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Question 1
Incorrect
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In the foetus where is the principle site of alpha fetoprotein (AFP) production
Your Answer: Yolk Sac
Correct Answer: Liver
Explanation:AFP is a glycoprotein that is synthesized in the fetal liver (primarily), umbilical vesicles and the gut. It is found in elevated quantities in the fetal serum and peaks at around 14 week of gestation.
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This question is part of the following fields:
- Biochemistry
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Question 2
Incorrect
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Which vitamin deficiency leads to Wernicke's encephalopathy?
Your Answer: B6
Correct Answer: B1
Explanation:Vitamin B1 deficiency can lead to Wernicke’s encephalopathy. Alcoholics are at particular risk. In obstetrics all women with hyperemesis gravidarum should receive thiamine supplementation to prevent Wernicke’s.
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This question is part of the following fields:
- Clinical Management
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Question 3
Incorrect
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Which of the following muscles does NOT receive innervation from the pudendal nerve?
Your Answer:
Correct Answer: Internal anal sphincter
Explanation:The internal anal sphincter is innervated by the splanchnic nerves. Sympathetic nerve supply from the inferior hypogastric plexus (for contraction) and parasympathetic supply from nervi erigentes (for relaxation).
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This question is part of the following fields:
- Anatomy
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Question 4
Incorrect
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Regarding the rectus sheath which of the following statements are true?
Your Answer:
Correct Answer: Above the arcuate line the internal oblique divides into two lamellae
Explanation:The rectus sheath is formed by the aponeurosis of the internal and external oblique muscles and the transversus abdominus muscle. The internal oblique divides into two lamellae and encloses the rectus muscle. Anteriorly it fuses with the aponeurosis of the external oblique and posteriorly with that of the transverus abdominus. Below the arcuate line the aponeurosis of all the flat muscles lies anteriorly and posteriorly it is only enclosed by the transveralis fascia.
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This question is part of the following fields:
- Anatomy
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Question 5
Incorrect
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A 26 year old patient sustains a 4th degree perineal tear following delivery of her 1st baby. Your consultant agrees to supervise you repair the tear. From the list below what is the most appropriate suture option for repairing the anal mucosa?
Your Answer:
Correct Answer: 3-0 polyglactin interrupted sutures
Explanation:Repair the vaginal mucosa using rapidly absorbed suture material on a large, round body needle. Start above the apex of the cut or tear (as severed vessels retract slightly) and use a continuous stitch to close the vaginal mucosa.
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This question is part of the following fields:
- Clinical Management
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Question 6
Incorrect
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Evidence from meta-analysis of RCTs is what level of evidence?
Your Answer:
Correct Answer: Ia
Explanation:The levels of evidence range from I-IV:
1a: Systematic reviews (with homogeneity) or metanalysis of randomized controlled trials: highest level of evidence.
1b: Individual randomized controlled trial (with narrow confidence interval)
1c: All or none randomized controlled trials
2a: Systematic reviews (with homogeneity) of cohort studies
2b: Individual cohort study or low quality randomized controlled trials (e.g. <80% follow-up)
2c: Outcomes Research; ecological studies
3a: Systematic review (with homogeneity) of case-control studies
3b: Individual case-control study
4: Case series (and poor quality cohort and case-control studies)
5: Expert opinion without explicit critical appraisal, or based on physiology, bench research or first principles. -
This question is part of the following fields:
- Epidemiology
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Question 7
Incorrect
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Which of the following causes an increase in Sex Hormone Binding Globulin (SHBG)?
Your Answer:
Correct Answer: Liver cirrhosis
Explanation:Liver cirrhosis is known to lead to decreased levels of SHBG. Other causes of high SHBG are:
Oestrogens e.g. oral contraceptives
Pregnancy
Hyperthyroidism
Liver cirrhosis
Anorexia nervosa
Drugs e.g. anticonvulsants -
This question is part of the following fields:
- Endocrinology
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Question 8
Incorrect
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A 35-year-old African female presents with a history of heavy menstrual bleeding and dysmenorrhoea for 4 months. Which of the following could be the most likely cause for this presentation?
Your Answer:
Correct Answer: Fibroid
Explanation:History of heavy menstrual bleeding and amenorrhoea favour the diagnosis of a fibroid uterus. All the given responses are causes for subfertility. Ectopic pregnancy presents with abdominal pain has an acute presentation. Endometriosis and adenomyosis usually don’t present with amenorrhoea or heavy bleeding respectively. PID presents with chronic pelvic pain and is not related to menstruation.
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This question is part of the following fields:
- Gynaecology
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Question 9
Incorrect
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A 43-year-old woman, with a history of bilateral tubal ligation, presents with regular but excessively heavy periods. She has a history of multiple uterine leiomyoma and her uterus is the size of a 12-week pregnancy.
Pap smear is normal; haemoglobin level is 93 g/L. She underwent dilatation and curettage 8 months ago but it did not result in symptom improvement nor was it able to find the underlying cause of her symptoms.
Which is the best next step in her management?Your Answer:
Correct Answer: Total abdominal hysterectomy
Explanation:Oral progestogen therapy for 21 days (day 5-26) is considered effective but is only a short-term therapy for menorrhagia. Myomectomy should only be considered if the woman would like to conceive later on. Due to the recurrent nature of fibroids, it is likely that the woman would need more surgeries in the future, which is not ideal. Furthermore, if there is a large number of fibroids or the size of the fibroids are large, myomectomy would not be an option for reasons such as the feasibility. If myomectomy for multiple fibroids prove to be unsuccessful, the ultimate outcome would still have to be a hysterectomy.
In cases where there is significant enlargement of the uterus, endometrial ablation would be difficult and the long-term cure rate of symptoms would be considerably low. The best next step would be a total abdominal hysterectomy since it would solve her menorrhagia and within a few years’ time, she would be expected to attain menopause anyway. Ponstan or mefenamic acid has been found to be superior to tranexamic acid for menorrhagia. However, it can still prove to be ineffective in some cases and also not a long term solution.
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This question is part of the following fields:
- Gynaecology
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Question 10
Incorrect
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Among the below given options, which is NOT associated with an increased risk for preeclampsia?
Your Answer:
Correct Answer: Age between 18 and 40 years
Explanation:Any new onset of hypertension associated with proteinuria after 20 weeks of gestation in a previously normotensive woman is referred to as Preeclampsia.
Most commonly found risk factors for pre-eclampsia are:
– Preeclampsia in a previous pregnancy
– Family history of preeclampsia
– a prior pregnancy with poor outcome like placental abruption, IUGR, fetal death in utero, etc
– An interdelivery interval greater than 10 years
– Nulliparity, increases risk by 8 times
– Pre-existing chronic medical conditions or chronic hypertension
– pre-existing or gestational Diabetes
– chronic Renal disease
– Thrombophilias g. protein C and S deficiency, antithrombin Ill deficiency, or Factor V Leiden mutation
– Antiphospholipid syndrome
– Systemic lupus erythematous
– Maternal age greater than or equal to 40 years
– Body Mass Index (BMI) greater than 30 kg/m2
– Multiple pregnancy
– Raised blood pressure at booking
– Gestational trophoblastic disease
– Fetal triploidyMaternal age between 18 and 40 years is found to be associated with a decreased risk for developing preeclampsia, and not an increased risk.
NOTE– Previously, age 16 years or younger was thought to be a risk factor for developing preeclampsia; however, recent studies conducted had failed to establish any meaningful relationship between the two. -
This question is part of the following fields:
- Obstetrics
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Question 11
Incorrect
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Which of the following is/are needed by women in increased amounts during pregnancy?
Your Answer:
Correct Answer: All of the options given
Explanation:The nutritional status of a woman before and during pregnancy is important for a healthy pregnancy outcome. Pregnancy is a state of increased requirement of macro and micronutrients, and malnourishment or inadequate dietary intake before and during pregnancy, can lead to adverse perinatal outcomes. Many nutritional interventions have been proposed for pregnant mothers. These include multiple micronutrients (MMN), iron/folate, balanced protein energy, calcium, zinc and folic acid supplementation.
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This question is part of the following fields:
- Physiology
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Question 12
Incorrect
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You see a patient in antenatal clinic who is concerned that she has never had chicken pox and may catch it during pregnancy. You check her Varicella status and she is non-immune. She asks you about vaccination. What type of vaccine is the varicella vaccine?
Your Answer:
Correct Answer: Attenuated
Explanation:Varicella is a live vaccine. The recent RCOG green top guidelines suggest vaccine can be considered postpartum or pre pregnancy but NOT whilst pregnant. In the non-immune pregnant woman they should be advised to avoid contact with people with chickenpox or shingles and to contact a healthcare professional promptly if exposed. If they have a significant exposure VZIG should be offered as soon as possible.
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This question is part of the following fields:
- Immunology
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Question 13
Incorrect
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A 25-year old woman presented to the medical clinic for her first prenatal check-up. Upon interview, the patient revealed that she has been smoking one pack of cigarettes per day for the past five years.
All of the following are considered correct regarding the disadvantages of smoking during pregnancy, except:Your Answer:
Correct Answer: Increased risk of developing small teeth with faulty enamel
Explanation:Small teeth with faulty enamel is more associated with fetal alcohol syndrome (FAS).
In FAS, the most common orofacial changes are small eyelid fissures , flat facies, maxillary hypoplasia, short nose, long and hypoplastic nasal filter, and thin upper lip. The unique facial appearance of FAS patients is the result of changes in 4 areas: short palpebral fissures, flat nasal bridge with an upturned nasal tip, hypoplastic philtrum with a thin upper vermillion border, and a flat midface. Other facial anomalies include micrognathia, occasional cleft lip and/or palate and small teeth with defective enamel.
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This question is part of the following fields:
- Obstetrics
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Question 14
Incorrect
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Which of the following has been shown to improve pruritus and liver function in patients with obstetric cholestasis?
Your Answer:
Correct Answer: Ursodeoxycholic acid
Explanation:Intrahepatic cholestasis characterized by reversible cholestasis typically occurring in the second or third trimester of pregnancy, elevated serum aminotransferases and bile acid level and resolution of symptoms by 2 to 3 weeks after delivery. Ursodeoxycholic acid has shown to reduce the symptoms of this condition.
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This question is part of the following fields:
- Clinical Management
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Question 15
Incorrect
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A 20-year-old female university student, who has never been sexually active, requests advice regarding contraception in view of wanting to start being sexually active.
Which contraceptive option would be most appropriate?Your Answer:
Correct Answer: The OCP and a condom.
Explanation:This patient should be advised to use both an OCP and a condom. The combined oestrogen/progestogen contraceptive pill (COCP) has been found to be very effective. However, she should be made aware that it would not provide any protection from any sexually transmitted diseases so she might still be at risk of developing a STD, depending on her sexual partner preferences. To ensure protection from STDs, she should be advised to use both condoms as well as the combined OCP. An IUCD (intrauterine contraceptive device) would not be preferable if she has multiple sexual partners (high risk of STDs). If she has been screened for STDs, does not actively have an STD and has only one sexual partner then IUCD is a possible option. Some issues that may arise with spermicide use could be related to compliance. This also applies to using condoms alone. These two options are less reliable as compared to COCP.
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This question is part of the following fields:
- Gynaecology
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Question 16
Incorrect
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A 31-year-old female patient seeks your opinion on an abnormal Pap smear performed by a nurse practitioner at a family planning facility. A high-grade squamous intraepithelial lesion is visible on the Pap smear (HGSIL).
Colposcopy was performed in the office. The impression is of acetowhite alterations, which could indicate infection by HPV. Chronic cervicitis is present in your biopsies, but there is no indication of dysplasia.
Which of the following is the most suitable next step in this patient's care?Your Answer:
Correct Answer: Conization of the cervix
Explanation:When cervical biopsy or colposcopy doesn’t explain the severity of the pap smear results cone biopsy is done. In 10% of biopsies, results will be different from that of the pap smear as in this patient with pap smear showing HSIL and colposcopy showing chronic cervicitis.
In such cases conization is indicated. Repeating the pap smear could risk prompt management of a serious problem. No destructive procedure, ablation or cryotherapy, should be done before diagnosis is certain.
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This question is part of the following fields:
- Gynaecology
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Question 17
Incorrect
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Hypemesis gravidarum occurs in what percentage of pregnancies?
Your Answer:
Correct Answer: 1.50%
Explanation:Nausea and vomiting experienced in 80% of pregnancies Hyperemesis gravidarum (HG) is an extreme form of nausea and vomiting which affects around 1.5% of women. Caused by high levels HCG. Definitions vary but most consider it to be defined by severe nausea and vomiting associated with weight loss greater than 5% of pre-pregnancy weight with metabolic disturbance (typically dehydration and/or ketosis).
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This question is part of the following fields:
- Clinical Management
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Question 18
Incorrect
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Which of the following dugs is a strong inducer of cytochrome P450?
Your Answer:
Correct Answer: Phenytoin
Explanation:It is important to be aware of which ant-epileptics induce cytochrome P450. Of the above Topiramate and Phenytoin are moderate and strong inducers respectively.
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This question is part of the following fields:
- Clinical Management
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Question 19
Incorrect
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Which one of the following has the most significant effect on slowing drug metabolism in pregnancy?
Your Answer:
Correct Answer: Progesterone effect on gastric motility
Explanation:Progesterone down regulates gastric motility meaning drugs are absorbed and metabolised more slowly, thus drugs are absorbed, metabolised and cleared more slowly. Most of the drugs are transported after binding to the albumin.
Lower albumin levels mean a greater unbound drug fraction but as this may be thought to increase drug concentrations it actually leaves more available for hepatic clearance or renal excretion so overall drug concentrations are unchanged and metabolism increased.
Increase in hepatic flow will increase the metabolism of the drug as the drug will be transported faster.
Increased renal blood flow will result in the faster clearance of the drug from the body. -
This question is part of the following fields:
- Clinical Management
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Question 20
Incorrect
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A 30 year old woman with a history of two previous C section deliveries, is rushed to the hospital for an emergency c-section at 36 weeks gestation due to antenatal haemorrhage. Upon examination of the uterus, the placenta has invaded the myometrium but the serosa is spared. Which of the following identifies this condition?
Your Answer:
Correct Answer: Placenta Increta
Explanation:Abnormal placental adherence to the uterus, generally termed Placenta Accreta, is divided into 3 conditions.
– Placenta accreta: refers to the invasion of the chorionic villi beyond the decidual surface of the myometrium.
– Placenta increta: the villi invade deep into the myometrium but spare the serosa;
– Placenta percreta: the chorionic villi invade through the myometrium, penetrate the uterine serosa, and may invade surrounding pelvic structures.These conditions can predispose patients to obstetric bleeding in the third trimester, often requiring emergency intervention.
Risk factors in the development of an abnormal placental adherence include previous c-sections. Placenta Previa, is also a cause of antepartum haemorrhage and serves as a risk factor in the development of abnormal placental adherence.
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This question is part of the following fields:
- Clinical Management
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Question 21
Incorrect
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Regarding Venous Thromboembolism (VTE) in pregnancy which of the following statements is TRUE?
Your Answer:
Correct Answer: Relative risk of VTE in pregnancy is 4 to 6 fold
Explanation:Venous thromboembolic disease (VTE) is the most common cause of direct maternal death in the UK. In the most recent triennium, there were 41 fatalities, giving a maternal mortality rate of 1.94 per 100 000 – more than twice that of the next most common cause, pre-eclampsia. As pregnancy is a hyper coagulable state. There are alterations in the fibrinolytics and thrombotic pathways. There is also an increased production of clotting factors during pregnancy.
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This question is part of the following fields:
- Clinical Management
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Question 22
Incorrect
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Among the following, which is the most common method used for termination of a pregnancy before 20 weeks in Australia?
Your Answer:
Correct Answer: Suction and curettage
Explanation:Medical abortion is preferred from 4 to 9 weeks of gestation and in Australia, suction curettage is the most frequently used method of abortion as it is considered useful from 6 to 14 weeks of gestation.
Mifepristone is a synthetic anti-progesterone, which is found to be effective for abortion when combined with misoprostol. There are evidences which suggest the effectiveness of misoprostol and mifepristone in both first and second trimesters. It is most commonly administered as a single dose of mifepristone followed by misoprostol, a prostaglandin, given orally or vaginally two days later. Prostaglandin can be repeated at an interval of 4 hours if required.
As the vaginal use shows only few gastrointestinal side effects Misoprostol is more effective and better tolerated vaginally than orally. Misoprostol is not approved for its use in termination of pregnancy, but is available in the market due to its indications in other conditions.
Methotrexate can be used orally or as an intramuscular injection followed by misoprostol up to seven days later, but this also is not a preferred method for termination of pregnancy in Australia. -
This question is part of the following fields:
- Obstetrics
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Question 23
Incorrect
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The following ultrasonic measurements may be used to confirm or establish gestational age:
Your Answer:
Correct Answer: Crown rump length
Explanation:Fetal ultrasound scanning is considered an essential part of routine antenatal care with first trimester scans recommended for confirming viability, accurate estimation of gestational age and determining the number of foetuses. Fetal crown-rump length (CRL) is measured in early pregnancy primarily to determine the gestation age (GA) of a foetus and is most reliable between 9+0 to 13+6 weeks’ gestation, but not beyond.
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This question is part of the following fields:
- Physiology
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Question 24
Incorrect
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Which of the following is true about the origin of the ovarian artery?
Your Answer:
Correct Answer: It arises from the Abdominal Aorta
Explanation:The ovarian arteries are considered the main blood supply for the ovaries. The ovarian arteries usually arise from the lateral aspect of the abdominal artery, though in some instances they may arise from the renal or iliac arteries.
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This question is part of the following fields:
- Anatomy
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Question 25
Incorrect
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Fetal immunoglobulin production begins at what gestation?
Your Answer:
Correct Answer: Week 10
Explanation:Fetal production of immunoglobulin begins early on, at about 10 weeks gestation with the production of IgM antibodies. Maternal IgG, which is a key component of fetal immunity, is passed on to the foetus through the placenta from 12 weeks of gestation. Secretory IgA is not produced until after birth.
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This question is part of the following fields:
- Immunology
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Question 26
Incorrect
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With regard to the cell cycle. In which part of the cycle does DNA replication occur?
Your Answer:
Correct Answer: Interphase
Explanation:DNA replication occurs during S phase but that isn’t one of the options. Remember Interphase comprises G1,S and G2 phases!
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This question is part of the following fields:
- Biochemistry
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Question 27
Incorrect
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Due to her inability to conceive, a 28-year-old nulligravid lady comes to the office with her husband. The patient and her spouse had been having intercourse every other day since they stopped using barrier contraception a year ago. Every 28 days, the patient experiences a 5-day period with two days of high flow. She has transient pelvic pain 14 days after her menstruation begins, but intercourse is painless.
The patient was admitted to the hospital in her late teens for a pelvic infection, and she had discomfort with intercourse, discharge, and fever during her stay. She hasn't had any previous medical or surgical procedures. Her younger sibling suffers from polycystic ovarian syndrome. The patient's husband is 32 years old, has no children, and a normal semen analysis. The patient has a blood pressure of 130/80 mm Hg and a pulse rate of 86 beats per minute. There are no anomalies on physical examination.
Which of the following is the most appropriate next step in this patient's care?Your Answer:
Correct Answer: Hysterosalpingogram
Explanation:Primary infertility is defined as the inability to conceive after a year of unprotected, timed sexual intercourse in a nulliparous patient under the age of 35. (After 35 years of age, infertility testing can begin after 6 months.) Because the patient’s partner’s sperm analysis is normal, female factor infertility is the most likely explanation. This patient’s adolescent hospitalizations are likely due to pelvic inflammatory disease (PID), a common cause of infertility caused by tubal scarring and blockage.
A hysterosalpingogram, which includes infusing radiocontrast into the cervix under fluoroscopy, is the first-line imaging technique for determining fallopian tube patency. A hysterosalpingogram is a non-invasive procedure that can detect uterine cavity irregularities (e.g., bicornuate uterus).
Peritoneal adhesions and endometriosis can be seen and treated directly using laparoscopy.
PID-related scarring inside the fallopian tubes can be assessed by laparoscopy with chromotubation; however, it is invasive, expensive, and not utilized first-line.
Ovulation is detected using a mid-cycle LH level. The LH surge can be detected in urine and serum 36 hours before ovulation. Regular menstrual periods are characterized by mittelschmerz (mid-cycle pelvic pain), which indicates ovulation. As a result, an LH level would be useless.
Ovarian reserve begins to deteriorate around the age of 35, and serum FSH levels rise in women who are losing their ability to ovulate. Because this patient is much younger and has regular periods, a drop in ovum quantity is unlikely to be the reason for infertility.
Increased serum androgen levels can prevent ovulation by inhibiting the release of GnRH and FSH through feedback inhibition. The patient has regular cycles and no hyperandrogenic symptoms, despite her sister having polycystic ovarian syndrome (e.g., hirsutism, irregular menses).
In a nulliparous patient under the age of 35, primary infertility is defined as the inability to conceive after a year of unprotected sexual intercourse. A hysterosalpingogram is used to determine the cause of infertility, such as tubal blockage caused by a previous pelvic infection.
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This question is part of the following fields:
- Gynaecology
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Question 28
Incorrect
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Which is the most useful tumour marker for monitoring of ovarian cancer patients?
Your Answer:
Correct Answer:
Explanation:CA-125 has found application as a tumour marker or biomarker that may be elevated in the blood of some patients with specific types of cancers, or other conditions that are benign. Increased level of CA125 appears in fifty percent of stage 1 ovarian cancer patients and more than 90% with stages 2-4 ovarian cancer. CA-125 is therefore a useful tool for detecting ovarian cancer after the onset of symptoms as well as monitoring response to treatment and for predicting a patient’s prognosis after treatment.
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This question is part of the following fields:
- Gynaecology
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Question 29
Incorrect
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Regarding Human Papillomavirus, what percentage of women develop antibodies?
Your Answer:
Correct Answer: 50%
Explanation:Human Papillomavirus has been is implicated in the development of genital warts as well as, head and neck, anogenital and cervical cancers, with the most important high-risk strains being 16 and 18. Over 50% of women worldwide are thought to possess antibodies against various strains of HPV after natural infection. Many infections are asymptomatic and are cleared within 2 years. Several vaccines have been formulated against HPV, one of which is Gardasil, a quadrivalent vaccine against HPV types 6,11, 16,18.
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This question is part of the following fields:
- Microbiology
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Question 30
Incorrect
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A 18-year-old girl arrives at the ER with severe abdominal pain. When it started, she was in the school band. She says the pain began 30 minutes ago in the left lower region and didn't radiate. On a scale of 1 to 10, the discomfort is a 7 and is not accompanied by nausea, vomiting, or diarrhoea. Menarche began at the age of thirteen. Her menses were erratic at first, but she has had regular periods for the past six months.
Her vital signs are stable, and she has no fever. She uses combination oral contraceptives and is sexually active. She denies taking any other drugs. A flat abdomen with regular peristalsis is revealed on physical examination. Pelvic examination indicates a regular vagina with a normal-appearing cervix. There is no mucopurulent cervical discharge. Bimanual examination is remarkable with a tender 5-cm mass in the left adnexa.
A pregnancy test result is negative. A pelvic sonogram exhibits a normal intrauterine pregnancy and a 5 X 6 cm complex mass of the left ovary, with focal areas of calcification.
Which of the following is the most likely diagnosis?Your Answer:
Correct Answer: Cystic teratoma
Explanation:Mature cystic teratomas of the ovary are often discovered as incidental findings on physical examination, during radiographic studies, or during abdominal surgery performed for other indications.
Most mature cystic teratomas can be diagnosed at ultrasonography (US) but may have a variety of appearances, characterized by echogenic sebaceous material and calcification.
Follicular cysts are simple fluid-filled cysts and never have calcifications.
Mucinous cystadenoma usually develop in the third to fifth decades of life and typically cause vague symptoms, such as increasing abdominal girth, abdominal or pelvic pain, emesis, fatigue, indigestion, constipation, and urinary incontinence However, calcifications are not usually seen.
Brenner tumour is also a benign epithelial ovarian tumour but it is solid, occurring most often in women over 50 years of age.
Serous cystadenoma also does not show calcifications.
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This question is part of the following fields:
- Gynaecology
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Question 31
Incorrect
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Question 32
Incorrect
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A fibroid is a type of
Your Answer:
Correct Answer: Leiomyoma
Explanation:A fibroid is a benign smooth muscle tumour or Leiomyoma. As such it is something of a misnomer. Leiomyosarcoma and Angioleiomyoma are malignant tumours of smooth muscle under the WHO sort tissue tumour classification Rhabdomyoma is a skeletal muscle tumour Myofibroma is seen in fibromatosis
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This question is part of the following fields:
- Clinical Management
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Question 33
Incorrect
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Endometrial tissue found within the myometrium is classed as
Your Answer:
Correct Answer: Adenomyosis
Explanation:Endometrial tissue found within the myometrium is Adenomyosis. If endometrial tissue is found at a distant site to the uterus it is termed endometriosis. Fibroids are smooth muscle tumours (Leiomyoma’s) sometimes called myoma’s.
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This question is part of the following fields:
- Clinical Management
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Question 34
Incorrect
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A woman comes to your office two weeks after undergoing a total vaginal hysterectomy with anterior colporrhaphy and the Burch surgery for uterine prolapse and stress urine incontinence.
Throughout the day, she complains of a continual loss of urine. She denies having any dysuria or urgency. Which of the following is the most likely cause of the problem?Your Answer:
Correct Answer: Vesicovaginal fistula
Explanation:Vesicovaginal fistula (VVF) is a subtype of female urogenital fistula (UGF). VVF is an abnormal fistulous tract extending between the bladder and the vagina that allows the continuous involuntary discharge of urine into the vaginal vault. The uncontrolled leakage of urine into the vagina is the hallmark symptom of patients with UGFs. Patients may complain of urinary incontinence or an increase in vaginal discharge following pelvic surgery or pelvic radiotherapy with or without antecedent surgery. The drainage may be continuous; however, in the presence of a very small UGF, it may be intermittent. Increased postoperative abdominal, pelvic, or flank pain; prolonged ileus; and fever should alert the physician to possible urinoma or urine ascites and mandates expeditious evaluation. Recurrent cystitis or pyelonephritis, abnormal urinary stream, and haematuria also should initiate a workup for UGF.
Urinary trace infection presents with dysuria and urgency.
Detrusor instability causes urge incontinence.
Neurogenic bladder from diabetic neuropathy would also have urgency. -
This question is part of the following fields:
- Gynaecology
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Question 35
Incorrect
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A 35-year-old Aboriginal woman is found to be lgM positive, but lgG negative after exposure to a child with rubella during the first trimester of pregnancy.
On laboratory investigation, rubella infection is confirmed as repeated serology testing shows not only a positive lgM, but also a rising titers of lgG.
Among the following next steps in management, which one is considered to be the most appropriate?Your Answer:
Correct Answer: Termination of the pregnancy
Explanation:Antenatal screening for rubella IgG is a routine recommended for all pregnant women at their first visit. All pregnant women who have a history of contact with rubella or any clinical features consistent with rubella –like illness should be screened for the presence of rising antibody titre and / or rubella specific IgM. Serological confirmation is mandatory for diagnosing rubella.
As in this case scenario, positive lgM for rubella indicates active rubella infection, in such cases it is recommended to repeat the test. If lgM is still positive, it confirms rubella infection. No further testing from another laboratory is required.
The risk for fetal infection and damage is higher if rubella infection occurs during the first trimester of pregnancy, which is 85% in the first two months of pregnancy and 50 -80% in the third month. Therefore, termination of pregnancy is usually recommended in this situation. NHIG has been used in trials for prophylaxis and prevention of congenital rubella syndrome after contact to a case with rubella infection, but the results have been discouraging, therefore, it is not advisable.
In the given case, rubella infection has been established already, so NHIG will not be of any benefit as primary prevention.
Rubella-containing vaccines like MMR vaccine is a live attenuated vaccine are contraindicated throughout pregnancy, it should be avoided; and women who remain susceptible to rubella should receive MMR vaccine postpartum.
Risk of fetal infection and/or fetal damage or for development of congenital rubella syndrome is related to the timing of maternal infection. Cases with Primary infection is found to be in higher risk
In cases of asymptomatic re-infection with a good history of previous positive serology, even though it is difficult to quantify, the risk of fetal infection has been reported to be < 5 percent. Congenital rubella syndrome following maternal re-infection is considered rare particularly if re-infection occurs after 12 weeks. If the clinical picture is typically of rubella or if possibility of previous immunity is inconclusive based on serology, then the risk is assumed to be the same as that of primary infection. -
This question is part of the following fields:
- Obstetrics
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Question 36
Incorrect
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A Bicornuate uterus is due to which of the following?
Your Answer:
Correct Answer: Abnormal fusion and reabsorption of the paramesonephric ducts
Explanation:A Bicornuate uterus (heart shaped) is the result of abnormal fusion and reabsorption of the paramesonephric ducts during embryogenesis. Mullerian agenesis typically results in failure to form a uterus. Mullerian duct fusion abnormalities can cause a bicornuate malformation. PKD-1 gene abnormalities are associated with PCOS. Crossed fused ectopia result in Horseshoe kidney.
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This question is part of the following fields:
- Embryology
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Question 37
Incorrect
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An 18-year-old woman came into your office looking for contraception assistance. Her new partner and she are arranging a trip to Thailand. She has no contraindications.
What is the best piece of advice?Your Answer:
Correct Answer: Oral contraceptive pills and condoms
Explanation:OCPs should be started in this patient as well as condoms to prevent likely sexually transmitted infections.
Condoms alone are not effective for prevention of pregnancy.
OCPs alone do not prevent from sexually transmitted infections.
It is not appropriate to inform the parents and the patient hasn’t refused any advice.
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This question is part of the following fields:
- Gynaecology
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Question 38
Incorrect
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What percentage of pregnant women have asymptomatic vaginal colonisation with candida?
Your Answer:
Correct Answer: 40%
Explanation:Vulvovaginal candidiasis is the most common genital infections and it is caused by candida albicans in 80-92% of the cases. It colonise the vaginal flora in 20% of non pregnant and 40% pregnant women.
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This question is part of the following fields:
- Clinical Management
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Question 39
Incorrect
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A pregnant patient with a chest infection is worried about the radiation risk of a chest X Ray. How many days of natural background radiation is equivalent to a chest X Ray?
Your Answer:
Correct Answer: 2.5
Explanation:X-rays carry low levels of risk during pregnancy and are not a significant cause for concern if the total exposure to ionising radiation is less than 5 rads throughout the pregnancy; a chest X-ray is about 0.00007 rads. The amount of radiation generated from a chest X-ray is equivalent to 2.4 days of natural background radiation. Non-urgent radiological tests should, however, be avoided between 10-17 weeks gestation as there is a higher risk of central nervous system teratogenesis during this time.
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This question is part of the following fields:
- Biophysics
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Question 40
Incorrect
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After a vaginal delivery, a patient suffers a perineal tear. On examination the laceration involves the external anal sphincter and has partially torn the internal anal sphincter. Which of the following classifies this tear?
Your Answer:
Correct Answer: 3c
Explanation:During childbearing the vagina and perineum are prone to lacerations that may involve the skin or can extend into the anal sphincter complex. It is important to be able to identify obstetric and anal sphincter injuries to provide adequate care and prevent complications. In the classification of obstetric tears according to RCOG guidelines:
First degree tear: injury to the perineal skin and/or the vaginal mucosa
Second degree tears: Injury to perineum involving perineal muscles but not the anal sphincter.
Third-degree tear: Injury to perineum involving the anal sphincter complex:
Grade 3a tear: Less than 50% of external anal sphincter (EAS) thickness torn.
Grade 3b tear: More than 50% of EAS thickness torn.
Grade 3c tear: Both EAS and internal anal sphincter (IAS) torn.
Fourth-degree tear: Injury to perineum involving the anal sphincter complex (EAS and IAS)
and anorectal mucosa. -
This question is part of the following fields:
- Anatomy
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Question 41
Incorrect
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Question 42
Incorrect
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Which of the following tests is used to detect antibodies or complement bound to red blood cell antigens in vivo?
Your Answer:
Correct Answer: Direct Coombs
Explanation:When the red cells are coated with immune IgG antibody, the cells do not agglutinate but when anti-IgG antiserum is added to these sensitized cells visible agglutination occurs. This is known as a positive direct coombs test.
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This question is part of the following fields:
- Physiology
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Question 43
Incorrect
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A 24-year-old woman comes to your office at 38 weeks of gestation with a urinary dipstick result positive for leukocyte and nitrite. She is otherwise asymptomatic so you send her urine for culture and sensitivity test.
From the options below mentioned, which is the next best management for her?Your Answer:
Correct Answer: Prescribe her with Oral Cephalexin
Explanation:There is an association between 20 to 30% increase in the risk for developing pyelonephritis during later pregnancy and untreated cases of bacteriuria in pregnancy. This is due to the physiological changes occurring to urinary tract during pregnancy, it is also found that untreated bacteriuria can be associated with even preterm birth and low birth weight. Risk of symptomatic urinary tract infection (UTI) during pregnancy can be reduced by antibiotic treatment of asymptomatic bacteriuria
The most common pathogen associated with asymptomatic bacteriuria is Escherichia coli, which accounts to more than 80% of isolates and the second most frequently cultured uropathogen is Staphylococcus saprophyticus. Other Gram-positive cocci, like group B streptococci, are less common. Gram-negative bacteria such as Klebsiella, Proteus or other Enterobacteriaceae are the other organisms involved in asymptomatic bacteriuria.
Although the context patient is asymptomatic, her urine dipstick shows positive nitrite and leukocyte, suggestive of urinary tract infection, so oral antibiotics like cephalexin or nitrofurantoin are advisable. Normally a five day course of oral antibiotic will be sufficient for the treatment of uncomplicated UTI or asymptomatic bacteraemia in pregnant women. As the patient is currently at her 38 weeks of gestation nitrofurantoin is contraindicated so it is best to prescribe her with Oral Cephalexin. This is because nitrofurantoin is associated with an increased risk of neonatal jaundice and haemolytic anaemia, so should not be used close to delivery, that is after 37 weeks of gestation or sooner if early delivery is planned.
Acute pyelonephritis should be treated with Intravenous antibiotic treatment, guided by urine culture and sensitivity reports as soon a available. A course of minimum of 10-14 days with IV + oral antibiotics is recommended as treatment for pyelonephritis, along with an increased fluid intake as intravenous fluids in clinically dehydrated patients. Even though urinary alkalisers are safe in pregnancy, prescription of urinary alkalisers alone is not recommended due to its low effectiveness compared to antibiotics, also as it can result in a loss of treatment efficacy urinary alkalisers should never be used in combination with nitrofurantoin.
At any stage of pregnancy, if Streptococcus agalactiae, a group B streptococcus [GBS], is detected in urine the intrapartum prophylaxis for GBS is usually indicated.
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This question is part of the following fields:
- Obstetrics
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Question 44
Incorrect
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In the absence of any gross pelvic abnormality, cephalopelvic disproportion can be correctly diagnosed by?
Your Answer:
Correct Answer: Trial of labour
Explanation:Cephalo-pelvic disproportion exists when the capacity of the pelvis is inadequate to allow the foetus to negotiate the birth canal. This may be due to a small pelvis, a nongynecoid pelvic formation, a large foetus, an unfavourable orientation of the foetus, or a combination of these factors. Diagnosis of CPD may be made when there is failure to progress, but not all cases of prolonged labour are the result of CPD. Use of ultrasound to measure the size of the foetus in the womb is controversial, as these methods are often inaccurate and may lead to unnecessary caesarean section; a trial of labour is often recommended even if size of the foetus is estimated to be large.
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This question is part of the following fields:
- Physiology
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Question 45
Incorrect
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Which of the following drugs is most appropriate to use to stimulate lactation?
Your Answer:
Correct Answer: Domperidone
Explanation:Domperidone and metoclopramide are D2 dopamine receptor antagonists. They are primarily used to promote gastric motility. They are also known as galactagogues and they promote the production of milk. Cabergoline and bromocriptine are prolactin inhibitors and they reduce milk production.
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This question is part of the following fields:
- Endocrinology
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Question 46
Incorrect
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Which of the following prolongs Prothrombin time?
Your Answer:
Correct Answer: Factor V deficiency
Explanation:Prothrombin time is increased in:
– Factor V deficiency
– Vitamin K deficiency (which affects factors 2,7 and 10)
– Warfarin therapy
– Severe liver failure
Protein C is an anticoagulant and deficiency results in a hyper-coagulable state with tendency towards thrombosis. -
This question is part of the following fields:
- Biochemistry
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Question 47
Incorrect
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A 26-year-old pregnant female in her first trimester was brought to the labour room with complaints of painless vaginal bleeding. On examination, her abdomen was non-tender and os was closed. Which of the following is the most likely diagnosis?
Your Answer:
Correct Answer: Threatened miscarriage
Explanation:Threatened miscarriage is a term used to describe any abnormal vaginal bleeding that occurs in first trimester, sometime associated with abdominal cramps. The cervix remains closed and the pregnancy may continue as normal.
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This question is part of the following fields:
- Obstetrics
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Question 48
Incorrect
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Which of the following inhibit Glucagon?
Your Answer:
Correct Answer: Uraemia
Explanation:Glucagon release is inhibited by increased blood glucose, ketones, free fatty
acids, insulin, raised urea levels and somatostatin. Glucagon is produced by alpha cells of the pancreas and increases the plasma glucose level by stimulating glycogenolysis and gluconeogenesis. -
This question is part of the following fields:
- Endocrinology
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Question 49
Incorrect
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A 16 week pregnant patient presents to the antenatal clinic. Protein values of ++ are found on urinalysis. Significant proteinuria is indicated in which of the following protein:creatinine values?
Your Answer:
Correct Answer: 30 mg/mmol
Explanation:Proteinuria of more than 1+ on dipstick should be investigated to quantify the amount of proteinuria. A protein: creatinine ratio can be used to determine the severity of proteinuria, where levels of more than 30 mg/mmol indicate significant proteinuria.
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This question is part of the following fields:
- Data Interpretation
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Question 50
Incorrect
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A 39-year-woman visits a gynaecological clinic for fertility advice. She is unable to conceive for the last 2 years. Pelvic ultrasound shows 3-4 follicles in both ovaries. An endocrinological profile is ordered showing low oestrogen, elevated FSH, and LH.
What is the most suitable advice for her?Your Answer:
Correct Answer: In-vitro fertilization
Explanation:Premature menopause has been diagnosed biochemically in this patient. Menopause is considered premature when it happens without warning in a woman under the age of 40.
Follicular development is common in ultrasonography investigations of women with primary ovarian failure, but ovulation is rare. So this woman isn’t ovulating.Exogenous oestrogen treatment in physiologic amounts does not appear to improve the rate of spontaneous ovulation.
Women with primary ovarian failure from any cause may be candidates for donor oocyte in vitro fertilisation (IVF).Oestrogens, clomiphene citrate, and danazol are examples of treatment approaches that have been shown to be ineffective in patients with premature ovarian failure.
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This question is part of the following fields:
- Gynaecology
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