Specialties PPQs Flashcards
Woman with a little bit of pink post-coital bleeding on wiping. Smear is fine, ultrasound is clear. What is the next investigation?
Hysteroscopy with biopsy
Secondary amenorrhoea. Table shows high prolactin (7000) and low LH
Prolactinoma
Woman with secondary amenorrhoea for 6 months. High FSH and LH
PCOS
Woman had abdo trauma 32 weeks, had anti-D. Had her anti-D at 28 weeks – what to do next?
Kleihauer test and give anti-D
Lady who had a tear after delivering baby, a few days later has offensive discharge, no fever or other symptoms
Perineal wound breakdown/infection
HIV with undetectable viral load. what is contraindicated in labour?
Fetal blood sampling
72 year old woman with PMB and endometrial thickness seen on USS, what’s the diagnosis?
Endometrial carcinoma
60 year old woman with PMB and superficial dyspareunia, what is the MOST LIKELY diagnosis?
Atrophic vaginitis
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? Repeat USS, Ca 125 levels, hysteroscopy, Pipelle biopsy, reassure & discharge
Pipelle biopsy (there’s a cut off for pre and post menopause: if more than 10 mm in pre and 4mm in post, either way this one had 12mm so qualifies for biopsy)
Woman with rupture of membranes, painless bleeding, and fetal distress on CTG. What was the likely diagnosis?
Vasa praevia
(if distress to baby = vasa praevia)
Woman had an implant inserted but she’s getting it removed. What is the most likely reason why?
Irregular bleeding
Cervical os is open in a young woman in early pregnancy. What is it?
Inevitable miscarriage
Mother had rupture of membranes at 32 weeks but is not in labour. What do you give her?
Steroids and erythromycin
Bloods shown with raised LH and FSH and all else normal in couple trying to get pregnant. What is the first question you want to ask the woman? Has the father ever had children, When was your last period, do you have hot flushes
When was your last period?
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
Primary dysmenorrhoea
Woman with painful breast after giving birth. She’s breast-feeding and has an abscess secondary to mastitis. Surgical excision, aspirate and culture, Ciprofloxacin
Aspirate and culture
Pregnant woman in early pregnancy with depression and anxiety on sertraline. What do you do? Stop sertraline, carry it on (benefits probably outweigh risks), prescribe high-dose folic acid, reduce the dose, amitriptyline
carry it on (benefits probably outweigh risks)
What do you do in a woman in labour after 4 hours of checking, she’s 4cm. Vaginal prostaglandin, Cervical sweep, Oxytocin, Ergometrine, ARM
ARM
Post partum haemorrhage with high BP - carboprost, misoprostol, ergometrine, syntocinon
Syntocinon (Ergo contraindicated in HTN)
Foreign woman has come in and is pregnant. What vaccine should she be offered? Hepatitis A, hepatitis B, whooping cough
Whooping cough
Foetus with transverse lie, recent SROM, CTG shows fetal distress. Most likely cause?
Cord prolapse
HRT question for a menopausal woman with flushes, last period 10m ago. What do you give her? Cyclical combined HRT, oestrogen only HRT, topical HRT, continuous HRT
Cyclical combined HRT
They called cyclical “sequential” in the exam
What’s the management for DVT risk in a pregnant woman after an elective Caesarean?
LMWH and Ted stockings
A pregnant woman with an itch. What tests do you test?
Bile acids
Woman with blocked tubes on hysterosalpingogram, what treatment should you do for fertility?
IVF
Heavy periods in a girl not yet sexually active. What do you give her?
Tranexamic acid
Woman previously had an abortion cos of severe spina bifida. No other clinical information given. What do you advice her on folic acid doses for her next pregnancy?
5mg folic acid from before conception (1-3 months) till 12 weeks pregnant
Old woman with itchy white vulval patches: VIN, vulvar cancer, lichen sclerosis?
Lichen sclerosis
Woman with high BMI (28) who basically had stress incontinence. What’s the first line management?
Pelvic floor exercises for 3 months (weight loss only recommended if BMI >30)
Poorly controlled diabetic mother, her newborn has an abnormal asymmetric Moro reflex - what’s wrong? (secondary to probably shoulder dystocia because of diabetes) HIE, fracture of humerus, brachial plexus injury?
Brachial plexus injury
What do you measure at booking for hepatitis B?
Hep B surface antigen
Man with azoospermia – what is the most likely cause? (think this was a repeat) varicocele, mumps orchitis?
Variocele?
Woman on COCP, has missed 6th and 7th day pill, had unprotected sex two days ago, her urine pregnancy is clear. What to do?
Emergency contraception. Advise barrier methods until 7 days of pill have been taken
Woman with endometriosis, had laparoscopic adhesiolysis – developed a whole range of sx - high CRP, low Hb, constipation, bowel sounds absents etc – what’s happened? Bowel obstruction, perforation, urinary retention, intrabdominal bleeding?
Perforation
Woman with offensive smelly lochia day 2 post-partum, had had some high vaginal swabs? Reassure and discharge, await swab results, give broad-spectrum antibiotics, abdo USS?
Give broad-spec abx?
Large mum (BMI >40), head comes out then goes back in, chin not visible. Rupture, short cord, shoulder dystocia, normal mechanism of labour?
Shoulder dystocia
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? Unknown (accounts for 30% of subfertility), prolactinoma (prolactin would be in 1000s), raised testosterone suggests PCOS (LH:FSH ratio>2/3)
Answer can be unknown
G2p1 woman is worried about delivery of current baby as she had a grade 3 tear in her last. What do you do different in this pregnancy?
Elective C-section
Woman gets headache 24hrs after delivery?
Post-dural puncture headache
Treatment for candidiasis?
Topical clotrimazole
Smoker, which extra tests does she require in pregnancy?
serial growth scans (if she smokes more than 10 per day)
Bloating, raised CA125, next step?
Pelvic USS
Which test is used to screen for Down syndrome at 15 weeks? Amniocentesis, Non-invasive pre-natal testing, Chorionic villus sampling, Quad test
Quad test (NIPT appears to refer to cell free DNA testing
Woman has menopausal symptoms and wants to start HRT, last period 6m ago?
Cyclical HRT
Woman has come for a sterilisation, has had protected sex since her last menstruation one week ago, just post-ovulation – Immediate tx? Insert IUD, Cancel surgery, Continue with surgery
Cancel surgery
LH raised more than FSH (3:1)
PCOS
16 year old girl suffering from PMS – what is the next step?
Complete a menstrual diary
Woman who is going away for 4 months with heavy, irregular periods, wants something that will regulate her periods + make them lighter: COCP, POP, depot progesterone, IUS?
COCP
Woman with fever, deep dyspareunia (PID) - Treatment?
Send home with oral abx
Woman in stage 2 of labour, pushing for 30 minutes, head pressing against perineum, when CTG becomes pathological – what do you do next? Emergency C section, forceps delivery, episiotomy?
Forceps delivery
45F has a radical hysterectomy (Wertheim’s hysterectomy) for CIN. Last cervical smear 2 years ago. When next smear?
6 months (vaginal vault smear, no cervical smear because cervix was removed)
Hysterectomy yesterday. How long to stay off work for: 48 hours/ 1 week/ 4 weeks/ 3 months?
4 weeks
Pregnant woman has scan which shows anencephaly, until when can she have a TOP? Any point during this pregnancy, 24 weeks, 28 weeks, she can’t have one?
Any point during this pregnancy
- Woman with white discharge and itch. Which treatment?
Topical clotrimazole
- 40-year-old with diagnosed premature ovarian failure and wanted medication to deal with the symptoms of menopause. What would you prescribe her?
Continuous combined HRT
- 37 year old wants to have the COCP. Which of the following is an absolute contraindication?
Smoking >15 cigarettes a day
Mild to moderate eczema treatments?
Topical retinoid ± benzoyl peroxide (BPO) Adapalene + BPO
· Topical antibiotic + benzoyl peroxide (BPO) Topical clindamycin 1% + BPO
· Azelaic acid 20%
Treatment for acne not responding to topical treatments?
Oral antibiotic (max 3m) + BPO / retinoid
* 1st line = tetracyclines (Lymecycline, doxycycline)
* 2nd line = macrolides (Erythromycin)
· COCP + BPO / retinoid
benzoyl peroxide (BPO)
Discuss roacutane
Roaccutane (synthetic form of vitamin A):
Very teratogenic – must be on 2 forms of contraception
SE: dryness, pruritis, conjunctivitis, muscle aches, teratogenic, deranged LFTs
Associated with low mood and suicidal ideation
Prescription - aim for an accumulated dose = body weight x 100
· I.E. 80kg = 8,000mg accumulated dose
*Dermatologist referral if:
Nodulocystic acne / scarring
Severe form (acne conglobata, acne fulminans)
Severe psychological distress
Diagnostic uncertainty
Failing to respond to medications
o Support:
NHS Choices leaflet on Acne
British Association of Dermatologist
What is the Steroid ladder?
Help (hydrocortisone) Every (Eumovate) Busy (Betnovate) Dermatologist (Dermovate)
School exclusion rules for impetigo?
School exclusion (until lesions crusted over or 48 hours after ABx started)
Signs of irritant nappy rash and treatment?
well-demarcated variety of erythema, oedema, dryness, scaling
Sparing skin folds (just skin in contact with nappy is erythematous)
If mild erythema and the child is asymptomatic:
Advise on the use of barrier preparation (available OTC) – applied thinly at each change
Zinc and Castor oil ointment BP, Metanium ointment, white soft paraffin BP ointment
o If moderate erythema and discomfort:
If >1-month-old = hydrocortisone 1% cream OD (max 7 days)
Signs of cadidia nappy rash and treatment?
erythematous papules and plaques with small satellite spots or superficial pustules
Sharply demarcated redness
Check for oral candidiasis
Advise against the use of barrier protection
Prescribe topical imidazole cream (e.g. clotrimazole, econazole, miconazole)
Signs of sebhorreic nappy rash and treatment?
cradle cap and bilateral salmon pink patches, desquamating flakes, skin folds
Prescribe oral flucloxacillin (clarithromycin if pen-allergic) for 7 days
Arrange to review the child
Treatment for sebhorreic dermatitis?
1st line if scalp affected à regular washing with baby shampoo à gentle brushing to remove scales
§ Soaking crusts overnight with white petroleum jelly or slightly warmed vegetable/olive oil, and shampooing in the morning / soften scales with baby oil, gentle brush, wash off with baby shampoo
§ Emulsifying ointment can be used if these measures don’t work
§ If other areas of skin affected, bathe infant ≥1/day using emollient as a soap substitute
o 2nd line if scalp affected à topical imidazole cream (e.g. clotrimazole, econazole, miconazole)
§ BD or TDS (depending on preparation) until symptoms disappear
§ Consider specialist advice if it lasts >4 weeks
o 3rd line if severe à mild topical steroids (e.g. 1% hydrocortisone)
Most common neck lump in children?
Lymphadenitis
S/S: transiently enlarged, tender lymph nodes
· There may often be multiple small tender bumps
Describe thyroglossal cysts:
· Most common midline congenital mass
· Failure of thyroglossal duct to involute
· S/S: midline mass that moves with swallowing
Describe branchial cleft abnormality:
· Most common lateral congenital mass
· Failure of pharyngeal clefts to involute
· S/S: cyst, sinus or fistula; may be infected
Most common cause of congenital adrenal hyperplasia?
21-alpha hydroxylase deficiency
What is virilisation?
The development of male physical characteristics (such as muscle bulk, body hair, and deep voice) in a female or precociously in a boy, typically as a result of excess androgen production.
Treatment for CAH Salt-losing crisis?
IV hydrocortisone, IV saline, IV dextrose
Long-term management of CAH?
Life-long glucocorticoids (hydrocortisone) to suppress ACTH levels (and hence testosterone)
Mineralocorticoids (fludrocortisone) if there is salt loss
Monitoring growth, skeletal maturity, plasma androgens and 17a-hydroxyprogesterone levels
Additional hormone replacement at times of illness or surgery [i.e. double hydrocortisone]
How much is given in the OGTT?
75g oral glucose
Complications of DKA treatment?
Cerebral oedema (25% mortality), aspiration pneumonia, inadequate resuscitation
Most common cause of delyaed puberty in males?
Constitutional delay
What indicates no testicular development?
volume <4ml
Signs of constitutional delay
S/S: low bone age, no puberty signs, no organic causes
· FHx; M > F – usually FHx of same delay in parent of same sex
Chronic disease, malnutrition
Psychiatric – excessive exercise, depression, anorexia nervosa
What is Kallmann’s syndrome?
LHRH deficiency and anosmia
Hypogonadotrophic (low LH and FSH) hypogonadism?
Hypothalamo-pituitary disorders – panhypopituitarism, intercranial tumours
§ Kallmann’s syndrome (LHRH deficiency and anosmia), Prader-Willi syndrome
§ Hypothyroidism (acquired)
Hypergonadotrophic (high LH and FSH) hypogonadism?
Congenital – cryptorchidism, Klienfelter’s syndrome (47 XXY), Turner’s syndrome (45 XO)
Acquired – testicular torsion, chemotherapy, infection, trauma, autoimmune
Management of constitutional delay?
CDGP [most do not need treatment; fantastic prognosis]:
1st line: reassure and offer observation
2nd line: short course sex hormone therapy:
· Boys à short course IM testosterone (every 6 weeks for 6 months)
· Girls à transdermal oestrogen (6 months) à cyclical progesterone once established
Androgen Insensitivity?
N.B. delayed puberty in a ‘girl’ with bilateral groin swellings are undescended testicles (genotype = XY; phenotype = XX)
What is breast devleopment staging called?
Tanner’s
Gonadotrophin-Dependant Precocious Puberty [GDPP] causes?
Premature activation of HPG axis
Idiopathic (no cause found in 80% girls and 40% boys)
CNS abnormalities (tumours, trauma, central congenital disorders)
Gonadotrophin-Independent Precocious Puberty [GIPP] ?
Early puberty from increased gonadal activation independent of HPG
§ Ovarian – follicular cyst, granulosa cell tumour, Leydig cell tumour, gonadoblastoma
§ Testicular – Leydig cell tumour, testotoxicosis (defective LH-R function; a familial GIPP)
§ Adrenal – CAH, Cushing’s syndrome
§ Tumours – b-hCG-secreting tumour of liver, tumours of ovary, testes, adrenals
§ McCune-Albright syndrome – a multiple endocrinopathy of thyrotoxicosis, Cushing’s, acromegaly
· S/S: polyostotic fibrous dysplasia, café-au-lait spots, ovarian cysts
§ Exogenous hormones – COCP, testosterone gels
Investigations for precocious puberty?
Investigations:
o Females [normally not of concern] → pelvic USS
Premature onset of normal puberty à multicystic ovaries and enlarging uterus
Rule out gonadal tumour, cysts
o Males [organic cause] → examination of testes, MRI (intracranial tumours), GnRH-stimulated LH/FSH
Most commonly has an organic cause
· N.B. if LH and FSH are normal, any virilisation has a primary cause (i.e. adrenal hyperplasia)
· CAH à initial growth spurt (tallest in class) à premature bone fusion (smallest in class)
Prader’s orchidometer measurement and examination of testes:
· Bilateral enlargement → GDPP (intercranial lesion; i.e. optic glioma in NF1)
· Unilateral enlargement→ gonadal tumour
· Small testes → tumour or CAH (adrenal cause)
Small testes and precocious puberty indicates what?
Tumour or congenital adrenal hyperplasia (adrenal cause)
Unilateral large testes and precocious puberty?
Gonadal tumour
Bilateral enlargement of tests + precocious puberty?
GDPP (intercranial lesion; i.e. optic glioma in NF1)
General investigations for precocious puberty
§ GOLD-STANDARD: GnRH stimulation test – suppressed LH/FSH if G-independent
· FSH, LH low = GIPP à other tests…
· FSH, LH high = GDPP à other tests…
§ Wrist XR (non-dominant) for skeletal age
§ General hormone profile à basal LH/FSH, serum testosterone and oestrogen
§ Urinary 17-OH progesterone if CAH suspecte
Management of precocious puberty?
REFER TO PAEDIATRIC ENDOCRINOLOGIST
Treatment for precocious puberty?
o If GDPP with no underlying pathology, often no treatment is required
o Gonadotrophin-Dependent Precocious Puberty (exclude neoplasms; n.b. 90% females no identifiable cause)
GnRH agonist (e.g. leuprolide) + GH therapy:
GnRH agonists overstimulate pituitary à desensitisation à arrest puberty
· GH therapy used as GnRH agonists can stunt growth
GnRH agonist + cryproterone (anti-androgen)
Supresses peripheral androgen action
o Gonadotrophin-Independent Precocious Puberty (exclude neoplasms):
McCune Albright or Testotoxicosis: 1st: ketoconazole or cyproterone; 2nd: aromatase inhibitors
CAH: hydrocortisone + GnRH agonist
achondroplasia vs hypochondroplasia?
o Achondroplasia (S/S: arms and legs short, normal length thorax)
o Hypochondroplasia (S/S: small stature, micromelia (small extremities), large head
Signs of Osteogenesis imperfecta?
S/S: blue sclera, short stature, loose joints, hearing loss, breathing problems
o Types = 7 forms (type 1 is the most common = abnormal pro-alpha 1 or 2 collagen polypeptides)
What gene is associated with achondroplasia, hypochondroplasia?
FGFR3 gene
Isolated short stature in a young girl, must exclude what?
Turner’s syndrome (45XO)
What arteries can be investigated using doppler USS?
Umbilical artery, foetal vessels, uterine artery
Mutation associated with skeletal dysplasias?
FGFR3
TTTS is graded in severity according to which scale?
Quintero staging
Causes of pre-term labour?
Cervical weakness, infection (chorioamnioitis), uterine abnormalities,
Risk factors for placental abruption:
Pre-eclampsia
Hypertension
Previous abruption
Trauma
Smoking
Cocaine
Multiple pregnancy
Polyhydramnios
Thrombophilia
Advanced maternal age
PPROM
Indomethacin causes what?
Ductus arteriosus closure
What maintains PDA?
Prostaglandin E1
PPROM at 37 weeks gestation?
Immediate induction of labour is advised in women > 37 weeks gestation
Conservative management of PPROM
Conservative Management
Intensive clinical surveillance for signs of chorioamnionitis (including regular recording of maternal temperature, heart rate, CTG and maternal biochemistry)
Rising WCC or CRP indicates development of chorioamnionitis
Lower genital tract swabs are routinely taken but cultures do NOT correlate well with risk of chorioamnionitis
Tocolysis is CONTRAINDICATED due to the increased risk of maternal and foetal infection in patients with PPROM
Medication to reduce preterm birth in those with previous history
IM hydroxyprogesterone caproate
Antibiotics in PPROM
Offer women with PPROM oral erythromycin 250 mg 4/day for a maximum of 10 days or until the woman is in established labour
If erythromycin is not tolerated or contra-indicated, consider oral penicillin
When to consider cervical cerclage in PPROM
Consider rescue cervical cerclage for women between 16-27 weeks with a dilated cervix and exposed, unruptured foetal membranes
Take into account gestational age (benefits are greater for earlier gestations) and extent of cervical dilatation
Explain to women:
Risks of rescue cerclage
That it aims to delay birth, thereby increasing the likelihood of the baby surviving and of reducing serious neonatal morbidity
Diagnosing Preterm Labour with Intact Membranes
Clinical history taking
Observations
Speculum examination (and digital vaginal examination if the extent of cervical dilatation cannot be assessed)
If clinical assessment suggests that the woman is in preterm labour and she is < 29+6 weeks pregnant, advise that treatment is necessary
If clinical assessment suggests that the woman is in preterm labour and she is > 30 weeks pregnant
Consider transvaginal ultrasound measurement of cervical length to determine likelihood of birth within 48 hours
If cervical length > 15 mm explain that it is unlikely that she is in preterm labour
If cervical length < 15 mm make a diagnosis of preterm labour and treat accordingly
Consider foetal fibronectin testing if transvaginal measurement of cervical length is unavailable or unacceptable
If negative (concentration < 50 ng/mL) explain that they are unlikely to be in preterm labour
If positive (concentration > 50 ng/mL) make a diagnosis of preterm labour and treat accordingly
