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  • Question 1 - A 28 year old woman presents for a scan at 13 weeks. Though...

    Correct

    • A 28 year old woman presents for a scan at 13 weeks. Though this is her second pregnancy, the first ended in a 1st trimester miscarriage. She has not reported any problems with the current pregnancy. The ultrasound scan showed a small gestational sac and no fetal cardiac activity.
      Which of the following is the most likely diagnosis?

      Your Answer: Missed Miscarriage

      Explanation:

      A miscarriage is defined as the spontaneous loss of a pregnancy before the age of viability at 24 weeks in the UK.

      A missed miscarriage is described as a loss of pregnancy without vaginal bleeding, loss of tissue, cervical changes or abdominal pain. During a scan, a fetal heartbeat is not observed, and the gestational sac may be small.

      A threatened miscarriage is when the cervix dilates and uterine bleeding is seen; the pregnancy could still be viable. A complete miscarriage occurs when all the products of conception are expelled from the uterus, bleeding has stopped, and the cervix has closed up after dilation.

      An inevitable miscarriage occurs with the usual symptoms of a miscarriage and a dilated cervix, suggesting that the passage of the fetal tissue is inevitable.

      Recurrent miscarriages are described as spontaneous pregnancy loss of more than 2 to 3 consecutive times.

    • This question is part of the following fields:

      • Clinical Management
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  • Question 2 - A 29 year old female who is 32 weeks pregnant, has been admitted...

    Incorrect

    • A 29 year old female who is 32 weeks pregnant, has been admitted to hospital with very severe hypertension. This is her second pregnancy. In the United Kingdom, what is the first line of treatment for hypertension whilst pregnant?

      Your Answer:

      Correct Answer:

      Explanation:

      Atenolol is considered teratogenic and has two main risks: fetal bradycardia and neonatal apnoea. ACE inhibitors and angiotensin II receptor blockers are also known to be teratogenic (even though large-scale studies are difficult to conduct during pregnancies).

    • This question is part of the following fields:

      • Obstetrics
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  • Question 3 - A 23-year-old woman, G1PO comes to your clinic at 12 week of pregnancy....

    Incorrect

    • A 23-year-old woman, G1PO comes to your clinic at 12 week of pregnancy. She is complaining of mild vaginal bleeding for the past 12 hours, along with bouts of mild cramping lower abdominal pain.
      On vaginal examination, the cervical os is closed with mild discharge containing blood clots and an ultrasonography confirms the presence of a live fetus with normal heart rate.
      Which among of the following is the most likely diagnosis?

      Your Answer:

      Correct Answer: Threatened abortion

      Explanation:

      Uterine bleeding in the presence of a closed cervix along with sonographic visualization of an intrauterine pregnancy with detectable fetal cardiac activity are diagnostic of threatened abortion.

      Abortion does not always follow a uterine bleeding in early pregnancy, sometimes not even after repeated episodes or large amounts of bleeding, that is why the term “threatened” is used in this case. In about 90 to 96% cases, the pregnancy continues after vaginal bleeding if occured in the presence of a closed os and a detectable fetal heart rate. Also as the gestational age advances its less likely the condition will end in miscarriage.

      In cases of inevitable abortion, there will be dilatation of cervix along with progressive uterine bleeding and painful uterine contractions. The gestational tissue can be either felt or seen through the cervical os and the passage of this tissue occurs within a short time.

      In case were the membranes have ruptured, partly expelling the products of conception with a significant amounts of placental tissue left in the uterus is called as incomplete abortion. During the late first and early second trimesters this will be the most common presentation of an abortion. Examination findings of this includes an open cervical os with gestational tissues observed in the cervix and a uterine size smaller than expected for gestational age and a partially contracted uterus. The amount of bleeding will vary but can be severe enough to cause hypovolemic shock, with painful contractions and an ultrasound revealing tissues in the uterus.

      An in utero death of the embryo or fetus prior to 20 weeks of gestation is called as a missed abortion. In this case the women may notice that the symptoms associated with early pregnancy like nausea, breast tenderness, etc have disappeared and they don’t ‘feel pregnant’ anymore. Vaginal bleeding may occur but the cervix remains closed and the ultrasound done reveals an intrauterine gestational sac with or without an embryonic/fetal pole, but no embryonic/fetal cardiac activity will be noticed.

      In case of complete abortion, miscarriage occurs before the 12th week and the entire contents of conception will be expelled out of uterus. If this case, the physical examination will show a small and well contracted uterus with an open or closed cervix. There is scant vaginal bleeding with only mild cramping and ultrasound will reveal an empty uterus without any extra-uterine pregnancy.

    • This question is part of the following fields:

      • Obstetrics
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  • Question 4 - You are called to see a patient in A&E who attended due to...

    Incorrect

    • You are called to see a patient in A&E who attended due to finger splinter that has been removed. The HCA took some routine obs that show her blood pressure to be 162/110. She is 32 weeks pregnant. According to the NICE guidelines which of the following is appropriate?

      Your Answer:

      Correct Answer: Admit and start oral labetalol

      Explanation:

      BP over 159/109 is classed as Severe. NICE guidance advises admission and treatment with oral Labetalol as 1st Line. Patient should have BP checked QDS and shouldn’t be discharged until BP is below 159/109

    • This question is part of the following fields:

      • Clinical Management
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  • Question 5 - A 32-year-old female presented with a lump in the upper outer quadrant of...

    Incorrect

    • A 32-year-old female presented with a lump in the upper outer quadrant of her left breast, which is 1.5cm in size and tender. What is the initial investigation to be done?

      Your Answer:

      Correct Answer: Ultrasound

      Explanation:

      Tenderness is usually suggestive of a benign breast mass such as a breast abscess. Ultrasound is used to distinguish solid from cystic structures and to direct needle aspiration for abscess drainage.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 6 - A young couple, both 26 years of age, presents to you with 11...

    Incorrect

    • A young couple, both 26 years of age, presents to you with 11 months’ duration of infertility. On investigation, she is found to be ovulating, and her hysterosalpingogram is normal. On semen analysis, the following results were found:
      Semen volume 5mL (2-6 mL)
      Sperm count 1 million/mL * (>20 million)
      Motility 15% (>40%)
      Abnormal forms 95% (<60%)
      A second specimen three months later confirms the above results.
      Which would be the most suitable next step in management?

      Your Answer:

      Correct Answer: Carry out in vitro fertilisation (IVF) using intracytoplasmic sperm injection (ICSI).

      Explanation:

      Achieving spontaneous pregnancy is rare in cases where a couple have been infertile with abnormal semen analysis (count <5million/mL and reduced motility), hence there is generally an indication for treatment. FSH injection usually would not be expected to improve the semen specimen. Rate of pregnancy would be much lower if at the time of intrauterine insemination, the total motile count is less 5 million. In this case, his count is 1 million. Pregnancy is likely to be achieved with donor sperm but as it would not contain the husband’s genetic material, it would be only considered later on once all other methods involving his own sperm have failed. Out of all the options, IVF would most likely result in a pregnancy, in which it allows the husband’s sperm to spontaneously fertilise the oocyte. Rate of pregnancy would roughly be 2% per treatment cycle. This rate would increase to roughly 20% if ISCI is also used.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 7 - A 50-year-old woman comes to the clinic complaining she is “urinating all the...

    Incorrect

    • A 50-year-old woman comes to the clinic complaining she is “urinating all the time. It started initially as some leakage of urine with sneezing or coughing, but now she leaks while walking to the bathroom.She voids frequently during the day and several times each night, also sometimes patient feels an intense urge to urinate but passes only a small amount when she tries to void. She now wears a pad every day and plans her social outings based on bathroom access.Patient had no history of dysuria or hematuria and had 2 vaginal deliveries in her 20s.She drinks alcohol socially, takes 2 or 3 cups of coffee each morning, and “drinks lots of water throughout the day.” When asked about which urinary symptoms are the most troublesome, the patient is unsure.
      Among the following which is the best next step in management of this patient?

      Your Answer:

      Correct Answer: Voiding diary

      Explanation:

      This patient experiences a stress based mixed urinary incontinence presented as leakage of urine while sneezing or coughing and urgency which is an intense urge to urinate with small voiding volume as her symptoms. Urinary incontinence is common and may cause significant distress in some, as seen in this patient who wears a pad every day.  Initial evaluation of mixed incontinence includes maintaining a voiding diary, which helps to classify the predominant type of urinary incontinence and thereby to determine an optimal treatment by tracking the fluid intake, urine output and leaking episodes.

      All patients with mixed incontinence generally require bladder training along with lifestyle changes like weight loss, smoking cessation, decreased alcohol and caffeine intake and practicing pelvic floor muscle exercises like Kegels. Depending on the predominant type, patients who have limited or incomplete symptom relief with bladder training may benefit from pharmacotherapy or surgery.

      In patients with urgency-predominant incontinence, timed voiding practice like urinating on a fixed schedule rather than based on a sense of urgency along with oral antimuscarinics are found to be useful.

      Surgery with a mid-urethral sling is performed in patients with stress-predominant incontinence which is due to a weakened pelvic floor muscles as in cystocele.

      In patients with a suspected urethral diverticulum or vesicovaginal fistula, a cystoscopy is usually indicated but is not used in initial evaluation of urinary incontinence due to its cost and invasiveness.

      Urodynamic testing involves measurement of bladder filling and emptying called as cystometry, urine flow, and pressure (eg, urethral leak point).  This testing is typically reserved for those patients with complicated urinary incontinence, who will not respond to treatment or to those who are considering surgical intervention.

      Initial evaluation of mixed urinary incontinence is done by maintaining a voiding diary, which helps to classify predominant type of urinary incontinence into stress predominant or urgency predominant and thereby to determine the optimal treatment required like bladder training, surgical intervention, etc.

    • This question is part of the following fields:

      • Obstetrics
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  • Question 8 - A 48-year-old woman presents to the clinic complaining of a one week history...

    Incorrect

    • A 48-year-old woman presents to the clinic complaining of a one week history of light vaginal bleeding.
      Her past medical history reveals she had a lumpectomy, postoperative radiotherapy, adjuvant chemotherapy and tamoxifen therapy 3 years ago as treatment for an oestrogen receptor-positive breast malignancy.
      She was prescribed tamoxifen in a dose of 10mg per day to take for the next five years.
      Since she completed her chemotherapy three years ago, she has no menstrual periods.
      What is the most probable cause of her current bleeding?

      Your Answer:

      Correct Answer: Endometrial polyp formation due to the tamoxifen.

      Explanation:

      The most likely cause of her bleeding is an endometrial polyp formation due to the tamoxifen.

      Tamoxifen is often prescribed to decrease risk of breast cancer recurrence in premenopausal women with oestrogen receptor-positive cancers.

      As with any medication, it has known side effects, which include endometrial polyp formation, subendometrial oedema and, rarely, endometrial carcinoma.

      A polyp or carcinoma can cause uterine bleeding, but a polyp is more likely to occur.

      Routine endometrial thickness screening is not recommended in all women taking tamoxifen. However, in cases of abnormal bleeding, ultrasound assessment of endometrial thickness, hysteroscopy and curettage are indicated to assess the endometrium in more detail.

      Tamoxifen is not associated with endometrial atrophy.

      Endometrial metastasis from a breast cancer is rare, and tamoxifen would not usually induce follicular development in a woman who has had chemotherapy and resultant amenorrhoea.

    • This question is part of the following fields:

      • Gynaecology
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  • Question 9 - A 36 year old patient is diagnosed with cervical cancer and staging investigations...

    Incorrect

    • A 36 year old patient is diagnosed with cervical cancer and staging investigations show there is parametrial involvement but it is confined within the pelvic wall and does not involve the lower 1/3 vagina. There is no evidence of hydronephrosis. What FIGO stage is this?

      Your Answer:

      Correct Answer: 2B

      Explanation:

      It is stage 2B. Stage I: is strictly confined to the cervix; extension to the uterine corpus should be disregarded. The diagnosis of both Stages IA1 and IA2 should be based on microscopic examination of removed tissue, preferably a cone, which must include the entire lesion.
      2010 FIGO classification of cervical carcinoma:
      Stage IA: Invasive cancer identified only microscopically. Invasion is limited to measured stromal invasion with a maximum depth of 5 mm and no wider than 7 mm.
      Stage IA1: Measured invasion of the stroma no greater than 3 mm in depth and no wider than 7 mm diameter.
      Stage IA2: Measured invasion of stroma greater than 3 mm but no greater than 5 mm in depth and no wider than 7 mm in diameter.

      Stage IB: Clinical lesions confined to the cervix or preclinical lesions greater than Stage IA. All gross lesions even with superficial invasion are Stage IB cancers.
      Stage IB1: Clinical lesions no greater than 4 cm in size.
      Stage IB2: Clinical lesions greater than 4 cm in size.

      Stage II: carcinoma that extends beyond the cervix, but does not extend into the pelvic wall. The carcinoma involves the vagina, but not as far as the lower third.
      Stage IIA: No obvious parametrial involvement. Involvement of up to the upper two-thirds of the vagina.
      Stage IIB: Obvious parametrial involvement, but not into the pelvic sidewall.

      Stage III: carcinoma that has extended into the pelvic sidewall. On rectal examination, there is no cancer-free space between the tumour and the pelvic sidewall. The tumour involves the lower third of the vagina. All cases with hydronephrosis or a non-functioning kidney are Stage III cancers.
      Stage IIIA: No extension into the pelvic sidewall but involvement of the lower third of the vagina.
      Stage IIIB: Extension into the pelvic sidewall or hydronephrosis or non-functioning kidney.

      Stage IV: carcinoma that has extended beyond the true pelvis or has clinically involved the mucosa of the bladder and/or rectum.
      Stage IVA: Spread of the tumour into adjacent pelvic organs.
      Stage IVB: Spread to distant organs.

    • This question is part of the following fields:

      • Clinical Management
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  • Question 10 - A woman comes to your office two weeks after undergoing a total vaginal...

    Incorrect

    • 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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