Y3 Exam 2

Question 1

List some complications of shoulder dystocia: (4)

Answer 1

• Brachial plexus injury (commonly Erb’s palsy (waiter’s tip))
• Perineal tears
• Fetal hypoxia (→ cerebral palsy if prolonged)
• Postpartum haemorrhage (T = trauma!)

Question 2

List some common causes of bilious vomiting: (4)

What is the 1st line investigation to identify a cause of bilious vomiting?

Answer 2

Intestinal obstruction:
• Malrotation
• Intusussecption
• Ileus
• Duodenal atresia

Abdominal Xray

Question 3

What are the 5 commonest in-utero causes of infection? (TORCH)

Answer 3

T - toxoplasmosis

O - other (syphilis & chickenpox (varicella-zooster virus))

R - rubella

C - cytomegalovirus

H - herpes simplex virus (HSV)

Question 4

What results of an OGTT are normal and thus above would qualify as gestational diabetes? (5,6,7,8!)

What is the initial management if fasting glucose is less than 7mmol/l?

What is the initial management if fasting glucose is more than 7mmol/l?

Answer 4

Results:
Fasting glucose: < 5.6 mmol/l
2h glucose: < 7.8 mmol/l

< 7 mmol/l: 2 week trial of diet & exercise → metformin

> 7 mmol/l: insulin +/- metformin

Question 5

What is the medical management of a miscarriage? - how does it work?

What is the surgical management of a miscarriage?

Answer 5

• *Misoprostol
• ** prostaglandin analogue (softens the cervix & stimulates uterine contractions to expel the miscarriage)
• *Surgical management:**
• *-** vacuum aspiration & curettage (products are sucked & scooped out) → misoprostol is given before procedure to soften the cervix

Question 6

What is the 1^st line investigation of endometrial cancer? - what is this used to look for/ what is normal?

What investigation is done if the above is abnormal?

What is the management of stage 1 & 2 endometrial cancer? (cancer confined to cervix/ invaded cervix only)

Answer 6

• *Investigations:**
• 1^st line:* Transvaginal US to look at endometrial thickness (should be <4mm)
• If ^ abnormal:* Endometrial biopsy (pipelle biopsy)

Management:
TAH & BSO
(total abdominal hysterectomy with bilateral salpingo-oophorectomy = removal of uterus, cervix & ovaries)

Question 7

What is Hirschprung’s Disease?

What is a common presentation of it?

What investigation is done? - what is used to confirm the diagnosis?

What is the definitive management?

Answer 7

Congenital condition in which nerves of the distal bowel & rectum are absent (myenteric plexus)

24h neonate hasnt passed meconium, distended abdomen and vomiting!

Rectal exam (forecful evacuation of stool will occur!!!) - confirmation is made by suction rectal biopsy

Definitive management: surgical removal of aganglionic bowel

Question 8

What is the difference between an STI & an STD?

Answer 8

STI: a sexually transmitted infection that is only an infection (it hasnt caused any disease yet)

STD: a sexually transmitted infection that has caused a disease (aka, it is causing harm, eg PID)

Question 9

What age group is classed as adolescence?

Which area of the brain changes the most during this period?
~ what 3 things is this brain area involved in?

Answer 9

11-25y

Prefrontal cortex
~ planning
~ social interaction & self-awareness
~ risk taking

Question 10

Name the 3 types of emergency contraception available and:

a) state the timeframe in which they are effective after UPSI
b) state their mechanism of action against pregnancy

List 2 contraindictations of EllaOne

Answer 10

• *EllaOne**
  a) effective up to 5 days after UPSI
  b) delays ovulation
  c) asthma, breastfeeding should be avoided for 1 week
• *IUD (copper coil)**
  a) effective up to 5 days after UPSI
  b) copper is spermicidal + prevents implantation
  c) insertion may cause PID
• *Levonorgestrel**
  a) effective up to 3 days after UPSI
  b) delays ovulation

Question 11

What are the 4 abnormalities seen in Tetralogy of Fallot?

What xray finding is seen in this condition?

What clinical sign may be seen on examination? - Why does this happen?

What is the definitive treatment and when does it occur?

Answer 11

1) Pulmonary valve stenosis
2) R ventricle hypertrophy
3) Ventricularseptal defect
4) Overriding aorta (L & R ventricle drain into aorta)

Boot shaped heart seen on xray

Central cyanosis - high pressure in R ventricle due to hypertrophy causes R→L shunt through ventricularseptal defect - less oxygenated blood enters systemic circulation

Surgical correction: performed when baby is 5kg (~ 6 months)

Question 12

State the diagnosis & commonest causative organism of a-e:

a) Child presents with rapdly-developing non-blanching purpuric skin rash, lethargy, headache, fever, vomting.

b) Child presents with mild fever, runny nose, lethargy and an itchy lace like rash on the body, which is bright red over the cheeks.

c) Unvaccinated child with a 4day history of cough, fever, lethargy has now developed a rash all over his body with a few grey spots inside his cheeks.

d) Child presents with a course red rash on his trunk that has a sandpaper texture, as well as a fever, sore throat and bright red tongue.

e) Child presents with an itchy, widespread, erythematous, vasicular rash that started on their face/ trunk & has quickly spread to their whole body. Child also has a fever and Mum noticed that the rash has started to crust over.

f) Child presents with lethargy, fever, cough & sore throat with new ulcers around their mouth and blistering red spots on their hands & feet.

Answer 12

a) Meningitis - Neisseria meningitidis
b) Slapped cheek - Parvovirus B19
c) Measles - Measles virus
d) Scarlet fever - Group A STREP
e) Chickenpox - Varicella Zooster virus
f) Hand, foot & mouth disease - Coxsackie A virus

Question 13

Match the congenital defect with genetic condition:

Ventricular septal defect
Aortic arch defect
Coarctation of the aorta
Pulmonary valve stenosis
Tetralogy of Fallot
Supravalvular aortic stenosis

Williams syndrome
Down’s syndrome
DiGeorge syndrome
Noonan syndrome
Turner’s syndrome

Answer 13

Downs syndrome: Ventricular septal defect, tetralogy of Fallot

DiGeorge syndrome: Aortic arch defect

Turner syndrome: Coarctation of the aorta

Noonan syndrome: Pulmonary valve stenosis

Williams syndrome: Supravalvular aortic stenosis

Question 14

Who is notified about a palliative patient and their wishes?

Answer 14

• GP practice (Palliative care register)
• OOH will have a record too

Question 15

What changes occur at birth regarding the foetal circulation? (6)

Answer 15

1) foramen ovale closes
2) ductus arteriosus closes
3) ductus venosus closes (blood vessel connecting umbilical vein→IVC)
4) Pulmonary vascular resistance falls
5) Pulmonary blood flow increases
6) Systemic vascular resistance increases

Question 16

What skills would you expect to see from each developmental domain in an 18m toddler?

• Gross motor (2)
• Fine motor (2)
• Language (1)
• Social (2)
• Self help (1)

Answer 16

• *Gross motor:** 1) walks up/down stairs unsupported
  2) kicks a ball
• *Fine motor:** 1) scribbles with crayon
  2) builds towers with 4+ bricks

Language: 1) starts to join words into sentences

• *Social**: 1) early pretend play
  2) says no when interfered with

Self help: 1) eats with fork

Question 17

What part of the GIT does coeliacs disease affect & what is the main histological finding seen?

List some clinical features seen in coeliac disease: (6)

What condition is closely associated with coeliac disease?

Answer 17

Small bowel (esp jejenum) - villous atrophy

• Failure to thrive (in children)
• Diarrhoea
• Weight loss
• Fatigue
• Dermatitis herpetiformis (itchy rash, usually on abdomen)
• Malabsorption

Type 1 diabetes (as well as other autoimmune conditions)

Question 18

Erb’s palsy results in damage to what nerves of the brachial plexus?

What obstetric emergency can result in Erb’s palsy?

Answer 18

C5 & C6

Shoulder dystocia

Question 19

What skills would you expect to see from each developmental domain in an 24m toddler?

• Gross motor (1)
• Fine motor (1)
• Language (1)
• Social (1)
• Self help (1)

Answer 19

Gross motor: climbs on play equipment (eg, slides)

Fine motor: scribbles with circular motion

Language: vocabulary of 30-50 words

Social: helps with simple household tasks

Self help: opens door by turning knob

Question 20

Paget’s disease of the breast is commonly mistaken for what condition?

What severe condition does Paget’s disease of the breast overlie?

What part of the breast is involved first in Paget’s disease of the breast?
~ List some presenting features (4)

Answer 20

Eczema !!

An underlying breast cancer

Nipple:
• Nipple discharge +/- blood
​• Eczema like rash on/ around the nipple
​• Burning/ pain of the nipple
​• Nipple inversion

Question 21

TRUE or FALSE

1. Grief is an individual experience.
2. Grief only lasts for a few months.
3. Bereavement is associated with increased mortality & morbidity.

Answer 21

1. True
2. False - grief can last for years
3. True!

Question 22

What skills would you expect to see from each developmental domain in a 6m infant?

• Gross motor (2)
• Fine motor (2)
• Language (2)
• Social (2)
• Self help (1)

Answer 22

• *Gross motor:** 1) rolls over
  2) starts to sit without support
• *Fine motor:** 1) uses 2 hands to pick up large objects
  2) transfers toy from 1 hand to another
• *Language**: 1) responds to name
  2) 2 syllable babble
• *Social**: 1) reaches for familiar people
  2) pushes things they don’t want away

Self help: 1) feeds self small food

Question 23

Someone with autism may have defecits in what 3 things?

What does the management of autism involve?

What congenital condition is autism commonly seen in?

Answer 23

• *1)** Social interaction
• *2)** Communiation
• *3)** Behaviour

Management: MDT team, no medications

Down syndrome

Question 24

A 48y old woman presents with intense ithcing in the perineal area, associated with pain on micturation and dyspareunia.

O/E you notcie white polygonal papules on the labia majora, coalescing into a patch affecting the labia minora. There is one fissuring area, which bleeds on contact. The skin is white, thin & shiny. Mild scarring is noted. There is no vaginal discharge.

What is the likely diagnosis:

a) Lichen Planus
b) Lichen Sclerosus

What is the 1^st line treatment for this condition?

Answer 24

LICHEN SCLEROSUS

3 month trial of topical steroids

Question 25

A diagnosis of pre-eclampsia requires what? (1 + 3) What is the prophylaxis used in high risk women for pre-eclampsia?

Answer 25

BP 140/90 + PLUS any of: Proteinuria Organ dysfunction (raised creatinine / elevated LFTs / seizures) Placental dysfunction (eg, foetal growth restriction) **Aspirin** from 12 weeks gestation

Question 26

What are the 5 things that a **CTG** measures? What is the normal HR of a fetus? ~ what is the range of normal variability within this?

Answer 26

* **Contractions** (num. of uterine contractions in 10 mins) * **Baseline fetal HR** (the average HR) * **Variability** (of fetal HR) * **Accelerations** (increase in HR of 15bpm for 15 secs) * **Decelerations** (decrease in HR by 15bpm for 15 secs) - concerning **Foetal HR** = 110 - 160bpm ~ normal variability = 5 - 25bpm

Question 27

List some of the criteria mentioned in **Wilson's criteria** for screening programmes:

Answer 27

**Knowledge of the disease:** ~ the disease to be screened for has to be well understood ~ the disease should be an important public health concern (eg affect the majority of the population) ~ there has to be a recognisible early stage of the disease **Testing for the disease:** ~ there has to be a sensitive test for the disease that is accepted by the public **Treatment of the disease:** ~ there has to be available treatment for the disease that is accepted by the public ~ the treatment has to be cost effective ~ outcome of treatment should be better if disease is detected early

Question 28

What do the 3 stages of labour consist of?

Answer 28

First stage - from the onset of labour (contractions) until 10cm cervical dilatation Second stage - from 10cm dilatation until the baby is delivered Third stage - from delivery of the baby to delivery of the placenta

Question 29

Describe the discharge associated with each condition below: 1) Bacterial vaginosis 2) Candidiasis 3) Chlamydia 4) Gonorrhoea 5) Trichomoniasis

Answer 29

1) Watery, FISHY discharge 2) Thick, white discharge (cottage cheese) 3) Watery, odourless discharge 4) Yellow discharge 5) Frothy, green discharge

Question 30

What is **placenta praevia?** When would **placenta praevia** be diagnosed in a pregnancy if it's present? What is the common presentation of placenta praevia? If someone is identified as having placenta praevia, when would they be given repeat US's? What is the management of placenta praevia regarding the delivery?

Answer 30

**Placenta praevia:** when the placenta is attached in the lower portion of the uterus - often covering the cervical os. At the **20 week anomaly scan** **Painless bleeding** *(antepartum haemorhage)* **32 & 36** weeks gestation (if present on the 32 week scan to guide decisions about delivery) C-section should be planned for 36-37 weeks (to avoid spontaneous labour as vaginal delivery is contraindicted)

Question 31

What is **anticipatory care planning (ACP)**? What might be discussed in an anticipatory care plan? Once a patient is 'palliative' & ACP has been discussed, what happens in regards to their records in the GP practice? ~ who is informed about this? ~ is the patient frequently reviewed? - who is involved in this?

Answer 31

This is a discussion with a **palliative** patient & their carers regarding their wishes for their future care. * Do they want a DNACPR? * Where do they want to die? * Would they want treatment for a simple infection? **Once palliative** & have had the ACP discussion, the patient is placed on a **Palliative Care Register** in the practice. ~ patients plan is sent to OOH & anyone who is invovled with their care ~ GP practice has regular palliative care meetings with an MDT to discuss all palliative patients

Question 32

What is Kawasaki disease? What are the 6 common features of Kawasaki disease? CREAM What is the main complication of Kawasaki disease? - What investigation is done to screen for this? What is the treatment of Kawasaki disease?

Answer 32

A systemic medium vessel vasculitis * *Fever for 5+ days** PLUS * *C** - conjunctivitis (red eyes) * *R** - rash * *E** - oedema/ erythema of *hands & feet* * *A** - adenopathy (usually cervical) * *M** - mucosal invovlement (strawberry tongue, cracked lips) Coronary artery aneurysm - ECHO Treatment: **aspirin** (to reduce risk of thrombosis) & **IV immunoglobulins IVIg**) (to reduce risk of coronary artery aneurysms)

Question 33

What is **health promotion?** What are the 3 areas of health promotion that can be targetted? What types of things are done to target these areas in order to promote good health?

Answer 33

**Health promotion:** any activity designed to enhance health/ reduce disease. • Educational ~ Provides people with the knowledge of diseases so they can mae informed choices regarding health ~ eg, smoking, diet • Socioeconomic ~ Makes healthy choices the easy/ cheaper choice ~ eg, sugar tax, more cycle paths • Psychological ~ Helps people with the psychological aspect of good health ~ Eg, is the individual ready to give up alcohol

Question 34

Where do most people choose to die? The **Gold Standards Framework** provide tools to GP's to help them with what?

Answer 34

Most people choose to die **in their own home.** To help them look after palliative patients in their own home.

Question 35

What are the 2 commonest causes of death in the UK now? What is the commonest cause of death in men aged 15-34y?

Answer 35

Cancer & IHD ## Footnote **Suicide**

Question 36

What skills would you expect to see from each developmental domain in a 12m toddler? * Gross motor (2) * Fine motor (2) * Language (2) * Social (1) * Self help (2)

Answer 36

* *Gross motor:** 1) stands without support 2) starts to walk without help (by 18m) * *Fine motor:** 1) stacks 2+ blocks 2) picks up 2+ toys in 1 hand * *Language**: 1) know's the meaning of 1 or 2 words 2) uses mama / dada specifically for parents **Social**: 1) points to things of interest * *Self help:** 1) feeds themself with spoon 2) lifts cup to mouth and drinks

Question 37

What condition is indicated by a **woody, tender uterus**?

Answer 37

Placental abruption

Question 38

The results of a womans cervical smear screening identifies the presence of high-risk human papillomavirus (hrHPV). What should happen next? If the next step is positive, what should be done? If the step was negative, what should be done?

Answer 38

The sample should be sent for cytology. Cytology **positive (dyskaryosis)**: Woman should be sent for colposcopy Cytology **negative**: Woman should have another smear in 12 months

Question 39

**Failure to progress in labour** is when the labour isn't developing at a satisfactory rate. Name the 3 things that progress in labour is influenced by: (**3 P's)** What is considered as a delayed 2^nd stage of labour in: a) **nulliparous** women b) **multiparous** women What is considered as a delayed 3^rd stage of labour in: * *a) active management** * ~ what does active management of the 3^rd stage of labour involve?* b) **physiological** **management**

Answer 39

* **Power** (of uterine contractions) * **Passenger** (size/ presentation/ position of baby!) * **Passage** (shape & size of mothers pelvis) * *Nulliparous**: 2^nd stage taking 2 hours * *Multiparous**: 2^nd stage taking 1 hour * *Active**: 3^rd stage taking longer than 30 mins * ~ IM oxytocin & controlled cord traction* * *Physiological**: 3^rd stage taking longer than 60 mins

Question 40

List 3 functions of **oxytocin**: List 2 uses of **nifedipine** throughout pregnancy:

Answer 40

**Oxytocin** • Ripening of cervix • Stimulates contractions of uterus • Squeezes mammary ducts to aid in breastfeeding **Nifedipine** • 2^nd line Pre-eclampsia treatment (to control hypertension) • Tocolysis (in premature labour)

Question 41

What is the most likely **diagnosis** of the following: Unvaccinated child presents with a fever, sore throat & difficulty swallowing. The child is sitting forward and drooling. What is the management of this?

Answer 41

Epiglottitis 1) Secure airway!!!!! 2) IV antibiotics (ceftriaxone) + Steroids (dexamethasone)

Question 42

In regards to multiple pregnancy, what do the following terms mean: 1. Monoamniotic 2. Diamniotic 3. Monochorionic 4. Dichorionic If you see the **lambda sign** on an US, what type of twins does that indicate?

Answer 42

**1. Monoamniotic:** Single amniotic sack (shared between babies) **2. Diamniotic:** 2 separate amniotic sacs (each baby has their own) **3. Monochorionic:** Single placenta (shared between babies) **​4. Dichorionic:** 2 separate placenta's (each baby has their own) **Lambda sign =** dichorionic, diamniotic (2 sacs & 2 placenta's)

Question 43

What is the commonest presenting symptom of **endometrial cancer?** List 2 other common symptoms: Name 2 protective factors against endometrial cancer:

Answer 43

POST-MENOPAUSAL BLEEDING ! ~ **Inter**menstrual bleeding ~ Unusually **heavy** menstrual bleeding **• Smoking** • COCP

Question 44

Between which ages is jaundice **more likely** to be pathological? What causes **physiological** jaundice? - what type of bilirubin will be elevated? What type of bilirubin will be elevated in **breast-milk** jaundice?

Answer 44

Before 24h, after 2 weeks (3 weeks if pre-term) **Physiological jaundice:** • HbF has shorter life span & liver function is immature so cannot conjugate as quick as is needed with the excess haemolysis • Bilirubin = *unconjugated* **Breast-milk jaundice:** *unconjugated* bilirubin

Question 45

What is the difference between an **STI** & an **STD**?

Answer 45

**STI:** a sexually transmitted infection that is *only* an infection (it hasnt caused any disease yet) **STD:** a sexually transmitted infection that has caused a disease (aka, it is causing harm, eg PID)

Question 46

What type of formula is used to treat CMPA? If the child still can't tolerate this formula, what would they be swapped to?

Answer 46

Hydrolysed formula An amino acid formula

Question 47

What would you hear when ascultating someone with an atrial septal defect? (2) Explain why you would hear these things!

Answer 47

**Fixed, split 2nd heart sound** → as blood is being shunted from L→R atria, there is more blood to flow through the pulmonary valve. This causes a delay in the valve closing compared to closing of aortic valve = split 2nd heart sound Pulmonary flow murmur (ejection systolic murmur) → due to increased blood flowing through the valve

Question 48

What is the medical management of an abortion? - Between which weeks can this be done? What is the surgical management of abortion? - Between which weeks can this be done?

Answer 48

*Medical management: 5-23⁺⁵ weeks* 1) **_Mifepristone_** (progesterone antagonist → degeneration of endometirum & increases uterine sensitivity to prostaglandins) 2) 36-48h later, give **_Misoprostol_** (prostagland analogue → contraction of myometrium & expulsion of uterine contents) *Surgical management: 5-12 weeks* **_Misoprostol_** given to woman before procedure to 'prime' the uterus → transcervical **_suction_** of uterin contents!

Question 49

A 14-year-old presents to her GP with her mother who is concerned that she is tired all the time and failing to meet deadlines for school projects. She is slightly overweight, but examination is otherwise normal. Urinalysis, FBC, U&Es, LFTs, TFTs and blood glucose are all normal. What would be the most appropriate next step? * Advise her that everything is normal and to seek further review if new symptoms develop * Advise her that the tests are normal and suggest seeking additional educational support * Discuss her lifestyle including sleep patterns and diet * Refer her to paediatrics for further investigation * Repeat the blood tests in case something has changed

Answer 49

**Discuss her lifestyle including sleep patterns and diet** *Repeating normal tests after a very short time scale is unlikely to provide new information. The history and initial examination/investigation suggest that lifestyle factors are likely to be the cause, so this needs to be explored and advice given accordingly.*

Question 50

What is the commonest causative organism of **bronchiolitis**? ~ what is the treatment? What is the commonest causative organism of **viral induced wheeze**? ~ what is the treatment? What is the commonest causative organism of **bacterial/ viral pneumonia**? ~ what is the treatment for each? What is the commonest causative organism of **croup**? ~ what is the treatment? What is the commonest causative organism of **epiglottitis**? ~ what is the treatment? What is the commonest causative organism of **whooping cough**? ~ what is the treatment?

Answer 50

**Bronchiolitis:** RSV ~ supportive treatment (viral infection - self resolves) **Viral induced wheeze:** RSV ~ 10 puffs of salbutamol +/- O2 if needed * *Bacterial pneumonia:** Strep pneumonia - amoxicillin * *Viral pneumonia:** RSV (supportive treatment) **Croup:** parainfluenza virus ~ dexamethasone **Epiglottitis:** H.influenza B ~ secure airways, ceftriaxone & dexamethasone **Whooping cough:** Bordetella pertussis ~ supportive management

Question 51

If a **whirlpool sign** is seen on a transvaginal US, what condition does this suggest? What is the definitive investigation to diagnose this condition? What are the 2 management options?

Answer 51

**Ovarian torsion** Laparoscopic surgery * *Management**: done whilst doing the laparoscopic surgery! 1) Detorsion of the ovary 2) Oophorectomy (removal of the affected ovary)

Question 52

What skills would you expect to see from each developmental domain in a 12m toddler? * Gross motor (2) * Fine motor (2) * Language (2) * Social (1) * Self help (2)

Answer 52

* *Gross motor:** 1) stands without support 2) starts to walk without help (by 18m) * *Fine motor:** 1) stacks 2+ blocks 2) picks up 2+ toys in 1 hand * *Language**: 1) know's the meaning of 1 or 2 words 2) uses mama / dada specifically for parents **Social**: 1) points to things of interest * *Self help:** 1) feeds themself with spoon 2) lifts cup to mouth and drinks

Question 53

Describe what coarctation of the aorta is: List the clinical signs/ symptoms of coarctation of aorta: (3) How would a child with coarctation of aorta usually present? What congenital condition is associated with coarctation of the aorta?

Answer 53

Narrowing of the descending aorta 1) Weak/ absent femoral pulse 2) Radio-femoral delay 3) Systolic murmur that's loudest at the back Presentation: sudden deterioration & collapse **Turner's syndrome**

Question 54

What is the commonest causative organism of **bronchiolitis**? ~ what is the treatment? What is the commonest causative organism of **viral induced wheeze**? ~ what is the treatment? What is the commonest causative organism of **bacterial/ viral pneumonia**? ~ what is the treatment for each? What is the commonest causative organism of **croup**? ~ what is the treatment? What is the commonest causative organism of **epiglottitis**? ~ what is the treatment? What is the commonest causative organism of **whooping cough**? ~ what is the treatment?

Answer 54

**Bronchiolitis:** RSV ~ supportive treatment (viral infection - self resolves) **Viral induced wheeze:** RSV ~ 10 puffs of salbutamol +/- O2 if needed * *Bacterial pneumonia:** Strep pneumonia - amoxicillin * *Viral pneumonia:** RSV (supportive treatment) **Croup:** parainfluenza virus ~ dexamethasone **Epiglottitis:** H.influenza B ~ secure airways, ceftriaxone & dexamethasone **Whooping cough:** Bordetella pertussis ~ supportive management

Question 55

**Premature** **menopause** occurs before what age? What is the cause of premature menopause? The symptoms of menopause are caused by a lack of what hormone? What test can be done to investigate menopause/ peri-menopause?

Answer 55

Beofre 40y Cause: premature ovarian insufficiency **Oestrogen!** **FSH** levels! - they will be **high** near menopause

Question 56

You are asked to see a 29-year-old woman in clinic who has recently found out she is pregnant. She has a history of type 1 bipolar affective disorder, for which she takes lithium. Despite treatment she suffered an episode of mania 9 months previously. How should this patient's psychiatric medication be managed during the antenatal period?

Answer 56

Gradually switch the **lithium** to an ***atypical antipsychotic***

Question 57

What antibodies are present in coeliac disease? What type of Ig are these antibodies? When testing for these antibodies, what do you also need to test for to avoid a false negative result?

Answer 57

Anti-tissue transglutaminase (**anti-TTG**) & anti-endomysial (anti-EMA) **IgA antibodies** Total IgA levels - some people are IgA deficient so their total IgA will be low, even if they have coeliacs

Question 58

A one-year old girl presents to the Emergency department with **intermittent** **abdominal** **pain**. Her father explains that during these episodes the child becomes irritable, **pale**, and **draws her legs up** towards her abdomen. There has been no vomiting, but the child has refused feeds for two days. The abdomen is soft, but there is a palpable, **sausage shaped mass** in the right flank. What is the likely diagnosis? What other *buzz word* would indicate this diagnosis? (common in later presentations) What is the 1st line investigation & management of this conditon? If the child had been vomiting & there was abdominal distension, what does this suggest?

Answer 58

**Intussusception** **Redcurrent jelly stool** Investigation: abdominal US Management: Enema (commonly air enema) Obstruction!

Question 59

Anaphylaxis is what type of hypersensitivity reaction? This type of reaction is mediated by what?

Answer 59

Type 1 hypersensitivity reaction IgE mediated mast cell degranulation

Question 60

What is the management of a baby with symptomatic patent ductus arteriosus? - what is the mechanism behind this? When would this management not be used and why? In these babies, what would the management be? - what is the timeframe for this?

Answer 60

**Indomethacin** (an NSAID) - it is a **prostagland inhibitor** so causes closure of ductus arteriosus Not used in term babies as their patent ductus arteriosus isnt prostaglandin sensitive! Watch & wait - most will close spontaneously within 1y. IF symptomatic, can be surgically ligated

Question 61

An 18m boy presents with a 4h history of **barking** **cough** (seal) and noisy breathing having been well the day before. Examination shows a runny nose, loud **stridor**, tracheal tug, sub-costal recession, well perfused peripheries and temp of 37.8c What is the likely diagnosis? What is the commonest causative organism? What age group is it most common in? How long does it usually last for? What is the management?

Answer 61

**Croup** Parainfluenza Commonest in **6m - 2y** Lasts for up to 48h Management: **steroids!** (dexamethasone)

Question 62

What skills would you expect to see from each developmental domain in a 3y? * Gross motor (1) * Fine motor (1) * Language (2) * Social (1) * Self help (1)

Answer 62

**Gross motor:** 1) Rides a tricycle **Fine motor:** 1) Draws/ copies a complete circle * *Language**: 1) Identifies 4+ colours 2) Asks questions: 'why' 'how' **Social**: 1) Gives directions to other children **Self help:** 1) Toilet trained (may still need help with wiping)

Question 63

The **Fit note** replaced the sick note in 2010. State whether the following are **true** or **false**. 1. A fit note can be completed by a DR & an advanced nurse practitioner. 2. It is an assessment as to whether the patient is able to work in their job specifically? 3. A fit note includes items of considerations to employers when signing a patients return to work. 4. A fit note is required if a patient has been off work for more than 7 days.

Answer 63

1. FALSE: fit note can **only** be completed by a DR 2. FALSE: it is an assessment of whether the patient is fit to work in *general.* 3. TRUE: items of considerations may include: phased return to work/ adjusted hours of work/ adaptations to the workplace 4. TRUE

Question 64

List the distinguishing features that differentiate IgA nephropathy from post-streptococcal glomerulonephritis: (2)

Answer 64

IgA Nephropathy: ~ 1-2 ***days*** post URTI ~ Renal biopsy: IgA immune complex deposits in the glomerulus Post-strep GN: ~ 1-3 ***weeks*** post URTI (usually strep throat) ~ Renal biopsy: IgG immune complex deposits in the glomerulus

Question 65

What are the 6 components of sepsis 6? ~ state the order you would do these in (take 3, give 3)

Answer 65

**1)** Give O2 if sats are below 94% **2)** Take blood cultures **3)** Give IV antibiotics **4)** Fluid challenge (give IV fluids) **5)** Measure blood lactate **6)** Measure urine output

Question 66

What are 2 side effects of the **progesterone injection** (depot injection)? ~ These S/E make it unsuitable for women over what age?

Answer 66

• Weight gain • Osteoporosis ~ over 45y

Question 67

*Palliative care emphasies QoL.* List some things that a GP can provide to palliative patients in order to to improve their QoL: (3) Does palliative care aim to hasten or postpone death?

Answer 67

1. Providing pain & symptom relief 2. Spiritual support 3. Psychosocial support **Neither**. Palliative care just makes the patient & family comfortable.

Question 68

A 1 year old girl is brought in to A/E by her parents as they are concerned about her breathing. She has been feeling unwell with the flu over the last few days. The parents describe a barking cough. They think she has had all her immunisations. She has a high grade fever. A constant high-pitched sound on inspiration can be heard and she has a hoarse voice. Humidified oxygen, dexamethasone and nebulised adrenaline is given. The symptoms do not improve. What is the most likely diagnosis?

Answer 68

**Bacterial Tracheitis** *Always consider bacterial tracheitis in a barking cough with continuous stridor that does not resolve.*

Question 69

What is **vasa praevia**? What are the triad of features commonly seen in vasa praevia presentation? What is the management of vasa praevia? (planned/ unplanned)

Answer 69

**Vasa praevia:** occurs when the fetal blood vessels cover the internal cervical OS. 1. Painless vaginal bleeding 2. Rupture of membranes 3. Fetal bradycardia → death * *Planned management:** elective C-section 34-36 weeks (before membranes rupture spontaneously) * *Unplanned management:** emergency C-section!

Question 70

The following would be red flags in a child's development if they hadn't achieved them by what age? 1) Social smile 2) Sitting unsupported 3) Walking unsupported 4) Words

Answer 70

1) No social smile by **2** months 2) Not sitting unsupported by **9** months 3) Not walking unsupported by **18** months 4) No words by **2** years

Question 71

What investigation is used to diagnose coarctation of aorta? What is the initial management of coarctation of aorta? What does this do physiologically to help? What are the 2 definitive managements of coarctation of aorta?

Answer 71

***ECHO*** Give **prostaglandin E** - this reopens the ductus arteriosis which increases cardiac ouput & relieves the strain on the L ventricle Surgical repair (narrowed part is resected and the 2 ends are anastamosed together) or stent insertion

Question 72

What is the commonest cause of **post-menopausal** bleeding? Why does this occur?

Answer 72

**Atrophic vaginitis** After menopause, the vaginal mucosa becomes drier and thinner - more likely to bleed, especially after sexual intercourse

Question 73

What are an **Exomphalus** and **Gastroschisis**? - whats the difference between them?

Answer 73

**Exomphalus** = herniation of abdominal contents at birth which ***ARE COVERED*** by the peritoneal membrane **Gastroschisis** = herniation of abdominal contents at birth which ***AREN'T COVERED*** by the peritoneal membrane!

Question 74

What are the 2 types of **instrumental** delivery options commonly used? Explain briefly how each are used to aid in delivery: List some risk factors of instrumental delivery to the mother: (4)

Answer 74

**Ventouse suction cup** Suction cup is put on babies head and is slowly pulled to help pull baby out of vagina **Forceps** Forceps are placed either side of babies head and babies head is slowly pulled out of vagina * Perineal tears * Episiotomy * Postpartum haemorrhage * (*stress*) Incontinence of bladder/ bowel

Question 75

What are the 5 domains of development?

Answer 75

1) Gross motor skills 2) Fine motor skills 3) Speech & language skills 4) Social & self help skills 5) Hearing & vision

Question 76

What is haemolytic uraemic syndrome (HUS)? What disease does HUS usually follow from? What is the commonest organism that causes HUS & what investigation is used to identify it's presence? What are the characteristic triad of features seen with HUS? → What invstigations would be done for each feature to identify them?

Answer 76

HUS occurs when there is thrombosis in small blood vessels throughout the body Gastroenteritis E.coli - stool sample will identify it 1) Haemolytic anaemia → FBC, blood film 2) AKI → U&E's to measure serum urea 3) Thrombocytopenia → FBC

Question 77

An ejection systolic murmur in the upper left sternal border & radiates to the back indicates what type of valvular condition? An ejection systolic murmur in the upper right sternal border & radiates to the carotids indicates what type of valvular condition?

Answer 77

**Pulmonary stenosis** **Aortic stenosis**

Question 78

When would **baby blues** typically present? When would **postnatal depression** typically present?

Answer 78

**Baby blues**: Within 2 weeks of delivery **Postnatal depression:** several weeks after delivery up to 1y

Question 79

Name the infection that the following organisms commonly cause: 1. Parvovirus B19 2. Coxsackie virus A 3. Group A Strep 4. RSV (2) 5. Parainfluenza virus

Answer 79

1. Slapped cheek 2. Hand, foot & mouth 3. Scarlet fever 4. Bronchiolitis, viral induced wheeze 5. Croup

Question 80

What is **placental abruption**? - name the 2 types List some clinical features seen in placental abruption: (4) What is the management of placental abruption if: 1. maternal +/- foetal compromise 2. **no** maternal/ foetal compromise

Answer 80

Premature separation of the placenta from uterus during pregnancy ~ Concealed & revealed * **Woody, hard uterus** * Sudden onset, severe abdominal pain * Vaginal bleeding (may be disproportionate to observations though) * Fetal distress on CTG (bradycardia/ reduced foetal movements) * **1. Emergency C-section*** 2. Conservative management with CTG & maternal monitoring

Question 81

A 3y old boy presents with 5 days of **vomiting** and **bloody** **diarrhoea**. He is tolerating oral fluids and recently visited a petting zoo. Examination showed no fever, HR 100, RR 25, no skin changes and mild general abdo discomfort. What is the likely diagnosis? - likely causative organism? What is a complication of this? ~ List the triad of features with this condition What is the management of this boys condition?

Answer 81

**Gastroenteritis** - E.coli **Haemolytic uraemic syndrome:** • haemolytic anaemia (causing jaundice) • AKI (causing high urea levels) • thrombocytopenia ***Conservative***: encourage fluids

Question 82

What day of a 28d cycle does ovulation usually occur on? What hormone spike triggers ovulation? Between which days of a 28d menstrual cycle is the: a) **follicular** phase b) **luteal** phase What physiologically occurs during the: a) **follicular** phase b) **luteal** phase

Answer 82

**Ovulation** = 14d ~ Stimulated by spike in **LH** a) follicular phase = days 0 - 14 b) luteal phase = days 14 - 28 **Follicular phase:** • Under FSH stimulation, follicles mature → ovulation • Mature follicles secrete oestrogen which negatively feedbacks on A.pituitary to decrease release of FSH & LH **Luteal phase:** • Follicle that released the ovum changes into corpus luteum which secretes progesteron to maintain endometrium • If no fertilisation occurs, corpus luteum degenerates → low progesterone → menstruation

Question 83

What is **placenta: 1. accreta 2. increta 3. percreta**? List 3 risk factors for placenta accreta: If placenta accreta isn't detected on antenal US, how does it usually present?

Answer 83

* When the placenta implants deeper than the endometrium...* * *Placenta accreta:** into the **surface** of myometrium ONLY * *Placenta increta:** into the myometrium but not through it * *Placenta percreta:** into AND through the myometrium (commonly onto pelvic organs!) * Previous placenta accreta * Previous C-section * Previous endometrial courettage procedures (eg, for abortion) *Difficulty delivering placenta & significant postpartum bleeding as a result!*

Question 84

For **l****actational amenorrhea** to be 98% effective as a form of contracteption, the woman must be doing what 2 things? ~ If these are done, how long is lactational amenorrhea effective as contraception for after birth? How many days after birth is fertility considered to return? If **postpartum** women are wanting to start a form of **contraception**, what are the available options to them? ~ when can each of these be started after delivery?

Answer 84

• **Fully breastfeeding** • **Amenorrhoeic** (no periods) ~ effective up to 6 months postpartum **21** days * *Postpartum contraception:** * Progesterone only pill / implant* - can be started **anytime** after birth * COCP* - should be avoided with breastfeeding, can *only* be started 6 weeks after birth * IUD/ IUS* - can either be inserted within first 48h after birth OR 4 weeks after delivery

Question 85

A 50-year-old accountant attends her GP after noticing that she is getting angry more easily at work, becoming impatient with her employees and clients, and is unable to relax when at home. She sleeps poorly at night but still enjoys exercise, reading and eating out. What is the most likely diagnosis? • Anxiety ​• Bipolar disease ​• Burnout ​• Depression ​• Substance misuse

Answer 85

**Burnout** *All the others would have symptoms which impact the patient more severely across all settings. There are no pointers to substance misuse in the stem.*

Question 86

List some features of **UC**: (CLOSEUP)

Answer 86

→ Continuous inflammation → Limited to colon & rectum → Only superficial mucosa affected → Smoking is protective → Excrete blood & mucus → Use aminosalicylates (1st line treatment) → Primary scleorising cholangitis

Question 87

What is **placenta: 1. accreta 2. increta 3. percreta**? List 3 risk factors for placenta accreta: If placenta accreta isn't detected on antenal US, how does it usually present?

Answer 87

* When the placenta implants deeper than the endometrium...* * *Placenta accreta:** into the **surface** of myometrium ONLY * *Placenta increta:** into the myometrium but not through it * *Placenta percreta:** into AND through the myometrium (commonly onto pelvic organs!) * Previous placenta accreta * Previous C-section * Previous endometrial courettage procedures (eg, for abortion) *Difficulty delivering placenta & significant postpartum bleeding as a result!*

Question 88

What is the 1st line management of an ovulatory cause of infertility? What is the 2nd line management if the above doesn't help? What is the 3rd line management if the woman is still unable to get pregnant? If all of the above fail, what is the final management to assist in successful pregnancy?

Answer 88

**Lifestyle modification:** weight loss, exercise, diet **2nd line:** Clomiphene **3rd line:** Laparoscopic ovarian drilling Assisted conception

Question 89

What is the commonest type of breast cancer in the UK? - what cells are cancerous in this cancer? If the cancer ***hasn't*** breached the basement membrane, what is the name of it? What is the commonest breast cancer in *younger* patients? - Mutations in what **gene** are associated with this cancer?

Answer 89

**Ductal carcinoma** - cancer of the ductal cells **Ductal carcinoma in situ!** Medullary carcinoma **BRCA1**

Question 90

What are the steps of the 2nd stage of labour? (The steps/ movements of the baby as it moves along the birth canal) (7)

Answer 90

1) Engagement: foetus head is fully engaged with pelvis 2) Descent: foestus starts to descend along birth canal 3) Flexion: foetus head flexes towards chest 4) Internal rotation: foetus internally rotates to face mothers back 5) Extension: foetal head extends & is delivered 6) Restitution: foetus externally rotates to face anteriorly 7) Expulsion: anterior shoulder is delivered, followed by the rest of body

Question 91

What is **cord prolapse**? Why is this an **obstetric emergency**? How is cord prolapse diagnosed? What is the management of this?

Answer 91

**Cord prolapse:** occurs when the umbilical cord exits the cervix before the presenting part of the foetus does **EMERGENCY:** the foetus can compress the cord → **fetal hypoxia**!!!! Cord prolapse should be suspected if there are signs of **foetal distress** on the CTG ~ **vaginal/ speculum examination** can confirm it. Women should lie in **left lateral** position/ **knee-chest** position until **emergency C-section** can be done

Question 92

Between which weeks of gestation would an induction of labour be offered (in an uncomplicated pregnancy!)?

Answer 92

Between 41 - 42 weeks

Question 93

Which of the following would not be described as a physical hazard? * Air pollution * Radiation * Machinery * Noise * Vibration

Answer 93

**Machinery** *Machinery is categorised as a mechanical hazard.*

Question 94

A 1 year old girl is brought in to A/E by her parents as they are concerned about her breathing. She has been feeling unwell with the flu over the last few days. The parents describe a barking cough. They think she has had all her immunisations. She has a high grade fever. A constant high-pitched sound on inspiration can be heard and she has a hoarse voice. Humidified oxygen, dexamethasone and nebulised adrenaline is given. The symptoms do not improve. What is the most likely diagnosis?

Answer 94

**Bacterial Tracheitis** *Always consider bacterial tracheitis in a barking cough with continuous stridor that does not resolve.*

Question 95

What condition is indicated if a woman presents with **recurrent miscarriages** & a history of **VTE** events? What is the treatment of this condition? (2)

Answer 95

**Antiphospholipid syndrome** Aspirin & LMWH

Question 96

List some adverse effects of an **epidural**: (5) What 2 simple analgesics are commonly given in labour alongside the additional pain relief options? ~ which simple analgesic is *avoided?*

Answer 96

* Increased risk of instrumental delivery * Prolonged 2^nd stage of labour * Hypotension * Motor weakness in legs (cannot walk around after) * Headache (after insertion - uncommon) **Paracetemol & codeine ~** *NSAIDs are avoided!!*

Question 97

A GP with a special interest in gastroenterology decides to increase her knowledge of oesophageal carcinoma. She opts to use a range of evidence. Within the Hierarchy of Evidence, which of the following sources of information is likely to have the greatest strength of evidence? * Case reports * Cohort studies * Expert opinion * Randomised controlled trials * Systematic reviews

Answer 97

**Systematic reviews** *Systematic reviews combine evidence from multiple studies, including RCTs, and therefore provide the strongest evidence.*

Question 98

An 8 year old boy is referred with behavioural problems to the child Psychiatry Department. He is always active at home and moves from task to task. He finds it difficult to concentrate to read or watch TV. He often puts himself into dangerous situations like climbing onto high roofs. His performance at school is poor where he is distractible and causes distractions to others. What is the most likely diagnosis?

Answer 98

ADHD

Question 99

What is **health education?** What is **health protection?**

Answer 99

**Health education:** involves communication with people aimed at changing their knowledge/ attitudes in regards to health so that they make better decisions regarding their health **Health protection:** targets factors that are beyond the control of individuals in order to achieve better health in the population. ~ eg sugar tax!

Question 100

List some common symptoms of **asthma**: (3)

Answer 100

* Wheeze * Cough (worse at night) * SOB

Question 101

If the CTG is showing signs of fetal distress, what can you do to determine whether the baby is hypoxic? How is this done?

Answer 101

Take a **fetal blood sample** Speculum is inserted and babies head is '**scratched**' to obtain a blood sample ⇒ ONLY shows if baby is hypoxic

Question 102

State the 5 criteria of the Bishops Score: ~ state the characteristics seen in each criteria that indicate onset of labour What is the Bishops Score used for? ~ what is the pivoting score?

Answer 102

→ Position of the cervix (anterior) → Effacement of the cervix (length - shorter = better) → Consistency of the cervix (soft) → Dilatation of the cervix (bigger = better) → Station of the presenting part (distance in cm in relation to the ischial spines) Bishops score is used to assess whether induction of labour would be successful ~ score of **8** indicates successful induction

Question 103

A 30-year-old businessman attends his GP as he is thinking about reducing his excess alcohol intake. At what stage of the ‘Change cycle’ is he? • Action • Contemplation • Maintenance • Precontemplation • Preparation

Answer 103

**Contemplation** *He has just started thinking about reducing his alcohol intake. At the precontemplation stage, he has given it no thought. He has not started to reduce alcohol yet or given an indication of a plan, so preparation and action are also incorrect. Maintenance occurs once the reduction in alcohol is established.*

Question 104

Describe what you might see in the following seizures: a) Tonic-clonic seizure b) Myoclonic seizure c) Absence seizure d) Atonic seizure

Answer 104

**Tonic-clonic seizure:** Muscles stiffen (go rigid = tonic) before generalised jerking of limbs (clonic) **Myoclonic seizure:** Sudden jerking of one limb - patient may be conscious! **Absence seizure:** Patient 'pauses' for a few seconds before restarting activity - patient often has no recollection **Atonic seizure:** Muscles suddenly loose all tone - patient falls over

Question 105

A 30-year-old businessman attends his GP as he is thinking about reducing his excess alcohol intake. At what stage of the ‘Change cycle’ is he? • Action • Contemplation • Maintenance • Precontemplation • Preparation

Answer 105

**Contemplation** *He has just started thinking about reducing his alcohol intake. At the precontemplation stage, he has given it no thought. He has not started to reduce alcohol yet or given an indication of a plan, so preparation and action are also incorrect. Maintenance occurs once the reduction in alcohol is established.*

Question 106

State the 3 vaccines that are live, attenuated:

Answer 106

**Live attenuated:** • MMR • Rotavirus • Nasal flu vaccine

Question 107

A pregnant woman attends the obstetric clinic for a routine early pregnancy scan. She has been struggling in the pregnancy so far with extreme, persisten nausea & vomiting. The US scan shows a **snowstorm** appearance. What is the most likely diagnosis? Name the 2 types and their causes: What would you expect to see regarding the **hCG**? - what condition can this often mimic & why? What is the treatment of this?

Answer 107

**Molar pregnancy** (hydatiform mole) **Complete mole:** 2 sperm fertilise 1 egg that contains *no* genertic material (empty egg) ~ no fetal material will form **Partial mole:** 2 sperm fertilise 1 *normal* egg, resulting in a cell that has 3 sets of chromosomes! ~ some fetal material may be seen **hCG** is abnormally high for gestational dates - can cause **hyper**thyroidism as hCG mimics TSH & overstimulates the thyroid gland **Treatment:** evacuation of the uterus to remove it - the products of conception are sent to histology to confirm the molar pregnancy

Question 108

What is the 1st line management of **menorrhagia** if: a) woman is trying to concieve & has **no** pain b) woman is trying to concieve but has pain c) woman is not trying to concieve

Answer 108

a) **Tranexamic acid** (anti-fibrinolytic) b) **Mefenamic acid** (reduced bleeding & pain) 3) **Mirena coil**

Question 109

Why does physiological anaemia occur during pregnancy?

Answer 109

Blood volume increases during pregnancy, but plasma volume \> RBC = anaemia (as RBC's are diluted!)

Question 110

What are the 2 criteria's/ tools that GP's often use to determine a bacterial or viral cause of a sore throat?

Answer 110

CENTOR & feverPAIN

Question 111

What is a '**just in case**' box? What 4 medications would be included within it?

Answer 111

**Just in case box:** Given to patients at end of life. It includes medicines that can be quickly administered if the patient has any distress. * Opioid for **pain**/breathlessness (morphine) * Sedative for anxiety/**agitation**/**breathlessness** (midazolam) * Anti-secretory for resp secretions (Hyoscine butylbromide injection) * Anti-emetic for **nausea** and vomiting (levomepromazine injection)

Question 112

Which of these interventions is an example of Tertiary Prevention? * Checking PSA levels in someone with a family history of prostatic cancer * Dalteparin injections prior to an operation to prevent a deep vein thrombosis * Joint replacement in severe osteoarthritis of the hip * Mammogram to detect asymptomatic breast lump * Warming up adequately before engaging in sport

Answer 112

**Joint replacement in severe osteoarthritis of the hip** *Tertiary prevention attempts to reduce the impact of an established disease or disability. Joint replacement in osteoarthritis is the only option which corresponds to this. The others are examples of primary and secondary prevention.*

Question 113

A 29y woman, smoker, referred to the antenatal clinic with a small amount of **dark** **brown vaginal bleeding** at 39+2 weeks gestation. A speculum exam showed some old blood in the vagina but no active bleeding. 2 hours later the emergency buzzer is pulled as the woman is distressed with extreme abdominal pain and fresh vaginal bleeding. The uterus has a **hard,** **woody** feeling. What is the likely diagnosis here? What is the management if there is maternal/ foetal compromise? What is the management is there isn't maternal/ foetal compromise?

Answer 113

**Placental abruption** **Maternal/ foetal compromise:** emergency C section **No compromise:** induction of labour

Question 114

List the 4 signs of labour: What drug is the 1st line for **tocolysis**? ~ what is tocolysis?

Answer 114

* Show (mucus plug from the cervix) * Rupture of membranes * Regular, painful contractions * Dilation of cervix (seen on examination) **Nifedipine (orally)** ~ the use of medications to stop uterine contractions

Question 115

A 61-year-old man has end stage multiple sclerosis. He is very weak and unable to walk. He sometimes aspirates food, causing significant distress and recurrent pneumonia. During a GP home visit, he expresses a wish to die and asks whether his GP would be willing to help him to end his life. How should the GP respond? * Advise him that it is against their beliefs and decline to discuss it further * Advise him that it is illegal and not for further discussion * Advise him that people have travelled abroad to do it, because it is illegal in the UK * Encourage him to discuss it further and explore the reasons for his request * Inform his family of his wish to die so that they are fully informed

Answer 115

**Encourage him to discuss it further and explore the reasons for his request** ## Footnote *Enabling discussion will allow the GP to find out details about the main concerns of the patient and address symptom control better.*

Question 116

**Failure to progress in labour** is when the labour isn't developing at a satisfactory rate. Name the 3 things that progress in labour is influenced by: (**3 P's)** What is considered as a delayed 2^nd stage of labour in: a) **nulliparous** women b) **multiparous** women What is considered as a delayed 3^rd stage of labour in: * *a) active management** * ~ what does active management of the 3^rd stage of labour involve?* b) **physiological** **management**

Answer 116

* **Power** (of uterine contractions) * **Passenger** (size/ presentation/ position of baby!) * **Passage** (shape & size of mothers pelvis) * *Nulliparous**: 2^nd stage taking 2 hours * *Multiparous**: 2^nd stage taking 1 hour * *Active**: 3^rd stage taking longer than 30 mins * ~ IM oxytocin & controlled cord traction* * *Physiological**: 3^rd stage taking longer than 60 mins

Question 117

A 2y old child presents with 4 month history of passage of foul smelling explosive stools 3-4/day, tiredness, pallor & poor weight gain. They have just developed an itchy rash on their abdomen. What is the likely diagnosis? - name of the rash? What investigations would you do to confirm this condition? What is the gold standard investigation to **confirm** the diagnosis?

Answer 117

**Coeliac's disease** - dermatitis herpetiformis * *Antibodies:** 1) Anti-TTG *plus* total IgA 2) Anti-EMA (if anti-TTG were positive) **Duodenal biopsy** (via endoscopy)

Question 118

Describe the damage involved in each degree of perineal tears: ~ First degree tear ~ Second degree tear ~ Third degree tear: 3A, 3B, 3C ~ Fourth degree tear What is the management of the various tears?

Answer 118

**First degree:** Tear limited to the superficial perineal skin or vaginal mucosa only ~ *Don't require treatment* **Second degree:** Tear extends to perineal muscles and fascia, but the anal sphincter is intact ~ *Requires a simple stitch* (midwife can do this) * *Third degree:** tear involves the external anal sphincter * *3A** - less than 50% thickeness of sphincter is torn * *3B** - more than 50% thickeness of sphincter is torn * *3C** - External & internal anal sphincters torn * ~ Requires surgical correction* * *Fourth degree:** tear extends to the rectal mucosa * ~ Requires surgical correction*

Question 119

If needing treatment, what is used to treat **Bacterial Vaginosis**? What is the treatment of **Candidiasis** infection? What is the treatment of **Chlamydia** infection? (In non pregnant/ breastfeeding people) What is the treatment of **Gonorrhoea** infection? What is the treatment of **Trichomoniasis** infection? What is the treatment of **Herpes** infection?

Answer 119

**Bacterial vaginosis**: Metronidazole **Candidiasis**: Antifungal cream/ pessary (clotrimazole)/ oral tablet **Chlamydia:** doxycycline 100mg 2x daily for 7 days **Gonorrhoea*:*** *IM ceftriaxone* (if sensitivities are known) / oral ciprofloxacin (if sensitivities aren't known) **Trichomoniasis:** Metronidazole **Herpes:** Aciclovir

Question 120

What skills would you expect to see from each developmental domain in an 18m toddler? * Gross motor (2) * Fine motor (2) * Language (1) * Social (2) * Self help (1)

Answer 120

* *Gross motor:** 1) walks up/down stairs unsupported 2) kicks a ball * *Fine motor:** 1) scribbles with crayon 2) builds towers with 4+ bricks **Language**: 1) starts to join words into sentences * *Social**: 1) early pretend play 2) says no when interfered with **Self help:** 1) eats with fork

Question 121

What score do GPs use to calculate someones risk of cardiovascular disease?

Answer 121

**ASSIGN** score

Question 122

A 3m girl is brought to the GP as her parents are worried about a skin lump that has appeared on her neck. It is non-tender and isn't bothering her, but it is growing in size. On examination there is a 2 x 2cm firm, well demarcated lesion with visible telangiectasia. There are no other skin lesions. What is the likely diagnosis? - what is this? What would the treatment be here? What would the treatment be if the lesion was near the eyes/ rapidly enlarging or was ulcerating?

Answer 122

**Haemangioma -** a vascular birth mark that isnt present at birth but appears from 6 weeks onwards. It will proliferate & grow up until 8m and then self resolve. **Treatment if asymptomatic:** *nothing* - they will self resolve (involute) **Treatment if problematic:** Oral propanolol

Question 123

State some risk factors for **uterine rupture**: (3) List some common **clinical** **features** of uterine rupture: (5) What is the management of **uterine rupture?**

Answer 123

**Risk factors of uterine rupture:** *_• VBAC_* (vaginal birth after C-section - C-section scar is a weak point in the uterus!) • The use of oxytocin to stimulate contractions • High BMI **Clinical features:** • Sudden abdominal pain • Vaginal bleeding *• Maternal shock* (hypotension, tachycardia, collapse) • Ceasing of uterine contractions • ABNORMAL CTG **Management:** EMERGENCY C-SECTION

Question 124

A 34-year-old woman has depression and is about to commence medication. Her GP has fully explained the treatment options and the patient has discussed their thoughts on the treatment before opting for medication. Which type of patient-doctor consultation style best describes this encounter? * Authoritarian * Guidance Cooperation * Mutual Participation * Paternalistic * Perceptual

Answer 124

**Mutual Participation** *Authoritarian and paternalistic approaches do not allow for patient input. Guidance-cooperation allows for some patient input, but not full discussion and rarely a final decision from the patient about the treatment they wish to opt for. Perceptual skills are a form of consultation skill on the part of the doctor, not a doctor-patient consultation style.*

Question 125

What is the 1st line investigation in SUFE? What is the management of SUFE?

Answer 125

**Xray of hip** Surgery: correction of femoral head positon PLUS screw fixation ~ Prophylactic fixation of contralateral hip may be done

Question 126

List the 4 signs of labour: What drug is the 1st line for **tocolysis**? ~ what is tocolysis?

Answer 126

* Show (mucus plug from the cervix) * Rupture of membranes * Regular, painful contractions * Dilation of cervix (seen on examination) **Nifedipine** ~ the use of medications to stop uterine contractions

Question 127

Women with risk factors for gestational diabetes are tested at what point of gestation? ~ What is the test used? ~ How is this test performed? What results of this test are normal and thus above would qualify as gestational diabetes? (5,6,7,8!)

Answer 127

**OGTT -** 24-28 weeks ~ Patient fasts throughout night, BM measured in morning before patient takes sugary drink (75g glucose) → BM measured 2h later **Results:** Fasting glucose: **\< 5.6 mmol/l** 2h glucose: **\< 7.8 mmol/l**

Question 128

What tool do GP's use to determine whether a patient with a chronic condition is nearing their end of life & palliative care should take place? What tool can be used to assess & review functional changes in palliative patients health? ~ a lower % indicates a better/ poor prognosis?

Answer 128

**SPICT** (supportive & palliative care indicators tool) **PPS** (palliative performance scale) ~ lower % on the scale indicates **poorer** **prognosis**

Question 129

What skills would you expect to see from each developmental domain in a 6m infant? * Gross motor (2) * Fine motor (2) * Language (2) * Social (2) * Self help (1)

Answer 129

* *Gross motor:** 1) rolls over 2) starts to sit without support * *Fine motor:** 1) uses 2 hands to pick up large objects 2) transfers toy from 1 hand to another * *Language**: 1) responds to name 2) 2 syllable babble * *Social**: 1) reaches for familiar people 2) pushes things they don't want away **Self help:** 1) feeds self small food

Question 130

What investigation is **essential** in order to diagnose meningitis in children? ~ What would be an absolute contraindictation to this?

Answer 130

**Lumbar puncture** ~ signs of raised ICP

Question 131

What 5 factors are assessed using the Bishop Score for induction of labour?

Answer 131

Fetal station (this is how far down into the pelvis the babies head is palpated in relation to the ischial spines) Cervical position (as the cervix ripens, it moves more anteirorly) Cervical dilatation (as the cervix ripens, it dilates) Cervical effacement (as the cervix ripens, it becomes shorter) Cervical consistency (as the cervix ripens, it becomes softer)

Question 132

What is the *gold standard* investigation for suspected vesico-uteric reflux in children? What investigation is used to look for any kidney scarring/ function of the kidney? What investigation is used to look at the structure (size & shape) of the kidney?

Answer 132

MCUG (micturicting urogram) DMSA US KUB

Question 133

List some common symptoms of **ovarian cancer**: (6) What are the 2 initial investigations if ovarian cancer is suspected?

Answer 133

* Abdominal bloating * Early satiety * Loss of appetite * Weight loss * Ascites * Pelvic pain ## Footnote **CA125 & Transvaginal US**

Question 134

A low birth weight is considered below what? A large baby is considered as weight what at birth?

Answer 134

**2500g** (2.5kg) ## Footnote **4.5kg**

Question 135

What is **voluntary** **euthanasia**? What is **non**-**voluntary** **euthanasia**? What is **involuntary** **euthanasia**? What is **physician** **assisted** **suicide**? ~ is this legal or illegal?

Answer 135

**Voluntary euthanasia:** patient with capacity requests euthanasia **Non-voluntary euthanasia:** patient without capacity has their death hastened **Involuntary euthanasia:** patient is killed against their wishes (more murder...) **Physician assisted suicide:** the DR provides the advice/ drugs needed for suicide ~ ILLEGAL!!!!

Question 136

Regarding breast cancer screening: a) which age groups are screened? b) how often is the screening? c) what does screening involve?

Answer 136

a) 50 - 70y b) every 3 years c) mammogram (xray of breasts)

Question 137

What are the 2 commonest methods used to **induce labour****?** What is a complication of induction of labour? ~ what can this result in? ~ what is the management of this complication?

Answer 137

* Membrane sweep * **Vaginal prostaglandins** (pessary) **Uterine hyperstimulation** ~ fetal distress & hypoxia! ~ *management:* removing vaginal prostaglandins +/- giving **tocolysis** (using terbutaline)

Question 138

What are the 5 things that a **CTG** measures? What is the normal HR of a fetus? ~ what is the range of normal variability within this?

Answer 138

* **Contractions** (num. of uterine contractions in 10 mins) * **Baseline fetal HR** (the average HR) * **Variability** (of fetal HR) * **Accelerations** (increase in HR of 15bpm for 15 secs) * **Decelerations** (decrease in HR by 15bpm for 15 secs) - concerning **Foetal HR** = 110 - 160bpm ~ normal variability = 5 - 25bpm

Question 139

What skills would you expect to see from each developmental domain in an 24m toddler? * Gross motor (1) * Fine motor (1) * Language (1) * Social (1) * Self help (1)

Answer 139

**Gross motor:** climbs on play equipment (eg, slides) **Fine motor:** scribbles with circular motion **Language**: vocabulary of 30-50 words **Social**: helps with simple household tasks **Self help:** opens door by turning knob

Question 140

What are the 2 criteria's/ tools that GP's often use to determine a bacterial or viral cause of a sore throat?

Answer 140

CENTOR & feverPAIN

Question 141

If a split bilirubin shows high levels of conjugated bilirubin, what underlying problem does this indicate? What is **biliary atresia?** - what investigation would you do (other than split bilirubin) What 3 features might biliary atresia present with? What is the management of biliary atresia?

Answer 141

Biliary tree obstruction (bile is unable to be transported to the bowel) Congenital condition in which there is *absent* / *stenoised* bile duct - prevents bile (and conjugated bilirubin) being transported to bowel *~ abdominal US* 1) Jaundice 2) Pale, chalky white stools 3) Hepatosplenomegaly Surgery - **kasai portoenterostomy** (small intestine is attached directly to the liver)

Question 142

What is **pre-eclampsia**? What is the 1^st line management? ~ 2^nd line management?

Answer 142

Pregnancy-induced hypertension occurring after 20 weeks gestation with proteinuria. **Labetelol ~** Nifedipine

Question 143

How long must diarrhoea persist for to be referred to as **chronic diarrhoea**?

Answer 143

More than 4 weeks

Question 144

What is **placental abruption**? - name the 2 types List some clinical features seen in placental abruption: (4) What is the management of placental abruption if: 1. maternal +/- foetal compromise 2. **no** maternal/ foetal compromise

Answer 144

Premature separation of the placenta from uterus during pregnancy ~ Concealed & revealed * **Woody, hard uterus** * Sudden onset, severe abdominal pain * Vaginal bleeding (may be disproportionate to observations though) * Fetal distress on CTG (bradycardia/ reduced foetal movements) * **1. Emergency C-section*** 2. Conservative management with CTG & maternal monitoring

Question 145

A 3-week-old boy presents to paediatric A&E with **persistent vomiting**. The mother reports that vomiting always occurs soon after feeds and often **hits the kitchen walls**. On abdominal examination, there are no peritonitic features, but, a small, firm, **olive shaped mass** is palpable in the epigastric area. What is the likely diagnosis? What is the investigation of choice? What is the definitive management?

Answer 145

**Pyloric stenosis** Abdominal US **Management:** surgery (laparoscopic pyloromyotomy)

Question 146

What is **vasa praevia**? What are the triad of features commonly seen in vasa praevia presentation? What is the management of vasa praevia? (planned/ unplanned)

Answer 146

**Vasa praevia:** occurs when the fetal blood vessels cover the internal cervical OS. 1. Painless vaginal bleeding 2. Rupture of membranes 3. Fetal bradycardia → death * *Planned management:** elective C-section 34-36 weeks (before membranes rupture spontaneously) * *Unplanned management:** emergency C-section!

Question 147

A 14-year-old presents to her GP with her mother who is concerned that she is tired all the time and failing to meet deadlines for school projects. She is slightly overweight, but examination is otherwise normal. Urinalysis, FBC, U&Es, LFTs, TFTs and blood glucose are all normal. What would be the most appropriate next step? * Advise her that everything is normal and to seek further review if new symptoms develop * Advise her that the tests are normal and suggest seeking additional educational support * Discuss her lifestyle including sleep patterns and diet * Refer her to paediatrics for further investigation * Repeat the blood tests in case something has changed

Answer 147

**Discuss her lifestyle including sleep patterns and diet** *Repeating normal tests after a very short time scale is unlikely to provide new information. The history and initial examination/investigation suggest that lifestyle factors are likely to be the cause, so this needs to be explored and advice given accordingly.*

Question 148

List 3 functions of **oxytocin**: List 2 uses of **nifedipine** throughout pregnancy:

Answer 148

**Oxytocin** • Ripening of cervix • Stimulates contractions of uterus • Squeezes mammary ducts to aid in breastfeeding **Nifedipine** • 2^nd line Pre-eclampsia treatment (to control hypertension) • Tocolysis (in premature labour)

Question 149

What is **Croup**? What is the commonest causative organism? What are the common presenting features of croup? (6) How long does croup usually last for? What is the management of croup?

Answer 149

An URTI causing oedema & swelling of the larynx. Parainfluenza virus ~ Increased work of breathing ~ Barking cough (sounds like a seal) ~ cold symptoms ~ hoarse voice ~ +/- stridor ~ +/- mild fever 1 - 2 days Oral dexamethasone

Question 150

A 55-year-old concert pianist has a stroke, leaving him with right arm weakness and dysphasia. Which of the following best describes the resultant activity limitation experienced by the patient? * Damage to nerves in right arm * Death of cerebral neurons * Difficulty socialising with friends * Inability to continue his occupation * Loss of normal function in right arm

Answer 150

**Loss of normal function in right arm** *Nerves in the arm are not affected by the stroke. Some cerebral neurons will have died but this is pathology not activity limitation. The other options would be described as participation restrictions resulting from the activity limitation.*

Question 151

List some common reactions people may have to **bad news/ grief**: (10)

Answer 151

* Shock * Anger * Denial * Bargaining * Relief * Sadness * Fear * Guilt * Anxiety * Distress

Question 152

In PCOS, would you expect the following to be low, normal or high? 1) Testosterone 2) Sex hormone binding globulin 3) LH 4) FSH 5) Insulin 6) LH:FSH ratio

Answer 152

1) Testosterone - high (insulin promotes release of androgens) 2) Sex hormone binding globulin - low (insulin decreases SHBG production) 3) LH - high 4) FSH - low (low FSH results in follicles not maturing and turning into cysts) 5) Insulin - high (insulin resistance is a feature of PCOS) 6) LH:FSH ratio - high (High LH & low FSH)

Question 153

Describe the **rule of 3's** for management of **prolonged** **foetal bradycardia:**

Answer 153

* *3 mins:** call for help * *6 mins:** move to theatre * *9 mins:** prepare for delivery of the baby * *12 mins:** deliver the baby (by 15 mins!)

Question 154

Describe the **rule of 3's** for management of **prolonged** **foetal bradycardia:**

Answer 154

* *3 mins:** call for help * *6 mins:** move to theatre * *9 mins:** prepare for delivery of the baby * *12 mins:** deliver the baby (by 15 mins!)

Question 155

How is a patient mean't to use Entonox? ~ how long does it take for it to work?

Answer 155

**Entonox** = gas & air (NO) ~ breathe it in at the **start** of a contraction ~ takes about 30s to work

Question 156

Anaphylaxis is what type of hypersensitivity reaction? This type of reaction is mediated by what?

Answer 156

Type 1 hypersensitivity reaction IgE mediated mast cell degranulation

Question 157

What are the 4 aspects of the **cycle of change**?

Answer 157

**1. Pre-contemplation** ~ does activity **2. Contemplation** ~ considers stopping activity **3. Action** ~ stops activity **4. Regression** ~ restarts activity

Question 158

List some features of **nephrotic** syndrome: (4) List some features of **nephritis** syndrome: (3)

Answer 158

**Nephrotic syndrome:** • proteinuria (+++) • oedema • hypoalbuminaemia • hyperlipidaemia **Nephritic syndrome:** • haematuria • hypertension • proteinuira (+)

Question 159

What is the commonest cause of macrosomia? List some risk factors of a macrosomic baby during birth: (5)

Answer 159

**Maternal diabetes** (eg, gestational diabetes) * Shoulder dystocia * Pernieal tears * Instrumental delivery/ C-section * Clavicle fracture of baby * Erbs palsy (brachial plexus injury - common from shoulder dystocia)

Question 160

When would a **primary** postpartum haemorrhage occur? When would a **secondary** postpartum haemorrhage occur? How many mls of blood needs to be lost for a classification of: a) **minor** PPH b) **major**/ **moderate** PPH c) **severe** PPH What are the 4 causes of a PPH? ~ what is the commonest cause?

Answer 160

* *Primary**: within the first 24h * *Secondary**: between 24h - 12 weeks after delivery * *Minor** PPH: under 1000mls * *Major/ moderate** PPH: 1000 - 2000mls * *Severe** PPH: 2000mls + * **T**issue (retained placenta) * **T*one (of uterus = uterine antony is commonest cause)*** * **T**rauma (eg, perineal tear) * **T**hombin (bleeding disorder)

Question 161

Regarding **pO2** & **pCO2**, what would be seen on a blood gas in: a) type 1 respiratory failure b) type 2 respiratory failure

Answer 161

**Type 1 resp failure:** low O2, normal CO2 **Type 2 resp failure:** low O2, high CO2 - respiraoty acidosis

Question 162

A bacterial growth of what suggests a UTI?

Answer 162

**10⁵**

Question 163

When palpating the anterior & posterior fonatelles on vaginal examination during delivery, what shapes do they typically have?

Answer 163

* *Anterior fontanelle:** diamond * *Posterior fontanelle:** triangle

Question 164

The following would be red flags in a child's development if they hadn't achieved them by what age? 1) Social smile 2) Sitting unsupported 3) Walking unsupported 4) Words

Answer 164

1) No social smile by **2** months 2) Not sitting unsupported by **9** months 3) Not walking unsupported by **18** months 4) No words by **2** years

Question 165

A GP with a special interest in gastroenterology decides to increase her knowledge of oesophageal carcinoma. She opts to use a range of evidence. Within the Hierarchy of Evidence, which of the following sources of information is likely to have the greatest strength of evidence? * Case reports * Cohort studies * Expert opinion * Randomised controlled trials * Systematic reviews

Answer 165

**Systematic reviews** *Systematic reviews combine evidence from multiple studies, including RCTs, and therefore provide the strongest evidence.*

Question 166

What is Perthes disease? (Legg-Calve-Perthes) What age group is it most common in? What is the typical presentation of someone with Legg-Calve-Perthes disease?

Answer 166

Avascular necrosis of the femoral head in children which is caused by disruption to the blood flow of the femoral head Ages 4-10y • Gradual\* onset limb & hip pain • Referred pain to the knee • Pain persists for \>4 weeks \* Gradual due to the femoral head becoming increasingly ischaemic

Question 167

A 7y old boy is brought in because parents are concerned that he **still** wets the bed most nights (dry throughout the day). He has no fever and abdominal/ spinal/ neuro examination is normal. What is the likely diagnosis? - how does this differ if the boy had previously been continent at night? What is the diagnosis if urinary incontinence occurs throughout the day too? What is the management of this boys condition?

Answer 167

* *Primary nocturnal enuresis** * - Secondary* notcurnal enuresis Diurenal enuresis **Management:** identify underlying cause & treat! ~ eg, reduce fluid intake in evenings ~ eg, check for UTI

Question 168

What skills would you expect to see from each developmental domain in a 3y? * Gross motor (1) * Fine motor (1) * Language (2) * Social (1) * Self help (1)

Answer 168

**Gross motor:** 1) Rides a tricycle **Fine motor:** 1) Draws/ copies a complete circle * *Language**: 1) Identifies 4+ colours 2) Asks questions: 'why' 'how' **Social**: 1) Gives directions to other children **Self help:** 1) Toilet trained (may still need help with wiping)

Question 169

A 34-year-old woman has depression and is about to commence medication. Her GP has fully explained the treatment options and the patient has discussed their thoughts on the treatment before opting for medication. Which type of patient-doctor consultation style best describes this encounter? * Authoritarian * Guidance Cooperation * Mutual Participation * Paternalistic * Perceptual

Answer 169

**Mutual Participation** *Authoritarian and paternalistic approaches do not allow for patient input. Guidance-cooperation allows for some patient input, but not full discussion and rarely a final decision from the patient about the treatment they wish to opt for. Perceptual skills are a form of consultation skill on the part of the doctor, not a doctor-patient consultation style.*

Question 170

List some symptoms of **pre-eclampsia:** (5) What medication is used to treat a seizure in **eclampsia**?

Answer 170

Headache Changes in vision (commonly blurred vision) Nausea / vomiting Ankle oedema Upper abdominal pain **Eeclampsia:** IV magnesium sulphate

Question 171

If a woman is \*Rh- and is carrying a Rh+ baby and there is no intervention, what will happen during delivery/ when there is mixing of blood? Why does this happen? When should this be checked for during pregnancy? What can be given as prophylaxis for this? \*Rh = rhesus

Answer 171

The women will start developing anti-D antibodies after any sensitising event (commonly giving birth) If someone is rhesus negative, they don't have the D antigen on their RBC's so if their blood comes into contact with someone that is rhesus positive then their blood will start producing antibodies against the foreign antigens. Rh status of mother & baby is checked at the booking appointment (week 10) If mother is negative & baby is positive, prophylaxis = anti D injection at 28 weeks gestation PLUS immediately after any sensitising events

Question 172

List 2 methods of prophylaxis of preterm labour:

Answer 172

Vaginal progesterone pessary/gel - this prevents cervical ripening & decreases activity of the myometrium Cervical cerclage - a stitch is put into the cervix to keep it closed until nearer term date

Question 173

What is SUFE? What age group & sex is it most common in? What is the biggest RF for SUFE? List some features seen in someone with SUFE: (3)

Answer 173

It's when the head of femur is displaced along the growth plate (it looks like it has slipped off) Teenage boys **Obesity** ~ Hip/ groin/ knee pain with *insidious* onset ~ Restricted ROM of hip ~ Painful limp

Question 174

What are the 3 **Rotterdam** criteria for **PCOS**? How many do you need to be diagnosed with PCOS? What is the gold standard investigation for PCOS? ~ what 'buzzword' will be seen on this?

Answer 174

* Irregular/ absent menstrual periods * Hyperandrogenism (eg acne/ hirsutism) * polycystic ovaries on US (\>12) (or ovarian volume 10cm³ plus) 2 out of the 3 criteria **Transvaginal US**: follicular arrangement within the ovary has a **string of pearls** appearance

Question 175

State the 5 criteria of the Bishops Score: ~ state the characteristics seen in each criteria that indicate onset of labour What is the Bishops Score used for? ~ what is the pivoting score?

Answer 175

→ Position of the cervix (anterior) → Effacement of the cervix (length - shorter = better) → Consistency of the cervix (soft) → Dilatation of the cervix (bigger = better) → Station of the presenting part (distance in cm in relation to the ischial spines) Bishops score is used to assess whether induction of labour would be successful ~ score of **8** indicates successful induction

Question 176

What are the 2 commonest methods used to **induce labour****?** What is a complication of induction of labour? ~ what can this result in? ~ what is the management of this complication?

Answer 176

* Membrane sweep * **Vaginal prostaglandins** (pessary) **Uterine hyperstimulation** ~ fetal distress & hypoxia! ~ *management:* removing vaginal prostaglandins +/- giving **tocolysis** (using terbutaline)

Question 177

List some **drug free techniques** to control pain during labour: (3) List the 4 main pain relief options for labour that involve medications:

Answer 177

* TENS machine * Birthing ball * Birthing pool * Entenox (gas & air = NO) * IM diamorphine * Remifentanil (administered as patient controlled anaesthesia - patient has a button to press when needing a dose) * Epidural

Question 178

A 50-year-old accountant attends her GP after noticing that she is getting angry more easily at work, becoming impatient with her employees and clients, and is unable to relax when at home. She sleeps poorly at night but still enjoys exercise, reading and eating out. What is the most likely diagnosis? • Anxiety ​• Bipolar disease ​• Burnout ​• Depression ​• Substance misuse

Answer 178

**Burnout** *All the others would have symptoms which impact the patient more severely across all settings. There are no pointers to substance misuse in the stem.*

Question 179

What part of the GIT does coeliacs disease affect & what is the main histological finding seen? List some clinical features seen in coeliac disease: (6) What condition is closely associated with coeliac disease?

Answer 179

Small bowel (esp jejenum) - villous atrophy * Failure to thrive (in children) * Diarrhoea * Weight loss * Fatigue * Dermatitis herpetiformis (itchy rash, usually on abdomen) * Malabsorption **Type 1 diabetes** (as well as other autoimmune conditions)

Question 180

What is **placenta praevia?** When would **placenta praevia** be diagnosed in a pregnancy if it's present? What is the common presentation of placenta praevia? If someone is identified as having placenta praevia, when would they be given repeat US's? What is the management of placenta praevia regarding the delivery?

Answer 180

**Placenta praevia:** when the placenta is attached in the lower portion of the uterus - often covering the cervical os. At the **20 week anomaly scan** **Painless bleeding** *(antepartum haemorhage)* **32 & 36** weeks gestation (if present on the 32 week scan to guide decisions about delivery) C-section should be planned for 36-37 weeks (to avoid spontaneous labour as vaginal delivery is contraindicted)

Question 181

If a pregnant woman is **HIV** positive, is she able to have a normal **vaginal delivery**? If a pregnant woman is **HIV** positive, is she able to **breastfeed**? What **prophylaxis** **treatment** is given to all babies born to HIV+ women?

Answer 181

**Vaginal delivery:** ONLY if her viral load is undetectable (\< 50 copies/ ml) - otherwise C-section recommended **Breastfeeding:** NO. Even if viral load is undetectable, HIV can be transmitted to baby through the breast milk! **Prophylaxis:** • Viral load is **undetectable** (\< 50 copies/ ml) = **1x** antiviral for 4 weeks • Viral load is **detectable** (\> 50 copies/ ml) = **3x** antiviral for 4 weeks

Question 182

A 44y woman attends the GP practice complaining of a 6y history of **abdominal pain** and **menorrhagia**. She describes the pain as being **worse immediately before and during the first day** of menstration. O/E the uterosacral ligament is thickened and the ovaries are enlarged. Laparscopic examination reveals **chocolate cysts.** What is the likely diagnosis?

Answer 182

**Endometriosis**

Question 183

A 16y boy presents with central abdominal pain & haematuria for 1 week. He also complains of pain in both knees. Examination reveals a non-blanching purpuric rash on his legs & buttocks. Urine dip shows blood ++ & protein +, kidney function is abnormal. What is the most likely diagnosis? - what is this? List the 4 common presenting features of this condition: What is the management of this condition? What monitoring needs to be done? (2)

Answer 183

**Henoch-Schonlein Purpura** - A type of IgA vasculitis * Purpura (rash on legs → buttocks) * Joint pain (commonly knee's & ankles) * Abdominal pain * Renal impairment **Management:** supportive (analgesia, rest, hydration) ~ most usually resolve within 4-6 weeks. **Monitoring**: needed whilst the disease is still active: • urine dipstick (to monitor renal impairment) • blood pressure (to monitor for hypertension)

Question 184

What 3 things are measured in the combined test during pregnancy? If Down Syndrome was indicated, what results would you expect to see in the above?

Answer 184

``` Nuchal translucency (**increased** in downs) PAPP-A hormone (**decreased** in downs) Beta-hCG hormone (**increased** in downs) ```

Question 185

What pathology is seen in the condition: "**transposition of the great arteries"**? What needs to occur postnatally to make it temporarily compatible with life? - Give examples of 3 things that could occur: This condition is usually detected antenatally. What is given immediately after birth before the baby is transferred for surgical correction? - What does this do?

Answer 185

The pulmonary artery arises from the left ventricle & the aorta arises from the right ventricle (they've swapped) There needs to be a shunt between R & L ventricles so that oxygenated blood goes to systemic circulation 1) patent ductus arteriosus (connection between pulmonary trunk & aorta) 2) atrioseptal defect 3) ventriculoseptal defect **Prostaglandin E** is given - prevents the ductus arteriosus from closing

Question 186

Delayed puberty & *anosmia* (lack of smell) would suggest what condition? What is the physiological cause behind delayed puberty in this condition?

Answer 186

Kallmann's syndrome **Hypogonadotropic hypogonadism:** hypothalamus doesn't secrete enough GnRH to stimulate anterior pituitary to secrete LH & FSH → little testosterone/ oestrogen secreted

Question 187

A 55-year-old concert pianist has a stroke, leaving him with right arm weakness and dysphasia. Which of the following best describes the resultant activity limitation experienced by the patient? * Damage to nerves in right arm * Death of cerebral neurons * Difficulty socialising with friends * Inability to continue his occupation * Loss of normal function in right arm

Answer 187

**Loss of normal function in right arm** *Nerves in the arm are not affected by the stroke. Some cerebral neurons will have died but this is pathology not activity limitation. The other options would be described as participation restrictions resulting from the activity limitation.*

Question 188

A 7m old child presents with recurrent milky vomiting and low weight for age. On further questioning of the primigravida mother, she informs you that the child was born prematurely and she has noticed that the child has a chronic cough and hoarse cry. Examination is unremarkable. What is the likely diagnosis? What is the cause of this in infants? - what age does it usually resolve by? What is the **management** if: a) no effect on growth b) effect on growth

Answer 188

**GORD** Immaturity of the lower oesophageal sphincter - age 1y * *Management:** * No effect on growth:* conservative advice * Effect on growth:* gaviscon mixed with feeds/ omeprazole!

Question 189

A 30 year old female, who is breast feeding, presents to her general practice. She has noticed some **swelling** and **tenderness** of her right **breast**. The pain becomes **worse on breast feeding**. She has had difficulty with breast feeding as her baby has a poor latch when feeding. On examination there is swelling and **erythema in a wedge-shaped distribution** on the right breast. The patient's observations are normal. What is the most likely diagnosis? What are the 2 causes of this condition?

Answer 189

**Mastitis** **Causes:** • blocked milk duct • infection (usually *staph aureus)*

Question 190

A 5y old boy complains of difficulty in hearing. He has had several fractures following minor falls. O/E his legs appear short & deformed and his sclera have a blue tinge. What is the likely diagnosis?

Answer 190

**Osteogenesis imperfecta** (brittle bone disease)

Question 191

In PCOS, would you expect the following to be low, normal or high? 1) Testosterone 2) Sex hormone binding globulin 3) LH 4) FSH 5) Insulin 6) LH:FSH ratio

Answer 191

1) Testosterone - high (insulin promotes release of androgens) 2) Sex hormone binding globulin - low (insulin decreases SHBG production) 3) LH - high 4) FSH - low (low FSH results in follicles not maturing and turning into cysts) 5) Insulin - high (insulin resistance is a feature of PCOS) 6) LH:FSH ratio - high (High LH & low FSH)

Question 192

What age are the first immunisations given at in the UK? What immunisations would you expect a **4month** old to have had? (4) What additional immunisations would you expect a **12month** old to have had? (2) What additional immunisation is given at age **13-14y**? (1) What additional immunisation is given at age **14y**? (1)

Answer 192

2 months old **Up to 4 months:** • Diphtheria, tetanus, polio, pertussis, HepB, H.influenza B • Pneumococcal disease • Meningococcal B • Rotavirus **12 months:** • Meningococcal C • Measles, mumps & rubella **13-14y:** • HPV vaccine (cervical cancer) **14y:** • Meningococcal ACWY

Question 193

What is **primary prevention?** What is **secondary prevention?** What is **tertiary prevention?**

Answer 193

**Primary prevention:** Preventing the onset of an illness **Secondary prevention:** Detection of a disease at an early stage in order to cure it/ lessen the symptoms **Tertiary prevention:** Measures to prevent disability caused by the disease

Question 194

A 14 month old girl presents with 12h of increasing wheeze and respiratory effort and a 3d history of runny nose and cough. Examination shows **bilateral** **wheeze**, no creps and sub-costal recession, a pink throat and red ears. Resp rate of 60 and temperature 37.5c What is the likely diagnosis? Under what age is it commonest in? What is the management?

Answer 194

**Viral induced wheeze** Commonest under 5s (especially under 3y) Management: **salbutamol** (10 puffs!)

Question 195

**Shoulder dystocia** is a medical emergency. This occurs when the shoulder gets stuck behind what structure? What sign is seen when the head is delivered but then retracts back into the vagina? What are the 2 initial management options to deliver the anterior shoulder?

Answer 195

**Pubic symphysis** *Turtle-neck sign* * *Episiotomy** (cutting the perineum to make the vaginal opening larger) * *McRoberts Manoeuvre** (mothers knee's to abdomen - this provides posterior tilt to pelvis, lifting pubic symphysis out of way)

Question 196

What are the 3 criteria *needed* for a diagnosis of **learning difficulty?** What are the 3 main causes of learning difficulty?

Answer 196

**1) Intellectual impairment (IQ \< 70)** **2) Social/ adaptive dysfunction** (eg deficits in communication/ self-care, social skills etc) **3) Onset before 18y (whilst brain is still developing)** 1) Head injury 2) Chromosomal abnormalities (eg Downs) 3) Congenital abnormalities (eg infection/ abnormal brain development)

Question 197

Which of the following would not be described as a physical hazard? * Air pollution * Radiation * Machinery * Noise * Vibration

Answer 197

**Machinery** *Machinery is categorised as a mechanical hazard.*

Question 198

What is the management of **mastitis** if it is caused by: a) blocked milk duct b) infection If an infective cause of mastitis is suspected, how is it diagnosed? What is a complication if an infective mastitis isn't treated?

Answer 198

**Blocked milk duct:** conservative - analgesia & continuation of breastfeeding **Infection:** antibiotics: **flucloxacillin** is 1^st line + continuation of breast feeding *Milk sample* is sent to lab for culture & sensitivities **Breast abscess** (requires surgical inscision & drainage!)

Question 199

What direction is blood shunted in a ventricular-septal defect? What pathology can occur over time if a ventricular-septal defect isnt corrected? What causes this? What condition does this result in and why? What clinical sign will be seen when this happens?

Answer 199

L→R ventricle Increased blood in R ventricle → increased blood (and thus pressure) in pulmonary circulation → pulmonary hypertension Pulmonary hypertension causes Eisenmenger syndrome: pressure in R ventricle is higher than L which causes blood to be shunted from R→L Central cyanosis (more blood is bypassing the lungs)

Question 200

What hormone stimulates milk production? What hormone stimulates milk contraction? (by contracting myoepithelial cells within the breast)

Answer 200

Prolactin Oxytocin

Question 201

List some features of **Crohn's**: (NESTS) +2

Answer 201

→ **_N_**O blood/ mucus (uncommon) → **_E_**ntire GI tract → **_S_**kip lesions on endoscopy → **_T_**erminal ileum most affected & **_T_**ransmural thickness of inflammation → **_S_**moking = risk factor → Weight loss → Structures/ fistulas

Question 202

Interpret the following: G3 P1

Answer 202

3 pregnancies of which only 1 has been delivered past 24 weeks gestation

Question 203

What is the medical management of an ectopic pregnancy? - how long after treatment is it advised to avoid pregnancy? What are the 2 surgical options of ectopic termination? ~ which one is 1st/ 2nd line

Answer 203

* *Medical:** * **Methotrexate IM*** - avoid pregnancy for 3 months due to teratogenic effects! **Surgical: *1^st line:***Laparoscopic salping**E**ctomy ~ removal of whole affected fallopian tube ***2^nd line:*** Laparoscopic salping**O**tomy ~ removal of only ectopic, fallopian tube is left

Question 204

What is an **episiotomy?**

Answer 204

**Episiotomy:** a cut is made in the perineum to avoid perineal tears during labour

Question 205

Which of these interventions is an example of Tertiary Prevention? * Checking PSA levels in someone with a family history of prostatic cancer * Dalteparin injections prior to an operation to prevent a deep vein thrombosis * Joint replacement in severe osteoarthritis of the hip * Mammogram to detect asymptomatic breast lump * Warming up adequately before engaging in sport

Answer 205

**Joint replacement in severe osteoarthritis of the hip** *Tertiary prevention attempts to reduce the impact of an established disease or disability. Joint replacement in osteoarthritis is the only option which corresponds to this. The others are examples of primary and secondary prevention.*

Question 206

A 61-year-old man has end stage multiple sclerosis. He is very weak and unable to walk. He sometimes aspirates food, causing significant distress and recurrent pneumonia. During a GP home visit, he expresses a wish to die and asks whether his GP would be willing to help him to end his life. How should the GP respond? * Advise him that it is against their beliefs and decline to discuss it further * Advise him that it is illegal and not for further discussion * Advise him that people have travelled abroad to do it, because it is illegal in the UK * Encourage him to discuss it further and explore the reasons for his request * Inform his family of his wish to die so that they are fully informed

Answer 206

**Encourage him to discuss it further and explore the reasons for his request** ## Footnote *Enabling discussion will allow the GP to find out details about the main concerns of the patient and address symptom control better.*

Question 207

What type of bilirubin is **always** abnormal in infants? When ordering LFT's, what should you order specificially to determine the cause of jaundice? What would you expect the stools of a baby with biliary atresia (obstruction of bile flow) to look like?

Answer 207

**Conjugated bilirubin!!** Split bilirubin Pale, chalky white stools

Question 208

Very high levels of bilirubin in infants can cause what serious condition? What type of bilirubin causes this condition & why? What is the treatment of raised unconjugated bilirubin levels? If untreated, what can this result in?

Answer 208

**Kernicterus** Unconjugated bilirubin - it's fat soluble so can cross the BBB whereas conjugated bilirubin is water soluble so cannot cross the BBB Phototherapy (babies are placed under blue light) Encephaloptahy (seizures)/ cerebral palsy

Question 209

Explain the pathology in each miscarriage & say whether miscarriage is certain or not: a) Threatened miscarriage b) Inevitable miscarriage c) Complete miscarriage d) Missed miscarriage

Answer 209

**a) Threatened miscarriage:** Mild bleeding, mild/ no pain, cervical os is closed, foetus present intrauterine - Miscarriage may or may not occurr **b) Inevitable miscarriage:** Heavy bleeding, pain, cevical os is open, foetus currently present intrauterine - Miscarriage is inevitable **c) Complete miscarriage** +/- bleeding/ pain, cevical os closed, NO products of conception intrauterine anymore (all have been expelled) - Miscarriage has already occurred **d) Missed miscarriage** Asymptomatic, cevical os closed, foetus currently present intrauterine but is dead

Question 210

What method is used in **primary prevention** of cervical cancer in the UK? What method is used in **secondary prevention** of cervical cancer in the UK? What 2 strains of HPV are associated with cervical cancer?

Answer 210

**HPV** vaccine to 12-14y olds **Smear tests** - every 5 years between 25-64y **Strains 16, 18**