 227

Question 228

What is the diagnostic criteria for giant cell arteritis?

Answer 228

3 of the following: Age at onset (over 50 years) New headache Temporal artery tenderness / reduced pulsation ESR greater than or equal to 50 Abnormal temporal biopsy Other signs and symptoms include: Jaw claudication Transient unilateral vision loss Carotid bruits, decreased pulse in arms, aortic regurgitation Tender palpable nodules, absent temporal pulse Increased risk of aortic dissection, aortic aneurysm

Question 229

How many women are affected by breast cancer?

Answer 229

1 in 8

Question 230

What is the definition of secondary amenorrhoea?

Answer 230

absence of menstruation \> 6 months in a woman who has previously menstruated

Question 231

Why aren't TCA's commonly used for depression?

Answer 231

Side-effects and toxicity in overdose

Question 232

What are potential routes of infection for septic arthritis?

Answer 232

Blood Eruption of bone abscess Direct invasion (penetrating wound, intra-articular injury, arthroscopy) Dissemination from osteomyelitis

Question 233

Where is a thoracic prolapse most likely to happen?

Answer 233

T11/T12

Question 234

What is the commonest cause of hip pain in children?

Answer 234

Transient synovitis

Question 235

What are the features of neurosyphillis?

Answer 235

Tabes dorsalis Brain atrophy Argyll Robertson Pupil

Question 236

Where does breast cancer spread to?

Answer 236

Local skin Pectoral muscles Lymphatic axillary and internal mammary nodes Blood Bone Lungs Liver Brain

Question 237

What is the purpose of histological assessment of breast cancer?

Answer 237

Histological assessment should be carried out to assess tumour type and to deter- mine oestrogen and progesterone receptor (ER/PR) status and HER2 status

Question 238

What are the investigations for female infertility?

Answer 238

rubella immunity, chlamydia, TSH, mid luteal progesterone if periods are regular, day 1-5 FSH, LH, PRL, testosterone if periods irregular, pelvic US, tubal patency test

Question 239

What is the presentation of klumpkes palsy?

Answer 239

claw hand (affects small muscles of hand, wasting of intrinsic muscles of hand, decreased sensaton over T1 dermatome)

Question 240

What are causes of polymyalgia rheumatica?

Answer 240

Genetic defects (assocaited with HLA DR4) Exposure to adenovirus / human parovirus B19

Question 241

What are the most common causative organisms for septic arthritis?

Answer 241

most common organism overall is Staphylococcus aureus in young adults who are sexually active Neisseria gonorrhoeae should also be considered

Question 242

What is the treatment for scleroderma?

Answer 242

Question 243

What are causes of secondary amenorrhoea?

Answer 243

causes: pregnancy, breast feeding, contraception, polycystic ovaries, early menopause, thyroid disease, cushing’s, raised prolactin (medication related or prolactinoma), hypothalamic, androgen secreting tumour (high testosterone), Sheehans syndrome (pituitary failure), Asherman’s syndrome (intrauterine adhesions)

Question 244

What is the management of pre-eclampsia?

Answer 244

oral labetalol is now first-line following the 2010 NICE guidelines. Nifedipine and hydralazine may also be used delivery of the baby is the most important and definitive management step - caesarean section Magnesium sulphate is used to prevent seizures Methyldopa can also be used for lowering blood pressure. Steroids are given for fetal lung maturity Induction of labour (avoid ergometrine - this precipitates

Question 245

What is management of breast cancer?

Answer 245

wide local excision or mastectomy, removal of sentinel lymph node; hormonal markers predict response to hormonal treatment (trastuzumab herceptin) antihormonal therapy is tamoxifen or chemotherapy tumours \<4cm usually are eligible for breast conservation therapy if sentinal node biopsy contains tumour then radiotherapy on all of the axillary lymph nodes or remove all (clearance) micrometastases are treated with hormonal therapy or chemo trastazumab to patients with over expression of Her2 (monoclonal Ab) +follow up (yearly mammograms for 10 years)

Question 246

What are hormonal findings for menopause?

Answer 246

FSH and LH ar high Oestrogen is low

Question 247

What is management of RA?

Answer 247

effective suppression of inflammation will improve symptoms and prevent joint damage and disability ## Footnote analgesics NSAIDs: disease modifying anti-rheumatic drugs (DMARD): methotrexate, sulfasalazine, hydroxychloroquine, leflunomide, penicillamine, gold biologics: TNF alpha inhibitor (Anakinra), anti B cell therapies (CD20, Rituximab), anti T cell therapies (Abatacept), IL-6 inhibitors (Tocilizumab) corticosteroids: (short term benefit vs long term toxicity) rarely appropriate as single drug therapy patient education: encourage to alternate rest with exercise

Question 248

Why is there an increase risk of maternal PE/DVT?

Answer 248

pregnancy is hypercoagulable state: increase in fibrogen, factor VIII, VW factor, platelets, decrease in natural anticoagulants (antithrombin III), increse in fibrinolysis)

Question 249

How do we monitor pregnancy?

Answer 249

Monitoring of liquor (colour, smell and volume) Auscultation of fetal heart (doppler, pinards or with CTG) - intermittent monitoring is undertaken every 15 minutes in the first stage of labour and every 5 minutes in the second stage. Palpation of uterine muscle contractions.

Question 250

What are potential outcomes from septic arthritis?

Answer 250

Complete recovery OR partial loss of the articular cartilage OR Fibrous bony ankylosis Joint destruction

Question 251

What is the characteristic X-ray finding for osteochondroma?

Answer 251

bony projection of bone which is capped with cartilage - exotosis

Question 252

What is management for secondary amenorrhoea?

Answer 252

control BMI, HRT if premature ovarian insufficiency, emotional support anatomical causes: surgery for imperforate hymen/transverse septum

Question 253

What is the presentation for a molar pregnancy?

Answer 253

period amenorrhoea +/- positive pregnancy test, +/- vaginal bleeding, +/- pain in the abdomen +/-GI or urinary symptoms, syncope, lower abdominal pain, bleeding (normally light)

Question 254

What is the name of the foot deformity assocaited with diabetic foot?

Answer 254

Charco neuropathy

Question 255

What are the different types of fractures?

Answer 255

Fractures have a variety of names. Below is a listing of the common types that may occur: Greenstick - Incomplete fracture. The broken bone is not completely separated. Transverse - The break is in a straight line across the bone. Spiral - The break spirals around the bone; common in a twisting injury. Oblique - Diagonal break across the bone. Compression - The bone is crushed, causing the broken bone to be wider or flatter in appearance. Comminuted - The break is in three or more pieces and fragments are present at the fracture site. Segmental - The same bone is fractured in two places, so there is a "floating" segment of bone. Main types are open vs closed

Question 256

What is the management of cervical cancer?

Answer 256

excision biopsy for stage 1a, radical hysterectomy or chemo-radio for stage 1b or 2, chemo-radio for stage 2b-4, chemothrapy is cisplatin, caesium insertion (brachy therapy) is another means of management

Question 257

What is the most common soft tissue tumour?

Answer 257

Lipoma

Question 258

What is the presentation of central cord syndrome?

Answer 258

Weakness of arms moreso than legs, perianal sensation and lower extremity power is preserved

Question 259

What are the investigations for chlamydia?

Answer 259

enzyme immunoassays, nucleic acid amplification test, urine testing for Chlamydia

Question 260

What type of vasculitis affects medium sized vessels?

Answer 260

Kawasaki's disease Polyarteritis nodosa

Question 261

What are the specific risks of antipsychotics in the elderly?

Answer 261

Increased risk of stroke Increased risk of VTE

Question 262

What is the managment for de quervains tenosynovitis?

Answer 262

analgesia steroid injection immobilisation with a thumb splint (spica) may be effective surgical treatment is sometimes required

Question 263

What are the symptoms of stress incontinence?

Answer 263

urine leakage on coughing, laughing, sneezing, exercise, sexual intercourse. May be demonstrated on examination with a full bladder. Severity ranges from mild to severe. (dysuria, haematuria, voiding symptoms (interrupted flow, recurrent UTI, straining to void, prolapse symptoms (vaginal lump, dragging sensation in vagina), bowel symptoms (anal incontinence, constipation, faecal evacuation, dysfunction, IBS))

Question 264

What is the presentation of endometrial cancer?

Answer 264

post-menopausal bleeding is most common feature, abnormal vaginal bleeding

Question 265

What are protective factors for endometrial cancer?

Answer 265

Combined oral contraceptive pill Smoking

Question 266

Who is more likely to be affected by trigger finger?

Answer 266

Women Over 40 People who have had dupuytrens disease Diabetes RA

Question 267

What is the organism responsible for syphillis?

Answer 267

Spirochaete - treponema pallidum

Question 268

What is the presentatino of syphillis?

Answer 268

primary: chancre lesion, raised painless papule with ulcerated centre, usually found at the site of inoculation; lymphadenopathy secondary: widepsread mucocutaneous lesions, fever, malaise, headache, lymphadenopathy, sore throat tertiary: characteised by gumma, usually found in liver, bone and testes

Question 269

What is the management of fibroids?

Answer 269

same as menorrhagia medical treatment is less efficient if fibroids are large and distort the cavity only if symptomatic **myomectomy**, hysteroctomy, transcervical resection (submucous), GnRH analogues or **ulipristal acetate** to temperarily shrink the fibroids (pre-op) progestin IUD, tranexamic acid, OCP, surgery interventional radiology: uterine artery embolisation and MRI- guided ablation of fibroids may be possible in specialist centres

Question 270

What is the management for spinal cord injury?

Answer 270

prevent a secondary insult, particularly in patients with incomplete injuries Airway- C spine control Breathing- ventilation and oxygenation Circulation- fluids, consider neurogenic shock (low BP and HR, loss of sympathetic tone, injuries about T6, TREAT WITH vasopressors) Disability- assess neuro function including PR and perianal sensation, logrolling surgical fixation for unstable fractures (vast majority fixed from posteriorly, pedicle screws preferred method) long-term management: spinal cord injury unit- intermediate term, physiotherapy, occupational therapy, psychological support, urological/sexual counselling

Question 271

What is managemnt of CIN?

Answer 271

LLETZ (large loop excision of the transformation zone) Thermal coagulation Laser ablation + follow-up LBC at 6 months for cytology to check for recurrence of disease and to reassure, also regular smears are required after treatment to ensure adequate treatment

Question 272

What are the features of synovial fluid on RA?

Answer 272

Incerased WBC Increased protein

Question 273

What are the casues of PPH?

Answer 273

pathology: 4 Ts tone (uterine atony) (commonest) trauma (cervical, vagina and perineal tears) tissue (retained placenta or membranes) thrombin (coagulation disorder)

Question 274

What is the operative management of hallux valgus?

Answer 274

(if non-operative fails or unacceptable to patient): release lateral soft tissues osteotomy 1st metatarsal +/- proximal phalanx

Question 275

What is the management of reactive arthritis?

Answer 275

acute: NSAID, joint injection (if infection excuded), AB in chlamydia infection (contacts as well) chronic: NSAID, DMARD (ex: sulphasalazine, methotrexate)

Question 276

What tendon dysfunction might cause medial or lateral pain and cause medial heel to move inwards and downwards?

Answer 276

Tibialis posterior tendon dysfunction

Question 277

What is noticeable about lupus arthritis?

Answer 277

This is SLE arthritis - notice how there is no bone damage - In lupus the deformity arises because the ligaments become weak.

Question 278

What is the management of osteomalacia?

Answer 278

calcium with vitamin D tablets

Question 279

What features may be present in JIA apart from joint pathology?

Answer 279

Type 1 pauciarticular = uveitis Type 2 pauciarticular = iridocyclitis Type 3 pauciarticular = iridocyclitis, dactylitis, potential family history of psoriasis For pauciarticular constitutional symptoms are rare _Polyarticular_ Can be RF positive or RF negative Constitutional sypmtoms such as low grade fever and malaise RF negative = hepatosplenomegaly, growth abnormalities, mild anaemia RF positive = erosions in X-rayoccur early, can be complicated by sjrogens, feltys, aortic regurgitation or pulmonary fibrosis

Question 280

What are typical antihypertensive agents used in chronic hypertension in pregnancy?

Answer 280

lifestyle changes change in medication as ACE inhibitors like ramipril and enalopril cause birth defects and impaired growth), use angiotensin receptor blockers (losartan, candesartan), anti diuretics and lower dietary sodium. Aim to keep BP \< 150/100 (**labetolol** (Beta blocker), **nifedipine** (ARB), **methyldopa** (alpha2 receptor adrenergic agonist), monitor for superimposed pre-eclampsia, if on beta-blockers for hypertension then monitor fetal growth,

Question 281

What are risk factors for cervical intraepithelial neoplasia?

Answer 281

HPV infection Smoking STDs Immunodeficiency Persistent infection

Question 282

What is the presentation for anterior cord syndrome?

Answer 282

Vibratory sensation and proprioception is preserved, profound weakness (Fine touch is in the ventral spinothalamic pathway which is in the anterior portion of the spinal cord) Complete motor paralysis below the level of the lesion due to interruption of the corticospinal tract Loss of pain and temperature sensation at and below the level of the lesion due to interruption of the spinothalamic tract Retained proprioception and vibratory sensation due to intact dorsal columns Autonomic dysfunction may be present and can manifest as hypotension (either orthostatic or frank hypotension), sexual dysfunction, and/or bowel and bladder dysfunction Areflexia, flaccid internal and external anal sphincter, urinary retention and intestinal obstruction may also be present

Question 283

Where is a cervical prolapse most likely to happen?

Answer 283

Most commonly C5/6

Question 284

What is the TNM staging of breast cancer?

Answer 284

Tumour (T) T1 – 0-2cm T2 - 2-5cm T3 - \>5cm T4 – fixed to skin or muscle Nodes (N) N0- none N1 – nodes in axilla N2 – large or fixed nodes in the axilla Metastases (M) M0 – none M1 - metastases

Question 285

What is the management for malignant bone tumours?

Answer 285

**chemotherapy**, **surgery**, **radiotherapy**, referral to specialist Tumour Centre for soft tissue tumours, **prophylactic internal fixation** to prevent pathological fracture fracture risk assessement is **Mirel’s Scoring System** (score 1-3 depending on site, pain, lesion type and size, if \>8 then internal fixation before radiotherapy) surgical excision, endoprosthetic replacement, chemotherapy, radiotherapy (in Ewing’s)

Question 286

What is the management of osteoarthritis?

Answer 286

non-operative: analgesia (NSAIDs, codeins, topical capsaicin) lifestyle changes (social, quality of sleep, especially weight loss) physiotherapy occupational therapy walking aids intra-articular steroid injection thermotherapy, electrotherapy, aids and devices) operative: arthroscopy (NICE advise only if symptoms of mechanical locking) osteotomy (aims to correct malaligned joint) arthroplasty (joint replacement, ex: total hip replacement) arthrodesis (joint fusion)

Question 287

What are complications of SLE?

Answer 287

Cardiovascular disease: Libman–Sacks endocarditis, myocardial infarction (MI) Serious infections; renal failure; hypertension Antiphospholipid syndrome: Hypercoagulable state; individuals prone to develop clots (e.g. deep vein thrombosis, hepatic vein thrombosis, stroke)

Question 288

What are the signs and symptoms of maternal DVT/PE?

Answer 288

asymptomatic, SOB/chest pain, unilateral leg welling/pain, unexplained tachycardia, calf muscle tenderness,

Question 289

What are the features of polymyositis and dermatomyositis?

Answer 289

Polymyositis = proximal muscle weakness Dermatomyositis = proximal muscle weakness + gottron's papules and heliotrope rash

Question 290

What are complications of Paget's disease?

Answer 290

Osteoarthritis Heart failure - excessive demand on the heart dues to increased hypervascularity Neural tissue compression Rarely - malignant transformation (osteosarcoma)

Question 291

What is the managment for female infertility?

Answer 291

clomifene, gonadotrophins, laparoscopic ovarian drilling, GnRH, tubal surgery, oocyte donation

Question 292

What is the diagnosis of JIA?

Answer 292

age of onset \<16y/o, duration of disease \>6 weeks, presence of arthritis is assessed by joint swelling or 2 of the following: painful or limited joint motion tenderness warmth

Question 293

What are the investigations for syphillis?

Answer 293

**microscopy** of fluid from mucocutaneous lesions, veneral diseases research lab (VDLR), **treponema pallidum haemagglutination assay** (TPHA), CXR, CT/MRI, lumbar puncture looking for complications

Question 294

Who is more predipsposed to DDH?

Answer 294

More common in girls More common in the left hip Common in the eastern euroean demographic

Question 295

What is the presentation of reactive arthritis?

Answer 295

mono or oligoarthritis, dactylitis and enthesitis also seen, disease may be systemic with skin and mucous membrane involvement (keratoderma blenorrhagica, circinate balanitis, urethritis, conjunctivitis, iritis) Reiter’s syndrome (arthritis, urethritis and conjunctivitis)

Question 296

What is the managent for fractures?

Answer 296

ABC, analgesia, assess VTE risk and implement prophylaxis low-molecular weight heparin plus anti-embolism stockings if appopriate ie. hip fractures) prophylaxis for crush syndrome, infection (open fractures), tetanus, as required - compartment syndrome can follow on from crush syndrome so be prepared. Crush syndrome causes acute tubular necrosis of the kidneys (rep fracture-specific treatment: reduce for displaced fractures non operative: simple splinting: neighbouring strap (metacarpal fractures) plaster of Paris: easily moulded, cheap. often applied acutely as a backslab to allow for swelling fibreglass cast: lighter, less bulky, more rigid (disadvantage if swelling occurs) and more durable than POP operative: internal fixation Kirschner wire (screws and plates) external fixation uniplanar or ring (ie. Ilizarov frame) rehabilitate physiotherapy occupational therapy

Question 297

What is the management of placenta praevia?

Answer 297

Delivery by caesarean section

Question 298

What is mallet toe?

Answer 298

mallet toe is flexion between intermediate and distal phalanx of any lesser toe

Question 299

What is hammer toe?

Answer 299

hammer toe is flexion between proximal and intermediate phalanx of any lesser toe

Question 300

What would bloods show you on rheumatoid arthritis

Answer 300

bloods: ESR + CRP (degree of synovial inflammation), anaemia of chronic disease, low albumin (correlates directly with disease severity), neutropenia (in Felty’s syndrome)

Question 301

What are potential investigations for menorrhagia?

Answer 301

FBCs TFTs Pelvic USS hCG Hysteroscopy and endometrial biopsy if simple treatment fails or suspicous features

Question 302

What are the findings of bloods on ankylosing spondylitis?

Answer 302

Chronic anaemia RhF negative Increased ESR

Question 303

What is the investigation for placenta praevia?

Answer 303

Low-lying placenta identified at 20 week anomaly ultrasound Needs confirmation in third trimester as may migrate away from lower segment

Question 304

What is the managment of female pelvico organ prolapse?

Answer 304

prevention: avoid constipation, manage chronic chest pathology (COPD, asthma), smaller family size, muscle training (PFMT)? (cannot treat fascial cases) conservative: pelvic floor exercises, ring and shelf pessaries (except if inability to hold it for 2 weeks) surgical: vaginal hysterectomy, anterior and posterior vaginal wall repair + perineometer, biofeedback, vaginal cones, electrical stimulation,

Question 305

What are the symptoms of STILLs disease?

Answer 305

Spiking fever for at least 2 weeks (high in the evening normal in the morning). Salmon red rash on trunk and thighs that accompanies the fever. Can be brought on by scratching ( Koebner's phenomenon) Generalised lymphadenopathy 50-75%. Non-tender. Hepatosplenomegaly Abdominal pain With or without transaminases Serositis (polyserositis, pericarditis in 36%). Tamponade and myocarditis is rare.

Question 306

What are the signs and symptoms for plantar fibromatosis?

Answer 306

asymptomatic unless very large or on weightbearing area

Question 307

Here is management of diabetes in pregnanct women

Answer 307

Important to note that there is increase in insulin requirement, early induction of labour and early feeding of baby to reduce neonatal hypoglycaemia before pregnancy, to prevent malformations: make sure blood sugars are 4-7mmol/L pre-conception and HbA1c \<6,5% (\<48mmol/L), folic acid 5mg, dietary advice, retinal and renal assessement during pregnancy, to prevent metabolic complications: increase insulin, can continue oral anti-diabetic agents, should be aware of hypos risk, watch for ketonuria/infections, repeat retinal assessement 28 and 34w, watch fetal growth, observe mother for PET, oral hypoglyacemics are usually avoided (according to book page 259) giving birth: induction of labout at 38-39 weeks is the norm, consider C-section if significant fetal macrosomia, maintain blood glucose in labour with insulin-dextrose insulin infusion, continuous CTG fetal monitoring in labour, early feeding of baby to reduce neonatal hypoglycaemia, switch back to pre-pregnancy regimen for insulin post delivery

Question 308

What might increase the chances of placental abruption?

Answer 308

Trauma Higher risk in multiple pregnancy, polyhydramnios, pre-eclampsia, smokers

Question 309

What is the investigation for endometrial cancer?

Answer 309

women \>= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (\< 4 mm) has a high negative predictive value hysteroscopy with endometrial biopsy MRI pelvis

Question 310

What are the investigations for molar pregnancy?

Answer 310

Transvaginal ultrasound Chest X-Ray to look for malignant spread

Question 311

What is the presentation for malignant bone tumour?

Answer 311

Pain NOT- activity related Deep-deated boring nature Night pain Difficulty weight bearing Analgesics are usually ineffective Swelling Warmth Pathological fractures Osteoporosis Joint effusion Deformtity Neurovascular effects

Question 312

Which condition is better walking up hill vs worse walking downhill?

Answer 312

Spinal claudication

Question 313

What are the causes of gout?

Answer 313

Increased production of uric acid (Purines) **Diet high in red meat, shellfish, anchovies** Increase in cell turnover Cancer treatment - tumour lysis syndrome Polycythemia vera (5-10% develop gout) Lesch-Nyhan syndrome (HGPRT deficiency) **Dehydration, alcoholic beverage consumption - decreased clearance of uric acid** **Chronic kidney disease**

Question 314

What are the different types of miscarriage?

Answer 314

Threatened Inevitable Incomplete Complete Septic Missed

Question 315

What are staging investigations for breast cancer?

Answer 315

staging investigations: Hb FBC, U&Es, LFTs, CXR, CT thorax and abdomen, isotope bone scan if lymph node spread,

Question 316

What are the nail changes associated with psoriatic arthritis?

Answer 316

Oncholysis Transverse nail ridging Nail pitting

Question 317

What are the signs of maternal DVT/PE?

Answer 317

haemoptysis, pleural rub

Question 318

What is the presentation of a molar pregnancy?

Answer 318

Minor bleed, positive, pregnancy test, vomitting Enlarged uterus Feeling of pelvic pressure

Question 319

What is the staging of endometrial cancer?

Answer 319

(FIGO stage 1-4 according to depth of myometrial invasion, cervical involvement and lymph node involvement) and type (1 or 2) stage 1 (carcinoma strictly confined to the uterus) stage 2 (carcinoma extended to the endocervix (2A) or cervical stoma (2B)) stage 3 (spread to serosa of uterus, pelvic peritoneum or pelvic lymph nodes) stage 4 (local metastasis to bladder/bowel (4A) or distant metastasis (4B))

Question 320

What are investigations for stress incontinence?

Answer 320

MSSU, urodynamics (3 day urinary diary, urine dipstick, Post voiding residual volume assessment Urodynamics (indicated if surgery is contemplated)

Question 321

What are findings on X-ray of RA?

Answer 321

Loss of joint space Peri-articular erosions Juxta articular osteoporosis Subluxation

Question 322

What joints are affected in rheumatoid arthritis?

Answer 322

MCP PIP

Question 323

What is the pathophysiology of scleroderma?

Answer 323

T helper cell mediated immune response, causes a chronic inflammatory response resulting in excessive collagen deposition and damage to microvasculature

Question 324

What are potential outcomes of osteomyelitis?

Answer 324

septicaemia death metastatic infection pathological fracture septic arthritis altered bone growth

Question 325

What is the investigation for gonorrhoea?

Answer 325

Microscopy of discharge reveals characteristic gram-negative diplococci

Question 326

What are the investigations / diagnosis for maternal DVT/PE?

Answer 326

D-dimer is unreliable, use ECG, leg Doppler, CXR, CTPA, V/Q scans to assess mismatch

Question 327

What os the pathophysiology of hallux valgus?

Answer 327

lateral angulation of great toe tendon pull realigned to lateral of centre of rotation of toe worsening deformity vicious cycle of increased pull creating increased deformity sesamoid bones sublux - less weight goes through great toe as deformity progresses abnormalities of lesser toes occur

Question 328

What are common side effects of tricyclic anti-depressants?

Answer 328

drowsiness dry mouth blurred vision constipation urinary retention

Question 329

What is the management of plantar fibromatosis?

Answer 329

non operative: avoid pressure, shoewear/orthotics operative: excision (80% recurrence) radiotherapy (80% recurrence) combination surgery/radiotherapy (higher complications risk, less recurrence)

Question 330

What is the pathophysiology of midfoot arthritis?

Answer 330

Post-traumaic arthritis Osteoarthritis Rheumatoid arthritis

Question 331

What are complications of Sjogren's?

Answer 331

Peridontal complications, oral infections, mucosal assocaited lymphoid tissue lymphoma There is a marked increased risk of lymphoid malignancy (40-60 fold).

Question 332

What are immunology findings in RA?

Answer 332

immunology: rheumatoid factor IgG, IgM anti-cyclic citrullinated antibodies (anti CCP, ACPA) ANA(?)

Question 333

What are possible analgesias in pregnancy?

Answer 333

Analgesia in labour Breathing, massage, TENS, paracetamol and dihydrocodeine TENS = transcutaneous electrical nerve stimulation Water Entonox (inhalational nitrous oxide and oxygen) Opioids (morphine, diamorphine, pethidine) Remifentanil patient controlled analgesia Epidural Consider maternal position and mobility as means of reducing pain and facilitating progress in labour Evidence demonstrates that continuous midwifery care reduces the need for analgesia and increased likelihood of SVD and maternal satisfaction with birth experience (RCM, 2012: Bohren et al 2017).

Question 334

What is midfoot arthritis management?

Answer 334

Activity/shoewear/orthotics XR guided injections Fusion

Question 335

What genes can result in breast cancer?

Answer 335

Both genetic and hormonal factors play a role; about 5–10% of breast cancers are hereditary and occur in patients with mutations of BRCA1, BRCA2, AT or TP53 genes

Question 336

What are the causes of female infertility?

Answer 336

ovulatory disfunction (25%) PCOS premature menopause Turner’s surgical removal hyperprolactinaemia weight loss/stress Sheehan’s syndrome tubal dysfunction (25%) previous PID endometriosis sterilisation uterine abnormality

Question 337

What are characteristic X-ray findings for a giant cell tumour of the bone? (note - giant cell tumours are benign tumours)

Answer 337

Giant cell tumour = forms multi-cystic bone lesions that look like soap bubbles

Question 338

What is the main finding in blood tests for molar pregnancy?

Answer 338

Increased beta HCG

Question 339

What are the classifications of SCFE?

Answer 339

Acute v chronic (3 weeks) Syable vs unstable

Question 340

What increases your chances of getting DDH?

Answer 340

First born Oligohydramnios Breech presentation Family history Lower limb deformities

Question 341

What are investigations for cauda equina syndrome?

Answer 341

MRI PR exam Lumbar CT myelogram if MRI is contraindicated

Question 342

Are antinulear antibodies and RF present in scleroderma?

Answer 342

ANA positive in 90% RF positive in 30%

Question 343

What is the hormone therapy for breast cancer?

Answer 343

What Type of Hormone Therapy do we Usually Give? If premenopausal – tamoxifen for 5 years If postmenopausal – tamoxifen for 5 years if excellent prognosis. BUT others get an aromatase inhibitor, eg ANASTROZOLE for 5-10 years

Question 344

What is the infective organism in chlamydia?

Answer 344

Chlamydia Trachomatis

Question 345

Which disc when prolapsed would cause: Sensory loss on the great tow and first dorsal webspace Motor weakness of the EHL and cause no change in reflex?

Answer 345

Disc = L4/5 Actual root value = L5

Question 346

What are the oncogenes made by papilloma viruses 16 and 18?

Answer 346

HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively E6 inhibits the p53 tumour suppressor gene E7 inhibits RB suppressor gene

Question 347

What are the investigations for ankylosing spondylitis?

Answer 347

X-ray of lungs (remember they have apical fibrosis and restrictive lung disease) MRI Bloods

Question 348

What are the features of adhezive capsulitis?

Answer 348

Features typically develop over days ## Footnote external rotation is affected more than internal rotation or abduction both active and passive movement are affected patients typically have a painful freezing phase, an adhesive phase and a recovery phase bilateral in up to 20% of patients the episode typically lasts between 6 months and 2 years

Question 349

What is the difference between overactive bladder and urge incontinence?

Answer 349

involuntary loss of urine when there is involuntary detrusor activity symptoms of urgency and frequency with or without associated incontinence

Question 350

What is the presenation median nerve injury

Answer 350

Ape-hand deformity - this is when you cannot abduct or oppose the thumb due to paralysis of the thenar muscles. Sensory deficit on volar aspect of thumb.

Question 351

What is an inevitable miscarriage?

Answer 351

when there is dilation of the cervix

Question 352

What are the blood results for SLE?

Answer 352

bloods: Coomb’s +ve haemolytic anaemia, neutropenia, lymphocytopenia, thrombocytopenia, increased ESR, normal CRP, renal profile

Question 353

What are the investigations for breast cancer?

Answer 353

triple assessement of any breast lump (clinical examination, radiological investigation (mammography/US) and biopsy) FNA cytology, core biopsy, mammography, US, sentinel lymph node biopsy (assess lymphatic spread), nipple scrape (Paget’s disease) or use discharge for analysis if present,

Question 354

What is cervical intraepithelial neoplasia?

Answer 354

Abnormal cells in the cervix detected by biopsy and histological examination are classified as cervical intraepithelial neoplasia (CIN). Graded 1 to 3 according to the proportion of cervix affected.

Question 355

What is the management of ankylosing spondylitis?

Answer 355

Physiotherapy Occupational therapy NSAIDs DMARDs (sulfasalazine) Anti-TNF therapy (such as etanercept and adalimumab) Treatment of osteoporosis Joint replacement surgery and spinal surgery

Question 356

What are triple negative breast cancers?

Answer 356

If the cancer does not have receptors for either HER2 or the hormones oestrogen and progesterone, it is called triple negative breast cancer. It affects up to 1 in 5 women (15–20%) with breast cancer and is more common in younger women

Question 357

What are the symptoms of ankylosing spondylitis?

Answer 357

inflammatory back pain, limitation of movements in antero-posterior as well as lateral planes at lumbar spines, limitation of chest expansion, bilateral sacroiliitis on XR Achilles tendonitis, dactylitis uveitis cardiac-aortic incompentence, heart block pulmonary-restrictive disease, apical fibrosis GI-IBD osteoporosis and spinal fractures neurological- AAD and cauda equina syndrome renal-secondary amyloidosis Tenderness over sacroiliac joints (grading of radiographic sacroilitis (grade 0-4 on ASAS classification)

Question 358

What is the most common malignant bone tumour?

Answer 358

Osteosarcoma?

Question 359

What is the presentation of fibroids?

Answer 359

usually asymptomatic or dysmenorrhoea (painful periods), menorrhagia (excessive bleeding), pelvic pain, pressure symptoms on bladder, intermenstrual bleeding (for submucous or intramural types), bloating

Question 360

What is claw toe?

Answer 360

Flexion between proximal and intermediate phalynx AND between intermediate and distal phalynx of any lesser toe

Question 361

What is the definition of a missed miscarriage?

Answer 361

When the fetus has died but the uterus has made no attempt to expel the products of conception. No symptoms or could have bleeding vaginally. Gestational sac seen on scan. No clear fetus or fetal pole with no fetal heart seen in the gestational sac.

Question 362

CIN staging

Answer 362

CIN 1: low grade dysplasia–will regress CIN 2: moderate dysplasia – may regress CIN 3: severe dysplasia – unlikely to regress

Question 363

What are risk factors for endometrial cancer?

Answer 363

Passmedicine: obesity nulliparity early menarche late menopause unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously diabetes mellitus tamoxifen polycystic ovarian syndrome hereditary non-polyposis colorectal carcinoma Obesity Tamoxifen therapy (although antagonistic with respects to breast tissue tamoxifen may serve as an agonist at other sites. Therefore risk of endometrial cancer is increased cancer) Early menarche / late menopause Oestrogen secreting tumours HRT Endometrial hyperplasia with atypia Genetic predisposition (lynch syndrome)

Question 364

What is a complete miscarriage?

Answer 364

Complete expulsion of the products of conception

Question 365

What is the pathogenesis of CIN?

Answer 365

HPV infects basal layers of cells, viral genes expressed as host cell matures, deregulation of host cycles as viral DNA is integrated in cells

Question 366

What is the treatment for Wegners?

Answer 366

Corticosteroids Cyclophosphamide / rituximab

Question 367

What is the name given to the osteophytes in the fingers?

Answer 367

patient over 45 and activity-related joint pain (pain after exertion) plus either morning stiffness \< 30 minutes, reduced ROM, deformity pain after exertion, If linked to trauma, prolonged morning-related stiffness, rapid deterioration of symptoms, hot swollen joint then -\> gout, other inflammatory arthrides, septic arthritis, malignancy

Question 368

What is the treatment for Sjogren's?

Answer 368

artificial saliva and tears pilocarpine may stimulate saliva production Moderate to severe SS = immunosuppressive treatment

Question 369

What is the cause of lesser toe deformities?

Answer 369

Imbalance between flexors/extensors Shoe wear Neurological Rheumatoid arthritis Idiopathic

Question 370

Who does de quervain's tenosynovitis usually affect?

Answer 370

Usually affects women who are aged 30-50 years old

Question 371

What are risk factors for gout?

Answer 371

Age (20-30+ years of hyperuricaemia increases the risk Male Alcohol Obesity Drugs that decrease urate excretion and increase production (thiazides, aspirin) Chronic lead toxicity

Question 372

What are X-Ray findings of perthes disease?

Answer 372

x-ray: early changes include widening of joint space, later changes include decreased femoral head size/flattening

Question 373

What are signs of secondary amenorrhoea?

Answer 373

hirsutism and other androgen-linked features (enlarged clitoris, acne, deep voice)

Question 374

What is the treatment of menorrhagia?

Answer 374

medical: progesterone only pill, tranexamic acid, mefenamic acid, combined oral contraceptive, mirena, GnRH analogues, surgery: trans-cervical resection of submucous fibroids, endometrial ablation, myomectomy, hysterectomy

Question 375

What are the investigations for cervical cancer?

Answer 375

Screening (prophylactic investigation) Cervical biopsy MRI of pelvis, CT of chest, abdomen, pelvis (to assess the spread)

Question 376

What cancers is the oral contraceptive protective for?

Answer 376

Ovarian cancer and endometrial cancer

Question 377

What are the investigations for PCOS?

Answer 377

Pelvic USS Testosterone and sex-hormone binding globulin Glucose tolerance test BP FSH:LH

Question 378

What are the differentials for lower abdominal pain in a young woman?

Answer 378

Ectopic pregnancy Appendicitis Endometriosis IBS Ovarian cyst accident / cyst rupture UTI

Question 379

What is the name of the benign and malignant cels of the cartilage, bone and fibrous tissue?

Answer 379

Cartilage = chondroma - chondrosarcoma Bone = osteochondroma - osteosarcoma Fibrous tissue = fibroma - fibrosarcoma

Question 380

What is the presentation of cervical cancer?

Answer 380

asymptomatic or irregular PV bleeding, postcoital bleeding, intermenstrual bleeding, discharge, pain late cases present with disease progression; renal failure following ureteric obstruction or bowel and bladder involvement classical hard, craggy, bleeding cervix on pelvic examination or colposcopy

Question 381

What is the management of gestational diabetes?

Answer 381

on mother: diabetic nephropathy and retinopathy may deteriorate. Increased risk of miscarriage, pre-eclampsia and operative delivery

Question 382

What are malignant primary tumours of the bone?

Answer 382

Chondrosarcoma Osteosarcoma Fibrosarcoma - fibrous tissue Multiple myeloma - this is from plasma cells

Question 383

What is the presentation of gestational hypertension?

Answer 383

Normal signs of hypertension Headaches Dizziness Blurred vision Epistaxis Angina Syncope Signs of heart failure

Question 384

What is the treatment for trigger finger?

Answer 384

Rest and medication – avoiding certain activities and taking non-steroidal anti-inflammatory drugs (NSAIDs) may help relieve pain. Splinting – where the affected finger is strapped to a plastic splint to reduce movement. Corticosteroid injections – steroids are medicines that can reduce swelling. Surgery on the affected sheath – surgery involves releasing the affected sheath to allow the tendon to move freely again. It's usually used when other treatments have failed. It can be up to 100% effective, although you may need to take 2 to 4 weeks off work to fully recover.

Question 385

What is the presentation for SCFE?

Answer 385

Detection: Pain in hip or knee Externally rotated posture and gait Reduced internal rotation, especially in flexion Plain X-Rays

Question 386

What is the main complication assocaited ith cauda equina syndrome?

Answer 386

if admission + MRI scan + operation \>48h then may result in permanent dysfunction of bladder and anal sphincter

Question 387

What are complications of bone fracture?

Answer 387

minutes to hours complications (immediate): **fat embolism** hours to days complications (early): **compartement syndrome** immobility wound infection **DVT and PE** neurovacular damage weeks to months complications (late): stiffness Sudek’s atrophy malunion pseudoarthrosis - a joint formed by fibrous tissue bridging the gap between the two fragments of bone of an oldfracture that have not united secondary osteoarthritis chronic osteomyelitis avascular necrosis CRPS type 1 implant failure psycholigcal & social aspects complications from bed rest

Question 388

What are the rheumatoid forefoot management options?

Answer 388

Shoewear/orthotics/activity Operative: - 1st MTPJ arthrodesis (this is also a treatment in hallux rigidus) 2-5th toe excision arthroplasty

Question 389

What can cause median nerve palsy?

Answer 389

Wrist lacerations Carpal tunnel syndrome

Question 390

What is the management of rozen shoulder?

Answer 390

Management ## Footnote no single intervention has been shown to improve outcome in the long-term treatment options include NSAIDs, physiotherapy, oral corticosteroids and intra-articular corticosteroids

Question 391

What are differentials for septic arthritis?

Answer 391

acute osteomyelitis, trauma, irratable joint, haemophilia, rheumatic fever, gout, Gaucher’s disease

Question 392

What is the management of lupus?

Answer 392

management depends on organ threat: mild/moderate- hydroxychloroquine, - azathioprine, methotrexate, mycophenolate, NSAIDs, anti-malarials, low-dose steroids severe- cyclophosphamide, rituximab, steroids, immunosuppressants

Question 393

What are normal hormonal changes for the start of labour?

Answer 393

Progesterone decreases whilst oxytocin and prostaglandins increase to allow for labour to initiate

Question 394

What are investigations for POP?

Answer 394

POP quantification (POPQ score) stage 0-6, measure of cm, USS/MRI (thickness of levator ani), urodynamics (exclude concurrent UTI), IVU (view ureters, bladder and kidneys with contrast), renal USS (if suspicion of obstruction)

Question 395

What is the managment of ovarian cancer?

Answer 395

protective: OCP, prophylactic oophorectomy, having many children Platinum based chemotherapy stage 1: total abdominal hysterectomy and bilateral salpingoophorectomy and omentectomy +/- chemotherapy stage 2: stage 1 + /- lymphadenectomy with surgical effort to remove all disease stage 3: stage 2 +/- neoadjuvant chemotherapy to reduce tumour mass before surgery stage 4: stage 3 + pallative chemotherapy

Question 396

What is a molar pregnancy?

Answer 396

**Molar pregnancy is an abnormal form of pregnancy in which a non-viable fertilized egg implants in the uterus and will fail to come to term**. A molar pregnancy is a gestational trophoblastic disease which grows into a mass in the uterus that has swollen chorionic villi. These villi grow in clusters that resemble grapes. A molar pregnancy can develop when fertilized egg had not contained an original maternal nucleus. The products of conception may or may not contain fetal tissue. It is characterized by the presence of a hydatidiform mole. Molar pregnancies are categorized as partial moles or complete moles, with the word mole, being used to denote simply a clump of growing tissue, or a growth.

Question 397

What are blood results for sjogren's?

Answer 397

Leukopenia Thrombocytopenia Anaemia Increased ESR

Question 398

What causes dupuytrens disease?

Answer 398

Formation of abnormal connective tissue within the palmar fascia

Question 399

What is the definition of pre-term labour?

Answer 399

onset of labour before 37 completed gestational weeks. sign is contraction with evidence of cervical change on vaginal examination

Question 400

What is the likely infective organism for vulvovaginal candidosis?

Answer 400

Candida albicans

Question 401

What type of hypersensitivity is present in Sjogren's syndrome? (in reference to the destruction of lacrimal and salivary glands)

Answer 401

Type 4

Question 402

What are the two classifications of spinal cord injury?

Answer 402

Complete and incomplete complete: no motor or sensory function distal to lesion, no anal squeeze, no sacral sensation, ASIA grade A, no chance of recovery incomplete: some function is present below site of injury, more favourable prognosis Patterns of injury: patterns of injury: tetraplegia/quadriplegia central cord syndrome anterior cord syndrome Brown-Sequard syndrome

Question 403

What is the treatment for vulvovaginal candidosis?

Answer 403

azole antifungals (clotrimazole (+ clotrimazole HC if vulvitis) and fluconazole)

Question 404

What are the symptoms of perthes disease?

Answer 404

hip pain: develops progressively over a few weeks limp stiffness and reduced range of hip movement

Question 405

What are risk factors for cervical cancer?

Answer 405

Human papillomavirus (HPV), particularly serotypes 16,18 & 33 is by far the most important factor in the development of cervical cancer. Other risk factors include: smoking human immunodeficiency virus early first intercourse, many sexual partners high parity lower socioeconomic status

Question 406

What is the presentation of osteomyelitis?

Answer 406

infant: failure to thrive, drowsy or irritable, metaphyseal tenderness + swelling, decreased range of motion positional change, commonest around knee child: severe pain, reluctant to bear body weight, tender fever + tachycardia, malaise, fatigue, nausea, vomiting), reduced range of motion adult: backache, history of UTI/urological procedure, history of diabetes, immunosuppression, commonest in thoracolumbar spine, limp, pain, general malaise, loss of appetite, fever, pseudoparalysis

Question 407

What is the presentation of bacterial vaginosis?

Answer 407

usually asymptomatic, watery grey/yellow ‘fishy’ discharge, may be worse after period/sex, sometimes sore/itch from dampness,

Question 408

What are causes of dysmenorrhoea?

Answer 408

Endometriosis Pelvic adhesions Chronic PID Ovarian cysts Pelvic venous conegestion Uterine fibroids

Question 409

What are the two different types of scleroderma?

Answer 409

**Limited (80%)** Skin involvement limited to fingers, forearms,face Late visceral involvement Some individuals develop CREST syndrome: Calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, telangiectasia Associated with anticentromere antibodies Relatively benign **Diffuse (20%)** Widespread skin involvement Early visceral involvement Rapid progression Associated with anti-DNA topoisomerase I antibodies Poor prognosis

Question 410

Where does osteomyelitis often start?

Answer 410

Starts at the metaphysis of long bones

Question 411

What are the complications of RA?

Answer 411

A wide variety of extra-articular complications occur in patients with rheumatoid arthritis (RA): respiratory: pulmonary fibrosis, pleural effusion, pulmonary nodules, bronchiolitis obliterans, methotrexate pneumonitis, pleurisy ocular: keratoconjunctivitis sicca (most common), episcleritis, scleritis, corneal ulceration, keratitis, steroid-induced cataracts, chloroquine retinopathy osteoporosis ischaemic heart disease: RA carries a similar risk to type 2 diabetes mellitus increased risk of infections depression Less common Felty's syndrome (RA + splenomegaly + low white cell count) amyloidosis

Question 412

Who is more likely to be affected by Sjogren's?

Answer 412

Sjogren's syndrome is much more common in females (ratio 9:1).

Question 413

What is a threatened miscarriage?

Answer 413

This is when there is bleeding from the gravid uterus before 24 weeks gestation, when there is a viable fetus and no evidence of cervical dilation. The uterus may remain viable and the pregnancy continues without any further problems. The cervix is closed in speculum examination.

Question 414

What test can measure tear production in Sjogren's?

Answer 414

Schirmer's test: filter paper near conjunctival sac to measure tear formation

Question 415

What causes stress incontinence?

Answer 415

Defect in anterior vaginal wall and pubo-urethral ligament Suburethral hammock

Question 416

What is the presentation of endometriosis?

Answer 416

dysmenorrhoea, deep dyspareunia, chronic pelvic pain, ovulation pain, infertility, dyschezia (pain of defecation), tenderness or palpable nodules on bimanual examination, frozen pelvis Passmedicine: chronic pelvic pain dysmenorrhoea - pain often starts days before bleeding deep dyspareunia subfertility non-gynaecological: urinary symptoms e.g. dysuria, urgency, haematuria. Dyschezia (painful bowel movements) on pelvic examination reduced organ mobility, tender nodularity in the posterior vaginal fornix and visible vaginal endometriotic lesions may be seen

Question 417

What are the bloods seen on RA?

Answer 417

bloods: ESR + CRP (degree of synovial inflammation), anaemia of chronic disease, low albumin (correlates directly with disease severity), neutropenia (in Felty’s syndrome)

Question 418

What is the clinical presentation for gout?

Answer 418

acute: monoarthritis, severe pain lasting 7-10 days, most commonly first metatarsophalangeal joint (podogra) chronic: gouty tophi on pinnae, hands +/- polyarthritis

Question 419

What is the presentation of polymyalgia rheumatica?

Answer 419

typically patient \> 60 years old usually rapid onset (e.g. \< 1 month) aching, morning stiffness in proximal limb muscles (not weakness) - typically lasts more than 1 hour also mild polyarthralgia, lethargy, depression, low-grade fever, anorexia, night sweats Muscle power is normal

Question 420

What is the management for ectopic pregnancy?

Answer 420

- medical: methotrexate - surgical: laparoscopic salpingectomy/ salpinotomy for few indications conservative + USS in following pregnancies

Question 421

What are the features of cardiovascular syphillis?

Answer 421

Aortic aneurysmn Aortic regurgitation

Question 422

What is the management for achilles tendonopathy?

Answer 422

Non-operative: ## Footnote activity modification, weight loss, shoe wear modification (slight heel), physiotherapy (eccentric stretching), extra-corporeal shockwave treatment, immobolisation (in below knee cast) Operative: Gastrocnemius recession Release and debridement of tendon

Question 423

What is placenta praevia?

Answer 423

PLacenta partially or completely covers the lower uterine segment

Question 424

What is the treatment for GCA?

Answer 424

Corticosteroids

Question 425

How is the diagnosis of scleroderma made?

Answer 425

**DIAGNOSTIC IMAGING** Upper endoscopy Esophageal fibrosis/reflux esophagitis **LAB RESULTS** Serologic tests ▫↑ANAs in almost all individuals with systemic sclerosis; low specificity ↑ACAs highly specific (limited) - anticentromere antibodies Anti-topoisomerase I antibodies (anti-Scl-70) highly specific (diffuse) Complete blood count (CBC) Anemia due to malabsorption, increased serum creatinine due to renal dysfunction **OTHER DIAGNOSTICS** Clinical presentation Skin thickening, swollen fingers, Raynaud's phenomenon, GI reflux **Pulmonary function tests** Restrictive ventilatory defect due to pulmonary interstitial fibrosis

Question 426

What are the different types of fibroids?

Answer 426

smooth muscle growth, can be: submucosa (protrude into uterine cavity) intramural (within uterine wall) subserosal (project out of uterus into peritoneal cavity)

Question 428

What is the cause of paget's disease of the bone?

Answer 428

Excessive bone resorption follwoed by disorganised compensatory bone formation

Question 429

What are x-ray findings on rheumatoid arthritis?

Answer 429

Loss of joint space Juxta-articular osteoporosis Periarticular erosions Subluxation

Question 430

What is the treatment for polymyalgia rheumatica?

Answer 430

Low dise corticosteroids The condition can regress after 1 or 2 years (or it can remain chronic)

Question 431

What are is the cause of pagets disease of the bone?

Answer 431

Unclear, possible causes include Slow virus infection of osteoclasts Mutations of SQSTM1, RANK genes involved in Osteoclasts' function regulation

Question 432

What is a septic miscarriage?

Answer 432

Following incomplete abortion there is always a risk of ascending infection into the uterus which can spread through the pelvis and is known as septic abortion

Question 433

What are the investigations for tibialis posterior tendon dysfunction?

Answer 433

Clinical MRI to assess tendon

Question 434

What is the presentation of placental abruption?

Answer 434

Pain Vaginal bleeding May be concealed and present with abdominal pain Woody hard uterus is a classic sign

Question 435

What is the screening programme for cervical cancer?

Answer 435

screening: 25-64 y/o, smear test every 3 years when \<50 y/o, every 5 years when \>50 y/o If low grade dyskariosis then repeat in 6 months

Question 436

How is the diagnosis of ovarian cancer made?

Answer 436

diagnosis: Ca125 (carcinoma antigen), pelvic USS, staging: pelvic MRI/CT chest/abdomen/pelvis, colonoscopy/OGD may be indicated is there is a possibility of primary GI malignancy, US guided biopsy of omentum, staging (1-4) stage 1 (tumour limited to ovaries) stage 2 (tumour involves one or both ovaries with pelvic extension stage 3 (tumour with peritoneal implants outside the pelvis or retroperitoneal and or inguinal nodes) stage 4 (tumour with distant metastasis) Diagnosis is difficult and often relies on diagnostic laparotomy

Question 437

What are risk factors for osteomyelitis?

Answer 437

diabetes mellitus sickle cell anaemia intravenous drug user immunosuppression due to either medication or HIV alcohol excess

Question 438

What are the causes of cauda equina syndrome?

Answer 438

compression of cauda equina due to: central lumbar disc prolapse (commonest), cord tumours, vertebral mets trauma (burst, fracture disc, spinal stenosis) infection (epidural abscess) iatrogenic (spinal surgery or manipulation, spinal epidural injection)

Question 439

What is the treatment of syphillis?

Answer 439

Penicillin

Question 440

What are immunology results for RA?

Answer 440

rheumatoid factor IgG, IgM anti-cyclic citrullinated antibodies (anti CCP, ACPA) ANA(?)

Question 441

What are investigations for downs syndrome in utero?

Answer 441

first trimerster screening: combined test nuchal translucency, hCG and PAPP-A (pregnancy associated plasma protein A), AFP (alpha fetoprotein) first and second trimester: intergrated test combined test and ALP (alpha fetoprotein), oestriol, inhibin A second trimester: quadruple test hCG, estriol, AFP, inhibin A second trimester: anomaly USS if risk is \<1 in 250 then are offered chorionic villus sampling or amniocentesis

Question 442

What is the presentation of benign bone tumours?

Answer 442

Activity related pain Swelling Pathological fracture Deformity Neurovascular effects (limb weakness, numbness)

Question 443

What is the treatment for Pelvic Inflammatory disease?

Answer 443

Low threshold for treatment Oral oflaxacin and oral metronidaole OR Intramuscular ceftrioaxone and oral doxycycline and oral metronidazole Surgical treatment may be indicated in the case of pelvic abscesses

Question 444

What is the presentation of vulkvovaginal candidosis?

Answer 444

usually asymptomatic, symptomatic trush (itching, discharge, classically thick, ‘cotton cheese’, but often just increased amount) Itch and discharge fissuring, erythema with satellite lesions, characteristic discharge

Question 445

What is the presentation of enteropathic arthritis?

Answer 445

can be both peripheral and axial disease, enthesopathy commonly seen If there is arthritis with IBD / Crohn's it's important to suspect enteropathic origin

Question 446

What is the pathophysiology of plantar fasciitis/fasciosis?

Answer 446

chronic degenerative change, fibroblast hypertrophy, absence inflammatory cells, disorganised and dysfunctional blood vessels and collagen, avascularity, can’t make extra cellular matrix required for repair and re-modelling -\> (microtears?)

Question 447

How can you interpret the progesterone withdrawal test?

Answer 447

So if there is anovulation then - progesterone given and then removed, bleeding 2-7 days later. This is dependant on sufficient estradiol concentration in the serum. If no bleeding = Low serum estradiol, hypothalamic pituitary axis dysfunction, non-reactive endometrium, outflow tract abnormality such as cervical stenosis. If it is not an outflow tract obstruction then it is likely to be due to low oestrogen. Withdrawal bleeding occurs after removal of oestrogen / progesterone therapy.

Question 448

What is the diagnosis of having a lump in dorsal foot - firm, non tender, change in size, smooth, occasionally lobulated, normally not fixed to skin or underlying tissue, never fixed to skin Pain from pressure from shoewear Pain from underlying problem

Answer 448

ganglia

Question 449

What are the radiological features of OA?

Answer 449

Loss of joint space Osteophytes Subchondral sclerosis Subchondral cyst

Question 450

What are clinical features of DDH?

Answer 450

Ortolani's sign and Barlow's sign One leg appears longer than the other Uneven skin folds in the buttocks One leg dragging behind the other

Question 451

What is the likely causative organism in osteomyelitis?

Answer 451

Staph. aureus is the most common cause except in patients with sickle-cell anaemia where Salmonella species predominate.

Question 452

What is the most common presentation of a baby?

Answer 452

LOA

Question 453

What are signs and symptoms of sjogrens?

Answer 453

Dry eyes (irritation, itching foreign body sensation, **keratoconjuncitivits**) Oral dryness reflecting salivary hypofunction Salivary gland enlargement (parotid, subamndibular etc) Extraglandular manifestations (MSK symptoms such as arthralgias and arthritis, rashes, interstitial nephritis, vasculitis)

Question 454

What is the presentation of trigger finger?

Answer 454

clicking sensation with movement of digit, clicking may progress to locking, may have to use other hand to “unlock” Lump in palm under pulley

Question 455

Which bone in normal labour is the presenting part?

Answer 455

Anterior parietal

Question 456

What are investigations for pelvic inflammatory disease?

Answer 456

FBC, CRP, hCG (ensure negative), MSSU, high vaginal swab, endocervical swabs, blood cultures if febrile, pelvic USS, screen for chlamydia and gonorrhoea (low vaginal swabs)

Question 457

What is the presentation of cauda equina syndrome?

Answer 457

injury or precipitating event symptoms located in buttock bilaterally, leg pain, back pain, varying dysaethesiae + weakness; leg weaknees together with absent reflexes bowel and/or bladder sphincter dysfunction (urinary retention +/- incontinence overflow) saddle anaesthesia, loss of anal tone & anal reflex

Question 458

What is the definition of primary infertility?

Answer 458

primary infertility: unprotected sexual intercourse for over 1 year and no history of pregnancy secondary infertility: unprotected sexual intercourse for over 1 year with a previous history of pregnancy

Question 459

What is the test for de quervains tenosynovitis?

Answer 459

Finklestein's

Question 460

What is the pathophyiology of charcot neuropathy?

Answer 460

2 theories: neurotraumatic (lack of proprioception and protective pain sensation) neurovascular (abnormal autonomic nervous system results in increased vascular supply and bone resorption characterised by rapid bone destruction occuring in 3 stages (fragmentation, coalescence, remodelling)

Question 461

Which disc when prolapsed would cause: Sensory loss in medial aspect of lower leg Motor weakness in the quads Reflex change in the knee jerk

Answer 461

Disc = L3/L4 Actual root value = L4

Question 462

What are is the presentation for female pelvic organ prolapse?

Answer 462

“mass down below”, “dragging sensation” vaginal: feeling/seeing a bulge, sensation of bulge, difficulty in inserting tampons, **dyspareunia** urinary: hesitancy, incomplete emptying, poor stream, prolonged stream, urinary incontinence, frequency/urgency, manual reduction of prolapse to start or complete void bowel: incontinence of void/flatus, feeling of incomplete emptying, straining, urgency, digital evacuation to complete defecation, splinting or pushing on or around the vagina or perineum to start or complete defecation

Question 463

What disease affects large vessles?

Answer 463

Giant cell arteritis Takayasu arteritis

Question 464

What are complications of SCFE?

Answer 464

Avascular necrosis: Stable slips (able to bear weight) have a low risk of AVN Unstable slips (unable to bear weight) have a high risk of AVN Chondrolysis Deformity Early osteoarthritis

Question 465

What is the most common type of IJA?

Answer 465

Pauciarticular (this is 55%) THEN Polyarticular (25%) Systemic onset (20%)

Question 466

What is the treatment for gonorrhoea?

Answer 466

Cephalosporin, widespread antibiotic resistance ceftriaxone 500 mg intramuscularly as a single dose with azithromycin 1 g oral as a single dose. The azithromycin is thought to act synergistically with ceftriaxone and is also useful for eradicating any co-existent Chlamydia infections.

Question 467

What is management and prevention of gout?

Answer 467

Limit medications that alter urate balance (e.g thiazides, aspirin) Initiate medications that decrease uric acid levels Xanthine oxidase inhibitors (allopurinol, febuxostat) Uricosuric medications (increase urate excretion at the kidney) Uricase medications - mimic enzyme that catalyzes urate conversion Other interventions = * management of obesity/diabetes * Diet modification (avoidance of soda, red meat and seafood) * Alcohol moderation * Increase in physical activity Note for uricosuric medications: Gouty patients with normal or low excretion of uric acid (underexcretors) may be candidates for treatment with uricosuric drugs with little risk of urinary calculi. Measurement of the amount of excreted urate has also been recommended to identify these patients.

Question 468

What is the difference between golfers elbow and tennis elbow?

Question 469

What are invesitagtions for bone tumours?

Answer 469

- MRI - XR (lesion is inactive or aggressive), - CT (ossification and calcification) - isotope bone scans (bone mets for staging) - angiography - PET - biopsy There may be tumour biomarkers in the blood

Question 470

What is managment of HIV to prevent vertical transmission?

Answer 470

mother is given antiviral therapy anyway (highly active anti-retroviral therapy, HAART), C-section and no breastfeeding if high load of anti-viral (zidovudine) prior to delivery and given to infant, maybe vaginal delivery if low viral load

Question 471

What is the presentation of gonorrhoea?

Answer 471

Purulent penile discharge Often asymptomatic in women

Question 472

What happens during stage 1 of labour?

Answer 472

**Latent** stage - intermittent, often irregular or painful contractions which bring about some cervical effacement and dilatation up to 4 cm. **Established** stage - Contractions become regular and painful. Result in progressive effacement and cervical dilation from 4 cm Complete when cervix is fully dilated (10 cm) Primagravida = 8 hours (usually not longer than 18 hours) Multigravida = 5 hours (unlikely to last more than 12 hours) Anticipated progress 0.5-1.0 cm per hour

Question 473

What is the management of maternal DVT/PE?

Answer 473

low molecular weight heparin, (WARFARIN IS TERATOGENIC) thromboprophylaxis (stockings, increase mobility) should be considered in those with risk factors or following C section, for 6w post-partum

Question 474

What is the management of osteoporosis?

Answer 474

minimise risk factors, ensure good calcium and vit D status, falls prevention strategies, medication (oral bisphosphonates usually first line of treatment, HRT, SERMS like raloxifene, denosumab, teriparatide (parathyroid hormone)), Ca2+ supplements, strontium ranelate, bisphosphonate requirements: good renal function, good calcium and vit D status, good dental health and hygiene advised, side effets include oesophagitis, iritis/uveitis, osteonecrosis of jaw, atypical femoral shaft fractures (usually 1-2y drug holiday after 10y)

Question 475

Who is SCFE more likely to be seen in?

Answer 475

More likely to be seen in overweight children (more likely to be male) Typical age is 9-14 years

Question 476

What are the investigations for plantar fasciitis/fasciosis?

Answer 476

diagnosis is clinical mainly, XR, USS and MRI

Question 477

What is non-operative treatment for lesser toe deformities?

Answer 477

activity modification, shoe wear (flat shoes with high toe box to accomodate deformity) orthotic insoles (metatarsal bar/dome support)

Question 478

What are the joint pattern for the following conditions? Psoriatic arthritis Reactive arthritis Enteropathic arthritis Ankylosing spondylitis

Answer 478

AS = Axial Enteropathic = Axial and peripheral Psoriatic = Axial and asymmetrical peripheral Reactive = Axial and asymmetrical peripheral

Question 479

What are the investigations for osteomalacia?

Answer 479

low 25(OH) vitamin D (in 100% of patients, by definition) raised alkaline phosphatase (in 95-100% of patients) low calcium, phosphate (in around 30%) PTH is raised x-ray: children - cupped, ragged metaphyseal surfaces; adults - translucent bands (Looser's zones or pseudofractures)

Question 480

What are bloods in paget's disease?

Answer 480

Normal Ca2+ but raised alkaline phosphatase

Question 481

What is the treatment for bacterial vaginosis?

Answer 481

oral metronidazole for 5-7 days 70-80% initial cure rate relapse rate \> 50% within 3 months the BNF suggests topical metronidazole or topical clindamycin as alternatives

Question 482

What is the aetiology of spontaneous miscarriage?

Answer 482

**Abnormal conceptus** chromosomal, genetic, structural - It is estimated that 50% of spontaneous miscarriages may be due to abnormal chromosomes. **Uterine abnormality** congenital, fibroids - Congenital uterine abnormalities result from a failure of normal fusion of the mullerian ducts - incidence of spontaneous miscarriage in this group is estimated to be double that of the normal population. Submucosal fibroids are especially associated with spontaneous miscarriage due to distortion of the uterine cavity. **Cervical incompetence** Primary, secondary - The cervix opens prematurely with absent or minimal uterine activity and the pregnancy is expelled. Trauma to the cervix can be an important aetiological factor such as cone biopsy treatment? **Maternal** increasing age, diabetes - Hormonal imbalances are also said to be a cause of spontaneous miscarriage. The corpus luteum is essential for ensuring the survival of the pregnancy during the first 8 weeks of term. If the corpus luteum is to be removed surgically then abortion will usually occur within 7 days. In threatened miscarriage, those that continue to have inevitable miscarriages will have lower levels of progesterone than those that continue pregnancies to term. Maternal causes of spontaneous miscarriage can include **SLE**, **thyroid disease**, acute maternal **infection** such as appendicitis, pyelitis. Maternal infection causes general toxic illness with high temperature that can stimulate uterine activity and loss of pregnancy. Unknown

Question 483

What is the management for PCOS?

Answer 483

**get BMI within 18-30 range, if BMI is normal** then use ovulation induction agent (clomiphene, gonadotrophins, GnRH, according to the group), **oral contraceptive pill** antiandrogen (combined hormonal contraception, spironolactone, eflornithine cream) endometrial protection (CHC, progestogens, mirena US (progestin IUD) (remember that endometrial hyperplasia is a complication. fertility (clomiphene/metformin) Cosmetic theapies for hirsuitism

Question 484

What is the investigation for endometrial cancer?

Answer 484

women \>= 55 years who present with postmenopausal bleeding should be referred using the suspected cancer pathway first-line investigation is trans-vaginal ultrasound - a normal endometrial thickness (\< 4 mm) has a high negative predictive value hysteroscopy with endometrial biopsy MRI pelvis/CT chest, abdomen, pelvis for staging

Question 485

What are the symptoms of placenta praevia?

Answer 485

Asymptomatic or can present with painless PV bleeding which can range from light to torrential.

Question 486

What are the complications of gonorrhoea?

Answer 486

Septic arthritis - most common cause of monoarthritis in sexually active adults

Question 487

What is the risk of having a baby with Down's syndrome if the woman is aged 40?

Answer 487

around 1%

Question 488

What is treatment of pseudogout?

Answer 488

Acute flares: NSAIDs Colchicine Glucocorticoids Management and prevention: Colchicine

Question 489

What is the treatment for Perthes disease?

Answer 489

To keep the femoral head within the acetabulum: cast, braces If less than 6 years: observation Older: surgical management with moderate results Operate on severe deformities

Question 490

What is the presentation of adenomyosis?

Answer 490

dysmenorrhoea, dysparenunia, menorrhagia, bulky tender uterus Endometriosis doesn't have menorrhagia by the looks of it so this would be the key difference between the two

Question 491

What is the Gustilo - Anderson classification of fractures?

Answer 491

Grades are according to soft tissue injury: Type 1: low-energy clean wound \< 1 cm with minimal soft tissue injury and fracture communition Type 2: Wound 1-10 cm with moderate soft tissue damage and fracture communition Type 3: high-energy wound \>10cm (3A no periosteal stripping, 3B periosteal stripping, 3C major vascular injury)

Question 492

What is the management of osteoporosis?

Answer 492

Minimise risk factors Ensure good calcium and Vitamin D status Falls prevention strategies Medications - hormone replacement therapy Side effects of HRT - increased risk of blood clots increased risk of breast cancer with extended use into late 50's/early 60's Increased risk of heart disease and stroke if used after large gap from menopause. Selective oestrogen receptor modulator raloxifene - only effective in preventing vertebral body fractures - doesn't affect hip fractures. Negative effects of SERMS- hot flushes if taken close to menopause, increased clotting risks, lack of protection at hip site Bisphosphonates are the main Rx option Oral Bisphosphonates generally the first line of treatment Adequate Renal function required Adequate Calcium and Vitamin D status Good Dental Health and Hygiene advised Notify dentist on Bisphosphonates Encourage regular check ups / well fitting dentures Alendronate - this is one of the popular bisphosphonates used to treat osteoporosis Side effects of bisphosphonates - Oesophagitis Iritis/uveitis Not safe when eGFR\<30 mls/min ONJ Atypical femoral shaft fractures Drug Holiday for 1-2 years Usually after 10 years Oral Bisphosphonates Bisphosphonates can also cause osteonecrosis of the jaw. - very rare Even though you increase the chance of atypical femoral shaft fracture - you are still 200 times more likely to break your hip by osteoporosis than bisphosphonates Denosumab - this is a monoclonal antibody against RANKL The RANK L ligand is responsible for regulating osteoclast activity Denosumab requires a subcutaneous injection every 6 months - safer in patients with significant renal impairment than bisphosphonates. Osteoclasts do not get the signal to resporb bone There is no negative feedback signal to osteoblasts continue to lay down bone Side effects of Denosumab: Allergy / rash Symptomatic hypocalcaemia if given when vitamin D deplete ONJ? Atypical femoral shaft fracture? Teriparatide - intermittent human parathyroid hormone - this is the first portion of parathyroid hormone - makes osteoblasts lay down bone - only anabolic bone treatment (only treatment that actually aids in the laying down of bone Side effects of Teriparatide - injection site irritation

Question 493

What is the management for endometrial cancer?

Answer 493

localised disease is treated with total abdominal hysterectomy with bilateral salpingo-oophorectomy. Patients with high-risk disease may have post-operative radiotherapy progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery

Question 494

What is the presentation of osteomalacia?

Answer 494

rickets: knock-knee, bow leg, features of hypocalcaemia osteomalacia: bone pain, fractures, muscle tenderness, proximal myopathy

Question 495

What is the managment of diabetc foot ulcer?

Answer 495

prevention modify the main detriments to healing (diabetic control, smoking, vascular supply, external pressure (splints/shoes/weight bearing), internal pressure (deformity), infection, nutrition surgical: improve vascular supply, debride ulcers and get deep samples for microbiology, correct any deformity to offload area, amputation

Question 496

What is osteomalacia?

Answer 496

normal bony tissue but decreased mineral content rickets if when growing osteomalacia if after epiphysis fusion

Question 497

What is the radiographical sign of SCFE?

Answer 497

Trethowan

Question 498

What are the findigns of ankylosing spondylitis on imaging?

Answer 498

XR (**sacroiliitis**, juxta-articular sclerosis, **syndesmorphyte** formation, marginal erosion, **fusion of adjacent vertabrae** (bamboo spine)), **disk calcification**, pseudoarthritis; MRI _Passmedicine_: sacroilitis: subchondral erosions, sclerosis squaring of lumbar vertebrae 'bamboo spine' (late & uncommon) syndesmophytes: due to ossification of outer fibers of annulus fibrosus chest x-ray: apical fibrosis

Question 499

What are the functions of oestrogen?

Answer 499

* Proliferation of endometrium * Promotes development of genitalia * Promotes growth of follicle * Causes LH surge * Responsible for female fat distribution * Increases hepatic synthesis of transport proteins * Upregulates oestrogen, progesterone and LH receptors * Increases TBG levels

Question 500

What are risk factors for preterm labour?

Answer 500

Acute illness Low BMI Multiple pregnancy Polyhydramnios Pre-term rupture of membranes Previous cervical surgery Previous preterm deliver Smoking Uterine abnormalities

Question 501

What are complications of pelvic inflammatory disease?

Answer 501

Infertility Chronic pelvic pain Ectopic pregnancy

Question 502

What are the joints affected in osteoarthritis?

Answer 502

Large weight-bearing joints (hip, knee) Carpometacarpal joint DIP, PIP joints

Question 503

What are the complications of pre-eclampsia in the mother?

Answer 503

mother: eclampsia, severe HT, cerebral haemorrhage, stroke, hemolysis, elevated liver enzymes, low platelets, liver and renal failure, disseminated intravascular coagulation, renal failure, pulmonary oedema, cardiac failure, impaired placenta perfusion,, growth, HELLP syndrome, pappiloedema, pulmonary oedema, placental abruption, disseminated intravascular coagulation

Question 504

What is the common history for transient synovitis?

Answer 504

Typical age group = 2-10 years Acute hip pain associated with viral infection

Question 505

What is the diagnostic criteria for RA?

Answer 505

diagnosis criteria: need 4 out of 7 (RF RISES) Rheumatoid factor Finger/hand joint involvement Rheumatoid nodules Involvement of 3 or more joints Stiffness - early morning Erosions/decalcification on XR Symmetrical arthritis

Question 506

What is the presentation of fracture?

Answer 506

pain nerve, blood vessel, skin damage visceral damage (pneumotheorax in rib fracture) disruption to overlying soft tissue

Question 507

What are investigations for achilles tendonopathy?

Answer 507

USS MRI

Question 508

What is the managment for charcot foot?

Answer 508

prevention immobilisation/non-weight bearing until acute fragmentation resolved correct deformity (deformity leads to ulceration leads to infection leads to amputation)

Question 509

What are the most common types of cervical cancer?

Answer 509

80-90% = squamous cell 10-20% = adenocarcinoma Ectocervix = squamous cell Endocervix = columnar cell

Question 510

Who is affected by frozen shoulder?

Answer 510

It is most common in middle-aged females. The aetiology of frozen shoulder is not fully understood. Associations ## Footnote diabetes mellitus: up to 20% of diabetics may have an episode of frozen shoulder

Question 511

What is the infective organism for Gonorrhoea?

Answer 511

Bacterial infection caused by Neisseria Gonorrhoeae

Question 512

What are non-operative methods of management for hallux valgus?

Answer 512

non-operative: shoe wear modification (wide +/- high toe box) orthotics to offload pressure/correct deformity activity modification analgesia

Question 513

What is the presentation of post partumhaemorrhage?

Answer 513

may present with tachycardia, tachypnoea, hypotension if severe bleeding

Question 514

What are the investigations for bacterial vaginosis\>

Answer 514

Gram stained smear of vaginal discharge

Question 515

What are complications of PCOS?

Answer 515

Type 2 diabetes Sleep apnoea Cardiovascular risk Endometrial hyperplasia and carcinoma

Question 516

What are the causative organisms for pelvic inflammatory disease?

Answer 516

Chlamydia trachomatis - the most common cause Neisseria gonorrhoeae Mycoplasma genitalium Mycoplasma hominis

Question 517

What would you find on examination of endometriosis?

Answer 517

adnexal masses or tenderness nodules or tenderness in posterior vaginal fornix or uterosacral ligaments, fixed (because of fibrous scar tissue) retroverted uterus, rectovaginal nodules

Question 518

What are risk factors for molar pregnancy?

Answer 518

Spontaneous abortion Previous molar pregnancy Infertility Maternal age of extremes (less than or equal to 15 or older than 35) Low dietary carotene (this is a precursor for vitamin A)

Question 519

When is it necessary to order a bone mineral density scan for osteoporosis?

Answer 519

Alongside a fracture assessment to make results more accurate (intermediate risk as assessed by the FRAX test requires a BMD scan) ## Footnote before starting treatments that may have a rapid adverse effect on bone density (for example, sex hormone deprivation for treatment for breast or prostate cancer). in people aged under 40 years who have a major risk factor, such as history of multiple fragility fracture, major osteoporotic fracture, or current or recent use of high-dose oral or high-dose systemic glucocorticoids (more than 7.5 mg prednisolone or equivalent per day for 3 months or longer).

Question 520

What are the features of dependant personality disorder?

Answer 520

Intense fear of separation and rejection Clings to relationships, unfortunately this means that a lot of these people end up in abusive relationships. They hold on to someone who completely takes care of them. Lacks self confidence Difficulty making simple decisions e.g what to eat.

Question 521

What are complications of molar pregnancy?

Answer 521

Malignancy Hyperthyroidism Hypermesis gravidarum (associated with large amounts of beta HCG) Preeclampsia

Question 522

What are the investigations for primary amenorrhoea?

Answer 522

GnRH, hCG, TFT, LH, FSH, prolactin, chromosomal karyotype, pelvic USS, oestrogen, TSH, progesterone challenge test (oral progesterone for 5 days, if there is endogenous oestrogen and normal anatomy, withdrawal bleeding will occur), pregnancy test, testosterone?

Question 523

What is the management of ganglia?

Answer 523

Non - operative = aspiration Operative = excision (including the root)

Question 524

What type of breast cancers responds well to hormonal therapy?

Answer 524

About 70% of breast cancers are ER positive. They respond well to treatment with hormonal therapies. Most commonly used hormone therapy drugs used to treat breast cancer are: tamoxifen aromatase inhibitors (anastrozole, exemestane and letrozole) goserelin (Zoladex) fulvestrant (Faslodex)

Question 525

What is the management of endometrial cancer?

Answer 525

surgery: stage 1: total abdominal hysterectomy and bilateral salpingoophorectomy stage 2: radical total abdominal hysterectomy (TAH) + bilateral salpingoophorectomy (BSO) + radiotherapy +/- lymphadenactomy stage 3: surgery + radiotherapy or radiotherapy alone stage 4: palliative radiotherapy (with progesterone if advanced stage) other: peritoneal washings (all laparoscopically), chemo if high risk histology, radiotherapy (external beam or caesium insertion)

Question 526

What is the investigation for male infertility?

Answer 526

semen analysis, repeat semen analysis if required CF screening if azoospermia, fat and hair distribution, STDs (chlamydia, gonorrhoea, NSTD), caryotype (Klinefelter syndrome), congenital absence of vas deferens,

Question 527

Where do secondary bone cancers often come from?

Answer 527

Be prepared for the laughing kid Breast Prostate Thyroid Lungs Kidneys

Question 528

What is the presentation of traumatic subarachnoid haemorrhage?

Answer 528

Immediately unconscious and in cardiac arrest Sudden onset - headache 'the worst headache in my life' Neck stiffness Photophobia

Question 529

What aere the signs and symptoms of granulomatosis with polyangitis?

Answer 529

Chronic pain (oral ulcers, bloody nasal mucus, **chronic sinusitis**, saddle nose) Haemoptysis, dyspnoea, cough, pleuritic chest pain (inflammation of the lung vessels) Decreased urine production, hypertension, haematuria, red cell casts, proteinuria (glomerular filtration) **Myalgia** **Arthralgia** Episcleritis

Question 530

When are you likely to be worried about NAI?

Answer 530

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

Question 531

Salter Harris Growth Plate Fractures

Answer 531

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

Question 532

What are the types of osteogenesis imperfecta?

Answer 532

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

Question 533

What is the definition of oligoouvlation?

Answer 533

Oligoovulation is infrequent or irregular ovulation (usually defined as cycles of ≥36 days or \<8 cycles a year)