Speciality Mock 17 th May 2022 - PowerPoint Presentation

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Speciality Mock

17

th May 2022Rachel Rozewicz - Ioanna Zimianiti - Vasiliki Kalogianni

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DISCLAIMERMedEd does not represent the ICSM Faculty or Student Union. This lecture has been designed and produced for the purpose of examination preparation by doctors and students to the best of their knowledge. This does not represent the thoughts of the Faculty of Medicine and should not be taken to be information coming from them.

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DISCLAIMER- This mock was not a 100% accurate reflection of the exam, but rather a way to revise content and reinforce some concepts!- The purpose of this session is not for you to complete the mock (unfortunately) but rather for us to share and discuss the correct answers with you!

You will have benefited by having done the mock beforehand, however feel free to stay even if you have not!

Slides will be shared at the end of the session and you can reach us with any extra questions!

Slide4

Which of the following elements is not included in the AMTS?

Options:

Time to the nearest hour Year of the First World War Repeating and remembering three words Recognition of two people 

What is AMTS?

Abbreviated mental test score

10 point assessment tool to rapidly screen for dementia/delirium

≤6 suggests possible delirium/dementia

What questions are in AMTS?

What is your age?

What is the time to the nearest hour?

Give the patient an address, and ask him or her to repeat it at the end of the test e.g. 42 West Street

What is the year?

What is the name of the hospital or number of the residence where the patient is situated?Can the patient recognize two persons (the doctor, nurse, home help, etc.)? What is your date of birth? (day and month sufficient) In what year did World War 1 begin? Name the present monarch/prime minister/president. Count backwards from 20 down to 1.

PSYCH – 1

Slide5

In which type of dementia is alpha-synuclein characteristically involved in the pathophysiology? 

Options:Lewy body dementia  

Alzheimer’s disease  Vascular dementia Frontotemporal dementia  

Alzheimer’s

Lewy body

Vascular

Frontotemporal

Amyloid plaques

Neurofibrillary tangles (tau protein)

Lewy bodies (Eosinophilic alpha-synclein neuronal inclusions) deposited in brain

Neuronal loss in brainstem nuclei (especially basal ganglia), paralimbic and neonacortical structures.

Thromboembolic or hypertensive infarction of small and medium sized vessels

Range of pathologies – neuronal loss, gliosis, protein inclusions

PSYCH – 2

Slide6

What is the male:female ratio of ADHD prevalence?  

What is ADHD:Inattention

Hyperactivity Impulsivity Demonstrated across 2 or more settings Risk factors for ADHD:Male gender

Low birth weightFamily history of ADHDMaternal smoking during pregnancy

PSYCH – 3

Options:

1:2  

1:1  

2:1 

4:1

 

Slide7

Audra is a 46 year old woman taken to A&E by a worried friend after she challenged a shop security guard. She claimed she was an undercover metropolitan police officer working on a top secret project and was annoyed that the security guard did not already know about this.

Her friend said that Audra had been speaking about this for many months and has a room in her house filled with newspaper cuttings about the metropolitan police.

She was still working in her job in a supermarket.  Audra’s records show only a history of mild depression in her 20s. She presents as well kempt, polite and not thought disordered. She was euthymic with no evidence of responding to unseen stimuli. What Audra’s most likely diagnosis? 

PSYCH – 4

Options:

First episode psychosis 

Delusional Disorder

 

Late onset Schizophrenia  

Schizoaffective Disorder 

Schizophrenia

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Definitions

Delusion

Fixed false belief Out of keeping with social/cultural backgroundPsychosis Encompasses a number of symptoms associated with significant alterations to a person’s perceptions, thoughts, mood and behavior

Positive symptoms include hallucination and delusionsNegative symptoms include emotional blunting, reduced speech, loss of motivation, self-neglect and social withdrawal

Schizophrenia

ICD-10 requires the following to be present most of the time for at least 1 month

One or more of:

Hallucinatory voices

Thought echo, insertion, withdrawal, broadcasting

Delusion of control, influence or passivity

Persistent delusions of any kinds

OR any two of:

Persistent hallucinations with fleeting/half formed delusionsBreaks in train of thought/incoherent speech/neologisms

Catatonic behaviorNegative symptomsSignificant change in overall behavior

Persistent delusional disorder

Most pervasive symptom is delusion

Schizoaffective disorder

Symptoms of schizophrenia and mood disorder are equally prominent

Drug induced psychosis

Substance-induced and usually remits within a month of cessation of use

Psychotic disorders:

Slide9

Audra is a 46 year old woman taken to A&E by a worried friend after she challenged a shop security guard. She claimed she was an undercover metropolitan police officer working on a top secret project and was annoyed that the security guard did not already know about this. Her friend said that Audra had been

speaking about this for many months and has a room in her house filled with newspaper

cuttings about the metropolitan police. She was still working in her job in a supermarket.  Audra’s records show only a history of mild depression in her 20s. She presents as well kempt, polite and not thought disordered.

She was euthymic with no evidence of responding to unseen stimuli

.

What Audra’s most likely diagnosis? 

PSYCH – 4

Options:

First episode psychosis -

no evidence of hallucinations or disordered thinking

Delusional Disorder

 

Late onset Schizophrenia  -

no evidence of hallucinations, disordered thinking or negative symptoms

Schizoaffective Disorder  -

euthymic, no affective symptoms

,

Schizophrenia  -

no evidence of hallucinations, disordered thinking or negative symptoms

Slide10

  Josh is a 23 year old man with a BMI of 16. He had been restricting his intake to 400 calories daily, and exercising for four hours each day

.  He has not looked at himself in the mirror for a year because he can’t stand how overweight

he looks, despite his mother telling him that he’s too thin now.  He is reviewed by the specialist eating disorders team. What treatment are they most likely to recommend as first line? PSYCH – 5

Options:

CBT for Eating Disorders  ⇢

1

st

line for adults with ED

Interpersonal Therapy  ⇢ can be effective in reducing binge eating episodes

Family Therapy  ⇢ 1

st

line for children with ED

Fluoxetine  ⇢ SSRIs – can be used to treat co-morbidities

Sertraline   ⇢ SSRIs – can be used to treat co-morbidities

Slide11

6. Steven has been brought to A&E by his family with concerns that he might harm himself.  He has a 3 week history of intermittent agitation and distress, stating that he needs to go to find his uncle in Yorkshire because “they’re trying to get me”. This morning, he ran out of the house into the road. He has been medically cleared. The psychiatry trainee thinks that he may need admission to a mental health unit, however, steven attempts to abscond from A&E whilst

waiting for the assessors to arrive. What should the psychiatry trainee advise? 

PSYCH – 6

Options:

The A&E team should detain Steven using section 5(2) of the Mental Health Act

The A&E team should stop him leaving A&E under the Mental Capacity Act.

 

C. The psychiatry trainee will place him under Section 2 of the Mental Health Act. 

D. The psychiatry trainee will detain Steven under section 5(2) of the Mental Health Act.

E. A DOLS assessor will come to assess him for Deprivation of Liberty Safeguards

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PSYCH – 6Mental Capacity Act

Gives any adult with capacity the right to make advance decisions and lasting power of attorneySays how to decide if someone has capacity

For any adult without capacity it tells professionals toAct in their best interestsConsult family/friends about decisionsAppoint IMCA for important decisionsApply Deprivation of liberty safeguards (DOLS) to anyone deprived of liberty

Mental Health Act

Allows detention of a patient with a

mental health disorder

who is

at risk of harm

to themselves or others

Certain sections allow treatment of mental disorders without consent

Capacity assessment

Patient lacks capacity of the answer to both questions is YES

Does the patient have impairment/disturbance of brain function?If YES, are they unable to make a decision as a result?-Communicate the decision -Understand information relevant-Retain the information-Balance the information (weigh up)

Section

Details

Requirements

2

28d for assessment and treatment

AMHP applies, 2 doctors (one MHA approved) make recommendation

3

6m for treatment

AMHP applies, 2 doctors (one MHA approved) make recommendation

4

72h for emergency assessment from community (no time for section 2)

AMHP applies, 1 doctor recommends5(2)72h for assessment when pt already in hospital (any ward - NOT A+E)1 doctor recommends (approved clinician)

5(4)

6h for assessment when patient already in hospital

(any ward - NOT A+E)

Registered MH nurse recommends

Slide13

PSYCH – 66. Steven has been brought to A&E by his family with concerns that he might harm himself

.  He has a 3 week history of intermittent agitation and distress, stating that he needs to go to find his uncle in Yorkshire because “they’re trying to get me”. This morning, he ran out of the house into the road. He has been medically cleared. The psychiatry trainee thinks that he may need admission to a mental health unit, however, steven attempts to abscond from A&E whilst

waiting for the assessors to arrive. What should the psychiatry trainee advise? 

Options:

The A&E team should detain Steven using section 5(2) of the Mental Health Act.  ⇢ A+E not MH ward

The A&E team should stop him leaving A&E under the Mental Capacity Act

.

 

⇢ cannot weigh up

The psychiatry trainee will place him under Section 2 of the Mental Health Act.  ⇢ need MHAA team

The psychiatry trainee will detain Steven under section 5(2) of the Mental Health Act. ⇢ A+E not MH ward

A DOLS assessor will come to assess him for Deprivation of Liberty Safeguards ⇢ takes long time

Slide14

You are the F1 on call and are asked to review a Mr King, a 70-year-old male who is on the orthogeriatric ward after a right neck of femur fracture. The nursing team have called you because they have become increasingly aggressive and shouts "why are you in my house?" You perform an A-E examination and notice that they have leg-length discrepancy, and they are unable to straight leg raise on the right. Otherwise, their blood tests show

no signs of infection. What are your next steps? 

PSYCH – 7

Options:

Pain relief 

⇢ ?meds already on, takes time,

Orientate the patient to time and place, 1:1 nursing

⇢ immediate, , keeps

pt

safe 

Investigate further causes 

⇢ ?already know cause, takes time

Lorazepam IM 

⇢ use least restrictive

Delirium (acute

confusional

state)

Management

Re-orientate (glasses/hearing aids, clock/orientation reminders/familiar objects/adequate lighting)

Identify and treat underlying causes (infection/pain/constipation…)

Medication –

halorperidol

,

benzodiaepines

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Mrs James, 92-year-old lady, has been brought into the GP by her daughter as she is worried that Mrs James has been forgetting things. She has noticed, for the past year, that Mrs James has been leaving the taps on overnight, sometimes leaves the keys in the front door and will call her daughter in a panic because she doesn't remember her way back home.  Last week, she found Mrs James sitting in her front garden without any trouser

s on, shouting at her neighbours.  

Last year, Mrs James was able to do her shopping, cook and dress without much assistance. Mrs James is a known type 2 diabetic, hypertensive and has been on metformin, atorvastatin, ramipril for over 15 years. What is your diagnosis? PSYCH – 8

Options:

Vascular dementia 

Alzheimer's dementia

 

Mixed dementia 

Fronto

-temporal dementia 

Delirium 

Alzheimer’s

Lewy body

Vascular

Frontotemporal

Gradual, progressive onset

Insidious onset, progressive with fluctuations

Abrupt or stepwise

Insidious onset, rapid progression

Slide16

Jane is a 23-year-old who has just given birth to a boy, Felix. Her partner, Lucia, has noticed that she has begun acting strangely with Felix. On further questioning, she has noticed that Jane has been talking about snakes in Felix's belly, that they talk to Jane and that

Felix "needs to be purified from the snakes". Lucia doesn't feel safe leaving Jane with the baby anymore. Lucia also mentions that jane has had episodes of very elated moods in the past

for which she usually takes quetiapine, but Jane stopped taking them when Felix was born. What are your next steps? Post-partum psychosis Acute onset of manic or depressive psychosis soon after childbirth Risk factorsPrevious episodes of psychosis

History of bipolar disorderFirst time mothersAfter instrumental deliveryFH of affective disorder ManagementHospitalization to mother + baby unit

Antipsychotics

ECT

PSYCH – 9

Options:

Admit Jane to a psychiatric ward 

⇢ not able to take baby

Admit Jane to a mother and baby unit

 

⇢ safe place, able to bond

Give Jane some time to get better, after encouraging Jane to take her medication 

⇢ risk of harm

Encourage Lucia to talk about her worries with Jane 

⇢ risk of harm

Call social services 

⇢ admission warranted

Slide17

Joshua is 2 months old

 and presents with decreased feeding (<50% of normal). Mum says his cry has been high-pitched and that he has felt hot. He was born at 37+2. There was GBS, covered with intrapartum antibiotics. He 

cries inconsolably when examined. HR 175, CRT 1-2s, RR 50, SATS 98% Chest clear, abdo SNT. No rashes are seen. Temp 38.6 degrees. Which one of the following is the most appropriate management plan for this case? 

PAEDS 1

Options:

a) Admit for observation on the ward, NGT feeds and send a NPA. 

b) Admit to the ward, start Co-amoxiclav IV to cover either chest or urine infective source. 

c) 

Admit, start iv Cefotaxime, send urine, blood and CSF for M,C &S and start maintenance iv fluids. 

d) Admit, start iv Benzylpenicillin and Gentamicin, send urine, blood and CSF for M,C &S and give fluid bolus. 

e) Send home with advice to give paracetamol and fluids in small volumes. Safety-net to return if a non-blanching rash occurs or if he has increased work of breathing.

inconsolable cry  =  

sign of meningism

Secondary care

Mx of meningitis

:

< 3 months: 

IV 

cefotaxime &

 

amoxicillin 

/ ampicillin

  >3 months: 

IV ceftriaxon

e

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FURTHER READING

NICE GUIDELINES ON Fever < 5s:

https://www.nice.org.uk/guidance/ng143

PAEDS 1

F

ever < 3 months - 

 NICE GUIDELINES:

Give IV antibiotics: ALL < 1 month, 1-3 months who appear unwell 

Choice of antibiotic:

 3rd-generation cephalosporin (

eg

cefotaxime) 

& antibiotic active against listeria (for example, ampicillin or amoxicillin). 

Slide19

A new mother brings her 8 week old baby boy

to the paeds assessment unit because his vomiting is getting worse. You ask her about the vomiting and discover it has been increasing over the last 1-2 weeks, is

non-bilious, happens after every feed and that her baby is hungry for food immediately afterwards. Which one of the following cap gas results will help confirm the most likely diagnosis?  (pyloric stenosis)PAEDS 2

Options:

a) pH 7.35, pCO2 5, pO2 9, HCO 23, BE -1, Na 137, K 4.5  

(

slighly

low PO2, otherwise normal)

b) pH 7.49, pCO2 6, pO2 9, HCO3 27, BE +4, Na 149, K4.5

(metabolic alkalosis with

hypernatraemia

)

c) 

pH 7.49, pCO2 5, pO2 9, HCO3 30, BE +4, Na 149, K 2.5

 

d) pH 7.49, pCO2 2.5, pO2 9, HCO3 21, BE 0, Na 149, K 2.5

(

resp

alkalosis with partial metabolic compensation,

hypernatraemia

, hypokalaemia)

e) pH 7.29, pCO2 9, pO2 5, HCO3 18, BE -6, Na 149, K 2.5

 (mixed

resp

&

metab

acidosis)

Pyloric stenosis summary:

Presentation

: 

2-8 weeks-old (M>F)

Projectile, non-bilious vomiting

Investigations

Bloods: 

Hypochloraemic

, 

hypokalaemic

, metabolic alkalosis (think: vomit of H" and K+, Cl-)

Definite: USS (target lesion)

Mx

Fluid

ressuscitate

Sx

(pyloromyotomy)

Slide20

Parents arrive in A+E with their unimmunised

3 year old daughter, who looks very unwell. You note she is

drooling rather than swallowing her saliva. What is the most likely cause of this presentation? (Epiglottitis) PAEDS 3

Options:

a)

Haemophilus Influenzae B 

b) Measles

( Fever, maculopapular rash, spreading down the ears, 

koplik

spots)

c) Meningitis C 

(drooling points more to epiglottitis)

d) Parainfluenza

(croup: coryzal symptoms & barking cough)

e) Respiratory 

Syncitial

 Virus

 (younger infants, cough, fever, wheeze)

Epiglottitis

Presentation

: 

High fever

Drooling

stridor

Unvaccinated

Investigations

EMERGENCY: DON’T DO ANYTHING, DON’T EXAMINE THE THROAT, CALL SENIORS

Mx

Urgent referral to ENT,

paeds

, anaesthetics

Slide21

Further reading

Slide22

Which presentation is consistent with physiological jaundice in the neonate?

Options:

a) Jaundice first noticed from day 7, breastfed,

pale chalky stools (obstructive jaundice). 

b)

Jaundice first noticed from day 2, breastfed, 11%

Wt

loss on D5, green stools, light urine with specks of orange in nappy.

 

c) Jaundice first noticed

at eight hours of age

, breastfed,

Hb 130

(↓; N for neonates:

140-240) 

on blood gas .

(haemolytic jaundice)

d) Jaundice in a baby

24 hours old

, breastfed,

tachypnoea, pale urine, meconium stools (too unwell)

. 

e) Jaundice referred to prolonged jaundice clinic, total

bilirubin 130, conjugated bilirubin 80. (high

uBR & prolonged jaundice > worry about obstructive jaundice)

PAEDS 4

NB:

Direct serum BR = conjugated, indirect =unconjugated BR

Slide23

Sarah is 2 years

old and presents with a limp in her right leg. This has been present for 2 days and she is not able to weight bear. She appears systemically well. Her

temperature is 38.6 degrees. Mum says she had a cough and cold last week but this has now subsided. She is a little less active than usual, but has no other systemic symptoms. There does not seem to be any focal tenderness when palpating her leg, but she cries when you attempt to move her hip (septic arthritis). What is the most appropriate management strategy?

PAEDS 5

Options:

a) Admit to the observation unit for 24 hours for ongoing observation

(red flags for septic arthritis)

.

 

b) Discharge home with safety netting advice and NSAIDS for 48 hours

(needs antibiotics)

c) Perform a full septic screen including lumbar puncture

(there is a focus of infection)

d) Start IV antibiotics and perform an MRI of her hip

 (no need of MRI, she needs a joint aspirate)

 

e)

Take bloods and blood cultures and refer for an orthopaedic opinion

(joint aspirate)

Septic arthritis:

Blood cultures

(haematogenous spread most common)

Imaging

Synovial fluid aspiration

NB

: For hip septic arthritis, aspiration needs to be done emergently by

ortho

, because it is an inaccessible joint

Slide24

Further reading

Kocher Criteria

Distinguishing transient synovitis from septic arthritis

More likely to be due to septic arthritis if:

Temperature >38.5C

Unable to bear weight on limb

ESR >40

WCC >12

LIMP IN CHILDREN: Refer urgently if

Fever & red 

Suspicion of maltreatment

< 3 

yrs

 (septic arthritis > transient synovitis)

>9 

yrs

 & painful/restricted movements to exclude SUFE

Slide25

OPTIONS:

1. 10 year old boy has a plasma glucose of 12 at the afternoon clinic. He records his plasma glucose on waking to be 6.9. 

2. The mother of an 8 year old girl reports her daughter has been extremely thirsty lately. She has also been very tired all the time and is significantly smaller than her classmates. She has been wetting the bed every night. 

3.

12 year old girl has a fasting plasma glucose of 7.5. Her random plasma glucose is 13. She has not had any polyuria, polydipsia nor changes in weight.

 

4. 15 year old boy has a random plasma glucose of 12 and fasting plasma glucose of 5. He has noticed some white patches on his skin. 

5. 7 year old girl has a fasting plasma glucose of 8. She recently saw the opticians, who said that she required glasses. Her glucose was taken at her GP randomly and found to be 10.

PAEDS 6

Which one of these would meet the criteria for diagnosis of T1DM?

T1DM: diagnostic criteria

Symptoms 

    +            

 Fasting ≥7.0mmol/L    

Random ≥11.1mmol/L

2 hours post load > 11.1

HbA1c > 48

If no symptoms 2 tests

Slide26

OPTIONS:

1. Cranial radiotherapy 

2. Craniopharyngioma 

3.

McCune Albright Syndrome

 

4. Neurofibromatosis 

5. Hamartomas

PAEDS 7

What is a gonadotrophin-independent cause of precocious puberty?

 

Precocious puberty

Gonadotrophin dependent causes

Premature activation of HPG axis

Idiopathic (most common)

CNS abnormalities (tumours, trauma (bleeding), central congenital disorders, neurofibromatosis, hamartomas)

Gonadotrophin

INdependent

causes

Ovarian/testicular

Adrenal (CAH, Cushing's)

Tumours

McCune Albright Syndrome

Obesity

McCune Albright syndrome:

polyostotic fibrous dysplasia, café-au-lait spots, ovarian cysts

Slide27

PAEDS 8

A 13 year old girl presents to

paediatric A&E with a new fever, rigors and progressively worsening cough. She is currently on medical treatment for Graves’ disease. How would you confirm the most likely complication causing this presentation?

OPTIONS:

1. 9am cortisol 

2. TFTs 

3. Blood Cultures 

4

. FBC 

5. CT Chest

Carbimazole SEs

Agranulocytosis & neutropenia

Pts on carbimazole should report symptoms and signs suggestive of infection,

esp

sore throat.

FBC if evidence of infection

STOP carbimazole if evidence of neutropenia

Slide28

A 18 month child has presented to paediatric A&E unable to weight bear. This child had previously started walking independently but is now refusing to walk. They are in clear distress

. Prior to this the patient was progressing well with no developmental concerns and is up to date with their immunisations. On examination there is an area of redness and swelling overlying the R hip.

They have been spiking fevers of 28 degrees but observations otherwise stable. Which of the following is the most important investigation?

PAEDS 9

OPTIONS:

1. Blood cultures

(you would do it as part of any suspected bacterial infection, but here we want most important investigation –

cf

Q5

paeds

)

2. Joint aspirate 

3. MRI femur 

4. FBC 

5. Hip X-ray

Slide29

FURTHER READING

Slide30

A baby born at 26/40 in on the neonatal ICU. She is 3 days old, is requiring respiratory support and having NG feeds. The nurses tell you she has just had a green vomit. On your assessment her heart sounds are normal, she is breathing quickly but chest sounds clear, abdomen is distended and bowel sounds are present. What is the most likely diagnosis?

PAEDS 10

OPTIONS:

A Duodenal atresia

(after first feed)

B

Necrotising

enterocolitis 

C Aspiration pneumonia

(

non bilious

)

D Pyloric stenosis

(non-bilious)

E Gastroenteritis

(non-bilious)

Necrotising enterocolitis: 

Preterm babies

When they are advancing feeds

Vomiting (can be bilious)

Abdo distension

AXR: dilated bowel loops, intramural gas

Mx: stop feeding, NG tube +/-

Sx

Slide31

An 8 year old boy is seen in clinic as he has a scout camp next month and is desperate to attend, however he is still struggling with bedwetting overnight. His mother has already bought an

enuresis alarm but this does not seem to be working, although they are using it appropriately

. What management is most appropriate?PAEDS 11

OPTIONS:

A Reassurance but no management 

B

DDAVP (desmopressin) sublingual 

C Oxybutynin

 

 

D

Behavioural

therapy intervention 

E Trimethoprim

 

Primary enuresis Mx:

Positive reward system

Enuresis alarm

Desmopressin

(also 1st line for short term control,

eg

sleepovers)

Slide32

A 7 year old with asthma presents with a 2 month history of increased cough and shortness of breath on exertion. He has been using his salbutamol inhaler several times most days

. His current regular medication is 400 ug

beclomathasone per day. What is the next step in treatment?

PAEDS 12

OPTIONS:

A

Long acting B2 agonist 

B oral steroids at 2mg/kg for 3 days 

C Slow release theophylline 

D increase inhaled steroids 

E

Use salbutamol regularly three times per day

Slide33

A 5-year-old boy presents to the emergency department as his mum has noticed he is ‘puffy around his eyes and ankles’. He is normally fit and well but has been lethargic over the last few days and has vomited on a few occasions (renal failure). His urine reveals

protein 3+, leucocytes negative, nitrites negative. His bloods reveal albumin 22 (low)

. He has no significant past medical history. Given the most likely diagnosis, what is the best initial management plan (nephrotic syndrome):

OPTIONS:

A Dexamethasone 40mg/m2/day for 4 weeks

 (very high steroid dose)

 

B Dexamethasone 60mg/m2/day for 4 weeks 

C Prednisolone 40mg/m2/day for 4 weeks

(you will reduce to 40 after 4 weeks)

D

Prednisolone 60mg/m2/day for 4 weeks 

E No medication, review in 4 weeks

PAEDS 13

Nephrotic syndrome:

Proteinuria

Peripheral oedema

Low albumin

Mx

: reducing dose of steroids (pred). If steroid resistant > specialist

Complications

: hypovolaemia, thrombosis, hyperlipidaemia

Slide34

You suspect a lady who is 35 years old, G4P3 30+6 might have a PE. You would like to investigate her for this. US doppler of the lower limbs comes back normal but you still strongly suspect a PE. She has a strong family history of breast cancer and is worried about radiation to her breast tissue. Which investigation would be most appropriate for her?

O&G - 1

OPTIONS:

A Repeat USS LL 

B

V/Q Scan (82%)

C CTPA (23%)

D CT Chest

E CXR 

PE in Pregnancy:

Investigations:

In A&E: ECG and CXR

If + signs of DVT

 compression Duplex USS (if positive = start

tx

)

If –

ve

sx

of DVT  CTPA

OR

V/Q

D-dimer testing should

not

be performed in the investigation of acute VTE in pregnancy

Slide35

https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/thrombosis-and-embolism-during-pregnancy-and-the-puerperium-acute-management-green-top-guideline-no-37b/

Slide36

You review a lady on the birth centre who is already in labour. She mentions that she has a headache and epigastric pain. The midwife checks her blood pressure and it’s 160/101 and 155/108

manually. What is the most appropriate management?

O&G - 2

OPTIONS:

A Repeat BP electronically

B IV nifedipine (30%)

C PO hydralazine

D

PO labetalol (64%)

E Wait and re-check BP in an hour

Pre-eclampsia:

Symptoms include:

severe headache

problems with vision, such as blurring or flashing before the eyes

severe pain just below the ribs

vomiting

sudden swelling of the face, hands or feet.

Slide37

1.5 Management of pre-eclampsia

1.8 Medical management of severe hypertension, severe pre-eclampsia or eclampsia in a critical care setting

https://www.nice.org.uk/guidance/ng133/chapter/recommendations#reducing-the-risk-of-hypertensive-disorders-in-pregnancy

Slide38

You review a lady in A&E. She is 8 weeks pregnant and very confident of the dates. She attended A&E because she had some PV bleeding at home after intercourse, which has now resolved. She has no pain. Normal observations. On a bedside scan the uterus is empty. What is the diagnosis?

O&G - 3

OPTIONS:

A

Complete Miscarriage (64%)

B Inevitable Miscarriage

C Incomplete Miscarriage

D

Pregnancy of unknown viability

E

Pregnancy of unknown location (31%)

 needs to have been previously visualized on USS

Slide39

Ectopic pregnancy and miscarriage: diagnosis and initial management

https://www.nice.org.uk/guidance/ng126

Slide40

Regarding anatomy, which of the following is true?

O&G - 4

OPTIONS:

A Bartholin’s gland is unilateral

B Bartholin’s gland is located lateral to the clitoris

C

Bartholin’s glands are bilateral and located lateral and inferior to the vaginal opening (90%)

D Skene’s gland is present in the male

E Bartholin’s gland is also known as the para-urethral gland

 para-urethral gland

Slide41

https://memorang.com/flashcards/19491/Bartholin+Duct+Cyst

Suggestion for future reading: Bartholin’s Cyst vs Abscess (+ management)

Slide42

You are asked to perform an ARM for a lady with GDM who was breech yesterday, but is cephalic today. The head is high and she is known to have polyhydramnios. Which emergency are you anticipating imminently?

O&G - 5

OPTIONS:

A Pre-eclampsia

B

Shoulder dystocia (23%)

C Umbilical cord prolapse (72%)

D Undiagnosed breech

E

Post-partum

haemorrhage

 fetal macrosomia

 4 “T’s” of PPH

Slide43

https://www.rcog.org.uk/guidance/browse-all-guidance/green-top-guidelines/umbilical-cord-prolapse-green-top-guideline-no-50/

Inducing labourNICE guideline [NG207]

https://www.nice.org.uk/guidance/ng207/chapter/recommendations#assessment-before-induction

Slide44

A 15 year old attends the GP for contraception advice. She is in a relationship with another 15 year old male. She is sexually active and uses barrier contraception. You are satisfied that she is competent to make this choice. Which of the following describes the legal framework on which you are allowed to prescribe contraception for her?

O&G - 6

OPTIONS:

A

Gillick Competence
(36%)

 decisions in a wider context

B European Convention of Human’s Rights


C Human

Fertilisation

and Embryology Act 1990

D Fraser Guideline (Family Law Reform Act 1969)(64%)

 relating specifically to contraception

E Abortion Act 19

6

7

Slide45

https://www.cqc.org.uk/guidance-providers/gps/gp-mythbuster-8-gillick-competency-fraser-guidelines

Slide46

A woman wants to terminate her pregnancy as she has 4 children already. She is 7 weeks pregnant. Which clause of the abortion act does this fall under?

O&G - 7

OPTIONS:

A A: that the pregnancy has not exceeded its twenty-fourth week and that the 
continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman or any existing children of her family 
(87%)

B B: that the termination is necessary to prevent grave permanent injury to the physical or mental health of the pregnant woman; 


C C: that the continuance of the pregnancy would involve risk to the life of the pregnant woman, greater than if the pregnancy were terminated; 


D D: that there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped 


E E: that there is substantial risk that if the child were born it would be given into the care of the state 


Slide47

https://www.bpas.org/get-involved/campaigns/briefings/abortion-law/#:~:text=The%201967%20Abortion%20Act%20took,woman'%20(emphasis%20added)

.

Slide48

You are the only doctor in a small rural GP practice. A 17 year old girl attends because she is 6 weeks pregnant and wishes to terminate the pregnancy. You do not wish to refer her to abortion services for personal reasons. What is the most appropriate next action?

O&G - 8

OPTIONS:

A Do not refer the patient as you are entitled to conscientiously object 


B Persuade the patient to not terminate the pregnancy 


C Tell the patient to join another GP practice 


D Urgent referral to another suitably qualified

colleague 
(95%)

E Prescribe mifepristone and misoprostol

Slide49

You see a 16 year old girl in Paediatric and Adolescent Gynaecology Clinic. She presents with primary amenorrhoea. Upon further history taking you elicit that she experiences lower abdominal pain every 28 days and suffered with recurrent UTIs as a child. The patient consents to examination and you note that she has undergone female genital mutilation. What is your immediate professional obligation under the FGM act 2003?

O&G -9

OPTIONS:

A Refer her to a specialist FGM doctor regardless of consent

B Report to

social services

regardless of consent


C Report to the police regardless of consent
(88%)

D Admit to hospital immediately as a safeguarding concern

E Call 999

Slide50

https://www.legislation.gov.uk/ukpga/2003/31/section/5B

Slide51

Which of the following statements is most accurate?

O&G - 10

OPTIONS:

A Lichen planus is strongly associated with developing VIN

(21%)

 lichen

sclerosus

B Lichens sclerosis presents with purple papules 


C Vaginal cancer is associated with maternal thalidomide use during pregnancy 


D Vulval cancer is associated with obesity 


E Differentiated type VIN is associated with

keratinising

squamous cell carcinoma of the vulva 
(57%)

Slide52

https://www.cancerresearchuk.org/about-cancer/vulval-cancer/stages-types-grades/vulval-intraepithelial-neoplasia

Slide53

A woman presents to your antenatal clinic and is noted to have a fasting glucose of 9mmol/l. How will this affect her pregnancy?

O&G - 11

OPTIONS:

A

Aspirin required from 12wks

B

Insulin required for management (35%)



always think pre-eclampsia

C

Folic acid 5mg until 12 weeks

D Metformin + Aspirin from 12wks

E Insulin + Folic acid 5mg until 12wks + Aspirin form 12wks (52%)

Slide54

https://www.niddk.nih.gov/health-information/diabetes/overview/what-is-diabetes/gestational/tests-diagnosis#:~:text=Oral%20Glucose%20Tolerance%20Test%20(OGTT)&text=You%20will%20need%20your%20blood,mean%20you%20have%20gestational%20diabetes

.

https://www.nhs.uk/conditions/gestational-diabetes/

Slide55

A 32 year old woman presents to you at 16wks with elevated BP without proteinuria on urine dip. Which of the following is the most appropriate with regards to her need for aspirin?

O&G -

12

OPTIONS:

A She requires weekly measurement for proteinuria and her management will depend on whether she develops proteinuria

B She requires formal PCR to determine whether there is proteinuria and

C She needs a full history to assess risk factors for pre-eclampsia and if she has enough risk factors she will need aspirin for pre-eclampsia (48%)

 chronic hypertension

D She needs aspirin from 12wks regardless of risk factors from her history (34%)

E She needs to start an ACE inhibitor

Slide56

O+G – 10 and 11

1.1 Reducing the risk of hypertensive disorders in pregnancy

https://www.nice.org.uk/guidance/ng133/chapter/Recommendations#antiplatelet-agents

Slide57

A woman presents at 36wks with a placenta reaching over the os. What is advised?

O&G -

13

OPTIONS:

A Further scan at 38

wks

(and then weekly)

B Admit and induce labour ASAP

C She should be advised re C-section (95%)

D She should be taking aspirin

E She should start prophylactic erythromycin due to the risk of infection

Slide58

Slide59

Thank youand GOOD LUCK!

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