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Question 1
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You review a 28 year old patient in the fertility clinic. She has a diagnosis of PCOS. She has been trying to conceive for 2 years. Her BMI is 26 kg/m2. She is a non-smoker. She has been taking Clomiphene and metformin for the past 6 months. What is the next most appropriate treatment?
Your Answer: Gonadotrophins
Explanation:Clomiphene shouldn’t be continued for more than 6 months. The second line options are Gonadotrophins or ovarian drilling.
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This question is part of the following fields:
- Clinical Management
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Question 2
Correct
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A 53 year old lady presents to clinic due to vulval itch and discolouration. examination reveals pale white discoloured areas to the vulva. A biopsy shows epidermal atrophy with sub-epidermal hyalinization and deeper inflammatory infiltrate. What is this characteristic of?
Your Answer: Lichen Sclerosus
Explanation:Lichen sclerosus is characterized by hypopigmented atrophic plaque in the perineal region along with features of pruritis and dyspareunia.
It is more common in post menopausal women and on histology there is epidermal atrophy, inflammatory infiltrate in the dermis and basal layer degeneration.Vitiligo is characterised by hypopigmentation but without any other symptoms.
Extramammary Paget’s disease is characterized by erythematous plaque located mostly in the perianal region but its histology is different.
Lichen simplex chronicus is a chronic scaly pruritic condition characterized by itchy papules and plaques plus lichenification and it mostly results from chronic irritation and itching of the area. -
This question is part of the following fields:
- Clinical Management
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Question 3
Correct
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A 24 year old, 16 week pregnant patient presents with vaginal discharge. There is heavy growth of N. gonorrhoea as shown on swabs taken. Which treatment course is most advisable?
Your Answer: Ceftriaxone 1g intramuscularly as a single dose with azithromycin 2 g oral as a single dose
Explanation:Gonorrhoea is a diplococcus bacteria known to infect the female genital tract. The bacteria is sexually transmitted and can cause an ascending infection in the uterus and fallopian tubes. According to the BASHH guidelines (British Association for Sexual Health and HIV), indication for therapy include confirmation of intracellular diplococci on microscopy or a confirmed positive NAAT. Treatment of gonorrhoea in pregnancy is as follows: Ceftriaxone 1g intramuscularly as a single dose with azithromycin 2g oral as a single dose. Pregnant individuals are not to be treated with quinolones or tetracyclines.
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This question is part of the following fields:
- Clinical Management
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Question 4
Correct
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You see a diabetic women in preconception clinic. Which of the following is appropriate advice regarding folic acid supplementation?
Your Answer: 5 mg daily until week 12
Explanation:The aim of pre-pregnancy counselling is to achieve the best possible glycaemic control before pregnancy and to educate diabetic women about the implications of pregnancy. Patient information leaflets about pregnancy should make clear the risks of pregnancy in diabetes, and include advice to take high dose (5 mg) folic acid pre-conception and for the first 12 weeks.
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This question is part of the following fields:
- Clinical Management
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Question 5
Correct
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Question 6
Incorrect
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In the 3rd trimester anaemia is defined by?
Your Answer: Haemoglobin < 105 g/l
Correct Answer:
Explanation:Haemoglobin decreases from 13.3 g/dL to 10.5 g/dL from the start of pregnancy i.e. First trimester till the 3rd trimester.
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This question is part of the following fields:
- Clinical Management
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Question 7
Incorrect
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Which vitamin deficiency leads to Wernicke's encephalopathy?
Your Answer: C
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 8
Incorrect
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A 32 year old women who is 25 weeks pregnant presents with vaginal bleeding and cramping lower abdominal pain. On examination the cervix is closed. Fetal cardiac activity is noted on ultrasound. What is the likely diagnosis?
Your Answer: Inevitable Miscarriage
Correct Answer: Antepartum Haemorrhage
Explanation:Antepartum haemorrhage (APH) is defined as bleeding from or in to the genital tract, occurring from 24+0 weeks of pregnancy and prior to the birth of the baby.
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This question is part of the following fields:
- Clinical Management
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Question 9
Correct
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A couple present to the fertility clinic after failing to conceive despite trying for 2.5 years. The semen analysis shows azoospermia. You perform a full examination of the male partner which reveals Height 192cm, BMI 20.5, small testes and scant facial hair. You decide to organise karyotyping. What is the result likely to show?
Your Answer: 47XXY
Explanation:Klinefelter syndrome is associated with testicular atrophy, eunuchoid body shape, tall, long extremities, female hair distribution and gynaecomastia. It is a common cause of hypogonadism seen during fertility workup.
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This question is part of the following fields:
- Clinical Management
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Question 10
Incorrect
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A 36 year old patient is seen in clinic for follow up of a vaginal biopsy which confirms cancer. What is the most common type?
Your Answer: Adenocarcinoma
Correct Answer: Squamous cell carcinoma
Explanation:Squamous cell carcinoma is the most common type of vaginal cancer.
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This question is part of the following fields:
- Clinical Management
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Question 11
Correct
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Galactopoiesis is maintained by which hormone?
Your Answer: Prolactin
Explanation:The production of milk is regulated by the hormone Prolactin. Oxytocin on the other hand is responsible for the let down reflex that occurs during breast feeding.
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This question is part of the following fields:
- Clinical Management
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Question 12
Incorrect
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A patient attends the maternity unit as her waters have broken but she hasn't had contractions. She is 39+6 weeks gestation. Speculum examination confirms prelabour rupture of membranes. What is the likelihood of spontaneous labour starting within 24 hours?
Your Answer: 90%
Correct Answer: 60%
Explanation:In pregnancy, term refers to the gestational period from 37 0 to 41 6 weeks. Preterm births occur between 24 0 and 36 6 weeks. 60% of the women will go into labour with in 24 hours in PPROM. After 24 hours have past without any contraction and the gestation age is more than 34 week than prostaglandins can be used to augment labour.
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This question is part of the following fields:
- Clinical Management
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Question 13
Incorrect
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A 46 year old women with a BMI of 34 is seen in clinic following hysteroscopy and biopsy for irregular menstrual bleeding. Histology shows hyperplasia without atypia. Following a discussion the patient declines any treatment but agrees she will try and lose weight. What is the risk of progression to endometrial cancer over 20 years?
Your Answer: 10-15%
Correct Answer:
Explanation:The risk of developing endometrial carcinoma is less than 5% over 20 years if the endometrium shows hyperplasia without atypia.
There are 2 types of Endometrial Hyperplasia:
1. Hyperplasia without atypia*
2. Atypical hyperplasiaMajor Risk Factors:
Oestrogen (HRT)
Tamoxifen
PCOS
Obesity
Immunosuppression (transplant) -
This question is part of the following fields:
- Clinical Management
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Question 14
Incorrect
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A patient has had limited response to conservative measures for her overactive bladder (OAB). Which of the following is the most appropriate pharmacological choice?
Your Answer: Imipramine
Correct Answer: Darifenacin
Explanation:Detrusor overactivity can be treated with anti-cholinergic agents such as oxybutynin or tolterodine, solifenacin, fesoterodine and darifenacin. They are used as first line agents. Imipramine is used for enuresis and desmopressin is used for nocturia.
NICE pathwayPrior to initiating anticholinergics:
Bladder training
Consider treating vaginal atrophy and nocturia with topical oestrogen and desmopressin respectively before commencing treatments below.
Consider catheterisation if chronic retention
1st line treatments:
1. Oxybutynin (immediate release) – Do not offer to frail elderly patients
2. Tolterodine (immediate release)
3. Darifenacin (once daily preparation)
DO NOT offer any of the 3 drugs below:
1. Flavoxate
2. Propantheline
3. Imipramine
2nd line treatment
Consider transdermal anticholinergic (antimuscarinic)
Mirabegron
Adjuvant Treatments
Desmopressin can be considered for those with nocturia
Duloxetine may be considered for those who don’t want/unsuitable for surgical treatment
Intravaginal oestrogen can be offered to postmenopausal women with OAB -
This question is part of the following fields:
- Clinical Management
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Question 15
Incorrect
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A patient has returned to your clinic. She presented with painful periods 18 months earlier and laparoscopy confirmed endometriosis. She now gets pain on opening her bowels as well as low back pain. What structure is likely to be involved?
Your Answer: Iliacus muscle
Correct Answer: Uterosacral ligament
Explanation:Lower abdominal pain during menstrual periods and lower back or leg pain are associated with endometriosis in the uterosacral ligaments. Endometriosis can cause diarrhoea and IBS type symptoms. Note Endometriosis on the uterosacral ligament can cause tender nodules to form. These can be palpated during pelvic exam. Tender nodules are specific to endometriosis of the uterosacral ligament so if the question mentions feeling a tender nodule during PV exam think endometriosis of the Uterosacral ligaments!
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This question is part of the following fields:
- Clinical Management
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Question 16
Incorrect
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What is the mechanism of action of Oxytetracycline?
Your Answer: Dihydrofolate Reductase Inhibitor
Correct Answer: Binds to 30S subunit of microbial ribosomes blocking attachment of aminoacyl-tRNA to the A site on the ribosome
Explanation:Tetracycline is classified as a broad spectrum antibiotic. It is a bacteriostatic inhibitor of protein synthesis acting at the ribosomal level. Tetracycline binds to the 30s ribosomal subunit preventing the binding of the aminoacidic charged T-RNA to the ribosome-mRNA complex.
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This question is part of the following fields:
- Clinical Management
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Question 17
Correct
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During pregnancy which one of the following laboratory parameters is decreased?
Your Answer: Platelet count
Explanation:In pregnancy, although it is a hypercoagulable state with an increase in clotting factors, the platelet count is decreased. Fibrinogen and erythrocyte sedimentation rate (ESR) may be both increased.
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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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According to the RCOG Green-top guidelines on prevention and management of post-partum haemorrhage (PPH) which of the following statements is true?
Your Answer: Most cases of PPH have identifiable risk factors
Correct Answer: For women delivering by caesarean section, Oxytocin 5 iu by slow IV injection should be used
Explanation:Misoprostol is not as effective as oxytocin but may be used if Oxytocin is not available e.g. home birth Recommended doses of Oxytocin For vaginal deliveries: 5 iu or 10 iu by intramuscular injection. For C-section: 5 iu by IV injection
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This question is part of the following fields:
- Clinical Management
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Question 19
Correct
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A 29 year old is diagnosed with stage 1A2 cervical cancer. Which of the following is the most appropriate treatment option?
Your Answer: LLETZ
Explanation:The treatment of stage 1A cervical cancer is excision of the margins using the Loop electrical excision procedure (LLETZ). Hysterectomy is not necessary. This treatment enables fertility to be preserved.
2010 FIGO classification of cervical carcinoma
0 – Carcinoma in situ
1 – Confined to the cervix (diagnosed microscopy)
1A1 – Less than 3mm depth & 7mm lateral spread
1A2 – 3mm to 5mm depth & less than 7mm lateral spread
1B1 – Clinically visible lesion or greater than A2 & less than 4 cm in greatest dimension
1B2 – Clinically visible lesion, greater than 4 cm in greatest dimension
2 – Invades beyond uterus but not to pelvic wall or lower 1/3 vagina
2A1 – Involvement of the upper two-thirds of the vagina, without parametrical invasion & Less than 4cm
2A2 – Greater than 4 cm in greatest dimension
2B – Parametrial involvement
3 – Extends to Pelvic side wall or lower 1/3 vagina or hydronephrosis
3A – No pelvic side wall involvement
3B – Pelvic side wall involved or hydronephrosis
4 – Extends beyond true pelvis 4A Invades mucosa bladder and rectum
4B – Distant Metastasis -
This question is part of the following fields:
- Clinical Management
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Question 20
Incorrect
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The COCP (Combined Oral Contraceptive Pill) causes all of the following biochemical effects EXCEPT?
Your Answer: Elevate Sex Hormone Binding Globulin
Correct Answer: Elevate FSH
Explanation:COCP’s act both centrally and peripherally. They inhibit ovulation. Both oestrogen and progestogen supress the release of FSH and LH hence preventing ovulation. Peripherally it acts by making the endometrium atrophic and hostile towards implantation. It also alters the cervical mucus and prevents the sperm from ascending the uterine cavity.
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This question is part of the following fields:
- Clinical Management
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SESSION STATS - PERFORMANCE PER SPECIALTY
