Random Specialities Facts + Past exam Qs

Question 1

Uterus palpable abdominally at how many weeks

Answer 1

Uterus palpable abdominally at 12-14 weeks

Question 2

Engagement =

Answer 2

If 2/5 head palpable abdominally, then more than half has entered the pelvis and so the head
must be engaged

Question 3

What is used to date pregnancies under 14w?

Answer 3

NICE guidelines: should date women using crown rump length if <14 weeks

Question 4

Causes of raised AFP

Answer 4

Alpha fetoprotein
o Produced by fetal liver
o Open neural tube defect or abnormalities such as gastrochisis - increased maternal AFP
o Indicates risk of third trimester complications
o Seldom used as USS more accurate

Question 5

 Low PAPP-A (1st tri)
 High B-hCG (1st/2nd)
 Low AFP (1st/2nd)
 Low oestriol (2nd)
 High inhibin (2nd)

Answer 5

DOWNS

Question 6

Absence of cranium
 Frog Eye appearance on USS
 Incompatible with life

Answer 6

Anencephaly

Question 7

 Partial extrusion of abdominal contents in peritoneal sac
 50% have chromosomal problem
 Isolated, small defects have good prognosis

Answer 7

Exomphalos

Question 8

 Free loops of bowel in amniotic cavity
 Rarely associated with other abnormalities
 Common if mother young
 >90% survive – requires postnatal surgery

Answer 8

Gastroschissis

Question 9

 Dependent on systemic vascular resistance and cardiac output
 Falls to a minimum in second trimester by 30/15mmHg due to  SVR
 By term, BP is at pre-pregnant levels
 HTN due to PET is largely due to  SVR
 Protein excretion in pregnancy is increased, but in absence of underlying renal disease, should be
<0.3g/24h

Answer 9

Normal BP changes in Pregnancy

Question 10

Normal BP changes in Pregnancy

Answer 10

 Dependent on systemic vascular resistance and cardiac output
 Falls to a minimum in second trimester by 30/15mmHg due to  SVR
 By term, BP is at pre-pregnant levels
 HTN due to PET is largely due to increased SVR
 Protein excretion in pregnancy is increased, but in absence of underlying renal disease, should be
<0.3g/24h

Question 11

Simple classification of PET

Answer 11

Mild (140/90-149/99mmHg) Moderate (150/100-159/99mmHg) Severe (>160/110mmHg)

Question 12

PCR level in PET

Answer 12

Level of 30mg/nmol = 0.3g/24h protein excretion

Question 13

PCR level in PET

Answer 13

Level of 30mg/nmol = 0.3g/24h protein excretion

Question 14

Sx of magnesium toxicity

Answer 14

Respiratory depression and hypotension

Preceded by loss of patellar reflexes, which are tested regularly

Question 15

ECG changes in pregnancy

Answer 15

ECG changes = LAD and T wave inversion

Question 16

Thromboprophylaxis in pregnancy?

Answer 16

LMWH

Question 17

What drug is given alongside anti-epileptics from week 36?

Answer 17

10mg vit K given from 36 weeks onwards

Question 18

 Acute hepatorenal failure, DIC and hypoglycaemia  high maternal and fetal mortality
 Extensive fatty change
 Malaise, vomiting, jaundice and vague epigastric pain (first sx = thirst)
 Early diagnosis and promt delivery essential
 Correction of clotting defects and hypoglycaemia required first
 Tx: supportive, dextrose, fluid balance, dialysis

Answer 18

Acute Fatty Liver

Question 19

lupus anticoagulant and/or anticardiolipin antibodies

Answer 19

Antiphospholipid Syndrome

Question 20

Criteria for APLS

Answer 20

Diagnosis

1+ clinical criteria
o Vascular thrombosis
o 1+ death of fetus >10 weeks
o PET or IUGR requiring delivery <34 weeks
o 3+ fetal loss <10 weeks, otherwise unexplained

With laboratory criteria measured twice >3 months apart
o Lupus anticoagulant
o High anticardiolipin antibodies
o Anti-B2 Glp I ab

Question 21

Diagnosis

1+ clinical criteria
o Vascular thrombosis
o 1+ death of fetus >10 weeks
o PET or IUGR requiring delivery <34 weeks
o 3+ fetal loss <10 weeks, otherwise unexplained

With laboratory criteria measured twice >3 months apart
o Lupus anticoagulant
o High anticardiolipin antibodies
o Anti-B2 Glp I ab

Answer 21

Criteria for APLS

Question 22

Preg SE of paroxetine?

Answer 22

Paroxetine -> cardiac defects

Question 23

 Not teratogenic
 Use associated with PTD, IUGR, stillbirth, SIDS and developmental delay

Which recreational drug?

Answer 23

Opiates

Question 24

Which recreational drug?

 Teratogenic
  Risk cardiac defects and gastroschicosis
 Pregnancy complications are similar to cocaine

Answer 24

Ecstasy

Question 25

Which recreational drug?

 Associated with facial clefs
 Cause neonatal hypotonia and withdrawal sx

Answer 25

BDZ

Question 26

Which recreational drug?

 Associated with other drug use makes it higher risk
 May cause IUGR and affect child development

Answer 26

Cannabis

Question 27

o Facial abnormalities
o IUGR
o Small or abnormal brain
o Developmental dlay
o Usually >18 units/day alcohol exposure

Which recreational drug?

Answer 27

Alcohol

Question 28

 Dose-response manner   risk miscarriage, IUGR, PTD, placental abruption, stillbirth and SIDS
 Associated with childhood illness
 PET is more severe if assoc.
 Consider high risk if women do not stop

Which recreational drug?

Answer 28

Tobacco

Question 29

Blood volume increases by how much in pregnancy?

Answer 29

40% increase in blood volume   red cell mass and net fall in Hb concentration

Question 30

AntiD dose 28w

Answer 30

AntiD (1500IU) should be given to all Rh –ve women at 28 weeks

Question 31

Bleeding from the genital tract after 24 weeks gestation

Answer 31

Antepartum Haemorrhage

Question 32

Delivery MUST be via (elec) CS?

Answer 32

Placentae praaevia

Question 33

SGA definition

Answer 33

Weight of fetus is <10th centile for gestation

Question 34

Weight of fetus is <10th centile for gestation (at term = <2.7kg)

Answer 34

SGA

Question 35

How long should the first stage of labour be?

Answer 35

<12hrs

Question 36

How long should the second stage of labour be?

Answer 36

40 mins - nulliparous
20 mins - multiparous
>1hr likely to need assistance

Question 37

Do frogs in canada ride in a pink limo?

Answer 37

Descent 
Flexion
Internal rotation
Crowning
Restitution 
Internal rotation of the shoulders
Anterior shoulder
Posterior shoulder
Lateral flexion

Question 38

Average time stage 3 of labour

Answer 38

15 mins

Question 39

What is mendelsons syndrome?

Answer 39

Aspiration of stomach contents under GA

Question 40

Keilland’s forceps

Answer 40

Occipito-posterior position

Question 41

Scalp pH <7.20 (capillary) indicates…

Answer 41

…significant hypoxia

Question 42

Name a systemic opiate used during delivery

Answer 42

 Pethidine
 Meptid
 Occasionally
diamorphine
 Given as IM
injections

 Can be self-
administered

 Can cause
sedation,
confusion and
feeling ‘out of
control’
 Antiemetics also
needed
 Causes respiratory
depression in
newborn – requires
reversal with
naloxone

Question 43

3 methods of anaesthesia in labour

Answer 43

Spinal
 Injection through dura mata into
CSF
 Produces short-lasting but effect
analgesia

 Method of choice for CS or mid-
cavity instrumental delivery if no

epidural in situ
 Complications = hypotension, total
spinal analgesia and respiratory
paralysis
Pudendal Nerve Block
 Local anaesthetic injected
bilaterally around pudendal nerve
where is passes ischial spine
 Low cavity instrumental deliveries
Epidural Anaesthesia
 Injection of local anaesthetic via
epidural catheter into epidural
space
 Between L3 and 4
 Local anaesthetic infused
continuously or to ‘top up’
intermittently
 Complete sensory and partial
motor blockade is the norm

Question 44

Complications of epidural

Answer 44

o Spinal tap affects 0.5%
o Puncture of dura mata  leakage of CSF and severe headache
o Pain worse when sitting up
o Treated with analgesia
o ‘Blood patch’ to seal the leak
o Inadvertent IV injection  convulsions and cardiac arrest
o Inadvertent injection of local anaesthetic into CSF + progression up SC  total spinal
paraesthesia

Must also monitor urination - no sensation to bladder. Encourage frequent urination

Question 45

Absolute contraindications to induction of labour?

Answer 45

 Acute fetal compromise
 Abnormal lie
 Placenta praevia
 Pelvic obstruction e.g. mass or deformity
 cephalopelvic disproportion
 >1 CS

Question 46

VBAC contraindications

Answer 46

 Usual contraindications for CS
 Vertical uterine scar
 Multiple previous caesarean
 After two CS, seldom attempt VD

Question 47

Zanavelli manoeuvre

Answer 47

replacement of the head and caesarean section - dystocia

Question 48

replacement of the head and caesarean section

Answer 48

Zanavelli manoeuvre:

Question 49

pressure on anterior and posterior shoulder to rotate shoulders from
transverse position

Answer 49

Wood’s screw manoeuvre

Question 50

Wood’s screw manoeuvre

Answer 50

pressure on anterior and posterior shoulder to rotate shoulders from
transverse position

Question 51

How long is lochia normal?

Answer 51

Lochia (uterine discharge) may be blood-stained for 4 weeks, but is thereafter yellow or white
 Menstruation is usually delayed by lactation (6 weeks after if not lactating)

Question 52

What two hormones control milk secretion?

Answer 52

 Prolactin from anterior pituitary stimulates milk secretion
o High at birth
o Rapid decline in E2 and P4  milk secreted
o Prolactin antagonised by E2/P4
 Oxytocin from posterior pituitary stimulates ejection

Question 53

What is colostrum?

Answer 53

Colostrum – yellow fluid containing fat-laden cells, proteins (IgA) and minerals
o Passed for first 3 days before milk

Question 54

Mild depression, how many core + bio?

Answer 54

MILD: 2 core + 2 bio

Question 55

Mod depression, how many core + bio?

Answer 55

MODERATE: 2 core + 6 bio

Question 56

Severe depression, how many core + bio?

Answer 56

SEVERE: ≥8 symptoms, inc all 3 core

Question 57

Organic / physical causes of depression?

Answer 57

Physical causes: hypothyroid, head injury, cancer, quiet delirium, meds etc

Adjustment disorder: following a life event, but not as severe
Normal sadness: part of life!
Bereavement: becomes a concern when grief (numbness, pining, depression, recovery) is
extremely intense, prolonged (>6/12) or delayed

Question 58

Can you stop antidepressants immediately?

Answer 58

Antidepressants cannot be stopped suddenly, wean over weeks, SSRIs increased risk of
bleeding, especially in older people (consider prescribing gastroprotective in older people
who are also taking NSAIDs or aspirin)

Question 59

What distinguishes type 1+2 bipolar?

Answer 59

*Classification: Type I – manic episodes interspersed with depressive episodes,
Type II- mainly recurrent depressive episodes, less prominent hypomanic episodes,
Rapid cycling BPAD - ≥4 affective episodes in a year, women, respond better to
valproate
*MIXED EPISODE: manic/hypomanic + depressive symptoms in a single episode,
present every day for at least a week (ICD-10)
*Ultra-rapid cycling: fluctuations over days or even hours

Question 60

Support groups for bipolar?

Answer 60

Bipolar UK
MIND
SANE
RETHINK
Samaritans

Question 61

Delusion definition

Answer 61

Delusion – false, fixed belief that the patient has and is convinced by contrary to the
evidence and rational argument that cannot be explained by the patient’s cultural,
religious or educational background.

Question 62

Neurodevelopmental aetiology of schizophrenia?

Answer 62

Neurodevelopmental: enlarged ventricles, overall smaller/lighter brains, no gliosis
( changes before adulthood). Further evidence: low pre-morbid IQ, poor
learning/mem/executive function. Early brain damage/abnormalities imperceptible
at first, more pronounced as brain matures through ongoing myelination and
synaptic pruning.

Question 63

What is the dopamine hypothesis in schizophrenia?

Answer 63

Neurotransmitters: dopamine hypothesis –POSITIVE symptoms from EXCESS
dopamine in MESOLIMBIC tracts, NEGATIVE symptoms from REDUCED dopamine in
MESOCORTICAL tracts. Serotonin hyperactivity, gluatamate dyfunction too

Question 64

List the subtypes of schizophrenia

Answer 64

Paranoid: delusion & hallucination
Hebephrenic: Affective changes (extension of prodrome) Disorganised speech
behaviour (silly/shallow), flat/inappropriate affect
Catatonic: Psychomotor disturbance (treat with BZDs)
Undifferentiated: Meets criteria but no specific dominant symptom
Post-schizophrenic depression: Some residual symptoms, but depression mainly
Residual: Previous +ve symptoms decreased, - ve symptoms prominent
Simple: No delusions/hallucinations, ‘defect state’ (-ve) gradually arises without an
acute episode

Question 65

List typical antipsychotic SEs

Answer 65

 Typical antipsychotics Extrapyramidal side effects
o Acute dystonia: early onset (hours), involuntary, painful sustained muscle
spasm eg torticolllis, oculogyric crisis; tongue and sternocledomastoid mostly
 tx with anticholinergic iv procyclidine
o Akathisia: hours –weeks, unpleasant restlessness of usually lower limbs 
change/↓ dose; add propranolol or BDZ
o Parkinsonism: days-weeks, triad: resting tremor, rigidity, bradykinesia 
change/↓ dose, add anticholingergic (procyclidine iv)
o Tardive dyskinesia: months-years; rhythmic involuntary movemetns,
continuous slow writhing movements, esp oral-lingual/limbs, tend to be
irreversible  /stop antipsychotic, avoid anticholinergic (worse), atypical
SSRI/clozapine
 ! Neuroleptic malignant syndrome: muscle stiffness and rigidity, altered
consciousness, disturbance of autonomic (feve, tachy, labile BP), raised CK and WCC,
acute renal failure secondary to rhabdomyolysis can  death. Normally when
changing/increasing dose of drug. Tx: immediately stop antipsychotic, medical ward,
hydration & oxygen, monitoring, dantrolene and bromocriptine

Question 66

List the atypical antipsychotics SEs

Answer 66

Atypical antipsychotics (metabolic syndrome, weight gain) :
Olanzapine – helps with
positive symptoms ( but causes weight gain)
Quietiapine – qt prolongation – need
ECG
Risperidone – may increase prolactina and aggression
Aripiprazole – expensive
but no side effects (use in patients with metabolic syndrome)

Question 67

Clozapine MoA?

Answer 67

Clozapine
 Blocsk D1 and D4 receptors, superiority due to added blockade of 5HT2 receptors and
increased GABA turnover
 Anticholinergic, antihistaminic, anti-adrenergic side effects: constipation, fever, BP
derangement, sedation, seizures, weight gain etc

Question 68

SEs of clozapine

Answer 68

Anticholinergic, antihistaminic, anti-adrenergic side effects: constipation, fever, BP
derangement, sedation, seizures, weight gain etc

Many interactions: lithium (↑seizure risk, anticholinesterase inhibitors, smoking
increases clearance  ↓ plasma conc, plasma conc ↑by caffeine
 C/I: previous/current neutropenia or blood dyscrasias, previous
MI/pericarditis.cardiomyopathty, liver disease
 Greatest worry is fatal agranulocytosis- leukopenia, eosinophilia, leucocytosis 
regular blood tests for WCC (weekly for 18 weeks  fortnightly until 1 year 
monthly indefinitely) . Fatal myocarditis/cardiomyopathy/pulmonoary embolism aslo
a worry.
 Evidence is that it REDUCES mortality in schizo by ↓ suicide!

Question 69

Define schizoaffective disorder?

Answer 69

Both features of schizophrenia and affective disorder, 50:50

Question 70

Define SCHIZOTYPCAL DISORDER

Answer 70

‘ Partial expression’ of the schizophrenia phenotype. Classified along with
schizophrenia in ICD-10, Cluster A with odd-eccentric personality disorder in DSM-IV.
No hallucinations and delusions.

Question 71

Define SCHIZOPHRENIFORM DISORDER

Answer 71

Schizophrenia-like psychosis that fails to fulfil duration criterion for schizophrenia in DSM-IV

Question 72

Transient ‘state of shock’ lasting minutes-hours,
max 1-3 days. Anxious but may seem dazed, may experience amnesia,
depersonalisation and derealisation, may stop talking)

Answer 72

Acute stress reaction

Question 73

Associated with persistent fear & prominent
avoidance of the feared situation, anticipatory anxiety attacks and
insight that the fear is irrational and disproportionate to the risk. Think
of impact on daily functioning. May be so severe that it induces panic
attack

Answer 73

Phobic anxiety disorders

Question 74

Fear of being unable to easily escape to a
safe place (e.g. home). May manifest in open spaces, or
confined spaces that are difficult to leave without
attracting attention. 95% have current or past diagnosis of
panic disorder. Onset in mid twenties or thirties

Answer 74

Agoraphobia

Question 75

Fear of being criticised or scrutinised; worry
that they will be embarrassed in public. Will tolerate an
anonymous crowd (unlike agoraphobics) but small groups
(e.g. meetings/dinner parties) are intimidating. May have
specific worries e.g. eating in public. Self-medication with
alcohol or drugs serves as avoidance and therefore
perpetuates problem.

Answer 75

Social phobia

Question 76

‘episodic paroxysmal anxiety’. Not restricted to
certain situations (i.e. not phobic) or objective danger. Patients may
develop fear of having further attacks – ‘anticipatory anxiety’. Many
also have agoraphobia. ‘Panic’ can persist until patients receives
reassurance or reverts to ‘safety behaviours’: actions to avoid
catastrophe, e.g. calling ambulance, taking aspirin.

Answer 76

Panic disorder

Question 77

Transient ‘state of shock’ lasting minutes-hours,
max 1-3 days. Anxious but may seem dazed, may experience amnesia,
depersonalisation and derealisation, may stop talking)

Answer 77

Acute stress reaction

Question 78

Abnormal psychological changes to adversity.
May follow common life changes.
o Onset within weeks and lasts less than 6mths
o Symptoms of anxiety and depression, without the biological
symptoms of depression. None of the symptoms should be of
sufficient severity or prominence in its own right to justify a
more specific diagnosis.

Answer 78

Adjustment disorder

Question 79

Organic DDx to rule out in anxiety disorders?

Answer 79

For anxiety, rule out endocrine – phaeo (urinary catecholamines),
hyperthyroid (TFTs); neuro – b12 deficiency; metabolic – hypoglycaemia.
Porphyria; cardio- arythmia, AF, mitral valve prolapse; substance misuse –
alcohol withdrawal (LFT – GGT), smoking withdrawal

Question 80

1st line Rx for PTSD

Answer 80

First line treatment is
trauma-focussed CBT
and EMDR

____________

Medicate if there is severe
ongoing threat, or if
patient is too distressed
for psychotherapy, or if
psychotherapy fails
SSRIs (paroxetine,
sertraline)
Sleep disturbance –
mirtazapine,
levomepromazine, Anxiety/hyperarousal –
BDZ (clonazepam),
busiprone,
antidepressants,
propranolol
Intrusive thoughts –
carbamazepine, valproate,
topiramate, lithium
Psychosis – olanzapine,
risperidone, quetiapine,
clozapine, aripiprazole

Question 81

Anxiety-producing obsessions which they try
to relieve with rituals (compulsions). These must cause distress or
interfere with the person’s social or individual functioning (usually by
wasting time) and should not be the result of another psychiatric
disorder.

Answer 81

OCD (duration >2w)

Obsessions – involuntary thoughts, images or impulses which are:
1. Recurrent and intrusive (unpleasant/distressing)
2. Enter mind against conscious resistance
3. Patients recognise obsessions as being the product of their
own mind even though they are involuntary and often
repugnant

Compulsions – repetitive mental operations or physical acts with the
following characteristics:
1. Feel compelled to perform them in response to their own
obsessions or irrationally defined rules
2. Performed to reduce anxiety through belief they will prevent a
dreaded event, even though they are not realistically
connected to the event

Question 82

What is a compulsion?

Answer 82

Compulsions – repetitive mental operations or physical acts with the
following characteristics:
1. Feel compelled to perform them in response to their own
obsessions or irrationally defined rules
2. Performed to reduce anxiety through belief they will prevent a
dreaded event, even though they are not realistically
connected to the event

Question 83

Define an obsession?

Answer 83

Obsessions – involuntary thoughts, images or impulses which are:
1. Recurrent and intrusive (unpleasant/distressing)
2. Enter mind against conscious resistance
3. Patients recognise obsessions as being the product of their
own mind even though they are involuntary and often
repugnant

Question 84

What conditions is OCD associated with?

Answer 84

BIO
Affected by illnesses in
which risk of OCD is increased: Sydenhem’s chorea, encephalitis
lethargica, Tourette’s syndrome. Strep throat infection may
produce anti-basal ganglia antibodies (c.f. streptococcal infection
causing Sydenham’s chorea). Neuroimaging has shown deficit in
frontal-lobe inhibition – intrusive/ritualistic thoughts might be
harder to suppress in OCD.

PSYCH
1. Anankastic personality traits: rigidity, orderliness. ¼ of OCD
patients have premorbid anankastic personality traits.
2. Stress: may precipitate OCD symptoms

Question 85

Syndrome characterised by
acute onset of fluctuating cognitive impairment (or deterioration in
pre existing cognitive impairment) associated with behavioural
abnormalities.

Answer 85

Delerium

Question 86

Causes of delirium?

Answer 86

1. Infective: UTI, chest infection, abscess, cellulitis, subacute
   bacterial endocarditis
2. Metabolic: anaemia, electrolyte disturbance, hepatic
   encephalopathy, uraemia, cardiac failure, hypothermia
3. Intracranial: CVA, head injury, encephalitis, primary or metastatic
   tumour, raised ICP
4. Endocrine: pituitary, thyroid, parathyroid, adrenal disease,
   hypoglycaemia, DM, vitamin deficiencies
5. Substances: intoxication or withdrawal of alcohol, BDZ,
   anticholinergics, psychotropics, lithium, antihypertensives,
   diuretics, anticonvulsants, digoxin, steroids, NSAIDs

Always consider the ‘great cerebral masqueraders’: TB, neurosyphilis,
AIDS

Question 87

DDx for delirium?

Answer 87

Wernicke’s encephalopathy – which is a medical emergency 

Korsakoff’s psychosis
 Mood disorder
 Functional psychiatric conditions (mania, depression, late onset
schizophrenia)
 Responses to major stress, dissociative disorders
 Dementia (hard to differentiate as people with established
dementia are vulnerable to delirium)

Question 88

Different seizure types

Answer 88

Generalised: involve whole cortex and lead to LOC
Focal: involve one area of cortex and may become secondarily
generalised. May be subclassified as simple partial or complex partial
Simple partial: localised motor/ sensory features ± LOC or memory
loss
Complex partial: ± aura/automatism, and associated changes in
conscious level

Question 89

Biological sources of epilepsy

Answer 89

1. Cerebrovascular damage
2. Cerebral tumours
3. Alcohol related seizures
4. Post traumatic seizures

Question 90

Cognitive decline, choreiform involuntary movements and personality change

Answer 90

Huntington

Question 91

What chromosome is Huntington’s gene on?

Answer 91

Autosomal dominant gene on Chr 4

Question 92

Classic triad: chorea, dementia and FH of HD

 Chorea: initial jerks, tics, gross involuntary movements of all parts
of the body, grimacing, dysarthria. Increased one with rigidity and
stiffness, positive primitive reflexes, abnormal eye movements
 Cognitive impairments  subcortical dementia
o Mental slowing
o Impaired executive function
o Speech deteriorates faster than comprehension
 Psychiatric disturbances
o Common in those with HD
o Changes in behaviour/ personality
o Affective disorders
o Schiphreniform psychoses
o These disturbances are not related to the severity of HD

Answer 92

HUNTINGTON’S DISEASE

Question 93

Alcohol MoA

Answer 93

Alcohol MOA: non-specific effects on neuronal cell wall fluidity and permeability,
as well as enhancement of GABA-A transmission (anxiolytic), release of dopamine
in mesolimbic system (‘reward’), inhibition of NMDA-mediated glutaminergic
transmission (amnesic)

Question 94

Profound short-term memory loss characterised by confabulation

Answer 94

Korsakoffs

Question 95

a. Most dramatic neuropsychiatric complication
b. Thiamine deficiency  mammillary body damage  ataxia,
nystagmus, ophthalmoplegia, acute confusion

Answer 95

Wernickes

Question 96

3 stages of alcohol withdrawal (severity)

Answer 96

Uncomplicated alcohol withdrawal syndrome: 4-12hrs after last drink.
Coarse tremor, sweating, insomnia, tachycardia, nausea and vomiting,
psychomotor agitation, anxiety. ± hallucinations (transitory visual, tactile or
auditory), craving for alcohol. Symptoms prolonged in heavier drinkers.
 Alcohol withdrawal syndrome with seizures: 5-15% of withdrawals
complicated by grand mal seizures 6-48hrs after last drink.
 Delirium tremens: 1-7 days after last drink with peak incidence @ 48hrs.
Severe dependence, comorbid infection and pre-existing liver damage
increase risk. Features of withdrawal and additionally: clouding of
consciousness, disorientation, amnesia for recent events, psychomotor
agitation, visual, auditory and tactile hallucinations (Lilliputian hallucinations
of diminutive people or animals), marked hour by hour fluctuations (worse at
night), if severe there is heavy sweating, fear, paranoid delusions, agitation,
suggestibility, temperature and sudden CV collapse. Reported mortality 5-
10%

Question 97

BDZ used in alcohol detox?

Answer 97

Chlordiazepoxide (lowest abuse potential)

Question 98

Lady has a diagnostic laparotomy. She has suprapubic pain that not even IV paracetamol is helping.
What is the likely reason?

Answer 98

Urinary retention

Question 99

Somali lady comes in doesn’t speak much English says she’s 42 weeks. Examination of abdomen suggests
a 32 week uterus.

Admit her to ward for ANC tomorrow
do HIV test as
HIV babies tend to be small, Induce her labour now,
do a transabdominal scan

Answer 99

do a transabdominal scan

Question 100

Leading cause of maternal death in UK

Answer 100

Heart disease remains the leading cause of women dying during pregnancy or up to six weeks after giving birth, followed by blood clots. Maternal suicide is the fifth most common cause of women’s deaths during pregnancy and its immediate aftermath, but is the leading cause of death over the first year after pregnancy.

However, there are striking inequalities: black women are five times and Asian women two times more likely to die as a result of complication

Question 101

Management of 4 year old with enuresis - dry by day.

Answer 101

Ans: reassure. (Enuresis is a problem over the age

of 5)

Question 102

Child with Downs has an NJ tube at home. It comes out and needs re-inserting. Who should put it back in? [Community paeds nurse; Community Paediatrician; Hospital Nursing staff; GP, healthworker]

Answer 102

Hospital Nursing staff

Question 103

You’re the duty GP. Mum calls about child with fever/non-blanching rash. What do you do/advise? [Go to their home with you bag to give IM benpen; Arrange an emergency ambulance to take em hospital; Tell them to go to A&E; Tell them to make an appointment with GP)

Answer 103

Arrange an emergency ambulance to take em hospital

Question 104

Child diagnosed with functional abdo pain. Associated with school. What’s the best management plan? [Encourage her to go to school and come back when her tummy starts to hurt; Have her work sent home whilst she still having pains; Change school; Make her go to school regardless of tummy pains, give her home tutoring]

Answer 104

Make her go to school regardless of tummy pains

Question 105

Child is slow to get dressed. Likes to arrange his toys in a particular way. [ASD; OCD; Oppositional defiant disorder etc]

Answer 105

ASD

Question 106

Child is an arsonist. Gets in fights. Attacks teachers. What is he likely to have at age 20? [Conduct disorder; ADHD, Dissocial personality disorder; Oppositional defiant disorder]

Answer 106

Conduct

Question 107

Neonate. Ortolani test positive. What you do? [Hip ultrasound at 12 weeks; Hip ultrasound at 6 months; Hip x-ray at 12 weeks; Hip ultrasound at 6 months]

Answer 107

12 = best answer

Before 6 months of age, ultrasound is preferred over radiographs for evaluation of DDH due to insufficient ossification of the hip. In the absence of clinical findings, ultrasound should be delayed until about 6 weeks of age to reduce false positive results.

Question 108

Child with downs in residence. Short term history of attacking people, anger outbursts etc. Best management? [Give antipsychotics; Move her to new home; Send her for neuropsychiatric assessment/therapy; Give antidepressant]

Answer 108

Send her for neuropsychiatric assessment/therapy

Question 109

Asthmatic child in A&E. Mother has been giving two puffs of salbutamol with spacer every 4 hours. Description given correlated to severe asthma. What your management? [Inhaled nebs; inhaled adrenaline, Discharge; 10 puffs of salbutamol through spacer]

Answer 109

Inhaled nebs

Question 110

Child has inspiratory stridor (doesn’t explicitly state, but gives a description implying this) since birth. Likely cause?

Answer 110

[Laryngomalacia;]

Question 111

A child with short stature. Estimated mid parental height is on 25th centile. His measurements are plotted on the chart (which was printed extremely faint. You could only make out the crosses and some of the centiles. It appeared the child was crossing multiple centiles since young age). What is the cause? [Constitutional delay; Malabsorption; Hypothyroidism; Familial short stature]

Answer 111

Malabsorption;

Question 112

Hyperactive child at home. Doesn’t pay attention at school. Diagnosis?

Answer 112

ADHD

Question 113

Child takes 4 tablets of grandmothers benzodiazepines 4 hours ago. She’s currently asleep, but was fully
awake with GCS 15. Your next step? [Activate charcoal; Gastric Lavage; IV flumenazil; admit for
monitoring]

Answer 113

admit for
monitoring

Only give with rest depression

Question 114

Afebrile child with D+V. Description alludes to shock. She is 15kg. What do you give her initially?

Answer 114

[300ml bolus of 0.9% saline]

Question 115

What defines a mild learning disability? [IQ: <80/<70/<60/<50/<30]

Answer 115

<70

Question 116

Which of the following is not an RF for suicide? [FHx of depression; FHx of suicide; Prev suicide attempt;
Male; Heroin-use]

Answer 116

FHx of depression

Question 117

75 yr lady bought in with daughter. “She” (not sure who it was referring to) says is anxious, being
increasingly forgetful lately, thinks she has dementia. Diagnosis?

Answer 117

A: Depression.

Question 118

You’re a GP. Elderly person presents with a history of the classical signs of Alzheimer’s. What do you do
next? [Prescribe donazepil; refer to memory clinic; MRI head; reassure]

Answer 118

memory clinic

Question 119

What bloods would you test for, to monitor Lithium toxicity? [U&E/Lithium levels/TFTs, Lithium levels,
TFTs, Nothing unless symptomatic, U&E/Lithium, TFT/Lithium]

Answer 119

U&E/Lithium levels/TFTs

Question 120

A person with a diagnosis of Bulimia nervosa. BMI 22. Wants to get help. Management? [CBT; CBT+
Fluoxetine; Fluoxetine; Psychoanalytic therapy]

Answer 120

CBT

Question 121

A teenage girl takes an OD of paracetamol after being “dumped” by boyfriend. Which feature is likely to
suggest further suicide risk? [She got dumped for another girl; She took the OD in front of him saying she wanted to teach him a lesson; N-acetyl cysteine was required; she felt hopeless]

Answer 121

she felt hopeless

Question 122

Elderly lady consented for operation by GP. Day of op decides not to have it but son insists she should go ahead. What should the doctor do. Options: [act in best interests; take word of the son as consent; assess the patient’s capacity;]

Answer 122

assess the patient’s capacity

Question 123

When interviewing a recovered Schizophrenic, what on MSE would make you think they were getting relapse? [Visual hallucination; being withdrawn;]

Answer 123

Visual hallucination

Question 124

Lady with social phobia. What feature would typically be associated with it? [Not liking big trains, people noticing you blush]

Answer 124

people noticing you blush

Question 125

3. Paeds derm treatment – also featured in 2014 paper. Options were a load of medicated creams/lotions + no treatment required.
   a. Nappy rash with satellite lesions
   b. Nappy rash with flexural sparing
   c. Chicken Pox
   d. Scabies
   e. Impetigo

Answer 125

a. Nappy rash with satellite lesions [A: Clotrimazole]
b. Nappy rash with flexural sparing [A: Zinc barrier cream]
c. Chicken Pox [A: Do nothing?]
d. Scabies [A: Permethrin]
e. Impetigo [A: Fusidic Acid]

Question 126

4. Mental Health Act
   [Options: Section 2; Section 3; Section 4; Section 5(2); Section 5(3); Deprivation of Liberty Safeguards (DoLS);
   Mental capacity act; Section 135 (even explained what it was! – taking someone to a place of safety from private property); No detention required]
   a. Inpatient with Mania detained under section 2, reaching the end of the term. He is still not showing signs of improvement and poses a risk to himself/others.
   b. Neighbours concerned about a man who they haven’t seen in a while. Psych nurse goes to visit and finds him confused, aggressive etc. She calls paramedics who give an IV infusion of saline.
   c. Doctor in a medical ward. Patient with some psych condition.

Answer 126

a) section 3
b) no detention
c) 5(2)

Question 127

5. Multiple pregnancies – [Options: Monochorionic; Monoamniotic; Dichorionic; Molar pregnancy; Twin-twin transfusion;]

Two fetal poles, one gestational sac

Snowstorm appearance

Answer 127

a) monochorionic

b) molar

Question 128

7. Paeds
   joint problems

a. Child bought in by grandmother. Said to have knocked knee in cupboard which has become swollen. His brother had swelling having banged head when he was young.
b. Child with posterior rib fractures and some other patterns of injuries
c. Girl with painful hot swollen knee joints. PMH of hot/swollen/painful wrist.
d. Girl not able to weight bear. Recently recovered from viral illness.
e. Girl not able to weight bear. Some joint(s) hurt. Mum has rheumatoid arthritis.

Answer 128

a) [Haemophilia]
b) [NAI]
c) [Septic arthritis]
d) [Post-viral synovitis]
e) [JIA]

Question 129

11. Paeds milestones - what age would you expect most children to have achieved these?

a. Smiling
b. Sitting unsupported -
c. Walking -
d. 2-3 word sentences
e. Pincer Grip

Answer 129

a) 6 weeks
b) 7/8months Sits without support (Refer at 12 months)
c) 13-15 months Walks unsupported (Refer at 18 months)
d) 3 years = 3-5 word sentences
e) 12 month Good pincer grip, early 9 months

Question 130

12. Jaundice
    [The usual options: ABO incompatibility; Biliary atresia; Physiological; Sepsis; Criggler-najjar etc.]

a. 28 day child with pale stools.
b. Child is blood group O. Mother is blood group AB.
c. Mum had group B strep.
d. A child who had jaundice for a few days (day 2-7). He’s fine now.

Answer 130

a) biliary atresia
b) ABO incompatibility
c) Sepsis
d) physiological

Question 131

13. Child with funny turns [Options: Infantile spasms; Reflex anoxic seizures; Breath holding attacks; Absence seizures ]

a. ~8 month who keeps clenching fists and bringing arms out towards parents.
b. Child falls. Parents pick him but has a tonic-clonic seizure. Is complete well afterwards.
c. Child at school. Complains of unusual smell. Then seems to ‘space out’. Afterwards she’s very drowsy
and sleeps for a few hours in the school nurses office. She has no recollection of what happened.

Answer 131

a) infantile spasms
Wests = developmental delay, infantile spasms, hypsarrythmia

b) reflex anoxic
c) absence

Question 132

14. Diarrhoea [options: toddlers diarrhoea; constipation with overflow; Crohn’s; Ulcerative colitis; …. ]
    a. Redcurrent jelly stools

Answer 132

Intussusception

Question 133

15. Psych

a. Student who recently finished exams found disorientated and slurring his words or similar - basically

Answer 133

alcohol excess

Question 134

16. Kids development
    a. MINECRAFT! 7 year old who refuses to do his homework and stays up late playing Minecraft on his iPad.
    Parents are worried about him.

Answer 134

Normal behaviour

Question 135

Gardasil - what 4 does it protect against. Name the one from the list: HIV, HSV1, HSV2, HPV11, HPV29?

Answer 135

6,11,16,18

Question 136

UTI in first trimester of pregnancy. What would be the safest and most effective treatment? Trimethoprim, Ciprofloxacin, Doxycycline, Cefalexin, Meropenem

Answer 136

Cefalexin

Question 137

Amenorrhoea for 4 months - what do u do?

Answer 137

Pregnancy test, FSH, need a withdrawal if PCOS

Question 138

19 year old abdo swelling, weight gain, irregular periods usually, can’t remember when last period was, denies being sexually active. What is the first test you would do?

Answer 138

Preg test

Question 139

Girl with cystic ovaries on US and something else. What other symptom would be the best indicator of her having polycystic ovaries? Dysmenorrhoea, Hirsutism, Obesity, Acne.

Answer 139

Hirsutism

Question 140

Woman with PCOS. Best medication to increase fertility.

Answer 140

Clomifene

Question 141

Woman with signs of premature ovarian failure. What test would be best to confirm this diagnosis: Oestradiol, Testosterone, FSH, LH

Answer 141

FSH

Question 142

Man with azoospermia. What would be the most likely cause? Hx of mumps, hx of testicular torsion, Varicocele

Answer 142

Varicocele

Question 143

Post menopausal woman with a PV bleed. What ix should you do? Laparotomy and hysteroscopy, outpatient US with endometrial biopsy, CT, MRI…

Answer 143

outpatient US with endometrial biopsy

Question 144

Asymptomatic woman, nulliparous, found to have a 5.4cm unilocular ovarian cyst on US, no fhx. Mgmt/Ix? USS guided cyst aspiration, laparoscopic removal of cyst, discharge and safety-net, rearrange USS in 3 months and Ca12.5 follow-up, yearly follow up

Answer 144

If pre menopausal – yearly follow up as over 5cm…
Women with simple ovarian cysts of 50–70 mm in diameter should have yearly ultrasound follow-up and those with larger simple cysts should be considered for either further imaging (MRI) or surgical intervention.

Question 145

Lady with cyclic pain 1 week before her period starts, trying for a baby for one year Diagnosis?

Answer 145

endometriosis

Question 146

Woman 8 weeks after normal vaginal delivery and second degree tear, still bleeding and mild lower pelvic pain. Diagnosis? Normal menstruation, PID, endometritis, lochia.. (lochia for 2-6weeks, period returns 6-8 weeks)

Answer 146

endometritis

Question 147

What is a 23 week USS useful for? Nuchal thickness for Down’s, congenital heart disease identification, predicting position of placenta at term..

Answer 147

congenital heart disease identification

NORMALLY 18-20 weeks

Question 148

What causes increased urinary volume and frequency in the first trimester? Increased GFR, pressure of uterus on bladder, glycosuria.

Answer 148

pressure of uterus on bladder

Question 149

Effect of taking fluoxetine during pregnancy on baby?

Answer 149

Persistent pulmonary hypertension of the newborn,

Question 150

Woman with Nexplanon. Most likely reason for wanting to change contraceptive? Weight gain, acne, mood swings,

Answer 150

irregular bleeding

Question 151

Pregnant lady being domestically abused by husband and scared to go home. What do you do in GP? Send her home and ask her to come back with husband, give her a leaflet about domestic abuse, call and arrange emergency accommodation

Answer 151

call and arrange emergency accommodation

Question 152

Woman with a slow growing painless lesion on labia.

Answer 152

Genital warts

Question 153

Woman with tender lump inside her vagina.

Answer 153

Bartholins cyst

Question 154

Young woman, pain during sex, ‘Strawberry cervix’ on examination

Answer 154

TV

Question 155

Woman with cheesy white discharge

Answer 155

candida

Question 156

Old woman complaining of superficial dyspareunia

Answer 156

atrophic vagina

Question 157

HRT options: COCP, Oral Oestrogen, Oral Progesterone, Transdermal oestrogen, Transdermal progesterone, all have continuous or cyclical, Bisphosphonates, Testosterone.

Women who has gone through menopause, had a hysterectomy. Wants HRT mainly to prevent osteoporosis and treat her hot flushes. Doesn’t want to take tablets.

Swimmer wants to treat hot flushes, doesn’t want a patch.

Woman with premature ovarian failure, wants to have periods.

Woman who just wants to treat osteoporosis, 62.

Answer 157

Transdermal oestrogen

Oral both (either cyclical or continuous depending on last period )

COCP or cyclical combined HRT (likely to have a bleed but not guaranteed)

bisphosphonates

Question 158

Breast
Option: mastitis, intraductal papilloma, malignancy, abscess, genital warts, Bartholins cyst

Lady high White cell count, fever, lump in breast

General breast tenderness - left sided, breastfeeding

Small slow growing lesion on labia, pregnant lady

Small painful lump inside vagina of sexually active woman

Answer 158

abscess

mastitis

genital warts

bartholins

Question 159

Bacteria causing acne?

Answer 159

Propionibacteria acnes

Question 160

Kid with history of anal fissure - what is your first cause of action? - inspect anal region, do DRE with little finger

Answer 160

inspect anal region

Question 161

A level student has recently come back from nigeria, with symptoms of jaundice, mild anaemia and fever with malaise,arthralgia.

Answer 161

Malaria

Question 162

Kid has pain in outer ear, ear was protruding outwards, and there was a lump behind his ear.

Answer 162

Mastoiditis

Question 163

Kid with temp of 39, cap refill 6s, generally unwell + bulging fontanelles, no description of rash. Options: Meningococcal septicamia, uti, pnemonia

Answer 163

Meningococcal septicamia

Question 164

4yo kid having acute asthma attack, given iv salbutamol and hydrocortisone. Sats still low, no chest sounds on auscultation. What do you do/give next? IM adrenaline, call for senior help, start atrovent

Answer 164

call for senior help

Question 165

Kid with cervical lymphadenopathy, fever, sore throat, red tongue with white spots. What does she have? Scarlet Fever, measles, chicken pox.

Answer 165

measles

Question 166

Child who had bulimia. What gives it away? (Options were dental enamel caries, striae, lacerations on wrist…)
bronchopulmonary dysplasia

Answer 166

dental enamel

Question 167

4 month old, about to have 3 batch of primary vaccinations. Which would be a complete contraindication to having the vaccine? Confirmed history of pertussis as a baby, currently ill with a fever of 38.5, got a rash at site of last vaccination, severe cow’s milk allergy,

Answer 167

currently ill with a fever of 38.5

Question 168

Perianal itching especially at night. What’s the best treatment option? (Options: Mebendazole, Cotrimazole)

Answer 168

Mebendazole

Question 169

5 month old with cough, runny nose, fever. Examination of chest you hear wheeze. What’s the main pathogen that causes this RTI? Options: Streptococcus Pneumoniae, Respiratory Syncytial Virus, Mycoplasma pneumoniae

Answer 169

Respiratory Syncytial Virus

Question 170

Respiratory Disease. Options: Meconium Aspiration, Group B Strep infection, PCP pneumonia, transient tachypnoea of newborn, Surfactant deficiency, , diaphragmatic hernia.

a) Heart sound not heard, scaphoid chest.
b) Baby was born at 41 weeks via emergency C section due to foetal distress. Needed ventilation straight away. X ray showed hyper inflated lungs with areas of consolidation. What does he have?
c) Baby born at 37 weeks, via forceps. Showing signs of resp distress. CXR shows areas of consolidation throughout.
d) Prem baby, resp distress, CXR looks like ground glass.

Answer 170

Diaphragmatic hernia

Meconium aspiration (mature fetus, distress caused gasping breath in) patchy opacities, hyperinflation, no air bronchograms )

GBS

Surfactant deficiency

Question 171

Treatments of Paed Rashes. Options: Hydrocortisone, Permethrin, Zinc…, Anti-fungal, Histamine cream, Nothing,

Nappy rash flexure sparing

Nappy rash with satellite lesions

Anal itch, worst at night

Scabies

Chickenpox

Answer 171

zinc

antifungal

mebendazole

permethrin

nothing (can use histamine cream) OR topical calamine

Question 172

Joint problems (same as 2015)

Options: haemophilia, JIA, post-viral synovitis, septic arthritis, NAI

Grandmother brings boy in with swollen knee. Boy’s brother died young of a minor head injury.

Posterior rib fractures

Unwell and not able to weight bear, fever

Recent URTI - not able to weight bear

Answer 172

Haemophilia

Nai

septic arthritis

Recent URTI - not able to weight bear post viral synovitis

Question 173

Suicide risk. What is the highest predictor of doing it again? bad relationship with mum, feeling hopeless about future, previous self harm

Answer 173

feeling hopeless about future

Question 174

80 year old man with new onset dementia, needs MRI but refuses. You need someone to make decision for him. - (options: talk to family with his permission, ask independent mental health advocate)

Answer 174

talk to family with his permission

Question 175

Guy who has visual hallucination and likely to fall over. but he is not giving consent to help regarding his falls and delirium. He wants to leave hosp. Difficult to understand what he is saying
Q: what is a big reason that makes you think he does not have consent? (Options: due to lack of understanding, due to lack of processing, due to his visual hallucination, due to him not communicating properly)

Answer 175

due to him not communicating properly

Question 176

Woman on SSRI, wanted to get pregnant, was wondering what risk it may have on her baby: Stillbirth, Pulmonary htn of the newborn, delayed labour, hypoglycemia at birth.

Answer 176

Pulmonary htn of the newborn

Question 177

Woman wants to know what risk her baby has of getting schizophrenia, since the baby’s father has it. 7-9%, 12-15%, 20-25%, 1%…

Answer 177

should be 10% (48% if both parents have it)

Question 178

Woman 5 weeks postpartum feels very sad, unable to cope, teary. Dx?

Answer 178

Postnatal depression (baby blues usually pnly for 1-2 weeks)

Question 179

What blood test should be frequently done if someone is on Lithium? Thyroid function, liver function, adrenal function, FBC,

Answer 179

Thyroid function

Question 180

Guy on medication for schizophrenia get muscle rigidity, altered consciousness, high blood pressure, tachycardia. Mgmt?

Answer 180

stop antipsychotic and dantrolene and bromocriptine

Question 181

60 year old woman, short term memory loss, struggling to complete her normal daily tasks, ataxia and dysphagia. What would you see on MRI?

Answer 181

NPH most likely

Question 182

40 year old man with moderate learning disability. He has a Hb of ~6 (below the normal range). Refuses blood transfusion but happy to take oral iron therapy. What law do you use to assess his decision (or something along those lines). [Options: Common Law; Mental Capacity Act; Mental Health Act; Disability Discrimination Act; ?European Convention on Human Rights]

Answer 182

MCA

Learning disability is NOT a mental health DISORDER

Question 183

Man who had come into GP for peeling of skin on his hands. Excessive hand washing 6 times daily which has got worse since his elderly father died 3 months ago following a wound infection(?) post operatively. (Options: Adjustment Disorder (lasts 6 months), OCD)

Answer 183

OCD

Question 184

Man with treatment resistant schizophrenia on clozapine, recently stopped smoking. High level of clozapine now. Most likely consequence? Agranulocytosis, seizures.. (seizures found in agranulocytosis)

Answer 184

Agranulocytosis

It is well documented that cigarette smoke can induce cytochrome P450 (CYP) isoenzymes, specifically CYP1A1, CYP1A2, and CYP2E1. Because clozapine is primarily metabolized by CYP1A2 (approximately 70%), smoking can induce clozapine metabolism and abruptly stopping smoking can increase clozapinelevels.

Question 185

Definitions
Options: Illusion, formication, micropsia, pseudo hallucination

Person sees flower on wallpaper - sees them as moving snakes:

Person sees things smaller

Definition of feel insects under skin.

Answer 185

Illusion

micropsia

fornication

Question 186

Agitated psych patient threating violence - what do you do? (Options: talk to consultant, call the police, talk to pt)

Answer 186

talk to pt

Question 187

Diagnosis:
Options: Somatic syndrome, malignancy, Munchausens, Borderline Personality Disorder

50 y woman ,constant stomach pain, had many ix eg multiple laprascopies with nothing found. Comes to A&E saying she needs another laproscopy.

Young girl who has come into A&E multiple times with different presentations, nothing found for any of them.

Woman with abdominal pain, weight loss, lethargy and feeling low.

Man who drinks and takes some drugs. Split up with girlfriends, cutting himself.

Answer 187

Maunchausens

Somatic

Malignancy

BPD

Question 188

1. 14 year old primary amenorrhoea + ejection systolic murmur

Answer 188

Turner’s / coarction

Question 189

2. What gives you macrosomia

Answer 189

gestational diabetes

Question 190

3. Cyclical pain, no heavy menstrual bleed, never sexually active

Answer 190

endometriosis

Question 191

4. Ethics – 14 year old pregnant, comes with sister, wants a TOP. What should you do?

Answer 191

Persuade her to tell her parents if she refuses and gillick competent, you can give her TOP.

Question 192

5. What situation would you use donor eggs?

Answer 192

POF

Question 193

6. What do you test for in Hep B infection antenatally?

Answer 193

HBsAg

Question 194

7. What is not a risk factor for primary PPH?

a. B thalassaemia trait
b. Retained products
c. Sepsis
d. Vaginal tear
e. Multiparity

Answer 194

a. B thalassaemia trait

Question 195

8. At antenatal check, woman with BP 150/90, what would you do?

Answer 195

Admit and assess

Question 196

9. Urogynae – leak urine when laughing and going up stairs, initial management?

Answer 196

Pelvic floor exercise

Question 197

10. What is the treatment for a bartholian abscess

Answer 197

malsupialisation

Question 198

11. Women with previous GDM what is the best way to investigation her blood glucose? OGTT at 28w, OGTT as soon as possible after booking (later at 28 weeks if normal)

Answer 198

OGTT as soon as possible after booking (later at 28 weeks if normal)

Question 199

12. Women with APH (spotting) otherwise well, what is the most important thing to rule out? Ectopic pregnancy, placenta praevia

Answer 199

Ectopic pregnancy

Question 200

13. What type of contraception can increase risk of osteoporosis?

Answer 200

Depot injections

Question 201

14. Women with excessive vomiting, under what circumstance would you admit her?

Answer 201

Ketonuria

Question 202

15. What is likely to cause this man’s azoospermia?

Answer 202

Varicocele, Mumps orchitis

Question 203

16. Which drug is likely to be teratogenic? [antiepileptics]

Answer 203

Sodium valproate

Question 204

Someone comes in at 28w with a Hb of 10.5 what would you do?

Answer 204

Simple advice - leafy Haemoglobin levels outside the normal UK range for pregnancy (that is, 11 g/100 ml at first contact and 10.5 g/100 ml at 28 weeks) should be investigated and iron supplementation considered if indicated.

Question 205

Menopause treatment – what HRT would you give

a. Premature menopause and wants a bleed
b. Someone want something for their bones
c. Women with menopausal symptoms, hysterectomised, does not want to take oral tablets
d. Perimenopausal women with menopausal symptoms, irregular menstruation, does swimming and does not patch
e. Women with menopausal symptoms and has eczema

Answer 205

cyclical HRT or cocp

bisphosphonate

transdermal oestrogen HRT

cyclical oral HRT

oral combined HRT

Question 206

2. STIs

a. Clue cells
b. Strawberry cervix
c. Painful multiple lesions on labia
d. Lichen sclerosis
e. Curdy white-yellow discharge
f. Blue dots on cervix

Answer 206

BV

Trichomonas and wet slide

herpes

thin vulval epithelium, white plaques

candidiasis

endometriosis (blue/ dark dots) nathobian cyst – yellow dots

Question 207

a. Mother with stillborn baby, generalized oedematous when born, mother had fever at 18w with rash on trunk

Answer 207

parvovirus

Question 208

4. What is the likely diagnosis
   a. Smear comes back as moderate dyskaroysis
   b. 76 year old had a single brown discharge
   c. Intermittent pain + vomiting

Answer 208

CIN2

atrophic vaginitis

ovarian torsion

Question 209

5. Gynae Management
   a. 47yo women with menorrhagia + dysmenorrhea, US showed multiple fibroids –

b. 32 yo has 2 children done with family, had COCP before
c. Women going away for holiday and would like to delay her periods.

Answer 209

hysterectomy

mirena

Norethisterone

Question 210

6. Obstetric complications
   a. Mother being prepared for CS, sudden tingling around her mouth?

b. Mother being prepared for CS and has a regional block, sudden tachycardia, SOB, difficulty in breathing
c. Mother had previous CS, sudden abdo pain and abnormal CTG
d. Another anaphylaxis one

Answer 210

Spinal block

anaphylaxis

uterine rupture

Question 211

1. Kid with fever of >39 what to do next

Answer 211

Septic screen

Question 212

When disappear?

a. Moro reflex newborns
b. Asymmetrical neck reflex newborns
c. Palmar and planter grasp newborn
d. Rooting newborn

Answer 212

3/4 months (drop extend arms)

3months (turn and extend arm)

5/6months

4months

Question 213

3. Mother with girl who doesn’t speak

Answer 213

refer for hearing assessment

Question 214

4. Kid fitting for over 5mins, normal glucose, what do you give?

Answer 214

Rectal diazepam/ bucal midazolam/IV lorazepam if you have access

Question 215

7. Dehydration + ill kid – weight 15kg what do you give initially?

Answer 215

300ml bolus IV

Question 216

8. Aspiration pneumonia what would you do 1st?

Answer 216

ABx

Question 217

9. Strawberry tongue

Answer 217

scarlet fever

Question 218

10. What is the purpose of debriefing after a child’s death in resuscitation?

Answer 218

To address emotional needs of everyone in the team.

Question 219

11. Child who pass stool every few days, when he does go, stools are pellet like and smelly, what is the likely diagnosis?

Answer 219

Overflow constipation

Question 220

12. Child with pruritus ani worse at night, what would you give to treat?

Answer 220

Mebendazole

Question 221

1. Skin condition treatment wtf
   a. Impetigo
   b. Rash involving flexures
   c. Rash not involving flexures
   d. Scapies
   e. Chickenpox

Answer 221

a. fusidic acid (first line)/ oral flucloxacillin
b. imidazole
c. zinc
d. permethrin
e. calmamine lotion

Question 222

3. By WHAT AGE would you refer the following kids if they haven’t achieve the following milestones
   a. Sit without support

b. Walk
c. Hops on one leg
d. Pincer grip
e. Smiles

Answer 222

3. By WHAT AGE would you refer the following kids if they haven’t achieve the following milestones
   a. Sit without support – normally by 6m with round back, refer by 8m (limit age 9 months)
   b. Walk – normally by 15m, refer by 18m (limit age 18 months)
   c. Hops on one leg – normally by 4y, refer by 5y (5y was the only upper limit answer)
   d. Pincer grip – normally by 10m, refer by 12m (limit age 12 months)
   e. Smiles – normally by 6w, refer by 8w (limit age 8 weeks)

Question 223

4. Poisons + investigations
   a. Drunk/ intoxicated kid
   b. Dehydrated, seizures, mother been giving some herbal oral rehydration fluid or something
   c. Sick kid with fever, vomiting, photophobia

Answer 223

a. Drunk/ intoxicated kid – urine drug screen
b. Dehydrated, seizures, mother been giving some herbal oral rehydration fluid or something – check plasma sodium
c. Sick kid with fever, vomiting, photophobia - LP

Question 224

5. Respiratory problems
   a. Neonate getting progressively worse at breathing over first 3h with opacities
   b. Still needs oxygen
   c. Ground grass appearance
   d. Nitrogen washout test
   e. Meconium aspiration

Answer 224

5. Respiratory problems
   a. Neonate getting progressively worse at breathing over first 3h with opacities - Group B strep pneumonia
   b. Still needs oxygen - Bronchopulmonary dysplasia
   c. Ground grass appearance - Respiratory distress syndrome/ primary surfactant deficiency
   d. Nitrogen washout test – congenital heart disease (after all that revision this was the only question that came up. Great)
   e. Meconium aspiration – asymmetrical patchy, opacities

Question 225

6. Childhood malignancies presentation
   a. Nephroblastoma, same as Wilms
   b. Retinoblastoma
   c. Osteoid sarcoma
   d. ALL
   e. Posterior fossa tumour

Answer 225

a. Nephroblastoma, same as Wilms – before 5, large abdo mass
b. Retinoblastoma – white pupillary reflex and a squint. (chromosome 13)
c. Osteoid sarcoma – painful bone
d. infection, anaemia, limp, bruising
e. Posterior fossa tumour – medulloblastoma

Question 226

7. Which virus caused the following conditions
   a. Kid with sore throat, cervical lymphademopathy, been given antibiotics, rash comes on.
   b. Rash that started from behind the ears and spread to trunk, parents are vegetarians and kid goes to school in north London

Answer 226

a. Kid with sore throat, cervical lymphademopathy, been given antibiotics, rash comes on. EBV
b. Rash that started from behind the ears and spread to trunk, parents are vegetarians and kid goes to school in north London – measles

Question 227

8. Gastroinestional
   a. Intermittent pain, dehydrated, vomited 3 times
   b. Sudden abdo pain, well child, something indentable on the L lower quadrant
   c. Scaphoid abdomen (never heard of that term before until the exam!)

Answer 227

a. Intermittent pain, dehydrated, vomited 3 times - Intussesception
b. Sudden abdo pain, well child, something indentable on the L lower quadrant – constipation
c. Scaphoid abdomen (never heard of that term before until the exam!) – diaphragmatic hernia

Question 228

2. Ethics – 78 year old fell and sustained a fractured NoF and refuse surgery, son is a lawyer and says his mother does not have capacity, what should you do?

Answer 228

Access capacity

Question 229

3. Someone who just started on an antipsychotic and becomes tachycardia, hyperthermia, sweating, urine drug screen negative.

Answer 229

Neuroleptic malignancy syndrome

Question 230

4. Which of the following condition would a kid’s twin brother has if he was diagnosed with it?

Answer 230

ADHD

Question 231

5. Diagnosed bipolar disorder – sudden renal failure, what do you check? Lithium levels, U&Es, Thyroid

Answer 231

Lithium levels

Question 232

8. Someone is brought in by their mother to AE and appears psychotic what section would you put them under?

Answer 232

Section 2 (in emerhency could do 4)

Question 233

9. Someone with acute dystonia what would you give?

Answer 233

Procyclidine

Question 234

10. Someone with bulimia, BMI 22, well and keen to get treatment.

Answer 234

CBT

Question 235

14. Out of the following people, who is likely to commit suicide?
    a. Women
    b. People who work in managerial roles
    c. People who are 40-50
    d. People who are married

Answer 235

c. People who are 40-50

Question 236

15. If all these children have learning disability, who is most likely to have mental disorder later on?
    a. Child with epilepsy
    b. Child with long term illness
    c. Child with malignancy

Answer 236

b. Child with long term illness

Question 237

18. Women with mild depression what is your management

Answer 237

CBT

Question 238

20. Women with sudden confusion what would you do first?

Answer 238

Urine dip

Question 239

21. One of the criteria for learning disability?

Answer 239

IQ <70

Question 240

1. Psychiatry drugs
   a. Failed 2 antipsychotics
   b. Someone who was started on haloperidol and has acute muscle spasm (acute dystonic)
   c. Someone who is aggressive and needs rapid tranqulisation
   d. Moderate Depression in young adult

Answer 240

a. Failed 2 antipsychotics – clozapine
b. Someone who was started on haloperidol and has acute muscle spasm (acute dystonic) – procyclidine
c. Someone who is aggressive and needs rapid tranqulisation – non psychotic: oral lorazepam, psychotic: lorazepam + haloperidol IM: lorazepam + haloperidol
d. Moderate Depression in young adult – CBT + medication (she said citalopram)

Question 241

3. Substance misuse

a. Something that works on 5HT receptors?

Answer 241

MDMA/ ectasy

Question 242

2. Psychiatry services who to refer to?
   a. Who would you refer a schizophrenic patient to if they are being discharged and needs support in the community regarding treatment?
   b. Someone with schizo and need help organizing their activities after they are being discharged?
   c. Girl who overdose in front of her boyfriend after a row, no previous suicide/ self-harm attempts. Good health. Only did it because she wanted attention from her boyfriend.

Answer 242

2. Psychiatry services who to refer to?
   a. Who would you refer a schizophrenic patient to if they are being discharged and needs support in the community regarding treatment? Community psychiatric nurse (she said) HTT
   b. Someone with schizo and need help organizing their activities after they are being discharged? Occupational therapist
   c. Girl who overdose in front of her boyfriend after a row, no previous suicide/ self-harm attempts. Good health. Only did it because she wanted attention from her boyfriend. – GP

Question 243

40 year old premature ovarian failure and wanted medication to deal with the symptoms of menopause. What would you prescribe her?

Answer 243

HRT

Question 244

Woman is pregnant and HIV negative at booking but her partner is HIV positive - what do you do?

Answer 244

Nothing

Question 245

What signifies onset of active labour?

Answer 245

Regular contractions

Question 246

Woman with white discharge and itch. Which treatment?

Answer 246

Oral Fluconazole, Topical Clotrimazole

Question 247

Pregnant woman with itchy feet, what investigation?

Answer 247

Liver function tests 

Question 248

Results show azoospermia. How should they be managed? IVF, egg donation, ICSI, IUI

Answer 248

ICSI

Question 249

Ovarian Cysts:
Options: Mature teratoma, Dysgerminoma, serous cystadenoma, endometroima
● Cyst contains hair and teeth.
● Ground glass appearance
● Woman has pain before periods and has been subfertile, cyst found on ovary.

Answer 249

● Cyst contains hair and teeth. - Teratoma
● Ground glass appearance - Endometrioma
● Woman has pain before periods and has been subfertile, cyst found on ovary - Endometrioma

Question 250

Gynae Cancer - endometiral cancer, VIN, vulval cancer, cervical cancer

• Post menopausal woman has bleeding
• 70 year old lady has some spotting and says she uses some steroid cream for a “rash down there”
• Woman had some bleeding and curettage of the endometrium had carcinomatous change (it genuinely said this or something like this!)
• Lady is on Tamoxifen, which cancer does this increase the risk of? Endometrial cancer

Answer 250

• endometiral cancer
• lichen sclerosis
• Endometrial cancer
• Endometrial cancer

Question 251

STIs

• Green discharge
• White discharge

Answer 251

STIs

• Green discharge- trichomonas
• White discharge- candid

Question 252

Heart Disease:
A newborn appears to be in severe respiratory distress and appears blue. Despite being given high flow O2, his saturations remain at 65%.
What is the next best step to take with regards to his management?
● Chest X-Ray
● Infusion of Prostaglandin
● Surgery
● Indomethacin

Answer 252

● Infusion of Prostaglandin

Question 253

3 months old baby with signs of HF, systolic murmur that radiates over the praecordium

Answer 253

VSD3

Question 254

What is the most important thing to look at in follow up of HSP? ESR, FBC, urine protein and RBCs, platelets

Answer 254

urine protein and RBCs

Question 255

6 year old child with 24 hour history of left peri-orbital swelling. Had an upper respiratory tract infection last week. Left proptosis, visual acuity was normal and had a fever of 38.9. What is the best diagnostic investigation? CT of nasal orbits, USS of nasal orbits, nasal endoscopy, intraocular pressure measurement, plain x-ray of nasal sinus

Answer 255

CT of nasal orbits

Question 256

Boy with itchy bottom, what do you prescribe? Miconazole cream, mebendazole solution

Answer 256

mebendazole

Question 257

Child with 6m of loose stools. Passed one hard blood streaked stool 10 days ago. What investigation? Colonoscopy, stool mc&s, anti TTG, DO NOTHING

Answer 257

DO NOTHING

Question 258

Infant with episodes of throwing arms forward with fists clenched. Febrile seizure, focal seizure, infantile spasms, partial seizure

Answer 258

infantile spasms

Question 259

Mother worried about 2.5 or 3? year old child’s bed wetting. Dry by day, wets bed at night. What do?

Answer 259

Reassure

Question 260

Child with fever of 39, high resp rate, nurse says chest is clear, what investigation do you do? CXR, urinalysis

Answer 260

urinalysis

Question 261

Child with fever, white exudate on one tonsil, diagnosis? Tonsillitis, Quinsy, diphtheria

Answer 261

Quinsy

Question 262

Child with episodes of smelling strange things, hard to communicate with during these episodes, falls asleep for an hour after and doesn’t remember anything. Diagnosis? Focal seizure, absence seizure, tonic clonic, narcolepsy

Answer 262

Focal seizure

Question 263

Mother complains her young child is a fussy eater. She eats soft foods and drinks a lot of milk. Also has been feeling tired recently. Diagnosis?

Answer 263

Iron deficiency anaemia

Question 264

Baby is almost a month old and jaundiced. Parents say has been jaundiced since day 2. Stools are grey or white. Diagnosis?

Answer 264

Biliary atresia

Question 265

Rashes:
Please match up the following pictures to the scenario described
Options (Photos of): Mongolian Blue Spot, Non-blanching rash with glass test (N. Meningitidis), Periorbital cellulitis, Molluscum contagiosum, Blanching rash on the trunk, Eczema on the face

● Child suffers from fever. The fever disappears but she has now developed a rash. She subsequently has febrile convulsions.

● Child appears severely unwell with a non-blanching rash…?

● Mother with cold sores has been kissing her child who has a background of eczema?

● Child has an URTI 2 weeks ago. Has now developed a rash over the back of the legs along with joint and abdominal pain.

Answer 265

● Child suffers from fever. The fever disappears but she has now developed a rash. She subsequently has febrile convulsions. - HHV6 - Roseola Infantum, blanching rash

● Child appears severely unwell with a non-blanching rash…? - Non-blanching rash with glass test (N. Meningitidis)

● Mother with cold sores has been kissing her child who has a background of eczema? Eczema on the face

● Child has an URTI 2 weeks ago. Has now developed a rash over the back of the legs along with joint and abdominal pain. HSP

Question 266

Treatment for skin lesions
Fusidic acid, zinc and castor oil barrier cream, 1% hydrocortisone, no treatment needed
●	Nappy rash with satellite lesions 
●	Nappy rash sparing flexures 
●	Impetigo measuring 8mm 
●	Chicken pox

Answer 266

Treatment for skin lesions
Fusidic acid, zinc and castor oil barrier cream, 1% hydrocortisone, no treatment needed
● Nappy rash with satellite lesions fluconazole
● Nappy rash sparing flexures zinc and castor oil
● Impetigo measuring 8mm fusidic acid
● Chicken pox do nothing

Question 267

ADHD:
Child comes in
Rx?

Answer 267

● Methylphenidate

Question 268

16 y o having sex with a 12 year old - what is your next action?

Answer 268

(call the police, safeguarding…)

Question 269

Boy always playing video games from teenage years, not interested in other people threatening to kill himself? Histrionic, Narcissistic Schizoid personality disorder

Answer 269

Schizoid

Question 270

Kid with spiral fracture. What do you do?

Answer 270

Admit

Question 271

Kid with petechial rashes, low RBC and raised WBC with a limp and I think and sick.

Answer 271

ALL

Question 272

Foreign kid that is drooling and something about not being vaccinated.

Answer 272

Epiglottitis

Question 273

Kid given dexamethasone for croup 12 hours ago by GP, was stable and well with good sats but still mild stridor. What else do you give? Repeat steroids, nebulised adrenaline, Inhaled salbutamol, oxygen

Answer 273

Repeat steroids,

Question 274

Kid with delayed milestones in language, GP clicked his fingers and she turned to look, what’s the next step - refer for hearing assessment, refer to SALT, refer for developmental assessment

Answer 274

refer for hearing assessment

may be unilateral

Question 275

Kid with globally delayed milestones, started to walk at like 18 months, saying 2 word phrases at 3 years, 50 word vocabulary at 3 years or something and some other stuff. What would be the most useful investigation? Detailed development history, MRI, hearing test, etc.

Answer 275

Detailed development history

Question 276

Another kid with a strawberry tongue, what was the likely diagnosis?

Answer 276

scarlet fever or Kawasaki

Question 277

Kid with anal itch, what do you give?

Answer 277

Mebendazole cream

Question 278

Kid with episodes of stiffening of hands and limbs, accompanied by screaming and sweating. Kid with impaired taste stuff, then awareness and then goes to sleep for like an hour and back to normal. No memory of event. Focal seizure, atypical migraine, Absence seizure, Epilepsy, narcolepsy

Answer 278

Focal seizure

Question 279

Another kid that would fall down and scream and stuff but was completely fine afterwards.

Answer 279

Temper tantrum

Question 280

Kid with yellow and grey stools and was like 4 weeks old or something. What do you test for? Conjugated bilirubin levels (always do bilirubin first), G6PD, Coombs Test

Answer 280

Conjugated bilirubin levels (always do bilirubin first)

Question 281

Kid with bouts of crying and episodes where they flex their knees and hips and red stool.

Answer 281

intussusception

Question 282

Hypochloraemic hypokalaemic pH shown, with some clinical information. What is the initial management for it? Correct electrolyte imbalance, surgical consult, abdominal USS

Answer 282

Correct electrolyte imbalance

Question 283

Premature kid that was born distended abdomen, vomiting, episode of blood in stool

Answer 283

NEC

Question 284

Question on a kid who had bloods that demonstrated: low platelets, normal white cells and normal red cells.

Answer 284

ITP

Question 285

7 year old kid headache and secondary nocturnal enuresis. He’s lost 1.5kg. Urine dipstick normal (i.e. no glucose, proteins, blood. Specific gravity ?1.010 to 1.030) What is the likely diagnosis? Urinalysis nil (plasma osmolality not given?). Diabetes insipidus, diabetes mellitus, behavioral enuresis, constipation

Answer 285

Diabetes insipidus

Question 286

Voraciously hungry kid, hypotonia and almond eyes what was the diagnosis? Initial problems feeding, and almond eyes. Down’s, Edwards , Patau’s, Prader-Willi

Answer 286

Prader-Willi

Question 287

7 year old kid has an accident and needs to have his leg amputated below knee. He says no and wants to wait for his mum to approve first but she’s on a business trip, dad says go for it. What do you do: Apply to Court to get amputation in best interests, Proceed with the dad’s consent (assuming dad is biological and still with the wife), wait for mum to give permission, kid is gillick competent - don’t operate.

Answer 287

Proceed with the dad’s consent (assuming dad is biological and still with the wife)

Question 288

Kid with nocturnal enuresis where behavioural therapy and enuresis alarm hasn’t worked. He’s going to friends for a sleepover. What is next management? Desmopressin, restrict fluids

Answer 288

Desmopressin

Question 289

Kid soiling his pants at school, something along those lines. What was the cause for it?

Answer 289

Constipation

Question 290

3 year old kid with unilateral nasal discharge with bleeding and crust or something like that, What was the most likely cause. Foreign body insertion, nasal polyp, cancer

Answer 290

Foreign body insertion

Question 291

Another case with an unwell child where chest was clear, had a fever. Lost weight recently. What do you do next? Glucose. CXR, urine dip, ABG and some other stuff

Answer 291

Glucose

always go with ABC…DEFG approach that’s what you do FIRST

Question 292

Neonate with some cardio problem. Systolic murmur loudest at the left sternal edge 2/6. What was it, PDA, ASD, VSD, tetralogy of Fallot.

Answer 292

tetralogy of Fallot

Question 293

Kid who basically had ADHD. What is the management? CBT, Parental training,
methylphenidate.

Answer 293

Parental training

Question 294

Child who has a hx of very dry skin, rash over arms, getting worse & spreading to ?extensor surfaces. Sister has itchy rash on ankles and wrists. (Sounds like Eczema) What would be the management? Fusidic acid, emollients+1% hydrocortisone, permethrin cream

Answer 294

emollients+1% hydrocortisone

Question 295

Hip pain on exercise and climbing stairs. Prolonged history, otherwise well. Perthes disease, osgood-schlater, septic arthritis

Answer 295

Perthes disease,

Question 296

3 year old Kid with hypochromic microcytic anaemia and low ferritin. What could be the cause? Folate deficiency, Thalassaemia, coeliacs, fussy eater

Answer 296

fussy eater (fussy eater common in this age, they take less iron and get anaemia, which explained the hypochromic microcytic anaemia blood film)

Question 297

Cerebral Palsy (described hemiplegic weakness with brisk reflexes), what area of the brain is affected? Motor cortex, basal ganglia, pyramidal tracts, cerebellum, internal capsule

Answer 297

Motor cortex

Question 298

Kid having 1st set of primary vaccinations, what would stop you giving it? Fever of >38.5, rash from previous vaccine, if her brother had a reaction to it

Answer 298

Fever of >38.5

Question 299

Kid with rough (i.e. sandpaper) rash on face & trunk, flushed face. No rash around mouth - scarlet fever, parvovirus

Answer 299

scarlet fever

Question 300

Kid with 2cm x 2cm neck mass (inframandibular) on L side, painful, neck mass, reactive neutrophils - blood film shows: toxic left shift with reactive neutrophilia
Glandular fever, thyroglossal cyst, mump, Lymphadenitis, lymphoma, mumps

Answer 300

Lymphadenitis

Question 301

Girl with sickle cell, has 0 reticulocytes - parvovirus, acute chest syndrome, stroke, diactylitis

Answer 301

parvovirus

Question 302

Graph of paracetamol ‘overdose’, it had been 7 hours - decide what to give (was given a chart with a treatment line and a measure of something - it was below treatment line)? Activated charcoal, N-acetylcysteine, Gastric lavage, Active monitoring

Answer 302

All patients with a timed plasma paracetamol level on or above a single treatment line joining points of 100mg/L at 4 hours and 15mg/L at 15 hours after ingestion should receive acetylcysteine (Parvolex or generics) based on a new treatment nomogram, regardless of risk factors (see figure 1 below)

Question 303

Newborn with purple spot on face [Sturg-Weber], what is the next best approach? Discharge to Gp follow up, Medical photography, Clotting studies, Send urgently to A&E, MRI/CT

Answer 303

MRI/CT

Question 304

Kid needs fluids, but you can’t get standard IV access. Where do you go? Jugular, brachial, carotid, Intraosseous

Answer 304

Intraosseous

Question 305

Kid with symptoms of nephrotic syndrome - 1st line treatment? ?Steroids, albumin solution

Answer 305

Steroids

Question 306

HIV with undetectable viral load. what is contraindicated in labour? Forceps, ventouse, foetal blood sampling, c section and some other stuff.

Answer 306

foetal blood sampling

Question 307

Standard chicken pox question. Doesn’t remember she had it. What do you do? Check IgG antibodies, check IgM antibodies, give her varicella Ig, give her aciclovir

Answer 307

Check IgG antibodies

Question 308

Woman with BMI 40, abdo distension, urinary symptoms, bowel symptoms and weight loss. What could be it? Ovarian cancer, colorectal cancer, endometrial cancer etc.

Answer 308

Ovarian cancer

Question 309

60 year old woman with PMB and superficial dyspareunia, what is the MOST LIKELY diagnosis?

Answer 309

Atrophic vaginitis

Question 310

Woman had an implant inserted but she’s getting it removed. What is the most likely reason why? Weight gain, irregular bleeding , hirsutism, etc

Answer 310

Irregular bleeding

Question 311

What cancer are you at increased risk at with HRT? Ovarian, endometrial, cervical, bowel, breast, etc.

Answer 311

breast

Question 312

Cervical os is open in a young woman early pregnancy. What is it?

Answer 312

Inevitable miscarriage

Question 313

Woman with pre-eclampsia, what drug do you give her first-line? Labetalol, Nifedipine, Methyldopa, and some others

Answer 313

Labetalol

Question 314

Mother had rupture of membranes at like 32 weeks. What do you give her? IM dexamethasone, magnesium sulphate, something that began with c

Answer 314

IM dexamethasone

Question 315

Intermittent pain in a young woman not pregnant? Ovarian torsion, primary dysmenorrhoea, endometriosis

Answer 315

endometriosis

1 in ten women endometriosis vs 1/100000 torsion

Question 316

17yr old girl wanting Emergency contraception more than 5 days after unprotected sex. Copper IUD, Levonestrogel, IUS, COCP

Answer 316

Copper IUD

Question 317

Babies head comes out but it kinda goes back in. What is the cause?

Turtle neck

Answer 317

Shoulder dystocia

Question 318

Some girl with painful periods in the first 2 days of her period ever since menarche, she has heavy bleeding. What is it? Primary dysmenorrhoea, endometriosis, endometrial cyst

Answer 318

Primary dysmenorrhoea

Question 319

Pregnant woman in early pregnancy with depression and anxiety on sertraline. What do you do? Stop sertraline, carry it on, prescribe high-dose folic acid, reduce the dose

Answer 319

Carry it on

Question 320

Post partum haemorrhage with high BP - carboprost, misoprostol, ergometrine, syntocinon

Answer 320

syntocinon

Question 321

What’s the management for DVT risk in a pregnant woman or something like that who’s coming in for a planned cesarean? LMWH, LMHW and Ted stockings, Ted stockings, Warfarin or something, Aspirin, Aspirin and Ted stockings

Answer 321

LMHW and Ted stockings

Question 322

Some pregnant woman with some itch. What tests do you do?

Answer 322

Bile acids

Question 323

Woman with blocked tubes, blocked tubes on hysterosalpingogram, what treatment should you do for fertility? IVF, IUI, ICSI.

Answer 323

IVF

Question 324

Some smear question she is 47 y/o. It was borderline HPV negative, what do you do? Repeat in 6w, repeat 6m, repeat 1y, discharge to routine (2y), discharge to routine (3y)

Answer 324

discharge to routine (3y)

Question 325

Down’s syndrome person gets pregnant. Mum is like allow that and wants termination for her and Down’s person wants to keep it. What should you do? Assess patient’s mental capacity without mum present (everyone assumed to have capacity until proven otherwise so asses it)

Answer 325

Assess capacity

Question 326

Heavy periods in a girl not sexually active. What do you give her? COCP, mefenamic acid, tranexamic acid

Answer 326

tranexamic acid

Question 327

Woman with high BMI (28) who basically had stress incontinence. What’s the first line management? Pelvic floor exercises, oxybutinin, bladder training (was this an option?, weight loss and all that

Answer 327

Pelvic floor

Question 328

What do you measure at booking for hepatitis b?

Answer 328

Hep B surface antigen

Question 329

What procedure is contra-indicated in HIV pregnant woman? Foetal blood sampling, C section, forceps, ventousse

Answer 329

Foetal blood sampling

Question 330

Man with azospermia - what is the most common cause? (think this was a repeat)
varicocele, mumps orchitis

Answer 330

varicocele

Question 331

Woman with offensive smelly lochia d2 post-partum, had had some high vaginal swabs? Reassure and discharge, await swab results, give antibiotics, abdo USS

Answer 331

give antibiotics

Question 332

Woman at term has just SROM’d, transverse lie clear liquid but fetal distress, why? Cord prolapse, vasa previa, placenta previa, placental abruption, uterine rupture

Answer 332

Cord prolapse

Question 333

Large mum (BMI >40), head comes out then goes back in, chin not visible. Rupture, short cord, shoulder dystocia, normal mechanism of labour

Answer 333

shoulder dystocia

Question 334

70yo w/ 2 pmbs, TVUS shows 6mm endometrium and 3 cm simple ovarian cyst. Next step? Ca125, diagnostic laparoscopy, pipelle,

Answer 334

Ca125

• all PM women with >1cm cyst = require RMI determination

RMI I combines three presurgical features: serum CA-125 (CA-125); menopausal status (M); and ultrasound score (U).The RMI is a product of the ultrasound scan score, the menopausal status and the serum CA-125 level (IU/ml) as follows:
RMI = U x M x CA-125.

● The ultrasound result is scored 1 point for each of the following characteristics: multilocular cysts, solid areas, metastases, ascites and bilateral lesions. U = 0 (for an ultrasound score of 0), U = 1 (for an ultrasound score of 1), U = 3 (for an ultrasound score of 2–5).
● The menopausal status is scored as 1 = premenopausal and 3 = postmenopausal.
● Postmenopausal can be defined as women who have had no period for more than one year or women over
the age of 50 who have had a hysterectomy.
● Serum CA-125 is measured in IU/ml and can vary between zero to hundreds or even thousands of units.

Question 335

How to calculate RMI?

Answer 335

RMI I combines three presurgical features: serum CA-125 (CA-125); menopausal status (M); and ultrasound score (U).The RMI is a product of the ultrasound scan score, the menopausal status and the serum CA-125 level (IU/ml) as follows:
RMI = U x M x CA-125.

● The ultrasound result is scored 1 point for each of the following characteristics: multilocular cysts, solid areas, metastases, ascites and bilateral lesions. U = 0 (for an ultrasound score of 0), U = 1 (for an ultrasound score of 1), U = 3 (for an ultrasound score of 2–5).
● The menopausal status is scored as 1 = premenopausal and 3 = postmenopausal.
● Postmenopausal can be defined as women who have had no period for more than one year or women over
the age of 50 who have had a hysterectomy.
● Serum CA-125 is measured in IU/ml and can vary between zero to hundreds or even thousands of units.

Question 336

The very last question was a bunch of tests for a woman who couldn’t conceive- all test normal and prolactin raised by like 2 points above normal value what’s most likely cause?

Answer 336

Unknown

Question 337

Drug to give for depression in a guy who had an MI.

Answer 337

Sertraline

Question 338

Old age boxer rips out cannula, attacks staff what do you do? Calm him with verbal de-escalation, make him some tea LOL, debrief the nurses, start iv Abx

Answer 338

verbal de-escalation

Question 339

Guy on haloperidol gets muscle problems

Answer 339

give IM procyclidine

Question 340

Woman experienced trauma 6 months ago/has PTSD best management?- trauma focused cbt wasn’t option, EMDR , (cognitive analytical therapy i think was on there)

Answer 340

EMDR

Question 341

Guy works as an IT engineer, doesn’t like sex, or people

Answer 341

schizoid

Question 342

Guy worries about running kids over so has to check the road or something everytime

Answer 342

OCD

Question 343

Woman basically worries about blushing in public (buzzword)-

Answer 343

social phobia

Question 344

Guy has a fear of public speaking, worried about embarrassing himself, hasn’t seen his personal tutor, hasn’t left the house in a few? weeks, gets sick thinking about it. social phobia, agoraphobia, avoidant personality disorder (or something like that)

Answer 344

Social

Question 345

Some schizo making a scene in public and police want to detain him, which MHA?

Answer 345

136

Question 346

Alcoholic wants to quit and wants something for reducing cravings (acamprosate, naltrexone, disulfiram)

Answer 346

Naltrexone safe if they haven’t already stopped

Question 347

Guy on antipsychotic comes in with tremor- most likely drug

Answer 347

haloperidol

Question 348

Child has classic symptoms of ADHD, how do you manage? Methlyephenidate, Family Therapy or CBT

Answer 348

Family Therapy

Question 349

Guy writes letters to the PM, think he’s being spied on by the government for the past 10 years, shows no other symptoms

Answer 349

Delusional disorder,

Question 350

Man with history of paranoid schizophrenia, his Ix and tests are strongly suggestive of an MI, needs treatment. He has capacity and refuses treatment - what should you do? Treat him under DoLs, treat under MCA, treat under MHA, respect his wishes

Answer 350

respect his wishes

Question 351

Lithium - what do you monitor?

Answer 351

Lithium, TFTs, U&E

Question 352

Patient on ward becomes aggressive, verbal de-escalation hasn’t worked. Tx? Oral haloperidol, oral lorazepam, IM lorazepam, IM haloperidol, IM haloperidol & lorazepam

Answer 352

IM lorazepam

Question 353

50y lady fell over gardening, comes in with paralysis of leg, no medical cause found? Conversion disorder

Answer 353

Conversion disorder

Question 354

• 70 year old lady has some spotting and says she uses some steroid cream for a “rash down there” – lichen sclerosis –

Answer 354

steroid treatment

 Lichen sclerosis is the commonest cause of vulval itching. There is severe itchiness, especially at night. Inflammatory adhesions can form, with potential labial fusion and stenosis of introitus.
 Leucoplakia (white plaques) and atrophic changes
 Treatment = ultra-potent topical steroids

Question 355

• Lady is 47 y/o. It was borderline dyskaryosis and HPV negative, what do you do? Repeat in 6w, repeat 6m, repeat 1y, discharge to routine (2y), discharge to routine (3y)

Answer 355

discharge to routine (3y)

Question 356

• Gardasil – what does it protect against. Name the one from the list: HIV, HSV1, HSV2, HPV11, HPV29?

Answer 356

HPV11

HPV 16/18 are implicated mostly in cervical cancer

Question 357

• Woman = BMI 40, abdominal distension, urinary symptoms, bowel symptoms and weight loss. What could be it? Ovarian cancer, colorectal cancer, endometrial cancer etc.

Answer 357

Ovarian cancer

Question 358

• Asymptomatic woman, nulliparous, found to have a 5.4cm unilocular ovarian cyst on US, no FHx. What is the next appropriate step? USS guided cyst aspiration, laparoscopic removal of cyst, discharge and safety-net, rearrange USS in 3 months and Ca125 follow-up

Answer 358

rearrange USS in 3 months and Ca125 follow-up

Question 359

• 60-year-old woman with PMB and superficial dysuria and dyspareunia, what is the most likely diagnosis?

Answer 359

Atrophic vaginitis
 This is vaginal irritation caused by thinning of the epithelium. It is due to reduction of circulating oestrogen levels. Caused by menopause and prolonged lactation.
 O/E = pale, thin vaginal walls with cracks and fissures. Loss of rugal folds.
 Swabs can be done for any superimposed infection risk.
 Manage with topical oestrogens or systemic HRT

Question 360

• What is the commonest type of endometrial cancer?

Answer 360

ADENOCARCINOMA
Other types are stromal sarcoma, myometrial sarcoma (a.k.a. leimyosarcoma), atypical myometrial tumours (e.g. leimyoblastoma, clear cell leiomyoma).

Question 361

• 72-year-old woman with PMB and endometrial thickness seen on USS, what’s the diagnosis?

Answer 361

Endometrial hyperplasia/cancer

Endometrial hyperplasia is the precursor to cancer. It can be simple or complex (atypical). Treat this with progesterone for its regression, and redo the biopsy 3 months later. This can be repeated up to one year. If it is still abnormal for 1 year, perform a hysterectomy.
The surgery done is a total abdominal hysterectomy and bilateral salpingo-oopherectomy.

Question 362

• Post-menopausal woman with a PV bleed. What ix should you do?
  Laparotomy and hysteroscopy, outpatient USS with endometrial biopsy, CT, MRI

Answer 362

outpatient USS with endometrial biopsy

Question 363

• 70-year-old women with 2 PMBs, TVUSS shows 6mm endometrium and 3cm simple ovarian cyst. What is the next appropriate step? Ca125, diagnostic laparscopy, pipelle

Answer 363

Ca125,

• * THIS IS THE NEXT STEP – NOT INVASIVE YET. FIRST WE HAVE TO CHECK CA125 LEVELS!!!!!!***

Question 364

• A 47 year old woman with a 2 cm simple ovarian cyst seen on USS, as well as 12mm endometrium. What do you do next?
  (a) Repeat USS
  (b) Ca 125 levels
  (c) Hysteroscopy
  (d) Pipelle biopsy
  (e) Reassure & discharge

Answer 364

Pipelle biopsy

Question 365

• Woman BP 120/80, smokes 5/day, what contraception for her?

Answer 365

COCP – no absolute contraindications.

Question 366

• Woman on COCP, has missed 6th and 7th day pill, had unprotected sex two days ago, her urine pregnancy is clear. What to do? Repeat in a week, reassure and discharge, emergency contraception

Answer 366

emergency contraception

Question 367

• Woman had a Nexplanon implant inserted but she’s getting it removed. What is the most likely reason why? Weight gain, irregular bleeding, hirsutism [REPEAT]

Answer 367

irregular bleeding

Question 368

• What type of contraception can increase risk of osteoporosis?

Answer 368

Depot injections

Question 369

• 32 year old has completed family. Had COCP before, what contraception now?

Answer 369

Mirena coil

Question 370

• What cancer are you at increased risk at with HRT? Ovarian, endometrial, cervical, bowel, breast, etc.

Answer 370

breast

 Hormone replacement therapy (HRT) includes the use of a small dose of oestrogen (with progesterone in women with a uterus) to help alleviate menopausal symptoms
 Side effects: nausea, breast tenderness, fluid retention, weight gain
 Complications: increased risk of breast cancer (higher risk when combined preparations of oestrogen AND progesterone), increased risk of endometrial cancer (LOWER risk when combined with progesterone), VTE, stroke, ischaemic heart disease (if taken >10 years after the menopause)

Question 371

• HRT question for a menopausal woman with flushes and stuff, last period ?10m ago (less than a year). What do you give her? Cyclical combined HRT, oestrogen only HRT, topical HRT, continuous HRT -

Answer 371

Cyclical combined HRT

They called cyclical, sequential in the exam

Question 372

• Woman who swims wants to treat hot flushes, doesn’t want a patch and has irregular menstruation.

Answer 372

Cyclical oral combined HRT or COCP depending on if she has bled in past 12 months and wants to have periods/get pregnant

Question 373

• Woman with premature ovarian failure, wants to have periods.

Answer 373

COCP

Question 374

• Woman who just wants to treat osteoporosis.

Answer 374

Bisphosphonates

Treatment for osteoporosis: bisphosphonates, strontium ranelate, SERMS e.g. raloxifene

Or denosumab ;)

Question 375

• 40 year old premature ovarian failure and wanted medication to deal with the symptoms of menopause. What would you prescribe her?

Answer 375

Cyclical combined HRT (oestrogen and progesterone) as she still has a uterus to decrease risk of endometrial cancer

Question 376

Hormonal profiles: GH, LH, FSH, prolactin, free androgens

• Anorexia =

Answer 376

hypothalamic hypogonadism. High GH, low LH, low FSH, normal prolactin

Question 377

Hormonal profiles: LH, FSH, prolactin,

• Prolactinoma =

Answer 377

high prolactin (causes low GnRH release) therefore low LH and FSH. Treat with dopamine agonists e.g. bromocriptine to restore ovulation as DA inhibits prolactin release.

Question 378

Hormonal profiles: LH, FSH,

• Menopause =

Answer 378

high LH, high FSH, low anti-mullerian hormone, low oestradiol and low inhibin

Question 379

Hormonal profiles: GH, LH, FSH, prolactin, free androgens

• PCOS =

Answer 379

raised LH:FSH ratio (>2.5), high free androgens

Question 380

presents as sharp unilateral pain immediately following intercourse or strenuous exercise. Bimanual examination in non-severe cases is generally unremarkable but the lower abdomen is tender. Ultrasound shows free fluid in the pelvic cavity.

Answer 380

Ruptured ovarian cyst

Question 381

can present with sharp unilateral pain with nausea and vomiting. There is a tender palpable adnexal mass on bimanual exam. USS: enlarged, oedematous ovary with impaired blood flow, whirlpool sign. Doppler scan may show little or no ovarian venous flow. USS whirlpool sign can also be seen when bowel twists on itself causing a volvulus.

Answer 381

Ovarian or adnexal torsion

Question 382

mid-cycle pain. Usually goes away over 24-48 hours.

Answer 382

Mittelschmerz

Question 383

Hx: A 28-year-old woman complains of a two year history of bad period pains which are not controlled by NSAIDs or the combined contraceptive pill. She also reports significant pains during intercourse

Answer 383

USS can show free-fluid. Laparoscopy will show endometriosis lesions.

Endometriosis

Question 384

bilateral lower abdo pain associated with vaginal discharge. Dysuria may also be present. Peri-hepatic inflammation secondary to chlamydia = Fitz Hugh Curtis syndrome. Fever is present and amylase can also be slightly raised. Treat the cause. Hysterosalpingography may show bilaterally blocked fallopian tubes.

Answer 384

Pelvic inflammatory disease –

Question 385

Cervical excitation on examination =

Answer 385

PID or ectopic pregnancy

Question 386

• Woman with really heavy periods and doesn’t want to get pregnant. What’s first line management?
  (a) COCP
  (b) Implant
  (c) IUS (if no desire for kids, give her the IUS, if wants kids then tranexamic acid)
  (d) IUD
  (e) Tranexamic Acid
  (f) Mefenamic Acid

Answer 386

(c) IUS (if no desire for kids, give her the IUS, if wants kids then tranexamic acid)

Question 387

• Heavy periods in a girl not sexually active. What do you give her?

Answer 387

Tranexamic acid

Question 388

• Some girl with painful periods in the first 2 days of her period ever since menarche, she has heavy bleeding. What is it? Primary dysmenorrhoea, endometriosis, endometrial cyst

Answer 388

Primary dysmenorrhoea,

Question 389

• Woman with PCOS. Best medication to increase fertility.

Answer 389

Clomiphene

Question 390

• Woman presents with cystic ovaries on USS and irregular periods. What other symptom would be the best indicator of her having polycystic ovaries? Dysmenorrhoea, Hirsutism, Obesity, Acne.

Answer 390

Hirsutism

Question 391

• Subfertile woman, all tests normal and prolactin raised by 2 points above normal value. What’s most likely cause?

Answer 391

• Subfertile woman, all tests normal and prolactin raised by 2 points above normal value. What’s most likely cause? Unknown (accounts for like 30% of subfertility), prolactinoma (prolactin would be in 1000s), raised testosterone suggests PCOS and LH:FSH ratio>2:1

Question 392

• Woman with blocked tubes, blocked tubes on hysterosalpingogram, what treatment should you do for fertility? IVF, IUI, ICSI.

Answer 392

IVF

Question 393

• Amenorrhoea for 4 months - what test do you do?

Answer 393

B-HCG / preg test

Question 394

• 19-year-old abdominal swelling, weight gain, irregular periods, can’t remember LMP and denies being sexually active. What is the first test you would do?

Answer 394

Pregnancy test,

Question 395

• Woman with cyclic pain 1 week before her period starts, trying for a baby for one year. What is the likely diagnosis?

Answer 395

endometriosis

Question 396

• Woman with signs of premature ovarian failure. What test would be best to confirm this diagnosis: Oestradiol, Testosterone, FSH

Answer 396

FSH

Question 397

• Male presents with azoospermia - what is the most common cause? [REPEAT 2016+2018]
  (a) Varicocele
  (b) History of mumps orchitis
  (c) History of testicular torsion

Answer 397

(a) Varicocele (accounts for 25% of male subfertility)

Question 398

• Results show azoospermia. How should they be managed? IVF, egg donation, ICSI, IUI

Answer 398

ICSI

Question 399

• Woman with BMI 28 (i.e. overweight) leaks urine when laughing and going up the stars. What’s the first line management?

Answer 399

Stress incontinence  pelvic floor exercises. 2nd line is surgery – retropubic mid-urethral tape
Urge incontinence (a.k.a. overactive bladder)  bladder training (at least 6 weeks). 2nd line = anti-muscarinics e.g. oxybutynin, tolterodine. Oxybutynin should be avoided in old people.
Overflow incontinence – due to bladder outlet obstruction e.g. prostate enlargement

Question 400

• 47-year-old woman with menorrhagia, dysmenorrhoea and USS with multiple fibroids. Doesn’t want any more children. What is good treatment?

Answer 400

Hysterectomy

Question 401

• 14 year old girl wants TOP, can’t/will not inform parents. What do you do?

Answer 401

Persuade her to tell her parents if she refuses and gillick competent, you can give her TOP

Question 402

• 14 year old with primary amenorrhoea and ejection systolic murmur. What is Dx?

Answer 402

Turner’s syndrome

Question 403

EMQ

(a) Mastitis
(b) intraductal papilloma
(c) malignancy
(d) abscess
(e) genital warts
(f) Bartholins cyst

• Lady high WCC, fever, lump in breast –
• General breast tenderness, left sided, breastfeeding –
• Small slow growing lesion on labia, pregnant lady –
  Small painful lump inside vagina of sexually active woman –
  What is the treatment for Bartholin’s cyst –

Answer 403

• Lady high WCC, fever, lump in breast – abscess
• General breast tenderness, left sided, breastfeeding – mastitis
• Small slow growing lesion on labia, pregnant lady – Genital Warts (pregnancy causes them to grow)
  Small painful lump inside vagina of sexually active woman – Bartholin’s Cyst
  What is the treatment for Bartholin’s cyst – marsupialisation

Question 404

Pessary for prolapse?

Answer 404

Urogynae – types of pessary (ring, shelf, hodgson). Uterine prolapse = ring pessary 

Question 405

• Woman with a slow growing painless lesion on labia -

Answer 405

Genital warts, also known as condylomata accuminata are common. Caused by many varieties of HPV (especially 6 and 11). Small, fleshy protuberances which are slightly pigmented. May bleed or itch. Treatment = topical podophyllum or cryotherapy are first-line. Multiple, non-keratinised warts respond better with topical agents; solitary, keratinised warts respond better to cryotherapy. Imiquimod is a topical cream used second line. These grow during pregnancy.

Question 406

• Woman with tender lump inside her vagina –

Answer 406

Bartolin’s cyst

With infection = abscess. Rx = antibiotics, or marsupialisation (insertion of a word catheter)

Question 407

• Old woman complaining of superficial dyspareunia –

Answer 407

atrophic vaginitis

Question 408

• Painful multiple lesions/genital ulcerations on labia – herpes  Rx

Answer 408

= oral acyclovir

Question 409

• Blue dots on cervix –

Answer 409

Nathobian cyst

Question 410

• Woman with cheesy, curd-like white discharge –

Answer 410

candidiasis

Question 411

• What is the appropriate treatment for candida?

Answer 411

Oral fluconazole, topical clotrimazole

DUO

Question 412

• Young woman, dyspareunia, ‘strawberry cervix’

Answer 412

= Trichomonas vaginalis

Question 413

• Yellow/green (frothy) discharge

-

Answer 413

= Trichomonas vaginalis

• Pinpoint areas of exudation may also be present. Treated with oral metronidazole

Question 414

• Clue cells =

Answer 414

bacterial vaginosis

• Rx = oral metronidazole for 5-7 days
  Caused by Gardnerella vaginalis. Raised vaginal pH >4.5 and a positive whiff test. Relapse rate is >50% within 3 months. Alternatives to oral metronidazole are topical metronidazole or topical clindamycin.

Question 415

Gram-negative diplococcus bacterial infection with vaginal discharge –>

Answer 415

Neisseria gonorrhoea. Rx: single dose of IM ceftriaxone 500mg and oral azithromycin 1g. These act synergistically and is useful for also killing co-existent Chlamydia [usually treated with azithromycin or doxycycline].

Question 416

• Cyst contains hair and teeth –

Answer 416

mature cystic teratoma (a.k.a. dermoid cyst)

Question 417

• Ground glass appearance –

Answer 417

endometrioma

Question 418

• Woman has pain before periods and has been sub-fertile

Answer 418

– chocolate cyst on ovary

Question 419

• What procedure is contra-indicated in HIV pregnant woman?
  (a) Foetal blood sampling
  (b) C-section
  (c) Forceps
  (d) ventouse

Answer 419

(a) Foetal blood sampling

Question 420

• Woman is pregnant and HIV -ve at booking but her partner is HIV +ve. What do you do?

Answer 420

Nothing

Question 421

• Standard chicken pox question. Doesn’t remember she had it. What do you do first?
  (a) Check IgG antibodies
  (b) Check IgM antibodies
  (c) Give her varicella Ig
  (d) Give her acyclovir

Answer 421

(a) Check IgG antibodies - first line. IgG = memory response mounted versus VZV.

Question 422

• Pregnant woman with itchiness, what test do you do? Serum bile acids, uric acids, FBCs, bilirubin, transaminases, or liver function tests?

Answer 422

Serum bile acids

Question 423

• UTI in first trimester of pregnancy. What would be the safest and most effective treatment? Trimethoprim, Ciprofloxacin, Doxycycline, Cefalexin, Meropenem

Answer 423

Cefalexin

 Trimethoprim is a folate antagonist and it is therefore teratogenic in the first trimester of pregnancy. Its use is also avoided throughout pregnancy
 In pregnant women, nitrofurantoin can be used instead for a UTI. But nitrofurantoin should be avoided in women at full-term due to risk of neonatal haemolysis.
 Tetracyclines (doxycycline), aminoglycosides, sulphonamides, trimethoprim, meropenem and quinolones (ciprofloxacin) are contraindicated in pregnancy.

Question 424

• Pregnant woman with gram negative bacilli in urine microscopy. Number was a bit low and on repeat was still low. What do you do? Watch and wait, give amoxicillin, urgent referral, some scans

Answer 424

give amoxicillin

Asymptomatic bacteriuria in pregnancy  immediate Abx: nitrofurantoin (avoid at term), or amoxicillin (3 times a day for 7 days), or cefalexin.

Question 425

• What is the leading cause of mortality (maternal) in the UK?

Answer 425

Cardiovascular disease

Question 426

• Down’s syndrome person gets pregnant. Mum is like allow that and wants termination for her and Down’s person wants to keep it. What should you do?

Answer 426

Assess patient’s mental capacity without mum present (everyone assumed to have capacity until proven otherwise so assess it)

Question 427

• Woman 38/40 has come in for her elective c/s, ECV failed, what do you do now?

Answer 427

(b) Carry on with the C-Section as planned

Question 428

• Woman previously had an abortion due to severe spina bifida. No other clinical information given. What do you advise her on folic acid doses for her next pregnancy?

Answer 428

5mg of folic acid before conception until week 12 pregnancy

This dose should be taken by all women at higher risk of conceiving a child with NTD - criteria:
 Either partner has NTD
 Previous pregnancy affected by NTD
 Family history of NTD
 Woman is taking antiepileptics, or has coeliac disease, diabetes, or thalassaemia trait
 Woman is obese i.e. BMI >30
All other healthy women should take 400mcg of folic acid until week 12 pregnancy.

Question 429

• Large mum (BMI >40), head comes out then goes back in, chin not visible. What is the cause? Uterine rupture, short cord, shoulder dystocia, normal mechanism of labour.

Answer 429

shoulder dystocia

Turtle head (not a poo)

Question 430

• Poorly controlled diabetic mother, newborn has an abnormal asymmetric Moro reflex - what’s wrong?
  (a) Hypoxic Ischaemic Encephalopathy
  (b) Fracture of humerus
  (c) Brachial plexus injury - secondary to probably shoulder dystocia because of diabetes

Answer 430

(c) Brachial plexus injury - secondary to probably shoulder dystocia because of diabetes

Question 431

• What’s the management for DVT risk in a pregnant woman or something like that who’s coming in for a planned cesarean? LMWH, LMWH and Ted stockings, Warfarin, Aspirin, Aspirin and Ted stockings

Answer 431

LMWH and Ted stockings

Question 432

• What do you do in a woman in labour after 4 hours of checking, she is 4cm dilated? Prostaglandins, Cervical sweep, Oxytocin, Ergometrine, ARM

Answer 432

Cervical sweep

Question 433

• What is a screening tool for Down’s syndrome risk?

Answer 433

Nuchal translucency

Question 434

• Foreign woman has come in and is pregnant. What vaccine should she be offered? Hepatitis A, hepatitis B, whooping cough

Answer 434

hepatitis B

Question 435

• What do you measure at booking for Hepatitis B?

Answer 435

Hep B surface antigen.
o If HepBsAg is positive, all babies should receive Hepatits B vaccination.
o Then HepBeAg should be checked too – if this is positive, also give baby Hepatitis B immunoglobulin
o Antibody response to the vaccination course should be checked at 12 months in high-risk infants, as 5% need further vaccination.

Question 436

• Woman at term has just undergone spontaneously rupture of membranes, transverse lie clear liquid but fetal distress, why? Cord prolapse, vasa previa, placenta previa, placental abruption, uterine rupture

Answer 436

Cord prolapse

Question 437

• Pregnant lady being domestically abused by husband and scared to go home. What do you do in GP? Send her home and ask her to come back with husband, give her a leaflet about domestic abuse, call and arrange emergency accommodation

Answer 437

call and arrange emergency accommodation

Question 438

• Pregnant woman in early pregnancy with depression and anxiety on sertraline. What do you do? Stop sertraline, continue sertraline use, prescribe high-dose folic acid, reduce the dose, amitriptyline

Answer 438

continue sertraline use

Question 439

• Effect of taking fluoxetine (paroxetine?) during pregnancy on baby?

Answer 439

Persistent pulmonary hypertension of the newborn

Question 440

• Cervical os is open in a young woman early pregnancy and there is increasing amounts of bleeding, and cramping pain. What is it?

Answer 440

Inevitable miscarriage

Inevitable – bleeding is worsening, os is open. Cramping pain is present
Incomplete – bleeding may have finished. Os is open. No cramping pain
Threatened – os is closed

Question 441

• Woman with mild pre-eclampsia, what drug do you give her first-line? Labetalol, Nifedipine, Methyldopa

Answer 441

Labetalol

if it was higher severity, and needed immediate relief then can give nifedipine

Question 442

• At antenatal check, woman with BP 150/90, what would you do?

Answer 442

Admit and assess

Question 443

• Mother had rupture of membranes at like 32 weeks. What do you give her?

Answer 443

IM dexamethasone

Question 444

• Which describes a 20 or 23 week antenatal USS the best? [REPEAT]
  (a) Tests for nuchal thickness for Down’s
  (b) Tests for congenital heart disease
  (c) Predicts position of placenta at term
  (d) Least amount of radiation to foetus
  (e) 2D with foetal biometry
  (f) Looks for multiple pregnancies

Answer 444

(b) Tests for congenital heart disease

Question 445

• What causes increased urinary volume and frequency in the first trimester? Increased GFR, pressure of uterus on bladder, glycosuria.

Answer 445

Increased GFR

Question 446

• Woman with rupture of membranes, painless bleeding and something along those lines. What was the likely diagnosis? placental praevia, Vasa praevia, Placental abruption, chorioamnionitis

Answer 446

placental praevia

Question 447

• Pregnant women with pain and bleeding, abdomen feels hard -

Answer 447

Placental abruption

Question 448

• A pregnant Turkish lady has low haemoglobin, low MCV, normal MCHC. What is the appropriate next management?
  (a) Blood transfusion
  (b) Iron transfusion
  (c) Oral iron tablets – consider if at 16 weeks and Hb <11; or at 28 weeks and Hb <10.5
  (d) Do bloods again in 2 weeks

Answer 448

(c) Oral iron tablets – consider if at 16 weeks and Hb <11; or at 28 weeks and Hb <10.5

Question 449

When would you admit a patient with excessive vomiting?

Answer 449

Ketonuria

Question 450

Cause of macrosomnia =

Answer 450

gestational diabetes

Question 451

Women with previous GDM, what is the best way to investigate her blood glucose?

Answer 451

OGTT at 28 weeks

Question 452

Woman with APH (spotting), otherwise well. What is the most important thing to rule out?

Answer 452

Ectopic pregnancy

Question 453

• Mother has a stillborn baby, generalised oedematous when it was born. Mother had a fever at 18 weeks with rash on trunk –

Answer 453

parvovirus

Question 454

• Mother was being prepared for C-section, and got a sudden tingling around her mouth? What is the cause?

Answer 454

Spinal block

Question 455

• Mother was being prepared for C-section, has a regional block. Sudden tachycardia, SOB, difficulty breathing. What is the diagnosis?

Answer 455

Anaphylaxis

Question 456

• Mother had a previous C-section. Now presents with sudden abdominal pain and abnormal CTG during labour. What is the diagnosis?

Answer 456

Uterine rupture

Question 457

• Post partum haemorrhage with high BP. What is given to manage this?
  (a) Carboprost
  (b) Misoprostol
  (c) Ergometrine
  (d) Syntocinon

Answer 457

(d) Syntocinon

Question 458

• Woman 8 weeks after normal vaginal delivery and second degree tear, still bleeding and mild lower pelvic pain. Diagnosis? Normal menstruation, PID, endometritis, lochia

Answer 458

endometritis

Question 459

• Woman with offensive smelly lochia 2 days post-partum, had had some high vaginal swabs? Reassure and discharge, await swab results, give antibiotics, abdominal USS

Answer 459

give antibiotics

Question 460

• What is not a risk factor for primary PPH?

a. B thalassaemia trait
b. Retained products
c. Sepsis
d. Vaginal tear
e. Multiparity

Answer 460

a. B thalassaemia trait

Question 461

Med Ed translations:

Pale

Answer 461

Anaemic/shocked

Question 462

Med Ed translations:

Pale and jaundiced

Answer 462

Haemolytic anaemia

Question 463

Med Ed translations:

Drooling

Answer 463

Epiglottitis

Question 464

Med Ed translations:

Recently moved from abroad and don’t have a red book

Answer 464

Unimmunised

Measles/epiglot/meningitis

Question 465

Med Ed translations:

“mum has a new boyfriend”

Answer 465

Child abuse

Question 466

Med Ed translations:

‘Pins and needles’ in hands

Answer 466

Panic attack

Question 467

Med Ed translations:

6 days of fever

Answer 467

Kawasaki’s Disease

Question 468

Med Ed translations:

Mum unable to let go of hand

Answer 468

Myotonic dystrophy

Question 469

Med Ed translations:

Rash with amoxicillin

Answer 469

EBV

Question 470

Med Ed translations:

Irritability

Answer 470

Meningitis

Question 471

Med Ed translations:

Fat teenager

Answer 471

SUFE

Question 472

Med Ed translations:

Gower’s sign positive

Answer 472

Duchenne’s

Question 473

Med Ed translations:

Cap refil >3

Answer 473

Shocked

Question 474

Med Ed translations:

Recently moved from abroad and don’t have red book

Answer 474

No guthrie screening. Think thyroid/PKU/cystic fibrosis

Question 475

Med Ed translations:

Heart appears boot shaped on CXR

Answer 475

Tetralogy

Question 476

Med Ed translations:

Port wine stain

Answer 476

Sturge-Weber

Question 477

Med Ed translations:

Confusion

Answer 477

Encephalitis/opathy

Question 478

Med Ed translations:

Barking cough

Answer 478

Croup

Question 479

Med Ed translations:

Birthday party

Answer 479

Anaphylaxis

Question 480

A healthy 10 month old boy has a 3 day history of coryza and fever up to 38 degrees.
He has a barking cough and over the last few hours has developed inspiratory stridor. He has mild-moderate respiratory distress, and oxygen saturations of 99% on air. He is not drooling. His temperature in the department is 38.2 degrees.

A – Oral dexamethasone and observe in the day unit until respiratory distress settles.
B – Obtain IV access and take a blood culture, commence IV ceftriaxone
C – Adrenaline nebuliser and discharge from A+E if respiratory distress has resolved.
D – Give facial oxygen and a salbutamol nebuliser, and review after 20 minutes
E – Discharge home with 10 puffs 4 hrly inhaled salbutamol and advice to return if increasing respiratory distress

Answer 480

A – Oral dexamethasone and observe in the day unit until respiratory distress settles

Question 481

Lucy is 3 years old and presents with cough and stridor. She appears unwell and is drooling. She has subcostal, substernal recessions and tracheal tug.

What is the most appropriate initial management?

A) Cannulate the child as soon as possible and give IV Ceftriaxone
B) Do not approach the child and call for immediate anaesthetic and ENT support
C) Examine the child’s throat to confirm the diagnosis
D) Give an adrenaline nebuliser and prepare to cannulate
E) Give oral dexamethasone and facial O2

Answer 481

B) Do not approach the child and call for immediate anaesthetic and ENT support

Question 482

Lucy is 3 years old and presents with stridor and a spreading rash after returning from a playdate at a friend’s house.

She is given IM adrenaline in the ambulance and presents to A&E 10 minutes later.

She has loud stridor, swollen lips and respiratory distress. Her SATS are 92% on air and she is wheezy.

What is the most appropriate initial management?

A) 15L O2 via a non-rebreathe bag
B) IM adrenaline
C) Nebulised adrenaline
D) Nebulised salbutamol
E) Obtain IV access and give IV Hydrocortisone

Answer 482

B) IM adrenaline

Question 483

Caoimhe is 4 weeks old. She is brought to A&E with noisy inspiratory breathing which has been more prominent over the last few weeks.
She appears well on examination but has some inspiratory stridor, more obvious when she cries.
She is gaining weight and is afebrile

What is the most likely diagnosis?

A) Croup
B) Epiglottitis
C) Foreign body aspiration
D) Laryngomalacia
E) Subglottic stenosis

Answer 483

D) Laryngomalacia

Question 484

Sunayna is 1 year old and presents with abdominal pain and vomiting. You have been asked to write up full maintenance fluids for her. She weighs 12kg

Which fluid regime would be most appropriate?

A) 500ml bag of 0.9% NaCl followed by 500ml bag of 10% dextrose over 24 hours

B) 1100ml of NaCl 0.9% over 24 hours

C) 1100ml of NaCl 0.9% plus 5% dextrose over 24 hours

D) 1200ml of NaCl 0.9% over 24 hours

E) 1200ml of NaCl 0.9% plus 5% dextrose over 24 hours

Answer 484

C) 1100ml of NaCl 0.9% plus 5% dextrose over 24 hours

3 options
Maintenance fluids

0.9% NaCl + 5% Dextrose
100mls/kg/day for each of first 10kg (ie 0-10kg)
50ml/kg/day for each of next 10kg (ie 10-20kg)
20ml/kg/day for every further kg
Eg 24kg = (100 x 10) + (50 x 10) + (20 x 4)
= 1000 + 500 + 80 = 1580 over 24 h

Bolus fluids
20ml/kg 0.9% NaCl in most situations
10ml/kg when……
DKA, Trauma, Fluid overload or heart failure

Dehydration corrections:
Usually over 24 hours
Maintenance fluids PLUS %dehydration

Most of your body is water -> estimate the % lost

Weigh the child if possible.
1kg weight loss = 1000ml lost

Estimate clinically if not possible
3% weight loss in 20kg child.
20kg = 20000g = 20000mls fluid
1% = 200ml, therefore 3% = 600ml

ADD the correction onto maintenance fluids over 24h

Question 485

Maria is 4 years old and weighs 17kg. She presents with a non-blanching rash and a fever of 39 degrees

Her heart rate is 180 and her blood pressure is 64/40

What is the most appropriate initial fluid management?

A) 1350ml 0.9% NaCl and 5% dextrose over 24 hours

B) 170ml 0.9% NaCl bolus

C) 340ml 0.9% NaCl bolus

D) 340ml 0.9% NaCl and 5% dextrose bolus

E) 340ml ringer’s lactate bolus

Answer 485

C) 340ml 0.9% NaCl bolus

Maintenance fluids

0.9% NaCl + 5% Dextrose
100mls/kg/day for each of first 10kg (ie 0-10kg)
50ml/kg/day for each of next 10kg (ie 10-20kg)
20ml/kg/day for every further kg
Eg 24kg = (100 x 10) + (50 x 10) + (20 x 4)
= 1000 + 500 + 80 = 1580 over 24 h

Bolus fluids
20ml/kg 0.9% NaCl in most situations
10ml/kg when……
DKA, Trauma, Fluid overload or heart failure

Dehydration corrections:
Usually over 24 hours
Maintenance fluids PLUS %dehydration

Most of your body is water -> estimate the % lost

Weigh the child if possible.
1kg weight loss = 1000ml lost

Estimate clinically if not possible
3% weight loss in 20kg child.
20kg = 20000g = 20000mls fluid
1% = 200ml, therefore 3% = 600ml

ADD the correction onto maintenance fluids over 24h

Question 486

Marco presents following 2 days of profuse diarrhoea and vomiting. He has dry lips and is tachycardic, but is not shocked. He is not tolerating any oral intake. You estimate that he is 3% dehydrated. He weighs 10kg.

What would be the most appropriate fluid regimen to correct his dehydration?

A) 200ml 0.9% NaCl bolus, repeated if necessary

B) 200ml 5% dextrose bolus, repeated if necessary

C) 1000ml 0.9% NaCl + 5% dextrose over 24h

D) 1030ml 0.9% NaCl + 5% dextrose over 24 h

E) 1300ml 0.9% NaCl + 5% dextrose over 24 h

Answer 486

E) 1300ml 0.9% NaCl + 5% dextrose over 24 h

3 options
Maintenance fluids

0.9% NaCl + 5% Dextrose
100mls/kg/day for each of first 10kg (ie 0-10kg)
50ml/kg/day for each of next 10kg (ie 10-20kg)
20ml/kg/day for every further kg
Eg 24kg = (100 x 10) + (50 x 10) + (20 x 4)
= 1000 + 500 + 80 = 1580 over 24 h

Bolus fluids
20ml/kg 0.9% NaCl in most situations
10ml/kg when……
DKA, Trauma, Fluid overload or heart failure

Dehydration corrections:
Usually over 24 hours
Maintenance fluids PLUS %dehydration

Most of your body is water -> estimate the % lost

Weigh the child if possible.
1kg weight loss = 1000ml lost

Estimate clinically if not possible
3% weight loss in 20kg child.
20kg = 20000g = 20000mls fluid
1% = 200ml, therefore 3% = 600ml

ADD the correction onto maintenance fluids over 24h

Question 487

Abdul is 6 years old and presents with 24 hours of cough and difficulty in breathing. He is found to be wheezy and is given 3x nebulised salbutamol, 2x ipratropium bromide and oral prednisolone.

30 minutes later he is still wheezy and shows signs of respiratory distress. He appears to be shivering and has vomited twice.

What is the most appropriate next management step?

A) Magnesium Sulfate bolus IV

B) Montelukast orally

C) Salbutamol bolus IV

D) Salmeterol inhaled (long acting B agonist)

E) Salbutamol nebuliser

Answer 487

A) Magnesium Sulfate bolus IV

MED ED RECKONS IV STEPS:

1) MgSO4
2) Salbutamol
3) Aminophylline

I’m not so convinced…most textbooks say salbutamol first

Question 488

George has brittle asthma. He presents with a severe exacerbation.

He is currently on an aminophylline and salbutamol infusion.

His oxygen saturations are 92% on 15L O2 and he appears tired.

What is the most appropriate next management step for George?

A) Aminophylline level and adjust dose accordingly

B) Atrovent nebuliser

C) Hydrocortisone IV

D) Intubation and transfer to PICU

E) Magnesium Sulfate IV

Answer 488

D) Intubation and transfer to PICU

If tiring do safest option

Question 489

Josh is 3 years old and presents with a 24 hour history of cough and difficulty in breathing.

He received inhaled salbutamol and atrovent on presentation.

You review him one hour later. He appears comfortable with no wheeze and good air entry. What would be the most appropriate next step in management?

A) Admit to the ward

B) Magnesium sulfate IV

C) Montelukast orally

D) Prednisolone orally and reassess in 1 hour

E) Salbutamol via spacer 1 hourly

Answer 489

D) Prednisolone orally and reassess in 1 hour

Question 490

Katie is 3 years old. She has been admitted to hospital 4 times with wheezing and has required IV medications once. She has eczema and was started on very low dose inhaled corticosteroids after her 2nd admission

She presents to follow up clinic and her mother reports that she is using her blue inhaler at least once most days. She wakes frequently overnight coughing.

What is the most appropriate advice to offer?

A) Admit to hospital for a sleep study

B) Start a course of oral corticosteroids

C) Start inhaled long acting B agonist

D) Start oral montelukast

E) Use salbutamol more frequently

Answer 490

D) Start Montelukast once a night

Question 491

You are called to the post-natal ward to see Billie, a 3 day old baby. The nurse is concerned that he is breathing quickly and appears pale.

He was born at term to a low risk pregnancy and required no resuscitation. There were no risk factors for sepsis. Antenatal scans were normal.

His RR is 65, HR 180, Cap refil 4 seconds with cool peripheries. Peripheral pulses are difficult to feel. He appears pale. HS I+II+0 and the chest is clear. BM=6.

What is the single most likely diagnosis?

A – Cardiac Arrythmia

B – Co-arctation of the aorta

C – Congenital Pneumonia

D – Hypoplastic left heart syndrome

E – Inborn error of metabolism

Answer 491

B – Co-arctation of the aorta

First Few Hours
Pulmonary/aortic atresia/critical stenosis
Hypoplastic heart syndrome
First few days
Transposition, Tetralogy, large PDA in premature infants
Co-arctation
First few weeks
Aortic Stenosis
Co-arctation
First few months
Any left to right shunt as pulmonary resistance falls.

Question 492

Julia is a 6 month old who was born at 33 weeks.
She presents with 4/7 difficulty in breathing and a cough. She has a runny nose and a fever of 38.2 degrees.
On auscultation you hear wheeze and creps bilaterally. She has significant recessions.

Which investigation is most likely to reveal the diagnosis?

A) Blood culture
B) Chest X-ray
C) Naso-pharyngeal aspirate
D) Per-nasal swab
E) Throat swab

Answer 492

C) Naso-pharyngeal aspirate

Question 493

Julia is a 6 month old baby born at 33 weeks.
She presents with 4/7 difficulty in breathing and a cough. She has a runny nose and a fever of 38.2 degrees.
She has wheeze and creps on her chest with moderate subcostal recessions. Her O2 SATS are 89% on air. She is feeding around 40% of normal.

What is the most appropriate initial management plan?

A) CPAP and NG tube for feeds

B) Inhaled salbutamol, nasal cannulae O2 and encourage breast feeds

C) Nasal cannulae O2 and NG tube for feeds

D) Nasal cannulae O2, oral augmentin and encourage breast feeds

E) Nebulised salbutamol, nasal cannulae O2 and NG tube for feeds

Answer 493

C) Nasal cannulae O2 and NG tube for feeds

Bronchiolitis
Viral infection affecting the lungs in infants < 12 months old
Commonly Respiratory synctial virus, but many other viral pathogens
Common – 30% of infants get it, and 3% of infants admitted to hospital in first 12 months of life
Presentation – URTI, followed by cough, then development of respiratory distress over 3-4 days. Peaks day 5, lasts 10-14 days.
Death rate 8 per 100000

Question 494

Nana Kwame is 2 days old. He became jaundiced yesterday and is receiving phototherapy.

He was born at term following an uncomplicated pregnancy with no risk factors for sepsis. Mum’s blood group is O+ve and the family is originally from Ghana. He is exclusively breast fed.

What is the most likely cause of his jaundice?

A) ABO incompatibility

B) Physiological/breast milk jaundice

C) Rhesus incompatibility

D) Sepsis

E) Sickle cell disease

Answer 494

A) ABO incompatibility

Question 495

Baby Smith is 1 day old and has developed jaundice which is above the phototherapy line.

She was born at 37 weeks following an uncomplicated pregnancy. Mum’s blood group is A+ve

On examination she appears quiet. Her respiratory rate is 85 breaths per minute. She has not yet tolerated a feed.

What is the single most likely diagnosis?

A) ABO incompatibility

B) G6PD deficiency

C) Inborn error of metabolism

D) Neonatal sepsis

E) Resus incompatibility

Answer 495

D) Neonatal sepsis

Question 496

Abbey is 10 days old and is referred in by the midwife as she appears jaundiced in her body and sclera.

She was born at 36 weeks following a C-section and received 48 hours of antibiotics.

She has been well since and is exclusively breast fed.
Birth weight : 3.2kg Current weight 3.3kg

Abbey appears well on examination and is alert and active. Her observations are stable.

What is the most likely diagnosis?

A) Biliary Atresia

B) Gilbert’s disease

C) Hypothyroidism

D) Physiological/breast milk jaundice

E) Urinary tract infection

Answer 496

D) Physiological/breast milk jaundice

Question 497

Ibrahim, 4 year old boy, presents to A&E with a 1 day history shortness of breath and lethargy. He had presented 2 days earlier with a low grade fever, dysuria and urinary frequency and was sent home with oral antibiotics.
He has been previously well, has never been admitted to hospital and was born at term with no complications. He is on no regular medications but is allergic to penicillin. His mother is on iron supplements from her GP for anaemia, otherwise no FHx of note.
He is now afebrile. HR 148, RR 40, SATS 98%
His sclera are yellow, HS1+2+0, Chest clear and abdomen soft non tender.

Blood tests are performed and return as follows:
Hb 5.2 WCC 7.4 Plts 250 Retics high
Na 136 K 5.1 Urea 4.6 Creat 42
Bili 96 AST 40 ALP 240 CRP 4

You request a blood film. What abnormalities would you expect to see?

A – Auer Rods
B – Heinz bodies with bite cells
C – Howell-Jolly bodies with macrocytosis
D – Microcytic Hypochromic anaemia
E – Small round cells (Spherocytes)

Answer 497

B – Heinz bodies with bite cells

Question 498

Joshua is 2 months old and presents to A&E. His mum reports that he has been feeding around 50% of usual over the last 24 hours and she has struggled to settle him to sleep. She says he has felt quite hot. She denies any coryzal symptoms or D+V.
He was born at 37+2. PROM but otherwise uneventful pregnancy. He is otherwise well.
He cries inconsolably when examined. HR 175, CRT 2s, RR 50 (crying), SATS 98% Chest clear, abdo SNT. No rashes are seen. Temp 38.3 degrees.
What is the most appropriate management?

A) Admit for observation on the ward
C) Admit, start IV Amoxicillin and Cefotaxime, perform full septic screen including LP and start maintenance fluids.
B) Admit to the ward, start augmentin IV and perform septic screen including LP
D) Admit, start IV Cefotaxime, perform full septic screen including LP and give fluid bolus
E) Send home with advice to return if a non-blanching rash occurs

Answer 498

B) Admit, start IV Amoxicillin and Cefotaxime, perform full septic screen including LP and start maintenance fluids.

Question 499

Glory is an 8 year old girl who has found it difficult to walk over the last 24 hours. She is unable to weight-bear on her left leg and complains of a rash over her left shin where she ran into a table 3 days earlier. She has been more lethargic over the last 24 hours and has lost her appetite. Her mum has given her codeine and paracetamol at home which has not controlled her pain.
She has a background of sickle cell anaemia and takes Penicillin V and folic acid.
Her temperature is recorded at 38.5 degrees, HR 130, RR 30, SATS 99%. Cap refil <2 seconds

A – Co-amoxiclav orally and regular codeine
B – IV Ceftriaxone and blood transfusion
C – IV Ceftriaxone and paracetamol
D – IV Ceftriaxone, oramorph, regular simple analgesia and IV fluids
E – Observe on ward and double dose of Penicillin V

Answer 499

D – IV Ceftriaxone, oramorph, regular simple analgesia and IV fluids

Substitution of glutamic acid for Valine at position 6 on B-haemoglobin gene.
HbSS, HbSC (less severe), HbS-Thal.
CRISES – Caused by deoxygenated, sickled haemoglobin -> shorter life span, occlusion in small vessels.
Vaso-occulsive crises
Infective (most common cause of mortality)
Functionally asplenic by 1 year old
Susceptible to encapsulated organisms eg pneumococcus
Osteomyelitis can be unusual organisms like Salmonella.
Haemolytic
Aplastic (eg Parvovirus B19)
Sequestration (mainly spleen but can be liver or lungs)

Question 500

Which of the following medications is not likely to be required in a child with Cystic Fibrosis?
A) Creon
B) Hydroxcarbamide
C) Insulin
D) Tobramicin
E) Ursodeoxycholic acid

Answer 500

B) Hydroxycarbamide

R : Respiratory
Bacterial infection/colonization eg Pseudomonas, Staph Aureus, Haemophilus
Allergic bronchopulmonary aspergillosis (ABPA)
C : Cardiac
Signs of right heart failure if pulmonary hypertension present
H : Hepatic
Cholestasis in infancy causing obstructive jaundice.
Fatty liver
Cirrhosis
Biliary obstruction and gall stones.
I : Intestinal
Meconium ileus (think of with signs of respiratory distress and a laparotomy scar)
Rectal prolapse
Distal intestinal obstruction syndrome
P : Pancreatic
Insufficiency in 85% of patients
Pancreatitis
Impaired glucose tolerance in 10%, IDDM in 7% of patients (DKA is uncommon).
S : Salt deficiency state
Hyponatraemic, Hypochloraemic metabolic alkalosis

Question 501

A baby has been brought to NICU because of bilious vomiting. You’ve found out the baby was born at term after an uncomplicated delivery and nothing was picked up in the fetal anomaly scan. You examine the abdomen and find it is not distended or tender, there is a patent anus. You get an abdominal Xray and it shows a dilated stomach and another smaller bubble of air next to the stomach but otherwise no other gas pattern. There is no pneumatosis coli. What is the most likely diagnosis?

a) Colonic atresia
b) Oesophageal atresia
c) Pyloric stenosis
d) NEC
e) Duodenal atresia

Answer 501

e) Duodenal atresia

Question 502

Princess, 4, has sickle cell anaemia. She presents in a haemolytic crisis. Her Hb is found to be 2.3 and her GCS is 8. Her parents are Jehovahs Witnesses and refuse any blood products under any circumstances after long discussions.
What is the most appropriate course of action?

A) Ask a local Jehovah’s witness minister to attend tomorrow morning to discuss with the parents
B) Give the blood transfusion and remove the parents from the room
C) Expand her circulating volume with 0.9% NaCl boluses up to 60ml/kg/day
D) Have social services take away parental responsibility
E) If parents continue to refuse, apply for an emergency court order and treat in the child’s best interests

Answer 502

E) If parents continue to refuse, apply for an emergency court order and treat in the child’s best interests

Question 503

• Alcoholic has cellulitis and was given chlordiazepoxide and antibiotics. What else would you give? Options: oral vitamin B1 [thiamine], pabrinex [thiamine, riboflavin, pyridoxine, ascorbic acid], vitamin B12 [cobalamin]

Answer 503

pabrinex

Question 504

• Old man who was ex-accountant has like MMSE 28/30, getting forgetful and needs wife to do his finances as he gets confused, but manages all other daily activities. what’s the diagnosis?

Answer 504

Mild cognitive impairment

Question 505

• Woman with learning difficulties in a care home with change in behaviour (she had a change in feeding time – rather than change in appetite), irritable because the carer that was looking after them has gone suddenly, what’s the diagnosis?

Answer 505

challenging behaviour, depressive episode

Question 506

• What drug can you give for depression in a guy who had an MI –

Answer 506

sertraline

Question 507

• What does clozapine cause?

Answer 507

neutropenia

Question 508

• Guy on haloperidol gets muscle problems -

Answer 508

IM procyclidine

Tetrabenazine - treats moderate/severe tardive dyskinesia
Propranolol - treats akathisia (restlessness).
IM procyclidine and benztropine - treats acute dystonia (spasm of facial muscles)

Question 509

• Suicide risk. What is the highest predictor of doing it again?

Answer 509

Feeling hopeless about future,

Question 510

• 80-year-old man with new onset dementia, needs MRI but refuses. Who is best to make a decision for him? Options: talk to family with his permission, ask independent mental health advocate

Answer 510

independent mental health advocate

Question 511

• Woman on SSRI wants to get pregnant, was wondering what risk it may have on her baby. Options: stillbirth, persistent pulmonary hypertension of newborn, delayed labour, neonatal hypoglycaemia

Answer 511

persistent pulmonary hypertension of newborn

Question 512

• Woman 5 weeks postpartum feels very sad, unable to cope, teary. Dx?

Answer 512

Postpartum depression

Question 513

• What is the risk of baby getting schizophrenia if the baby’s father has it?
  Options: 7-9%, 12-15%, 20-25% (parent = 10-15%, sibling = 10%, MZ twin = 50%)

Answer 513

12-15%

Question 514

-	40-year-old man with moderate learning disability has a Hb of ~6 (below normal range). He refuses blood transfusion but happy to take oral iron therapy. What law do you use to assess his decision?
o	Common Law
o	Mental Capacity Act
o	Mental Health Act
o	Disability Discrimination Act
o	European Convention on Human Rights

Answer 514

o Mental Capacity Act

Question 515

• What is high in anorexia nervosa?

Answer 515

Growth hormone

Question 516

• Man with treatment resistant schizophrenia on clozapine, recently stopped smoking. High level of clozapine now. Most likely consequence? Agranulocytosis, seizures

Answer 516

seizures

Question 517

• Failed 2 antipsychotics, what is next line treatment?

Answer 517

Clozapine

Question 518

(dark brown line down the centre of the abdomen – fades after you have the baby)

Answer 518

o Linea nigra

Question 519

o Striae gravidarum

Answer 519

(stretch marks

Question 520

o Increased loudness of S1 and S2
o Increased splitting of mitral and tricuspid components of S1
o Loud S3 by 20 weeks gestation
o 5% develop S4
o 95% develop a systolic murmur that disappears after delivery
o 20% develop a transient diastolic murmur
o 10% develop continuous murmurs due to increased mammary bloodflow

Answer 520

• Pregnancy changes to heart sounds

Question 521

Changes to maternal coagulation in pregnancy?

Answer 521

 Factors V, VII, X increase
 Fibrinogen increases
 Fibrinolysis decreases
 Factors XI, Protein S decrease

Question 522

Pregnancy - Number of glandular ducts is increased by

Answer 522

Oestrogen

Question 523

Pregnancy, what increases the number of breast gland alveoli.

Answer 523

• Progesterone

Question 524

Pregnancy - what causes:
• Delay in gastric emptying
• Reduced colonic motility ( constipation).

Answer 524

Progesterone during pregnancy is the cause of constipation

Question 525

What causes increased urinary frequency in 1st trimester?

Answer 525

• Urinary tract becomes dilated during pregnancy, and most women have some evidence of stasis or hydronephrosis (R>L).
• These changes predispose pregnant women to ascending UTI (taken very seriously as more likely to get pyelonephritis with pyrexia  pre-term labour) therefore frequent MSU
• GFR increases by 50%
• Polyuria
• Plasma creatinine, urate and urea decrease. NB: need to adjust reference ranges
• Glycosuria may occur.

Question 526

What stimulates TSH receptor in pregnancy?

Answer 526

• Thyroid: BMR increases by 30%. TSH levels unchanged. T3/4 increase but overall free levels remain the same as there is a concomitant increase in TBP. Increased hbCG in the first trimester binds to TSH receptors and stimulates T3/4 production, and produces a negative feedback which suppresses and decreases TSH levels. The physiological high T3/4 and low TSH may be mistaken for hyperthyroidism; n.b. by the second trimester, serum TSH levels return to normal

Question 527

Diabetic wants to get pregnant. When is best to do so?

Answer 527

o Recent HbA1c – advise to continue contraception until HbA1c is at least under 8% (under 6.1% is ideal)

o Commence aspirin 75mg OD if the foetal heart is seen, due to the increased risk of pre-eclampsia
o If the patient conceives with an HbA1c >10%, consider termination

Question 528

Increase or decrease anti-epileptics in pregnancy?

Answer 528

Want lowest possible dose / number of drugs to control seizures HOWEVER:
o Increased metabolism, dilution and clearance of antiepileptic (e.g. due to increased GFR and hyperemesis) – may therefore need to increase dose of antiepileptic

o High risk times for seizures:
 1st trimester
 Labour
 Postnatal period

 Avoid sodium valproate, which carries a 25% risk of congenital abnormalities – causes neural tube defects and developmental delay (autism, poor concentration and poor fine motor control):

• Sodium valproate is the only antiepileptic that has been shown to cause developmental delay.
• Advise that women who breastfeed have much better sleep, and are therefore less likely to have a seizure (as breastfeeding at night does not require the mother to fully wake up, and releases oxytocin, meaning she will be able to get back to sleep more easily). Breastfeeding while taking anticonvulsants is generally regarded as being safe – occasionally, if feeding coincides with a peak in drug levels, the baby may become drowsy, but in this case all that is needed is to change the time of feeds in relation to tablet taking.

NB: often chronic conditions like asthma and epilepsy follow the rule of thirds: During pregnancy:
• 1/3 will get better
• 1/3 will get worse (typically those that are hardest to control even before pregnancy)
• 1/3 will stay the same

Question 529

Effect of graves on pregnancy

Answer 529

o Anti-TSH receptor stimulating antibody (causes Graves’ disease) – can cross the placenta and cause Graves’ disease in the foetus. Signs = foetus moves a lot, growth restriction, sustained foetal tachycardia.
o Anticholinesterase antibody (causes myasthenia gravis).
o TSH receptor stimulating antibodies cross the placenta and will cause thyrotoxic fetus (increased movement, sustained increased HR etc but the medication used to treat mother also crosses the placenta therefore if the mother is euthyroid, so will be the fetus)

Normal antenatal care

Question 530

Components of combined test.

What chance of downs would allow additional testing?

Answer 530

o Can also do combined screening test – nuchal translucency plus bloods (hCG, PAPP-A and oestradiol). The combined screening test can be done between 11 and 13+6 weeks, but is optional.

o If someone has a 1 in 150 or greater chance of having a baby with Down’s syndrome, send them for diagnostic tests:
 CVS (samples the placental tissue) – is not definitive, as the placenta may have a mosaicism that means its genetics are not the same as those of the foetus.
• From 11 weeks
• 1-2% risk of procedure-related miscarriage
 Amniocentesis (samples the amniotic fluid)
• From 15 weeks
• 1% risk of procedure-related miscarriage
o NB: if definitive diagnosis of Down’s from amniocentesis, then would perform an extra cardiac scan

Question 531

Management of high risk cervical incompetence?

At what cervical length should Rx be offered?

What is this Rx?

Answer 531

 if a woman was found to be high-risk of cervical incompetence e.g. previous surgery or previous PTL due to this, cervical length is checked, and it is usually done as an add-on to the dating and anomaly scan. In very high-risk women, frequency of scanning might be increased e.g. at 16 weeks as well and every 2-3 weeks thereafter. Cervical length becomes less accurate after 22 weeks.

For women with cervical length <25mm:
• Cervical suture (aims to close the internal os). Taken out at 36-37 weeks GA or earlier if she goes into labour.
• Vaginal progesterone (proposed that this causes uterine quiescence) – given 2x a day, either vaginally or rectally until 36 weeks from when shortened cervical length is found

Question 532

What additional aspects are assessed for on doppler if there is reduced growth?

Answer 532

If there is a problem with the growth, they will also do Doppler studies:
• Maternal:
o Uterine artery (marker for increased risk of PET or IUGR)
• Fetal:
o Umbilical artery – normal is forward flow through artery. If you start to get high resistance in the placenta this will manifest as changes in the umbilical artery, leading firstly to absent end-diastolic flow (stasis), and then as it worsens it will lead to reverse end-diastolic flow
o MCA – head-sparing (growth of brain is maintained at the cost of other organs) leads to increased velocity through MCA and lower pulsatility index (PI)
o Ductus venosus (from liver to IVC) – reflects the cardiac cycle, absent ‘a’ wave is abnormal

Question 533

List causes of asymmetrical / non

Answer 533

o	IUGR:
	Asymmetrical:		(Big head and small abdomen)
•	Uteroplacental insufficiency – the foetus preferentially diverts blood to the vital organs to combat this insufficiency. This means bloodflow to the kidneys and liver is reduced, resulting in reduced production of liquor, and less storage of glycogen in the liver which in turn results in a discrepancy between the growth of the foetal head and the abdomen. 
•	Pre-eclampsia 
	Symmetrical:
•	Pre-eclampsia 
•	Current maternal disease:
o	Renal disease (including renal transplantation)
o	Hypertension
o	Congenital heart disease
o	Severe anaemia
o	Sickle cell disease
o	SLE
o	Cystic fibrosis
o	HIV 

 if baby is <10th centile on GAP growth chart – deliver at 37 weeks

Question 534

• This is an ultrasound finding, and happens after the first ultrasound scan.
• You see two sacs on the first ultrasound scan, so say it is a twin pregnancy. However, you later do another scan and find that one sac has disappeared.

Answer 534

Vanishing twin syndrome:

Question 535

• Intracardiac potassium chloride is given to one or more foetuses under ultrasound guidance, in order to reduce the number of foetuses in the pregnancy.
• Aim is to improve the outcomes for the remaining foetuses by reducing the risk of miscarriage and preterm labour.
• Is usually performed at 12-14 weeks gestation.
• Procedure-related risk of miscarriage of wanted foetuses is around 6%.

Answer 535

Selective fetocide (multifetal pregnancy reduction):

Question 536

o Very rare complication of vaginal deliveries.
o Occurs when the first twin is presenting breech, and its head is prevented from entering the pelvis by the head of the cephalic-presenting second twin.
o If it is diagnosed during the first stage of labour, a caesarean section should be performed.
o If it is diagnosed during the second stage of labour, general anaesthesia is required to allow manipulation of the foetuses.

Answer 536

• Locked twins:

Question 537

Why is the incidence of ectopics rising?

Answer 537

• Incidence = 1 in 100 (1% of pregnancies), but this is rising due to the rising incidence of PID, asymptomatic chlamydial infection, and an increase in the number of IVF pregnancies (10-15% of ectopics occur following IVF).

Risk factors:
• PID (due to tubal damage and pelvic scarring) associated with STIs
• Endometriosis (due to tubal damage)
• Previous peritonitis or pelvic surgery, e.g. for appendicitis (due to pelvic scarring)
• Previous tubal surgery (e.g. for sterilisation, reversal of sterilisation, previous ectopic pregnancy)
• Previous ectopic pregnancy (due to tubal damage and pelvic scarring)
• Coil in situ (increases risk of abnormal implantation)
• Progesterone-only pill (increases risk of abnormal implantation because it works by reducing the motility of the cilia in the Fallopian tubes)
• IVF (increases risk of abnormal implantation)
• Age >40
 Heterotopic ectopic pregnancy – have ovulated twice, and get one intrauterine pregnancy and one ectopic pregnancy.

o You have to warn the patient that methotrexate is teratogenic, so they should not attempt to conceive for 3 months after treatment.

Question 538

Why should ectopics NOT get pregnant for 3 months?

Answer 538

o You have to warn the patient that methotrexate is teratogenic, so they should not attempt to conceive for 3 months after treatment.

So only if medical

Question 539

List reasons why CKD is dangerous in pregnancy?

Answer 539

• Impact of CKD on pregnancy:
o Women more likely to be chronically hypertensive, or if not already hypertensive, to develop gestational hypertension.
o Increased risk of pre-eclampsia (the risk in the general population is about 5%, but in people with CKD it is about 50%).
o Increased risk of preterm birth
o Increased risk of foetal growth restriction
o Drugs the mother is taking for her CKD may have an effect on the foetus.
o Deterioration in renal function (particularly in CKD stages 3-5) as the mum’s kidneys cannot cope with the physiologically increased GFR that occurs as a result of pregnancy. This means that pregnancy shortens the time to these women needing a kidney transplant/dialysis.
 In pregnant women, haemodialysis should be increased to 5 times a week (normal = 3 times a week) to improve outcomes – increases foetal growth etc.

Question 540

2 main causes of LATE miscarriage?

Answer 540

• Infection – bacterial vaginosis (change in the natural flora of the vagina) has been linked to second trimester miscarriage, as have the causative organisms above.
• Cervical incompetence (the cervix is slightly dilated, so the membranes bulge out through it. Can occur due to e.g. previous LLETZ procedure or multiple previous abortions)

Question 541

What two ABx are given as prophylaxis post surgical termination?

Answer 541

• Metronidazole – for prophylaxis against E. coli infection
 Oral erythromycin – for chlamydia prophylaxis

Histology/antiD/counselling on endometritis

Question 542

FETOPLACENTOMATERNAL

CAUSES OF STILLBIRTH

Answer 542

Causes:
•	Maternal conditions:
o	Diabetes
o	Pre-eclampsia
o	Sepsis
o	Obstetric cholestasis 
o	Acute fatty liver of pregnancy
o	Thrombophilias:
	Protein C and protein S resistance
	Factor V Leiden
	Antithrombin III deficiency
•	Foetal conditions:
o	Rhesus disease – causes severe anaemia. Gets more severe with subsequent pregnancies. 
o	Chromosomal abnormality 
o	Structural abnormalities
o	IUGR 
o	Twin-to-twin transfusion syndrome 
o	Alloimmune thrombocytopenia 
o	Infection:
	Listeria
	Toxoplasmosis
	Parvovirus 
•	Placental conditions:
o	Postmaturity – placenta starts to deteriorate 
o	Placental abruption
o	Placenta praevia causing significant bleed 
o	Recurrent antepartum haemorrhage – repeated small abruptions can compromise foetal wellbeing and cause IUGR 
o	Cord prolapse

Question 543

o “Woody uterus” – hard uterus that is tender throughout on palpation

Answer 543

P ABRUPT

Question 544

PP RFs

Answer 544

o	Placenta praevia in previous pregnancy
o	Previous caesarean section
o	Previous TOP
o	Multiparity 
o	Age >40
o	Multiple pregnancy (because they have a bigger bulk of placenta, so it is more likely that some of the placenta will go into the lower segment)
o	Smoking
o	Deficient endometrium 
o	IVF

Question 545

When should placentae praevia women be admitted?

Answer 545

o Admission at 36 weeks is recommended for women with major placenta praevia, because of the unpredictability of the timing of labour and the potential for heavy bleeding once labour starts and the cervix starts to dilate.

Question 546

Diabetes-related changes in pregnancy:

Answer 546

• The woman becomes more resistant to her own body’s insulin, partly due to the placenta secreting “anti-insulin” hormones (human placental lactogen, glucagons and cortisol).
• The body loses its ability to smoothly regulate glucose levels, due to changes in glucose handling. This results in lower fasting glucose levels and higher postprandial levels than when not pregnant.
• Renal threshold for glucose changes, so most women will have glycosuria at some point in pregnancy.
• These effects increase through the second and third trimesters.
• In order to cope with these changes, a woman will have doubled her insulin production by the end of pregnancy.

Question 547

DM risks to baby

Answer 547

•	Foetal insulinaemia:
o	Macrosomia (accelerated fetal growth)
o	Organomegaly
o	Polycythaemia
o	Hypoglycaemia
o	Respiratory distress syndrome 
•	Neonatal hypoglycaemia  early feeding, ideally breastmilk + top up milk if necessary to prevent hypo 
•	Increased risk of shoulder dystocia  brachial plexus injury e.g. Erb’s palsy and fetal hypoxia 
•	Intrauterine death/stillbirth

Question 548

DM risks to mother

Answer 548

• Complications of diabetes e.g. hypos, retinopathy, nephropathy
• Difficult birth due to macrosomic baby  increased requirement for intervention e.g. assisted vaginal delivery (instrumental) or c-section
• Increased risk of developing pre-eclampsia (greatest risk in women with pre-existing diabetes)
• Increased risk of infections e.g. thrush

Question 549

Changes in pregnancy that are protective against anaemia:

Answer 549

o Increased production of red cells
o Increased iron absorption in gut
o Increased transferrin (therefore increasing the total iron binding capacity)

Question 550

T/F
o Red cell volume increases
o Plasma volume increases (haemodilution)
o Serum iron and serum ferritin levels decrease
o Renal clearance of folate increases
o These changes mean that you get a physiological anaemia in pregnancy anyway, but if your Hb falls below 100g/dl this is pathological.

Answer 550

T
T
T
T
T

Question 551

What iron do you Rx preggo ladies with if non-compliant with tablets?

Answer 551

• IV iron = monofer. This is a single dose iron injection, and is given when someone’s compliance with oral iron supplements is in doubt. Give a small test dose first to check that it does not cause an allergic reaction.

Question 552

platelet count falls during pregnancy and goes back to normal after delivery.

Answer 552

o Gestational thrombocytopenia

Question 553

Pathological platelet level in pregnancy

Answer 553

• Normal platelets in pregnancy = 100-400. <100 is pathological.
• Platelets are physiologically lower in pregnancy due to the dilutional effect of plasma volume expansion.

Question 554

What delivery should be avoided in ITP in pregnancy?

Answer 554

 Use of suction or forceps should be avoided, as the ITP can be transmitted to the baby, and performing suction could result in a suction haematoma

Question 555

Most common cause of DIRECT maternal death in UK?

Answer 555

• Pulmonary embolism is the most common cause of direct maternal death in the UK

Question 556

When does post partum thyroiditis typically present?

Answer 556

Postpartum thyroiditis:
• Affects 5-11% of women
• Usually occurs around 12 weeks postpartum

o Treatment is not always necessary, as the condition is usually self-limiting and treatment will not speed up recovery, although it will relieve troublesome symptoms.
o Hyperthyroid symptoms can be managed with beta blockers
o Hypothyroid symptoms can be managed with thyroxine replacement

o 3-4% of patients will remain permanently hypothyroid and will require long-term thyroxine replacement
o A third will be euthyroid for a few years, but will then go on to develop permanent hypothyroidism
o Recurrence in future pregnancies is common

Question 557

Mainstay of asthma monitoring in pregnancy?

Answer 557

• Peak flow and FEV1 are unaffected by pregnancy, so remain the mainstay of monitoring asthma.

Question 558

Methyldopa contraindication?

Answer 558

o Methyldopa is contraindicated in patients with depression, and is usually discontinued in the postnatal period due to the increased risk of postnatal depression.

Question 559

Other causes of proteinuria besides PET?

Answer 559

• Contamination with blood
• Contamination with liquor (e.g. if membranes have ruptured)
• Contamination with vaginal discharge
• UTI (should be suspected if leukocytes, nitrites and/or blood are also present in the urine) – however, pre-eclampsia should not be excluded if a UTI is found, as the two can occur simultaneously

Question 560

Left lateral tilt?

Answer 560

Avoid canal compression

Question 561

Obstetric cholestasis - what needs to be ruled out first?

Answer 561

Obstetric cholestasis is a diagnosis of exclusion – should perform serology for hepatitis and ultrasound scanning for gallstones before making a diagnosis of obstetric cholestasis

Question 562

Complications of obstetric cholestasis:

Answer 562

• Maternal:
o Constant itching – debilitating
o Insomnia
o Postpartum haemorrhage – due to malabsorption of vitamin K and deranged clotting if liver function is very abnormal
• Fetal:
o Foetal and neonatal intracranial haemorrhage – due to maternal malabsorption of vitamin K
o Premature labour – 40% of patients with obstetric cholestasis will deliver before 37 weeks.
o Foetal distress in labour – meconium-stained liquor is likely to occur
o Intrauterine death/stillbirth – bile acids are cardiotoxic to the baby, and can cause it to go into complete heart block. The higher the bile acids, the higher the risk of complete heart block and resultant stillbirth. It is therefore important to diagnose obstetric cholestasis due to this small risk of stillbirth.

Question 563

Management of obstetric cholestasis

Answer 563

• Antenatal:
o Symptomatic relief:
 Piriton
 Aqueous cream with menthol
 Ursodeoxycholic acid – lowers bile acids and reduces itching
o Vitamin K 10mg OD – from 32 weeks onwards, to counteract the malabsorption of vitamin K that this condition causes and prevent the resultant complications.
o Foetal monitoring in DAU:
 Growth scans
 Doppler
 Twice-weekly CTG monitoring
o Counselling about the risk of preterm delivery, foetal distress, induction of labour and stillbirth – may suggest elective caesarean section, because due to the increased risk of foetal distress during labour, women are more likely to end up needing an operative delivery anyway
o Advise patient to come straight to triage if there are reduced foetal movements
o Weekly LFTs, bile acids and prothrombin time
o Induction of labour at 37-38 weeks

o Check LFTs at 6 weeks post-delivery – in obstetric cholestasis, the woman will clear her bile acids and stop itching spontaneously in the days following delivery. If she still has itching at six weeks, you would therefore be worried that you have missed something else.

Question 564

Best pain relief for VBAC?

Answer 564

o Pain relief:
 Epidural is the best option so that c-section can be done immediately in case of scar rupture

• If a patient attempting VBAC needs induction, you should not use prostaglandins to induce, as they triple the risk of uterine rupture. Can break waters and use balloon.

Question 565

Induction of VBAC. What is contraindicated?

Answer 565

o Pain relief:
 Epidural is the best option so that c-section can be done immediately in case of scar rupture

• If a patient attempting VBAC needs induction, you should not use prostaglandins to induce, as they triple the risk of uterine rupture. Can break waters and use balloon.

Question 566

What is an unstable lie?

Answer 566

o An unstable lie is when the foetal lie is different at each palpation.
o At term, an unstable lie can be managed expectantly, because spontaneous version to a cephalic presentation often occurs due to the increase in uterine activity.
o If the lie becomes transverse, this can be corrected by ECV followed by induction of labour.
o If the lie remains unstable, caesarean section is indicated.

Question 567

Causes of face presentation?

Answer 567

o Congenital goitre
o Congenital tumours of the neck (rare)
o Anencephaly (however, this is now rare due to increased prenatal diagnosis and termination of foetuses with anencephaly)

Question 568

What is malposition?

Answer 568

• The position is the alignment of the foetal head within the pelvis during delivery.
• Under normal circumstances, the head usually engages in an occipito-transverse position. With descent, the head rotates to an occipitoanterior position in order to present the narrowest diameter for delivery.
• Any position that does not follow this pattern is regarded as a malposition, with the most important two positions being the occipitoposterior position and deep transverse arrest.

• Occipitoposterior position:
o Occurs in approximately 20% of women in early labour.
o Risk factors:
 Anthropoid and android pelvises (have an anteroposterior diameter greater than or equal to the transverse diameter)
 Anterior placenta
o An OP position is the commonest cause of an unengaged head at term in a primagravida.

 During the second stage, an episiotomy is recommended if the OP position persists, because a wider diameter presents, and this increases the risk of a severe perineal tear occurring.
 If rotation fails to occur spontaneously, it can be achieved using the following techniques:
• Manual rotation
• Kielland’s rotational forceps
• Ventouse extraction with spontaneous rotation

Question 569

Once in active labour, how much should the cervix progress by?

Answer 569

• Dilatation of the cervix – should be 1cm per hour in a nulliparous woman, and 1-2cm per hour in a multiparous woman

Question 570

____ is bounded by the pubic crest, the iliopectinaeal line and the sacral promontory. It is oval in shape, and its widest diameter is transverse.

Answer 570

Pelvic inlet

Question 571

______ is bounded by the lower border of the pubic symphysis, the ischial spines and the tip of the sacrum. It is oval in shape, and its widest diameter is anteroposterior.

Answer 571

pelvic outlet

Question 572

Failure to progress management:

Answer 572

• First line = if someone is not progressing, first thing to do is perform ARM as this will cause release of endogenous prostaglandins to enhance labour
• Second line = can give syntocinon to stimulate contractions, and increase their strength and frequency:
o Regular contractions will improve descent of the foetus, and will also help to correct a foetal malposition by rotating the head against the pelvic floor muscles.
 NB: if contractions are already 5 in 10 then might not be suitable
o Has similar side effects to ADH, e.g. fluid overload.

• The presence of good contractions over several hours without significant progression in terms of cervical dilation is an indication for caesarean section.
• Failure to progress in the second stage of labour is an indication for instrumental delivery.
• If the head is almost crowning, an episiotomy may be all that is necessary in order for vaginal delivery to occur.

Question 573

Normal acceleration

Answer 573

• Accelerations – these are increases in the foetal heartrate of 15bpm or more, lasting 15 seconds or more. They are normal.

Question 574

Definition of a deceleration

Answer 574

Decelerations – these are falls in the foetal heartrate below the baseline of 15bpm or more, lasting 15 seconds or more. Different patterns of decelerations can be seen, depending on their timing with the contractions

Question 575

What is an early deceleration?

What is it caused by?

Answer 575

o Early decelerations – the foetal heartrate slows at the same time as the onset of the contraction, and returns to the baseline at the end of the contraction.
 Caused by fetal head compression (high PSNS stimulation)

Single deceleration lasting 3 mins is pathological

Question 576

What is a late deceleration, and what is it caused by?

Answer 576

o Late decelerations – the foetal heartrate begins to fall during the contraction, with its trough more than 20 seconds after the peak of the contraction, and returning to baseline after the contraction.
 Occur due to decreased uterine blood flow to baby which is detected by the aortic arch chemoreceptors and leads to high PSNS stimulation. It is associated with hypoxia  fetal blood sample

Single deceleration lasting 3 mins is pathological

Question 577

What is a variable deceleration and what is it caused by?

Answer 577

o Variable decelerations – the timing of the slowing of the foetal heartrate in relation to the contraction varies, and can occur in isolation. There is typically rapid onset and recovery, but other features e.g. loss of the normal baseline variability may make this type of deceleration more suspicious.
 Occur due to cord compression. Vein compression leads to decreased venous return and arterial pressure leading to increased SNS to maintain blood pressure. Compression of arteries leads to increase in BP and therefore PSNS activity, lowering HR. When the compression of arteries is relieved it may cause hypotension leading to a reactive tachycardia transiently. If it is persistent, requires FBS.

Single deceleration lasting 3 mins is pathological

Question 578

What is a sinusoidal pattern

Answer 578

o Sinusoidal pattern – there is a regular oscillation of the baseline, with absent variability, lasting for at least 10 minutes and with an amplitude of 5-15bpm above and below the baseline.

Question 579

Big square (AKA 4 little ones) on CTG

Answer 579

1 min

Question 580

Helper management of shoulder dystocia

Answer 580

o H: help call
o E: evaluate episiotomy (this will now allow the shoulders to deliver but will allow manipulation of the baby to achieve delivery
o L: legs  McRobert’s position – take woman out of the lithotomy position, straighten her legs and then bend them, pushing her thighs as far into the abdomen as you can. This straightens the spine and also expands the pelvis so that the shoulder can be delivered more easily. Is successful in about 90% of shoulder dystocias.
o P: pressure  apply suprapubic pressure to dislodge the anterior shoulder.
o E: enter manoeuvres  internal rotation techniques to try and rotate the baby
o R: remove posterior arm by inserting hand into the vagina and aiding delivery
o R: roll on to all fours (if above measures fail)

Question 581

Management of uterine inversion?

Answer 581

• Complete = uterine fundus passes through the cervix.
• Incomplete = fundus is still above the cervix.
• Can occur spontaneously, e.g. in association with a fundal placental site or an unicornuate uterus, or may be a result of mismanagement of the third stage of labour.
• Delivering the placenta and membranes by controlled cord traction should help prevent this.
• May present as PV bleeding, or as severe lower abdominal pain, followed by collapse and haemorrhage. The pain is secondary to tension on the infundibulopelvic ligaments.
• Management:
o Resuscitate patient – ABC approach
o Put uterus back in its correct position, either manually or hydrostatically
o Oxytocin infusion

Question 582

Indications for forceps

Answer 582

• There are two main types of forceps:
o Traction forceps (aka non-rotational forceps – are only suitable for occipitoanterior and occipitoposterior positions) – Simpson’s, Anderson’s, Neville-Barnes’ or Wrigley’s
o Rotational forceps – Keilland’s
• Main maternal complication is trauma – worst kind is trauma all the way up to the top of the vagina.
• Indications for forceps delivery:
o Medical conditions complicating labour e.g. cardiovascular disease
o Unconscious mother – means she is unable to assist with pushing and therefore ventouse is not suitable
o Gestation <34 weeks
o Face presentation
o Known or suspected foetal bleeding disorder
o Breech presentation:
 Use long Piper’s forceps to deliver the head
 Assistant supports the baby’s legs horizontally
 The forceps are applied downwards and used to pull the head out

Question 583

2 Types of ventoux

Answer 583

• One of the complications of ventouse is retinal detachment or retinal haemorrhage
• Two types:
o Disposable = KIWI
o Machine
• Can be used with any position of foetal head, as they permit rotation of the foetal head during traction.
• Indications for ventouse delivery:
o Delay in 2nd stage of labour due to maternal exhaustion
o Delay in 2nd stage of labour due to foetal malposition (occipitoposterior or occipitotransverse position)
o Abnormal CTG
• Ventouse delivery should not be used for babies born before 34 weeks gestation.
• Use of the ventouse requires maternal effort and adequate contractions.
• Method:
o The cup is applied in the midline, over or just anterior to the occiput.
o Apply traction in time with the maternal contractions and maternal effort, along the pelvic curve, i.e. initially in a downward direction and then upwards as the head crowns.
o The procedure should be complete within around 15 minutes of cup application.
o CTG monitoring should be used throughout.

Question 584

Tear

just involves the superficial skin or the vaginal mucosa

Answer 584

o First-degree tear – just involves the superficial skin or the vaginal mucosa
o Second-degree tear – involves the superficial muscles e.g. the transverse perinea
o Third-degree tear – involves the external or internal anal sphincters:
 3a – into the external anal sphincter, less than 50% of the external sphincter fibres are involved
 3b – more than 50% of the external sphincter fibres are involved
 3c – into the internal anal sphincter
o Fourth-degree tear – into the anorectal mucosa
o Buttonhole tear – a full-thickness tear, but higher up (through the vagina and into the rectal mucosa), meaning the anal sphincters and anal canal are intact, but there is a tear going into the rectum.

Question 585

tear

involves the superficial muscles e.g. the transverse perinea

Answer 585

o First-degree tear – just involves the superficial skin or the vaginal mucosa
o Second-degree tear – involves the superficial muscles e.g. the transverse perinea
o Third-degree tear – involves the external or internal anal sphincters:
 3a – into the external anal sphincter, less than 50% of the external sphincter fibres are involved
 3b – more than 50% of the external sphincter fibres are involved
 3c – into the internal anal sphincter
o Fourth-degree tear – into the anorectal mucosa
o Buttonhole tear – a full-thickness tear, but higher up (through the vagina and into the rectal mucosa), meaning the anal sphincters and anal canal are intact, but there is a tear going into the rectum.

Question 586

Tear involves the external or internal anal sphincters:

Answer 586

o First-degree tear – just involves the superficial skin or the vaginal mucosa
o Second-degree tear – involves the superficial muscles e.g. the transverse perinea
o Third-degree tear – involves the external or internal anal sphincters:
 3a – into the external anal sphincter, less than 50% of the external sphincter fibres are involved
 3b – more than 50% of the external sphincter fibres are involved
 3c – into the internal anal sphincter
o Fourth-degree tear – into the anorectal mucosa
o Buttonhole tear – a full-thickness tear, but higher up (through the vagina and into the rectal mucosa), meaning the anal sphincters and anal canal are intact, but there is a tear going into the rectum.

Question 587

tear into the anorectal mucosa

Answer 587

o First-degree tear – just involves the superficial skin or the vaginal mucosa
o Second-degree tear – involves the superficial muscles e.g. the transverse perinea
o Third-degree tear – involves the external or internal anal sphincters:
 3a – into the external anal sphincter, less than 50% of the external sphincter fibres are involved
 3b – more than 50% of the external sphincter fibres are involved
 3c – into the internal anal sphincter
o Fourth-degree tear – into the anorectal mucosa
o Buttonhole tear – a full-thickness tear, but higher up (through the vagina and into the rectal mucosa), meaning the anal sphincters and anal canal are intact, but there is a tear going into the rectum.

Question 588

a full-thickness tear, but higher up (through the vagina and into the rectal mucosa), meaning the anal sphincters and anal canal are intact, but there is a tear going into the rectum.

Answer 588

o First-degree tear – just involves the superficial skin or the vaginal mucosa
o Second-degree tear – involves the superficial muscles e.g. the transverse perinea
o Third-degree tear – involves the external or internal anal sphincters:
 3a – into the external anal sphincter, less than 50% of the external sphincter fibres are involved
 3b – more than 50% of the external sphincter fibres are involved
 3c – into the internal anal sphincter
o Fourth-degree tear – into the anorectal mucosa
o Buttonhole tear – a full-thickness tear, but higher up (through the vagina and into the rectal mucosa), meaning the anal sphincters and anal canal are intact, but there is a tear going into the rectum.

Question 589

• Prostaglandin F2a

Answer 589

(carboprost) is given as IM, comes in viles of 250mg and can be given every 15 minutes (up to 8 times but rare to give this much)

Question 590

• Prostaglandin E2

Answer 590

(prostin/propess) not used to control bleeding as they do not cause retraction of muscles. Instead used to induce labour. Side effect profile of prostaglandins is to relax other spinchters

Question 591

• Prostaglandin E1

Answer 591

(misoprostol) is used to induce labour, medical ToP, or treatment of gastric ulcers. Typically given per rectum. Dose = 800-1000mg (4 or 5 tablets of 200mg)

Question 592

Commonest causes of maternal mortality in the UK:

Answer 592

•	Direct deaths:
o	Thromboembolism – commonest cause 
o	Hypertensive disorders (including eclampsia) 
o	Haemorrhage
o	Genital tract sepsis 
o	Amniotic fluid embolism
o	Early pregnancy deaths (deaths before 24 weeks’ gestation):
	Ectopic pregnancy
	Miscarriage 
	Termination of pregnancy 
•	Indirect deaths:
o	Cardiac disease
o	Psychiatric deaths (commonest cause in most recent report) 

• Direct (a cause that you can only get while you are pregnant)
• Indirect (a condition that you had before you were pregnant or developed while pregnant but that was not related to the pregnancy, but was made worse by the pregnancy)

Question 593

Managment of GBS?

What is it based on?

Answer 593

o Intrapartum IV antibiotics can be given prophylactically to the mother during delivery to try to prevent transmission of GBS to the newborn baby. In the UK, the choice of whether to administer these intrapartum antibiotics is done via a risk-based approach, with mothers with risk factors for infection being offered antibiotics:
 Those who have had GBS infection detected in a previous pregnancy
 Those with a previous baby with early or late-onset GBS disease
 Those in preterm labour
 Those with a pyrexia (>38oc) during labour
o Benzylpenicillin is the antibiotic of choice.

Question 594

o Originates at the uterus and inserts into the inguinal canal and continues to the labia majora
o May be mistakenly clipped during female sterilisation procedure

Answer 594

• Round ligament

Question 595

o Sits behind the uterus and attaches to the anterior sacrum.
o Can be affected n endometriosis this can be affected.
o Major support structure for the uterus
o Damage may result in uterine prolapse
o If abnormal, may be palpated through the posterior fornix

Answer 595

• Uterosacral ligament

Question 596

o From sacrum to ischial spines

o Important landmark for pudendal block (local anaesthetic in the perineum)

Answer 596

• Sacrospinous ligament

Question 597

o Peritoneal fold that drapes over and attaches the uterus, fallopian tubes and ovaries to the pelvis.

Answer 597

• Broad ligament

Question 598

o Contains the ovarian vessels
o Suspends the ovary
o It is only divided if the ovary is taken away (as this contains the blood supply)

Answer 598

• Infundibular pelvic ligament

Question 599

o Also suspends the ovary

Answer 599

• Ovarian ligament

Question 600

the space between the uterus and the rectum

Answer 600

• Pouch of Douglas = the space between the uterus and the rectum

Question 601

39 year-old woman undergoes sterilization. 6 months later she falls pregnant

Answer 601

round ligament clipped instead of fallopian tubes.

Question 602

A 60 year-old woman is undergoing a hysterectomy. The surgeon divides the structure containing the ovarian vessels

What ligament?

Answer 602

this is the infundibular pelvic ligament.

Question 603

A 33 year-old woman presents with dysmenorrhea and deep dyspareunia. Vaginal examination notes tenderness and nodularity in posterior fornix

Answer 603

uterosacral ligament

Question 604

Layers that are cut in order during a C section

Answer 604

•	Skin
•	Fat (Camper's fascia)
•	Rectus sheath
•	Scarpa's fascia (superficial)
•	Stretch muscle open (not cut through)
•	Peritoneum
•	N.B. Urachus = remnant of canal that drains the bladder in the fetus found superior to the bladder
 Avoid the inferior epigastric arteries during laparotomies (risk of haematoma)

Question 605

1st line ADHD

Answer 605

Psychoeducation is considered a first-line intervention for all patients

Question 606

Learning disability/ developmental tests:

Answer 606

Bayley’s Developmental Scales, Griffiths Mental Development Scales, and Kaufman Scales are widely used to assess the development of young children.

Specific cognitive assessments + IQ:
Wechsler Preschool and Primary Scale of Intelligence (WPPSI)
Wechsler Intelligence Scale for Children (WISC)

Reading, language, and mathematical ability can be assessed using the Wechsler Individual Achievement Test (WIAT); when children have normal IQ and are found to have a specific difficulty (e.g., reading and spelling), this points toward a specific diagnosis (e.g., dyslexia).

Question 607

Test for feto-maternal haemorrhage which detects fetal cells in maternal circulation. It estimates the volume of FMH to determine the amount of ADDITIONAL anti-D?

Answer 607

Kleihaur test

Question 608

What reverses respiratory depression caused by mag sulfate?

Answer 608

Calcium gluconate

Question 609

BMI over 30. What dose folic?

Answer 609

5mg high dose

Question 610

Neonatal sepsis
Hypothyroidism
Prader-Willi
Downs
Myaesthenai gravis
Maternal BDZ

Answer 610

Neonatal hypotonia

Question 611

What Rx should be used in frail elderly endometrial cancer PTs unfit for surgery?

Answer 611

High dose progestogens

Question 612

Does not cross suture lines

Answer 612

Cephalohaematoma

Caput succedanum does

Question 613

Child received another live vaccine 2 weeks ago. Can they get MMR?

Answer 613

NO

Question 614

MMR vaccine Sx

What is a contraindication?

Answer 614

Malaise
Fever
Rash
At 1 week

2nd dose 3/4
Live attenuated

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

Question 615

Contraindication to MMR?

Answer 615

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

Question 616

Safest antiepileptic in preg

Answer 616

Lamotrigine

Question 617

Liver in thoracic cavity

Answer 617

Poor prognostic factor for Congenital diaphragmatic hernia

Question 618

Review and refer for undescended testicle when?

Answer 618

3 months

Question 619

Continuous machinery murmer
systolic accentuation
Wide pulse pressure
bounding peripheral pulses are frequently present

Answer 619

PDA

Question 620

Downs
DM
Turners

What condition is associated with all?

Answer 620

Hypothyroidism

Question 621

Is there an increased risk of neonatal sepsis with HIV?

Answer 621

Actually the same as non

Question 622

Changes in Hb levels after birth?

Answer 622

Fall from 15-20g/dl to 10-11g/dl at 3 months

Question 623

What immune cell predominates in blood at birth?

What does this change to and when does this occur?

Answer 623

Lymphocyte

@ 4m -> neutrophil

Question 624

What percentage fetal Hb by 3m?

Answer 624

5%

Question 625

When does hand preference develop?

Answer 625

18m

Question 626

Reassuring signs in a child not walking by 18m?

Answer 626

Bottom shuffling

FHx

Question 627

Normal neuro exam but decreased tone
Associated in a delay in GROSS motor ONLY
Otherwise normal development

Answer 627

Benign central hypotonia

CP would also have poor fine motor

Question 628

No organisms on CSF

Inflammatory cells visualised

Answer 628

Brain abscess

Question 629

Hypotonia
Smooth skin
Soft cartilage
Undescended testes / big clitoris 
Lanugo hair

Answer 629

Prom baby Sx

Question 630

Test to visualise renal scarring

Answer 630

DSMA

Question 631

Renal Test for speed of draining and reflux

Answer 631

DTPA

Question 632

Test for assessing vesico-ureteric reflux

Answer 632

Micturating cysturethrogram

Question 633

Dec hip abduction
+ve trendlenburg
Asymmetry of skin creases
Reduced apparent leg length

Answer 633

Mixed congenital sublux of hip

Question 634

Defective proximal renal tubular function, phosphataemia and rickets

Answer 634

Cystinosis

Question 635

Hirschprungs associated with which men?

Answer 635

2A/B

Question 636

Vomiting
Diarrhoea
Digestive disorder 
Strenuous exercise 
Preg
Eating disorder
Low carb diet

Answer 636

Ketones

Question 637

MoA of clomifene?

Answer 637

SERM
Dec neg feedback of oestrogen on hypothalamus
Inc GnRH -> LH/FSH pulses -> ovulation

Question 638

RFs gastroschesis

Answer 638

Maternal age <20
Alcohol
Tobacco
Socio economic dep

Question 639

Number 1 cause of painless GI bleed in 1-2YO requiring transfusion?

Answer 639

Meckels

Question 640

Increased membrane permeability and fluid losss from intravascular compartment
Rarely seen with clomifene
Associated with HCG or GnRH

Abdo bloating 
NV
Ascites 
Hypoproteinuria
Oliguria 
ARDS
VTE
PE

Answer 640

Ovarian hyperstimulation syndrome

Question 641

High grade fever THEN rash

Answer 641

Roseola infantum

Question 642

Hand foot and mouth cause

Answer 642

Coxsackie A6

Question 643

Rise in clozapine level?

Answer 643

Recent stop smokin

Question 644

Only effective Rx for large fibroids if want to conserve fertility

Answer 644

Myomectomy

Question 645

COCP 2 pills missed

Answer 645

Take 2 that day and continue as normal

Question 646

Whooping cough Rx

Answer 646

Clarithromycin or azithromycin if <21 days from onset (possible after but unlikely to help)

Question 647

Treat muscle spasticity

Answer 647

Baclofen

Question 648

Child under 2, phimosis, whaddyado?

Answer 648

Normal

Review in 6month

Question 649

Weight gain
Myocarditis
Arrythmias
Excessive salivation

SEs of what drug?

Answer 649

Clozapine

Also agranulocytosis…

Question 650

Common complication of viral gastroenteritis

Answer 650

Lactose intolerance

Question 651

Most common cause gastroenteritis

Answer 651

Rotavirus

Question 652

CATFISH

Mneumonic for atypical UTI

Answer 652

Creatinine
Abdo/pelv mass
Terribly ill
Flow problems
Infected with non-e-coli organism
Septicaemia 
Halted response to ABx

Question 653

Most common cause headache in child

Answer 653

Migraine

Question 654

Prophylaxis for PPROM

Answer 654

10 day erythromycin

Day unit assessments

Question 655

HCG secreted by

Answer 655

Synctiotrophoblast

Question 656

Day 21 progesterone (OR 7 days from end of cycle)

Answer 656

Ovulation

Question 657

Any evidence of infection in miscarriage

Answer 657

Surgical evacuation

Question 658

Low plasma haptoglobin

Answer 658

Haemolysis

Haptoglobin binds haemoglobin in blood

Question 659

Stop COC for how long before surgery?

Answer 659

4 weeks - switch to POP

Question 660

Confirm pertussis?

Answer 660

Nasal swab

Question 661

Akathisia

Answer 661

Restlessness

Question 662

1st line nit Rx

Answer 662

Wet combing

Question 663

SE of hysterectomy?

Answer 663

Vag vault prolapse

Enterocele

Question 664

SUFE Rx

Answer 664

Internal fixation

Question 665

Stop methotrexate when before pregnancy?

Answer 665

Both man and women stop 3 months before trying

Question 666

Fever
Tonsillitis
Malaise
Sandpaper rash

Answer 666

Scarlet fever

Question 667

Endometrial hyperplasia
PM
Atypia

Answer 667

Total abode hysterectomy + bilateral salpingoophorectomy

Question 668

Hep B
Breastfeeding
Is it safe

Answer 668

Ayeeeees

Question 669

POP

How long to work

Answer 669

2 days

Question 670

1st line for premenstrual syndrome

Answer 670

COC

Question 671

Supravalvular aortic stenosis

Answer 671

Williams

Question 672

Contraception with weight gain

Answer 672

ONLY

Depo-provera injection

Question 673

Post partum thyroiditis diagnosis

Do you need to assess for TPO

Answer 673

No

TFTs alone enough

Question 674

Most common ovarian cancer

Answer 674

Serous carcinoma

Question 675

Fever >38 in <3 month

Answer 675

Admit

Question 676

Saddle shaped nose

Hutchinsons incisors

Answer 676

Syphilis

Question 677

Painless haematuria
Flank pain
Anorexia
Fever

Answer 677

Wilms

3-5yo

Question 678

Most common complication of TOP

Answer 678

Infection

Question 679

1st line anxiety disorder

Answer 679

SSRI

Question 680

SOB on feeding
Sweaty
Recurrent chest infections

Answer 680

HF

Question 681

POP missed pill

Answer 681

Take pill

Use condoms 48hrs

Question 682

COCP missed pill

Answer 682

1 = take asap and no action
2 = take asap and take next normal pill time

Question 683

Amiodarone and BFing

Answer 683

NO

Question 684

Bowed legs in a 3yo

Answer 684

Normal -> unless >4yo

Question 685

U+E seen in pyloric stenosis

Answer 685

Increased bicarb

Low K+ + Cl-

Question 686

Child drowsy post febrile seizure

Answer 686

Not a febrile seizure

Question 687

Rx for GBS

Answer 687

Intrapartum Ben Pen

Question 688

DNA vaccines induce

Answer 688

TH1 response

Question 689

Triple test

Answer 689

AFP
Oestriol
HCG

Question 690

Trimethroprim contraindicated in which stage preg

Answer 690

1 trim

Question 691

+ve hydrogen breath test

Answer 691

Lactose intolerance

Question 692

Peristent pulmonary hypertension

Answer 692

Fluoextine in 3rd trimester

Question 693

Failure to progress

Answer 693

20hrs reg contractions in primp

14 if multip

Question 694

Ix for retained products of conception

Answer 694

Exam under anaesthesia

boggy uterus

Question 695

Pierre robin Sx

Answer 695

Pierre rob in mouth
Cleft palate
Micrognathia
Posterior displacement of tongue

Question 696

Cleft palate
Micrognathia
Posterior displacement of tongue

Answer 696

Pierre rob in mouth

Question 697

WilliamS syndrome

Answer 697

Short, Struggles in School, Smiley, Supravalvular aortic StenoSiS

Question 698

Short, Struggles in School, Smiley, Supravalvular aortic StenoSiS

Answer 698

WilliamS syndrome

Question 699

Main side effect POP

Answer 699

Bleedin

Question 700

Hyper G Questionnaire?

Answer 700

PUQE scoring system

Pregnancy unique quantification of emesis scoring

Question 701

CRASH N BURN

Answer 701

Kawasaki
Conjunctivits 
Rash
Adenopathy
Strawberry tongue
Hand swelling/feet / peeling
BURN = 5 days fever

Question 702

Most ectopics located in

Answer 702

Ampulla

Question 703

Most ectopics rupture in

Answer 703

Isthmus

Question 704

Female
Amenorrhoea
Lumps inguinally
May have breast development

Answer 704

Androgen insensitivity

46XY

Question 705

1st line imbetigo

Answer 705

fusidic acid

Question 706

AGITATED PT ON WARD

1st action

Answer 706

Not lorazepam

Assess pt in a safe environment with another person

Question 707

Suboptimal SpO2 in first 10 mins of life

Is this reassuring

Answer 707

Its fine - expected

Question 708

Child does not want mole removed

Parents do

Answer 708

If you judge a child does not want a cosmetic procedure you must not perform it

Question 709

Moro should disappear at

Answer 709

4m

Question 710

Ullipristal given up to

Answer 710

5 days later

Question 711

How long should contraception continue after menopause

Answer 711

1 yr if over 50

2 yrs if under

Question 712

Increased AFP

Answer 712

Omphalocele

NT defects

Question 713

Mod severe tardive dyskinesia

Answer 713

Tetrabenzene

Question 714

Ebstein anomaly

Answer 714

TR + stenosis

Question 715

Lochia abnormal after

Answer 715

6w

Question 716

Breech need US when

Answer 716

6w even if normal B+O

Question 717

Perthe Rx under 6yo?

Answer 717

Observe
Consider Spica cast
Surgery at 6yo

Question 718

Precious puberty - what effect does TSH have

Answer 718

Stimulates FSH receptors

Question 719

Waterhouse freidrichson

Answer 719

Rare complication of men meningitis
Bilateral adrenal necrosis
Lack of adrenal hormones and worsening hypotension

Question 720

How long is VZIG useful?

Answer 720

10 days post exposure

Oral aciclovir given within 24 hrs of any rash

Question 721

Blocks A2 receptors and increases appetite

also causes sedation

Answer 721

Mirtazipine

Question 722

10-15% have febrile seizures

Answer 722

Roseola infantum

Question 723

Why does aripiprazole have reduced SEs

Answer 723

Partial antagonist of dopamine

Question 724

Continuous hum below clavicle

Answer 724

Venous hum

Innocent murmer

Question 725

How much should a 6w old baby eat?

Answer 725

150-180ml/kg/day

Question 726

+ve triple test result

Answer 726

> 1 in 250 chance downs

Question 727

Ergometrine MoA

Answer 727

alpha adrenrgic
Dopamine
Serotinergic binding

Question 728

Hyponatraemia. Which anti epileptic?

Answer 728

Carbemazipine

Question 729

Produced by theca cells

Answer 729

Testosterone

Question 730

Produced by ovary and secreted throughout cycle

Answer 730

Oestradiol

Question 731

Triggers first meiotic divisions

Answer 731

LH

Question 732

Early stage endometrial carcinoma

Answer 732

Laparoscopic hysterectomy (vs open)

Question 733

Ischiocarvernosis cut during episiotomy

Answer 733

False

Question 734

Pelvic outlet is formed by

Answer 734

Ishcial tuberosity
Pubic arch
Sacrum

Question 735

Broad ligament of uterus contains

Answer 735

Fallopian tubes and uterine artery

Question 736

What week does fetal heart start

Answer 736

Usually 5w

Question 737

Blastocyst divides in 3. What is formed

Answer 737

Embryo

Placentae

Question 738

Tetrabenazine

Answer 738

Tardive dyskinesia

Question 739

Gland like spaces
Call-exner bodies
Coffee bean nuclei
Oestrogen
PM bleed

Answer 739

Granulosa ovarian tumours

Question 740

Cremaster preserved but signs of torsion

Blue dot on transillumination

Answer 740

Torsion of the hydatid of morgagni
DIFFERENT to torsion
Still requires surgery
More common in younger males

Question 741

Prehns sign

Aka pain disappears on elevation of the testicle

Answer 741

Epidydimitis

Question 742

Small for dates = RF
Shock seen is out of proportion with bloodless (due to vagal stimulation)
Cannot palpate uterine fundus

Answer 742

Uterine inversion

Question 743

Excessive salivation
Mouth twitching
Grunting
Slurred speech
High amplitude spikes in left centrotemporal region

Answer 743

Benign rolandic seizures

Accounts for 20% of childhood epilepsy

Question 744

Epilepsy triggered by alcohol

Can occur on waking

Answer 744

Juvenile myoclonic epilepsy

Question 745

3 spike wave complex on EEG

Answer 745

Absence seizure

Question 746

Abnormal Poo pattern in child

Answer 746

<3 per week

Question 747

Slow spike waves

Very frequent seizures

Answer 747

Lennox-gaustaut

Question 748

Common organisms of ophthalmic neonatorum

Answer 748

Staph A, chlamidya, gonorrhoea

Question 749

Single dose cef + azithro

Answer 749

The gon is gone

Question 750

Transient synovitis gets better when

Answer 750

1-2 weeks

If not recall -> consider perthes

Question 751

How long must PTSD symptoms last before diagnosis

Answer 751

1 month

Question 752

Pseudomyxoma

Answer 752

Mucinous carcinoma

Question 753

Baby blues. When present, when disappear by

Answer 753

usually days 3-5

Gone by 10d

Question 754

PND. When present, when disappear by

Answer 754

Begins within 3m

Resolves by 6m usually

Question 755

PN psychoses. When present, when disappear by

Answer 755

70% present at day 3
Rapid onset
Always presents by 3 weeks

Prognosis variable

Question 756

75% of endometrial cancers are picked up in what stage

Answer 756

1

Question 757

MMR associated thrombocytopenia. Is it a thing.

Answer 757

Yes its a thing

Question 758

Vomiting
Lethargy
Jaundice
Cataracts
Hepatomegaly (3cm)

Answer 758

Galactosaemia

Question 759

Can cows milk protein intolerance occur with breast fed infants

Answer 759

Yeas

Trace amounts present in milk

Question 760

N+V in preg
When present
When better

Answer 760

usually 4-7w

Better by 12-14 in most

Question 761

When to admit hyperemesis

Answer 761

Ketones +2
U+E imbalance
Severe dehydration

Question 762

SEs lactulose

Answer 762

Atonic colon

Hypokalaemia

Question 763

Opiods and SSRI

Answer 763

List of serotonin syndrome

Question 764

Bronchiolitis

T1/2 resp failure

Answer 764

Begins as T1. T2 as child tires

T2 - hypoxia and hypercapnia

Question 765

Eisenmenger

Answer 765

R->L shunt due to pulmonary hypotension

Question 766

How long is urine pregnancy test +ve after termination

Answer 766

4 weeks

Question 767

How should endometrial hyperplasia be classified?

Answer 767

The revised 2014 World Health Organization (WHO) classification is recommended. This separates endometrial hyperplasia into two groups based upon the presence of cytological atypia: i.e. (i) hyperplasia without atypia and (ii) atypical hyperplasia.

Question 768

What should the initial management of hyperplasia without atypia be?

Answer 768

Women should be informed that the risk of endometrial hyperplasia without atypia progressing to endometrial cancer is less than 5% over 20 years and that the majority of cases of endometrial hyperplasia without atypia will regress spontaneously during follow-up.

Reversible risk factors such as obesity and the use of hormone replacement therapy (HRT) should be P identified and addressed if possible.

Observation alone with follow-up endometrial biopsies to ensure disease regression can be considered, especially when identifiable risk factors can be reversed. However, women should be informed that treatment with progestogens has a higher disease regression rate compared with observation alone.

Progestogen treatment is indicated in women who fail to regress following observation alone and in P symptomatic women with abnormal uterine bleeding.

Both continuous oral and local intrauterine (levonorgestrel-releasing intrauterine system [LNG-IUS]) progestogens are effective in achieving regression of endometrial hyperplasia without atypia.

Question 769

What should the duration of treatment and follow-up of hyperplasia without atypia be?

Answer 769

6 months and re-check

Hysterectomy is indicated in women not wanting to preserve their fertility when (i) progression to atypical hyperplasia occurs during follow-up, or (ii) there is no histological regression of hyperplasia despite 12 months of treatment, or (iii) there is relapse of endometrial hyperplasia after completing progestogen treatment, or (iv) there is persistence of bleeding symptoms, or (v) the woman declines to undergo endometrial surveillance or comply with medical treatment.

Question 770

What should the initial management of atypical hyperplasia be?

Answer 770

Women with atypical hyperplasia should undergo a total hysterectomy because of the risk of underlying malignancy or progression to cancer.

LAP rather than Abdominal

There is no benefit from intraoperative frozen section analysis of the endometrium or routine lymphadenectomy.

Postmenopausal women with atypical hyperplasia should be offered bilateral salpingo-oophorectomy P together with the total hysterectomy.

For premenopausal women, the decision to remove the ovaries should be individualised; however, bilateral salpingectomy should be considered as this may reduce the risk of a future ovarian malignancy.

Endometrial ablation is not recommended because complete and persistent endometrial destruction cannot be ensured and intrauterine adhesion formation may preclude endometrial histological surveillance.

If atypia and really want to stay fertile -> counsel on risk of cancer and ongoing surveillance + IUS

Question 771

F/U for atypia hyperplasia who doesn’t want hysterectomy

Answer 771

3 monthly

Question 772

When should anendometrial hyperplasia lady conceive?

Answer 772

Disease regression should be achieved on at least one endometrial sample before women attempt to P conceive.

Women with endometrial hyperplasia who wish to conceive should be referred to a fertility specialist to discuss the options for attempting conception, further assessment and appropriate treatment.

Question 773

Cyst <5 cm Pre menopausal

Whaddyado

Answer 773

Women with small (less than 50 mm diameter) simple ovarian cysts generally do not require follow-up as these cysts are very likely to be physiological and almost always resolve within 3 menstrual cycles.

Question 774

Cyst >1cm PM

Whaddya do

Answer 774

Ca 125 + RMI

RMI = U x M x CA-125.

Question 775

Chemo for ovarian cancer (stages 2-4)
NB chemo not routinely recommended for stage 1 - Consider three cycles of adjuvant carboplatin plus paclitaxel10 for women with high-risk stage I disease (grade 3 or stage Ic) if they are prepared to accept treatment of shorter duration but increased toxicity.

Answer 775

It is recommended that paclitaxel in combination with a platinum- based compound or platinum-based therapy alone (cisplatin or carboplatin) are offered as alternatives for first-line chemotherapy (usually following surgery) in the treatment of ovarian cancer.

Question 776

Do all postmenopausal women with ovarian cysts require surgical evaluation and is there a role for conservative management?

Answer 776

Asymptomatic, simple, unilateral, unilocular ovarian cysts, less than 5 cm in diameter, have a low risk of malignancy. In the presence of normal serum CA125 levels, these cysts can be managed conservatively, with a repeat evaluation in 4–6 months. It is reasonable to discharge these women from follow-up after 1 year if the cyst remains unchanged or reduces in size, with normal CA125, taking into consideration a woman’s wishes and surgical fitness.

Question 777

When should laparotomy be undertaken for PM cysts?

Answer 777

All ovarian cysts that are suspicious of malignancy in a postmenopausal woman, as indicated by a RMI I greater than or equal to 200, CT findings, clinical assessment or findings at laparoscopy, require a full laparotomy and staging procedure.

Question 778

PM cyst
Cysts fulfilling ALL of the following criteria: RMI<200
asymptomatic, simple cyst, < 5 cm, unilocular, unilateral

Answer 778

CONSERVATIVE

Repeat assessment in 4–6 months
CA125, TVS ± TAS

Question 779

PM
Cysts with ANY of the following features:
symptomatic, non-simple features, > 5 cm, multilocular, bilateral

Answer 779

Consider surgery salpingo-oophorectomy (usually bilateral)

Question 780

PM
RMI >200
Next step

Answer 780

CT abdo pelvis
MDT review
Either full staging procedure or
Pelvic clearance (TAH + BSO + omentectomy + peritoneal cytology) by a suitably trained gynaecologist

Question 781

What are the risks and benefits of planned VBAC versus ERCS from 39+0 weeks of gestation?

Answer 781

Women should be made aware that successful VBAC has the fewest complications and therefore the chance of VBAC success or failure is an important consideration when choosing the mode of delivery.
Women should be made aware that the greatest risk of adverse outcome occurs in a trial of VBAC resulting in emergency caesarean delivery.
Women should be informed that planned VBAC is associated with an approximately 1 in 200 (0.5%) risk of uterine rupture.
Women should be informed that the absolute risk of birth-related perinatal death associated with VBAC is extremely low and comparable to the risk for nulliparous women in labour.
Women should be informed that ERCS is associated with a small increased risk of placenta praevia and/or accreta in future pregnancies and of pelvic adhesions complicating any future abdominopelvic surgery.
The risk of perinatal death with ERCS is extremely low, but there is a small increase in neonatal respiratory morbidity when ERCS is performed before 39+0 weeks of gestation. The risk of respiratory morbidity can be reduced with a preoperative course of antenatal corticosteroids.

Question 782

VBAC success rate

Answer 782

Women should be informed that the success rate of planned VBAC is 72–75%.

Question 783

When to refer URGENTLY for suspected ovarian cancer?

Answer 783

Refer the woman urgently if physical examination identifies ascites and/or a pelvic or abdominal mass (where it is clear that this is not due to uterine fibroids).

Carry out tests in primary care if a woman (especially if 50 or over) reports having any of the following symptoms on a persistent or frequent basis — particularly more than 12 times per month:
Persistent abdominal distension (women often refer to this as 'bloating').
Feeling full (early satiety) and/or loss of appetite.
Pelvic or abdominal pain.
Increased urinary urgency and/or frequency.
Consider carrying out tests in primary care if a woman reports unexplained weight loss, fatigue or changes in bowel habit.
Advise any woman who is not suspected of having ovarian cancer to return to her GP if her symptoms become more frequent and/or persistent.
Carry out appropriate tests for ovarian cancer in any woman of 50 or over who has experienced symptoms within the last 12 months that suggest irritable bowel syndrome (IBS), because IBS rarely presents for the first time in women of this age.
Measure serum CA125 in primary care in women with symptoms that suggest ovarian cancer.
If serum CA125 is 35 IU/ml or greater, arrange an ultrasound scan of the abdomen and pelvis.

Question 784

STAGING of endometrial cancer

Answer 784

1 - confined to uterus
A = half

2 = cervix

3 = local/regional spread
A = Serosa of uterus/adnexae
B = vagina
C1 = positive pelvic LNs
C2 = para-aortic LNs

4A = bladder or bowel
4B = Distant mets / inguinal

Question 785

STAGING of cervical cancer

Answer 785

0 = Carcinoma in situ 
1 = cervix only
2 = uterus/parametrial/vagina
3 = pelvic wall / lower 3rd vagina
4a = bladder/bowel
4b = distant mets

Question 786

STAGING of ovarian cancer

Answer 786

1 = limited to ovaries
A = 1 ovary
B = both 
C = ruptured capsule
2 = pelvis limited
3 = Abdomen limited
4 = distant mets

Question 787

Vulval cancer Rx

Answer 787

Wide radical local excision of the primary tumour with a minimum margin of 15 mm of disease-free tissue is often sufficient.

Dissection of the groin nodes (unilateral or bilateral) should be performed when the depth of invasion is greater than 1 mm (FIGO stage Ib or worse) or the maximum diameter of the tumour is greater than 2 cm.

Groin node surgery should be undertaken through separate incisions (triple incision technique) to reduce morbidity. The incidence of skin bridge recurrence in early-stage disease is low.

In unifocal tumours of less than 4 cm maximum diameter where there is no clinical suspicion of lymph node involvement, patients can be safely managed by removal of the identified sentinel lymph nodes.

Question 788

Rapid tranquillisation guidelines:

Answer 788

In general IM lorazepam or haloperidol+promethiazine:

Insufficient evidence to guide choice / no prev antipsychotic -> LORAZEPAM

CV disease -> LORAZEPAM

No response to lorazepam -> HALOPERIDOL with PROMETHIAZINE

Question 789

Women in 1st stage of labour
No SROM
Failing to progress
Whaddjya do?

Answer 789

For women with intact membranes in whom delay in the established first stage of labour is confirmed, advise the woman to have an amniotomy, and to have a repeat vaginal examination 2 hours later whether her membranes are ruptured or intact.

Question 790

Do you measure HbA1c in GDM?

Answer 790

NICE: Measure HbA1c levels in all women with gestational diabetes at the time of diagnosis to identify those who may have pre‑existing type 2 diabetes

Question 791

When do you offer testing for GDM in a women with a Hx of GDM?

Answer 791

NICE: Offer self‑monitoring of blood glucose or a 75 g 2‑hour OGTT as soon as possible for women with a history of gestational diabetes who book in the first trimester.