Bits and bobs Flashcards

Question

What birth defects are sodium valproate associated with

Answer 1

neural tube defects

Answer 2

aim for mono therapy lamotrigine is often best choice 5mg folic acid prior to getting pregnant if possible

Answer 3

Appearance, Pulse, Grimace, Activity, and Respiration each either 2/1/0 Appearance/Colour: pink, peripheral blue, all blue Pulse: >100, <100, absent Reflex irritability: cries on stimulation/sneeze/cough, grimace, nil Muscle tone:active movement, limb flexion, flaccid Respiratory effort:Strong crying, weak irregular, nil

Answer 4

Radiology may show translucent bones, multiple fractures, particularly of the long bones, wormian bones (irregular patches of ossification) and a trefoil pelvis.

Answer 5

clear appearance glucose 70% of plasma protein 0.3 g/l WCC 2 per mm^3 (neuts)

Answer 6

Cloudy Glucose low (< 1/2 plasma) bacteria using up the glucose Protein high (> 1 g/l) bacteria releasing proteins WCC 10 - 5,000 polymorphs/mm³ the immune system releases neutrophils in response to bacteria

Answer 7

Clear/cloudy Glucose 60-80% of plasma glucose* viruses don’t really use glucose Protein normal/raised viruses may release a small amount of protein WCC 15 - 1,000 lymphocytes/mm³ the immune system releases lymphocytes in response to viruses

Answer 8

Slight cloudy, fibrin web glucose Low (< 1/2 plasma) Protein high >1g/l WCC 30-300 lymphocytes/mm3

Answer 9

surgery - craniotomy IV antibiotics: IV 3rd-generation cephalosporin + metronidazole intracranial pressure management: e.g. dexamethasone

Answer 10

It is caused by a defective gene for dystrophin on the X-chromosome. Dystrophin is a protein that helps hold muscles together at the cellular level. Becker's muscular dystrophy is very similar to Duchennes, however the dystrophin gene is less severely affected and maintains some of its function.

Answer 11

X-linked recessive If a mother is a carrier and she has a child, that child will have a 50% chance of being a carrier if they are female and 50% chance of having the condition if they are male Given that boys have a single X-chromosome and girls have two, girls have a spare copy of the dystrophin gene. Female carriers of the condition do not usually notice any symptoms. This makes Duchenne's muscular dystrophy an X-linked recessive condition.

Answer 12

if child is <3 years old if child is febrile

Answer 13

Retinal haemorrhages Subdural haematoma Encephalopathy

Answer 14

absence seizures

Answer 15

Benign rolandic epilepsy

Answer 16

duodenal atresia hirschsprung's disease

Answer 17

multiple cardiac problems may be present endocardial cushion defect (most common, 40%, also known as atrioventricular septal canal defects) ventricular septal defect (c. 30%) secundum atrial septal defect (c. 10%) tetralogy of Fallot (c. 5%) isolated patent ductus arteriosus (c. 5%)

Answer 18

Regular thyroid checks (2 yearly) - at risk of hypothyroidism Echocardiogram - cardiac defects Audiometry regular - hearing impairment - recurrent otitis media and glue ear etc. Regular eye checks - myopia, strabismus, cataracts

Answer 19

In obstructive jaundice (both intrahepatic cholestasis and extrahepatic obstruction) the serum bilirubin is principally conjugated. Conjugated bilirubin is water soluble and is excreted in the urine, giving it a dark colour (bilirubinuria).

Answer 20

the presence of proteinuria (>3.5 g/24 hours) hypoalbuminaemia (<30 g/L) peripheral oedema.

Answer 21

chronic myeloid leukemia 65+

Answer 22

Acute lymphoblastic leukemia anaemia, thrombocytopenia, neutropenia

Answer 23

autosomal recessive abnormal variant called haemoglobin S (HbS) abnormal gene for beta-globin on chromosome 11

Answer 24

haemoglobin electrophoresis

Answer 25

General: - avoid dehydration and triggers - vaccines inc pneumococcal polysaccharide vaccine every 5 years - abx prophylaxis eg penicillin V - hydroxycarbamide (stimulate fetal HbF) - blood transfusion - bone marrow transplant can be curative vaso-occlusive pripism: - aspiration of blood splenic sequestration: - blood transfusion and fluid resus aplastic: - blood transfusion acute chest: - abx and antivirals - blood trans - ventilation

Answer 26

high (needing to constantly make new rbc) may be low in aplastic crisis normal is 0.45–1.8 percent

Answer 27

parovirus B19 reticulocytes may be low

Answer 28

Haemaglobin electrophoresis

Answer 29

A blood film shows target cells and Howell-Jolly bodies.

Answer 30

hypermobile, stretchy skin autosomal dominant type 3 collagen aortic regurg,dissection, mitral prolapse beighton score

Answer 31

The Rotterdam criteria are used for making a diagnosis of polycystic ovarian syndrome. A diagnosis requires at least two of the three key features: Oligoovulation or anovulation, presenting with irregular or absent menstrual periods (generally defined as fewer than six to nine menstrual cycles per year) Hyperandrogenism, characterised by hirsutism and acne Polycystic ovaries on ultrasound (or ovarian volume of more than 10cm3)

Answer 32

pelvic ultrasound: transvaginal FSH, LH, prolactin, TSH, and testosterone are useful investigations (raised LH:FSH ratio is a 'classical' feature but is no longer thought to be useful in diagnosis. Prolactin may be normal or mildly elevated. Testosterone may be normal or mildly elevated - however, if markedly raised consider other causes) 2-hour 75g oral glucose tolerance test (OGTT)

Answer 33

weight loss, orlistat if bmi>30

Answer 34

Full blood count, which can show anaemia, leukopenia, thrombocytopenia and high numbers of the abnormal WBCs Blood film, which can show blast cells Bone marrow biopsy Lymph node biopsy

Answer 35

ejection systolic murmur due to bicuspid aortic valve A bicuspid aortic valve is an aortic valve that has two flaps (cusps) instead of three. It may cause a narrowed or obstructed aortic valve opening (aortic valve stenosis), or systolic subclavicular from coarctation

Answer 36

it is an oral, live attenuated vaccine 2 doses are required, the first at 2 months, the second at 3 months the first dose should not be given after 14 weeks + 6 days and the second dose cannot be given after 23 weeks + 6 days due to a theoretical risk of intussusception

Answer 37

focal neurological signs papilloedema significant bulging of the fontanelle disseminated intravascular coagulation signs of cerebral herniation For patients with meningococcal septicaemia a lumbar puncture is contraindicated - blood cultures and PCR for meningococcus should be obtained.

Answer 38

Presentation: myelopathy: pain (affecting the neck, upper or lower limbs) loss of fine motor function (dexterity, clumsy) loss of sensory function causing numbness, loss of autonomic function, hoffmans Causes: Cervical spondylosis (osteophyte), disc herniation Investigation: MRI Management: decompressive surgery

Answer 39

Presentation: cancer patient, back pain, bilateral weakness, UMN signs. First symptom: back pain Investigation: MRI of whole spine Management: high dose dexamethasone and oncology assessment

Answer 40

- ipsilateral dorsal column signs - ipsilateral corticospinal tract signs - contralateral spinothalamic tract signs

Answer 41

Presentation: bilateral dorsal column signs, may have bilateral corticospinal tract signs (affects posterior cord) Cause: B12 deficiency Prevention: Always replace vitamin B12 before folate - giving folate to a patient deficient in B12 can precipitate subacute combined degeneration of the cord

Answer 42

Presentation: teenage corticospinal, spinocerebellar, dorsal column and peripheral nerves Information: autosomal recessive trinucleotide repeat disorder resulting in reduced level or function of the frataxin protein. Investigation: genetic analysis Management: supportive

Answer 43

Pathophysiology: development of a fluid-filled cyst (a syrinx) around the spinal canal. Causes: Chiari malformation, tumour, trauma Presentation: ‘central cord syndrome’ bilateral spinothalamic and/or bilateral corticospinal tract symptoms. The upper limbs are affected first whilst the lower limbs are spared until much later. As the fibres of the spinothalamic tract enter the spinal cord and immediately decussate, they pass close to the spinal canal, meaning they are often the first of these white matter fibres to be compressed and damaged. As the cervical cord is the most likely location of the lesion, there is classically said to be a “cape-like” loss of pain and temperature sensation. Investigation: full spine MRI with contrast and brain MRI Management: treat cause. If persistent : shunt

Answer 44

Presentation: back pain, bilateral leg weakness or unilateral, positional element: better on walking up hill and sitting forward. Ddx claudication Investigation: MRI Management: Laminectomy

Answer 45

Presentation: young man, lower back pain and stiffness, worse in morning Investigation: plain x ray of sacroiliac joints Management: encourage regular exercise such as swimming, NSAIDs are the first-line treatment, physiotherapy

Answer 46

Myelopathy: bilateral as spinal cord and bladder/bowel, not always painful “clumsiness” “loss of manual dexterity” Radiculopathy: radiating limb pain, often in the pattern of the dermatome, sharp/shooting in character, with only a small proportion (about 5%) having associated neurologic symptoms such as dermatomal sensory loss, and even less commonly myotomal muscle weakness.

Answer 47

C5 – Elbow flexion (and shoulder abduction) C6 – Wrist extension (and shoulder adduction) (and elbow flexion) C7 – Elbow extension (and wrist flexion) C8 – Finger flexion and thumb extension T1 – Finger abduction

Answer 48

L2 – Hip flexion L3 – Knee extension L4 – Ankle dorsiflexion L5 – Great toe extension S1 – Ankle plantarflexion

Answer 49

T4 T4 at the Teat Pore

Answer 50

T10 BellybuT-TEN

Answer 51

L1 L for ligament, 1 for 1nguinal

Answer 52

L4 Down on aLL fours - L4

Answer 53

L5 Largest of the 5 toes

Answer 54

S1 the smallest 1

Answer 55

central disc prolapse at L4/5 or L5/S1

Answer 56

1. Dry baby and maintain temperature 2. Assess tone, respiratory rate, heart rate 3. If gasping or not breathing give 5 inflation breaths* 4. Reassess (chest movements) 5. If the heart rate is not improving and <60bpm start compressions and ventilation breaths at a rate of 3:1

Answer 57

1. Safety 2. Stimulate - put hand on head, shake a limb, flick fingers and toes 3. Shout - 2222 4. Open airway - head tilt-chin lift, jaw thrust if ?spinal injury 5. Look, listen, feel 6. 5 rescue breaths (pinch nose and breathe into their nose) CPR 15 chest compressions, 2 ventilations (1 hand or 2 hands) ⅓ to ½ of chest 100-120 per minute, allow for recoil, lower sternum (for one minute, if no help yet go get help yourself)

Answer 58

Unilateral resting tremor (improves with voluntary movement)

Answer 59

Antipsychotics or antiemetic metoclopramide can cause EPSE. In patients with parksinons, prescribe antiemetic domperidone as it doesn’t cross BBB therefore doesn’t cause EPSE

Answer 60

SPECT/DaTSCAN

Answer 61

size < 35 no pain unruptured no heart beat hCG <1,000IU/L another intrauterine pregnancy Expectant management involves closely monitoring the patient over 48 hours and if B-hCG levels rise again or symptoms manifest intervention is performed.

Answer 62

size < 35 minimal pain unruptured no heart beat hCG <1,500IU/L must be willing to attend follow up

Answer 63

size > 35 pain unruptured or ruptured fetal heart beat hCG >5,000IU/L Salpingectomy is first-line for women with no other risk factors for infertility Salpingotomy should be considered for women with risk factors for infertility such as contralateral tube damage

Answer 64

damage to tubes (pelvic inflammatory disease, surgery) previous ectopic endometriosis IUCD progesterone only pill IVF (3% of pregnancies are ectopic)

Answer 65

ampulla of fallopian tube

Answer 66

transvaginal USS

Answer 67

expectant then pregnancy test in 7-10 days to confirm refer if any pain etc (ectopic?)

Answer 68

refer to early pregnancy assessment service transvaginal USS Expectant : if no infection risk/bleeding risk. pregnancy test in 3 weeks Medical : misoprolol (prostaglandin analogue --> stimulate contractions) Surgical : Manual vacuum aspiration under local anaesthetic as an outpatient or electric vacuum aspiration under general anaesthetic

Answer 69

Medical : misoprolol Surgical: Evacuation of retained products of conception (ERPC)

Answer 70

Ladd's procedure

Answer 71

oligohydramnios congenital diaphragmatic hernia

Answer 72

'involuntary discharge of urine by day or night or both, in a child aged 5 years or older, in the absence of congenital or acquired defects of the nervous system or urinary tract'

Answer 73

ventricular septal defect (VSD) right ventricular hypertrophy right ventricular outflow tract obstruction, pulmonary stenosis overriding aorta

Answer 74

Low molecular weight heparin eg dalteparin, enoxaparin, and tinzaparin If previous DVT Or x number of risk factors: Age > 35 Body mass index > 30 Parity > 3 Smoker Gross varicose veins Current pre-eclampsia Immobility Family history of unprovoked VTE Low risk thrombophilia Multiple pregnancy IVF pregnancy 4 or more risk factors warrants immediate treatment with low molecular weight heparin continued until six weeks postnatal. I 3 risk factors low molecular weight heparin should be initiated from 28 weeks and continued until six weeks postnatal. If diagnosis of DVT is made shortly before delivery, continue anticoagulation treatment for at least 3 month, as in other patients with provoked DVTs.

Answer 75

continuing the pregnancy involves greater risk to the physical or mental health of: The woman Existing children of the family The threshold for when the risk of continuing the pregnancy outweighs the risk of terminating the pregnancy is a matter of clinical judgement and opinion of the medical practitioners.

Answer 76

Continuing the pregnancy is likely to risk the life of the woman Terminating the pregnancy will prevent “grave permanent injury” to the physical or mental health of the woman There is “substantial risk” that the child would suffer physical or mental abnormalities making it seriously handicapped

Answer 77

First Trimester (0 to 13 Weeks) Second Trimester (14 to 26 Weeks) Third Trimester (27 to 40 Weeks)

Answer 78

More than 5 % weight loss compared with before pregnancy Dehydration Electrolyte imbalance assess severity with Pregnancy-Unique Quantification of Emesis (PUQE) score. This gives a score out of 15: < 7: Mild 7 – 12: Moderate > 12: Severe

Answer 79

admission should be considered in cases of ketonuria and/or weight loss despite use of oral anitemetics Unable to tolerate oral antiemetics or keep down any fluids More than 5 % weight loss compared with pre-pregnancy Ketones are present in the urine on a urine dipstick (2 + ketones on the urine dipstick is significant) Other medical conditions need treating that required admission

Answer 80

multiple pregnancies trophoblastic disease hyperthyroidism nulliparity obesity Smoking is associated with a decreased incidence of hyperemesis.

Answer 81

complete - 2 sperm, no genetic material in ovum partial - 2 sperm, genetic material in ovum

Answer 82

More severe morning sickness Vaginal bleeding Increased enlargement of the uterus Abnormally high hCG Thyrotoxicosis (hCG can mimic TSH and stimulate the thyroid to produce excess T3 and T4) Ultrasound of the pelvis shows a characteristic “snowstorm appearance”. histology of material after for diagnostic. 1. referred to the gestational trophoblastic disease centre 2. evacuation of uterus 3. effective contraception is recommended to avoid pregnancy in the next 12 months 4. monitor hCG until normal 5. check for choriocarcinoma

Answer 83

Glasgow coma scale (GCS) out of 15 Motor response 6. Obeys commands 5. Localises to pain 4. Withdraws from pain 3. Abnormal flexion to pain (decorticate posture) 2. Extending to pain 1. None Verbal response 5. Orientated 4. Confused 3. Words 2. Sounds 1. None Eye opening 4. Spontaneous 3. To speech 2. To pain 1. None

Answer 84

Grade 0 No muscle movement Grade 1 Trace of contraction Grade 2 Movement at the joint with gravity eliminated Grade 3 Movement against gravity, but not against added resistance Grade 4 Movement against an external resistance with reduced strength Grade 5 Normal strength

Answer 85

Ankle = S1 Miss out 2 Knee = L3,4 Brachioradialis = C5,6 Biceps = C5,6 Triceps = C7

Answer 86

Surgical third nerve palsy : painful, dilated pupil Diabetes : not painful, reactive pupil

Answer 87

lower motor neuron facial nerve palsy - forehead affected oral prednisolone within 72 hours if the paralysis shows no sign of improvement after 3 weeks, refer urgently to ENT

Answer 88

Clinical assessment (history and examination) Imaging (ultrasound or mammography) Histology (fine needle aspiration or core biopsy)

Answer 89

Thrombectomy within 6 hours of onset Thrombolysis within 4.5 hours onset Both if occlusion if proximal anterior circulation on CTA or MRA

Answer 90

Receptive aphasia Fluent speech, doesn’t make any sense, comprehension impaired Lesion in superior temporal gurus Supplied by inferior division of left MCA

Answer 91

Non-fluent laboured and halting speech. Repetition impaired (expressive) Inferior frontal gyrus Superior division of left MCA Spoken word is heard at the ear. This passes to Wernicke's area in the temporal lobe (near the ear) to comprehend what was said. Once understood, the signal passes along the arcuate fasciculus, before reaching Broca's area. The Broca's area in the frontal lobe (near the mouth) then generates a signal to coordinate the mouth to speak what is thought (fluent speech).

Answer 92

Speech fluent but repetition is poor Aware of errors Arcuate fasiculus (connection between brocas and wernikes) Spoken word is heard at the ear. This passes to Wernicke's area in the temporal lobe (near the ear) to comprehend what was said. Once understood, the signal passes along the arcuate fasciculus, before reaching Broca's area. The Broca's area in the frontal lobe (near the mouth) then generates a signal to coordinate the mouth to speak what is thought (fluent speech).

Answer 93

Minimal muscle atrophy Weakness ‘Pyramidal’ pattern i.e. weakness of upper limb extensors, lower limb flexors So upper limb is flexed and lower limb extended (think hemiplegic gait) Slightly reduced power Hyperreflexia of deep tendon reflexes- as no UMN regulating that reflex Absent superficial reflex - babinski positive Hypertonia + or - clonus (Spasticity occurs in pyramidal tract lesions) such as clonus and clasp-knife rigidity Pronator drift

Answer 94

stabilising the patient followed by surgical intervention with a burr hole or craniotomy to evacuate the haematoma.

Answer 95

middle meningeal artery eminem getting hit by a lemon

Answer 96

concave crescent-shaped

Answer 97

bridging veins old man drinking alcohol in a cave with a bridge outside and a crescent moon in the sky

Answer 98

Small or incidental acute subdurals can be observed conservatively. If big or signs then surgical options include monitoring of intracranial pressure and decompressive craniectomy.

Answer 99

Ruptured cerebral aneurysm or trauma

Answer 100

adult polycystic kidney disease Ehlers-Danlos syndrome Coarctation of the aorta

Answer 101

Acute blood (hyperdense/bright on CT) is typically distributed in the basal cisterns, sulci and in severe cases the ventricular system. may be normal - do LP

Answer 102

LP is performed at least 12 hours following the onset of symptoms to allow the development of xanthochromia (the result of red blood cell breakdown). Xanthochromia helps to distinguish true SAH from a ‘traumatic tap’ (blood introduced by the LP procedure). As well as xanthochromia, CSF findings consistent with subarachnoid haemorrhage include a normal or raised opening pressure

Answer 103

CT intracranial angiogram

Answer 104

1. referral to neurosurgery after confirmation 2. coil by interventional radiologists 3. or craniotomy 4. 21-day course of nimodipine (a calcium channel inhibitor targeting the brain vasculature) 5. Hydrocephalus is temporarily treated with an external ventricular drain

Answer 105

Similar to that of other musculoskeletal lower back pain: analgesia, physiotherapy, exercises If symptoms persist after 4-6 weeks then referral for consideration of MRI is appropriate

Answer 106

associated with HLA-DR2 it is associated with low levels of orexin (hypocretin), a protein which is responsible for controlling appetite and sleep patterns early onset of REM sleep

Answer 107

typical onset in teenage years hypersomnolence cataplexy (sudden loss of muscle tone often triggered by emotion) sleep paralysis vivid hallucinations on going to sleep or waking up

Answer 108

multiple sleep latency EEG

Answer 109

daytime stimulants (e.g. modafinil) and nighttime sodium oxybate

Answer 110

weight loss Co-cyprindiol (Dianette) for 3 months* Topical eflornithine Specialist: Electrolysis Laser hair removal Spironolactone (mineralocorticoid antagonist with anti-androgen effects) Finasteride (5α-reductase inhibitor that decreases testosterone production) Flutamide (non-steroidal anti-androgen) Cyproterone acetate (anti-androgen and progestin)

Answer 111

Co-cyprindiol (Dianette) for 3 months* Topical adapalene (a retinoid) Topical antibiotics (e.g. clindamycin 1% with benzoyl peroxide 5%) Topical azelaic acid 20% Oral tetracycline antibiotics (e.g. lymecycline)

Answer 112

weight loss Clomifene (causes ovulation, selective estrogen receptor modulator (SERM).) Laparoscopic ovarian drilling In vitro fertilisation (IVF)

Answer 113

Mirena coil for continuous endometrial protection Inducing a withdrawal bleed at least every 3 – 4 months with either: Cyclical progestogens (e.g. medroxyprogesterone acetate 10mg once a day for 14 days) Combined oral contraceptive pill

Answer 114

high LH high LH:FSH ratio

Answer 115

high LH and FSH

Answer 116

Growth hormone therapy can be used to prevent short stature Oestrogen and progesterone replacement can help establish female secondary sex characteristics, regulate the menstrual cycle and prevent osteoporosis Fertility treatment can increase the chances of becoming pregnant

Answer 117

High LH, High/normal testosterone

Answer 118

buccal smear or chromosomal analysis to reveal 46XY genotype

Answer 119

Hyponautramia, shocked, hyperkalaemia Poor feeding Vomiting Dehydration Arrhythmias as aldosterone is low so not adequate resorption of sodium and water/excretion of potassium

Answer 120

21-hydroxylase deficiency 11-beta hydroxylase deficiency (5%) 17-hydroxylase deficiency (very rare)

Answer 121

autosomal recessive

Answer 122

Hydrocortisone- Cortisol replacement Fludrocortisone - Aldosterone replacement Female patients with “virilised” genitals may require corrective surgery

Answer 123

21-hydroxylase deficiency (90%) (responsible for biosynthesis of aldosterone + cortisol) 21-hydroxylase is the enzyme responsible for converting progesterone into aldosterone and cortisol. Progesterone is also used to create testosterone, but this conversion does not rely on the 21-hydroxylase enzyme. In CAH, there is a defect in the 21-hydroxylase enzyme. Therefore, because there is extra progesterone floating about that cannot be converted to aldosterone or cortisol, it gets converted to testosterone instead. The result is a patient with low aldosterone, low cortisol and abnormally high testosterone. High progesterone also seems to inhibit menstruation and so leads to primary or secondary amenorrhoea.

Answer 124

The hypothalamus reduces the production of GnRH in response to significant physiological or psychological stress. This leads to hypogonadotropic hypogonadism and amenorrhoea. The hypothalamus responds this way to prevent pregnancy in situations where the body may not be fit for it, for example: Excessive exercise (e.g. athletes) Low body weight and eating disorders Chronic disease Psychological stress

Answer 125

High prolactin levels act on the hypothalamus to prevent the release of GnRH. Without GnRH, there is no release of LH and FSH. This causes hypogonadotropic hypogonadism. eg pituitary adenoma

Answer 126

Sheehan's syndrome (SS) is postpartum hypopituitarism caused by necrosis of the pituitary gland. It is usually the result of severe hypotension or shock caused by massive hemorrhage during or after delivery. Patients with SS have varying degrees of anterior pituitary hormone deficiency.

Answer 127

Cessation of menstruation for 3-6 months in women with previously normal and regular menses, or 6-12 months in women with previous oligomenorrhea

Answer 128

menopause before the age of 40 years

Answer 129

Raised LH and FSH levels (gonadotropins) Low oestradiol levels hypergonadotrophic hypogonadism

Answer 130

FSH level persistently raised (more than 25 IU/l) on two consecutive samples separated by more than four weeks to make a diagnosis. menopause symptoms

Answer 131

Traditional hormone replacement therapy Combined oral contraceptive pill Adequate vitamin D and calcium intake

Answer 132

A diagnosis of perimenopause and menopause can be made in women over 45 years with typical symptoms, without performing any investigations. NICE guidelines (2015) recommend considering an FSH blood test to help with the diagnosis in: Women under 40 years with suspected premature menopause Women aged 40 – 45 years with menopausal symptoms or a change in the menstrual cycle

Answer 133

presents following recent dilatation and curettage, uterine surgery or endometritis with: Secondary amenorrhoea (absent periods) Significantly lighter periods Dysmenorrhoea (painful periods)

Answer 134

Hysteroscopy is the gold standard investigation, and can involve dissection and treatment of the adhesions reoccurence is common

Answer 135

fluoxetine, citalopram or venlafaxine

Answer 136

The developing syncytiotrophoblast of the pregnancy produces hCG. In an intrauterine pregnancy, the hCG will roughly double every 48 hours. This will not be the case in a miscarriage or ectopic pregnancy. A rise of more than 63% after 48 hours is likely to indicate an intrauterine pregnancy. A repeat ultrasound scan is required after 1 – 2 weeks to confirm an intrauterine pregnancy. A pregnancy should be visible on an ultrasound scan once the hCG level is above 1500 IU / l. A rise of less than 63% after 48 hours may indicate an ectopic pregnancy. When this happens the patient needs close monitoring and review. A fall of more than 50% is likely to indicate a miscarriage. A urine pregnancy test should be performed after 2 weeks to confirm the miscarriage is complete.

Answer 137

Serum 25-hydroxyvitamin D - less than 25 nmol/L is deficient Serum calcium may be low Serum phosphate may be low Serum alkaline phosphatase may be high Parathyroid hormone may be high

Answer 138

Vitamin D (ergocalciferol). children between 6 months and 12 years is 6,000 IU per day for 8 – 12 weeks.

Answer 139

achondroplasia

Answer 140

10% dextrose Day 1 – 60 mls/kg/day Day 2 – 90 mls/kg/day Day 3 – 120 mls/kg/day Day 4 – 150 mls/kg/day From day 2 Na 3 mmol/kg/day K 2 mmol/kg/day Ca 1 mmol/kg/day (rarely)

Answer 141

(Age + 4) x2 = weight in kg

Answer 142

0.9% sodium chloride + 5% glucose (+/- KCl) Weight Daily (ml/24h) First 10 kg 100 ml/kg Next 10 kg 50 ml/kg Every other kg 20 ml/kg Rate (ml/h): Total (ml) / 24

Answer 143

Reduced consciousness Cold, mottled peripheries Low blood pressure Prolonged capillary refill time Weak peripheral pulses Anuria 10%

Answer 144

Thirst Dry lips Restlessness, irritability Sunken eyes Reduced skin turgor Decreased urine output Altered responsiveness Normal blood pressure Normal CRT Skin colour normal 5%

Answer 145

Deficit(%) x 10 x Wt(kg) + maintenance

Answer 146

give 50 ml/kg low osmolarity oral rehydration solution (ORS) solution over 4 hours, plus ORS solution for maintenance, often and in small amounts continue breastfeeding consider supplementing with usual fluids (including milk feeds or water, but not fruit juices or carbonated drinks)

Answer 147

20 mls/kg of 0.9% sodium chloride bolus (note: no glucose) 10ml/kg more appropriate on some occasions eg cardiac, kidneys, DKA Seek expert advice (for example, from the paediatric intensive care team) if 40–60 ml/kg of IV fluid or more is needed as part of the initial fluid resuscitation.

Answer 148

jittery movements increased muscle tone hyperreflexia convulsions drowsiness or coma

Answer 149

bleeding after delivery of the baby and placenta 500ml after a vaginal delivery 1000ml after a Caesarean section

Answer 150

Minor <1000 Moderate 1000-2000 Major >2000

Answer 151

Primary - within 24 hours of birth Secondary > 24 hours after birth

Answer 152

T – Tone (uterine atony – the most common cause) T – Trauma (e.g. perineal tear) T – Tissue (retained placenta) T – Thrombin (bleeding disorder

Answer 153

Previous PPH Multiple pregnancy Obesity Large baby Failure to progress in the second stage of labour Prolonged third stage Pre-eclampsia Placenta accreta Retained placenta Instrumental delivery General anaesthesia Episiotomy or perineal tear

Answer 154

Treating anaemia during the antenatal period Giving birth with an empty bladder (a full bladder reduces uterine contraction) Active management of the third stage (with intramuscular oxytocin in the third stage) Intravenous tranexamic acid can be used during caesarean section (in the third stage) in higher-risk patients

Answer 155

Resuscitation with an ABCDE approach Lie the woman flat, keep her warm and communicate with her and the partner Insert two large-bore cannulas Bloods for FBC, U&E and clotting screen Group and cross match 4 units Warmed IV fluid and blood resuscitation as required Oxygen (regardless of saturations) Fresh frozen plasma is used where there are clotting abnormalities or after 4 units of blood transfusion

Answer 156

- rubbing uterus/fundus - catheter

Answer 157

Oxytocin (slow injection followed by continuous infusion) 40 units in 500ml Ergometrine (intravenous or intramuscular) stimulates smooth muscle contraction (contraindicated in hypertension) Carboprost (intramuscular) is a prostaglandin analogue and stimulates uterine contraction (caution in asthma) Misoprostol (sublingual) is also a prostaglandin analogue and stimulates uterine contraction Tranexamic acid (intravenous) is an antifibrinolytic that reduces bleeding

Answer 158

Intrauterine balloon tamponade – inserting an inflatable balloon into the uterus to press against the bleeding B-Lynch suture – putting a suture around the uterus to compress it Uterine artery ligation – ligation of one or more of the arteries supplying the uterus to reduce the blood flow Hysterectomy is the “last resort” but will stop the bleeding and may save the woman’s life

Answer 159

- retained products of conception - infection (endometritis)

Answer 160

- USS for RPOC - high vaginal swab for infection

Answer 161

Ovarian torsion

Answer 162

28 and 34 weeks

Answer 163

delivery of a Rh +ve infant, whether live or stillborn any termination of pregnancy miscarriage if gestation is > 12 weeks ectopic pregnancy (if managed surgically, if managed medically with methotrexate anti-D is not required) external cephalic version antepartum haemorrhage amniocentesis, chorionic villus sampling, fetal blood sampling abdominal trauma

Answer 164

all babies born to Rh -ve mother should have cord blood taken at delivery for FBC, blood group & direct Coombs test Coombs test: direct antiglobulin, will demonstrate antibodies on RBCs of baby Kleihauer test: add acid to maternal blood, fetal cells are resistant (do after a sensitisation event to see if further foses of anti-d are required)

Answer 165

oedematous (hydrops fetalis, as liver devoted to RBC production albumin falls) jaundice, anaemia, hepatosplenomegaly heart failure kernicterus treatment: transfusions, UV phototherapy

Answer 166

Ovulation pain

Answer 167

the fetus is no longer alive, but no symptoms have occurred

Answer 168

vaginal bleeding with a closed cervix and a fetus that is alive

Answer 169

vaginal bleeding with an open cervix

Answer 170

retained products of conception remain in the uterus after the miscarriage

Answer 171

a full miscarriage has occurred, and there are no products of conception left in the uterus

Answer 172

a gestational sac is present but contains no embryo

Answer 173

transvaginal ultrasound

Answer 174

is the total number of pregnancies a woman has had

Answer 175

refers to a patient that is pregnant for the first time

Answer 176

refers to a patient that is pregnant for at least the second time

Answer 177

refers to the number of times the woman has given birth after 24 weeks

Answer 178

refers to a patient that has never given birth after 24 weeks gestation

Answer 179

technically refers to a patient that has given birth after 24 weeks gestation once before (see below) The term primiparous, or “primip” is a bit confusing. Technically, it refers to a woman that has given birth once before. However, it is often used on the labour ward to refer to a woman that is due to give birth for the first time (and has never given birth before). You may hear patients referred to on the labour ward as a “primip” when they have never given birth before.

Answer 180

20 weeks If fetal movements have not yet been felt by 24 weeks, referral should be made to a maternal fetal medicine unit

Answer 181

Whooping cough (pertussis) from 16 weeks gestation Influenza (flu) when available in autumn or winter Live vaccines, such as the MMR vaccine, are avoided in pregnancy.

Answer 182

A set of booking bloods are taken for: Blood group, antibodies and rhesus D status Full blood count for anaemia Screening for thalassaemia (all women) and sickle cell disease (women at higher risk) Patients are also offered screening for infectious diseases, by testing antibodies for: HIV Hepatitis B Syphilis Screening for Down’s syndrome may be initiated depending on the gestational age. Bloods required for the combined test are taken from 11 weeks onwards.

Answer 183

ebsteins anomaly

Answer 184

Congenital deafness Congenital cataracts Congenital heart disease (PDA and pulmonary stenosis) Learning disability

Answer 185

More severe cases in the mother, such as varicella pneumonitis, hepatitis or encephalitis Fetal varicella syndrome Severe neonatal varicella infection (if infected around delivery)

Answer 186

When they are not sure about their immunity, test the VZV IgG levels. If positive, they are safe. When they are not immune, they can be treated with IV varicella immunoglobulins as prophylaxis against developing chickenpox. This should be given within ten days of exposure.

Answer 187

oral aciclovir

Answer 188

Fetal growth restriction Microcephaly, hydrocephalus and learning disability Scars and significant skin changes located in specific dermatomes Limb hypoplasia (underdeveloped limbs) Cataracts and inflammation in the eye (chorioretinitis)

Answer 189

Listeriosis in pregnant women has a high rate of miscarriage or fetal death. It can also cause severe neonatal infection.

Answer 190

Miscarriage or fetal death Severe fetal anaemia Hydrops fetalis (fetal heart failure) Maternal pre-eclampsia-like syndrome

Answer 191

30 minutes

Answer 192

Fetal anaemia is caused by parvovirus infection of the erythroid progenitor cells in the fetal bone marrow and liver. These cells produce red blood cells, and the infection causes them to produce faulty red blood cells that have a shorter life span. Less red blood cells results in anaemia. This anaemia leads to heart failure, referred to as hydrops feta

Answer 193

below 32 weeks gestation Other risk factors for SDLD include male sex diabetic mothers Caesarean section second born of premature twins

Answer 194

ground glass appearance

Answer 195

dexamethasone to mum before delivery endotracheal surfactant CPAP O2 to maintain sats between 91-95

Answer 196

Infants who still have an oxygen requirement at a post-menstrual age of 36 weeks are described as having bronchopulmonary dysplasia (BPD) or chronic lung disease.

Answer 197

cxr widespread opacification, hyperinflation and atelectasis, may have cystic changes A formal sleep study to assess their oxygen saturations during sleep supports the diagnosis and guides management. Babies may be discharged from the neonatal unit on a low dose of oxygen to continue at home, for example 0.01 litres per minute via nasal cannula. They are followed up to wean the oxygen level over the first year of life.

Answer 198

gas in bowel wall - sign of NEC

Answer 199

abdo xray dilated loops of bowel

Answer 200

G6PD enzyme assay around 3 months after an acute episode of hemolysis RBCs with the most severely reduced G6PD activity will have hemolysed → reduced G6PD activity → not be measured in the assay → false negative results

Answer 201

anti-malarials: primaquine ciprofloxacin sulph- group drugs: sulphonamides, sulphasalazine, sulfonylureas infections broad (fava) beans

Answer 202

family history + blood results :MCHC high, high reticulocytes, spherocytes if ambiguous: EMA binding test and the cryohaemolysis test for atypical presentations : electrophoresis analysis of erythrocyte membranes is the method of choice

Answer 203

Gastroschisis vaginal delivery may be attempted newborns should go to theatre as soon as possible after delivery, e.g. within 4 hours

Answer 204

Exomphalos (omphalocoele) caesarean section is indicated to reduce the risk of sac rupture a staged repair may be undertaken as primary closure may be difficult due to lack of space/high intra-abdominal pressure Associations Beckwith-Wiedemann syndrome Down's syndrome cardiac and kidney malformations

Answer 205

Intracranial calcification Hydrocephalus Chorioretinitis

Answer 206

glucose < 2.6 mmol/L asymptomatic encourage normal feeding (breast or bottle) monitor blood glucose symptomatic or very low blood glucose admit to the neonatal unit intravenous infusion of 10% dextrose

Answer 207

polygenic inheritance maternal antiepileptic use increases risk

Answer 208

three or more consecutive miscarriages.

Answer 209

Idiopathic (particularly in older women) Antiphospholipid syndrome Hereditary thrombophilias eg factor V leidin Uterine abnormalities

Answer 210

Chronic histiocytic intervillositis is a rare cause of recurrent miscarriage, particularly in the second trimester. It can also lead to intrauterine growth restriction (IUGR) and intrauterine death. The condition is poorly understood. Histiocytes and macrophages build up in the placenta, causing inflammation and adverse outcomes. It is diagnosed by placental histology showing infiltrates of mononuclear cells in the intervillous spaces.

Answer 211

Small for gestational age is defined as a fetus that measures below the 10th centile for their gestational age (doesn't state if pathoplogical or not) intrauterine growth restriction (IUGR), is when there is a small fetus (or a fetus that is not growing as expected) due to a pathology

Answer 212

Idiopathic Pre-eclampsia Maternal smoking Maternal alcohol Anaemia Malnutrition Infection Maternal health conditions

Answer 213

Genetic abnormalities Structural abnormalities Fetal infection Errors of metabolism

Answer 214

Short term complications of fetal growth restriction include: Fetal death or stillbirth Birth asphyxia Neonatal hypothermia Neonatal hypoglycaemia Growth restricted babies have a long term increased risk of: Cardiovascular disease, particularly hypertension Type 2 diabetes Obesity Mood and behavioural problems

Answer 215

symphysis fundal height (SFH) from 24 weeks serial growth scans with umbilical artery doppler if need closer invetsigation due to: - SFH being < 10th centile at 24 weeks - Three or more minor risk factors - One or more major risk factors - Issues with measuring the symphysis fundal height (e.g. large fibroids or BMI > 35)

Answer 216

when growth is static

Answer 217

less than 2500g

Answer 218

shoulder dystocia

Answer 219

Ultrasound to exclude polyhydramnios and estimate the fetal weight Oral glucose tolerance test for gestational diabetes

Answer 220

Constitutional Maternal diabetes Previous macrosomia Maternal obesity or rapid weight gain Overdue Male baby

Answer 221

large for gestational age (also known as macrosomia) when the weight of the newborn is more than 4.5kg at birth. An estimated fetal weight above the 90th centile is considered large for gestational age.

Answer 222

diamniotic, dichorionic twin pregnancies

Answer 223

diamniotic, dichorionic

Answer 224

Monochorionic diamniotic

Answer 225

monochorionic, monoamniotic

Answer 226

elective caesarean section at between 32 and 33 + 6 weeks.

Answer 227

36 and 36 + 6 weeks for uncomplicated monochorionic diamniotic twins 37 and 37 + 6 weeks for uncomplicated dichorionic diamniotic twins Vaginal delivery is possible when the first baby has a cephalic presentation (head first) Caesarean section may be required for the second baby after successful birth of the first baby Elective caesarean is advised when the presenting twin is not cephalic presentation

Answer 228

pre-term birth

Answer 229

MSU for sensitivities and cultures routinely (at booking and at appointments) - treat asymptomatic bacteraemia during pregnancy MSU and dip when symptomatic

Answer 230

400mcg per day from prior to getting pregnant Women with folate deficiency/epileptic drugs/pre-existing diabetes/BMI>30 are started on folic acid 5mg daily.

Answer 231

Booking clinic 28 weeks gestation

Answer 232

Hb <115 non-pregnant <110 first trimester (booking appt) <105 2nd/3rd trimester <100 post partum

Answer 233

ferrous sulphate 200mg three times daily

Answer 234

pernicious anaemia (checking for intrinsic factor antibodies).

Answer 235

Doppler ultrasound The Wells score is not validated for use in pregnant women. D-dimers are not helpful in pregnant patients, as pregnancy is a cause of a raised D-dimer.

Answer 236

Chest xray ECG There are two main options for establishing a definitive diagnosis: CT pulmonary angiogram (CTPA) or ventilation-perfusion (VQ) scan. CTPA is the test for patients with an abnormal chest xray CTPA carries a higher risk of breast cancer for the mother (minimal absolute risk) VQ scan carriers a higher risk of childhood cancer for the fetus (minimal absolute risk) Patients with a suspected deep vein thrombosis and pulmonary embolism should have a Doppler ultrasound initially, and if a DVT is present, they do not require a VQ scan or CTPA to confirm a PE. The treatment for DVT and PE are the same. The Wells score is not validated for use in pregnant women. D-dimers are not helpful in pregnant patients, as pregnancy is a cause of a raised D-dimer.

Answer 237

low molecular weight heparin (LMWH). Examples of LMWH are enoxaparin, dalteparin and tinzaparin. The dose is based on the woman’s weight at the booking clinic, or from early pregnancy. LMWH should be started immediately, before confirming the diagnosis in patients where DVT or PE is suspected and there is a delay in getting the scan. Treatment can be stopped when the investigations exclude the diagnosis. When the diagnosis is confirmed, LMWH is continued for the remained of pregnancy, plus six weeks postnatally, or three months in total (whichever is longer). There is an option to switch to oral anticoagulation (e.g. warfarin or a DOAC) after delivery. An individual risk assessment is performed before stopping anticoagulation, with advice from a haematologist if necessary.

Answer 238

Unfractionated heparin Thrombolysis Surgical embolectomy

Answer 239

Pre-eclampsia is caused by high vascular resistance in the spiral arteries and poor perfusion of the placenta. This causes oxidative stress in the placenta, and the release of inflammatory chemicals into the systemic circulation, leading to systemic inflammation and impaired endothelial function in the blood vessels.

Answer 240

NICE guidelines for diagnosis: Systolic blood pressure above 140 mmHg Diastolic blood pressure above 90 mmHg PLUS any of: Proteinuria (1+ or more on urine dipstick) Organ dysfunction (e.g. raised creatinine, elevated liver enzymes, seizures, thrombocytopenia or haemolytic anaemia) Placental dysfunction (e.g. fetal growth restriction or abnormal Doppler studies Triad : hypertension after 20 weeks, proteinuria, oedema

Answer 241

seizures due to pre-eclampsia

Answer 242

From 12 weeks until birth One high-risk factors: Pre-existing hypertension Previous hypertension in pregnancy Existing autoimmune conditions (e.g. systemic lupus erythematosus) Diabetes Chronic kidney disease 2 or more moderate risk factors: Older than 40 BMI > 35 More than 10 years since previous pregnancy Multiple pregnancy First pregnancy Family history of pre-eclampsia

Answer 243

Urine protein:creatinine ratio (above 30mg/mmol is significant) Urine albumin:creatinine ratio (above 8mg/mmol is significant)

Answer 244

The NICE guidelines (2019) recommend the use of placental growth factor (PlGF) testing on one occasion during pregnancy in women suspected of having pre-eclampsia. Placental growth factor is a protein released by the placenta that functions to stimulate the development of new blood vessels. In pre-eclampsia, the levels of PlGF are low. NICE recommends using PlGF between 20 and 35 weeks gestation to rule-out pre-eclampsia.

Answer 245

folic acid 5mg stick to metformin and insulin aim for same levels as in gestational diabetes retinopathy screening after booking and at 28 weeks planned delivery between 37 and 38 + 6 weeks

Answer 246

hypoglycaemia of newborn macrosmia

Answer 247

purple stays purple, stay positive

Answer 248

9 things CF congenital hypothyroidism sickle cell metabolic diseases: maple syrup, PKU etc

Answer 249

cystic hydroma branchial cyst

Answer 250

Often treatment for candidiasis is started empirically, based on the presentation. Testing the vaginal pH using a swab and pH paper can be helpful in differentiating between bacterial vaginosis and trichomonas (pH > 4.5) and candidiasis (pH < 4.5). A high vaginal charcoal swab with microscopy can confirm the diagnosis.

Answer 251

1. oral fluconazole 150 mg as a single dose first-line clotrimazole 500 mg intravaginal pessary as a single dose if oral therapy is contraindicated If there are vulval symptoms, consider adding a topical imidazole in addition to an oral or intravaginal antifungal 1. if pregnant then only local treatments (e.g. cream or pessaries) may be used - oral treatments are contraindicated

Answer 252

NAAT A standard charcoal endocervical swab should be taken for microscopy, culture and antibiotic sensitivities before initiating antibiotics. This is particularly important given the high rates of antibiotic resistance.

Answer 253

A single dose of intramuscular ceftriaxone 1g if the sensitivities are NOT known A single dose of oral ciprofloxacin 500mg if the sensitivities ARE known

Answer 254

This is with NAAT testing if they are asymptomatic, or cultures where they are symptomatic. BASHH recommend a test of cure at least: 72 hours after treatment for culture 7 days after treatment for RNA NATT 14 days after treatment for DNA NATT

Answer 255

Various non-specific skin lesions Polyarthralgia (joint aches and pains) Migratory polyarthritis (arthritis that moves between joints) Tenosynovitis Systemic symptoms such as fever and fatigue

Answer 256

First-line for uncomplicated chlamydia infection is doxycycline 100mg twice a day for 7 days. The guidelines previously recommended a single dose of azithromycin 1g orally as an alternative.

Answer 257

Azithromycin 1g stat then 500mg once a day for 2 days

Answer 258

Lymphogranuloma venereum (LGV) is a condition affecting the lymphoid tissue around the site of infection with chlamydia. It most commonly occurs in men who have sex with men (MSM). LGV occurs in three stages: The primary stage involves a painless ulcer (primary lesion). This typically occurs on the penis in men, vaginal wall in women or rectum after anal sex. The secondary stage involves lymphadenitis. This is swelling, inflammation and pain in the lymph nodes infected with the bacteria. The inguinal or femoral lymph nodes may be affected. The tertiary stage involves inflammation of the rectum (proctitis) and anus. Proctocolitis leads to anal pain, change in bowel habit, tenesmus and discharge. Tenesmus is a feeling of needing to empty the bowels, even after completing a bowel motion. Doxycycline 100mg twice daily for 21 days is the first-line treatment for LGV recommended by BASHH

Answer 259

Chlamydial conjunctivitis

Answer 260

Trichomonas vaginalis is a type of parasite spread through sexual intercourse. Trichomonas is classed as a protozoan, and is a single-celled organism with flagella.

Answer 261

Pelvic inflammatory disease Chronic pelvic pain Infertility Ectopic pregnancy Epididymo-orchitis Conjunctivitis Lymphogranuloma venereum Reactive arthritis

Answer 262

Contracting HIV by damaging the vaginal mucosa Bacterial vaginosis Cervical cancer Pelvic inflammatory disease Pregnancy-related complications such as preterm delivery.

Answer 263

Preterm delivery Premature rupture of membranes Low birth weight Postpartum endometritis Neonatal infection (conjunctivitis and pneumonia)

Answer 264

high vaginal charcoal swab with microscopy

Answer 265

metronidazole

Answer 266

> 4.5 - BV - trichomonas

Answer 267

clinical but can do: Viral PCR swab from a lesion can confirm the diagnosis and causative organism.

Answer 268

Primary HSV-2 <28 weeks gestation - aciclovir during the initial infection - regular prophylactic aciclovir starting from 36 weeks gestation - if asymptomatic at delivery can have a vaginal delivery (provided it is more than six weeks after the initial infection) Primary HSV-2 >28 weeks gestation - aciclovir during the initial infection followed immediately by regular prophylactic aciclovir. - Caesarean section Recurrent HSV-2 carries a low risk of neonatal infection (0-3%), even if the lesions are present during delivery. Regular prophylactic aciclovir is considered from 36 weeks gestation to reduce the risk of symptoms at the time of delivery.

Answer 269

Antibody testing for antibodies to the T. pallidum bacteria can be used as a screening test for syphilis. Patients with suspected syphilis or positive antibodies should be referred to a specialist GUM centre for further testing. Samples from sites of infection can be tested to confirm the presence of T. pallidum with: Dark field microscopy Polymerase chain reaction (PCR) The rapid plasma reagin (RPR) and venereal disease research laboratory (VDRL) tests (assessing for active infection) 2481632 thing

Answer 270

deep intramuscular dose of benzathine benzylpenicillin (penicillin)

Answer 271

bacteria that causes non-gonococcal urethritis

Answer 272

Nucleic acid amplification tests (NAAT)

Answer 273

Course of doxycycline followed by azithromycin for uncomplicated genital infections: Doxycycline 100mg twice daily for 7 days then; Azithromycin 1g stat then 500mg once a day for 2 days (unless it is known to be resistant to macrolides) Moxifloxacin is used as an alternative or in complicated infections. Azithromycin alone is used in pregnancy and breastfeeding (remember doxycycline is contraindicated).

Answer 274

Antibody testing for screening (blood test) - needs 3 months to show up Testing for the p24 antigen. This can give a positive result earlier in the infection compared with the antibody test. PCR testing for the HIV RNA levels tests directly for the number of viral copies in the blood, giving a viral load.

Answer 275

500-1200 cells/mm3 is the normal range Under 200 cells/mm3 is considered end-stage HIV (AIDS) and puts the patient at high risk of opportunistic infections

Answer 276

Viral load is the number of copies of HIV RNA per ml of blood. “Undetectable” refers to a viral load below the lab’s recordable range (usually 50 – 100 copies/ml). The viral load can be in the hundreds of thousands in untreated HIV.

Answer 277

Two NRTIs (e.g. tenofovir and emtricitabine) plus a third agent.

Answer 278

Prophylactic co-trimoxazole (Septrin) to protect against pneumocystis jirovecii pneumonia (PCP)

Answer 279

Yearly cervical smears

Answer 280

Normal vaginal delivery is recommended for women with a viral load < 50 copies / ml Caesarean section is considered in patients with > 50 copies copies / ml and in all women with > 400 copies / ml IV zidovudine should be given during the caesarean if the viral load is unknown or there are > 10000 copies / ml

Answer 281

not recommended

Answer 282

PEP involves a combination of ART therapy. The current regime is Truvada (emtricitabine and tenofovir) and raltegravir for 28 days. PEP is not 100% effective and must be commenced within a short window of opportunity (less than 72 hours) HIV tests are done immediately and also a minimum of three months after exposure to confirm a negative status. Individuals should abstain from unprotected sexual activity for a minimum of three months until confirmed as negative.

Answer 283

Lactobacilli are the main component of the healthy vaginal bacterial flora. These bacteria produce lactic acid that keeps the vaginal pH low (under 4.5). The acidic environment prevents other bacteria from overgrowing. When there are reduced numbers of lactobacilli in the vagina, the pH rises. This more alkaline environment enables anaerobic bacteria to multiply.

Answer 284

Multiple sexual partners (although it is not sexually transmitted) Excessive vaginal cleaning (douching, use of cleaning products and vaginal washes) Recent antibiotics Smoking Copper coil Bacterial vaginosis occurs less frequently in women taking the combined pill or using condoms effectively.

Answer 285

Vaginal pH can be tested using a swab and pH paper. The normal vaginal pH is 3.5 – 4.5. BV occurs with a pH above 4.5.

Answer 286

Metronidazole is the antibiotic of choice for treating bacterial vaginosis This is given orally, or by vaginal gel. Clindamycin is an alternative but less optimal antibiotic choice.

Answer 287

Whenever prescribing metronidazole advise patients to avoid alcohol for the duration of treatment. This is a crucial association you should remember, and something examiners will look out for when you are explaining the treatment to a patient. Alcohol and metronidazole can cause a “disulfiram-like reaction”, with nausea and vomiting, flushing and sometimes severe symptoms of shock and angioedema.

Answer 288

inflammation and infection of the organs of the pelvis, caused by infection spreading up through the cervix Most common causes: Neisseria gonorrhoeae tends to produce more severe PID Chlamydia trachomatis Mycoplasma genitalium

Answer 289

Pus cells on microscopy. The absence of pus cells is useful for excluding PID. Raised CRP/ESR

Answer 290

refer to GUM A single dose of intramuscular ceftriaxone 1g (to cover gonorrhoea) Doxycycline 100mg twice daily for 14 days (to cover chlamydia and Mycoplasma genitalium) Metronidazole 400mg twice daily for 14 days (to cover anaerobes such as Gardnerella vaginalis)

Answer 291

topical podophyllum or cryotherapy are commonly used as first-line treatments depending on the location and type of lesion multiple, non-keratinised warts are generally best treated with topical agents solitary, keratinised warts respond better to cryotherapy

Answer 292

HPV 6 and 11

Answer 293

Double swabs: a NAAT swab (endocervical or vulvovaginal) and a high vaginal charcoal media swab. Triple swabs: a NAAT swab (endocervical or vulvovaginal), a high-vaginal charcoal media swab and an endocervical charcoal media swab.

Answer 294

Pseudomonas aerginosa

Answer 295

HELLP SYNDROME - COMPLICATION OF PRE-ECLAMPSIA

Answer 296

Four weekly ultrasound scans to monitor the fetal growth and amniotic fluid volume from 28 to 36 weeks gestation. The initial management: Fasting glucose less than 7 mmol/l: trial of diet and exercise for 1-2 weeks, followed by metformin, then insulin Fasting glucose above 7 mmol/l: start insulin ± metformin Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin

Answer 297

still birth

Answer 298

Immediately after shoulder dystocia is recognised, additional help should be called. Fundal pressure should not be used. An episiotomy is not always necessary. Induction of labour at term can actually reduce the incidence of shoulder dystocia in women with gestational diabetes. McRoberts manoeuvre is the first line intervention as it is known to be simple, rapid and effective in most cases

Answer 299

75 minutes

Answer 300

Gestational diabetes can be diagnosed by either a: fasting glucose is >= 5.6 mmol/L, or 2-hour glucose level of >= 7.8 mmol/L '5678'

Answer 301

High ALP and GGT, with a lesser rise in ALT.

Answer 302

Edinburgh scale

Answer 303

OGTT 24-28 weeks

Answer 304

squamous cell cancer (80%) adenocarcinoma (20%)

Answer 305

HPV 16,18 & 33

Answer 306

HPV 6 & 11

Answer 307

HPV 16 & 18 produces the oncogenes E6 and E7 genes respectively E6 inhibits the p53 tumour suppressor gene E7 inhibits RB suppressor gene

Answer 308

1. Test for high-risk human papillomavirus strains (hrHPV) If negative return to normal recall 2. If positive → cytology If cytology negative, retest hrHPV in 12 months If hrHPV is then negative return to recall, if hrHPV positive repeat again in 12 months If hrHPV is positive at 24 months, cytology is normal refer to colposcopy anway 3. If cytology positive → colposcopy

Answer 309

Retest in 3 months If inadequate again --> colposcopy

Answer 310

Age 25 years: first invitation. Age 25-49 years: screening every 3 years. Age 50-64 years: screening every 5 years. Women 65 years of age or older if they have not had a cervical screening test since 50 years of age or a recent cervical cytology sample is abnormal.

Answer 311

cervical screening in pregnancy is usually delayed until 3 months postpartum unless missed screening or previous abnormal smears.

Answer 312

Cervical cytology at diagnosis. Cervical cytology should then be offered annually for screening.

Answer 313

Individuals who have been treated for CIN1, CIN2, or CIN3 should be invited 6 months after treatment for a test of cure repeat cervical sample in the community

Answer 314

Large loop excision of the transformation zone (LLETZ)

Answer 315

Confined to cervix, only visible by microscopy and less than 7 mm wide: A1 = < 3 mm deep A2 = 3-5 mm deep Gold standard of treatment is hysterectomy +/- lymph node clearance Nodal clearance for A2 tumours For patients wanting to maintain fertility, a cone biopsy with negative margins can be performed Radical trachelectomy is also an option for A2

Answer 316

Confined to cervix, clinically visible or larger than 7 mm wide: B1 = < 4 cm diameter B2 = > 4 cm diameter Radiotherapy with concurrent chemotherapy is advised Radiotherapy may either be bachytherapy or external beam radiotherapy Cisplatin is the commonly used chemotherapeutic agent For B2 tumours: radical hysterectomy with pelvic lymph node dissection

Answer 317

Stage 2: Extension of tumour beyond cervix but not to the pelvic wall A = upper two thirds of vagina B = parametrial involvement Stage 3: Extension of tumour beyond the cervix and to the pelvic wall A = lower third of vagina B = pelvic side wall NB: Any tumour causing hydronephrosis or a non-functioning kidney is considered stage III Radiation with concurrent chemotherapy Radiotherapy may either be bachytherapy or external beam radiotherapy Cisplatin is the commonly used chemotherapeutic agent If hydronephrosis, nephrostomy should be considered

Answer 318

Extension of tumour beyond the pelvis or involvement of bladder or rectum A = involvement of bladder or rectum B = involvement of distant sites outside the pelvis Radiation and/or chemotherapy is the treatment of choice Palliative chemotherapy may be best option for stage IVB

Answer 319

pre term labour in future pregnancies

Answer 320

development of follicle beyond secondary stimulates granulosa cells to multiply and produce oestrogen Induces LH receptors on granulosa cells of the dominant follicle

Answer 321

stimulates proliferation of granulosa cells exerts negative feedback on the secretion of gonadotrophins works with progesterone to maintain lining in luteal phase

Answer 322

stimulates theca cells to synthesise androgens the mid-cycle surge in LH causes ovulation

Answer 323

Helps to build and maintain endometrial lining progesterone is produced in large amounts by the corpus luteum to maintain the lining the drop in progesterone due to degeneration of corpus luteum (due to no hCG) causes endmetrial shedding

Answer 324

Primordial follicles Primary follicles Secondary follicles Antral follicles (also known as Graafian follicles)

Answer 325

adenocarcinoma

Answer 326

obesity Nulliparity (Nulliparity is a risk factor for endometrial cancer. This is because during pregnancy, the balance of hormones shifts towards progesterone, which is a protective factor.) early menarche late menopause unopposed oestrogen. The addition of a progestogen to oestrogen reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously diabetes mellitus tamoxifen polycystic ovarian syndrome hereditary non-polyposis colorectal carcinoma

Answer 327

Age over 55 with post menopausal bleeding (must be >12 months since last period) Consider if over 55 and: Unexplained vaginal discharge Visible haematuria plus raised platelets, anaemia or elevated glucose levels

Answer 328

Transvaginal ultrasound for endometrial thickness (normal is less than 4mm post-menopause) Hysteroscopy with endometrial biopsy Pipelle biopsy, which is highly sensitive for endometrial cancer making it useful for excluding cancer

Answer 329

Stage 1: Confined to the uterus Stage 2: Invades the cervix Stage 3: Invades the ovaries, fallopian tubes, vagina or lymph nodes Stage 4: Invades bladder, rectum or beyond the pelvis

Answer 330

total abdominal hysterectomy with bilateral salpingo-oophorectomy, also known as a TAH and BSO (removal of uterus, cervix and adnexa). progestogen therapy is sometimes used in frail elderly women not consider suitable for surgery

Answer 331

intermenstrual bleeding

Answer 332

abnormal proliferation of the endometrium in excess of the normal proliferation that occurs during the menstrual cycle. A minority of patients with endometrial hyperplasia may develop endometrial cancer types: hyperprolifertaion without atypia atypical hyperplasia

Answer 333

Intrauterine system (e.g. Mirena coil) Continuous oral progestogens (e.g. medroxyprogesterone or levonorgestrel) and retest in 3 months If atypia : hysterectomy advised

Answer 334

CA-125 If CA-125 is over 35 the do abdo USS Diagnosis is difficult and usually involves CT for staginh and diagnostic laparotomy

Answer 335

Family history: mutations of the BRCA1 or the BRCA2 gene many ovulations*: early menarche, late menopause, nulliparity

Answer 336

epithelial cell tumour - serous tumour

Answer 337

germ cell tumours

Answer 338

ovarian torison

Answer 339

raised alpha-fetoprotein (α-FP) raised human chorionic gonadotrophin (hCG)

Answer 340

Age (peaks age 60) BRCA1 and BRCA2 genes (consider the family history) Increased number of ovulations Obesity Smoking Recurrent use of clomifene Factors that increase the number of ovulations, increase the risk of ovarian cancer. These include: Early-onset of periods Late menopause No pregnancies

Answer 341

Ascites Pelvic mass (unless clearly due to fibroids) Abdominal mass

Answer 342

?teratoma Alpha-fetoprotein (α-FP) Human chorionic gonadotropin (HCG)

Answer 343

Endometriosis Fibroids Adenomyosis Pelvic infection Liver disease Pregnancy

Answer 344

Ovarian cancer will be managed by a specialist gynaecology oncology MDT. It usually involves a combination of surgery and chemotherapy.

Answer 345

Ovarian cancer will be managed by a specialist gynaecology oncology MDT. It usually involves a combination of surgery and chemotherapy.

Answer 346

Stage 1: Confined to the ovary Stage 2: Spread past the ovary but inside the pelvis Stage 3: Spread past the pelvis but inside the abdomen Stage 4: Spread outside the abdomen (distant metastasis)

Answer 347

squamous cell carcinomas

Answer 348

Biopsy of the lesion Sentinel node biopsy to demonstrate lymph node spread Further imaging for staging (e.g. CT abdomen and pelvis)

Answer 349

topical steroids and emollients

Answer 350

abnormal discharge

Answer 351

Wide local excision to remove the cancer Groin lymph node dissection Chemotherapy Radiotherapy

Answer 352

IUD - copper coil IUS - things like mirena coil

Answer 353

A for Abruption previously; B for Blood pressure (i.e. hypertension or pre-eclampsia); R for Ruptured membranes, either premature or prolonged; U for Uterine injury (i.e. trauma to the abdomen); P for Polyhydramnios; T for Twins or multiple gestation; I for Infection in the uterus, especially chorioamnionitis; O for Older age (i.e. aged over 35 years old); N for Narcotic use (i.e. cocaine and amphetamines, as well as smoking)

Answer 354

A lump of endometrial tissue outside the uterus is described as an endometrioma. Endometriomas in the ovaries are often called “chocolate cysts”.

Answer 355

Low calcium, low phosphate, high ALP and high PTH

Answer 356

autosomal recessive

Answer 357

microcytic anaemia

Answer 358

Full blood count shows a microcytic anaemia. Haemoglobin electrophoresis is used to diagnose globin abnormalities. DNA testing can be used to look for the genetic abnormality Pregnant women in the UK are offered a screening test for thalassemia at booking.

Answer 359

chromosome 16

Answer 360

chromosome 11

Answer 361

Patients with beta thalassaemia minor are carriers of an abnormally functioning beta globin gene. They have one abnormal and one normal gene. Thalassaemia minor causes a mild microcytic anaemia and usually patients only require monitoring and no active treatment.

Answer 362

Patients with beta thalassaemia intermedia have two abnormal copies of the beta-globin gene. This can be either two defective genes or one defective gene and one deletion gene. Thalassaemia intermedica causes a more significant microcytic anaemia and patients require monitoring and occasional blood transfusions. If they need more transfusions they may require iron chelation to prevent iron overload.

Answer 363

Patients with beta thalassaemia major are homozygous for the deletion genes. They have no functioning beta-globin genes at all. This is the most severe form and usually presents with severe anaemia and failure to thrive in early childhood. Thalassaemia major causes: Severe microcytic anaemia Splenomegaly Bone deformities Management involves regular transfusions, iron chelation and splenectomy. Bone marrow transplant can potentially be curative.

Answer 364

deficiency in factor VIII

Answer 365

Deficiency in factor IX

Answer 366

bleeding scores coagulation factor assays genetic testing.

Answer 367

Infusions of the affected factor (VIII or IX) - either prophylacticly or in response to bleeding Desmopressin to stimulate the release of von Willebrand Factor Antifibrinolytics such as tranexamic acid

Answer 368

FORCEPS acronym Fully dilated cervix generally the second stage of labour must have been reached OA position preferably OP delivery is possible with Keillands forceps and ventouse. The position of the head must be known as incorrect placement of forceps or ventouse could lead to maternal or fetal trauma and failure Ruptured Membranes Cephalic presentation Engaged presenting part i.e. head at or below ischial spines the head must not be palpable abdominally Pain relief Sphincter (bladder) empty this will usually require catheterization

Answer 369

Less time in utero receiving iron from the mother Red blood cell creation cannot keep up with the rapid growth in the first few weeks Reduced erythropoietin levels Blood tests remove a significant portion of their circulating volume

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Iron deficiency anaemia secondary to dietary insufficiency. This is the most common cause overall. Blood loss, most frequently from menstruation in older girls

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helminth infection, with roundworms, hookworms or whipworms. This can be very common in developing countries and those living in poverty. It is more unusual in the UK. Treatment is with a single dose of albendazole or mebendazole.

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autosomal recessive aplastic anaemia (pancytopaenia)

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iron deficicency A total iron-binding capacity (TIBC) test measures the blood's ability to attach itself to iron and transport it around the body. A transferrin test is similar. If you have iron deficiency anaemia (a lack of iron in your blood), your iron level will be low but your TIBC will be high.

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Iron is mainly absorbed in the duodenum and jejunum. It requires the acid from the stomach to keep the iron in the soluble ferrous (Fe2+) form. When there is less acid in the stomach, it changes to the insoluble ferric (Fe3+) form. Therefore, medications that reduce the stomach acid, such as proton pump inhibitors (lansoprazole and omeprazole) can interfere with iron absorption.

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thymomas 15% autoimmune conditions

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Specific antibodies against the acetylcholine receptors AChR antibodies If negative test anti-muscle-specific tyrosine kinase antibodies single fibre electromyography: high sensitivity (92-100%) CT thorax to exclude thymoma CK normal

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long-acting acetylcholinesterase inhibitors: pyridostigmine is first-line immunosuppression is usually not started at diagnosis, but the majority of patients eventually require it: prednisolone initially azathioprine, cyclosporine, mycophenolate mofetil may also be used thymectomy

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plasmapheresis intravenous immunoglobulins Plasmapheresis removes circulating antibodies, including the autoimmune antibodies responsible for the disease. Immunotherapy with intravenous gammaglobulin appears to diminish the activity of the disease.

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Suxamethonium is a depolarising NMBD - it acts by binding to and activating the receptor, at first causing muscle contraction, then paralysis. Due to a decreased number of available receptors, MG patients are typically resistant to depolarising NMBDs and may require significantly higher doses.

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beta blockers lithium phenytoin antibiotics: gentamicin, macrolides, quinolones, tetracyclines

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- Radial - Humeral - Femoral