|
66 |
EMQ. Tranexamic acid |
|
67 |
Role-play. Trans man |
|
68 |
EMQ. Mycoplasma genitalium |
|
69 |
EMQ. Listeriosis and pregnancy |
66. EMQ. Tranexamic acid.
This
topic featured in the exam in 2019 and 2021, probably prompted by WHOT.
Abbreviations.
EBL: estimated
blood loss.
PPH: postpartum
haemorrhage.
TA: tranexamic
acid.
WHOT: WHO’s
“Updated WHO Recommendation on TA for the
Treatment of PPH”. 2017.
Scenario
1.
Which, if any, of
the following describe the main mode of action of tranexamic acid? This is not
a true EMQ as there may be more than one correct answer.
Option list.
|
A |
inhibition of conversion of plasminogen to plasmin |
|
B |
inhibition of fibrinolysis |
|
C |
inhibition of factor Xa |
|
D |
inhibition of heparin activity |
|
E |
inhibition of plasmin activity |
|
F |
promotion of conversion of fibrinogen to fibrin |
|
G |
promotion of conversion of prothrombin to thrombin |
|
H |
promotion of platelet activation |
|
I |
promotion of platelet production |
Scenario
2.
Which, if any, of
the following statements are true?
Option list.
|
A |
GOH say that TA should be considered when an apixaban
antagonist is required |
|
B |
GOH say that TA should be considered when a clopidogrel
antagonist is required |
|
C |
GOH say that TA should be considered when a factor Xa
agonist is required |
|
D |
GOH say that TA should be considered when a factor Xa
antagonist is required |
|
E |
GOH say that TA should be considered when a heparin antagonist is required |
|
F |
GOH say that TA should be considered when Protein C is
deficient |
|
G |
GOH say that TA should be considered when Protein S is
deficient |
|
H |
none of the above |
Scenario
3.
Which, if any, of
the following statements are true in relation to TA? This is not a true EMQ as
there may be more than one correct answer.
Option list.
|
A |
TA is teratogenic in rats and should be avoided in the
first trimester |
|
B |
TA has not been shown to be teratogenic and is safe to
use in pregnancy |
|
C |
TA is excreted is contraindicated in breastfeeding as
the levels equate to maternal levels |
|
D |
TA levels in breast milk are one hundredth of maternal
levels |
|
E |
none of the above. |
Scenario
4.
Which, if any, of the
following statements are listed by eMC as contraindications?
Option list.
|
A |
asthma |
|
B |
barbiturate use |
|
C |
consumption coagulopathy |
|
D |
convulsions |
|
E |
severe renal impairment |
Scenario
5.
Which, if any, of
the following is included in the definition of PPH in WHOT?
Option list.
|
A |
EBL ≥ 500 mL after vaginal birth or
C section |
|
B |
EBL ≥ 1,00 mL after vaginal birth
or C section |
|
C |
EBL ≥ 500 mL after vaginal birth or
≥ 1,00 mL C section |
|
D |
EBL ≥ 1,000 mL after vaginal birth
or ≥ 500 mL C section |
|
E |
none of the above |
Scenario
6.
What other
category of patient is included in the WHOT definition of PPP?
Option list. There is none, to make you think.
Scenario
7.
Which of the
following are included in the WHOT recommendations?
Option list.
|
A |
TA to be given to all women with a history of PPH |
|
B |
TA to be given to all women in established labour |
|
C |
TA to be given to all having C section |
|
D |
TA to be given to all women having episiotomy |
|
E |
TA to be given to all women having instrumental
delivery |
|
F |
none of the above |
Scenario
8.
Which, if any, of
the following are included in WHOT?
Option list.
|
A |
TA should be given within 3 hours of the birth |
|
B |
TA should be given within 6 hours of the birth |
|
C |
TA should be given IV as a bolus of 10g |
|
D |
TA should be given IV at a dose of 1g in 10mL over 5
minutes |
|
E |
TA should be given IV at a dose of 1g in 10mL over 10
minutes |
|
F |
TA should be given IV at a dose of 5g in 20mL over 5
minutes |
|
G |
TA should be given IV at a dose of 5g in 20mL over 10
minutes |
Scenario
9.
Which, if any, of
the following statements is included WHOT?
Option list.
|
A |
the benefit from TA declines by about 10% for every 5
minutes of delay in starting Rx |
|
B |
the benefit from TA declines by about 10% for every 10
minutes of delay in starting Rx |
|
C |
the benefit from TA declines by about 10% for every 15
minutes of delay in starting Rx |
|
D |
the benefit from TA declines by about 10% for every 20
minutes of delay in starting Rx |
|
E |
the benefit from TA declines by about 10% for every 25
minutes of delay in starting Rx |
|
F |
the benefit from TA declines by about 10% for every 30
minutes of delay in starting Rx |
|
G |
none of the above |
Scenario 10.
Which, if any, of
the following statements are included in WHOT?
Option list.
|
A |
TA is
relatively cheap |
|
B |
TA has a shelf
life of 5 years |
|
C |
TA can be
stored safely at room temperature |
|
D |
TA is widely
available in most countries |
|
E |
none of the
above. |
Scenario
11.
Which, if any, of
the following statements are true of the differences between the updated
version of WHOT in 2017 and the 2012 version?
|
A |
TA to be used from the start of treatment of PPH |
|
B |
TA to be used only for cases with suspected or proven
genital tract trauma |
|
C |
TA to be used as early as possible |
|
D |
TA not to be used > 5 hours after the birth |
|
E |
clearer instructions were given about the rate of
administration |
Scenario 12.
Which, if any, of
the following statements are true of GTG52?
Option list.
|
A |
it is being updated |
|
B |
it advises use of TA for all cases of PPH with no
contraindications |
|
C |
it advises prophylactic use of TA for women at ↑ risk of bleeding prior to C
section |
|
D |
in its present form it puts obstetricians at risk of
being found negligent |
|
E |
none of the above. |
Scenario 13.
Which paper in the
NEJM in 2023 was a bit of a spanner in the works?
Scenario 14.
What were the key
findings in the paper?
67. Role-play. Trans man.
Candidate’s instructions.
You are an ST5 doctor in the gynaecology clinic, your next
patient is Mr Vic Williams; you have received the following letter from the GP.
Take a history from the patient and make a management plan.
GP
referral letter.
Dear Doctor,
I should be most grateful if you would see Vic
Williams, a 35-year-old transgender man. He appears to have a premature
menopause and I have no idea about the implications particularly about bone
health. He has some hot flushes, but say that they are not a problem and he
doesn’t want HRT. He was referred to the gender identity clinic one year ago
but the waiting list for a first appointment is two years, so he is not yet on
any hormone therapy. He has two children, both by normal delivery before he
decided to transition and was ‘Victoria’. The children are 12 and 14 and seem
well-adjusted to the maternal gender change. Vic has no significant medical
history. I shall be most grateful for your expert opinion. Dr. P.E.R. Plexed.
68. EMQ. Mycoplasma genitalium.
Mycoplasma genitalium. EMQ.
Questions.
Many of the questions are not true EMQs as they have more
than one correct answer. I have tried to include all the facts I think might
feature in the exam and packing more than one into a question reduces the total
number of questions and makes the document a bit more manageable. It also
reduces the amount of typing I have to do.
Abbreviations.
BASHHMG: British Association for Sexual Health and HIV’s “National
guideline for the management of infection with Mycoplasma genitalium”. 2018
CT: Chlamydia trachomatis.
MG: Mycoplasma genitalium.
MP: Mycoplasma pneumoniae.
MSSU: mid-stream specimen of urine.
NAAT: nucleic acid amplification test.
NCSP: National
Chlamydia Screening Programme.
NHSCS: NHS
Cervical Screening Programme
PID: pelvic inflammatory disease.
STI: sexually-transmitted infection.
EMQ as there may be more than one correct answer.
Option list.
|
A |
MG was first
isolated in 2001 |
|
B |
MG was first
isolated from men with non-gonococcal urethritis (NGU) |
|
C |
MG belongs to
the Cutemollies class |
|
D |
MG is the
smallest known yeast with the ability to self-replicate |
|
E |
MG is the
smallest known bacterium with the ability to self-replicate |
|
F |
MG has an
unusual, double-layered cell wall |
|
G |
MG has an
unusual protrusion at one end |
|
H |
MG’s protrusion
enables it to adhere to epithelial cells |
|
I |
MG’s protrusion
enables it to invade epithelial cells |
|
J |
MG is best seen
on a Gram stain |
Scenario
2.
Which, if any, of
the following statements are true in relation to Mycoplasmas?
Option list.
|
A |
are the largest known bacteria |
|
B |
have no cell wall |
|
C |
have no nuclei |
|
D |
are resistant to ß-lactam antibiotics |
|
E |
are resistant to sulphonamides |
|
F |
colonies show a ‘scrambled egg’ appearance on culture
on agar |
|
G |
particularly affect mucosal surfaces. |
Scenario
3.
Which, if any, of
the following statements are true in relation to Mg?
Option list.
|
A |
when the organism was originally found, culture took 50
days |
|
B |
Mg is facetious |
|
C |
Mg is a facultative aerobe |
|
D |
Mg is a facultative anaerobe |
|
E |
Mg is a facultative aerobe & anaerobe |
|
F |
Mg is fastidious |
Scenario
4.
Which, if any, of
the following are true in relation to the approximate prevalence of
MG?
Option list.
|
A |
it is ~ 0.1% |
|
B |
it is ~ 1.0% |
|
C |
it is ~ 5.0% |
|
D |
it is ~ 5-10% |
|
E |
it is > 10% |
|
F |
none of the above |
Scenario
5.
Which, if any, of
the following is true in relation to screening for MG? This is a true
EMQ with only one correct
answer.
Option list.
|
A |
screening for MG is now included in the NCSP |
|
B |
screening for MG is now offered as part of the NHSCS |
|
C |
screening should be offered to all sexually active women
< 30 years old |
|
D |
screening should only be offered to those with symptoms
suggestive of infection |
|
E |
screening should be offered to all partners of those
with MG infection |
|
F |
none of the above |
Scenario
6.
Which, if any, of
the following are included in BASHHMG as risk factors for infection
with MG?
Option list.
|
A |
Cigarette smoking |
|
B |
Multiple dancing partners |
|
C |
Multiple sexual partners |
|
D |
Non-white ethnicity |
|
E |
Younger age |
|
F |
None of the above |
Scenario
7.
Which of the
following statements is true in relation to MG and co-infection with
other organisms?
Option list.
|
A |
MG excretes bactericidal toxins and co-infection is
rare |
|
B |
MG co-infection is most often with chlamydia |
|
C |
MG co-infection is most often with E. coli |
|
D |
MG co-infection is most often with HIV |
|
E |
MG co-infection is most often with TB |
|
F |
None of the above |
Scenario
8.
Which of the
following statements is true in relation to MG and men?
Option list.
|
A |
It is the most common cause of NGU |
|
B |
It is the most common cause of epididymitis |
|
C |
It is the most common cause of prostatitis |
|
D |
It is a well-recognised cause of male sub-fertility |
|
E |
Most men with MG infection are asymptomatic |
|
F |
None of the above |
Scenario
9.
Which, if any, of the
following statements are true in relation to MG and women?
Option list.
|
A |
MG is linked to an ↑
risk of cervicitis |
|
B |
MG is linked to an ↑
risk of endometritis |
|
C |
MG is linked to an ↑
risk of female infertility |
|
D |
MG is linked to an ↑
risk of miscarriage |
|
E |
MG is linked to an ↑
risk of otitis media |
|
F |
MG is linked to an ↑
risk of pelvic inflammatory disease |
|
G |
MG is linked to an ↑
risk of postcoital bleeding |
|
H |
MG is linked to an ↑
risk of postmenopausal bleeding |
|
I |
MG is linked to an ↑
risk of preterm birth |
|
J |
MG is linked to an ↑
risk of damage to Fallopian tube cilia |
|
K |
MG is linked to an ↑
risk of puerperal psychosis |
|
L |
MG is linked to an ↑
risk of puerperal sepsis |
|
M |
Most infected women are asymptomatic |
|
N |
None of the above |
Scenario
10. Which, if any, of the following statements are true in
relation to current concerns
about Mg?
Option list.
|
A |
It could become a ‘superbug’, resistant to most
antibiotics, within a decade |
|
B |
Infection is often misdiagnosed as chlamydia with ↑ risk of antibiotic resistance |
|
C |
‘superbug’ status would be likely to lead to an ↑ in renal failure |
|
D |
‘superbug’ status would be likely to lead to an ↑ in female infertility |
|
E |
‘superbug’ status would be likely to lead to an ↑ in male infertility |
Scenario
11. Which, if any, of the following are used in the recommended
test for MG infection in
women?
Option list.
|
A |
blood testing for MG IgG |
|
B |
blood testing for MG IgM |
|
C |
cervical smears checked microscopically for the
diagnostic intracellular inclusion bodies |
|
D |
culture and sensitivity of cervical swab specimens
using MG-specific culture medium |
|
E |
culture and sensitivity of 1st. void MSSU using MG-specific
culture medium |
|
F |
culture and sensitivity of vaginal swab specimens using
MG-specific culture medium |
|
G |
NAATs that detect the MG G-antigen |
|
H |
NAATs that detect MG DNA |
|
I |
NAATs that detect MG RNA |
|
J |
serum testing for MG-specific antigen |
|
K |
vaginal swabs taken by the woman |
|
L |
none of the above |
Scenario
12. Which, if any, of the following statements are true in
relation to testing for antibiotic
resistance after initial tests
are +ve for MG?
Option list.
|
test for
resistance to cephalosporins |
|
|
B |
test for
resistance to macrolides |
|
C |
test for
resistance to penicillin |
|
D |
test for
resistance to quinolones |
|
E |
test for
resistance to macrolides |
|
F |
test for
resistance to streptomycin |
|
F |
test for
resistance to sulphonamides |
|
F |
test for
resistance to tetracyclines |
|
G |
None of the
above |
Scenario 13.
Which, if any, of
the following statements are true in relation to estimates of
antibiotic resistance in current strains of MG in the UK?
Option list.
|
A |
20% are
resistant to cephalosporins |
|
B |
40% are
resistant to macrolides |
|
C |
50% are
resistant to penicillin |
|
D |
50% are
resistant to quinolones |
|
E |
10% are
resistant to streptomycin |
|
F |
90% are
resistant to sulphonamides |
|
F |
40% are
resistant to tetracyclines |
|
F |
None of the
above |
Scenario
14. Which, if any, of the following is BASHHMG’s recommended 1st.
line treatment of
uncomplicated MG?
Option list.
|
A |
azithromycin 1 gram daily for 7 days |
|
B |
doxycycline 100 mg twice daily for 7 days |
|
C |
doxycycline 100 mg twice daily for 10 days |
|
D |
doxycycline 100 mg twice daily for 7 days |
|
E |
doxycycline 100 mg twice daily for 7 days then
azithromycin 1 gram daily for 2 days |
|
F |
moxifloxacin 400mg orally once daily for 7 days |
|
G |
moxifloxacin 400mg orally once daily for 10 days |
|
H |
none of the above |
Scenario
15. Which, if any, of the following is BASHHMG’s recommended 1st.
line treatment of
complicated MG?
Option list.
|
A |
doxycycline 100 mg twice daily for 10 days |
|
B |
doxycycline 100 mg twice daily for 14 days |
|
C |
moxifloxacin 400mg orally once daily for 10 days |
|
D |
moxifloxacin 400mg orally once daily for 14 days |
|
E |
none of the above |
Scenario
16. This is not an EMQ or SBA! Fill in the gaps in the table
below, using option list.
|
Drug name |
Category of drug |
|
azithromycin |
|
|
doxycycline |
|
|
moxifloxacin |
|
Option List.
|
Category of drug |
|
macrolide |
|
tetracycline |
|
quinolone |
Scenario
17. Which, if any, of the following statements is true in
relation to test of cure (TOC) after
treatment of MG?
Option list.
|
A |
TOC should be offered to everyone who has been treated
for MG |
|
B |
TOC should only be offered to those who had signs of infection
before treatment |
|
C |
TOC should only be offered to those who had symptoms of
infection before treatment |
|
D |
TOC should only be offered to those who had signs and
symptoms before treatment |
|
E |
TOC should only be offered to those who continue to
have signs or symptoms two weeks or more after the start of treatment |
|
F |
none of the above |
Scenario
18. Which, if any, of the following statements are true in
relation to the timing of test of
cure (TOC) after treatment of
MG?
Option list.
|
A |
TOC is best done at 3 weeks after start of treatment |
|
B |
TOC is best done at 4 weeks after start of treatment |
|
C |
TOC is best done at 5 weeks after start of treatment |
|
D |
TOC is best done at 6 weeks after start of treatment |
|
E |
TOC should not be done < 2 weeks from the start of
treatment |
|
F |
TOC should not be done < 3 weeks from the start of
treatment |
|
G |
TOC should not be done < 4 weeks from the start of
treatment |
69. EMQ. Listeriosis and pregnancy .
Lm: Listeria monocytogenes.
TOC: test of cure.
Scenario
1.
Which organism is
responsible for human listeriosis?
|
A |
Listeria diogenys |
|
B |
Listeria frigidaire |
|
C |
Listeria hominis |
|
D |
Listeria monocytogenes |
|
E |
Listeria xenophylus |
Scenario
2.
Which, if any, of
the following statements are true about Lm?
Option list.
|
A |
it is a small, Gram -ve rod |
|
B |
it is a Gram +ve coccus |
|
C |
it is flagellated |
|
D |
it has no cell wall |
|
E |
it is an obligate aerobe |
|
F |
it functions within host cells |
|
G |
it can easily be mistaken for commensal organisms |
|
H |
none of the above |
Scenario
3.
Which of the
following are associated with an increased risk of contracting LM?
|
A |
age > 60 years |
|
B |
age < 1 year |
|
C |
blond hair |
|
D |
pregnancy |
|
E |
strabismus |
Scenario 4.
Which of the
following are true of the susceptibility of pregnant women to Lm?
Option list.
|
A |
they are not more susceptible |
|
B |
they are more susceptible x 2 |
|
C |
they are more susceptible x 5 |
|
D |
they are more susceptible x 10 |
|
E |
they are more susceptible x 20 |
|
F |
they are > 20 times more susceptible |
|
G |
none of the above. |
Scenario
5.
When does Lm most
often occur?
Option list.
|
A |
1st. trimester |
|
B |
2nd. trimester |
|
C |
3rd trimester |
|
D |
1st. + 2nd. trimesters |
|
E |
2nd. + 3rd trimesters |
|
F |
all trimesters equally |
|
G |
puerperium |
|
H |
none of the above |
Scenario
6.
What is the
incubation period for Lm?.
Option list.
|
A |
7±3 days |
|
B |
7±5 days |
|
C |
10±3 days |
|
D |
10±5 days |
|
E |
14±3 days |
|
F |
14±5 days |
|
G |
none of the above. |
Scenario
7.
What is the
significance of Granulomatosis Infantisepticum ?
Option list.
|
A |
it is a
fabrication by the author and of no significance |
|
B |
it is
pathognomonic of Lm infection |
|
C |
it is the cause
of vertical transmission of Lm |
|
D |
I refuse to
answer Latin questions as they make me think of Boris Johnson |
|
E |
none of the above |
Scenario
8.
Which of the
following are accurate about cervico-vaginal infection? This is not a true
EMQ as there may be >1 correct answer.
Option list.
|
A |
Lm is as often found in the cervix as in the bowel. |
|
B |
Lm is as often found in the vagina as in the bowel. |
|
C |
Lm is less often
found in the cervix than in the bowel. |
|
D |
Lm is less often
found in the vagina than in the bowel. |
|
E |
Lm is more often
found in the cervix than in the bowel. |
|
F |
Lm is more often
found in the cervix than in the bowel. |
|
G |
no one knows and no one cares |
Scenario
9.
A GP phones about
a primigravida at 28 weeks. She has possibly ingested food
contaminated by Lm. She is asymptomatic and afebrile. What
advice will you give?
Option list.
|
A |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 2 weeks |
|
B |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 4 weeks |
|
C |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 6 weeks |
|
D |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 8 weeks |
|
E |
prescribe appropriate antibiotic(s) for 7 days with
follow-up for TOC |
|
F |
prescribe appropriate antibiotic(s) for 7 days with
follow-up for TOC |
|
G |
prescribe appropriate antibiotic(s) for 7 days with
follow-up for TOC |
|
H |
admit to hospital for investigation and intensive
treatment if Lm infection found |
|
I |
none of the above |
Scenario
10. A GP phones about a primigravida at 28 weeks. She has
possibly ingested food
contaminated by Lm. She has mild symptoms but is afebrile.
What advice will you give?
Option list.
|
A |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 2 weeks |
|
B |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 4 weeks |
|
C |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 6 weeks |
|
D |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 8 weeks |
|
E |
prescribe appropriate antibiotic(s) for 7 days with
follow-up for TOC |
|
F |
prescribe appropriate antibiotic(s) for 7 days with
follow-up for TOC |
|
G |
prescribe appropriate antibiotic(s) for 7 days with
follow-up for TOC |
|
H |
admit to hospital for investigation and intensive
treatment if Lm infection found |
|
I |
none of the above |
Scenario
11. A GP phones about a primigravida at 28 weeks. She has
possibly ingested food
contaminated by Lm. She is symptomatic and her temperature
is 38.2oC. What advice will you give?
Option list.
|
A |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 2 weeks |
|
B |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 4 weeks |
|
C |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 6 weeks |
|
D |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 8 weeks |
|
E |
prescribe appropriate antibiotic(s) for 7 days with
follow-up for TOC |
|
F |
prescribe appropriate antibiotic(s) for 7 days with
follow-up for TOC |
|
G |
prescribe appropriate antibiotic(s) for 7 days with
follow-up for TOC |
|
H |
admit to hospital for investigation and intensive
treatment if Lm infection found |
|
I |
none of the above |
Scenario
12. Which, if any, of the following would be appropriate for
consideration as 1st. line
treatment of Lm in pregnancy? This is not a true EMQ as
there may be more than 1 correct answer.
Option list.
|
A |
ampicillin |
|
B |
ampicillin + gentamycin |
|
C |
ampicillin + streptomycin |
|
D |
amoxicillin + clavulanic acid |
|
E |
clarithromycin |
|
F |
erythromycin |
|
G |
erythromycin + metronidazole |
|
H |
trimethoprim |
|
I |
none of the above |
Scenario
13. Is listeriosis a notifiable infection in the UK? Yes/No.
