Week 10

Question 1 All of the following tests should be part of a routine initial (first trimester) antenatal screen EXCEPT? a) a full blood count b) blood group and Antibody screen c) a vaginal ultrasound d) a serological test for syphilis e) hep B surface antigen C. The Current recommendations on antenatal screening by the Royal Australian and New Zealand College of Obstetricians and Gynaecologists are that at the first antenatal visit, tests should be offered for: Blood group and antibody screen Full blood examination Rubella antibody status Syphilis serology Midstream urine examination by culture Hepatitis B serology Where the blood group has already been performed it does not need to be repeated. However, the antibody screen should be repeated at the beginning of each pregnancy and all Rhesus negative women and all those who have had isoimmunisation of any type in the past should be re-screened. Although a previous high rubella antibody titre is generally used to exclude this investigation from first visit testing, there is some evidence that antibody levels may decline after rubella immunisation, especially since antibody levels are rarely boosted by exposure to wild viruses in the community. All pregnant women should be offered hepatitis C and HIV screening at the first antenatal visit and if necessary after exposure to risk of infection. It is imperative that the woman is provided with appropriate counselling as to the limitations of the testing and the implications of both positive and negative findings. Documented normal cervical cytology within the preceding 18 months may be used to delay repeat screening if there is no clinical indication for another Papanicolaou smear.(dont do without indication) Routine vaginal ultrasound during the first trimester is not recommended except where the viability of the pregnancy is in question such as when the woman has had first trimester bleeding. (Beckmann CRB et al. Obstetrics & Gynaecology, 3rd Ed, Lippincott, Williams & Wilkins, Philadelphia, 1998, p 71. ) (The RANZCOG statement on antenatal testing can be found at their website Available: http://www.ranzcog.edu.au/Open/statements/Html/C-obs3.htm )

Question 2

Martin is 5 years old. His mother reports he has been waking her at night screaming in apparent fear. She is extremely worried. Although Martin is obviously frightened with these episodes he does not seem completely awake and she is unable to comfort him or wake him fully. He is sweaty, tachypnoeic and tachycardic. Martin does not recall these episodes in the morning. Martin is MOST LIKELY suffering from: a) nightmares b) hyperthyroidism c) night terrors d) anxiety e) epilepsy C. Night terrors are a disorder of arousal from NREM sleep, usually occurring in 3 to 8 year olds. The child only partially wakes, cannot be fully roused or comforted, and will have no recall of the episode. Autonomic symptoms as described are common. With nightmares, the child wakes fully, and frequently has full recall of their dreams. Night terrors may be precipitated by anxiety or an experience which has frightened the child prior to sleep. (Hay WW, Hayward AR, Levin MJ, Sondheimer JM, et al. (2003) Current Paediatric Diagnosis and Treatment, 16th Edition, Lange Medical Books/McGraw-Hill, p748 )

Question 3 Tonsillectomy would be recommended for each of the following patients EXCEPT: a) claire aged 3, who has had four episodes of tonsillitis in the last 12 months, each time associated with a febrile convulsion. b) sarah aged 4, who has had six episodes of a sore throat in the last 12 months and now has bilateral large tonsils and enlarged cervical lymph nodes c) steven aged 25, who has recently required incision and drainage of a quinsy (peritonsillar abscess) d) olive aged 63, who has noticed that right tonsil has enlarged recently. She also has an enlarged cervical lymph node on the right e) peter aged 10 whose parents complain that he snores loudly, and sometimes 'stops breathing' at night. He has large tonsils. B. It is not unusual for young children to have several episodes of 'sore throat' each year. These could be due to a number of conditions including pharyngitis, laryngitis, tonsillitis either viral or bacterial, or from exposure to irritants like cigarette smoke. Children such as Sarah, in the preschool age group frequently have large tonsils, adenoids and cervical glands as part of the normal growth pattern of lymphoid tissue. In these children a tonsillectomy would not be recommended. In all of the other cases, tonsillectomy is likely to be recommended. Claire's four episodes of (proven) tonsillitis have been accompanied by a worrying if not sinister symptom. Steven's quinsy is a clear indication for tonsillectomy, and Olive may have a malignancy. Peter's snoring and sleep apnoea also justifies tonsillectomy. (Harris, C (2002)'Childhood ENT Disorders', Australian Family Physician, Vol 31, no 8 p701-703 )

(Tjandra,J;Clunie,G;ThomasR (2001)'Textbook of Surgery' 2nd ed Blackwell Science Asia, Melbourne p359 ) (Drake A and Carr M (2003) Tonsillectomy. Available: http://www.emedicine.com/ent/topic315.htm ) (Beers MH, Berkhow R. (1999/2003) The Merck Manual of Diagnosis and Treatment Seventeenth edition Available: http://www.merck.com/pubs/mmanual/section14/chapter173/173d.htm ) (Loadsman JA and Hillman DR (2001) British Journal of Anaesthesia, Vol 86, No 2 254266 Available: http://www.usyd.edu.au/anaes/lectures/BJA_SAS.html ) * Question 4 Eve is 9 weeks pregnant. She presents with a history of 24 hours of intermittent dark blood loss staining her underwear. On vaginal examination, the uterus is the expected size and the cervical os is closed and non-tender. You should advise her that: a) she is likely to have miscarried b) approximately half of all pregnant women suffer bleeding during the first trimester c) she requires admission to hospital for a D&C d) there is a higher incidence of congenital malformations in fetuses where bleeding occurred in the first trimester e) she should have an ultrasound E. Eve has a threatened abortion as the os is closed and there is no history of passage of products of conception. This occurs in 25% of pregnancies and half of these progress to spontaneous abortion. For those who carry the pregnancy to term there is however no increased risk of congenital malformation. An ultrasound examination will be helpful, as it will demonstrate the presence (or absence) of a foetus appropriately sized for dates. The demonstration of a foetal heart is very reassuring. At 9 weeks, when a foetal heartbeat is present and not slow, 90% of pregnancies will continue despite bleeding. (Beckmann CRB et al. Obstetrics & Gynaecology, 3rd Ed, Lippincott, Williams & Wilkins, Philadelphia, 1998, p 175. ) (Beers MH, Berkhow R. (1999/2003) The Merck Manual of Diagnosis and Treatment Seventeenth edition Available: http://www.merck.com/pubs/mmanual/section18/chapter252/252a.htm ) (Threatened abortion. Available: http://www.gpnotebook.co.uk/simplepage.cfm?ID=214958095 ) (Sklar AJ (2003) Threatened Abortion. Available: http://www.emedicine.com/med/topic3308.htm ) (Creighton University, School of Medicine. Ultrasound of early pregnancy. Page 14 Available: http://radiology.creighton.edu/ultraofearlypreg.html ) Question 5 Samantha is 18 months old. She is usually well, with no significant past history, and is up to date with her childhood vaccinations. Samantha has been miserable and unwell for 24 hours with a clear runny nose, and a fever of 39 to 40 degrees Celsius. She has no cough, no diarrhoea or vomiting, and is drinking well, even though her appetite for solids is decreased. Suddenly Samantha has a generalised tonic clonic seizure, lasting 3 minutes. Which of the following statements regarding febrile convulsions in children is TRUE?

a) most febrile convulsions are focal or partial seizures b) samantha has a 20 - 30% chance of developing epilepsy c) the most common cause is CNS infection such as meningitis d) 30 - 50% of children experiencing a febrile convulsion may experience recurrent febrile convulsions e) the peak incidence is 4 - 5 years of age D. Febrile convulsions may be recurrent in 30 - 50% of cases, but this does not usually worsen long term prognosis. Most febrile convulsions occur in children aged 3 months to 5 years, with the peak incidence between 6 months and 20 months of age. More than 90% of seizures are generalised. Acute upper respiratory tract infections are the most common cause of febrile convulsions. In children under the age of two years if the cause of the febrile convulsion is not obvious, a lumbar puncture must be performed to exclude CNS infections. Only rarely do febrile seizures lead to epilepsy, the incidence being about 2 3%. The chance of developing epilepsy is increased if there is a family history of epilepsy, the child has a pre-existing neurological abnormality, the initial seizure is in a child under one year of age, the seizure is prolonged (greater than 15 minutes), has complex or focal features, or if the child fits more than once in one day. (Hay WW, Hayward AR, Levin MJ, Sondheimer JM, et al. (2003) Current Paediatric Diagnosis and Treatment, 16th Edition, Lange Medical Books/McGraw-Hill, p729 - 735. ) (Murtagh, J. (1997), General Practice, Second Edition, McGraw-Hill, Sydney ) * Question 6 Vera Smith, aged 61, has noticed a swelling in the front of her neck, which is enlarging quite rapidly. She is otherwise well, without symptoms of hypothyroidism or hyperthyroidism. On examination she has a multinodular goitre, with a dominant nodule of 4 cm diameter in the right upper pole of her thyroid gland. Of the following investigations, which is the MOST important? a) TSH, T3, T4 b) ultrasound Scan c) fine Needle Biopsy of dominant nodule d) CT scan e) nuclear Medicine Scan C.The incidence of malignancy in a dominant thyroid nodule is approximately 7%, and the fine needle biopsy is the appropriate investigation to exclude malignancy. Vera has several features consistent with a thyroid malignancy, including a rapidly growing solitary lump, her age (over 60) and the fact that the dominant nodule is >3cm. Detection or exclusion of malignancy is the MOST important issue initially. Thyroid function tests must also be performed routinely even though the patient is clinically euthyroid but they do not help in determining malignancy. Ultrasound scan adds little to clinical examination, but may be used to guide the biopsy needle. CT scan may be useful to assess retrosternal extension, but there are currently no symptoms of this problem. Nuclear medicine scan is useful to determine the functional status of a nodule but carcinoma cannot be excluded on the basis of radionuclide scan. (Tjandra,J;Clunie,G;ThomasR (2001)'Textbook of Surgery' 2nd ed Blackwell Science Asia, Melbourne p 336 )

(Hunter,J (International Ed) 2002'Davidson's Principles and Practice of Medicine' 19th Ed Churchill Livingstone, Edinburgh pp702-703 ) (Lee S (2002) Goiter, Nontoxic. Available: http://www.emedicine.com/med/topic919.htm ) (Thyroid goiter (multi-nodular). Available: http://www.gpnotebook.co.uk/simplepage.cfm?ID=550502415 ) (Beers MH, Berkhow R. (1999/2003) The Merck Manual of Diagnosis and Treatment Seventeenth edition Available: http://www.merck.com/pubs/mmanual/section2/chapter8/8g.htm )

Question 7 All of the following are true of ectopic pregnancy EXCEPT: a) an ectopic pregnancy is one where there is implantation outside the uterine cavity b) the primary risk factor for ectopic pregnancy is a history of salpingitis c) the prevalence of ectopic pregnancies has decreased over the last 20-30 years d) ectopic pregnancy is one of the leading causes of maternal mortality e) less than 50% of women who have an ectopic will go on to have a successful spontaneous pregnancy C. The prevalence of ectopic pregnancies (pregnancies where implantation occurs outside the uterine cavity) has increased by up to six fold since 1970. The reason behind this increase may be because of an increase in the prevalence of sexually transmitted diseases and tubal sterilisations or because women are conceiving later in life with a corresponding increase in the number of years open to cause tubal problems. Ectopic pregnancy remains one of the leading causes of maternal mortality and probably because of underlying tubal problems <50% of women who have an ectopic will go on to have a successful spontaneous intrauterine pregnancy. (Beckmann CRB et al. Obstetrics & Gynaecology, 3rd Ed, Lippincott, Williams & Wilkins, Philadelphia, 1998, p 183-84. ) (Beers MH, Berkhow R. (1999/2003) The Merck Manual of Diagnosis and Treatment Seventeenth edition Available: http://www.merck.com/pubs/mmanual/section18/chapter252/252b.htm ) (Ectopic pregnancy. Available: http://www.gpnotebook.co.uk/simplepage.cfm?ID=389349382 ) (Sepilian V (2002) Ectopic pregnancy. Available: http://www.emedicine.com/med/topic3212.htm ) Question 8 Regarding urinary tract infection (UTI) in children, which of the following statements is CORRECT? a) the most common organism causing UTI is E. coli b) a bag urine specimen with > 105 colony forming units (cfu) per ml is diagnostic c) further investigation is unnecessary in children under the age of 3 months d) the presence of multiple organisms in a urine sample suggests severe underlying renal disease e) urine specimens should be stored at room temperature prior to laboratory assessment

E. coli is responsible for more than 80% of childhood urinary tract infections(UTIs). Multiple organisms in any urine sample suggests specimen contamination. A bag specimen of urine is only of value for excluding a UTI, as the sample is easily contaminated. However, a 'clean catch' or MSU (midstream urine) sample showing > 105 colony forming units (cfu) per ml is highly suggestive of a UTI. Most children, especially those under two years of age, with a confirmed UTI require further investigation. Urine specimens are best assessed immediately, but can be stored for up to 24 hours at 4 degrees Celsius to prevent bacterial multiplication. (Hay WW, Hayward AR, Levin MJ, Sondheimer JM, et al. (2003) Current Paediatric Diagnosis and Treatment, 16th Edition, Lange Medical Books/McGraw-Hill, p715 - 716. ) (Murtagh, J. (1997), General Practice, Second Edition, McGraw-Hill, Sydney ) Question 9 Betty Crocker aged 62 first noticed a swelling just below and in front of her left ear, a month ago. The overlying skin is normal and the swelling has enlarged rapidly and has become painful. She has no other symptoms and is otherwise well. Which of the following is the MOST likely diagnosis? a) sjorgrens syndrome b) pleomorphic adenoma c) salivary duct calculus d) metastatic squamous cell carcinoma e) parotid abscess D. The rapid growth of a swelling in the region of the parotid gland, and the development of pain suggests a malignant process. 15-20% of parotid tumours are malignant, and in Australia the most common parotid malignancy is metastatic squamous cell carcinoma from a skin primary in the head and neck region. Sjorgrens syndrome produces persistent and painful parotid swelling, but growth is usually slow, and there are associated symptoms, notably dryness of the mouth and eyes. Pleomorphic adenoma is the most common form of parotid tumour, but this benign tumour grows slowly and rarely causes pain. Salivary duct calculi produce intermittent swelling of the salivary gland, often related to eating, and are more common in the submandibular gland than the parotid. The swelling of parotid abscess enlarges progressively over a short time frame and is very painful, accompanied by fever and general malaise. (Tjandra,J;Clunie,G;ThomasR (2001)'Textbook of Surgery' 2nd ed Blackwell Science Asia, Melbourne pp371-374 ) (Chahin F (2003) Salivary gland tumors, major, benign. Available: http://www.emedicine.com/med/topic2789.htm ) (Yoskovitch A (2002) Submandibular Sialadenitis/Sialadenosis. Available: http://emedicine.com/ent/topic598.htm ) * Question 10 A 26-year-old G3P2 who is 30 weeks gestation telephones you to say that she has had an episode of bright red vaginal bleeding. It occurred several hours ago and she has had no associated symptoms. She estimates she lost about a teaspoon of blood. What would be the MOST APPROPRIATE IMMEDIATE management? a) tell her to call back if it happens again

b) tell her to come in immediately for further evaluation c) make her an appointment at your next antenatal clinic d) send her directly for an ultrasound examination e) ask her to monitor fetal movements for the next 24 hours and to ring you tomorrow C. Although this bleeding may have a benign cause it is important to recognise that she may have a placenta praevia or have had a placental abruption. Both of these conditions require urgent attention because of the risk of maternal and fetal morbidity and mortality. The patient should be examined (vital signs, examination of the uterus and foetus and a sterile speculum examination to assess the nature of the bleeding and whether or not the os is closed). An ultrasound to assist in confirmation of the diagnosis will be necessary as part of your evaluation but should occur only after the patient has been assessed and is stable. (Beckmann CRB et al. Obstetrics & Gynaecology, 3rd Ed, Lippincott, Williams & Wilkins, Philadelphia, 1998, p 260-266. ) (Beers MH, Berkhow R. (1999/2003) The Merck Manual of Diagnosis and Treatment Seventeenth edition Available: http://www.merck.com/pubs/mmanual/section18/chapter252/252e.htm ) (Placental abruption. Available: http://www.gpnotebook.co.uk/simplepage.cfm?ID=-1972699124 ) (Deering SH & Satin A (2002) Abruptio Placentae Available: http://www.emedicine.com/med/topic6.htm ) Question 11 Brian is 9 years old. He has been complaining of itchy hands for over a week and is constantly scratching. On inspection, you note a lumpy excoriated rash between several of his fingers on both hands. You suspect Brian may have scabies. Which of the following statements regarding scabies is CORRECT? a) it is important to take a thorough history of animal contact, including pets b) family and close contacts only require treatment if they are symptomatic c) persistent itch 5 days after treatment indicates treatment failure, and treatment should be repeated d) permethrin 5% cream may be used to treat scabies in a child of Brian's age e) Brian should be excluded from school for seven days, or until the itch has subsided D. Permethrin 5% cream is a suitable treatment option in children over the age of 6 months. Sarcoptes scabiei, the mite which causes scabies, is spread by close human contact and is not from animals. All family members and close contacts should be treated, regardless of symptoms. Patients and their families should be advised that the itch does not resolve immediately and may take three weeks to subside. It is unnecessary to retreat for scabies during this time based on the persistence of itch. Brian only needs to be kept away from school until he has begun appropriate treatment. (Murtagh, J. (1997), General Practice, Second Edition, McGraw-Hill, Sydney ) (Antibiotic Guidelines, Version 12, 2003. Go to 'Scabies' Available: http://etg.hcn.net.au/ ) Question 12 Margaret Myles aged 46 is distressed and agitated. She is holding her head, and complaining of 'the worst headache I have ever had'. This headache began suddenly 2 hours ago. She has vomited twice, and is photophobic. Her temperature is 37.8 degrees

Celcius, her pulse 110/min and her blood pressure 140/80 mm Hg. Which of the following is the MOST appropriate action? a) give intravenous fluids (1 L normal saline over 1 hour) and metoclopramide (maxolon) then oral soluble aspirin b) request an emergency CT scan of her head c) perform or refer for urgent lumbar puncture d) do not leave the patient unattended in your rooms, as she is likely to be seeking narcotics e) perform a full clinical neurological assessment B. The sudden onset of 'the worst headache' the patient can ever recall accompanied by vomiting, must raise the suspicion of subarachnoid haemorrhage.(SAH). While this is rare, and only 1 patient in 8 who presents with sudden extreme headache will have a SAH, it is a diagnosis which must not be missed. SAH occurs most frequently in patients under 65 years of age, the majority being in the fourth decade. Women are more frequently affected than men. All patients with this clinical picture require investigation commencing with emergency head CT scan to exclude SAH. Lumbar puncture may be undertaken as the next investigation if the CT scan does not confirm SAH. Blood or xanthochromia may be detected in a smaller SAH, and meningitis may be excluded. Migraine may be considered after exclusion of SAH and meningitis. This is not a typical presentation from a drug-seeker, but that possibility should not be completely ignored. While clinical examination is always important, detailed neurological assessment is not appropriate initially. (Tjandra,J;Clunie,G;ThomasR (2001)'Textbook of Surgery' 2nd ed Blackwell Science Asia, Melbourne pp518-519 ) (Hunter,J (international Ed)2002'Davidson's Principles and Practice of Medicine' 19th Ed Churchill Livingstone, Edinburgh pp1162-1164 ) (Becske T and Jallo G (2003) Subarachnoid hemorrhage. Available: http://www.emedicine.com/neuro/topic357.htm Question 13 In women of reproductive age the most common causes of vaginal discharge and irritation in DESCENDING order of occurrence are: a) bacterial vaginosis, candidiasis, trichomoniasis b) candidiasis, bacterial vaginosis, trichomoniasis c) chlamydia, candidiasis, bacterial vaginosis d) candidiasis, herpes simplex, bacterial vaginosis e) candidiasis, chlamydia, gonorrhoea B. Bacterial vaginosis is the most common cause of vaginal discharge and irritation. It is often misdiagnosed by women and their doctors as "thrush". Proven candidal infections are the second most common, accounting for around 35% of infections. Trichomoniasis is a sexually transmitted disease that causes vaginitis. Chlamydia and gonorrhoea infect the cervix and urethra and do not cause "vaginitis" per se. Herpes may cause vaginal pain and irritation if vesicles occur in the vagina but is not commonly associated with discharge. (Beckmann CRB et al. Obstetrics & Gynaecology, 3rd Ed, Lippincott, Williams & Wilkins, Philadelphia, 1998, p 327-330. )

(Beers MH, Berkhow R. (1999/2003) The Merck Manual of Diagnosis and Treatment Seventeenth edition Available: http://www.merck.com/pubs/mmanual/section18/chapter238/238a.htm ) (Vaginitis. Available: http://www.gpnotebook.co.uk/simplepage.cfm?ID=-677773282 ) (Ching S & Nguyen PH (2002) Vaginitis. Available: http://www.emedicine.com/med/topic2358.htm ) Question 14 All of the following may be extra-intestinal features associated with Crohn's Disease EXCEPT: a) fever b) weight loss c) delayed growth and sexual development d) erythema nodosum e) alopecia E. Alopecia is not a recognised association or feature of Crohn's Disease. Arthritis/arthralgia, fever, stomatitis, weight loss, delayed growth and sexual development, uveitis, conjunctivitis, renal stones, pyoderma gangrenosum and erythema nodosum may all be associated with this condition. (Hay WW, Hayward AR, Levin MJ, Sondheimer JM, et al. (2003) Current Paediatric Diagnosis and Treatment, 16th Edition, Lange Medical Books/McGraw-Hill, p643 - 646. * Question 15 Michael Peters, aged 12, sustained a blow to his left temple when he fell while climbing a tree. He was dazed, but able to recount what had happened. An hour later he complained of an increasingly severe headache and vomited once, and then was brought to hospital. His pulse is now 54 bpm, BP 130/90 mm Hg and he is drowsy and confused. His left pupil is larger than his right. Which is the MOST appropriate advice to give Michael's parents? a) Michael probably has a skull fracture, and will need an urgent skull x ray b) Michael has severe concussion, and will be observed closely overnight c) Michael requires emergency surgery as soon as possible d) Michael requires an urgent CT scan of his head as he may have bleeding into his brain e) Michael is gravely ill and has only a 50% chance of survival of bleed C. The history of the injury is highly suggestive of an extradural (epidural) haematoma. Although Michael did not lose consciousness initially, his condition has deteriorated rapidly and significantly. He is now bradycardic, hypertensive and his pupil is dilated on the side of the injury. His level of consciousness is also deteriorating. An extradural haematoma will result in death if not evacuated promptly. There is approximately 75% chance he will have a fracture overlying the haematoma, but skull x ray is not indicated. There may be 'concussive' injury to the underlying brain but the life-threatening factor is the raised intracranial pressure from the extradural haematoma. While it would be ideal to have a CT scan, the rapidly deteriorating condition means that emergency surgery should not be delayed. Michael is clearly gravely ill, but the mortality from SAH is around 10% for obtunded patients and 40% for patients who are comatose prior to surgery. Prognosis is better for

young patients, but deteriorates with associated other intracranial injuries and with delay between injury and surgical intervention. (Tjandra,J;Clunie,G;ThomasR (2001)'Textbook of Surgery' 2nd ed Blackwell Science Asia, Melbourne pp500-501 ) (Liebeskind D (2002) Epidural hematoma. Available: http://www.emedicine.com/neuro/topic574.htm ) Question 16 All of the following are associated with the timing of secondary sexual maturation EXCEPT: a) body weight b) adequate sleep c) phenotype d) optic exposure to sunlight e) latitude of habitation Correct Girls must attain a critical body weight (irrespective of height) before sexual maturation will begin. A body weight of 38 - 48 kilograms must be achieved before menses begins and a proportion of body fat of 16-24% is required to sustain ovulatory cycles. Other critical elements to the timing of secondary sexual maturation include adequate sleep and vision. Blind girls have delayed menarche and blind boys have delayed spermatogenesis and ejaculation. Chromosomal abnormalities such as Turner's syndrome result in premature ovarian failure and lack of secondary sexual maturation. Latitude has no impact. (Beckmann CRB et al. Obstetrics & Gynaecology, 3rd Ed, Lippincott, Williams & Wilkins, Philadelphia, 1998, p 422-424. ) (Beers MH, Berkhow R. (1999/2003) The Merck Manual of Diagnosis and Treatment Seventeenth edition Available: http://www.merck.com/pubs/mmanual/section19/chapter275/275b.htm ) (Puberty. Available: http://www.gpnotebook.co.uk/simplepage.cfm?ID=879427597 ) Question 17 Cindy is 13 months old. She presents with two days of fever, runny nose and cough. Her cough is becoming increasingly distressing, and she is quite tachypnoeic. On auscultation of her chest you hear some expiratory wheeze and scattered crepitations. Cindy's breathing is obviously laboured and there is rib retraction. You diagnose bronchiolitis. Which of the following statements is CORRECT? a) parenteral penicillin is the treatment of choice b) chest x-ray may show hyperinflation c) parainfluenza virus is the most common pathogen d) corticosteroids are contraindicated e) most children with bronchiolitis will require hospital inpatient treatment B. Chest x-ray findings in bronchiolitis typically include hyperinflation with depression of the diaphragm and horizontal ribs. There may also be streaky hilar shadows, mild interstitial infiltrates and some segmental atelectasis. RSV (respiratory syncitial virus) is

by far the most common pathogen, although some cases may be due to the parainfluenza, influenza and adenoviruses. Antibiotics are not indicated. Corticosteroids are not contraindicated, but their use has not been shown to modify the course of the disease. Whilst some very young or very unwell children may require supportive inpatient management, most children with bronchiolitis can be confidently managed as outpatients. (Hay WW, Hayward AR, Levin MJ, Sondheimer JM, et al. (2003) Current Paediatric Diagnosis and Treatment, 16th Edition, Lange Medical Books/McGraw-Hill, p506 - 507.) (Hull D and Johnston D. (1993) Essential Paediatrics. 3rd ed. Churchill Livingstone. ) Question 18 Six weeks ago, you excised a skin lesion from the cheek of 65 year old Bill Bailey. The wound had healed well when you removed the sutures five days later, but the pathology report was not available. You told Bill you would contact him if anything further needed to be done, as he was leaving on an extended holiday. In doing some paperwork today, you discover to your horror, Bill's pathology report, which states: There is a squamous cell carcinoma (SCC) measuring 5 mm in diameter, with a depth of 4 mm. The lesion has been completely excised but extends to within 1mm of one lateral margin, and to within 2 mm of the base of the excision. What is your MOST appropriate course of action? a) contact Bill urgently, apologising for the delay and explain that he should have further excision as a clearance margin of 5mm in depth and laterally is required to minimise local recurrence or metastasis b) contact Bill, apologising for your delay, and advise it was a skin cancer (SCC) but it has been completely excised, and there is minimal risk of local recurrence or metastasis c) do not attempt to contact Bill during his holiday as the matter is not urgent. Clearance of 1mm in all directions is adequate to minimise local recurrence d) do not disturb Bill as the holiday is important to him, but ensure that you recall him when he returns to discuss options for further surgery e) contact Bill, saying you have just received the report which the laboratory must have lost. Advise him he had a skin cancer (SCC) and that he should have further excision on his return, as there is a very small risk this cancer could spread A. Squamous cell carcinomas (SCC) can recur locally, and unlike basal cell carcinomas, they can also metastasise. Local recurrence is unusual with lesions less than 4mm in depth, but a complete clearance margin of 5mm is recommended to minimise risk. It is important to accept responsibility for your failure to follow up as planned, and then to recommend further excision. It is wise in these circumstances to contact your medical defence organisation and explain the circumstances. Clearance of 1mm in all directions is adequate for a basal cell carcinoma, but not a SCC. The re-excision should not wait until his return unless this is imminent. It is not appropriate to 'shift the blame' onto the pathology laboratory. (Tjandra,J;Clunie,G;ThomasR (2001)'Textbook of Surgery' 2nd ed Blackwell Science Asia, pp403-404 ) (Goldman G (2003) Squamous cell carcinoma. Available: http://www.emedicine.com/derm/topic401.htm ) Question 19 Patricia, 25 years, has been diagnosed with polycystic ovarian disease. In counselling this patient regarding long-term consequences the MOST APPROPRIATE advice would be: a) there are no long term consequences

b) there is an increased risk of endometrial hyperplasia c) there is an increased risk of cervical cancer d) there is a decreased risk of cardiovascular disease e) the onset of menopause is delayed B. Polycystic ovarian syndrome is a metabolic condition whose long term consequences include an increased risk of cardiovascular disease, non insulin dependent diabetes and endometrial hyperplasia The latter is due to unopposed action of oestrogen in anovulatory cycles There is no effect on the timing of the onset of menopause. (Magowan B. Churchill's Pocketbook Obstetrics & Gynaecology, 1997, Churchill Livingstone, Edinburgh, p 159. ) (Polycystic ovarian syndrome. Available: http://www.gpnotebook.co.uk/simplepage.cfm?ID=-40239066 ) (Khan MI & Klachko DM (2002) Polycystic ovarian syndrome. Available: http://www.emedicine.com/med/topic2173.htm ) Question 20 Peter is a 2 month old Aboriginal boy. He was born at term in an uncomplicated normal vaginal delivery, and he has been well. He lives with his family in the city. His mother has brought him in for his immunisations. Which ONE of the following statements is CORRECT? a) hepatitis B vaccine is contraindicated given high HBV carriage rates in indigenous communities b) it is best not to discuss potential risks of vaccination with Peter's mother as this would be culturally inappropriate c) it may be appropriate to vaccinate Peter with BCG d) MMR should be given at 6 months of age to indigenous children e) IPV should be substituted for OPV in children of Aboriginal descent C. Indigenous Australians are at increased risk of acquiring tuberculosis. BCG is recommended for indigenous neonates in 'regions of high incidence' of pulmonary TB. It is usually given to eligible infants soon after delivery. Otherwise, the Standard Vaccination Schedule now applies to all Australian children. All parents and guardians must be given appropriate information regarding vaccination so as to be able to give informed consent to vaccination. (The Department of Health and Aged Services, Australia (2000), The Australian Immunisation Handbook, 7th ed, Australia, p68-69. ) Question 21 Rodney, aged 30, a diesel mechanic, presents with a painful right eye. He was using a metal lathe at work last night, and states that he was wearing his safety goggles as required. He was aware that the eye was a little irritable at the end of his shift, but it was not until this morning that it became painful. On examination, Rodney's visual acuity is 6/6 in his left eye and 6/7.5 in the right. No obvious foreign body is seen, but the pupil is slightly distorted. You do not have a slit lamp. Of the following, which is the MOST appropriate initial action? a) instill antibiotic drops and apply an eye pad Check visual acuity in 24 hours b) irrigate the eye copiously until the pH is neutral c) loose fitting eye shields to both eyes, commence antibiotics and antiemetics d) AP and lateral facial x ray

e) reassure Rodney that his safety goggles will prevent serious eye injury C. The history of eye pain after working with metal and high-speed machinery should raise the suspicion of penetrating eye injury. This may still occur despite safety goggles being worn. Not all goggles conform to standards, and not all workers wear them correctly! Visual acuity is not always greatly reduced, but the pupil commonly shows a 'tear-drop' deformity. There may be hyphaema. Facial X ray and CT may be useful in locating an intra-ocular foreign body, but the first step should be to protect the eye from further damage, hence the eye shields which must not press upon the cornea. While awaiting urgent review by an ophthalmologist, apply loose fitting eye shields to both eyes, commence antibiotics (a cephalosporin eg cefazolin would be appropriate), and an antiemetic to prevent vomiting. This could otherwise occur due to pain, stress or while travelling for review, with the attendant risk of raising the intra-ocular pressure. Organise AP and lateral facial xray. (Manalopoulos, J (2002) 'Emergency primary eye care' Australian Family Physician Vol31, No 3 march 2002, p234 ) (Grigsby W (2001) Corneal laceration. Available: http://www.emedicine.com/emerg/topic114.htm ) Question 22 All of the following are causes of secondary amenorrhoea EXCEPT: a) diabetes b) autoimmune disorders c) Asherman's syndrome d) eating disorders e) drug abuse A. Secondary causes of amenorrhoea and oligomenorrhoea include eating disorders, drug abuse, Asherman's syndrome (intrauterine adhesions), thyroid or adrenal dysfunction, uterine or vaginal obstruction, familial early menopause, chromosomal abnormalities and autoimmune disorders. (Farrell E. Premature menopause. Australian Family Physician 2002, 31(5) 419-421 ) (Beers MH, Berkhow R. (1999/2003) The Merck Manual of Diagnosis and Treatment Seventeenth edition Available: http://www.merck.com/pubs/mmanual/section18/chapter235/235d.htm ) (Nelson L (2002) Amenorrhea. Available: http://www.emedicine.com/med/topic117.htm ) (Amenorrhoea. Available: http://www.gpnotebook.co.uk/simplepage.cfm?ID=-670695424 ) Question 23 Sally, aged 14 years, has known mitral valve prolapse with regurgitation. For which of the following procedures should she be given antibiotic prophylaxis? a) urethral catheterisation b) flexible bronchoscopy c) dental examination d) placement of orthodontic bands e) local anaesthetic injection D. In patients with mitral valve prolapse with valvular regurgitation antibiotic prohylaxis is required for dental procedures which produce bleeding from the gingiva, mucosa or

bone, and thus includes the placement of orthodontic bands. Prophylaxis is not required for routine dental examination (except where scaling of the teeth is to be performed), nor for the other options listed. (Antibiotic Guidelines, Version 12, 2003. Go to 'Prevention of endocarditis' Available: http://etg.hcn.net.au/ ) Question 24 Warren Jacobsen aged 40 had a malignant melanoma removed from his thigh last week. Which of the following factors is MOST important in determining his overall prognosis? a) the depth of invasion in the skin and subcutaneous tissue b) the fact that he has numerous freckles and melanocytic naevi c) the diameter of the lesion removed d) a family history of malignant melanoma e) the site of the lesion- on his lower limb A. The single most important feature in determining the ultimate prognosis in melanoma is the depth of invasion of skin and subcutaneous tissue. Melanoma classification systems are based on either the vertical thickness of the lesion in millimetres as in Breslow's classification, or the anatomic level of invasion of the layers of skin as in Clark's classification. The diameter of the lesion is not as important. Family history, multiple freckles and melanocytic naevi are risk factors for melanoma, not indicators of prognosis. The site of the lesion is of some prognostic importance, but those on the extremities have a better outlook than those on the trunk or face. (Tjandra,J;Clunie,G;ThomasR (2001)'Textbook of Surgery' 2nd ed Blackwell Science Asia, pp406-408 ) (Hunter,J (international Ed)2002'Davidson's Principles and Practice of Medicine' 19th Ed Churchill Livingstone, Edinburgh pp1094-1095 ) (Heistein J (2001) Skin malignancies, melanoma. Available: http://www.emedicine.com/PLASTIC/topic456.htm ) Question 25 Which of the following statements about group B Strep in pregnancy is CORRECT? a) most women are colonised by group B Strep during pregnancy b) group B Strep colonisation of pregnant women poses no risk to the woman or her foetus c) group B Strep colonisation of pregnant women is associated with premature labour d) women are usually symptomatic if they are colonised with Group B Strep e) group B Strep detection requires serological testing of the pregnant woman C. Group B Strep infection is the leading cause of neonatal infection, and is implicated in premature labour and other maternal morbidity. 10-30% of women may be colonised with vaginal Group B Strep during pregnancy, but the infection may be transient or intermittent. It usually causes no symptoms for the woman. Transmission to the infant almost always occurs after the onset of labour, or membrane rupture. There is little evidence that treating GBS colonisation earlier in pregnancy is beneficial as it may recur. However, treating women who test positive for GBS on a vaginal swab at 35-37 weeks gestation, with intrapartum antibiotics has been shown to significantly reduce the incidence of neonatal GBS sepsis. Testing for Group B Strep colonisation of pregnant women by vaginal swab is therefore offered by many in the third trimester.

(Beckmann CRB et al. Obstetrics & Gynaecology, 3rd Ed, Lippincott, Williams & Wilkins, Philadelphia, 1998, p 215-216 ) (CDC American guidelines on Group B Strep Screening. Available: http://www.cdc.gov/groupbstrep/gbs/gen_public_guidelines_summary.htm ) * Question 26 Felicia is a 15 month old girl. She has symptoms and signs consistent with a viral upper respiratory tract infection (URTI), including a fever of 38.8 degrees Celsius. Her weight is 11kg. Which of the following is CORRECT regarding the prescription of oral paracetamol in this case? a) daily dose should not exceed 90mg/kg/day b) dosage should be calculated at 30mg/kg/dose 4 hourly c) dosage should be calculated at 15mg/kg/dose 6 hourly d) dosage should be calculated at 20mg/kg/dose 6 hourly e) daily dosage should not exceed 60mg/kg/day A. Daily oral paracetamol dosage should not exceed 90mg/kg/day, up to a maximum of 4g. 60mg/kg/day is the maximum dosage for infants aged less than 6 months. The recommended paracetamol dose in children is 15mg/kg orally every 4 hours, or 20mg/kg rectally every 6 hours. (Antibiotic Guidelines, Version 12, 2003. Go to 'Analgesics and adjuvants in children: simple analgesics' Available: http://etg.hcn.net.au/ ) Question 27 Muriel Thompson aged 80 fell onto her outstretched right hand sustaining a Colles' fracture. Which of the following is the most frequent LATE complication of this fracture for a patient of Muriel's age? a) delayed union of the fracture b) ischaemic necrosis of the distal fragments c) neuralgic pain in the arm and hand d) stiffness of the wrist and fingers e) ulnar nerve weakness D. Joint stiffness is common following a Colles' fracture and especially with prolonged periods of immobilisation. All of the other complications are relatively uncommon. Union is usually not delayed but there may be a degree of mal-union. Appropriate management of the elderly patient with a Colles' fracture includes early mobilisation aiming to restore function. (Marshall,VC et al (eds)1997 Annotated Multiple Choice Questions Blackwell, Oxford ) Question 28 Which of the following statements concerning a retained placenta is CORRECT? a) antibiotic cover is rarely necessary after a manual removal of placenta b) physiologically the third stage of labour takes on average two hours to complete c) when delivering the placenta the doctor or midwife should pull the cord upwards on a 45 degree angle d) there is no association between placenta praevia and placenta accreta e) with the use of oxytocics and continuous cord traction most placentas are delivered within 10 minutes

E. Physiologically the third stage of labour (when the placenta is delivered) occurs within 30 minutes. If it has not occurred within this timeframe it is unlikely to occur spontaneously. The use of oxytocics and gentle continuous cord traction (where the traction is exerted in a downward direction, towards the bed) after signs of separation are observed, has meant that 97% of third stages are complete by 10 minutes. Antibiotic cover is necessary should a manual removal of placenta be needed because of passage of the hand from a non-sterile (vagina) to a sterile (uterus) environment. Placenta accreta (where placental villi penetrate the uterine wall preventing separation) occurs more commonly in cases of placenta praevia and after caesarean section. (Magowan B. Churchill's Pocketbook Obstetrics & Gynaecology, 1997, Churchill Livingstone, Edinburgh, p 94. ) (Beers MH, Berkhow R. (1999/2003) The Merck Manual of Diagnosis and Treatment Seventeenth edition Available: http://www.merck.com/pubs/mmanual/section18/chapter253/253h.htm ) (Retained placenta. Available: http://www.gpnotebook.co.uk/simplepage.cfm?ID=2060451851 ) Question 29 Amanda, aged 24 years, is HIV positive. She has just given birth to twin sons, George and Harry, by normal vaginal delivery. Regarding vertical transmission of HIV from mother to baby, which ONE of the following statements is INCORRECT? a) the first born twin is more likely to be infected than is the second born twin b) higher rates of transmission are likely with low maternal CD4 lymphocyte count c) breast feeding is a possible route of vertical transmission d) high maternal plasma HIV RNA increases transmission risk e) transmission to the foetus is most likely in the antenatal (in utero) period E. Studies indicate that maternal transmission of HIV to the infant is most likely in the perinatal period. The other options are correct. Advanced maternal disease is also a risk factor for increased transmission risk. (Braunwald, E., Fauci, A.S., Isselbacher, K.J & Kasper DL et al. (2001), Harrison's Principles of Internal Medicine, 15th ed, McGraw-Hill, New York. ) (Hay WW, Hayward AR, Levin MJ, Sondheimer JM, et al. (2003) Current Paediatric Diagnosis and Treatment, 16th Edition, Lange Medical Books/McGraw-Hill, p1140 1142. ) Question 30 Hazel Hyde aged 40, has a month-long history of a burning pain in the ball of her right foot. She says it's "as though I'm standing on a sharp stone". The pain radiates into the tips of her toes. Pressure applied over the heads of the third and fourth metatarsal heads reproduces her pain, but there is no other abnormality noted. What is the MOST likely diagnosis? a) plantar interdigital (Morton's) neuroma b) plantar fasciitis c) rheumatoid arthritis of the metatarsophalangeal joint d) gout e) stress fracture of the metatarsals A. Interdigital neuroma represents a gradual and persistent thickening of the perineurium of one, or less commonly two or more interdigital nerves. Hazel's history is typical, as is

the examination finding of reproduction of the pain by direct pressure over the head of the 3rd and 4th metatarsal heads. Plantar fasciitis causes primarily heel pain. The absence of heat, redness or swelling over the metatarsal heads makes gout and rheumatoid arthritis unlikely. Stress fractures of the metatarsals cause pain that is felt more along the shafts of the metatarsals, and is unlikely to radiate to the tips of the toes. (Needell S (2002) Morton Neuroma Available: http://www.emedicine.com/radio/topic882.htm ) Question 31 With regards premenstrual dysphoric disorder which of the following is CORRECT? a) symptoms should be isolated to the late luteal phase of the menstrual cycle b) symptoms should be isolated to the late follicular phase of the menstrual cycle c) symptoms disappear the instant menstruation commences d) symptoms do not usually cause marked interference with work, school, social activities, or relationships with others e) symptoms may be an exacerbation of a chronic condition (e.g. major depressive disorder) A. While PMT is the term commonly used by women to describe the constellation of symptoms some experience prior to periods, Premenstrual Dysphoric Disorder is a much more specific condition listed by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The diagnostic criteria for PMDD are: At least five of the following symptoms (one of which must be 1, 2, 3 or 4, below) must be present in the majority of menstrual cycles in the last year. Symptoms should be isolated to the late luteal phase of the menstrual cycle and remit within days of onset of menses. 1 Markedly depressed mood, feelings of hopelessness, self-deprecating thoughts 2 Marked anxiety, tension, feelings of being "keyed up" or "on edge" 3 Marked affective lability 4 Persistent and marked anger or irritability or increased interpersonal conflicts 5 Decreased interest in usual activities 6 Subjective sense of difficulty concentrating 7 Lethargy, easy fatigability, marked lack of energy 8 Marked change in appetite 9 Marked change in sleep pattern 10 Subjective sense of being overwhelmed or out of control 11 Physical symptoms (e.g., breast tenderness or swelling, headaches, joint or muscle pain, sensation of bloating, weight gain) Symptoms cause marked interference with work, school, usual social activities, or relationships with others. The problem is not an exacerbation of the symptoms of a chronic condition (e.g., major depressive disorder). The above criteria must be confirmed by prospective daily ratings during at least three consecutive symptomatic cycles to confirm a provisional diagnosis. (Beckmann CRB et al. Obstetrics & Gynaecology, 3rd Ed, Lippincott, Williams & Wilkins, Philadelphia, 1998, p 474-480. )

(Htay T (2002) Premenstrual Dysphoric Disorder Available: http://www.emedicine.com/med/topic3357.htm ) Question 32 Classic symptoms of endometriosis include all of the following EXCEPT: a) pelvic pain b) dysmenorrhoea c) dyspareunia d) oligomenorrhoea e) infertility D. Endometriosis is the presence of endometrial tissue outside the uterine cavity. It causes pelvic pain, dysmenorrhoea, dyspareunia and infertility. Oligomenorrhoea is not associated with endometriosis. (Beckmann CRB et al. Obstetrics & Gynaecology, 3rd Ed, Lippincott, Williams & Wilkins, Philadelphia, 1998, p 367 ) (Clinical features. Available: http://www.gpnotebook.co.uk/simplepage.cfm?ID=1362427910&linkID=14184&cook=y es ) (Kapoor D (2003) Endometriosis. Available: http://www.emedicine.com/med/topic3419.htm ) * Question 33 When treating a premenopausal woman who has irregular cycles, severe hot flushes and no contraindications to hormone replacement therapy the MOST APPROPRIATE therapy is: a) continuous oestrogen therapy b) continuous combined (oestrogen and progestogen) therapy c) sequential oestrogen therapy d) sequential combined (oestrogen and progestogen) therapy e) continuous progestogen therapy D. Hormone replacement therapy is indicated in women who are suffering from severe menopausal symptoms provided they have no contraindications to its use. Sequential combined HRT is the best option for premenopausal women who do not require contraception as it can alleviate symptoms and control irregular cycles. The use of continuous or sequential unopposed oestrogen is associated with endometrial hyperplasia and the development of endometrial cancer and is contraindicated in women who have not had a hysterectomy. Continuous combined HRT is recommended for the treatment of symptoms in women who are more than one year postmenopausal. These women will probably remain amenorrhoeic on such a regimen. Progestogen alone is not always effective at treating menopausal symptoms. (Murtagh J. (1998) General practice, 2nd edition, McGraw Hill Publishers, Sydney. Page 861.) (Reddish S. Menopause: A treatment algorithm, Aus Fam Phys, 2002: 31(5) 423-424 Available: http://www.racgp.org.au/downloads/pdf/20020515mayafp_reddish.pdf ) Question 34

Sherri, 56 years, complains that she loses control of her "waterworks" when she puts her key in the front door. With this history, which form of incontinence is she MOST LIKELY to have? a) stress incontinence b) urge incontinence c) overflow incontinence d) incontinence from a urinary fistula e) incontinence secondary to a neuropathic bladder B. Urge incontinence occurs when there is an inability to delay micturition and may be precipitated by various triggers including the sound of running water or placing a key in the door when arriving home. Stress incontinence occurs when the intra-abdominal pressure is raised as with coughing or sneezing. Overflow incontinence is due to obstruction and may be secondary to uterovaginal prolapse or a hypotonic bladder as in a neuropathic bladder. A urinary fistula is associated with continuous dribble of urine or leakage of small amounts on effort. (Murtagh J. (1998) General practice, 2nd edition, McGraw Hill Publishers, Sydney. Page 709-710. ) (Incontinence classification. Available: http://www.gpnotebook.co.uk/simplepage.cfm?ID=886046729&linkID=19307&cook=ye s) * Question 35 Teresa, 25 years, presents having experienced an episode of postcoital bleeding two days ago. What is the MOST APPROPRIATE management? a) reassure her and ask her to return if it recurs b) undertake cauterisation of the cervix to prevent further bleeding c) treat her with metronidazole gel to eradicate infection d) send her to the emergency department for immediate assessment e) undertake diagnostic cervical cytology and screening for sexually transmitted diseases E. Postcoital bleeding is a serious symptom that could be indicative of cervical pathology. It is not an emergency requiring assessment in hospital. Common causes of postcoital bleeding include a cervical erosion, an infection such as chlamydia and other less common pathologies in this age group such as a cervical polyp. Medical practitioners must however ensure that they exclude precancerous or cancerous lesions of the cervix by making sure that cervical cytology (Pap smear) is performed as well as appropriate STI (sexually transmitted infection) screening. If the bleeding is recurrent, or the cervix looks abnormal colposcopy is recommended. Cauterisation of the cervix is sometimes performed if a friable cervical erosion is present, bleeding is recurrent and other cervical pathology has been excluded. (Greer IA et al. (2001) Mosby's colour atlas and text of Obstetrics and Gynaecology. Mosby, Edinburgh, pages 4 & 37 ) (Postcoital bleeding. Available: http://www.gpnotebook.co.uk/simplepage.cfm?ID=1060110324&linkID=16808&cook=yes ) Question 36

Cheryl, 28 years, P1G0, presents at 8 weeks gestation complaining of constant nausea and vomiting. Which of the following statements is CORRECT? a) only a minority of women suffer nausea and vomiting during pregnancy b) metoclopramide is contraindicated during pregnancy c) women should try to have frequent small feeds if they are nauseated during pregnancy d) nausea and vomiting during pregnancy should subside by 9 weeks gestation e) if nausea and vomiting occur in the evening then a more sinister cause should be suspected C. At least two thirds of women experience nausea during the first trimester and 50% experience vomiting. Symptoms can occur at any time of the day although classically they predominate in the morning. These symptoms usually subside by 12-16 weeks gestation. The best advice for women is to take small frequent meals but if the symptoms persist antiemetics such as metoclopramide can be used safely. (Beckmann CRB et al. Obstetrics & Gynaecology, 3rd Ed, Lippincott, Williams & Wilkins, Philadelphia, 1998, p 224-225. ) (Hyperemesis gravidarum. Available: http://www.gpnotebook.co.uk/simplepage.cfm?ID=-1811546073 ) (Michelini GA (2002) Hyperemesis Gravidarum Available: http://www.emedicine.com/med/topic1075.htm ) Question 37 Which of the following elements on an antenatal CTG at term is considered "abnormal"? a) accelerations of at least 15 beats in height for at least 15 seconds b) at least one reactive movement in a 15-20 minute CTG recording c) a deceleration lasting>3 minutes after a Braxton Hicks contraction d) beat to beat variability on the trace e) a baseline of 120-160 beats per minute C. Decelerations occurring after contractions are ominous, particularly if they are prolonged. A healthy CTG shows a baby that is moving and having accelerations in heartbeat after movement. The beat to beat variability is indicative of an intact central nervous system. (Beckmann CRB et al. Obstetrics & Gynaecology, 3rd Ed, Lippincott, Williams & Wilkins, Philadelphia, 1998, p 120-125. ) (Cardiotocography. Available: http://www.gpnotebook.co.uk/simplepage.cfm?ID=-1187708893 ) Question 38 With regards pregnancy induced hypertension (pre-eclampsia), all of the following are true EXCEPT? a) a pregnancy fathered by a different male increases the risk of pre-eclampsia in a multigravid woman b) pre-eclampsia is more common at the extremes of reproductive age c) the classic features of pre-eclampsia are hypertension, oedema and proteinuria d) the risk of pre-eclampsia is increased if there is underlying renal disease e) it is more common in multigravidas then primigravidas

E. Pre-eclampsia is a multisystem disease associated with hypertension, oedema and proteinuria. Risk factors include chronic hypertension, renal disease, age<20 years or >35 years and primiparity. (Greer IA et al. (2001) Mosby's colour atlas and text of Obstetrics and Gynaecology. Mosby, Edinburgh, pages 170-171 ) (Warden M & Euerle B. (2002) Preeclampsia (Toxaemia of pregnancy) Available: http://www.emedicine.com/med/topic1905.htm ) * Question 39 Angelina, 27 years G3 P2, has a transverse lie at 36 weeks gestation. Should her membranes rupture what would be the MOST APPROPRIATE MANAGEMENT? a) advise her to come in to labour ward when contractions are five minutely b) lie her down on her side and take her straight to the operating theatre for a caesarean section c) wait for the head to engage with contractions and proceed to a normal vaginal delivery d) commence intravenous augmentation of labour in order to facilitate a swift delivery e) instruct the patient to adopt the knee chest position (kneeling with head down) and transfer her to theatre for an immediate caesarean section E. Cord prolapse occurs when the umbilical cord lies beside or in front of the presenting part. It is more common in malpresentations, polyhydramnios, during breech deliveries and with premature rupture of the membranes. It is an obstetric emergency, as the umbilical vessels constrict once exposed to the extrauterine environment. Unless the cervix is fully dilated and an immediate operative vaginal delivery can be conducted, an emergency caesarean section is required. During the transfer to theatre the woman should be positioned so that gravity can assist in keeping the presenting part off the cord, i.e the knee - chest position. The presenting part should also be pushed up and away from the cord digitally in order to reduce pressure on the cord. (Greer IA et al. (2001) Mosby's colour atlas and text of Obstetrics and Gynaecology. Mosby, Edinburgh, page 223 ) (Cord prolapse. Available: http://www.gpnotebook.co.uk/simplepage.cfm?ID=-804913148 ) Question 40 In counselling a woman regarding use of the mini pill (progestogen only contraceptive pill, POP) which of the following is CORRECT? a) her menstrual cycles will continue to be regular b) one mode of action of the POP is thickening of cervical mucus c) the POP involves taking sugar pills for seven out of 28 days d) women have 12 hours to remember to take the POP before it loses efficacy e) the POP is just as efficacious as combined oral contraception in women of all ages B. The principal mode of action of the progestogen only pill is via thickening of cervical mucus. In about one third of women the minipill will also inhibit ovulation but in the majority this is not the case. As a result of the variability of the effect of the POP on ovulation and the effects of progesterone on the endometrium, menstrual cycles may be regular, irregular or spotting can occur throughout the cycle in POP users. Women take the minipill everyday without a break (28 active pills with no inactive pills) and should be instructed to take it in the same three-hour period each day in order to maintain

maximal efficacy. Menstrual cycles may be regular or irregular or spotting may occur throughout the cycle. In general it is less efficacious than combined oral contraception because it does not uniformly inhibit ovulation. However in older women who are less fertile and who use the POP correctly the efficacy of the POP can approximate that of combined oral contraception. (Greer IA et al. (2001) Mosby's colour atlas and text of Obstetrics and Gynaecology. Mosby, Edinburgh, page 64 ) (Samra OA & Wood E. (2002) Hormonal contraceptives Available: http://www.emedicine.com/med/topic3211.htm#section~hormonal_contraceptives ) (Family Planning Queensland, Fact Sheet, POP Available: http://www.fpq.asn.au/!factsheets&brochures/fs-POmethod-POP.htm ) (Family Planning Queensland, Fact Sheet, COC Available: http://www.fpq.asn.au/!factsheets&brochures/fs-CH-cocp.htm ) 32 questions were answered correctly. 8 questions were answered incorrectly. 0 questions were unjudged by the system. 40 questions were attempted. 40 questions are available in this quiz. 8 questions were Mastery questions. 6 Mastery questions were correctly answered in this quiz.

-------------------------------------------------------------------------------List of Incorrect Questions Question 7 Question 9 Question 21 Question 23 * Question 26 Question 31 * Question 33 List of Correct Questions Question 2 * Question 4 Question 5 * Question 6 Question 8 * Question 10 Question 11 Question 12 Question 13 Question 14 Question 3

Question 1

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