Clinical Management STRATOG NEW

A 16-year-old woman presents with secondary amenorrhoea. She is healthy, The answer is follicle-stimulating hormone
with no past medical history. Her BMI is 17. What is the most appropriate measurement. The likely diagnosis is amenorrhoea
initial investigation? caused by weight loss, so follicle-stimulating
hormone measurements would be appropriate.
Thyroid function test Since she is clinically euthyroid, thyroid function
Karyotype tests would be of limited value.

Follicle-stimulating hormone measurement

Dehydroepiandrosterone sulphate (DHEAS) measurement
Bone mineral density scan

You are asked to assess a patient who is receiving magnesium sulphate
infusions for severe pre-eclampsia. They have passed only 5 ml urine in the
last 2 hours. Tests demonstrate that their deep tendon reflexes are absent.
What other observation should you take?
Temperature
Respiratory rate
The answer is respiratory rate. This patient has
signs of magnesium toxicity (absent deep tendon
reflexes), which is probably secondary to renal
impairment. Respiratory depression is a sign of
increasing magnesium toxicity is; therefore, the
most appropriate follow-up would be to investigate
the patients respiratory rate.

Pulse rate
Glasgow coma score
Blood pressure

A cardiotocograph shows type 1 variable decelerations. What is the cause of this The answer is umbilical cord compression. Variable
feature? decelerations are due to umbilical cord
compression. Early decelerations are caused by
Umbilical cord compression compression of the fetal head, and late
Placental insufficiency decelerations are caused by fetal hypoxia that is
secondary to placental insufficiency. Fetal
Fetal movements
movements are related to accelerations.
Fetal hypoxia
Fetal head compression
You answer an emergency call for a postpartum haemorrhage. The The answer is uterine atony. Approximately 70% of
midwife estimates that the patient has lost approximately 500 ml of blood. all postpartum haemorrhages are due to uterine
What is the most likely cause of the bleeding? atony.

Vaginal tear
Uterine atony
Retained placenta tissue
Coagulopathy
Cervical trauma

Whilst you are attending to a patient in the antenatal ward, the patient collapses The answer is get help. Basic and Advanced Life
and becomes unresponsive. You open their airway but they are not breathing. Support guidelines highlight the need to get help if
What should you do next? a patient has collapsed and is unresponsive. You
should then place the patient in left lateral tilt and
Left lateral tilt commence cardiac compressions at a rate of 30:2.
Give a precordial thump Artificial ventilation is not mandatory in the ALS
guidelines.
Get help
Commence cardiac compressions
Commence artificial ventilation

A 17-year-old woman presents to the sexual health clinic with vulval ulceration The answer is herpes simplex virus. A painful
and difficulty in passing urine. She is sexually active and has had unprotected genital ulcer has developed in a sexually active
intercourse with her new boyfriend. She takes the combined oral contraceptive patient who has not used barrier contraception.
pill. What is the most likely diagnosis? Syphilis is usually associated with the presence of
a painless ulcer. Candida is not a sexually
Syphilis transmitted disease and rarely presents with
Human papillomavirus ulceration. Human papillomavirus causes warts,
and herpes varicella zoster causes chicken pox
Herpes varicella virus
and shingles.
Herpes simplex virus
Candida albicans
A primigravid woman presents in spontaneous labour at 39 weeks of gestation.
At 18:00h, her cervical dilatation is 6 cm. A further vaginal examination at
22:00h reveals that cervical dilatation is still at 6 cm. At 02:10h, the fetus is in
the occipitoposterior position and uterine activity is present. What is the most
appropriate action?
Repeat vaginal examination after 4 hours
Repeat vaginal examination after 2 hours
Membrane sweep
Commence intravenous oxytocin
Amniotomy
An 18-year-old woman presents to an early pregnancy unit with light vaginal
bleeding after 10 weeks of amenorrhea. She had taken a pregnancy test 4
weeks ago that had tested positive. A transvaginal ultrasound scan showed an
irregular gestation sac with no fetal pole. What is the likely diagnosis?
Threatened miscarriage
Incomplete miscarriage
Hydatidiform mole
Complete miscarriage
Anembryonic pregnancy
A 55-year-old woman presents to the clinic enquiring about the use of hormone
replacement therapy (HRT). She had a hysterectomy 8 years ago for fibroids.
She has no contraindications or other past medical history, except a strong
family history of osteoporosis. Her main symptoms are hot flushes and vaginal
dryness. What would be your first treatment option?
Selective serotonin reuptake inhibitor
The answer is amniotomy. This case demonstrates
slow/no progression during the first stage of labour
and malpositioning of the fetus. The most
appropriate initial intervention would be an
amniotomy (artificial rupture of the membranes).
The answer is anembryonic pregnancy. Threatened
miscarriage refers to vaginal bleeding in the
presence of a viable pregnancy; however, this
pregnancy is not viable. There are products of
conception (gestation sac) that are visible on the
scan so this is an incomplete miscarriage, which is
usually associated with heavy vaginal bleeding. In
this case, the patient is considered to be pregnant,
although no embryonic tissue is present. Therefore,
the most likely diagnosis is anembryonic
pregnancy.
The answer is estrogen-only HRT. HRT provides
the most effective method of treating climacteric hot
flushes and vaginal dryness, as well as
postmenopausal osteoporosis. Estrogen-only HRT
is appropriate following a hysterectomy, as the risk
of endometrial carcinoma is not present.
 Oral calcium therapy only
Estrogen-only HRT
Combined sequential HRT
A selective estrogen receptor modulator

A 68-year-old woman presents with two episodes of postmenopausal bleeding.
She has a BMI of 23 and is otherwise healthy. An ultrasound shows that her
endometrial cavity is 4 mm thick, and an endometrial pipelle sample is taken that
yields a small volume of tissue. The pathology report suggests a neoplasm. What
is the most likely diagnosis?
Serous carcinoma
Endometrioid adenocarcinoma
The answer is serous carcinoma. Serous
carcinomas are typically seen in postmenopausal
women. The development of these carcinomas is
not associated with a raised BMI, diabetes or
hypertension. The uterine tumour can be very
small (even in the presence of extra uterine
spread), and therefore, results from an ultrasound
and even hysteroscopy can appear normal.

Endometrial polyp
Endometrial hyperplasia
Leiomyoma

A nulliparous woman presents with spontaneous rupture of membranes at 41 The answer is commence intravenous oxytocin.
weeks of gestation. At 18:00h, her cervical dilatation is 3 cm. A further vaginal The membranes have ruptured already so
examination at 22:00h reveals that her cervical dilatation is still 3 cm. At 02:10h, amniotomy is not required. No progression has
the fetus is in the occipitoposterior position and uterine activity is present. What been made during the first stage of labour.
is the most appropriate action? Therefore, the patient should be administered
intravenous oxytocin.
Repeat vaginal examination after 4 hours
Membrane sweep
Commence intravenous oxytocin
Caesarean section
Administer prostaglandin per vaginam

Polyglactin sutures are used extensively in surgical procedures, particularly to The answer is braided, absorbable and synthetic.
ligate vessels. What are the key features of polyglactin sutures? Polyglactin sutures are used to ligate pedicles and
close the uterus during a caesarean section. To
 Non-braided, non-absorbable and natural achieve this, the sutures are braided to prevent the
Non-braided, absorbable and synthetic knots from slipping.

Non-braided, absorbable and natural

Braided, non-absorbable and synthetic
Braided, absorbable and synthetic

The answer is Fraser. This law refers specifically

A 15-year-old patient visits her GP requesting a method of contraception. When taking
her history, you discover a personal history of thromboembolic events. She has had to contraception.
three sexual partners in 5 months. She also complains of dysmenorrhea. You advise on
contraception being mindful of which medical law?

Abortion Act 1967

Bolam
Bolitho
Fraser
Gillick

A patient with a previous caesarean section arrives at term to your unit in The best answer is CFM and vaginal assessment 2
spontaneous labour. The midwife reports the cervix is 6 cm dilated, there is a hours following the last VE.
longitudinal lie and the vertex is well applied to the cervix. The patient is
contracting three times in 10 minutes. You are asked to assess the patient by the
registrar on call as he is in theatre. What initial management would you suggest?

You immediately perform a fetal blood sample

You suggest continuous fetal monitoring (CFM) and syntocinon infusion
You suggest continuous fetal monitoring (CFM) and vaginal assessment 2
hours following the last VE
You suggest intermittent monitoring and 1 hourly vaginal assessments
You suggest mobilisation and a cooks catheter

A patient with a previous caesarean section arrives at term to your unit in The best answer is scar rupture as the fetus is
spontaneous labour. The midwife reports the cervix is 6 cm dilated, there is a compromised.
longitudinal lie and the vertex is well applied to the cervix. The patient is
contracting three times in 10 minutes. The contractions stop and there is a fetal
bradycardia. What is the most likely diagnosis?

Placental abruption
Scar dehiscence
Scar rupture
Tetanic uterine contractions
Uterine atony

A 28-year-old primiparous woman is induced at 39+2 for raised BP and The best answer is on the sagittal suture line,
proteinuria. She progresses well to full dilatation, but after pushing for 2 hours approximately 3 cm anterior (in front) of the
there is no vertex visible. On examination, the head is felt to be OA, at +1 station. posterior fontanelle.
A decision is made for an instrumental delivery, and the baby is delivered via
assisted vaginal delivery in theatre. For a ventouse delivery to be successful, the
ventouse cup needs to be applied to the flexion point of the fetal head. Which of
the following statements best describes the location of the flexion point?

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

Directly over the anterior fontanelle
Directly over the posterior fontanelle
On the sagittal suture line, approximately 2 cm posterior (behind) the
posterior fontanelle
On the sagittal suture line, approximately 3 cm anterior (in front) of the
posterior fontanelle

A 28-year-old primiparous woman is induced at 39+2 for raised BP and

proteinuria. She progresses well to full dilatation, but after pushing for 2 hours The best answer is a 3b degree tear. Note the the
there is no vertex visible. On examination, the head is felt to be OA, at +1 station. risk of perineal tearing after instrumental delivery is
A decision is made for an instrumental delivery, and the baby is delivered via 7% for forceps and 4% for ventouse.
assisted vaginal delivery in theatre. (Same scenario as question above.) Shortly
after delivery, you examine the perineum. Your episiotomy has extended, and the
tear involves approximately 60% of the external anal sphincter. The internal anal
sphincter and anal mucosa are intact. How would you classify this perineal
trauma?

Second degree tear

3a degree tear
3b degree tear
3c degree tear
Fourth degree tear

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

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

External iliac lymph nodes

Hypogastric lymph nodes
Inguinal lymph nodes
Internal iliac lymph nodes
Para-aortic lymph nodes

A 30-year-old primigravida who is pregnant after IVF attends the Early Pregnancy
Unit with severe right sided abdominal pain. An ultrasound scan shows an empty The answer is laparoscopy and salpingectomy if
uterus. -hCG levels are 5,500 iu/L. What is the appropriate course of action? there is an ectopic pregnancy.
 Expectant management, evaluate after 48 hours with repeat hCG levels
Laparoscopy and salpingectomy if there is an ectopic pregnancy
Laparoscopy and salpingotomy if there is an ectopic pregnancy
Methotrexate injection
Repeat scan in 7 days

The midwife has asked you to review a 34-year-old multigravida who is 7 cm

dilated and progressing well. The CTG shows a variability of <5. She was given The answer is repeat FBS within 30 minutes.
pethidine when she was 6 cm dilated. A fetal blood sampling is done and reveals
a pH of 7.23. What will be your next line of management?

Delivery is indicated
Reassure the patient
Repeat FBS after 1 hour
Repeat FBS if fetal heart rate abnormality persists
Repeat FBS within 30 minutes

A 75-year-old woman presents with increased weight, loss of hair and a dislike of The answer is hypothyroidism.
cold weather. She was noted to have a high prolactin and normal electrolytes.
She is otherwise fit and well. What is the likely cause of the high prolactin?

Antiemetic use
Hypothyroidism
Neuroleptic use
Prolactinoma
Renal failure