61 . Corticosteroids have the following side effects:
i) Osteoporosis TRUE
ii) Cushing's disease FALSE
iii) Euphoria TRUE
iv) Bruising TRUE
v) Peptic ulceration TRUE
Explanations
i) Corticosteroids have the following side effects: Osteoporosis (TRUE)
Steroids decrease calcium absorption from the gut and increase its reabsorption from bone.
ii) Corticosteroids have the following side effects: Cushing's disease (FALSE)
A subtle question!
Corticosteroid therapy can result in Cushing's SYNDROME. However Cushing's DISEASE is a specific condition caused by increased production of ACTH from the pituitary.
iii) Corticosteroids have the following side effects: Euphoria (TRUE)
Steroids can cause mood changes including both depression and euphoria.
iv) Corticosteroids have the following side effects: Bruising (TRUE)
Steroids decrease inflammation by inhibiting the production of prostaglandins, but this also causes bruising, decreased wound healing and peptic ulceration.
v) Corticosteroids have the following side effects: Peptic ulceration (TRUE)
As branch 4.
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62 . Digoxin:
i) Has a narrow theraputic window TRUE
ii) Is primarily removed from the circulation by the liver FALSE
iii) Causes xanthopsia in toxic doses (xanthopsia is a visual disturbance where everything appears to have a yellowish tint) TRUE
iv) Characteristically causes a sinus tachycardia in toxic doses FALSE
v) Is more likely to cause toxic effects in patients with hypokalaemia TRUE
Explanations
i) Digoxin: Has a narrow theraputic window (TRUE)
The effective dose and the dose at which digoxin starts to cause side effects are very close together and the theraputic window is therefore narrow.
ii) Digoxin: Is primarily removed from the circulation by the liver (FALSE)
This is false: 90% of digoxin is excreted by the kidneys. Thus patients with renal failure require smaller maintenence doses and are at greater risk of toxicity. Digitoxin is an alternative therapy and this drug is predominantly metabolised by the liver
iii) Digoxin: Causes xanthopsia in toxic doses (xanthopsia is a visual disturbance where everything appears to have a yellowish tint) (TRUE)
Features of digoxin toxicity incude:
- Nausea and vomiting
- Cardiac arrhythmias (esp. ventricular ectopics and AV block)
- Xanthopsia
- Hyperkalaemia in acute overdose and hypokalaemia in chronic overdoses
iv) Digoxin: Characteristically causes a sinus tachycardia in toxic doses (FALSE)
Digoxin can cause almost every form of arrhythmia but the drug is positively ionotropic and negatively chronotropic so typically causes a sinus bradycardia, SA and AV block. It can also cause ventricular tachycardia and cardiac arrest.
v) Digoxin: Is more likely to cause toxic effects in patients with hypokalaemia (TRUE)
Potassium levels should always be checked before starting a patient on digoxin and they should be monitored throughout treatment.
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63 . Staphylococcus aureus
i) Is principally carried in the anterior nares TRUE
ii) Is coagulase-negative FALSE
iii) Produces extracellular enzymes including catalase, coagulase and hyaluronidase TRUE
iv) Is gram-negative and tends to form solid clusters on solid media FALSE
v) Produces skin and soft tissue infections such as impetigo and cellulitis TRUE
Explanations
i) Staphylococcus aureus Is principally carried in the anterior nares (TRUE)
Staph aureus is mainly carried in the anterior nares. Approximately 30% of adults are carriers.
ii) Staphylococcus aureus Is coagulase-negative (FALSE)
Staph aureus is coagulase-positive
iii) Staphylococcus aureus Produces extracellular enzymes including catalase, coagulase and hyaluronidase (TRUE)
Staph aureus secretes enzymes including catalase, coagulase, proteases and hyaluronidase. It also porduces various extracellular toxins, some of which are directly cytotoxic and others which act a super antigens causing the polyclonal proliferation of T cells.
iv) Staphylococcus aureus Is gram-negative and tends to form solid clusters on solid media (FALSE)
Staph aureus is gram-positive. It grows both aerobically and anaerobically on blood agar and other non-selective media. Most strains produce haemolysis on blood agar. Identification is confirmed by positive coagulase and DNAse tests.
v) Staphylococcus aureus Produces skin and soft tissue infections such as impetigo and cellulitis (TRUE)
Stap aureus produces skin and soft tissue infections. Deeper infections may occur after trauma, surgery or the implantation of prosthetic materials. It can also produces a bacteraemia resulting in metastatic infections such a endocarditis and osteomyelitis.
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64 . Strep. Pneumoniae
i) Is a beta-haemolytic, gram-positive diplococcus FALSE
ii) Is a common commensal of the nasopharynx in both adults and chidren TRUE
iii) Is usually sensitive to pencillin TRUE
iv) Is invariably sensitive to pencillin FALSE
v) Is the commonest bacterial cause of both meningitis and pneumonia in adults in the United Kingdom TRUE
TOTALS: 3 2.66
Explanations
i) Strep. Pneumoniae Is a beta-haemolytic, gram-positive diplococcus (FALSE)
Strep. pneumoniae is a gram-positive diplococcus. It produces alpha haemolysis on blood agar.
ii) Strep. Pneumoniae Is a common commensal of the nasopharynx in both adults and chidren (TRUE)
Strep. pneumoniae is a common commensal of the nasopharynx. It is found in the nasopharynx of 20-40% of children and 10-20% of adults.
iii) Strep. Pneumoniae Is usually sensitive to pencillin (TRUE)
Until recently Strep. Pneumonia was invariably sensitive to penicillin. Resistence to penicillin is increasing worldwide but high-level resistence remains uncommon in the United Kingdom.
iv) Strep. Pneumoniae Is invariably sensitive to pencillin (FALSE)
Until recently Strep. Pneumonia was invariably sensitive to penicillin. Resistence to penicillin is increasing worldwide but high-level resistence remains uncommon in the United Kingdom
v) Strep. Pneumoniae Is the commonest bacterial cause of both meningitis and pneumonia in adults in the United Kingdom (TRUE)
Following the success of the meningococcus group C vaccine, Strep pneumoniae is probably the commonest cause of bacterial meningitis in adults in the UK. It is also the commonest cause of pneumonia in adults in the UK
Further notes:
Strep. Pneumoniae is a common bacterial pathogen and a major cause of otitis media, sinusitis, meningitis and pneumonia. It less commonly causes peritonitis, endocarditis, septic arthritis and osteomyelitis. It is gram-positive and on solid media appears as a diplococcus. It is alpha-haemolytic, produces a negative catalase reaction and is optochin sensitive. Serotypes are base on antigenic differences between capsular polysaccharides.
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65 . Helicobacter pylori
i) Is a gram negative bacterium TRUE
ii) Invades and colonises the gastric mucosa FALSE
iii) Inhibits G cell secretion of gastrin FALSE T
iv) Promotes chemotaxis of mast cells into the gastric epithelium and lamina propria TRUE
v) Is the leading cause of gastric MALToma TRUE
Explanations
i) Helicobacter pylori Is a gram negative bacterium (TRUE)
It is a gram negative, spiral, motile microaerophilic bacteria.
ii) Helicobacter pylori Invades and colonises the gastric mucosa (FALSE)
H. Pylori inhabits the mucous adjacent to the gastric mucosa
iii) Helicobacter pylori Inhibits G cell secretion of gastrin (FALSE)
Stimulate G cells to produce increased amounts of gastrin resulting in increased acid production by the parietal cells.
iv) Helicobacter pylori Promotes chemotaxis of mast cells into the gastric epithelium and lamina propria (TRUE)
H. Pylori infection is characterized by a marked infiltration of the gastric epithelium and the underlying lamina propria by neutrophils, T and B lymphocytes, macrophages and mast cells.
v) Helicobacter pylori Is the leading cause of gastric MALToma (TRUE)
H Pylori infection is a leading cause of gastric MALToma. In patients with MALToma and H pylori infection, H. Pylori eradication typically causes spontaneous regression of the MALToma, depending on the stage of the MALToma
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66 . The following antibiotics have broad spectrum activity against both gram positive and gram negative bacteria
i) Amoxycillin TRUE
ii) Vancomycin FALSE
iii) Meropenem TRUE
iv) Gentamycin FALSE
v) Metronidazole FALSE
Explanations
i) The following antibiotics have broad spectrum activity against both gram positive and gram negative bacteria Amoxycillin (TRUE)
An aminopenicillin active against both gram positive and gram negative bacteria.
Simple penicillin (penicillin V and benzylpenicillin) are active only against gram positive organisms as they cannot cross the gram negative lipopolysaccharide outer membrane. The addition of an amino group makes the molecule more hydrophillic allowing it to cross through the porins in the lipopolysaccharide layer of gram negative bacteria.
ii) The following antibiotics have broad spectrum activity against both gram positive and gram negative bacteria Vancomycin (FALSE)
Vancomycin is only effective agaianst gram positive bacteria
iii) The following antibiotics have broad spectrum activity against both gram positive and gram negative bacteria Meropenem (TRUE)
From a relatively new class of drug (Cabepenems) it is active against most gram +ve and -ve bacteria including pseudomonas.
iv) The following antibiotics have broad spectrum activity against both gram positive and gram negative bacteria Gentamycin (FALSE)
Gentamycin is an aminoglycoside, potent against gram -ve bacteria but with porr activity against gram +ve bacteria
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67 . Regarding symptomatic pre-eclampsia
i) It may develop from 12 weeks gestation FALSE
ii) Diuresis is a prodromal symptom prior to a fit FALSE
iii) Hyporeflexia is a recognised sign. FALSE
iv) The circulating blood volume is decreased. TRUE
v) Diazepam is the treatment of choice for imminent eclampsia. FALSE
Explanations
i) Regarding symptomatic pre-eclampsia It may develop from 12 weeks gestation (FALSE)
May develop from 20 weeks onwards.
ii) Regarding symptomatic pre-eclampsia Diuresis is a prodromal symptom prior to a fit (FALSE)
The prodromal period is characterised by oliguria as the circulating volume is reduced.
iii) Regarding symptomatic pre-eclampsia Hyporeflexia is a recognised sign. (FALSE)
HYPERreflexia is a pre-eclamptic sign and if present requires close monitoring and prevention of subsequent fits.
iv) Regarding symptomatic pre-eclampsia The circulating blood volume is decreased. (TRUE)
This is due to numerous factors including: hypoproteinaemic induced oedema and decreased aldosterone secretion.
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68 . Preterm birth is associated with:
i) Neonatal hypernatraemia FALSE
ii) Extended posture TRUE
iii) Increased Lanugo TRUE
iv) Poor breast development TRUE
v) Recurrent Bradycardia TRUE
Explanations
i) Preterm birth is associated with: Neonatal hypernatraemia (FALSE)
Renal tubular immaturity results in a decreased ability to reabsorb sodium leading to HYPOnatraemia
ii) Preterm birth is associated with: Extended posture (TRUE)
This is a factor used in the Dubowitz score for gestational age assessment.
iii) Preterm birth is associated with: Increased Lanugo (TRUE)
This is a soft downy body hair
iv) Preterm birth is associated with: Poor breast development (TRUE)
This tissue development is sacrificed in place of more essential development
v) Preterm birth is associated with: Recurrent Bradycardia (TRUE)
The premature neonate may be hypoxic or hypercapnic. The bradycardia is a paradoxical response to these conditions, which may indicate neurological immaturity.
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69 . A 29 year old primigravid woman presents to A+E at 17 weeks of pregnancy with a fever, cough and breathlessness. She smokes 5 cigarettes a day but does not drink alcohol. The following are true:
i) If CXR and ECG are normal, P.E (pulmonary emoblism) may be excluded. FALSE
ii) A positive D-dimers result will confirm P.E. FALSE
iii) An ECG showing the 'S1Q3T3' pattern is pathognomonic of P.E in this case. FALSE
iv) If heparin therapy is initiated it should be continued throughout the pregnancy. TRUE
v) Warfarin is contraindicated in breastfeeding mothers. FALSE
Explanations
i) A 29 year old primigravid woman presents to A+E at 17 weeks of pregnancy with a fever, cough and breathlessness. She smokes 5 cigarettes a day but does not drink alcohol. The following are true: If CXR and ECG are normal, P.E (pulmonary emoblism) may be excluded. (FALSE)
These may both be normal or inconclusive. Further evidence may be gained by a V/Q scan.
ii) A 29 year old primigravid woman presents to A+E at 17 weeks of pregnancy with a fever, cough and breathlessness. She smokes 5 cigarettes a day but does not drink alcohol. The following are true: A positive D-dimers result will confirm P.E. (FALSE)
D-dimers allow for fairly accurate reassurance of the absence of a thromboembolic event when a NEGATIVE result is obtained. However a positive result gives no clear diagnostic information as it may be raised naturally in pregnancy.
iii) A 29 year old primigravid woman presents to A+E at 17 weeks of pregnancy with a fever, cough and breathlessness. She smokes 5 cigarettes a day but does not drink alcohol. The following are true: An ECG showing the 'S1Q3T3' pattern is pathognomonic of P.E in this case. (FALSE)
Although this pattern appears in classical P.E presentation, S1Q3T3 i.e Deep S wave in lead I, presence of a Q wave and inverted T wave in lead III, may be caused by pregancy alone in the abscence of P.E.
iv) A 29 year old primigravid woman presents to A+E at 17 weeks of pregnancy with a fever, cough and breathlessness. She smokes 5 cigarettes a day but does not drink alcohol. The following are true: If heparin therapy is initiated it should be continued throughout the pregnancy. (TRUE)
Heparin should be given IV initially until the APPT is roughly doubled. This may be changed to subcutaneous unfractionated heparin after about 1 week.
v) A 29 year old primigravid woman presents to A+E at 17 weeks of pregnancy with a fever, cough and breathlessness. She smokes 5 cigarettes a day but does not drink alcohol. The following are true: Warfarin is contraindicated in breastfeeding mothers. (FALSE)
Warfarin may be used during breastfeeding.
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70. regarding placenta previa
i) most patients present with vaginal bleeding TRUE
ii) the matenal mortality rate is about 3% FALSE
iii) smoking is a risk factor TRUE
iv) it is more common in multiparous women TRUE
v) immadiate delivery is always indicated FALSE
Explanations
i) regarding placenta previa most patients present with vaginal bleeding (TRUE)
it is usually of sudden onset during the third trimester,bright red and painless
ii) regarding placenta previa the matenal mortality rate is about 3% (FALSE)
The maternal mortality rate secondary to placenta previa is approximately 0.03%.
iii) regarding placenta previa smoking is a risk factor (TRUE)
-other risk factors include:
Prior previa (4-8%)
First subsequent pregnancy following a cesarean delivery
Multiparity (5% in grand multiparous patients)
Advanced maternal age
Multiple gestations
Prior induced abortion
iv) regarding placenta previa it is more common in multiparous women (TRUE)
5% in grand multiparous patients
v) regarding placenta previa immadiate delivery is always indicated (FALSE)
If the fetus is preterm and immediate delivery is unnecessary (eg, fetus <37>
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71 . Breech positions:
i) Occur in less than 5% of labours TRUE
ii) Most commonly occur as the 'extended breech' TRUE
iii) Are more common in primiparous women FALSE
iv) External Cephalic Version is successful in converting on average <>
v) Require delivery at 38 weeks FALSE
Explanations
i) Breech positions: Occur in less than 5% of labours (TRUE)
Figures quoted are typically around 3%.
ii) Breech positions: Most commonly occur as the 'extended breech' (TRUE)
This is when hips are flexed and there is extension at the knees.
iii) Breech positions: Are more common in primiparous women (FALSE)
Are more common in multiparous women. This is thought to be due to lax uterine and abdominal muscles allowing more free movement into malpositions.
iv) Breech positions: External Cephalic Version is successful in converting on average <>
ECV has an average rate of success of 65%.
It may be attempted from 37 weeks in a hospital environment. Cochrane reviews have suggested that it may be used successfully until term without increasing perinatal mortality.
v) Breech positions: Require delivery at 38 weeks (FALSE)
Delivery at 38 weeks was used in the past but it is thought that with adequate planning, a breech position may go to term and be delivered vaginally if appropriate.
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72 . A woman at 32 weeks gestation starts rhythmical contractions while at home. She is brought to labour ward where examination reveals she is 6cm dilated, membranes intact. Reasonable management will include:
i) Administration of an oral tocolytic agent FALSE
ii) Prophlactic antibiotics FALSE
iii) Rupture of membranes to aid progression FALSE
iv) Prophylactic episiotomy during labour TRUE
v) Awareness that fetal mortality is ~10% at 32 weeks. FALSE
Explanations
i) A woman at 32 weeks gestation starts rhythmical contractions while at home. She is brought to labour ward where examination reveals she is 6cm dilated, membranes intact. Reasonable management will include: Administration of an oral tocolytic agent (FALSE)
Tocolytic agents are of questionable use but are not indicated when cervical dilatation is >5cm as labour is very likely to insue.
ii) A woman at 32 weeks gestation starts rhythmical contractions while at home. She is brought to labour ward where examination reveals she is 6cm dilated, membranes intact. Reasonable management will include: Prophlactic antibiotics (FALSE)
Her membranes are intact. If PROM (premature rupture of membranes) had occured some time before, high vaginal swabs should be taken and antibiotic administration suggested.
iii) A woman at 32 weeks gestation starts rhythmical contractions while at home. She is brought to labour ward where examination reveals she is 6cm dilated, membranes intact. Reasonable management will include: Rupture of membranes to aid progression (FALSE)
Membranes should be kept intact for as long as possible. They may protect from hypoxia in cases of cord compression.
iv) A woman at 32 weeks gestation starts rhythmical contractions while at home. She is brought to labour ward where examination reveals she is 6cm dilated, membranes intact. Reasonable management will include: Prophylactic episiotomy during labour (TRUE)
Though the fetus will be smaller than at term, it is immature, thus pressure may be more deforming and traumatic to the premature head.
v) A woman at 32 weeks gestation starts rhythmical contractions while at home. She is brought to labour ward where examination reveals she is 6cm dilated, membranes intact. Reasonable management will include: Awareness that fetal mortality is ~10% at 32 weeks. (FALSE)
Fetal mortality is very low/approaching normal at 32 weeks.
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73 . Complications in Labour:
i) Meconium aspiration is more common in post-term pregnancy TRUE
ii) Forceps or ventouse may only be used if the cervix is fully dilated TRUE
iii) Epidural analgesia increases the risk of aspiration of gastric contents FALSE
iv) Face presentation has an increased incidence of cord prolapse TRUE
v) Suspected placenta praevia should be confirmed by digital examination FALSE
Explanations
i) Complications in Labour: Meconium aspiration is more common in post-term pregnancy (TRUE)
There is a higher incidence in post term labours. It is a sign of fetal distress and/or chorioamnionitis at earlier gestations.
ii) Complications in Labour: Forceps or ventouse may only be used if the cervix is fully dilated (TRUE)
In the past, forceps were used for vaginal delivery with incomplete dilatation, this should not be current practice.
iii) Complications in Labour: Epidural analgesia increases the risk of aspiration of gastric contents (FALSE)
Epidural analgesia does not affect the cardiac sphincter
iv) Complications in Labour: Face presentation has an increased incidence of cord prolapse (TRUE)
There is an increased risk of cord prolapse associated with other malpresentations also.
v) Complications in Labour: Suspected placenta praevia should be confirmed by digital examination (FALSE)
Digital examination should not be performed unless in theatre with staff prepared for caesarian section as it increases the risk of serious haemorrhage.
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74 . In the management of Post Partum Haemorrhage:
i) Uterine atonia is the commonest cause TRUE
ii) Patients should be sat upright to aid breathing. FALSE
iii) Uterine packing is an initial measure FALSE
iv) Platelets should be given early FALSE
v) if due to incomplete placental expulsion requires urgent exploration of the uterine cavity TRUE
Explanations
i) In the management of Post Partum Haemorrhage: Uterine atonia is the commonest cause (TRUE)
This is responsible in ~90% of cases. Genital tract trauma accounts for ~7% and clotting disorders ~3%.
ii) In the management of Post Partum Haemorrhage: Patients should be sat upright to aid breathing. (FALSE)
Patient may be shocked and should be postioned in the lithotomy position or with bed tilted head down.
iii) In the management of Post Partum Haemorrhage: Uterine packing is an initial measure (FALSE)
Initial management should include rubbing up a uterine contraction, atonia being the commonest cause. Other Management includes:
-IV access
-Initiation of an oxytocic eg. syntometrine
-Fluids +/- blood transfusion.
iv) In the management of Post Partum Haemorrhage: Platelets should be given early (FALSE)
Initially blood loss should be replaced by blood (uncrossmatched if necessay). Platelets or FFP can be given if coagulation failure develops.
v) In the management of Post Partum Haemorrhage: if due to incomplete placental expulsion requires urgent exploration of the uterine cavity (TRUE)
This should be done to remove unexpelled material as the uterus will be unable to contract and halt the bleeding.
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75 . Regarding pain relief in labour:
i) Entonox is given at a concentration of 50% Nitrous Oxide in oxygen TRUE
ii) Pethidine is contraindicated in a mother taking Tricyclic antidepressants FALSE
iii) Pethidine is containdicated in pre-eclampsia TRUE
iv) Bupivicaine is commonly used in labour epidural anaesthesia TRUE
v) Headache is an immediate sign of accidental dural tap in epidurals FALSE
Explanations
i) Regarding pain relief in labour: Entonox is given at a concentration of 50% Nitrous Oxide in oxygen (TRUE)
This is known as 'gas and air'
ii) Regarding pain relief in labour: Pethidine is contraindicated in a mother taking Tricyclic antidepressants (FALSE)
Pethidine may increase the TCA effect and should be used with caution but is not contraindicated.
Pethidine is containdicated in mothers taking MAOI's as it increases the risk of hypertensive crises
iii) Regarding pain relief in labour: Pethidine is containdicated in pre-eclampsia (TRUE)
The metabolite to pethidine is proconvulsant and increases the risk of eclamptic fit.
iv) Regarding pain relief in labour: Bupivicaine is commonly used in labour epidural anaesthesia (TRUE)
Trade name 'Marcain'
v) Regarding pain relief in labour: Headache is an immediate sign of accidental dural tap in epidurals (FALSE)
Headache, if due to dural tap, commonly occurs after 1-2 days.
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76 . Cervical intraepithelial neoplasia (CIN):
i) Usually arises from the transformation zone of the cervix TRUE
ii) Is more common in women with AIDS TRUE
iii) CIN III lesions will progress to cervical cancer at a rate of between 1% and 5% per year TRUE
iv) Will often present with post coital bleeding FALSE
v) Is sucessfully treated using cryotherapy FALSE
Explanations
i) Cervical intraepithelial neoplasia (CIN): Usually arises from the transformation zone of the cervix (TRUE)
Cervical intraepithelial neoplasia (CIN) almost always arises from the transformation zone of the cervix.
ii) Cervical intraepithelial neoplasia (CIN): Is more common in women with AIDS (TRUE)
CIN is more common in this group of patients because they will be immunosuppressed and are more likely to have a history of multiple sexual partners in which case they are at greater risk of HPV infection which is particularly implicated in the development of CIN
iii) Cervical intraepithelial neoplasia (CIN): CIN III lesions will progress to cervical cancer at a rate of between 1% and 5% per year (TRUE)
CIN is a major risk factor for the development of cervical cancer and grade III lesions carry a significant risk of progression to cancer, the risk of progression is usually quoted as being 1.8% per year.
The 1.8% risk is cumulative over the years so that in a ten year period 18% of women with untreated CIN III lesions will develop cancer.
iv) Cervical intraepithelial neoplasia (CIN): Will often present with post coital bleeding (FALSE)
This is false: CIN is an asymptomatic condition that is usually only detected by a smear test.
v) Cervical intraepithelial neoplasia (CIN): Is sucessfully treated using cryotherapy (FALSE)
Cryotherapy is a poor choice for treatment for two reasons. Firstly it does not preserve any tissue for biopsy and secondly it does not destroy tissue to a depth of 5mm. (5mm is the depth necessary to ensure that all dysplastic cells in the glands are destroyed)
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77 . Cervical cancer:
i) is most common in women between 20 and 40 years of age. FALSE
ii) is more common in women who have had many sexual partners TRUE
iii) does not occur without pre-existing grade III cervical intraepithelial neoplasia (CIN) FALSE
iv) commonly presents with a painful abdomen FALSE
v) rarely responds to radiotherapy treatment FALSE
Explanations
i) Cervical cancer: is most common in women between 20 and 40 years of age. (FALSE)
Cervical cancer can affect sexually mature women of all ages, but it is more commonly seen in middle age and above.
ii) Cervical cancer: is more common in women who have had many sexual partners (TRUE)
One of the major risk factors for the development of cervical cancer is infection with certain geneotypes of the human papiloma virus (HPV). The more sexual partners a woman has had the greater the chance of her becoming infected with this virus and consequently her risk of cervical cancer is greater.
iii) Cervical cancer: does not occur without pre-existing grade III cervical intraepithelial neoplasia (CIN) (FALSE)
This is false. Cervical cancer is much more likely to arise from existing CIN III lesions, however it may arise directly from CIN I and CIN II lesions. It can also arise where there is no pre-existing lesion at all.
iv) Cervical cancer: commonly presents with a painful abdomen (FALSE)
This is not a common presentation for cervical cancer, pain usually only occurs in advanced lesions.
The most common initial symptoms include:
- intermenstrual bleeding
- post coital bleeding
- post menopausal bleeding
- vaginal discharge
v) Cervical cancer: rarely responds to radiotherapy treatment (FALSE)
This is false. Radiotherapy and surgery form the mainstay of treatment for cervical cancer. Radiotherapy may be used without surgery or may be combined with surgery to remove large tumours and reduce the incidence of recurrences.
Chemotherapy is also gaining popularity, but is usually combined with either surgery or radiotherapy.
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78 . The Menopause is associated with:
i) Low FSH FALSE
ii) Elevated prolactin FALSE
iii) Low 17-beta oestradiol TRUE
iv) Reduction in vaginal acidity TRUE
v) Decreased osteoblastic activity TRUE
Explanations
i) The Menopause is associated with: Low FSH (FALSE)
FSH levels rise perimenopausally and FSH levels >40 IU/L indicates menopause.
ii) The Menopause is associated with: Elevated prolactin (FALSE)
There is no increase seen.
iii) The Menopause is associated with: Low 17-beta oestradiol (TRUE)
This accounts for many of the physical changes seen at and after the menopause e.g vaginal atrophy and dryness, prolapse etc.
iv) The Menopause is associated with: Reduction in vaginal acidity (TRUE)
In the reproductive years the vagina is kept at increased acidity, reducing the passage of infection. This decreases with menopause.
v) The Menopause is associated with: Decreased osteoblastic activity (TRUE)
There is decreased bone formation and increased bone resorption.
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79 . The Menstrual Cycle
i) Ovulation coincides with the LH (leutinising hormone) peak FALSE
ii) In the follicular phase, rising oestradiol initially provides negative feedback on FSH levels TRUE
iii) Increasing progesterone leads to thinning of cervical mucus FALSE
iv) A normal 21 day progesterone is an indirect indicator of ovulation TRUE
v) The average length of each menstrual cycle tends to decrease with increasing age between the ages 20 and 50 TRUE
Explanations
i) The Menstrual Cycle Ovulation coincides with the LH (leutinising hormone) peak (FALSE)
Ovulation coincides with the LH downslope, occuring after the peak.
ii) The Menstrual Cycle In the follicular phase, rising oestradiol initially provides negative feedback on FSH levels (TRUE)
When oestrodiol levels rise to a peak this feedback changes to a positive stimulatory effect leading to the LH and FSH surges.
iii) The Menstrual Cycle Increasing progesterone leads to thinning of cervical mucus (FALSE)
It is the rising levels of oestradiol just before ovulation that causes thinning of cervical mucus. Progesterone increases in the luteal phase causing cervical mucus to again become thick and impenetrable. Thin mucus allows the passage of semen more easily, thus this is necessary around the time of ovulation.
iv) The Menstrual Cycle A normal 21 day progesterone is an indirect indicator of ovulation (TRUE)
It is highly suggestive of ovulation but it is not a DIRECT indicator as it only indicates adequate function and secretion by the corpus leuteum, presuming therefore that ovulation has occured.
v) The Menstrual Cycle The average length of each menstrual cycle tends to decrease with increasing age between the ages 20 and 50 (TRUE)
Mean cycle length Age 18-30 = 29 days
Mean cycle length Age 46-51 = 24 days
Data from Sherman et al 1975
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80 . A 16 year old girl presents to her GP with secondary amenorrhoea of 7 months duration. She has no medical history of note and denies any sexual activity.
i) Androgen insensitivity syndrome is a possible cause FALSE
ii) Given the history, a pregnancy test would be of little value FALSE
iii) Thyroid function tests should be included in the initial investigative tests. TRUE
iv) A progestin challenge followed by a withdrawral bleed is suggestive of an anovulatory disorder. TRUE
v) Low levels of FSH and LH are suggestive of a hypothalamic disorder TRUE
Explanations
i) A 16 year old girl presents to her GP with secondary amenorrhoea of 7 months duration. She has no medical history of note and denies any sexual activity. Androgen insensitivity syndrome is a possible cause (FALSE)
The answer is false: patients with this condition may present with primary amenorrhoea, but never a secondary amenorrhoea.
Androgen insensitivity syndrome (also known as Testicular feminization syndrome) is a condition in which the patient has a male, XY karyotype, but has a congenital defect in their androgen receptors. As a result the patient has external female genitalia but fails to undergo sexual maturation. Many of these cases are detected in infancy, but some will only present when the patient fails to develop secondary sexual characteristics.
Such patients will present with primary amenorrhoea and failure to develop secondary sexual characterisitics in their early to mid teens.
ii) A 16 year old girl presents to her GP with secondary amenorrhoea of 7 months duration. She has no medical history of note and denies any sexual activity. Given the history, a pregnancy test would be of little value (FALSE)
Patients, espescially young patients, may deny sexual activity due to fears of confidentiality and embarassment. So, even if the history is not suggestive of pregnancy, a test is still useful as pregnancy is the leading cause of secondary amenorrhoea.
NB: always seek the patient's consent before carrying out any test.
iii) A 16 year old girl presents to her GP with secondary amenorrhoea of 7 months duration. She has no medical history of note and denies any sexual activity. Thyroid function tests should be included in the initial investigative tests. (TRUE)
Thyroid dysfunction (both hyperthyroidism and hypothyroidism) is a common cause of secondary amenorrhoea and should be checked.
iv) A 16 year old girl presents to her GP with secondary amenorrhoea of 7 months duration. She has no medical history of note and denies any sexual activity. A progestin challenge followed by a withdrawral bleed is suggestive of an anovulatory disorder. (TRUE)
This is true: A progestin challenge followed by a withdrawral bleed is suggestive of anovulatory dysfunction.
This result should be further assessed by measuring serum LH and FSH levels to confirm the diagnosis of anovulation.
v) A 16 year old girl presents to her GP with secondary amenorrhoea of 7 months duration. She has no medical history of note and denies any sexual activity. Low levels of FSH and LH are suggestive of a hypothalamic disorder (TRUE)
This is true. Low levels of FSH and LH suggest that the amenorrhoea is a result of a problem occuring at the level of the hypothalamus. These disorders may be classified as functional (where there is no abnormal pathology) or non-functional where the problem is secondary to a pathological process in the hypothalamus or pituitary.
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