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Clinical Management test (Part 1)

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1) You review a patient in the fertility clinic. The ultrasound and biochemical profile are consistent with PCOS. She has been trying to conceive for 2 years. Her BMI is 26 kg/m2. She is a non‐ smoker. Which of the following is the most appropriate first line treatment?

2) A 45 year old women is seen in clinic following hysteroscopy and biopsy due to irregular menstrual bleeding. Her BMI is 34 kg/m2. This shows hyperplasia without atypia. Following a discussion the patient declines any treatment but agrees she will try and lose weight. Which of the following is the most appropriate regarding follow up?

3) A 27 year old women who is 26 weeks pregnant attends clinic with a classical chickenpox rash. The lesions are fairly sparse and she is systemically well. According to the Greentop Guidelines which of the following is appropriate?

4)

A 21 year old patient presents to the emergency department with sudden onset of severe lower
abdominal and pelvic pain. History reveals she missed her last 2 periods. She normally has
regular 28 day cycles. She smokes 5 cigarettes per day.
On examination she has lower abdominal tenderness and on vaginal exam there is cervical
tenderness. Observations are as follows:
Temperature: 37.2 oC
Blood pressure: 90/54
Heart rate: 115
Respiration rate: 18
Pregnancy test positive
What would be the most appropriate management of this patient?

5) According to the RCOG Green‐top guideline on management of PPH, up to what volume of blood loss (in the absence of clinical shock signs) is it appropriate to continue basic measures rather than full resuscitation protocols

6) Regarding PCOS (PolyCystic Ovary Syndrome) which of the following criteria are recognized as the current gold standard for diagnosis of PCOS

7) 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 (PROM). According to NICE guidelines after what time period should induction be offered?

8) According to the green top guidelines all of the following complications of laparoscopy should be discussed with the patient EXCEPT which one?

9) A 33 year old women with known stage III cervical cancer presents to A&E with lower abdominal and unilateral flank pain. From the following list what is the likely diagnosis?

10) Which of the following has been shown to improve pruritus and liver function in patients with obstetric cholestasis?

11) A 26 year old women presents for her 12 week scan. She has been pregnant once before but had a 1st trimester miscarriage. She reports no problems with this pregnancy and has had no vaginal bleeding or spotting. The scan shows no fetal cardiac activity and a small gestational sac. What is the likely diagnosis?

12) You are called to see a 19 year old primigravida woman in A&E who is 11 weeks pregnant, has severe vomiting and is unable to keep fluids down. For the previous 3 weeks she has been nauseated with occasional vomiting but this has gradually deteriorated over the past 5 days.

BP: 102/60
HR: 96
RR: 16
Sats: 98%OA
Urinalysis: Ketones ++, protein+, leucocytes negative, nitrites negative, glucose negative
Na+ 131 mmol/l
K+ 3.3 mmol/l
Urea 14.0 mmol/l
Creatinine 99 µmol/l
Which of the following is an appropriate part of her initial treatment?
Her observations and U&Es are as follows:

13) What guidelines apply specifically to contraceptive advice and treatment in under 16's?

14) What guidelines apply specifically to contraceptive advice and treatment in under 16's?

15) You are asked to review a patient in the first stage of labour as the midwife is concerned about her progress. This is her first pregnancy. She has dilated from 4cm to 6cm in 4 hours. At your initial assessment she is 6cm dilated with membranes intact. You review her again 2 hours later and the cervix is now 6.5cm dilated with membranes in tact. What is the most appropriate management?

16)

A 27 year old women has a miscarriage at 8 weeks. Her observations the following day are:
-Temperatue 36.5 oC
 Blood Pressure 90/60
 Heart Rate 95
She has a FBC taken and the results are:
 Hb: 67 g/l
 WCC: 7.6 x10*9/l
 PLT 175 x 10*9/l
What is the most appropriate course of management?

17) A patient arrives on labour ward she is 37 weeks pregnant. Her last pregnancy ended with delivery via uncomplicated lower segment C‐Section 4 years ago. Contractions are 5 minutes apart and on examination and the cervix is 5cm dilated. She wants to know the risk to the baby of proceeding with vaginal delivery (VBAC). What is the additional risk of perinatal death with VBAC?

18) Which of the following conditions would prevent prescription of a POP to a women or warrant referral to a specialist contraceptive provider?

19)

A 28 year old primigravida women was admitted from A&E yesterday after attending due to severe nausea and vomiting and started on IV saline with potassium, IV pabrinex and IV cyclizine.
She is currently 11 weeks pregnant. For the previous 3 weeks she has been nauseated with occasional vomiting but had really struggled to keep any fluids down for 3 days prior to admission. Her U&Es in A&E were as follows:

Na+ 119 mmol/l
K+ 3.1 mmol/l
Urea 14.0 mmol/l
Creatinine 99 µmol/l
You are asked to review her on the ward as she is dysarthric and disorientated. You repeat her
U&Es which are as follows:
Na+ 139 mmol/l
K+ 3.6 mmol/l
Urea 5.0 mmol/l
Creatinine 55 µmol/l
What is the likely diagnosis?

20)

A 41 year old women has abdominal hysterectomy for fibroids. You are asked to review her 76 hours post‐operatively as she is complaining of left sided flank pain and has a fever (Temperature 38.0 oC). BP is 140/90 Heart rate 88. Bloods show creatinine 110mmol/l (pre‐op 70mmol/l). Urine dip shows blood
++ nitrites negative. What is the likely diagnosis?

21) A patient is in the 1st stage of labour at full term and is planning for vaginal delivery. In her previous pregnancy she sustained a 3b perineal tear. Which of the following is the most appropriate measure to minimise perineal trauma?

22)

A 23 year old patient presents to the emergency department with sudden onset of severe lower abdominal and pelvic pain. History reveals she normally has regular 28 day cycles but she missed her last period. Past medical history reveals 2 termination of pregnancy procedures in the past 3 years. The most recent one 6 months ago. She smokes 5 cigarettes per day.
On examination she has lower abdominal tenderness and on vaginal exam there is cervical
tenderness. Observations are as follows:
Temperature: 37.2 oC
Blood pressure: 100/60
Heart rate: 110
Respiration rate: 16
Urine sample & blood results: awaited
What is the likely diagnosis?

23)

You are asked to review a 44 year old patient with her partner in fertility clinic. She reports her
last period was 5 months ago and the one prior to that 4 months earlier. She hasn't taken
contraception of any form for 4 years. Her BMI is 29 kg/m2. She is a non-smoker. The results of
initial investigations are below:
 Partners semen analysis: All parameters within normal fertile range on 2 samples
 Sexual health screen: Negative for HIV, syphilis, gonorrhoea and chlamydia
 Ultrasound: left ovary measures 1.9 x 1.8 cm. The right ovary wasn't clearly seen.
 FSH 36 IU/L (Reference Range 5-25 IU/L female ovulation)
 LH 44 IU/L (Reference Range Mid-cycle: 20-105 mIU/mL)
 HBA1C 39 mmol/mol (Refernece range: <42mmol/mol)  Progesterone 3 nmol/l (Reference range: Day 21 >16 nmol/l)
 Prolactin 4 ng/ml (reference range: 2 - 29 ng/ml)
 What is the likely diagnosis?

24) A 26 year old primigravida woman attends A&E due to worsening vomiting. She is currently 10 weeks pregnant. For the past 4 weeks she has had moning sickness but for the last 4 days she has been unable to tolerate any oral fluids without vomiting and thinks she has lost weight. On questioning she has no significant past medical history prior to this pregnancy. She is currently taking the following medication:

 Folic acid 400 mcg OD
 Vitamin D 10 mcg OD
Her observations are as follows:
 Blood pressure: 96/62
 Heart rate: 96
 Respiration rate: 15
 Temperature: 37.1 oC
 Urinalysis: Protein + Ketones ++ Leucocytes negative Nitrates negative
 Fingerpick glucose: 6.1
What is the likely diagnosis?

25) A 25 year old women has a medically managed miscarriage. Assuming she has no complications what would you advise regarding further pregnancy te

26) According to the RCOG Green‐top guidelines on prevention and management of post‐partum haemorrhage (PPH) which of the following statements is true?

27) A 45 year old women is seen in clinic following hysteroscopy and biopsy due to irregular menstrual bleeding. Her BMI is 34 kg/m2. This shows atypical hyperplasia. Which of the following is the most appropriate 1st line management?

28) Which vitamin deficiency leads to Wernicke's encephalopathy?

29) An 18 year old patient comes to see you in clinic. Her BMI is 25.0 and her BP is 122/80. She is a non‐smoker and there is no personal or family history of VTE or migraine. She would like to start the pill for her acne. She has used topical Zineryt in the past but still has moderate acne. What is the most appropriate option?

30) Early amniocentesis has a higher fetal loss rate and increased incidence of fetal talipes and respiratory morbidity compared with other CVS. When is the earliest appropriate gestational age to perform amniocentesis?

31) A 22 year old patient who is 18 weeks pregnant presents with vaginal discharge. Swabs are taken which show heavy growth of neisseria gonorrhoea. Which of the following is the most appropriate treatment regime?

32) You are performing a diagnostic laparoscopy on a patient. What is the appropriate distension pressure upon completion of trocar insertion?

33) 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?

34)

A 26 year old patient attends the A&E department. She reports becoming acutely short of breath with chest pain 1 hour prior to attending. She is not on any regular medication. Of note she had an uncomplicated birth by normal vaginal delivery at term 3 weeks ago. Her observations are as follows:
Blood pressure: 100/60
Heart Rate: 100
Respiratory Rate: 20
Oxygen sats: 94% on air
What is the likely diagnosis?

35) You are discussing laparoscopy risks with the patient. What of the following statements regarding entry techniques is true?

36) When consenting someone for laparoscopy you discuss the risk of vascular injury. The incidence of vascular injury during laparoscopy according to the Green‐top guidelines is?

37) Testing for PKU is done via blood assay for Phenylalanine (Guthrie inhibition assay) When should this be done?

38) A patient has been seeing you due to itching during pregnancy and you have diagnosed cholestatic jaundice. What is the most appropriate advice regarding testing LFTs postnatally?

39)

A 39 year old women is seen in clinic following hysteroscopy and biopsy due to irregular menstrual bleeding. Her BMI is 25 kg/m2. This shows hyperplasia without atypia. Which of the following is the most appropriate management option?
What is the likely diagnosis?

40) You review a patient in the fertility clinic. The ultrasound and biochemical profile are consistent with PCOS. She has been trying to conceive for 2 years. Her BMI is 26 kg/m2. She is a non‐ smoker. You plan to initiate Clomiphene. According to NICE guidance how long should  treatment continue for (assuming patient remains non‐pregnant)?

41) According to the RCOG Green‐top guidelines on prevention and management of post‐partum haemorrhage (PPH) which of the following statements is true?

42)

A 25 year old women who is 20 weeks pregnant is seen in A&E with a 36 hour of feeling nauseated, shivery and having loin pain.
Her observations are as follows:
Blood Pressure 88/56.
Pulse Rate 110
Temperature 38.8oC
Urine dip: leucocytes +++, protein +++, nitrites positive, blood negative, glucose negative
Which of the following is an appropriate measure according to the RCOG guidelines?

43) You consultant asks you to close following a planned Caesarian section (CS) delivery. Which of the following statements is true regarding CS?

44) 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?

45) A patient attends for a routine diagnostic outpatient hysteroscopy. Which of the following statement are true?

46) Fraser guidelines apply to which of the following situations?

47) A 25 year old women who is 20 weeks pregnant is seen in A&E with a 36 hour of feeling nauseated, shivery and having loin pain. Her observations are as follows:

Blood Pressure 88/56.
Pulse Rate 110
Temperature 38.8oC
Urine dip shows leucocytes +++ and protein +++
You take bloods. What serum lactate level is indicative of tissue hypo‐perfusion?

48) You are performing a diagnostic laparoscopy on a patient. What is the appropriate distension pressure upon completion of trocar insertion?

49) You are asked to review a 44 year old patient with her partner in fertility clinic. She reports her last period was 5 months ago and the one prior to that 4 months earlier. She hasn't taken contraception of any form for 4 years. Her BMI is 29 kg/m2. She is a non‐smoker. The results of initial investigations are below:

 Partners semen analysis: All parameters within normal fertile range on 2 samples
 Sexual health screen: Negative for HIV, syphilis, gonorrhoea and chlamydia
 Ultrasound: left ovary measures 1.9 x 1.8 cm. The right ovary wasn't clearly seen.
 FSH 36 IU/L (Reference Range 5‐25 IU/L female ovulation)
 LH 44 IU/L (Reference Range Mid‐cycle: 20‐105 mIU/mL)
 HBA1C 39 mmol/mol (Refernece range: <42mmol/mol)  Progesterone 3 nmol/l (Reference range: Day 21 >16 nmol/l)
 Prolactin 11 ng/ml (reference range: 2 ‐ 29 ng/ml)

What is the best option for her regarding fertility treatment?

50) At what gestation does a mother typically first become aware of fetal movements?

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