MSRA part 2 Flashcards
1
Q
What are the risk factors for fibroids
A
increasing age (until the menopause); early menarche; older age at first pregnancy; comorbidities such as obesity and hypertension; black and Asian ethnicity; family history.
2
Q
What is menopause
A
The point at which menstruation stops
3
Q
How does adenomyosis present and how is it diagnosed and managed?
A
presents with dysmenorrhoea, menorrhoagia, dyspareunia - it is diagnosed on TV US and managed with non-hormonal symptomatic relief (transexamic acid, mefenamic acid) or hormonal (mirena coil 1st line)
4
Q
What is the criteria used to diagnose PCOS and what are the key features?
A
The Rotterdam criteria:
Oligoovulationoranovulation, presenting with irregular or absent menstrual periods
Hyperandrogenism, characterised by hirsutism and acne
Polycystic ovaries (12) onultrasound(orovarian volumeof more than 10cm3)
5
Q
What causes PCOS?
A
Insulin resistanceis a crucial part of PCOS. When someone is resistant to insulin, theirpancreashas to producemore insulinto get a response from the cells of the body. Insulin promotes the release ofandrogensfrom theovariesandadrenal glands. Therefore, higher levels of insulin result in higher levels ofandrogens(such astestosterone). Insulin also suppressessexhormone-binding globulin(SHBG) production by theliver. SHBG normally binds to androgens and suppresses their function. Reduced SHBG further promoteshyperandrogenismin women with PCOS.
6
Q
What is the mainstay of treatment for PCOS?
A
For PCOS the mainstay of treatment is weight loss, reducing the risk of endometrial cancer with progesterone therapies, infertility, hirsutism
7
Q
What is the Nucleic acid amplification tests(NAAT)
A
chlamydiaandgonorrhoea
8
Q
Can you give TCA in breastfeeding
A
most TCAs can be used during breastfeeding if clinically appropriate
9
Q
Which medications are compatible with breast feeding?
A
e.g. analgesics and antipyretics: short courses of paracetamol, acetylsalicylic acid, ibuprofen; antibiotics: ampicillin, amoxicillin, cloxacillin and other penicillins, erythromycin bronchodilators (e.g. salbutamol), corticosteroids, antihistamines, antacids
10
Q
Which medications when taken when breastfeeding suppresses lactation?
A
oestrogens, including estrogen-containing contraceptives, thiazide diuretics, ergometrine
11
Q
What are the pre-abortion checks?
A
rhesus blood status
12
Q
What is defined as a clean wound in tetanus wound management
A
Less than 6 hours old, non-penetrating, negligible tissue damage
13
Q
When are you completely immune from heavily tetanus contaminated wounds
A
3 doses of vaccinations (full UK course if 5 doses) within 10 years
14
Q
What do you do if there is tetanus prone wound who was vaccinated over 10years ago
A
Give a booster vaccine
15
Q
When is whooping cough vaccine given?
A
dTaP/IPV vaccine (whooping cough) should be given at 16-32weeks gestation
16
Q
When are statin not recomended?
A
Active liver disease, ALT/AST greater than 3x the upper limit
17
Q
How are immunosuppressed patients with tetanus injuries managed
A
patients who are immunosuppressed may not be adequately protected against tetanus despite being fully immunised. The management should be similar to an incompletely immunised patient (clean wound - tetanus vaccine) dirty (IgG and booster)
18
Q
When is dilation ad evacuation for abortion recommended?
A
Above 14weeks
19
Q
Describe when the follicular and luteal phase take place.
A
Thefollicular phaseis from the start ofmenstruationto the moment ofovulation(the first 14 days in a 28-day cycle). Theluteal phaseis from the moment ofovulationto the start ofmenstruation(the final 14 days of the cycle).
20
Q
How does a cervical ectropion present and how is it treated?
A
Ectropion may present withincreased vaginal discharge,vaginal bleedingordyspareunia(pain during sex). Intercourse is a common cause of minor trauma to the ectropion, triggering episodes ofpostcoital bleeding.
It is causing toubling bleeding treatment is required, it requires cauterisation or colposcopy.
21
Q
Define secondary amenorrhoea
A
Secondary amenorrhoea is defined as the cessation of previously established menstruation for 6 cycles or for 6 or more months.
22
Q
What are the common causes of primary amenorrhoea?
A
common causes of primary amenorrhoea include anatomical abnormalities due to genetic or congenital conditions, functional hypothalamic amenorrhoea and polycystic ovary syndrome (PCOS).
23
Q
What are the common causes of secondary amenorrhoea?
A
more common causes of secondary amenorrhoea include polycystic ovary syndrome, functional hypothalamic amenorrhoea, premature ovarian insufficiency, and hyperprolactinaemia.
24
Q
What are the causes for hypergonadotropic hypogonadism
A
Hypergonadotrophic hypogonadism is caused by Turner syndrome (XO), damaged gonads (mumps), congential absent ovaries
25
What blood tests would be worth testing for in secondary amenorrhoea?
Remember chronic illness can also cause amenorrhoea - FBC and iron for anaemia, U&E for CKD, anti-ttg for coeliacs
26
What is the treatment for PID?
The treatment for PID is 14days doxy+metro with IM Cef
27
When does puberty take place in girls and boys?
Puberty in girls start at 8-14 and 9-15 in boys
28
Why would thin people have delay of their puberty?
Aromatase is an enzyme found in adipose (fat) tissue, that is important in the creation of oestrogen. Therefore, the more adipose tissue present, the higher the quantity of the enzyme responsible for oestrogen creation. There may be delayed puberty in girls with low birth weight, chronic disease or eating disorders, or athletes.
29
How does atrophic vaginitis present?
Dryness Bleeding due to localised inflammation Dyspareunia (discomfort or pain during sex)
30
What is lichen sclerosis and where does it affect?
Lichen sclerosus is a chronic inflammatory skin condition that presents with patches of shiny, “porcelain-white” skin. It commonly affects the labia, perineum and perianal skin in women. It can affect other areas, such as the axilla and thighs. It can also affect men, typically on the foreskin and glans of the penis.
31
How is androgen insensitivity inherited?
X-linked
32
How do you manage bleeding less than 6weeks into the pregnancy?
Women with a pregnancy less than 6 weeks’ gestation presenting with bleeding can be managed expectantly provided they have no pain and no other complications or risk factors (e.g. previous ectopic). Expectant management before 6 weeks gestation involves awaiting the miscarriage without investigations or treatment. An ultrasound is unlikely to be helpful this early as the pregnancy will be too small to be seen. A repeat urine pregnancy test is performed after 7 – 10 days, and if negative, a miscarriage can be confirmed. When bleeding continues, or pain occurs, referral and further investigation is indicated.
33
What is fitz-hugh-curtis syndrome?
Fitz-Hugh-Curtis syndrome is a complication of pelvic inflammatory disease. It is caused by inflammation and infection of the liver capsule (Glisson’s capsule), leading to adhesions between the liver and peritoneum. Bacteria may spread from the pelvis via the peritoneal cavity, lymphatic system or blood.
34
How is vaginal pH used?
Testing the vaginal pH using a swab and pH paper can be helpful in differentiating between bacterial vaginosis and trichomonas (pH > 4.5) and candidiasis (pH < 4.5).
35
Why is tamoxifen weird?
Tamoxifen has an anti-oestrogenic effect on breast tissue, but an oestrogenic effect on the endometrium. This increase the risk of endometrial cancer.
36
Lymphogranuloma venereum
Lymphogranuloma venereum (LGV) is a condition affecting the lymphoid tissue around the site of infection with chlamydia. It most commonly occurs in men who have sex with men (MSM). LGV occurs in three stages
37
What is meig syndrome?
This is a rare condition in which 40% of ovarian fibromas are associated with ascites and pleural effusion. The ascitic fluid transudates through the transdiaphragmatic lymphatics into the right pleural cavity.
38
How are premenopausal ovarian cysts managed?
Less than 5cm cysts will almost always resolve within three cycles. They do not require a follow-up scan.
5cm to 7cm: Require routine referral to gynaecology and yearly ultrasound monitoring.
More than 7cm: Consider an MRI scan or surgical evaluation as they can be difficult to characterise with ultrasound.
39
How are postmenopausal ovarian cysts managed
Cysts in postmenopausal women generally require correlation with the CA125 result and referral to a gynaecologist. When there is a raised CA125, this should be a two-week wait suspected cancer referral. Simple cysts under 5cm with a normal CA125 may be monitored with an ultrasound every 4 – 6 months.
40
What are the markers for ovarian germ cell tumours?
Lactate dehydrogenase (LDH)
Alpha-fetoprotein (α-FP)
Human chorionic gonadotropin (HCG)
41
What does high levels of insulin effect the ovaries?
The high insulin levels contribute to halting the development of follicles in the ovaries, leading to anovulation and multiple partially developed follicles (seen as polycystic ovaries on the scan).
42
When is the progesterone injection CI?
It is worth making a note and remembering two key side effects of the progesterone depot injection (e.g. Depo-Provera): weight gain and reduced bone mineral density (osteoporosis). These side effects are unique to the depot and do not occur with other forms of contraception. Reduced bone mineral density makes the depot unsuitable for women over 45 years.
43
Does contraception effect the timing of the menopause?
Hormonal contraceptives do not affect the menopause, when it occurs or how long it lasts, although they may suppress and mask the symptoms. This can make diagnosing menopause in women on hormonal contraception more difficult.
44
How is POI diagnosed?
Diagnosing POI: The FSH level needs to be persistently raised (more than 25 IU/l) on two consecutive samples separated by more than four weeks to make a diagnosis. The results are difficult to interpret in women taking hormonal contraception.
45
How is HRT managed in perimenopausal women with periods compared to no periods?
Women that still have periods should go on cyclical HRT, with cyclical progesterone and regular breakthrough bleeds. Postmenopausal women with a uterus and more than 12 months without periods should go on continuous combined HRT.
46
How long do the vasomotor symptoms last for?
Vasomotor symptoms are likely to resolve after 2 – 5 years without any treatment. Management of symptoms depends on the severity, personal circumstances and response to treatment.
47
Which do you replace first B12 or folate?
B12 (B) comes before Folic acid to prevent combined degeneration of the cord
48
What is oligomenorrhoea?
Oligomenorrhoea is infrequent menstruation defined by a cycle length between 6 weeks and 6 months.
49
What is Amaurosis Fugax?
Amaurosis fugax refers to an attack of transient and painless loss of vision in one eye.
It is a common clinical symptom indicative of transient retinal ischaemia, usually associated with stenosis of the ipsilateral carotid artery or emboli (cardiac and aortic).
50
What is the second line cream for eczema after topical steroids and emollients?
topical tacrolimus is recommended, within its licensed indications, as an option for the second-line treatment of moderate to severe atopic eczema in adults and children aged 2 years and older that has not been controlled by topical corticosteroids
51
What is a stye?
A stye (also known as a 'hordeolum') is an acute localized infection or inflammation of the eyelid margin, usually caused by staphylococcal infection, and can be:
External — appears on the eyelid margin, caused by infection of an eyelash follicle or associated gland.
Internal — occurs on the conjunctival surface of the eyelid, caused by infection of a Meibomian gland.
52
What is the management of a stye?
Consider prescribing a topical antibiotic only if there are clinical features of spreading infection causing conjunctivitis, such as copious muco-purulent discharge. Treatment is warm pressors, should self resolve after they pop.
53
Define amenorrhoea?
Pathological amenorrhoea is the failure to menstruate for at least 6 months (or 6 cycles)
54
What is lhermitte's sign?
Flex neck causes electric shock in MS
55
What is Kernigs and Bradinski sign?
Flex hip and extend knee, positive Kernigs if spin pain in meningitis
Bradinski is flexing neck in meningitis
56
What heart condition requires a reduction in levothyroxine
IHD
57
What are the symptoms of suboptimal hypothyroidism control and how would you manage it?
In patients with persistent fatigue, somnolence, or subtle cognitive problems (forgetfulness, befuddlement) the dose can be increased by 25 μg daily, or on alternate days
58
What are the symptoms of suboptimal hypothyroidism control and how would you manage it?
In patients with persistent fatigue, somnolence, or subtle cognitive problems (forgetfulness, befuddlement) the dose can be increased by 25 μg daily, or on alternate days
59
How do you monitor hypothyroidism reaction to treatment
For adults who are taking levothyroxine for primary hypothyroidism, consider measuring TSH every 3 months until the level has stabilised (2 similar measurements within the reference range 3 months apart), and then once a year.
60
Which drugs decrease levothyroxin absorption and increase levothyroxine clearance
Drugs which prevent absorption of levothyroxine include:
calcium salts
ferrous sulphate
aluminium hydroxide
cholestyramine
Drugs which increase clearance of levothyroxine include:
phenytoin
carbamazepine
phenobarbitone
rifampicin
61
Penicillin and what other drugs cause interstitial glomerulonephritis? And how is it diagnosed?
penicillin, rifampicin, NSAIDs, allopurinol, furosemide
Acute interstitial nephritis causes an 'allergic' type picture consisting usually of raised urinary WCC and eosinophils, alongside impaired renal function
62
What are the side effects of sulfonylurea
Weight gain and hypoglycaemia?
63
Would you give sulfonlyuea in hepatic or liver impairment, if not what is the problem?
No, reduced clearance thus greater hypoglycaemic effect
64
What causes watery, blood-stained discharge from the nipple with no palpable lumps or skin changes
Duct Papilloma
65
What causes an itchy, erythematous, scaly rash affecting the nipple and areola
Paget disease of the breast
66
Which bacteria commonly causes pneumonia after an influenza infection?
Staph Aureaus
67
What is the diagnosis of TSH: Low, T4: Low
Sick euthyroid syndrome
67
What is the diagnosis of TSH: High, T4: Low
Primary hypothyroidism
67
What is achlasia?
Failure of oesophageal peristalsis and of relaxation of the lower oesophageal sphincter (LOS) due to degenerative loss of ganglia from Auerbach's plexus i.e. LOS contracted, oesophagus above dilated. Achalasia typically presents in middle-age and is equally common in men and women.
67
Name 4 clinical features of Achlasia and does it effect solid and liquids equally?
Clinical features
dysphagia of BOTH liquids and solids
typically variation in severity of symptoms
heartburn
regurgitation of food
may lead to cough, aspiration pneumonia etc
67
How quickly does an doppler US for DVT need to be performed if DVT Wells score is 2 or more or if DVT Wells score is 1 or less with a +ve D-dimer
if a proximal leg vein ultrasound scan cannot be carried out within 4 hours interim therapeutic anticoagulation should be administered whilst waiting for the proximal leg vein ultrasound scan (which should be performed within 24 hours)
67
When should a Miscarriage be suspected?
Miscarriage should be suspected if a woman who is pregnant, or has symptoms of pregnancy (such as amenorrhoea or breast tenderness), presents with vaginal bleeding, with or without pain, in the first 24 weeks of pregnancy.
68
How is a miscarriage managed <6weeks?
First line is expectant management
Depending on the risks and progression medical or surgical management is the option.
68
What is involved with expectant management of a miscarriage?
If the resolution of bleeding and pain indicates that the miscarriage has completed during 7–14 days of expectant management.
To repeat a urine pregnancy test after 7–10 days and return if it is positive.
That a negative pregnancy test means that the pregnancy has miscarried.
To return if bleeding continues or pain develops.
68
When would you consider (5) medical or surgical management of a miscarriage?
The woman is at increased risk of haemorrhage (for example, she is in the late first trimester).
The woman has previous adverse and/or traumatic experiences associated with pregnancy (for example, stillbirth, miscarriage or antepartum haemorrhage).
The woman is at increased risk from the effects of haemorrhage (for example, if she has coagulopathies or is unable to have a blood transfusion).
There is evidence of infection.
Expectant management is not acceptable to the woman.
68
When would you consider medical management of miscarriage
Medical management is offered if expectant management is not clinically appropriate or a woman has ongoing symptoms after 14 days of expectant management.
68
What are the 5 types of miscarriage and what are they?
Threatened miscarriage — when vaginal bleeding, with or without lower abdominal pain, occurs in the first 24 weeks of gestation. Pregnancy may continue.
Inevitable miscarriage — when specific clinical features indicate that a pregnancy is in the process of physiological expulsion from within the uterine cavity. Pregnancy will not continue and will proceed to incomplete or complete miscarriage.
Missed miscarriage (also known as delayed or silent miscarriage) — when a non-viable pregnancy is identified on an ultrasound scan without associated pain and bleeding.
Incomplete miscarriage — when products of conception are partially expelled from the uterus. Many incomplete miscarriages may be missed miscarriages.
Complete miscarriage — when all the products of conception have been expelled from the uterus, and bleeding has stopped.
69
What is the difference between Focal impaired awareness seizure and Absence seizure
Focal impaired awareness seizures involved movement of some kind.
Absence seizures involved no movement
70
What kind of mechanism causes HSP?
IgA vasculitis typically secondary to an URTI
71
What are the features of HSP?
Features
palpable purpuric rash (with localized oedema) over buttocks and extensor surfaces of arms and legs
abdominal pain - a common feature and may precede other symptoms, there may be melaena
polyarthritis
features of IgA nephropathy may occur e.g. haematuria, renal failure
72
What happens when you co-prescribe digoxin and thiazides?
Digoxin toxicity
73
What is the most common form of progressive ataxia in the UK and how is it inherited?
Friedreich's ataxia, autosomal recessive
The Friedreich's ataxia mutation results in iron overload in mitochondria and neuronal death.
74
What checks are needed before starting amiodarone?
Liver enzymes, thyroid function tests (hypo and hyperthyroidism) and serum potassium, an ECG and
Chest X-ray (Pulmonary pneumonitis, fibrosis)
Eye examination (Corneal deposits, optic neuritis)
75
How frequently do you need amiodarone monitoring and what are you monitoring?
6monthly TFT, LFT, U&E
76
What are the eye side effects of amiodarone?
Peripheral neuropathy, retinopathy, optic neuropathy, corneal deposits
77
What are the cardiac side effects of amiodarone?
bradycardia
lengths QT interval
78
ANA antibody is?
SLE
79
80
What is the next line treatment for COPD patients who are not controlled with a SABA and do not have asthmatic/steroid responsiveness symptoms
LABA + LAMA
81
What is erythema multiform, what causes it and what is its severe version and how do you identify it?
A hypersensitivity reaction that is most commonly triggered by infections (HSV, mycoplasma pneumoniae) lots of drugs, cancer, SLE. It may be divided into minor and major forms. Major effects the mucous membranes.
82
How does low Vitamin D levels effects serum calcium and phosphate levels and how does this effect bones?
Results in low Ca and Phosphate absorption from the gut causing low serum levels resulting in raised PTH and stimulation of bone resorption resulting in osteomalacia or rickets in children
83
What is Mammary duct ectasia
Mammary duct ectasia, also known as breast duct ectasia, is a non-cancerous condition that occurs when a milk duct under the nipple widens and thickens, sometimes causing a blockage and fluid build-up
84
Post-streptococcal glomerulonephritis, what causes it and how does it present?
Immunologically there is a depression in C3 levels, reflected in the C3 and IgG deposition seen in immunofluorescence.
Pepsi coloured urine and peripheral oedema.
Post streptococcal glomerulonephritis characteristically occurs 7 to 14 days after infection with group A beta haemolytic streptococcus, and accounts for 90% of acute glomerulonephritis.
85
What is Streptococcus pyogenes
Group A haemolytic streptococci
86
How does antipsychotics increase the risk of VTE?
It increases it
87
What is the triad presentation of normal pressure hydrocephalus and what can cause it?
A classical triad of features is seen
Gait abnormality (may be similar to Parkinson's disease)
Urinary incontinence
Dementia and bradyphrenia
Trauma, SAH, Infection, Radiotherapy
88
What can furosemide do to calcium?
Causes hypocalcaemia
89
Give 5 side effects of a IUD or IUS
IUDs make periods heavier, longer and more painful the IUS is associated with initial frequent uterine bleeding and spotting. Later women typically have intermittent light menses with less dysmenorrhoea and some women become amenorrhoeic
uterine perforation: up to 2 per 1000 insertions and higher in breastfeeding women
the proportion of pregnancies that are ectopic is increased but the absolute number of ectopic pregnancies is reduced, compared to a woman not using contraception
infection: there is a small increased risk of pelvic inflammatory disease in the first 20 days after insertion but after this period the risk returns to that of a standard population
expulsion: risk is around 1 in 20, and is most likely to occur in the first 3 months
90
Which anti-emetic is good for intracranial causes of nausea and vomiting
Cyclizine
91
What do you give to PAD patients
NICE recommend that all patients with established peripheral arterial disease be prescribed atorvastatin 80mg (regardless of their total cholesterol) and clopidogrel as an antiplatelet.
92
how does Isoniazid effect the liver
Isoniazid inhibits the P450 system
93
94
What are the other features of mycoplasma pneumonia
cold agglutins (IgM): may cause an haemolytic anaemia, thrombocytopenia
erythema multiforme, erythema nodosum
meningoencephalitis, Guillain-Barre syndrome and other immune-mediated neurological diseases
bullous myringitis: painful vesicles on the tympanic membrane
pericarditis/myocarditis
gastrointestinal: hepatitis, pancreatitis
renal: acute glomerulonephritis
95
What are the features of HSP
Paplable purpura on legs and buttox
Haemuaturea
Intussupception, bowel ischaemia/perf, blood stool
96
What are the UKMEC 3/4 for IUD/IUS
Ongoing PID (previous PID is UKMEC1)
Symptomatic chlamydia or gonorrhoea
Pelvic tuberculosis
Organ transplant
Long QT
Gestational trophoblastic disease
Breast, cervical or endometrial cancer (ovarian cancer is ok)
Fibroids distorting the cavity
Liver cancers can not get hormones
