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Clinical Management STRATOG NEW

A 16-year-old woman presents with secondary amenorrhoea. She is healthy,


with no past medical history. Her BMI is 17. What is the most appropriate
initial investigation?
Thyroid function test
Karyotype

The answer is follicle-stimulating hormone


measurement. The likely diagnosis is amenorrhoea
caused by weight loss, so follicle-stimulating
hormone measurements would be appropriate.
Since she is clinically euthyroid, thyroid function
tests would be of limited value.

Follicle-stimulating hormone measurement


Dehydroepiandrosterone sulphate (DHEAS) measurement
Bone mineral density scan
You are asked to assess a patient who is receiving magnesium sulphate
infusions for severe pre-eclampsia. They have passed only 5 ml urine in the
last 2 hours. Tests demonstrate that their deep tendon reflexes are absent.
What other observation should you take?
Temperature
Respiratory rate

The answer is respiratory rate. This patient has


signs of magnesium toxicity (absent deep tendon
reflexes), which is probably secondary to renal
impairment. Respiratory depression is a sign of
increasing magnesium toxicity is; therefore, the
most appropriate follow-up would be to investigate
the patients respiratory rate.

Pulse rate
Glasgow coma score
Blood pressure
A cardiotocograph shows type 1 variable decelerations. What is the cause of this
feature?
Umbilical cord compression
Placental insufficiency
Fetal movements
Fetal hypoxia
Fetal head compression

The answer is umbilical cord compression. Variable


decelerations are due to umbilical cord
compression. Early decelerations are caused by
compression of the fetal head, and late
decelerations are caused by fetal hypoxia that is
secondary to placental insufficiency. Fetal
movements are related to accelerations.

You answer an emergency call for a postpartum haemorrhage. The


midwife estimates that the patient has lost approximately 500 ml of blood.
What is the most likely cause of the bleeding?

The answer is uterine atony. Approximately 70% of


all postpartum haemorrhages are due to uterine
atony.

Vaginal tear
Uterine atony
Retained placenta tissue
Coagulopathy
Cervical trauma
Whilst you are attending to a patient in the antenatal ward, the patient collapses
and becomes unresponsive. You open their airway but they are not breathing.
What should you do next?
Left lateral tilt
Give a precordial thump
Get help

The answer is get help. Basic and Advanced Life


Support guidelines highlight the need to get help if
a patient has collapsed and is unresponsive. You
should then place the patient in left lateral tilt and
commence cardiac compressions at a rate of 30:2.
Artificial ventilation is not mandatory in the ALS
guidelines.

Commence cardiac compressions


Commence artificial ventilation
A 17-year-old woman presents to the sexual health clinic with vulval ulceration
and difficulty in passing urine. She is sexually active and has had unprotected
intercourse with her new boyfriend. She takes the combined oral contraceptive
pill. What is the most likely diagnosis?
Syphilis
Human papillomavirus
Herpes varicella virus
Herpes simplex virus
Candida albicans

The answer is herpes simplex virus. A painful


genital ulcer has developed in a sexually active
patient who has not used barrier contraception.
Syphilis is usually associated with the presence of
a painless ulcer. Candida is not a sexually
transmitted disease and rarely presents with
ulceration. Human papillomavirus causes warts,
and herpes varicella zoster causes chicken pox
and shingles.

A primigravid woman presents in spontaneous labour at 39 weeks of gestation.


At 18:00h, her cervical dilatation is 6 cm. A further vaginal examination at
22:00h reveals that cervical dilatation is still at 6 cm. At 02:10h, the fetus is in
the occipitoposterior position and uterine activity is present. What is the most
appropriate action?
Repeat vaginal examination after 4 hours

The answer is amniotomy. This case demonstrates


slow/no progression during the first stage of labour
and malpositioning of the fetus. The most
appropriate initial intervention would be an
amniotomy (artificial rupture of the membranes).

Repeat vaginal examination after 2 hours


Membrane sweep
Commence intravenous oxytocin
Amniotomy
An 18-year-old woman presents to an early pregnancy unit with light vaginal
bleeding after 10 weeks of amenorrhea. She had taken a pregnancy test 4
weeks ago that had tested positive. A transvaginal ultrasound scan showed an
irregular gestation sac with no fetal pole. What is the likely diagnosis?
Threatened miscarriage
Incomplete miscarriage
Hydatidiform mole
Complete miscarriage
Anembryonic pregnancy
A 55-year-old woman presents to the clinic enquiring about the use of hormone
replacement therapy (HRT). She had a hysterectomy 8 years ago for fibroids.
She has no contraindications or other past medical history, except a strong
family history of osteoporosis. Her main symptoms are hot flushes and vaginal
dryness. What would be your first treatment option?
Selective serotonin reuptake inhibitor

The answer is anembryonic pregnancy. Threatened


miscarriage refers to vaginal bleeding in the
presence of a viable pregnancy; however, this
pregnancy is not viable. There are products of
conception (gestation sac) that are visible on the
scan so this is an incomplete miscarriage, which is
usually associated with heavy vaginal bleeding. In
this case, the patient is considered to be pregnant,
although no embryonic tissue is present. Therefore,
the most likely diagnosis is anembryonic
pregnancy.
The answer is estrogen-only HRT. HRT provides
the most effective method of treating climacteric hot
flushes and vaginal dryness, as well as
postmenopausal osteoporosis. Estrogen-only HRT
is appropriate following a hysterectomy, as the risk
of endometrial carcinoma is not present.

Oral calcium therapy only


Estrogen-only HRT
Combined sequential HRT
A selective estrogen receptor modulator
A 68-year-old woman presents with two episodes of postmenopausal bleeding.
She has a BMI of 23 and is otherwise healthy. An ultrasound shows that her
endometrial cavity is 4 mm thick, and an endometrial pipelle sample is taken that
yields a small volume of tissue. The pathology report suggests a neoplasm. What
is the most likely diagnosis?
Serous carcinoma
Endometrioid adenocarcinoma

The answer is serous carcinoma. Serous


carcinomas are typically seen in postmenopausal
women. The development of these carcinomas is
not associated with a raised BMI, diabetes or
hypertension. The uterine tumour can be very
small (even in the presence of extra uterine
spread), and therefore, results from an ultrasound
and even hysteroscopy can appear normal.

Endometrial polyp
Endometrial hyperplasia
Leiomyoma
A nulliparous woman presents with spontaneous rupture of membranes at 41
weeks of gestation. At 18:00h, her cervical dilatation is 3 cm. A further vaginal
examination at 22:00h reveals that her cervical dilatation is still 3 cm. At 02:10h,
the fetus is in the occipitoposterior position and uterine activity is present. What
is the most appropriate action?

The answer is commence intravenous oxytocin.


The membranes have ruptured already so
amniotomy is not required. No progression has
been made during the first stage of labour.
Therefore, the patient should be administered
intravenous oxytocin.

Repeat vaginal examination after 4 hours


Membrane sweep
Commence intravenous oxytocin
Caesarean section
Administer prostaglandin per vaginam
Polyglactin sutures are used extensively in surgical procedures, particularly to
ligate vessels. What are the key features of polyglactin sutures?

The answer is braided, absorbable and synthetic.


Polyglactin sutures are used to ligate pedicles and
close the uterus during a caesarean section. To

Non-braided, non-absorbable and natural


Non-braided, absorbable and synthetic

achieve this, the sutures are braided to prevent the


knots from slipping.

Non-braided, absorbable and natural


Braided, non-absorbable and synthetic
Braided, absorbable and synthetic
The answer is Fraser. This law refers specifically
A 15-year-old patient visits her GP requesting a method of contraception. When taking
her history, you discover a personal history of thromboembolic events. She has had to contraception.
three sexual partners in 5 months. She also complains of dysmenorrhea. You advise on
contraception being mindful of which medical law?
Abortion Act 1967
Bolam
Bolitho
Fraser
Gillick
A patient with a previous caesarean section arrives at term to your unit in
spontaneous labour. The midwife reports the cervix is 6 cm dilated, there is a
longitudinal lie and the vertex is well applied to the cervix. The patient is
contracting three times in 10 minutes. You are asked to assess the patient by the
registrar on call as he is in theatre. What initial management would you suggest?

The best answer is CFM and vaginal assessment 2


hours following the last VE.

You immediately perform a fetal blood sample


You suggest continuous fetal monitoring (CFM) and syntocinon infusion
You suggest continuous fetal monitoring (CFM) and vaginal assessment 2
hours following the last VE
You suggest intermittent monitoring and 1 hourly vaginal assessments
You suggest mobilisation and a cooks catheter
A patient with a previous caesarean section arrives at term to your unit in

The best answer is scar rupture as the fetus is

spontaneous labour. The midwife reports the cervix is 6 cm dilated, there is a


longitudinal lie and the vertex is well applied to the cervix. The patient is
contracting three times in 10 minutes. The contractions stop and there is a fetal
bradycardia. What is the most likely diagnosis?

compromised.

Placental abruption
Scar dehiscence
Scar rupture
Tetanic uterine contractions
Uterine atony
A 28-year-old primiparous woman is induced at 39+2 for raised BP and
proteinuria. She progresses well to full dilatation, but after pushing for 2 hours
there is no vertex visible. On examination, the head is felt to be OA, at +1 station.
A decision is made for an instrumental delivery, and the baby is delivered via
assisted vaginal delivery in theatre. For a ventouse delivery to be successful, the
ventouse cup needs to be applied to the flexion point of the fetal head. Which of
the following statements best describes the location of the flexion point?

The best answer is on the sagittal suture line,


approximately 3 cm anterior (in front) of the
posterior fontanelle.

Approximately 3 cm anterior (in front) of the anterior fontanelle


Directly over the anterior fontanelle
Directly over the posterior fontanelle
On the sagittal suture line, approximately 2 cm posterior (behind) the
posterior fontanelle
On the sagittal suture line, approximately 3 cm anterior (in front) of the
posterior fontanelle
A 28-year-old primiparous woman is induced at 39+2 for raised BP and
proteinuria. She progresses well to full dilatation, but after pushing for 2 hours
there is no vertex visible. On examination, the head is felt to be OA, at +1 station.
A decision is made for an instrumental delivery, and the baby is delivered via
assisted vaginal delivery in theatre. (Same scenario as question above.) Shortly

The best answer is a 3b degree tear. Note the the


risk of perineal tearing after instrumental delivery is
7% for forceps and 4% for ventouse.

after delivery, you examine the perineum. Your episiotomy has extended, and the
tear involves approximately 60% of the external anal sphincter. The internal anal
sphincter and anal mucosa are intact. How would you classify this perineal
trauma?
Second degree tear
3a degree tear
3b degree tear
3c degree tear
Fourth degree tear

A 54-year-old woman presents to her GP with malaise, a history of recent weight


loss and bloating. On examination the GP notes a large pelvic mass. He sends
her for an urgent abdminal ultrasound scan and initiates a 2-week-wait referral.
This patient is discussed at an MDT meeting and it is decided to proceed with a
laparatomy. During the laparotomy, a full examination is performed to look for
possible metastatic spread. If this cancer is presumed to be ovarian, which lymph
nodes would you expect the disease to drain to first?

The best answer is para-aortic lymph nodes.

External iliac lymph nodes


Hypogastric lymph nodes
Inguinal lymph nodes
Internal iliac lymph nodes
Para-aortic lymph nodes
A 30-year-old primigravida who is pregnant after IVF attends the Early Pregnancy
Unit with severe right sided abdominal pain. An ultrasound scan shows an empty
uterus. -hCG levels are 5,500 iu/L. What is the appropriate course of action?

The answer is laparoscopy and salpingectomy if


there is an ectopic pregnancy.

Expectant management, evaluate after 48 hours with repeat hCG levels


Laparoscopy and salpingectomy if there is an ectopic pregnancy
Laparoscopy and salpingotomy if there is an ectopic pregnancy
Methotrexate injection
Repeat scan in 7 days
The midwife has asked you to review a 34-year-old multigravida who is 7 cm
dilated and progressing well. The CTG shows a variability of <5. She was given
pethidine when she was 6 cm dilated. A fetal blood sampling is done and reveals
a pH of 7.23. What will be your next line of management?

The answer is repeat FBS within 30 minutes.

Delivery is indicated
Reassure the patient
Repeat FBS after 1 hour
Repeat FBS if fetal heart rate abnormality persists
Repeat FBS within 30 minutes
A 75-year-old woman presents with increased weight, loss of hair and a dislike of
cold weather. She was noted to have a high prolactin and normal electrolytes.
She is otherwise fit and well. What is the likely cause of the high prolactin?
Antiemetic use
Hypothyroidism
Neuroleptic use
Prolactinoma
Renal failure

The answer is hypothyroidism.

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