A. Advise condom use for next 7 days
B. Perform a pregnancy test
C. Omit pill break at end of pack
D. No action neededia
Answer: D
The advice from the Faculty of Family Planning and Reproductive Health Care has changed over recent years. The following recommendations are now made for women taken a combined oral contraceptive (COC) pill containing 30-35 micrograms of ethinylestradiol
If 1 or 2 pills missed (at any time in the cycle)
• take a pill as soon as possible and then continue taking pills daily, one each day
• no additional contraceptive protection needed
If 3 or more pills missed
• take a pill as soon as possible and then continue taking pills daily, one each day
• the women should use condoms or abstain from sex until she has taken pills for 7 days in a row
• if pills are missed in week 1 (Days 1-7): emergency contraception should be considered if she had unprotected sex in the pill-free interval or in week 1
• if pills are missed in week 2 (Days 8-14): after seven consecutive days of taking the COC there is no need for emergency contraception*
• if pills are missed in week 3 (Days 15-21): she should finish the pills in her current pack and start a new pack the next day; thus omitting the pill free interval
*theoretically women would be protected if they took the COC in a pattern of 7 days on, 7 days off
2. A 21-year-old female is seen in the first seizure clinic in the outpatient department. A decision is made not to start her on anti-epileptic medication. What restrictions on driving should she be informed about?
A. No restrictions but inform DVLA
B. No restrictions, no need to inform DVLA if not on medication
C. Cannot drive for 1 month from date of seizure
D. Cannot drive for 6 months from date of seizure
E. Cannot drive for 1 year from date of seizure
Answer: E
Patients cannot drive for 1 year following a seizure
The guidelines below relate to car/motorcycle use unless specifically stated. For obvious reasons, the rules relating to drivers of heavy goods vehicles tend to be much stricter
Specific rules
• first seizure - 1 year off driving
• stroke or TIA - 1 month off driving
• multiple TIAs over short period of times - 3 months off driving
• craniotomy - 1 year off driving*
• narcolepsy/cataplexy: cease driving on diagnosis, can restart once 'satisfactory control of symptoms'
Syncope
• simple faint: no restriction
• unexplained, low risk or recurrence: 4 weeks off
• explained and treated: 4 weeks off
• unexplained: 6 months off
*if the tumour is a benign meningioma and there is no seizure history, licence can be reconsidered 6 months after surgery if remains seizure free
3. If 59-year-old man with a history of gout presents with a swollen and painful first metatarsophalangeal joint. He currently takes allopurinol 400mg od as gout prophylaxis. What should happen to his allopurinol therapy?
A. Stop and recommence 4 weeks after acute inflammation has settled
B. Reduce allopurinol to 100mg od until acute attack has settled
C. Stop and switch to colchicine prophylaxis
D. Stop and recommence 2 weeks after acute inflammation has settled
E. Continue allopurinol in current dose
Answer: E
Gout: management
Gout is a form of microcrystal synovitis caused by the deposition of monosodium urate monohydrate in the synovium. It is caused by chronic hyperuricaemia (uric acid > 450 µmol/l)Acute management:
NSAIDs
intra-articular steroid injection
colchicine has a slower onset of action. The main side-effect is diarrhoea
if the patient is already taking allopurinol it should be continued.
Allopurinol prophylaxis - see indications below
allopurinol should not be started until 2 weeks after an acute attack has settled
initial dose of 100 mg od, with the dose titrated every few weeks to aim for a serum uric acid of < 300 µmol/l
NSAID or colchicine cover should be used when starting allopurinol
Indications for allopurinol*
recurrent attacks - the British Society for Rheumatology recommend 'In uncomplicated gout uric acid lowering drug therapy should be started if a second attack, or further attacks occur within 1 year'
tophi
renal disease
uric acid renal stones
prophylaxis if on cytotoxics or diuretics
*patients with Lesch-Nyhan syndrome often take allopurinol for life
4. A 2-month-old girl is brought to surgery with poor feeding and vomiting. Mother reports that her urine has a strong smell. A urinary tract infection is suspected. What is the most appropriate management?
A. Urine culture + empirical oral antibiotic therapy + ultrasound as soon as possible
B. Urine culture + empirical oral antibiotic therapy + outpatient referral to paediatrics
C. Urine culture + oral antibiotics based upon results + ultrasound within 6 weeks
D. Urine culture + empirical oral antibiotic therapy + ultrasound within 6 weeks
E. Refer immediately to hospital
Answer: E
Urinary tract infections (UTI) are more common in boys until 3 months of age (due to more congenital abnormalities) after which the incidence is substantially higher in girls. At least 8% of girls and 2% of boys will have a UTI in childhood.
Presentation in childhood depends on age:
infants: poor feeding, vomiting, irritability
younger children: abdominal pain, fever, dysuria
older children: dysuria, frequency, haematuria
features which may suggest an upper UTI include: temperature > 38ºC, loin pain/tenderness
NICE guidelines for checking urine sample in a child:
if there are any symptoms or signs suggestive or a UTI
with unexplained fever of 38°C or higher (test urine after 24 hours at the latest)
with an alternative site of infection but who remain unwell (consider urine test after 24 hours at the latest)
Urine collection method
clean catch is preferable
if not possible then urine collection pads should be used
cotton wool balls, gauze and sanitary towels are not suitable
invasive methods such as suprapubic aspiration should only be used if non-invasive methods are not possible
Management
infants less than 3 months old should be referred immediately to a paediatrician
children aged more than 3 months old with an upper UTI should be considered for admission to hospital. If not admitted oral antibiotics such as cephalosporin or co-amoxiclav should be given for 7-10 days
children aged more than 3 months old with a lower UTI should be treated with oral antibiotics for 3 days according to local guidelines, usually trimethoprim, nitrofurantoin, cephalosporin or amoxicillin. Parents should be asked to bring the children back if they remain unwell after 24-48 hours
antibiotic prophylaxis is not given after the first UTI but should be considered with recurrent UTIs
5. A 19-year-old male with a history of asthma presents to the surgery due to shortness of breath. On examination his peak flow is 250 l/min (usual 600 l/min). Pulse is 100 bpm and the respiratory rate is 24 / min. Examination of the chest reveals a bilateral expiratory wheeze but is otherwise unremarkable. What is the most appropriate management?
A. Oxygen + nebulised salbutamol + prednisolone arrange immediate admission to A&E via ambulance
B. Nebulised salbutamol + advise to double inhaled steroids + allow home if settles with follow-up review
C. Oxygen + nebulised salbutamol + prednisolone arrange immediate admission to medical team via ambulance
D. Oxygen + nebulised salbutamol + prednisolone and review following treatment
E. Nebulised salbutamol + prednisolone + allow home if settles with follow-up review
Answer: D
Whilst his respiratory rate is consistent with a 'moderate' exacerbation his peak flow, less than 50% of usual, means he should be treated as for a 'severe' exacerbation. The British Thoracic Society give specific recommendations on dealing with acute asthma in primary care
Asthma: assessment and management in primary care
Patients with acute severe asthma are stratified into moderate, severe or life-threatening
Moderate
• PEF > 50% best or predicted• Speech normal• RR <>
Severe
• PEF 33 - 50% best or predicted• Can't complete sentences• RR > 25/min• Pulse > 110 bpm
Life-threatening
• PEF <>
Management of moderate asthma
beta 2 agonists such as salbutamol, either nebulised or via a spacer (4-6 puffs, given one at a time and inhaled separately, repeated at intervals of 10-20 minutes)
if PEF between 50-75% then prednisolone 40-50mg
Management of severe asthma
consider admission
oxygen 40-60%
beta 2 agonists such as salbutamol, either nebulised or via a spacer (4-6 puffs, given one at a time and inhaled separately, repeated at intervals of 10-20 minutes)
prednisolone 40-50mg
if no response then admit
Management of life-threatening asthma
arrange immediate admission (999 call)
oxygen 40-60%
nebulised beta 2 agonists such as salbutamol, and ipratropium prednisolone 40-50mg or IV hydrocortisone 100mg
6. A 21-year-old female presents for review. She is 14 weeks pregnant and has been seen by the midwives for her booking visit. There have been no pregnancy related problems to date. Tests taken revealed the following:
Blood group: A Rhesus negative
What is the most appropriate management regarding her rhesus status?
A. Give first dose of anti-D at 28 weeks
B. No action required unless antenatal vaginal blood loss
C. Give first dose of anti-D as soon as possible
D. Give anti-D just prior to delivery
E. No action required
Answer: A
Rhesus negative woman - anti-D at 28 + 34 weeks
NICE recommend giving rhesus negative woman anti-D at 28 weeks followed by a second dose at 34 weeks
Antenatal care: timetable
NICE issued guidelines on routine care for the healthy pregnant woman in March 2008. They recommend:
10 antenatal visits in the first pregnancy if uncomplicated
7 antenatal visits in subsequent pregnancies if uncomplicated
women do not need to be seen by a consultant if the pregnancy is uncomplicated
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