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.
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. 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.
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.
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.
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.
Question 5 Wasting of the thenar muscles as an isolated sign is MOST likely