March 2017

‫بسم هللا الرحمن الرحمن‬ 2 – MARCH 2017 RECALLS TELEGRAM GROUP start 3 November 1 - Patient with endometrial hyperplasia without atypia risk of progression to endometrial cancer R. of endometrial hyperplasia without A.<1% atypia progressing to endometrial cancer is < 5% over 20 years and B.2% majority will regress spontaneously .during f/up C.4% Source : RCOG/BSGE Green-top Guideline No. 67 D.10% But risk of co-existing cancer is <1% and in atypia, risk is 25-33% up to . 59% TOG: Malignant potential TOG MALIGNANT POTENTIAL : * HYPERPLASIA WITHOUT ATYPIA……….2% WHEN ATYPICAL HYPERPLASIA( SIMPLE OR COMPLEX) WAS AT DIIAGNOSIS *…..23% * WHEN COMPLEX ATYPICAL HYPERPLASIA AT INITIAL DIAGNOSIS ……29% : 2 - . Risk of placenta previa after 3 CS ANSWER : A 3 % With one, two, or > three previous CS a 1%, 1.7% or A.3% 2.8% risk respectively of placenta praevia in 2.8 % ,subsequent pregnancies B.10% Placenta accreta occurs in 11 – 14%of placenta praevia and 1 prior CS and % C.30% 23 – 40%of placenta praevia and 2 prior CS 67 % of placenta praevia and > 5 prior CS6 D.50% E.60% 3 - Para 1 CS due to labour dystocia want to know her chance to : have successful VBAC ANSWER : C VBAC score by 5 features: admission Bishop score, age, previous CS A.30% .indication, BMI and previous vaginal birth VBAC score of > 16 …. > 85% success rate, VBAC score of 10 .. 49% B.40 .success rate IOL, no previous vaginal delivery, BMI > 30 and previous CS for labour .dystocia .. 40% successful VBAC C.60% previous CS for fetal malpresentation 84% Successful VBAC previous CS for labour dystocia (64% success rate), fetal distress D.70% )61%((73% success rate), Unsuccessful OVD E.80% In case of term it reduce 4_6% in 38 wk 1-1.7% in 39 and 11% 4 - Patient forelective CS at 38wks need to know how much in 37 wk steroid will reduce respiratory :morbidity at this GA Neonatal deaths 31% (95% CI 19–42%) Reduced respiratory distress syndrome 44% (95% CI 31–57%) A.4-6% Reduced intraventricular haemorrhage 46% (95% CI 31–67%) Antenatal corticosteroid use is also associated with B.40% A reduction in necrotising enterocolitis Respiratory support C.50%D.60% Intensive care admissions Systemic infections in the first 48hours of life compared with E.70% no treatment or treatment with placebo 5 - Patient with previous abruption need to know recurrence in :current pregnancy A.3% Prev. one abruption 4.4% (10-folds)recurrence. Prev. 2 abruption B.4-6% 20-25% recurrence ANSWER : B C.10% D.19% E.25% 6 - Previous shoulder dystocia want to know recurrence :compared to general population A. 2fold B.3fold C.4fold GTG: Incidence of SD 0.58-0.7%, Recurrence 1-25%, Conventional RFs predict 16% of SD D.5fold Infants of diabetic mothers have 2-4 fold ↑ for SD Midcavitary forceps = 10 fold SVD, Elective CS in > EFW 4.5kg of E.10fold diabetic mothers 7 - Female and partner retained from trip from somewhere suspected zika virus infection when to check for zika virus infection or seroconversion Check for zika virus infection > 4wks after trip from area suspected zika virus infection to A.2wks B 4 WS….2 WEEKS MAX I P…… AND 2 WS FOR .exclude recent zika virus infection, then no need extra fetal U/S f/up (28-30wks) IMMANSWER : Where ZIKV is identified on laboratory testing (RT-PCR for symptomatic patients with onset B.4wks of symptoms within the previous week), referred to a fetal medicine service. If the test for ZIKV is -ve, serial (4-weekly) fetal U/S scans to monitor fetal growth and anatomy C.8wks If there is fetal abnormality on U/S and Zika virus PCR on amniocentesis is +ve, it is highly likely that the abnormality is Zika virus associated. When brain abnormalities are D.12wks identified on U/S scan, do fetal brain MRI that may detect further abnormalities. When a significant brain abnormality or microcephaly is confirmed, discuss TOP with the woman, E.16wks .regardless of gestation Consider condoms to prevent against infection for women whose partner has been to an :area with ZIKV transmission for 28 days after his return home if he had no ZIKV symptoms, either whilst abroad or • within 2 weeks of his leaving the affected country for 6 months following recovery if he had ZIKV symptoms during that period • On returning to the UK, they should avoid becoming pregnant for a further 28 days; this allows for a maximum two week incubation period and possible two-week viraemia and .seroconversion :Transmission The bite of infected female Aedes mosquito are, similar to dengue fever (caused by a related flavivirus) and chikungunya (an alphavirus). So, IgM & IgG can’t differentiate .between them Human-mosquito-human, & direct human to human transmission does not occur. sexual .transmission of the virus in human semen can occur Maternal fetal transmission have been confirmed. ZIKV can cross the placental barrier and .the virus has been detected in blood and tissues of affected fetuses/infants N/E that ZIKV can be transmitted to babies through breast milk 4 weeks the new guidlines 8 - The most common time for presentation of post 1in8 ( f ) with x linked recessive all (f) baby carriers[ E.5/100000 :12 .7yrs develop 2ry sexual ch. 9 yrs in boys B.1in 16 100% m to f transmission ] . before 8 yrs old in girls.10yrs E.16 / 1.000 total births + neonatal deaths 1. The Father will not pass to boys.zero unaffected child Male to male never 1 – DUCHENE MUSCULLAR B.1in4 risk of having affected child 1 : 4 2 – HEMOPHILIA A risk of having affected son 1 : 4 3 – COLOR BLINDNESS D.0.77 per 1.9yrs D. 1-3 days B.10% . 0.. As X-Linked :baby if (f ) is carrier 25% affected / 25% carrier 50% SEX – LINKED RECESSIVE A.000 live birt D.Precious puberty the cut off time Answer : A 8 YS A.8yrs C.12yrs 11 .6wks E.92 / C.Haemophilia male female stutus not mentioned pregnant by baby boy want to know risk to X-linked . 1 – 3 wks C.Hospital want to benchmark still birth rate which is consistent with :UK stillbirth rate ANSWER : A : SB rate * In singleton births.partum psychosis: A. B.ch.30% Answer : 50%( 2/3) .1in2 risk of doughter carrier 1 : 2 occurs ATROPHY C.25% * In triplet and higher-order multiple births.and all (m ) baby normal [ no (m) to ( m) transmission 10 .8wks 9 .5/10000 1.5% A.Unrecognised ureteric injury during laproscopy A.5/1000 3% Extended perinatal mortality rate = 5..4wks D.1in 200 * In twin births. 1.000 total births = SB 4. After ventose delivery ask about the accepted preductal oxygen in :2min .1in 20 D. whereas a CT intravenous urogram (CT IVU) will locate the injury Upper 1/3 -to-end re-anastomosis of the ureter (uretero ureterostomy) Middle 1/3 -ureterostomy or a trans-uretero-ureterostomy end-to-side anastomosis of the injured ureter with the contra-lateral healthy ( )ureter Lower 1/3 -neocystostomy (re-implantation of ureter into bladder) 13 .15% . 50% unrecognised bladder injury. but does not exclude other types of injuries Intravenous administration of indigo carmine colours the urine blue within 5 to 10 minutes and will assist a cystoscopic assessment as well as identify a urine leak laparoscopically Insertion of a stent alone can be therapeutic if injury was angulation (kinking) of ureter . Bladder injury rates 0.1in10 C. Most injuries occur during dissection of bladder -ureteric bar.Ureteroscopy may locate the approximate height and extent of injury Retrograde. Ultrasound and/or CT .02% .During laproscopy for severe endometriosis ANSWER : A 1 IN 5 ureteric injury is A.3%.1in 25 14 .30% brim (where the ureter comes into close proximity with the infundibulo-pelvic ligament which D.1in 5 B.40% contains the ovarian vessels) and lateral to the cervix (during division or )coagulation of the uterine artery or the uterosacral and cardinal uterine ligaments E. 50% recognised. 15% of bowel injuries unrecognised B. antegrade and/or intravenous uretero-pyelography can confirm or refute the diagnosis and determine the location of an injury Electrocautery may be involved in up to 1/4 of ureteric injuries Thermal injury r fistula that will often present clinically between 10 and 14 days postoperatively.at the time of laparoscopy The most common sites of ureteric injury in laparoscopic surgery are at the pelvic C.50% Transection is the most commonly reported at laparoscopy 1/3 of ureteric injuries are recognised intraoperatively.8.scan. 2/3 are unrecognised (missed) of the ipsilateral kidney 25% Cystoscopy allows visualisation of the ureteric orifices and urine jets which rules out obstruction. 5% * extensive vaginal/vulval tear. 20% with forceps ANSWER : B .50% 17 . 90.80 .10% vacuum.95 4 MIN 75 – 80 % E. Ventose delivery THIS TABLE FOR SVD TIME TARGET A.When prescribed complication in OB&GYN as very rare means A. 70 .Patient need to have forceps delivery in second stage ask about risk of 3/4 perineal tear with forceps * 3rd & 4th degree perineal tear.1in 1000 ANSWER : C B.30% D. 10% with B.95 5 MIN 80 – 85 % 10 MIN 85 – 95 % :15 . 65.<1/100000 E.40% E.90 3 MIN 70 – 75 % D.20% C.1in10000-1/100000 D. 1–4 % .1in 1500 C.with vacuum and 8–12 % with forceps A.70 2MIN 65 – 70 % C. 12% B.65 SPO2 1 MIN 60 – 65 % B. 60 .1in 30 16 -40 years lady first trimester pregnancy ask about her risk to : have miscarriage Answer : E A. Main cause of litigation due to ctg is Answer : b A.intial cefm for 30 minutes then intermittent auscultation ANSWER : B B.5yrs B. failure to act B.indefinitely :20 . intermittent auscul using ctg machine D. photocopy CTG traces and store them indefinitely in .C.Patient delivered baby at the acid base PH7. 10yrs NICE: Intrapartum care: care of healthy women and their babies during childbirth C.failure to monitor D.inappropriate oxytocin use Choose the most appropriate action * .20% E.case of possible adverse outcomes E. intermittent A using hand held Doppler C. US to see fetal heart 19 .CEFM E.25% 18 .Keep CTG traces for 25 years and. store them electronically In cases where there is concern that the baby may experience D.failure to recognise an abnormal one C. if possible.failure to refer D.Patient present in labour nulliparous was low risk following with consultant serial scan baby in 70th centile how to follow her in labour A.15% D.1 HCO -11 at zero APGAR 3 then 5 and 9 he and his mother did fine for how long do you keep the ctg paper ANSWER : E A.20yrs .25yrs developmental delay. exam in 2hrs F. The swelling may B.chingon * Choose appropriate mangment A.oxytocin C.cat2 cs obscure the fontanel and cross suture lines (distinguishing it from cephalohematoma).CEFM E.A.for significant hyperbilirubinemia D.nulliparous contraction3/10 admitted cx 4cm checked in 4hrs was cx 5cm ANSWER : C 23 Unstable neonate post ventouse delivery low APGAR found to have :scalp swelling with ill defined edges whats your diagnosis A. watch C. cephalohaematoma B.ARM D.multiparous poor uterine contraction 2/10 admitted cx os 4cm check in 4hrs 8cm MI ANSWER : E 22 .cat4 cs E.forceps D 21 .cat1cs Patients with subgaleal hematoma may present with hemorrhagic shock.ARM .CS B.ECV F.capaut D.cat3 cs .ICH E.subglialial H C. Patient in second stage of labour you want to infiltrate the perineum with lignocaine without vasopressor how much you give A.exam in4hrs 24 .7mg/kg [wt. intact membrane with the presenting part on Rt.ARM 27 . and fully effaced cervix with the head at the level of the ischial spine :Choose the single most appropriate next action ANSWER : A A.instrumental delivery H.3rd pregnancy 38wks now breech present with reduced fetal movement twice normal US AF breech extended and normal ctg opted for VD 25 . on examination the cervix is 6 cm dilatation . 1mg/kg B.G. ‚ conc . intermittent auscultation a & d are right answers B. to dose & solution conc. D.5mg/kg Total ml acc. CEFM but the 4hs is the routine and rt op position may add some risk for fetal C. Occipito posterior position .3mg/kg . she is low risk and 39 wks GA . 1or 2% = [)3or7( ‚ 10] x E.parous term low risk pregnancy present in labour at 4cm intact membranes cord felt pulsating through the membrane on pelvic exam 26 .2mg/kg C.exam in 2hrs distress so fetal monitoring is needed so i choose a D.A 30 year old nullipara presented to labour ward .exam in 2hr I.exam in 4hrs E. ELCS at 39wks . rising to 16%–18% with one affected child and 50% if two children are affected.lupus anticoagulant More than 90% of mothers of affected offspring have anti-Ro antibodies.quent infants tend to be affected in the same . and 50%–70% have anti-La antibodies C.IOL 37 -40wks C.antinuclear abs In babies of Ro/La-positive mothers.way as their siblings 29 .dstranded DNA associated with photosensitivity. commonly D. IOL CS for all ( nice : may permit vd ) 1st episode genital herpes in B.38 wks patient with primery herps plus HIV what measures you do to prevent vertical transmission A.US for umbilical artery Doppler steroids E.SLE lady pregnant worried about fetal risk what test should be done A.many others options if complicated deliver before 37 wks 30 .CS at 38 wks F. APS antibodies Another name Sjogan ANSWER : C SLE B. subse.lation is <1%.5% came after lunch to diabetic joint clinic urine++ glucose US baby ok in 40th centile otherwise patient stablE . increase pre lunch insulin if uncontrolled type 1 or 2 DM iol before 37 weeks with D. although anti-Ro/La are present in about 30% of patients with SLE. as the risk of neonatal transmission of HSV is very high at 41% and in recurrence 0 – 3 C.admit to control glucose B. Anti Ro &La antibodies The prevalence of anti-Ro in the general popu. particularly within 6 weeks of EDD. Sjögren’s syndrome.:28 . acyclovir T3. subacute lupus erythematosus and ANA-negative SLE E.known type 1 daibeties at 36wks GA controlled in insulin HBA1C 6. reassurance and to be seen in 2wks G. the risk of transient cutaneous lupus is about 5% and the risk of CHB about 2% The risk of neonatal lupus is increased if a previous child has been affected.% D.vaginal delivery * most appropriate mangment A. Explain to pregnant women with diabetes who have an ultrasound- diagnosed macrosomic fetus about the risks and benefits of vaginal birth. zika virus Vertical transmission in Rubella infection occurs during maternal viraemia. [2008 Causative agent A.type 2 diabeties para 2 with 1 previous CS HBA1C 7.others 2 33 .4. the risk B. [2008 * 1. and it declines to 45% after 16 weeks D.4% US baby in 70th centile keen for vaginal delivery * 7. about C.varicella virus F. induction of labour and caesarean section.p.Patient pregnanat came from Zambia found to have parasitaemia >2% ANSWER : C . or by elective caesarean section if indicated.known diabetic at 33wks variable control HBA1C 7.4% urine++ glucose US baby in 10th centile otherwise ok 32 . [new 2015 * 1.Epstien bar virus of fetal infection is 90% before 12 weeks of gestation.2 Advise pregnant women with type 1 or type 2 diabetes and no other complications to have an elective birth by induction of labour.3 Consider elective birth before 37+0 weeks for women with type 1 or type 2 . between 37+0 weeks and 38+6 weeks of pregnancy.1.31 .diabetes if there are metabolic or any other maternal or fetal complications new 2015 ] Diabetes should not in itself be considered a contraindication to attempting vaginal birth after a previous caesarean section.4.measels virus E.falcipram 55% at 12–16 weeks.4. MMR vaccine) or had measles . which may .5.children and adults with chickenpox koplicks spot Pathogonomic 35 . and legs and arms. flat or slightly raised spots that may join together into larger blotchy patches usually first appears on the head or neck. roseola or rubella is unlikely to be caused by measles if the person has been fully vaccinated (had 2 doses of the . before spreading outwards to the rest of the body is slightly itchy for some people can look similar to other childhood conditions. such as slapped cheek syndrome. It may then spread to the chest and tummy (the trunk). It consists of a number of small spots.be slightly itchy The rash usually starts behind the ears before spreading around the head and neck.4F) or over feeling sick a headache aching.what is commonest cause for malaria in UK Answer :c . They tend to be more common and more severe in older .after about a week .The main symptom of chickenpox is a red rash made up of spots or blisters It usually takes between one and three weeks for symptoms to appear after becoming infected (the incubation period) Early symptoms Sometimes other symptoms may start a day or two before the rash appears :These can include : feeling tired and generally unwell a high temperature (fever) of 38C (100. painful muscles loss of appetite Not everyone has these symptoms. pregnant present with flu like symptom tell to come back if she devolped any …presented 2days latter with itchy red spot behind ears and scalp then the forehead ANSWER :F RUBELLAE ** A red-pink rash Picture of the rubella rash The rubella rash is typically a red-pink colour.You'll usually feel most ill on the first or second day after the rash develops :The rash is made up of small red-brown. In most cases the rash disappears by itself within three to five days ** The measles rash appears around 2 to 4 days after the initial symptoms and normally fades .pregnant at 38 wks admitted with pnaemonia her GP give history of generlised skin rash and conjunctivitis and otitis media 3days ago red spots with blue white centers found in the mouth ANSWER : D 36 .34 . many others options antinatal and count again post natal 37 .Patient delivered vaginaly and devolped PPH whats the level of HB to define postnatal anaemia .antenatal antiembolism stoking and postnatal and didn't give any comments about antenatal so if 10 days postnatalLMWH 2 or 3 or 4 or more risk give 10 E.115 g D. *suitable prophylaxis In post natal you have 2 option A. 120g B.??.partum 1 score C. or rot.smocker with HTN BMI 32 admitted to control her BP SMOKER +32 + ADMITION = 3 RISK FACTORS= ( now as admission ) ANSWER : E +10 days pp 38 .patient with growth varicose vein and instrumental delivery.onther pregnant with antithrombin deficiency and prvious history of VTE Mid.105g 1ST AND 2ND TRIMESTER 110 MG 3RD TRIMESTER 105 MG . P..LMWH 10days post natal d This mean deal as 2 group and F.100 g E. A. P.31yrs lady undergone CS BMI 30 blood loss 1100 ml ANSWER : E 40 .vivax E. no need for thromboprophylaxis Again count the risk factor for h. 41 . highdose antenatal LMWH and 6wks postnatal BMI 30 or above and p. thromboprophylaxis from 28wks what factors present now G. P.falcipram D.malarae B. P.aneinatal LMWH and 6wks post natal BMI above 30 and antepartum 1 score B.theraputic LMWH and 6wks postnatal If in question only mentioned D. ANSWER :B He did not say 39 . 110g C.ovale C.A. . . anthracycline Anthracycline (Doxorubicine. Epirubicine) in T2 & T3 .Cadiotoxic need echo coming step in Management* A.interventional radiology .. A.US C. anesthetist concerned but said patient stable .CXR ANSWER : B 43 .Bakri balloon C.mamogram B. cyclophpshamide C.steroid D.lynch ANSWER : E 44 . MRI E.42 .Breast cancer suspected in pregnant lady referred to breast specialist 1st line investigation:. 3doses of carbpoprost G.uterine artery ligation F.hystrectomy E.patient with previous scar in her 2 nd CS placenta found to involve the uterovesical space deliverd and trying to control bleeding uterotonic and B lynch but still there is bleeding from one corner at vesicoureteric junction.Patient pregnant with breast cancer need chemotherapy needed A.CT D.B.oxytocin B.etoposide B. surgical interventions should be initiated sooner rather than later. the team should consider transfer to the operating theatre for examination under anaesthesia. However.137. Two case series from the USA. 30 minutes or more after the first dose was given). If bleeding occurs at the time of caesarean section. C Conservative surgical interventions may be attempted as second line.* -There are no trials comparing the prostaglandin carboprost (15-methyl prostaglandin F2a) with other uterotonic agents.Patient pregnant came from vacation to some African area screening for syphilis was positive need confirmation which test Answer : b . This may be repeated every 15 minutes to a total dose of 2 mg (eight doses).138 comprising 26 and 237 cases. without resort to surgical interventions in 85% and 95% of cases. respectively. C . with an awareness of the impending need for laparotomy and/or hysterectomy * If pharmacological measures fail to control the haemorrhage. a second experienced clinician should be involved in the decision for .e. C Ideally and when feasible.It is recommended that a laminated diagram of the brace suture technique be kept in theatre Resort to hysterectomy sooner rather than later (especially in cases of placenta accreta or uterine rupture). Two of the four failures in the smaller series were associated with placenta accreta. if significant atonic haemorrhage continues after a third dose of carboprost. The recommended dose is 250 micrograms intramuscularly. It is also possible to inject intramyometrial carboprost through the abdominal wall in the absence of laparotomy. intramyometrial injection of carboprost may be used (although not licensed).ergometrine and 2doses of carboprost intramyometrial but again start to bleed anesthetist concerned and mention patient unstable Answer : g HYSTERECTOMY ( UNSTABLE ) 46 .patient previous 3 scar have atony respond at start to oxytocin. have reported on the use of carboprost in the successful management of PPH. without significant improvement (i. depending on clinical circumstances and available expertise. D Intrauterine balloon tamponade is an appropriate first-line ‘surgical’ intervention for most women where uterine atony is the only or main cause of haemorrhage.hysterectomy 45 . cardiolipin antibody tests.A. FTA-ABS becomes +ve before VDRL or RPR . FTA (fluorescernce treponemal antibody test ( D. lesion smear Treponemal antibody tests . +ve in untreated 2ry / latent / tertiary syphilis. become -ve with ttt * Treponemal antibody tests . tropenema NB: Diagnostic test for Syphilis fluorescent test Agglutination test.TPHA (treponema Pallidum haemagglutination) and FTA-ABS (fluorescent treponemal antibody - absorption test) .remain +ve even with adequate ttt.tropenema agglutination particles C. VDRL B.TPHA (treponema Pallidum haemagglutination) and FTA-ABS (fluorescent treponemal antibody - E.RPR absorption test) Diagnosis * Dark ground microscopy for spirochaetes / serology (routine ( screening * VDRL / RPR (rapid plasma reagin) . MCDA with co twin death next step A. DCDA (Triplet) refer to tertiary level fetal medicine centre. + scan / 4wks from 20 to 32wks to detect FGR (discordant or concordant) MCMA. 28 wk 11ws -13wks+6ds for chorionicity 47 . DCTA App. + scan /2wks from 16 to 24wks to detect TTTs . MCTA.? E.DC twins. CS C. 16wks C. 12wks B. TCTA App.Patient with MCDA when to start U/S Answer : B A. it is not our job.* Do not monitor for FFTS in T1. MRI brain for other twin D.? Forget Answer : c 15 %Risk of death in other twin is 15 25 % Risk of neurological abnormalities is 48 . 20 wks D. IOL B. only (no scan) at 16 wks then App. Start from 16 wks. above our level 46 . DCDA (Twins and Triplet). every 2 weeks until 24 wks uncomplicated MCDA 9 antenatal appointments uncomplicated DC twin 8 antenatal appointments uncomplicated MCTA and DCTA triplet 11 antenatal appointments uncomplicated TCTA triplet 7 antenatal appointments * MCDA. 24 wks E.Ptient with HIV on HAART present at 35wks with PPROM VL < 50 next step . Ischemic heart disease 51 .tachycardia.at booking if negative repeat at 24-28wks B.basal crepitation and O2 saturation 91 and low urine out put diagnosis Answer : b A.IOL now D. Intraventricular Hge D . Cryopreciptate C. at 18wks and if negative repeat 24-28wks C. Pul.Postpartum patient with preeclampsia devolped dyspnia . Platelets D. Pul embolism B.CS at term C. SAH B. At 28wks E. FFP B.3 fibrinogen 1. Idiopathic intracranial hypertension Answer : a E.oedema C. At 16 -24wks Answer : a 50 . Pneumonia D.2 what blood component pt need A.Patient have massive PPH finding platelets 80 APTT 1. At 24-28wks D.Screening for GDM in current pregnancy for previous GDM.CVT C.A.pregnant lady with high BP C/O of headache for many days present collapse GCS3 BP 200/120 your diagnosis A. Preeclampsia 52 . CS now B. factor VIII E. wait for VD E. when should be A.? Answer: c 49 . Packed RBCs Answer: b To maintain fibrinogen more than 2 ( new gtg) . MI E. 5 L of warmed clear fluids. Need no Acidosis.Patient postoperative 18 hrs on PCA collapsed with pinpoint pupil RR12 normal O2 saturation wt medication ???BP 80/40 A. initially 2 l of warmed isotonic crystalloid and / or 1.5 times normal  activated partial thromboplastin time (APTT) < 1. not venous thromboembolism.During S2 CS which measure has evidence in reduction of neonatal trauma A. infuse up to 3. studies. of art. Intralipid Answer : b 54 . Atropine D. ↑ R. at a dose of 12–15 ml/kg 4 units FFP + 10 units crPPT  empirically in severe bleedeing while awaiting result of coag. recombinant Factor VIIa  acting by activation of clotting factors.5 times normal. DC shock E. Hypothermia or Thrmbocytopenia to act well 53 . Naloxone C.??64 .Pull method E. delivery by breech B. 6:4 RBCs:FFP FFP 4 units for every 6 units of RBCs / if prothrombin time/activated partial thromboplastin time is > 1.5 times normal  fibrinogen > 2 g/l..5 litres of colloid. forceps for disimpaction C.Untill blood is available. so need platelet > 20 X 109 / l & fibrinogen > 1 g/l. Cryoprecipitate 2 pools if hge is ongoing and fibrinogen < 2 g/l  to maintain plasma fibrinogen level of > 2 g/l Cryoprecipitate 2 pools ↑ fibrinogen by 1 g/l  30 mg/Kg concentrate fibrinogen platelets should be transfused when the platelet count is < 75 X 109 / l the main therapeutic goals of the management of massive blood loss as maintaining:  Hb > 80 g/l  platelet count > 50 X 109/l  prothrombin time (PT) < 1. Adrenaline B. pressure from below by the Answer : d or a the 2 are other same D. The risk can be further reduced by limiting exposure to the fertile period of the cycle and ensuring that all genital infections have been treated. IOL C.03%. Start cART F. Report to occupational health tomorrow / C.001% – 0.many other options Answer : e 55 .* What action you do Ptn.• Couples who are serodiscordant choosing to have intercourse should . is +ve >check the doctor + take prophylaxis either in occupational health (morning working A. Reassure and check for seroconversion E. Report to occupational health tomorrow D.patient asylum seeker refused HIV testing during CS on Friday evening your assistant ST2 have needle stick injury 56 .try to test ptn. if the male partner has a viral load of < 50 copies/ml and is taking HAART. This risk is significantly reduced.. [.> D] 55 . Deliver by CS hours) or in accident&emergency department (evening hours) B. > HIV-ve .Patient pregnant HIV -ve at booking discovered her hasband HIV +ve 6month ago she is worried about risk to baby the risk of hiv per /sexual intercourse> Answer : d 1% The risk of transmission for each act of sexual intercourse is 0. 6mins D.57. 10mins Answer :b 4 min Perimortem CS: > 20 wks. 3mins B. if > 4 min with no response from CPR. Perimortem CS time A.57 . achieved within < 5 min . 4mins C. CVS hasband D. Amniocentesis C. CVS B. Steroid B. Amniocentesis C.Patient high BMI and first pregnancy smoke on occasion her sister has still birth because of SGA want to know at 18wks GA Answer : c 60 . Uterine artery Doppler D. many other options Answer : e ffDNA 61 .Patient known thalsaemia carrier. Use of nuccal translucency E. Plan delivery C.* select the suitable Mx A. Haemoglubinopathy for the A. Combined test Answer : f EMQ A.Primigravida comes to booking at 11 wks and wants to the risk of her baby having Down syndrome B. Haemoglubinopathy for the hasband D.Patient serial scan indicate static growth Answer : b 60 . Non invasive maternal test F. Umbilical artery Doppler E. U/S for EFW 58 . Nuchal translucency E. hasband status unknown and cant test him he is in prison . Non invasive maternal test F.Midwife referred patient at 28wks with SFH less than 10th centile Answer : e 59 . meteclopromide C. laboratory screening should be offered. 62 .Patient with protracted vomiting at 11 wks pregnancy first line antiemetic A.5 cases per 10.000 pregnancies). 64 . hasband was adoption know nothing about his mother Answer : c CF or thalassemia NICE CG 62 0f ANC: Screening for sickle cell diseases and thalassaemias should be offered to all women ASAP in pregnancy (ideally by 10 weeks). cyclizine im iv oral B. Where prevalence of sickle cell disease is high (fetal prevalence > 1. all pregnant women should be offered screening for haemoglobinopathies using the Family Origin Questionnaire. the father of the baby should be offered counselling and appropriate screening without delay.  If the Family Origin Questionnaire indicates a high risk of sickle cell disorders.5 cases per 10. patient & hasband born in UK .000 pregnancies).Pregnant combined test show risk for Down 1/12 patient cystic hygroma and short femur whats your diagnosis A. patient and hasband born in UK.  Mean corpuscular haemoglobin is < 27 picograms  laboratory screening. Edward synd C. Down syn B.ondansteron .Midwife did family questionare.hasband parent born in Turkey Answer : c 63 . laboratory screening to all pregnant women to identify carriers of sickle cell disease and/or thalassaemia.Midwife did family questionare. Where prevalence of sickle cell disease is low (fetal prevalence < 1. If the woman is identified as a carrier . Turner Answer : d 65 . Patau D. anti D 500 C. depressed st in lead avl B.elevation of st in wave in V2 V3 V6 68 .anti D 250 B. plasmaphresis .Common finding in ECG of patient with MI Answer : b A. man age>40 yrs C.corticosteroid 66 .Couple with 1st and 2nd trimester miscarriage came for counseling what can be the most Answer :B :likely cause of miscarriage A.women age <20 yrs B.working with vedio monitor 67 . Answer : a D.patient blood group negative received FFP group positive what you give Answer: D A. g.Patient known Von W disease bleed during labour wt . no need for antiD Pregnant lady known haemophillia her baby status not known. electrolytes should be monitored . . D. medication ANSWER : D A.S If not respond to DDAVP.cryopreciptate * Desmopressin (DDAVP) Aspirin and NSAIDs should not be given to women with vWD factor VIII levels may be indicated. If additional fluid is required. plan of delivery will be and when to check factor VIII A.fVIII C. . e. desmopressin E.. delivery. epidural or C. prior to procedures. CS check factor VIII now B.platelet D. induction of labour C. FFP or plasma-derived factor concentrates containing vWF and factor VIII may be used to control or prevent severe bleeding *( DDAVP ) Fluid intake should be restricted to 1 litre for 24 hours following DDAVP administration to prevent maternal hyponatraemia. fVII B.allow VD and avoid FBS and instrumental delivery Answer: A check factor VIII in 3rd tm 70 . LABA C. steroid B.leukotriene .Asthmatic pregnant lady received short acting beta blocker .theophillin D.71 . and 800 steroid but her asthma not controlled next step A. Which condition put pregnant lady in high risk of MI A.which condition without other risk factor let you consider thromboprophylaxis during pregnancy ANSWER: B A.hypothyoidism Answer : B B.D .72 .predinsolone C. prepregnancy counseling which drug to stop ANSWER : D A. IUGR ??.diabeties B.ciclosporin B. Ramipril 73 .calcium D.sickle cell anaemia C.marfan 74 .celiac disease and a 4-fold ↑ risk of acute myocardial infarction D.migraine TOG 2014: Migraine have a > 2-fold ↑ risk of pre-eclampsia. a 17-fold ↑ risk of stroke C.Pregnant lady with renal transplant stable came for . paternal genotype E.Azithromycin 2 g PO 78 .amniocentesis answer : c no anti d needed 75 .ibd .CFFDNA F.offer antiD 250 antibiotics A.pregnant lady has previous hydropic baby father is DD RH negative Answer : f 77 .4 stat Potentially incubating syphilis/epidemiological ttt D.Benzathine penicillin G 2. cefodar different concenteration oral 1 . heart failure .active SLE inflammatory polyarthropathy .offer antiD 250 B. benzyl penicillin 3g then 1.augmentin single dose 2 . all of them take score 3 * All medical comorbidities: cancer.early pregnancy confirmed IUP 2wks ago at 8 wks presented with vaginal bleeding US done empty uterus 76 .ns . all PID regimen 3 . 14 days F.anti D 500 C.Doxycycline 100mg PO BD.ivud * hyperemesis in the 1st trimester * any vte provoked by surgery * any hight risk thrombophelia * any surgery in perperium el surgery all of them take score 4 AntiD* * previous vte not provoked by surgery * ohss in yhe 1st trimester A. scd .measure maternal antibodies G.5g 4hrly Testing and ttt for syphilis is the same HIV+ve as HIV -ve C.Sudanese asylum seeker screening venereal disease confirmed by TPHA and also HIV positive has mitronidazole allergy cause her vomiting and rash Answer :C 79 -3 days postpartum referred by her midwife due to excessive lochia and clots abd pain and mild pyrexia Answer : A. gentamycin plus clindamycin . gentamycin plus clindamycin UK national guidelines on the management of syphilis 2015: B.4 MU IM E. no anti D needed D.pregnant at 12 wks had vaginal bleeding and evacuation of ROPC after 4 days discovered RH D negative Answer : A. benzyl penicillin 2. type 1 dm with nephropathy .CVS h. 2 others not remember MATERNAL MORTALITY Any pre pregnancy dis …….Lady murded by her hasband * early pregnancy Answer c A.accidental E.HCG in 48 hrs C.not maternal death 81 . and died 82 .CT with contrast TOG 2014: Magnetic resonance imaging with T2- B. ….80-Pregnant lady with headache no neurological deficit O/E what Invest.indirect A. Answer : C A...coincidental D.indirect After 6 weeks ……….MRI without contrast weighted imaging and magnetic resonance venography (MRV) is the imaging modality of C.choice D.MRV .surgical mx D. scan in 7 to 10 days B.late ANSWER : A F.direct Within 6 weeks ………early B.late C.lady with pre eclampsia developed ICH take 5wks in ICU .direct Any dis related to preg.Lady is collapsed 48 hrs post delivery postmortem was Esimenger synd ANSWER B 83 .expectant mx . tortion F.appendicitis C. ANSWER E.Lady after egg collection of 20 folliclle present with abd pain and sense of fullness in the lower tight clothes at width (not exactly but nea ANSWER C : 89.Pregnant lady US CRL 8mm no cardiac activity ANSWER 85 . Young lady present with sudden onset of LT iliac fossa pain nausea and vomiting ANSWER : E . ectopic B.others options ANSWER :A 84 .hetertopic E. evacuation RPOC :A F.Surrogate for her sister retained 2 babies at 6wks confirmed single IUP present with sudden onset of lower abd pain and tenderness Answer : D 88. OHSS D.miscarriage 87 .Pregnant US show MGD 24mm :A 86 – pregnant with vaginal spotting on u/s crl 7 mm and no cardiac activity Diagnosis * A. B.others 91 .O negative B. previous colonization 1 – previous baby with invasive GBS inf. cross match blood ANSWER : A C.Indication for IAP for patient had GBS in previous pregnancy : and had healthy baby ANSWER : B INDICATION FOR OFFERING GBS-SPECEFIC IAP A.90. / INC 6/ 1000 Intact memb. 4 – pyrexia ( +38 c ) in labour ( give ab broud – sp to C. 2 – GBS bacteruria in current preg. GBS bacturia in current 3 – vaginal swap + ve for GBS in current preg.Patient with RH D negative kell negative devolped PPH need blood A. Lscs not necessary for GBS .PROM SCREENING 33 – 35 WS IF PREV.PPROM include GBS) 5 – chorioamnionitis ( b-s ab include GBS cover D. . paracetamoL .FL TOP next step *.Which analgesic should be avoided during sepsis A.14 days post medical TOP call the midwife that her PT is positive ANSWER D 96 .HC A.AC C. mife 200mg miso 100 mg 6hrly max 4doses . US D. reassure and prescribe analgesic B.Booking US CRL 90 BPD 12 AC ? what to use to date her pregnancy ANSWER : D . A. do pregnancy test 1wk later E.NSAID Source: GTG No.CRL D.pregnancy C. morphine ANSWER : B B. surgical evacuation C.92.BPD B. others 94.Pregnant with IUFD at 26 wks wt the best regimen to induce labour ANSWER : C A. early pregnancy loss follow medical TOP call gyn C/O of cramps and some bleeding otherwise ok ANSWER : A 95 . cocodamol NSAIDs should be avoided for pain relief in cases of sepsis as they impede the ability of polymorphs D. 64b Bacterial sepsis following .to fight GAS infection 93 .HC E. mife 200 mg miso200mcg 6hrly 5doses mefiprostol 200 mg for all increse sensitivity of myometrium to pg 5 times mefiprostol –misoprostol interval 36 – 48 hs 97 . involve face Polymorphic eruption of preg. Have B. periumlical spare C.B.mife 200mcg miso 100mcg 6hrly 4doses C.presence of C3 no impact on maternal / fetal outcome 98 . 2 .Cystic fibrosis both parent carrier under gone IVF 12 embryo how many will be affected Answer : b 3 A. mife 200mg miso 100mg 6hrly 5doses D.Pregnant lady with rash involve the abd striae what is good prognostic finding for baby ANSWER : B TOG 2013 A. CEMAC report 2006-2008 common cause of death in preeclampsia :is Answer : B ICH A.of labour 1.13 Either the 'hands on' (guarding the perineum and flexing the baby's head) or the 'hands poised' (with hands off the perineum and baby's head but in readiness) technique can be .warm compresses 100 .13.used to facilitate spontaneous birth .13.12 Do not perform perineal massage in S2 .P.edema Answer : c NICE 2014.6 coucasian affecting 1 / 2000 and carrier risk is 1/25 in uk Aurosomal recessive disease 99 . eclampsia B.ICH C.4 Commonest leathal g condition in D. perineal massage B.Evidence based step to avoid perineal trauma during vaginal delivery answer : C A. B. February 2017: Intrapartum interventions to reduce perineal trauma: 1.3 C. hand on technique C. Hyperplasia description low gland to stroma ratio but cells show large nucleus A.3% C.complex with atypia Answer : b B.simple with atypia D.. simple without atypia C.8% Answer : C B.33 % may reach 59% . 4% D.3% Endometrial hp without atpia cancer less than 5% / 20 ys Risk of co existing cancer 1% In case of atypia the risk 25.instrument used to dissect the ureter in abd hysterectomy Answer : lahey 102 .complex without atypia 104 .Patient with HMB diagnosed as having endometrial hyperplasia without atypia whats the risk of it to devolp cancer A.Instrument used to held skin edges Allis together for staples to be in sit 103 .<1% B.Demonstrated pictures for many instrument * 101 . male problem C. obese and semen analysis shows azoospermia what is the most likely cause ? A -unexplained B.Y chromosome microdeletion Answer : B ? .uterine factor E.women is 25 ys .hypothyroidism C.unexplained B.ovulotory 105 – couples with 2ry infertility of one year .tubal factor D. male is 40 ys .105 -Couple with infertility of one yr women 25yrs man 40yrs whatis th e most likely cause Answer : b A. clomid 100mg od C.clomid 50mg od B.2 LH 1 prolactin 750 answer : E.infertile couple man ok woman PCO with anovulation induced with clomid 50mg estrogen level was high follicle 20mm but progestron on day 23 of 26 cycle showed un ovulation 3 ithink Aswer : c Follicle 20 no clomid ( LUF / harm the pt.D – klinfilter syndrome E – kallmann syndrome Clue 2ry inf.nfertility 3 yrs all normal woman PCO received 6 cycle of clomifen citrate day 23 out of 26 cycle progestron range between 32 to 67 Answer : h IVF infertility * Oligomenorrhea A.progestron C. PT .Young referred from her gp with oligomenorrhea every 3 to 5month ithink her hormonal profile FSH 28.IUI h.IVF 106 .clomid 50mg +timed hcg D.repeat hormone premenstrual wk D. LH 11 prolactin 500 110 . PT F. Obesity azospermia Un explained can be good choice if it wasnot for word ( obese ) other option are cause of 1ry infertility INFERTILITY A.many other options ANSWER : D POF 109 .repeat hormone day 1 to 5 of cycle E.control her family by barrier method .MRI i. cc G. ) Just need a trigger 107 .infertility 2yrs all investigations normal except woman PCO with anovulation evident by progestron Red level clomid for 6 m lap drilling add Answer : a metformin or gonadotophin ( FSH & LH ) IVF 108 .hormonal profile FSH 0.ovarian drilling G.karyotyping j. gnrh analo F.breast pain .ocp B.Young oligomenorrhea feel nausea .CT h.clomid 100mg +timed hcg E.fatigue.. irregular last was 9month ago.same scenario with high BP and adult polycystic kidney PCO and not in sexaual relation Answer : d As kidney disease ass with endometrial hyperplasia and HMB so Mirena 114 . veracy ‫الصدق واالمانه‬ D.111 -1 9 yrs secondary amenorrhea hormonal profile FSH 88 LH high prolactin low Answer : I oligomenorrhea* karyotyping A.merina E. autonomy F.justice G.28yrs in relationship not want pregnancy concerned about her irregular period.induction of ovulation F.others ‫العداله‬ .BP 150/104 not in sexual relation ship ( pco >>>>>ht) Answer : c 113 .paternalism ‫االبوة‬ ‫الحكم الذاتى‬ E. ocp Turner mosaic B.vaginal progesterone dialy C.CC 112 . Answer : a Ethics A.cyclical progesterone D.beneficience ‫االعانه‬ C. non malficience ‫عدم االيذاء‬ B.Young concerned about her period . metaanalysis Case-control Study Case-control studies begin with the outcomes and F.case control not affected by the condition. Have level of IQ and they are not complete ‫د‬MR SO THE doctor discuss the patient and the examinar put this word ‫اخمد البيهوتي‬ 116 -Patient with IUGR Ithink abnormal CTG need CS patient refused and said she rely on nature and every thing will be ok Answer : e *autonomy[1] is the capacity to make an informed. Example: Non- to see effect of carbiplatin on 5yrs use of bicycle helmets and risk of fatal head survival of patient with cancer 119 . Example: Smokeless tobacco cessation in South Asian C.retrospective observational study communities: a multi-centre prospective cohort study.DR conduct study among drs to see effect of smoking and non smoking in lung cancer Answer : b . un-coerced decision *Paternalis is the opposite 117 .systematic review Some time cohort my be retrospective E. Answer :E autonomy 115 .cohort compared with another group of people who are B.RCT do not follow people over time. Croucher R. et al. Researchers choose people with a particular result (the cases) G. Addiction. 2012 D.other option and interview the groups or check their records to Answer :a ascertain what different experiences they had. DR conducted study over 15 yrs with the outcome to the odds of having an experience without the outcome.Patient Down syn with HMB affecting her quality of life accompanied by her mother who agree to offer merina to her daughter ..DR looks in literature to see effect of merina in HMB Answer : D 120 .Pregnant at 36wks ask for induction because her hasband will travel somewhere you refuse to offer her induction Cohort Study (Prospective Observational Anawer : A Answer :a Study) A clinical research study in which people who STUDY as Q99 M 2016 presently have a certain condition or receive a particular treatment are followed over time and A.You discuss the mother and patient about merina pros and cons Answer : E some down sy.. They compare the odds of having an experience 118 . ischema activation C.brainstorming B. Prospective .ischema refinement D.Case control you start with the disease Cohort start with exposure risk factor Some time cohort my be retrospective COHART STUDY Systemic review : collection of data of different type of study FROM litrature as retrospective .1step perception .may use studies collected in systemic review and filter them according to exclusionand inclusion criteria high level of evidence LEARNING A. case control no conclusion Of certain supject . cohort study .collect all studies about that supject . no inclusion or exclusion criteria Meta-analysis : collection of data from same type conclusion More specific in data collection . E. Readers rely on their prior knowledge and world experience when trying to comprehend a text. and Application. Each option may be used once. more than once or not . It is this organized knowledge that is accessed during reading that is referred to as schema (plural schemata) 122 -scenario for 5 steps OF Answer : d 123 .pathology of subject(not remember it ) Schema Activation.Group of student sit discuss how to solve problem of project Answer : a Teaching methods solved EMQs Options A Brainstorming B Delphi technique C Doughnut rounds D Goldfish bowl E Lecture F Problem based learning G Schema activation H Schema refinement I Simplified procedural hierarchy J Snowballing K complex procedural hierarchy For each of the teaching scenarios described in the items below select the single most correct term from the list of options.snowballing F.goldfishbowel Answer : B G.icebreaking 121 .at all . Construction.The facilitator let group of learners to study about physiology. These are recorded onto a flip chart ANSWER A Brainstorming Q 2 You are asked to teach a group of 3 trainees on the structure of the cell membrane and membrane receptors.members of the group to assimilate Answer D Goldfish bowl Q4 The lecturer gave the student a tutorial on the anatomy. After several such operations. techniques and use of instruments that are vital to a safely conducted operation. Both of you facilitate learning by a role play in front of the whole group to demonstrate behaviour you want the . The learners recall what they have experienced in the tutorial and attempt to solve clinical . Each of the trainees is given a chapter to read on the relevant subjects. the consultant then asked the trainee to describe the operation in order to ascertain that he had grasped the steps. physiology and endocrinology appropriate to amenorrhoea followed by a series of clinical cases which including post-chemotherapy amenorrhoea. Turner syndrome. You get the trainees together and everyone contributes ideas. The consultant would be immediately available Answer K complex procedural hierarchy Q6 You are required to lead a group of senior trainees on concepts in the clinical management of hirsutism. evaluation and feedback . the consultant asked the trainee to carry out the operation while assisted by another . A week later they cover the facts by sitting together and testing . Then. After several operations with ongoing assessment.different perspectives. You also require each trainee to develop 10 questions on the subject material. The consultant then assisted the trainee in the procedure. hyperprolactinaemia and complete androgen insensitivity syndrome. dur ing which the educational experience of the trainee consists of observing surgical techniques. you give the group a series of clinical problems in which . You begin by activating their recall of the relevant physiology and biochemistry and give them tutorial to clarify their understanding of the basic concepts.problems Answer H Schema refinement Q5 consultant asked a trainee to assist in the operation of total abdominal hysterectomy.trainee.each other by using their questions ANSWER C Doughnut rounds Q 3 You are paired with a Consultant and are required to demonstrate good practice in “Breaking Bad News” to a group of 14 trainees.Q 1 You are asked to initiate ideas for research among a group of junior trainees . experiences and . In the first instance. just like when we were house-officers .  Directly observed procedures [with feedback]: You’ll observe observes your junior doctor/student carrying out a task (e.intrauterine contraceptive device or vaginal pessary).g insertion of an indwelling urinary catheter. you ask the trainees to recall their knowledge of basic endocrinology concerning the hypothalamic -pituitary ovarian . then you pair them and then the pairs join up into 2 groups of 20 each. reading our case notes in front our consultants.  Mini-CEX: consists of a consultation between you & your patient.reach a consensus Answer J Snowballing Q8 You are required to teach a group of junior trainees on the subject of changes in the postmenopausal women. [Something like OSCE. you notice a lady In the labour ward whose is poorly progressing & you’ll take the chance & gather your students to discuss & mange.the tutorial and solve clinical problems Answer H Schema refinement Q7 You are required to lead the development of a consensus on the educational expectations of medical students in the gynaecological operation theatre . but here the role-player is a real patient]. in the speciality and who are about to start their clerkship. Your consultant[teacehr] will explore the clinical knowledge. judgment and reasoning of the learner using patient records and test results. NB: Case-based discussion & Mini-CEX are known as Workplace-based assessments  Problem-based learning: A group of learners [doctors/students] will have multiple sessions[meetings with facilitators] over a certain period of time to discuss a given problem.hirsutism was the presenting complaint. which is observed and assessed by your consultant. . Individuals are asked to think about the issues themselves. or. Your group consists of 40 medical students who have had limited experience. The trainees recall what have experienced in .  Brainstorming: Not clear for me but this is a spontaneous group discussions & flip charts.  The 1-minute preceptor: These are the teaching opportunities that arise in the clinical environment. For example you were taking a walk with your students In the hospital when suddenly a pregnant woman collapses In front of you.axis Answer G Schema activation All the best Mustafa  Teaching methods at a glance:  Case-based discussion: you will present your case[patient] to your supervisor.The large 2 groups continue working on the and then join up to . then base further teaching on the knowledge displayed by the students.platelet aggregation 126 .  Schema refinement: Tuotorial on a subject. or solve problems in the workplace  PQ[Patient questionarre] &TO [Team observation]: assesses doctor communication skills. questionable information need confirmation D. FOLLOWED by clinical scenarios.].  Peercoaching: Peer coaching is a confidential process through which two or more professional colleagues work together to reflect on current practices. expand.stop training 125 . by patient input[PQ] or your collegeus[TO] 124 . teach one another. Your consultant will let you to operate TAH by your self after several encounters[observing then assisting then…. increase thromboxane B. evaluation or feedback.  Complex procedural hierarchy: Teaching over a significant time span. you start at a very basic level . DHEA ANSWER : D . refine.Mechanism of action of asprin A.There is no demand for assessment. extend again B.  Simplified procedural hierarchy: The learner is simply shown how to do something [eg you show them how to assemble a laparoscope].  Schema activation: The tuotorial is PRECEEDED by recalling te basics.specific attention and not to extend again C..Senario about trainee score 3 in appraisal his consultant comment that they extend to him due to poor performance and he sit many times for part one . share ideas. irreversible inhibition of COX ANSWER : B C.Active metabolite of androgen is A.what to do for him now ANSWER : C A.  Goldfish bowl : Involve a role-play set by the facilitator.testesterone B. and build new skills.  Snowballing: When you are unsure of the current level of knowledge or skills of the learners. attitdue & professionalism . conduct classroom research.  Delphi technique : A panel of experts gatehr to reach a consensus  Doughnut rounds: The learner themselves are asked to make points/questiosn & later discuss them among themselves. C.dihydrosterone = androstanalone or standalone 127 .40 yrs lady present with multilocular or solid component( not sure ) not simple cyst CA125 30 Answer : B .DHEAS d. bilateral Consider surg. expectant without features.5 and in her note there cyst 1 yr ago not followed 4x4x4. phenobarbitone RMI = U x M x CA125 * The ultrasound result is scored 1 point for each of the following *Postmenopausal ovariancharacteristics: cyst multilocular cysts. unilateral .50yrs present with simple ovarian cyst 4x4x4.BSO * The menopausal status is scored as: 1 = premenopausal 3 = • C. CA125 * Cysts fulfilling ALL of the following: asymptomatic. metastases. unilocular.AED that reduced by COCs is ANSWER : C A.CT TAS *Cysts with ANY of the following: symptomatic. TAH+BSO postmenopausal RMI I < 200 D. follow up salpingo-oophorectomy (usually bilateral) RMI I > 200 h. non-simple G. phenytoin B. .MDT with multilocular Answer :B ovarian cyst CA125 30 129 .lamotrigne D.60 yrs present . simple cyst. multilocular. Consider conservative management = Repeat assessment in 4–6 months CA125.ascites and bilateral lesions A.carbamazepine C.repeat US in 4 month U = 0 (for U/S score of 0) U = 1 (for U/S score of 1) U=3 (for U/S score of 2–5) B. E. MRI < 5 cm.unilateral SO 128 .5 and CA125 is 25 (repeated question in all recalls) Answer : A 130 . solid areas. TVS ± F. > 5 cm.. suspectcyst tortion and prepare for LAPROSCOPY .131 . Suspect appendicitis send for surgery e. analgesia and observation B.9years girl came with her parent to the ER with sudden onset of Lt iliac fossa pain with nausea and vomiting ithink high TWBC Answer : E A. Suspect cyst accident give analgesia C. Suspect cyst torsion and give analgesia D. Q 130 Q12 8 Q 129 . 132 - Patient with history of subfertility and PID present with Rt iliac fossa pain nausea and vomiting …TWBCS 19.000 CRP 20 US non compressible mass 5cm diameter 10mm what is the diagnosis ANSWER : A A. acute appendicitis * Ct for app. In preg. Potentially carcinogenic and is it useful after u/s B. fallopian tube infection * MRI is the alternative immging * THE ACOG dicatates mri if us not incluosive C.pelvic abscess 5 - yrs survival A. 40 -50 B.60-70 C.70-80 D.80-90 E. . (not exact numbers) 133 - Ovarian cancer in young did unilateral SO histopathology reviled tumor confined to ovary intact capsule negative wash ANSWER : D stage 1 a 134 - Cervical cancer undergone radical trachelectomy tumor completely excised found parameterial invasion and no other abnormalities ANSWER : A stage 2b 135 - Vulvar cancer histopathology come after surgery positive 1 LN with extracapsular extension ANSWER : A stage 3c 136 80 yrs lady present with 1cm vulval mass near the clitoreal hood next step ANSWER : B A. excisional biopsy B. keyes biopsy from margin C. wide local excision D. biopsy from centre( ithink 137 - Young lady in sexually active present with pain less fleshy lesion at vulva diagnosis A.hpv B.syphlis C.herps simplex D.H.dec ANSWER A HPV FLESHY PAINLESS SYPHALIS ULCER PAINLESS CANCER CERVIX . 50 yrs Cx screening mild dyskaryosis HPV negative next step ANSWER : C A.RR 5yrs D.RR in 3yrs C. Answer : c 138 . no intervention now SEND IUD FOR CULTURE AND GIVE AB . GIVE ALTERNATIVE CC & GYNE REFERAL TO CHECK RESOLUTION OF SYMPTOMS + NHSCSP: RESULT 2016 :139 . colposcopy B.Lady using IUD for yrs asymptomatic cervical screening revieled actinomycosis ACTINOMYOSIS LIKE ORGANISM (ALOS) COMMONLY A/W IUD A. hystrctomy .treat the condition ** IF NO SYMPTOMS NO ACTION ** IF SYMPTOMS REMOVE IUD ( ENSURE NO UPSI IN THE B.remove IUD PAST 5 DAYS ) C. . RR 3yr Colposcopy : Colposcopy referral guidelines Women should be referred for colposcopy if they have 1 .4yrs Risk a/w HRT is much lower than R.1 yr TOG Oct.3yrs TOG Jan.2014 Over a mean f/up of 5 years.one severe dyskaryosis 8 .one smear with possibility of glandular neoplasia 11 - after treatment (by loop or thermocoagulation) if highrisk HPV positive (irrespective of cervical smear result) Colposcopic examination Colposcopic examination involves magnified stereoscopic visualisation of the cervix. a/w obesity. For colposcopic examination of the cervix to be satisfactory. then the entire transformation zone can be visualised 141 .HPV positive 4 .multiple punch biopsies ( if colpo abnormality .5yrs The absolute ↑ in breast cancer risk is 6 extra cases per 1000 women for 5 years of estrogen and progestogens.one smear with possibility of invasion 9 . 140 .hysterectomy B. HPV d RR 5yrs E .one mild dyskaryosis with highrisk 6 .50 yrs Cx screening high grade colposcopy unsatisfactory next :step( CONE / LLITZ) A.2ys recurrence ANSWER : E C. HRT did not ↑ recurrence rates.borderline nuclear abnormality (squamous or glandular) with highrisk 3 . moderate alcohol intake or delaying 1st pregnancy after 35 years E.one moderate dyskaryosis 7 .three consecutive inadequate smears 2 . and reverts back to the population risk 5 years after stopping . If the new squamocolumnar junction can be seen colposcopically.2015 D.After how long risk of HRT for breast cancer revert like general population for lady taking HRT for 5yrs after stop treatment A. the entire transformation zone and the full extent of abnormal (atypical) epithelium is visible must be visible.but unsatisfactory=not seen tz) C. It allows a clinical opinion to be formed and acilitates directed tissue sampling. but ↓ rate of B. . EAS) .and to the integument (skin) around the anus G. inferior C..in the recovery room patient devolped hypovolemic shock retained for laprotomy ANSWER : INF EPIGASTIC ART. inferior gluteal The Inferior rectal nerves (inferior anal nerves.Patient durig VD had 4th degree tear and massive bleeding ANSWER : B The inferior rectal artery arises from the internal pudendal artery 144 .Vascular injury* A.internal pudendal anal canal and the lower end of the rectum. they D. 143 . Superior gluteal B. and is distributed F. internal iliac to the Sphincter ani externus (external anal sphincter. ovarian hemorrhoidal nerve) usually branch from the pudendal nerve but occasionally arises directly from the sacral plexus. uterine cross the ischiorectal fossa along with the inferior hemorrhoidal[disambiguation needed] vessels. toward the E.Patient bleed after sacrospinous fixation inferior gluteal art.others 142 . from Internal pudendal art .Patient undergone laproscopic salpingectomy for ectopic pregnancy surgon tell intraoperative haemostesis secureD. chest infection C.3 .6 . we do exesion but otherwise we do re-tortion Post hysterectomy complication A.Patient consented for laproscopic hysterectomy with past history of dermoid cyst removal.Secondary port in laparoscopy: inferior epigastric artery .laproscopic removal of the tube D. remove x from y E. go as planned 145 .9 .Mediolateral episiotomy bleeding: perineal artery .7 . UTI D.4 . Intra op surgeon find dermoid cyst X 4cm adherent to the pelvic wall in the overy Y ANSWER : G 146 .remove x &y F. laprscopic biopsy and abundant G.Erb's palsy: C5-C6 injury .Midline episiotomy bleeding: inferior rectal artery .For the best interest of the pt.abundant and further assessment C. GANGEROUS tube or overy With clear diagnosis.Opened for appendicitis laproscopically appendix found normal but there is torted ischemic Rt fallopian tube with watery dischargE ANSWER : C Beneficience.Pudendal block haematoma/ sacrospinous fixation: Pudendal artery 5 . abundant and medical ttt B.Cephalohaematoma following ventouse delivery: subperiosteal blood vessels .infected vault haematoma .1 .Forceps delivery followed by vaginal haematoma: vaginal artery . wound infection B.Klumpke's paralysis: C8-T1 injury -10 unexpected pathology A.TOT: obturator artery .2 .Ruptured uterus with retroperitoneal haematoma: internal iliac artery ?? 8 . 3days post op not recoverd well ask for analgesia with abd and back pain not febrile mild tachycardia poor urine out put ANSWER :G This scenario my be with urinary tract injery ( bladder) if in the option with any key word loin pain …creatinine……choose it 149 .12 hrs post surgery pulse 100 BP 90/45 poor urine out put but said .in 3hrs its 80 ml O/E tender abdomen ANSWER :H V.Patient smocker present 48 hrs post hysterectomy with fever temp 39 ..others post op complication 147 . check fluid blance h.fundus ANSWER :A .E. common symptoms for VH is vaginal discharge 150 -The commonest site for uterine perforation during surgical evacuation A.no symptoms is infection and discharge rigid tender abdomin means internal HE .anterior wall B. cervical D. vault haematoma F.tachycardia and tachypnea ANSWER :B 148 .active bleeding I . bowel injury G. Heamtoma taking more than 24 hrs and fever shd be sign .posterior C. cervical preparation with prostaglandins or misoprostol is associated with a reduction in cervical resistance and need for cervical dilatation in premenopausal women compared with placebo. Hawkins-Ambler dilator requires less force to achieve cervical dilatation than the parallel-sided Hegar dilators that are used in many NHS units in the UK. with significant reductions in dilatation force. Cervical preparation with C. Experienced operator . haemorrhage and uterine or cervical trauma.151 -What you do to reduce risk of uterine perforation during evacuation A. Avoiding excessive force . ultrasound guidance in experienced hands as can laparoscopic guidance if an abdominal procedure is being carried out Prevention of uterine perforation initially involves risk assessment and adequate preparation. avoiding excessive force and the use of half-size dilators again reduces the risk of perforation Reports have also suggested that the use of a tapered . Therefore. However. less Cx dilatation prostaglandins. done under US guidance age. The option of medical TOP would reduce the risk of perforation in the second trimester. This involves accurate estimation of gestational age. particularly in the presence of an intact sac. position and attitude of the uterus together with an experienced operator all reduce the risk of uterine perforation ================================== As per RCOG guidelines2 on best practice in outpatient hysteroscopy. position and attitude of the uterus. the RCOG advises that practitioners consider oral or vaginal cervical preparation based on individual patient circumstances.17–19 The advantages of prostaglandin administration prior to surgical TOP are well established. Adequate and gradual cervical dilatation. Accurate estimation of gestational B. Identifying the size. Correct equipment and bimanual assessment correctly identifying the size.20 Adequate and gradual cervical dilatation. Additionally. there are no randomised controlled trials to guide practice in cases of first-trimester miscarriage.21 Additionally. straiten the Cx caudally ANSWER :A TOG 2014: Medical TOP. ultrasound guidance in experienced hands can reduce the risk of . although no such benefit is noted in postmenopausal women. as can laparoscopic guidance if an abdominal procedure is being carried out on the patient at the same time 152 . GNRH anal +tibilone .Patient with breast cancer positive receptors on tamoxifen with severe PMS ttt A. SSRI Answer : d B.perforation. E patch +merina D.OCP Not ssri but snri C. 1 A .formmative formative C.4 E.MRCOG 2+MRCOG3 is ANSWER : A A.3 H.form + sum .summative summative B. Dr mostafa c. sum +form D.2 E.5 153 . Multiple sclerosis patient with history of difficulty emptying bladder with high residual volume ANSWER: B A.UI in 82 years old ttt A. indwelling catheter B.154 . oxybutanin B.Commonest symptom of vault prolapsed ANSWER : A A. CISC C. although it may be offered as second-line therapy if . merabegron C.urodynamic :155 . mirabegron B.deluxtine ANSWER : D Duloxetine 1.SUI C.sexual symptom ANSWER : A 156 .7.trospium D. vaginal bulge B. Do not routinely offer duloxetine as a second-line treatment for women with stress UI. constipation D. deluxtine 157 .19 Do not use duloxetine as a first-line treatment for women with predominant stress UI.Patient tried 3 antimuscurinic not tolerate them next step A.voiding dysfunction E.trospium C. V. (Suprapubic catheterisation is preferred due to reduced risk of ascending infection. refer to GUM C.admit 159 .EMQ patient C/O watery blood stained vaginal discharge and colicky pelvic pain wt finding A. PMFT &bladder retraining C.hystrectomy 160 .ASC D. and allowing normal micturition to be restored without multiple removals/recatheterisations.PHVP with short vagina VAGINA 162 .80yrs with vault prolapse and sopting normal vaginal exam patient had comorbidities ANSWER : E ……HE SAID NORMAL 161 . PMFT B. pessay F.actually EMQ patient SLE on methotrexate and predinsolone devolped herps simplex with pain and palbable bladder optin ANSWER : B A. 158 . being a less painful procedure.) Vault prolapsed A. SSF E. polyp protruding through Cx Autonomic neuropathy.give acyclovir B.Patient with anterior vaginal wall prolapsed and uterine prolapse ask for definitive ttt ANSWER : H VH . resulting in urinary retention.laproscopic SC short vagina it for normal vagina h.pessary plus local estrogen answer : asc………ssi contraindicated for G. colposuspension Before operation B.Confirmation of post hystroscopic sterlisation . or offered advice as described in recommendation 1. [new 2013] * If conservative treatment for SUI has failed. offer: synthetic mid- urethral tape (see recommendations 90–94) or open colposuspension (see recommendation 95). Only an experienced laparoscopic surgeon working in an MDT with expertise in the assessment and treatment of UI should perform the procedure. urodynamic Colposuspension Do not offer laparoscopic colposuspension as a routine procedure for the treatment of stress UI in women.Patient athlet devolped SUI post VD O/E anterior prolapse grade 2 patient start PFMT not improved next step ANSWER : B A. Answer : c 164 . or autologous rectus fascial sling (see recommendation 96). [new 2013 Colposuspension Laparoscopic colposuspension is not recommended as a routine procedure for the treatment of ]2006[ . [2006] Considerations following unsuccessful invasive SUI procedures or recurrence of symptoms Women whose primary surgical procedure for SUI has failed (including women whose symptoms have returned) should be referred to tertiary care for assessment (such as repeat urodynamic testing including additional tests such as imaging and urethral function studies) and discussion of treatment options by the MDT.9 if the woman does not want continued invasive SUI procedures. 163 .stress UI in women.6. X.most common serious complication with abd hysterectomy A.The following enhanced recovery in gyn surgery A.bowel injury E.40% 0.Risk of pelvic adhesion following midline incesion . D.20% Transenersr 23 % C. 2 women in every 1000 (uncommon) * Venous thrombosis or pulmonary embolism.50% 167 .ray with out time limit C. PE B. 7 women in every 1000 (uncommon) * Pelvic abscess/infection.urinary tract injury C.5 % without sur. 4 women in every 10 000 (rare) * Haemorrhage requiring blood transfusion. HSG in 3month Answer : a 165 .ovarian failure ? Answer : c bl transfusion :ABDAbdominal Hysterectomy CFoforOM HYSTERECTOMY FSerious risks * the overall risk of serious complications from abdominal hysterectomy is approximately four women in every 100(common) Damage to the bladder and/or the ureter (7 women in every 1000) and/or long-term disturbance to the bladder function (uncommon) *Damage to the bowel. A. A.blood transfusion D.10% Answer : d B. 4 women in every 1000 (uncommon) . complex carbohydrate drink before major surgery B. 23 women in every 1000 (uncommon) * Return to theatre.can drink up to 4 hrs to prevent dehydration 166 .it work immidiatly B. 24month E.abnormal Cx C.vaginal septum C.Which of the following reduce post Answer : B Operative wound infection A. Answer : d 168 .bowel preparation Pelvic pain A.thikening of uterosacral ligment E.18 month D. Subfertility couple normal male partner female mild endometeriosis when to offer IVF A.fistula D.6month B.12month C.tender bilateral adenxial mass Answer a .uretheral prolapsed B.30month 169 . sheaving use clipers B. wash with antiseptic solution C. 170 .37 yrs yrs with history of chronic pelvic pain Answer : E 173 .Most common site of tubal pregnancy Answer : ampulla . emollient 175 .FISH 174 .56yrs old thin vulval skin fused labia taken fluconazole orally and topically no relieve best Answer : b :option A. Patient with suspected deletion of chromosome 9 or 10 want to know investigation of ANSWER : A choice to confirm A.Patient age ? with dysmenorrhea and blood with defecation( or something like this) Answer : c thickening of utrosacral ligament 172 . PCR C.high potency steroid C. microarray CGH 32 B.17yrs with history of dysuria recurrent UTI and dyspareunia 171 . biopsy B.. Current evidence suggests that bowel injury is not reduced. but is more readily identified . (3m 6m 12m) Open laparoscopy will reduce the incidence of vascular trauma and is advocated in patients with an anticipated complicated entry due to previous surgery.How long to continue ttt with clomofine (cc) before stop ttt. 176 . . . . there are concerns that paroxetine reduces tamoxifen’s effectiveness by inhibiting its bioactivation by cytochrome P450 2D6 (CYP2D6). such as breast cancer.Serotonin Norepinephrine Reuptake Inhibitor ( SSNRI) will be treatment of choice as SSRIs paroxetine and fluoxetine should not be offered to women with breast cancer who Is on tamoxifen The selective serotonin re-uptake inhibitor (SSRI) antidepressants paroxetine [14] and fluoxetine [14] may be offered to women with breast cancer for relieving menopausal symptoms. in ER positive on tamoxifen significant amount of evidence exists for the efficacy of selective serotonin reuptake inhibitors (SSRIs) and selective noradrenaline reuptake inhibitors ( SNRIs) in the treatment of . resulting in an . general clinicians should probably avoid using phytoestrogens and progestogens/progesterone as first-line therapy. the hormone receptor expression of the tumour should be taken into account.are for the SNRI venlafaxine at a dosage of 37. but not to those taking tamoxifen. If possible. particularly hot flushes.increased risk of death from breast cancer . as these preparations may have an effect on breast tissue (an SNRI may be the best choice here).vasomotor symptoms Although there are some data for SSRIs such as fluoxetine12 and paroxetine. The main drawback of SNRIs can be reduced by uptitrating the dosage.5 mg twice daily The main drawback with these preparations (especially the SNRIs) is the high incidence of nausea In women with estrogen/progesterone-dependent tumours. In ER negative Women with vaginal dryness can use moisturisers and lubricants such as Replens .13 the most convincing data . Also. . . Dr / hamada said aboroumh With my best wiches for all .