Oxford Clinical Specialities

Question 1

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

Answer 1

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

Question 2

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 2

Answer is B

Question 3

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

Answer 3

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.

Question 4

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?

Answer 4

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
  • In some women, symptoms of depression may occur with some forms of HRT - this would not be a contraindication.

Question 5

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

Answer 5

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.

Question 6

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

Answer 6

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.

Question 7

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

Answer 7

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.

Question 8

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

Answer 8

B

Hyphae indicate the presence of Candida or ‘thrush’. Antibiotics are not
appropriate treatment for a fungal infection. Clotrimazole is an antifungal
topical treatment.

Question 9

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®

Answer 9

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.

Question 10

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

Answer 10

E

The reason why inductions are booked at 42 weeks is that the risk of
intrauterine death increases signifi cantly thereafter.

Question 11

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

Answer 11

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.

Question 12

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

Answer 12

D

Amoxicillin, clindamycin and metronidazole are ineffective against Chlamydia and doxicycline is contraindicated in pregnancy.

Question 13

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

Answer 13

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.

Question 14

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

Answer 14

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.

Question 15

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

Answer 15

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.

Question 16

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

Answer 16

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.

Question 17

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

Answer 17

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

Question 18

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

Answer 18

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.

Question 19

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

Answer 19

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.

Question 20

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

Answer 20

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.

Question 21

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

Answer 21

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.

Question 22

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

Answer 22

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

Question 23

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

Answer 23

A

Adenomata by defi nition are derived from the ovarian glandular
epithelium.

Question 24

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

Answer 24

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

Question 25

A 24-year-old man who has sex with men has read on the
Internet that his sexual orientation puts him at risk of hepatitis
B virus (HBV) infection. He is interested in being immunized. His hepatitis
status results are as follows:

● Hepatitis B virus surface antigen (HBsAg) negative
● Hepatitis B virus core antibody (HBcAb) positive
● Hepatitis B virus surface antibody (HBsAb) negative
● Hepatitis B virus e antigen (HBeAg) negative
Which is the single most appropriate advice regarding his results and proposed
immunization?

A He has evidence of previous exposure to HBV and is a ‘high-risk’
carrier; immunization will not help
B He has evidence of previous exposure to HBV and is a ‘low-risk’
carrier; immunization will not help
C He has evidence of previous exposure to HBV with a partial immune
response; immunization is unlikely to help
D He has evidence of previous exposure to HBV with an appropriate
immune response; immunization is unnecessary
E He has no evidence of previous exposure to HBV, and should
proceed with immunization as planned

Answer 25

C

Patient has detectable HBcAB. Only way that an individual can develop core antibody is in reponse to Hep B infection. There is no core antigen in the vaccine. However, the patient is HBsAg negative and HBeAg negative so he is not a chronic virus carrier. Unfortunately, he has not developed any HBsAb which is the antibody that confers protective immunity (and what the vaccine aims to produce). There is some controversy as to whether vaccinating patients with a blunted ressponse to previous hepatitis B virus infection acheives anything. However, there is no evidence base for it.

Question 26

A 16-year-old girl has had painful periods for 6 months. Her
periods are regular and last 3 days. She misses a couple of days
of school every month due to the pain. She is not sexually active. Which
is the single most appropriate initial management?

A Combined oral contraceptive pill
B Gonadotrophin-releasing hormone analogues
C Intrauterine system (Mirena®)
D Mefenamic acid
E Tranexamic acid

Answer 26

D

Mefenamic acid is eff ective for the management of period pain, and can
be taken around the time of the period only. Tranexamic acid has some
pain-relieving properties, but is more eff ective for the treatment of heavy
periods. An IUS would be one option, but as the patient is not sexually
active this would not be the fi rst-line management. The pill may lighten
periods, but does not necessarily relieve the pain. Gonadotrophinreleasing
hormone analogues have no role.

Question 27

A 36-year-old woman who is HIV positive discovers that she is
pregnant. She is uncertain whether to continue the pregnancy, in
particular because of the risk of the child acquiring her HIV infection. Her
health is good and she has not yet needed to take antiretroviral therapy.
If the pregnancy is managed appropriately, which is the single probability
of her baby acquiring HIV infection?

A 0% (i.e. no risk)
B Approximately 1%
C Approximately 15%
D Approximately 25%
E Approximately 40%

Answer 27

B

The risks associated with modern management using antiretroviral drugs
and elective Caesarean section are very low, although they are not eliminated
completely.

Question 28

26-year-old woman with no children has had amenorrhoea
for 6 weeks and has some pelvic discomfort. Her pregnancy
test is positive. Her pulse rate is 68 bpm and her blood pressure is
110/80 mmHg. An ultrasound scan shows an empty uterus, with normal
adnexae. Her serum beta-human chorionic gonadotrophin (

Answer 28

C

Although the history and empty uterus are suggestive of ectopic pregnancy,
the

Question 29

A 32-year-old primiparous woman is ‘small for dates’ at 34
weeks’ gestation. An ultrasound scan shows a singleton fetus
with an abdominal circumference at the 10th centile. The amniotic fl uid
volume and umbilical artery Dopplers are normal. Which is the single
most appropriate management?

A CTG monitoring on alternate days
B Reassure her that the baby is growing appropriately
C Repeat the ultrasound scan in 2 weeks’ time
D Repeat the ultrasound scan in 4 weeks’ time
E Urgent delivery by Caesarean section

Answer 29

C

Serial ultrasound scans to detect changes in abdominal circumference are
accurate in diagnosing growth restriction. As this baby’s abdominal circumference
is less than the 10th centile, it may be growth restricted, and
a scan should be repeated after 2 weeks.

Question 30

A 30-year-old nurse sustained a signifi cant needle-stick injury
during her last shift, 36 hours ago. The patient (i.e. ‘donor’)
involved is HIV positive. He is taking antiretroviral therapy and his last viral
load was 1000 copies/mL (acceptable load is < 5000 copies/mL). He is
hepatitis B virus immune and negative for hepatitis C virus. The nurse also
had unprotected sex earlier in her current menstrual cycle, and there is a
possibility that she may be pregnant. Which is the single most appropriate
advice regarding HIV post-exposure prophylaxis (PEP)?

A It is already too late for her to start taking PEP
B PEP is contraindicated because of the possibility that she is pregnant
C She does not need PEP as the patient’s viral load is so low
D She should start PEP without further delay
E The risks associated with PEP are higher than the risk of acquiring
HIV

Answer 30

D

If the donor in a needle-stick injury is at high risk for blood-borne viruses,
PEP should be started straight away until confi rmatory testing can be
done. Delays reduce the eff ectiveness. Many antiretroviral drugs are safe
in pregnancy. Indeed, pregnant HIV-positive women are advised to take
antiretroviral drugs to reduce the risk of HIV transmission to the fetus.

Question 31

A 37-year-old woman is 15 weeks pregnant and requests a triple
test to rule out Down’s syndrome. Which is the single most
appropriate advice to give her?

A It is too early in pregnancy to have the triple test
B It is too late in pregnancy to have the triple test
C She could have the triple test arranged today
D She must fi rst agree to have an amniocentesis if the test is screen
positive
E The triple test will defi nitely be screen positive because of her age

Answer 31

C

The triple test measures maternal serum levels of

Question 32

A 42-year-old man attends a genitourinary medicine clinic and
asks for a routine check for sexually transmitted infections. He
has no symptoms and no abnormal clinical fi ndings. Serological tests for
syphilis show:
● Rapid plasma reagin (RPR) positive at a titre of 1:64
● Treponema pallidum particle agglutination (TPPA) assay positive
● Fluorescent treponemal antibody absorption test (FTA-ABS) positive
The same tests were negative 18 months ago. Which single stage of syphilis
can be diagnosed?

A Early latent
B Late latent
C Primary
D Secondary
E Tertiary

Answer 32

A

There are four stages of syphilis:

Primary - characterized by painless ulcers called cancres at the site of infection. They may not be noticed. Chancres occur about 3 weeks after infection

Secondary - occurs 2-10 weeks after the chancres appear. Symptoms include a rash, mouth ulcers, lymphadenopathy, fever and myalgia

Latent - occurs months to years after the initial infection if it goes untreated and is usually asymptomatic but the infection remainds in the body

Tertiary - occurs after the initial infection in a minority of people and can affect almost any part of the body

Testing for syphilis - can be complex because of different stages.

However, in an individual who is asymptomatic but has positive serological tests, this implies that the infection is latent. If the patient is known to have acquired the infection within the last 2 years, it is early latent. In this case, we can be completely confident that the infection is less than 2 years old, because we are told that the syphilis serology was ngeative 18 months ago.

Question 33

A 33-year-old woman has severe headache, blurred vision,
abdominal pain, and bleeding per vaginum at 33 weeks’ gestation.
The fetal heartbeat is absent. Which is the single most important
associated clinical sign that may help in diagnosis?

A Brisk tendon refl exes
B Enlarged thyroid gland
C Oedema
D Raised jugular venous pressure
E Tachycardia

Answer 33

A

These symptoms indicate severe pre-eclampsia. Brisk refl exes are commonly
associated with pre-eclampsia. The others are just general clinical
signs.

Question 34

A 22-year-old woman is 6–8 weeks pregnant, and is brought
into the Emergency Department in cardiac arrest. No other
medical information about her is available. Which is the single most likely
cause of her cardiac arrest in early pregnancy?

A Miscarriage bleeding
B Pre-existing cardiac disease
C Pulmonary embolus
D Ruptured ectopic pregnancy
E Sepsis following termination of pregnancy

Answer 34

D

The commonest cause of arrest and death in early pregnancy is hypovolaemia
due to ruptured ectopic pregnancy, and it is the fi rst consideration
in a collapsed patient in early pregnancy. Heavy vaginal bleeding rarely
presents in arrest, as help tends to be sought early for visible bleeding.
The risk of pulmonary embolus is raised throughout pregnancy, but the
most severe morbidity and mortality occur in later trimesters or postpartum,
and both sepsis due to termination and pre-existing cardiac conditions
are fortunately rare.

Question 35

A 29-year-old gravid 2 + 1 woman is 35 + 6 weeks pregnant.
She has a history of a previous Caesarean section. She has
had regular uterine contractions for 4 hours and a per vaginum ‘show’.
Following speculum examination, which is the single most appropriate
management?

A CTG monitoring
B Fibronectin test
C IM steroid
D Rescue cerclage
E Tocolysis

Answer 35

A

This woman may be in labour and the single most appropriate plan of management in her case will involve a speculum examination and CTG to assess this. It is inappropriate to insert a cerclage at this gestation. A fibronectin test is contraindicated if there is PV bleeding. A single course of antenatal corticosteroids is administered to a woman between 24+0 and 34+6 weeks’ gestation.

Question 36

A 22-year-old woman has acute onset of right iliac fossa pain
but no vomiting. She has marked tenderness to palpation in
the right iliac fossa. There is no rebound tenderness and some voluntary
guarding. Her temperature is 37.2°C, her pulse rate is 80 bpm,
and her blood pressure is 115/80 mmHg. Her pregnancy test is negative.
An ultrasound scan shows a 7 cm right-sided haemorrhagic ovarian
cyst with no free fl uid. Which is the single most appropriate initial
management?

A Admit her with a view to conservative management
B Allow her to go home, with advice to come back if the pain worsens
C Perform immediate laparoscopy in case the diagnosis is torsion
D Refer to the surgeons to rule out appendicitis
E Request a computed tomography (CT) scan to confi rm the
diagnosis

Answer 36

A

A patient with marked tenderness should not be allowed home. The history, examination and ultrasound findings are highly suggestive and are commensurate with a haemorrhagic cyst accident which should be managed conservatively. The absence of vomiting, peritonism and a pyreixa make torsion and appendicitis unlikely and there is no need to refer the patient to the surgeons at this stage as the diagnosis is basically straightforward. Therefore no further imaging is required at this stage.

Question 37

A 70-year-old woman has had vulval itching and discomfort for
12 months. There is widespread erythema on both labia minora
extending on to the majora and involving the fourchette. There are no
ulcers and there is no inguinal lymphadenopathy. Which is the single most
appropriate initial management?

A Empirical treatment with potent corticosteroid ointment
B Immediate punch biopsy to exclude cancer
C Referral to the sexual health clinic to rule out sexually transmitted
infection
D Treatment with oestrogen cream for atrophy
E Vulval excision to treat the aff ected area

Answer 37

A

This is lichen sclerosus et atrophicus, a poorly understood infl ammatory
condition. It responds well to potent corticosteroid ointment, and biopsy
is indicated if there is no response to treatment, or if an actual suspicious
lesion such as an ulcer is present. Oestrogen cream is only eff ective for
pure atrophy, and the likelihood of a sexually transmitted infection in a
70-year-old is very small. Excision is reserved for neoplastic conditions.

Question 38

A 24-year-old woman has dysmenorrhoea and deep dyspareunia.
A transvaginal ultrasound scan shows a 4 cm endometrioma
on the left ovary. The patient wants relief of her pain symptoms. She has
also been trying to conceive for over 12 months. Which is the single most
appropriate treatment to use?

A Combined oral contraceptive pill
B Danazol
C Gonadotrophin-releasing hormone analogues
D Laparoscopic surgery
E Medroxyprogesterone acetate (Provera®)

Answer 38

D

All of the medical treatments listed are eff ective for pain, although
there is increasing evidence that surgery gives the best results overall.
Endometriomata tend to respond poorly to medical treatment, and usually
require excision. Only surgical treatment has been demonstrated to
improve subsequent fertility.

Question 39

A previously well 67-year-old woman has abdominal distension,
a large irregular pelvic mass, and ascites. An ultrasound scan, CT
scan, and a raised CA125 confi rm a likely ovarian carcinoma. Which is the
single most appropriate fi rst-line management?

A External beam radiotherapy
B High-dose progestogen therapy
C Hysterectomy, bilateral oophorectomy, omentectomy, and
debulking
D Symptomatic palliative care
E Vincristine-containing chemotherapy

Answer 39

C

Primary pelvic clearance and tumour debulking are the mainstays of ovarian
cancer treatment initially. Neoadjuvant chemotherapy is a reasonable
option in some women, but involves the use of carboplatin and paclitaxel,
not vincristine. Hormonal treatment and radiotherapy have little or no
place in ovarian cancer treatment, and palliative care is for women with
terminal disease who have not responded to surgery and chemotherapy.

Question 40

A 19-year-old woman is taking carbamazepine as treatment for
her epilepsy. She is 16 weeks pregnant. She had been fi t-free for
5 years before becoming pregnant, but has had two episodes of absence
seizures in the past month. She has not informed the Driver and Vehicle
Licensing Agency (DVLA) of her recent seizures. Which is the single most
appropriate action to take at this stage?

A Advise her to inform the DVLA immediately of her recent seizures
B Advise her to seek a second opinion about the safety of driving
C Inform the DVLA medical adviser immediately about the recent
seizures
D Inform the patient’s GP about the recent seizures
E Reassure the patient that there is no need to inform the DVLA

Answer 40

A

Patients who have had a seizure should refrain from driving for 1 year. It
is the patient’s responsibility to inform the Driver and Vehicle Licensing
Agency (DVLA), who may then seek information from the doctor.
However, the doctor should inform the patient of this requirement, as
they may be unaware of it.

Question 41

A 22-year-old primigravida undergoes a Neville-Barnes forceps
delivery. The fetal head is delivered in the occiput posterior
(OP) position. On examination the woman has a tear involving approximately
one-third of the external anal sphincter thickness. What is the
single most appropriate classifi cation of this tear?

A Second-degree tear
B Third-degree 3a tear
C Third-degree 3b tear
D Third-degree 3c tear
E Fourth-degree tear

Answer 41

B

It is important to recognize and appropriately treat perineal tears in order
to prevent future morbidity, particularly anal incontinence. Risk factors
for tears include primiparity, large babies (> 4 kg), occiput posterior (OP)
position, induction, epidural use, prolonged second stage, forceps use,
and midline episiotomy.

Classification is as follows:
● first degree: injury to the perineal skin only

● second degree: injury to the perineum involving the perineal muscles
but not the anal sphincter

● third degree: injury to the perineum involving the anal sphincter complex,
consisting of the external anal sphincter (EAS) and internal anal
sphincter (IAS):

● 3a: less than 50% of EAS thickness torn
● 3b: more than 50% of EAS thickness torn
● 3c: both EAS and IAS torn

● fourth degree: injury to the perineum involving the anal sphincter complex
(EAS and IAS) and anal epithelium.