Oxford Clinical Specialities Flashcards
(42 cards)
An 18-year-old woman who is 34 weeks pregnant has abdominal
pain and moderate fresh vaginal bleeding. The symphysio-fundal
height measures 41 cm and the uterus feels tense and tender. The
patient’s pulse rate is 98 bpm and her blood pressure is 90/50 mmHg.
Which is the single most likely diagnosis?
A Cervical ectropion
B Placental abruption
C Placenta praevia
D Pre-term labour
E Vasa praevia
B
- Woman is shocked - abdominal pain and tense uterus suggest abruption however blood loss can be concealed
- So do not expect large amounts of visible bleeding
- Placenta previa is usually painless and blood loss is greater so is often noticed earlier
- No contractions so labour has not started although delivery will be expedited as the patient is unwell
- A cervical ectropion may bleed - but it will not cause pain and shock
- No contractions so labour has not started although delivery will be expedited as the patient is unwell
A 22-year-old woman comes to the antenatal booking clinic at 12
weeks’ gestation. Which is the single most appropriate group of
booking investigations?
A Full blood count, blood group, and hepatitis C serology
B Full blood count, blood group, and Venereal Disease Research
Laboratory (VDRL) test
C Full blood count, thalassaemia screen, and thyroid function test
D Full blood count, thalassaemia screen, and urea and electrolytes
E Full blood count, thyroid function test, and VDRL test
Answer is B
A 20-year-old woman and her 23-year-old husband have been
trying to conceive for 6 months without success. Her periods are
regular. Which is the single most appropriate management?
A Arrange a semen analysis for the husband
B Arrange a laparoscopy and dye test for the woman
C Arrange luteal-phase progesterone levels for the woman
D Arrange referral to the assisted-conception unit for in-vitro
fertilization (IVF)
E Reassure the couple and suggest that they keep trying
E
Normal healthy couples can take up to a year to conceive, so investigations are not normally started until after 1 year of regular attempts to conceive.
A 55-year-old woman has hot fl ushes. Her last period was 2 years
ago. She is keen to start hormone replacement therapy (HRT).
Which is the single most appropriate question to ask her before commencing
HRT?
A Do any of your relatives have Alzheimer’s disease?
B Do you know whether you have osteoporosis?
C Have any of your relatives suff ered from premature menopause?
D Have you ever suff ered from deep vein thrombosis?
E Have you ever suffered from depression?
D
- Overall, HRT doubles the risk of venous thromboembolism, so other risk factors need to be considered.
- HRT helps to reduce the risk of fracture in osteoperosis
- No association with Alzheimer’s disease
- HRT may actually be protective
- No association with Alzheimer’s disease
- In some women, symptoms of depression may occur with some forms of HRT - this would not be a contraindication.
- HRT helps to reduce the risk of fracture in osteoperosis
A 34-year-old primiparous woman is having generalized tonic–
clonic convulsions. She is 32 weeks pregnant. Her blood pressure
on arrival is 150/110 mmHg, she has 3+ proteinuria, and she is still having
convulsions. The fetal heart rate is reassuring. Which is the single most
appropriate management?
A Diazepam and plan delivery
B Diazepam plus antihypertensive drug, and plan delivery
C Magnesium sulphate
D Magnesium sulphate plus antihypertensive drug
E Magnesium sulphate plus antihypertensive drug, and plan delivery
E
- Magnesium sulphate is the evidence based treatment for eclamptic seizures.
- This patient also needs to have her blood pressure controlled carefully and delivery expedited.
A 23-year-old woman is 34 weeks pregnant and has raised blood
pressure. She is on 200 mg labetalol twice daily. Her blood pressure
is 160/105 mmHg and she has 3+ proteinuria. She feels well, with no
headaches or epigastric pain. The cardiotocograph (CTG) is reassuring.
All blood tests are normal. Which is the single most appropriate management?
A Admit her to hospital for urgent delivery
B Admit her to hospital to stabilize her blood pressure
C Arrange for her to attend the day unit for twice-daily CTG
D Increase the labetalol dose, and follow up with the community
midwife
E Increase the labetalol dose, and follow up in the day unit
B
- Although the patient is currently asymptomatic - her blood pressure is above 160/100 mmHg - she has significant proteinuria, despite labetalol treatment.
- She needs admission for careful monitoring and controlled management with antihypertensives and consideration of delivery if there is no improvement.
A 14-year-old girl requests emergency contraception. She had
unprotected intercourse with her 14-year-old boyfriend 2 days
ago. She appears to understand the nature of emergency contraception.
Which is the single most appropriate management?
A Advise her that she cannot have emergency contraception, as it is too
long since intercourse took place
B Advise her that she is too young to be legally prescribed emergency
contraception
C Prescribe emergency hormonal contraception and advise her about
future contraception
D Prescribe emergency hormonal contraception only after informing
her parents
E Prescribe emergency hormonal contraception only after informing
social services
C
The girl appears to be Gillick competent, as she understands the nature
of the treatment. Therefore she should be prescribed emergency contraception
like any other patient. Emergency contraception can be given
up to 72 hours after unprotected sex. Thought must be given to ongoing
contraception to avoid further incidents.
A 31-year-old woman has vulval soreness and recurrent white vaginal
discharge. Microscopy shows the presence of hyphae. Which is
the single most appropriate treatment option?
A Clindamycin
B Clotrimazole
C Doxycycline
D Erythromycin
E Metronidazole
B
Hyphae indicate the presence of Candida or ‘thrush’. Antibiotics are not
appropriate treatment for a fungal infection. Clotrimazole is an antifungal
topical treatment.
A 35-year-old woman who is taking Cerazette® (a progestogenonly
contraceptive pill) has a chest infection and is prescribed
amoxicillin. Which single piece of advice should be given about her contraception?
A No additional contraceptive precautions are required
B Use additional precautions for the duration of the antibiotic course
C Use additional precautions for the duration of the antibiotic course
and for 2 days after the end of the course
D Use additional precautions for the duration of the antibiotic course
and for 7 days after the end of the course
E Use additional precautions for the remainder of the current packet
of Cerazette®
A
Most people remember that there is some interaction between the
combined oral contraceptive pill and antibiotics. In truth, the evidence
is slight, but the offi cial advice to women taking the combined oral contraceptive pill is to use additional contraceptive methods for the duration
of the course and for 7 oral-contraceptive-pill-taking days afterwards
(i.e. the pill-free week does not ‘count’, so if a pill-free week is coming
up, the woman might want to run two packets together).
However, this rule does not apply to progestogen-only contraceptive pills, such as Cerazette®, and the woman should continue to take this continuously at the same time every day.
A 32-year-old primipara is seen at 42 weeks’ gestation. She is
keen to go into labour naturally and refuses an induction of
labour. Which is the single best reason to give for allowing induction of
labour when counselling her?
A There is an increased risk of Caesarean section beyond 42 weeks’
gestation
B There is an increased risk of intrauterine growth restriction beyond
42 weeks’ gestation
C There is an increased risk of placental abruption beyond 42 weeks’
gestation
D There is an increased risk of shoulder dystocia beyond 42 weeks’
gestation
E There is an increased risk of unexplained fetal death beyond 42
weeks’ gestation
E
The reason why inductions are booked at 42 weeks is that the risk of
intrauterine death increases signifi cantly thereafter.
The midwife on the delivery suite calls for help. A woman who
has just had a normal delivery with active management of the
third stage of labour is bleeding heavily. The bleeding started 15 minutes
after delivery of the placenta. Her estimated blood loss is 900 mL. Her
pulse rate is 95 bpm and her blood pressure is 100/55 mmHg. Which is
the single most appropriate fi rst-line management?
A Massage the uterus and give IM carboprost (Haemabate®)
B Massage the uterus and give IM Syntocinon
C Massage the uterus and start a Syntocinon infusion
D Massage the uterus and start a blood transfusion
E Take the woman to theatre immediately for examination under
anaesthesia
B
Massaging the uterus helps to stimulate a contraction - the commonest cause is uterine atony. Syntocinon IM is the first-line treatment. Is is a synthetic version of oxytocin and stimulates contractions. If bleeding doest not stop, Synotocinin infusion and carboprost can be used along with other approaches for a major haemorrhage such as blood transfusion and fresh froze plasma.
Blood loss of over 1000 mL or clinical signs of shock are considered to represent a major incident.
A 32-year-old woman has increasing white vaginal discharge. She
is 7 weeks pregnant. Her Chlamydia swab is positive. All other
tests are normal. Which is the single most appropriate treatment?
A Amoxicillin
B Clindamycin
C Doxycycline
D Erythromycin
E Metronidazole
D
Amoxicillin, clindamycin and metronidazole are ineffective against Chlamydia and doxicycline is contraindicated in pregnancy.
A 42-year-old woman has frequency, urgency, and urge incontinence.
Examination is unremarkable and a midstream specimen
of urine is sterile. She is treated empirically for detrusor overactivity with
oxybutynin. Which is the single mechanism of action for this drug?
A Anti-adrenergic
B Anti-GABAergic
C Antimuscarinic
D Antinicotinic
E Antiserotonergic
C
Detrusor contraction is activated via muscarinic cholinergic receptors and oxybutynin is a direct anti-muscarinic agent. Sertonin and noradrenaline (norepinephrine) are important for sympathetic actvitation which reduces detrusor activity intrinsically. There are no nicotinic or GABAergic receptors in the bladder.
60-year-old woman is recovering post-operatively following
a vaginal hysterectomy and anterior vaginal repair. She has
had voiding diffi culty and has been catheterized for 3 days. A catheter
specimen of urine is taken due to a low-grade pyrexia, and it confi rms the
presence of a urinary tract infection (UTI). Which single organism is most
likely to be causative?
A Escherichia coli
B Klebsiella pneumoniae
C Proteus species
D Pseudomonas species
E Staphylococcus epidermidis
A
E. coli is by far the commonest cause of sporadic or catheter-related
urinary tract infection. Pseudomonas species are usually only associated
with prolonged catheterization, and Staphylococcus epidermidis is usually
a contaminant.
A 24-year-old woman has had an abnormal vaginal discharge
for the past week. It is off -white and non-itchy, with an off ensive
odour. She has had one sexual partner in the last 8 months, and he has
no symptoms. There is an off -white vaginal discharge of pH 6.4 pooling in
the posterior fornix, with no infl ammation of the vulva or vagina. Which
is the single most likely fi nding on a Gram-stained sample of the vaginal
discharge?
A Gram-negative intracellular diplococci
B Gram-positive and Gram-negative mixed bacteria
C Numerous lactobacilli
D Polymorphonuclear leucocytes
E Yeast cells with hyphae
B
This is a description of BV ==> caused by an altered vaginal flora and overgrowth of a number of different micro-organisms, which may show up on Gram staining.
A 24-year-old woman has regular painful uterine contractions
at 26 weeks’ gestation. She is 2 cm dilated. Her membranes are
intact. The cardiotocograph (CTG) is reassuring. Which is the single most
appropriate management plan?
A Admit her and administer analgesics and Syntocinon
B Admit her and administer antibiotics and intramuscular steroids
C Admit her and administer antibiotics and tocolytic drugs
D Admit her and administer tocolytic drugs and intramuscular steroids
E Reassure her and send her home
D
This woman has gone into premature labour, but this is at an early
stage, so there is a possibility that it can be stopped with tocolytic drugs.
However, steroids should still be given to mature the fetal lungs in case
delivery goes ahead. There is no indication of infection, so antibiotics are
not routinely given.
A 14-year-old girl has been sexually active for 6 months and
seeks sexual health advice. She has a regular partner and has no
symptoms. She is very anxious that her mother does not fi nd out that she
is sexually active, and wants reassurance that her confi dentiality will be
maintained. In which single situation might breaching her confi dentiality
be justifi ed?
A She is found to have a sexually transmitted infection
B She is in a sexually abusive relationship
C She requests a prescription for the oral contraceptive pill
D She requests a termination of pregnancy
E None of the above, as she has an absolute right to confi dentiality
B
The doctor has to judge whether the girl is Gillick competent and if she is, she can consent to treatment herself. However, if she is thought to be the victim of any kind of sexual abuse and/or coercion, safeguarding rules trump her right of confidentiality and the doctor has a duty of care to at least seek advice - for example from the local named doctor
A 25-year-old woman has her fi rst routine cervical cytology test
as part of the NHS Cervical Screening Programme. This shows
‘mild dyskaryosis, CIN 1’, and she is advised to have a repeat smear performed
in 6 months’ time. She has had the same sexual partner for 18
months and they both tested negative for sexually transmitted infections
at the start of the relationship. She has a body mass index (BMI) of 30
kg/m2 and uses a progestogen-only oral contraceptive pill. She smokes
15 cigarettes daily and drinks approximately 25 units of alcohol per week.
She wants to know if there is anything she can do that might help to
reverse the abnormality. Which single action that she can be advised
about is most likely to decrease her risk?
A Get vaccinated against human papillomavirus (HPV) infection
B Give up smoking cigarettes
C Reduce alcohol consumption
D Reduce body mass index
E Switch to an alternative contraceptive pill
B
All of these are protective against cervical changes. HPV vaccination has now been introduced into the UK and will help to prevent changes from occuring. However, in this case, in which the changes are already present, it will not be effective. The evidence shows that smoking is the most important risk factor in women who show mild change.
A 24-year-old woman requests post-coital contraception. Her
condom broke 36 hours ago, on day 7 of a regular 29-day cycle.
This is her second condom accident in 2 months. She has tried the oral
contraceptive pill, but stopped it 6 months ago because of concerns
about weight gain. She is undecided about future contraceptive use. A
pregnancy test is negative. Which is the single most eff ective form of
post-coital contraception for her?
A A combined oral oestrogen/progestogen pill
B A progestogen-only pill
C Insertion of a copper-containing intrauterine device (IUD)
D Insertion of a progestogen-containing intrauterine system (IUS)
E No post-coital contraception is required
C
Combined oral contraceptive pills are no longer used for post-coital
contraception. There is no effi cacy advantage, and they have more sideeff
ects than Levonelle® (a progestogen-only pill). Levonelle® may be an
option. However, it does not off er the additional benefi t of an ongoing
method of contraception, and there is also a recognized failure rate. An
IUD is always the most eff ective form of post-coital contraception for
anyone, but in this case it has the added advantage of providing ongoing
contraception (this is the patient’s second condom accident in 2 months,
and she cannot tolerate oral contraceptives). Mirena® coils are not used
for post-coital contraception.
A 27-year-old man has had mild dysuria for 1 week. He has been
having sex with his current girlfriend for 4 weeks, occasionally
using condoms. She has no symptoms. He last had sex with his previous
female partner 3 months ago. There is a slight mucoid discharge at the
urethral meatus. Which single organism is the most likely cause?
A Chlamydia trachomatis
B Mycoplasma hominis
C Neisseria gonorrhoeae
D Trichomonas vaginalis
E Ureaplasma urealyticum
A
Chlamydia is the commonest sexually transmitted infection in the UK.
Around 50% of men have no symptoms, but those that do may have
dysuria, epididymo-orchitis, clear penile discharge, and low-grade fever.
A 32-year-old man has a history of weight loss and general
malaise. He takes an HIV test. The result is positive and his CD4
+ count is 180 x 106/L (12%) (normal range is 450–1600 x 106/L). He
is otherwise well. He does not feel ready to start antiretroviral therapy
straight away, but is keen to stay well in the interim. For which single
organism should he be off ered primary prophylaxis?
A Cryptococcus neoformans
B Mycobacterium avium intracellulare
C Mycobacterium tuberculosis
D Pneumocystis jirovecii
E Toxoplasma gondii
D
Pneumocystitis jirovecci (previously known as Pnuemocystis carinii) can cause severe pneumonia (Pneumocystis carinii pneumonia or PCP) in immunocompromised individuals. The risk increases when the CD4+ count falls below 200 X 10(6)/L, especially if the viral load is detectable. Therefore, measures are taken to try and prevent this with antibiotic prophylaxis. It has been standard practice for many years to offer HIV patients with a CD4+ count of less than 200 X 10(6)/L primary prophylaxis against Pneumocystis.
Without prophylactic therapy - Pneumocystis is the single most likely serious or life-threatening opportunistic infection they will develop. Patients can develop Cryptococcus neoformans infection but is much less common and primary prophylaxis is not given, although secondary prophylaxis would be continued in those who do develop it until their CD4+ count rises in response to therapy.
Mycobacterium avium intracellulare is unlikely to be a problem with a CD4+ count of more than 100/ul and primary prophylaxis is not routinely given. Mycobacterium tuberculosis can of course affect any patient regardless of CD4+ count but primary prophylaxis is not given. Toxoplasma gondii is unlikely to be a problem with a CD4+ count of more than 50/ul so primary prophylaxis would not be given in this case.
A 29-year-old man from South Africa has collapsed at work.
An eye witness gives a clear description of a convulsion. The
man is drowsy, barely rousable, and unable to communicate. His wife
states that she fears he may be HIV positive. His breathing becomes
erratic, and artifi cial ventilation is being considered. In which single situation
should an HIV test be carried out, given that he is unable to give
informed consent?
A At the request of his wife, as next of kin
B If knowledge of his HIV status would benefi t his care
C Prior to admitting him to the Intensive Therapy Unit
D Prior to any invasive procedure being performed
E Prior to making the decision to ventilate
B
General principles of consent mean that the patient is the only person
capable of giving consent for any investigation or treatment. If the medical
information may guide his treatment (e.g. determining which drugs to
start), investigations can be performed when he is unable to give consent.
However, this is rarely straightforward, and the GMC guidance on consent
should be read. Universal precautions mean that full infection control
precautions should be taken for all patients, regardless of whether
they are known to be HIV positive or not
A 23-year-old woman has a large, 20-week-sized cystic mass on
her ovary. She undergoes laparotomy and oophorectomy, and
histology confi rms that this is a benign mucinous cystadenoma. Which is
the single most likely ovarian tissue of origin for this type of cyst?
A Epithelial
B Follicular
C Germ cell
D Sex cord
E Stromal
A
Adenomata by defi nition are derived from the ovarian glandular
epithelium.
A 22-year-old woman who is struggling to conceive has the following
hormone profi le, taken on day 6 of her cycle:
● Luteinizing hormone (LH): 12 IU/mL (normal pre-menopausal range,
3–13 IU/mL)
● Follicle-stimulating hormone (FSH): 4 IU/mL (normal range, 3–20 IU/
mL)
● Testosterone: 18 ng/dL (normal range, 6–86 ng/dL)
An ultrasound scan shows numerous peripheral ovarian follicles. Which
single set of symptoms is she most likely to have?
A Amenorrhoea and infertility
B Amenorrhoea and pelvic pain
C Oligomenorrhoea and facial hair
D Oligomenorrhoea and pelvic pain
E Oligomenorrhoea and temporal headaches
C
A reversed LH:FSH ratio of around 3:1 and numerous small peripheral
follicles in the ovaries are characteristic of polycystic ovarian syndrome.
The symptoms of this include reduced periods, reduced fertility, hirsutism,
acne, and weight gain
