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OBFINALS REVISION SESSION who are we? what we do? disclaimer: Theknowledge and expertise.hored by medical students and junior doctors to the best of their Cardiology Respiratory Gastroenterology Stroke Haematology Renal Endocrine Paediatrics ENT + General Surgery Musculoskeletal Ophthalmology online medical school finals Infections revision series & many more! Become an ambassador of Crash Course Finals! Do you want to build your CV and portfolio? Represent our network and grow yours! Email us with 200 words. about why you’d be a great ambassador and what you’d bring to the role CrashCourseFinalsUK@gmail.comeasy medium hardkeep up to date with all our teaching sessionsHouse rules go on mute questions in chat be respectfulROUND: 1 What is the most likely diagnosis for the 1. A 28 year old woman presents at 27 weeks cause of vaginal bleeding in this patient? gestation presents to the antenatal clinic with vaginal bleeding. She denies any pain. On Placental abruption A examination, the cervix is closed and the uterus Cervical polyp is non-tender. B Vasa praevia C Placenta praevia D Placenta Praevia PAINLESS vaginal bleeding and closed cervix = What is the most likely diagnosis for the most likely placenta praevia cause of vaginal bleeding in this patient? Vasa praevia may cause painless vaginal bleeding but less common than placenta praevia Placental abruption assc with PAINFUL vaginal bleeding and uterine tenderness Placental abruption A Cervical polyp B C Vasa praaevia Placenta praevia D What is the most appropriate initial management for hypertension in this pregnant woman? 2. A 28 year old pregnant woman attends for a A Labetalol routine check-up at 28 weeks gestation. She is found to have a BP of 148/97mmHg. PMH: asthma. B Nifedipine Urinalysis shows no proteinuria. C Ramipril Amlodipine D NICE Guidelines: What is the most appropriate initial management for hypertension in this pregnant woman? A Labetalol B Nifedipine C Ramipiril Pregnancy-induced hypertension => hypertension over 20 weeks gestation with no evidence of proteinuria D Amlodipine Management: oral labetalol 1st line oral nifedipine (e.g. if asthmatic) and hydralazine What is the most likely type of miscarriage in this patient? 3. A 30 year old woman at 10 weeks gestation presents to the emergency department with A Threatened abdominal pain and vaginal bleeding. On examination, the cervix is open and products of conception are B Complete visualised within the cervical canal. C Inevitable D Missed Miscarriage => the loss of a pregnancy before 24 weeks. Early miscarriage is before 12 weeks gestation. Late miscarriage is between 12 and 24 weeks gestation. What is the most likely type of miscarriage in this patient? A Threatened B Complete C Inevitable D Missed4. A 32 year old woman presents to the emergency What is the most appropriate next step in management? department with lower abdominal pain and vaginal spotting. The patient is haemodynamically stable and her serum beta-human chorionic gonadotrophin A Immediate salpingotomy (B-hCG) level is 4,500 mIU/mL. Transvaginal Immediate salpingectomy ultrasound reveals an empty uterus and a live B embryo with a visible fetal heartbeat in the right C Methotrexate fallopian tube. She has no relevant past medical history. Serum B-hCG measurements D What is the most appropriate next step in management? A Immediate salpingotomy Immediate salpingectomy B Methotrexate C D Serum B-hCG measurements Therefore, in this patient: salpingotomy vs salpingectomy salpingectomy would be the most appropriate as no other RFs for infertility eg no PMH of any damage to contralateral fallopian tube What is the most appropriate management for this patient? 5. A 24 year old woman with a confirmed intrauterine pregnancy at 11 weeks of gestation A Methotrexate presents to the sexual health clinic requesting B Mifepristone termination of pregnancy. She states that her decision is based on personal circumstances and C Misoprosol followed by mifepristone requests a medical abortion. D Mifepristone followed by misoprostol What is the most appropriate management for this patient? Management Mifepristone (anti-progestogen) Methotrexate Misoprostol (prostaglandin analogue) 1 – 2 days later A Mifepristone Methotrexate used for medical management of ectopic pregnancy B C Misoprosol followed by mifepristone D Mifepristone followed by misoprostol What is the most appropriate method of contraception for this patient? 6. A 22 year old woman presents to the GP asking for contraception. She states that she would like a A Combined oral contraceptive pill (COCP) method with the least possible maintenance and something that she doesn’t have to remember to B Copper intrauterine device (IUD) take. PMH: appendectomy at age 14, pelvic Nexplanon (contraceptive implant)) C inflammatory disease D Levonorgestrel intrauterine system (LNG-IUS)Explanation: The patient has requested a contraceptive method with least possible maintenance and something that she won’t have to remember to take => consider IUD or IUS or the implant What is the most appropriate method of contraception for this patient? But PID can be a contraindication the the IUD or IUS Most appropriate option for this patient would be Combined oral contraceptive pill the Nexplanon (contraceptive implant) A (COCP) Copper intrauterine device (IUD) B Nexplanon (contraceptive implant) C Levonorgestrel intrauterine system D (LNG-IUS)ROUND: 27. An 83 year old presents to the GP with a What is the next most appropriate history of urinary incontinence. She describes management of this patient? having the urge to pass urine and not making it to the bathroom in time at times. She has tried A Mirabegron bladder retraining but this has not been successful. The patient has a past medical history of B Oxybutynin osteoarthritis and mild cognitive impairment. Her C Tolteridone observations are stable. On examination, she has D Botulinum toxin type A limited mobility and frailty.Mirabegron is used an alternative medical treatment for urge incontinence with less of an anticholinergic burden so better for frail elderly patients. What is the next most appropriate management of this patient? *But it is contraindicated in uncontrolled hypertension. Blood pressure needs to be monitored regularly during treatment. It works as a beta-3 agonist, stimulating the sympathetic nervous system, leading to raised blood pressure. This can lead to a hypertensive crisis and an increased risk of TIA and stroke. A Mirabegron B Oxybutynin Management of urge incontinence: Bladder retraining (gradually increasing the time between voiding) for at least C Tolteridone six weeks is first-line Anticholinergic medication, for example, oxybutynin, tolterodine and solifenacin D Botulinum toxin type A Mirabegron is an alternative to anticholinergic medications Invasive procedures where medical treatment fails What is the most appropriate management for this patient? 8. A 25 year old woman presents to the GP with a Clomifene history of irregular menstrual cycles. She also A describes suffering from acne and excessive hair B Weight reduction and lifestyle modifications growth. Her BMI is 20. She does not currently have C Topical elfornithine any plans for pregnancy. D Combined oral contraceptive pill PCOS: Clomifene can be used to manage infertility in patients with PCOS, but it is not stated that this patient is struggling with infertility and she has no plans to become pregnant currently What is the most appropriate Weight reduction not appropriate for this patient as normal BMI management for this patient? Topical elfornithine can be used for hirsutism and acne in PCOS patients if they do not respond to COCP initially COCP can be used for hirustism and acne in PCOS patients, as well as Clomifene general treatment for PCOS and if they require contraception - it A can help to regulate their cycle and induce a monthly bleed Weight reduction and lifestyle B modifications C Topical elfornithine D Combined oral contraceptive pill What is the most immediate step in management for this patient? 9. A 29-year old primigravida at 34 weeks gestation presents to the emergency department after her partner witnessing her A Oral labetalol having a seizure. She described having a generalized tonic-clonix seizure. Her BP is 170/100 mmHg and a urine dipstick shows 3+ B Urgent cesarean section proteinuria. A fetal ultrasound is performed, which indicates C IV phenytoin appropriate growth for gestational age. IV magnesium sulfate D Eclampsia => Pregnancy-induced HTN + proteinuria + seizures Administer IV magnesium sulfate What is the most immediate step in management for this patient? Magnesium sulphate is used to both Oral labetalol prevent and treat seizures A Urine output, reflexes, respiratory rate and oxygen saturations should be Urgent cesarean section monitored during treatment B Respiratory depression can occur: calcium gluconate is the first-line C IV phenytoin treatment for magnesium sulphate induced respiratory depression IV magnesium sulfate Treatment should continue for 24 D hours after last seizure or delivery Considering the most likely diagnosis, 10. A 62 year old woman presents to the GP with which of the following is not a risk factor for this patient? vaginal bleeding ongoing for the past couple of months. She is post-menopausal and went through A Smoking menopause at the age of 57. She has never been pregnant before. PMH: asthma and hypertension. B Obesity She has smoked 20 cigarettes a day for the past Late menopause 30 years. Her BMI is 36 kg/m2. C D NulliparityThe most likely diagnosis is endometrial cancer (think of this when see postmenopausal bleeding) Risk factors: excess oestrogen Considering the most likely diagnosis, nulliparity which of the following is not a risk factor early menarche for this patient? late menopause unopposed oestrogen. The addition of a progestogen to oestrogen A Smoking reduces this risk (e.g. In HRT). The BNF states that the additional risk is eliminated if a progestogen is given continuously metabolic syndrome B Obesity obesity diabetes mellitus PCOS C Late menopause tamoxifen hereditary non-polyposis colorectal carcinoma D Nulliparity Protective factors multiparity combined oral contraceptive pill smoking (the reasons for this are unclear) Which of the following is the most appropriate management strategy for her antiepileptic medication? 11. Mrs. Johnson, a 30-year-old pregnant woman with a history of epilepsy, presents for a routine Continue lamotrigine at current A dose throughout pregnancy prenatal visit. She is currently taking lamotrigine for B Switch to levetiracetam seizure control. Taper off antiepileptic C medication D Prescribe folic acid NHS Guidelines: Which of the following is the most appropriate management strategy for her antiepileptic medication? Continue lamotrigine at current A dose throughout pregnancy B Switch to levetiracetam C Taper off antiepileptic Lamotrigine + Carbamezapine are generally safe for use in pregnancy medication Prescribe folic acid D What is the most appropriate management strategy for Mrs. 12. Mrs. Anderson, a 34-year-old breastfeeding Anderson's mastitis? mother, presents to her primary care physician A Antibiotic therapy with a painful, swollen, and red area on her left breast. On examination, there is erythema and Recommend warm compresses B and breast massage to warmth over the affected area, consistent with promote milk drainage mastitis. Advise continuing breastfeeding C on the affected breast to promote milk flow Refer to lactation consultant D for breastfeeding advice What is the most appropriate management strategy for Mrs. Anderson's mastitis? A Antibiotic therapy Advise continuing breastfeeding B on the affected breast to promote milk flow Recommend warm compresses C and breast massage to promote milk drainage Refer to lactation consultant D for breastfeeding adviceround three What is the most appropriate management for this patient? 13. A 21 year old woman presents to the pharmacy requesting emergency contraception after having A Ulipristal acetate unprotected sexual intercourse 2 days ago. She requests Copper intrauterine device an oral method of emergency contraception. PMH: acne, B (IUD) Combined oral asthma with previous admissions to hospital. C contraceptive pill Levonorgestrel D What is the most appropriate management for this patient? There are three options for emergency contraception: Levonorgestrel should be taken within 72 hours of UPSI A Ulipristal acetate Ulipristal should be taken within 120 hours of UPSI Copper coil can be inserted within 5 days of UPSI, or within 5 days of the estimated date of ovulation Copper intrauterine device B (IUD) This patient would fit time window for all emergency options, but… Combined oral Copper IUD: patient wants an oral form C contraceptive pill COCP not used for emergency contraception Ullipiristal acetate avoided in severe asthma and can assume pt’s Levonorgestrel asthma is severe as required admissions to hospital D So levonorgestrel is most appropriate What is the most appropriate next step 14. Mrs. Rodriguez, a 32-year-old woman, is in managing Mrs. Rodriguez's umbilical cord prolapse? admitted to the labor and delivery unit with umbilical cord prolapse. Upon vaginal examination, A Immediate caesarean section delivery the umbilical cord is palpated alongside or below the Perform a manual reduction of the presenting part of the fetus. Fetal heart rate B prolpased cord monitoring shows signs of fetal distress. Position the woman to the knee- C chest position Insert urinary catheter D Umbilical cord prolapse is a medical emergency that requires prompt delivery to prevent fetal compromise and adverse outcomes. Cesarean section delivery is the preferred mode of delivery in cases of umbilical What is the most appropriate next step cord prolapse to expedite delivery and minimize fetal hypoxia. in managing Mrs. Rodriguez's umbilical cord prolapse? A Immediate caesarean section delivery Perform a manual reduction of the B prolpased cord Position the woman to the knee- C chest position D Insert urinary catheter15. A 30 year old woman presents with vaginal bleeding at 10 weeks gestation. She also describes What is the most likely diagnosis? ongoing nausea and vomiting. Transvaginal ultrasound shows a “snowstorm” appearance with multiple cystic spaces in the uterus and the absence A Ectopic pregnancy of a fetus or fetal heart activity. Her serum beta- human chorionic gonadotrophin (B-hCG) is B Missed miscarriage significantly elevated and she also has a TSH with a high thyroxine. Placental abruption C Molar pregnancy D (hydatidiform mole)What is the most likely diagnosis? A Ectopic pregnancy B Missed miscarriage C Placental abruption Molar pregnancy D (hydatidiform mole) What is the most appropriate management for this patient? 16. A 25 year old woman attends the antenatal clinic at 27 weeks gestation. An oral glucose Diet and lifestyle A modifications tolerance test is performed and her fasting glucose is recorded as 7.2 mmol/l and her glucose at Insulin B 2 hours is recorded as 9.1mmol/l. C Metformin Sitagliptin D What is the most appropriate management for this patient? Gestational Diabetes: Fasting glucose less than 7 mmol/l: trial of diet and exercise for A Diet and lifestyle 1-2 weeks, followed by metformin, then insulin modifications Fasting glucose above 7 mmol/l: start insulin ± metformin B Insulin Fasting glucose above 6 mmol/l plus macrosomia (or other complications): start insulin ± metformin C Metformin D Sitagliptin What is the recommended treatment regimen for hormone replacement therapy (HRT)? 17. Mrs. Thompson, a 51-year-old woman, visits her GP after experiencing hot flushes, A Oral oestrogen night sweats and mood changes. She states that it has been 4 months since her last B Transdermal oestrogen menstrual period. PMH: HTN, hysterectomy. The GP explains that she is experiencing Continuous combined HRT C perimenopausal symptoms. D Cyclical combined HRTWhat is the recommended treatment regimen for hormone replacement therapy (HRT)? A Oral oestrogen Transdermal oestrogen B Continuous combined HRT C Cyclical combined HRT D What is the most appropriate next step 18. A 28 year old woman, gravida 2 para 1, has in the management of this patient? just delivered a baby boy vaginally. Following delivery of the placenta, the uterus is noted to A IV Oxytocin be boggy and relaxed. The bleeding persists despite rubbing of the uterus. The patient has B Intrauterine balloon tamponade also been catheterised. The patient has experienced 1000mls of blood loss since delivery. Tranxaemic acid C D B-Lynch suture Postpartum Haemorrhage (PPH) MECHANICAL Treatment: Rubbing the uterus What is the most appropriate next step Catheterisation in the management of this patient? MEDICAL Treatment: IV Oxytocin A IV Oxytocin IV or IM Ergometrine IM Carboprost Sublingual Misoprostol Intrauterine balloon tamponade B IV Tranxaemic acid C Tranxaemic acid SURGICAL Treatment: Intrauterine balloon tamponade B-Lynch suture D B-Lynch suture Uterine artery ligation Hysterectomy Thank you very much for listening! Note: Certificates will be received once feedback is completed Paediatrics SBA Session next session Tuesday 19th March 7-8pm