mcq for final MBBS

1. True or false
a. Pregnancy increases the severity of epilepsy in all patient who are taking antepileptic treatment
b .Pregnancy is contra indicated if women had fits within 1 year
c.Its advisable to prescribe combination of anteepileptic drugs during pregnancy
d.Combined oral contraceptive is drug of achoice for a women who is taking anti epileptic
e.Breastfeeding is contra indicated in a woman who is taking atiepileptic drugs


answer

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Epilepsy in pregnancy - a clinical approach for medical students

( This is not my own notes, got from a friend)

A 21 year old woman who is an epileptic on medication is planning a pregnancy. The couple come to you for advice

1. What important aspects of the disease you would consider before advising on pregnancy?

            *Disease severity & control, when was the last fit

            *What are the drugs – valproate, carbamazapine, phenitoin or any other

            *Single drug or combination of drugs

            *Type of seizer (some types of seizers are best manage with certain drugs)

            *Family, social support and economic background

            *Level of education

2.  If not in good control, how are you going to advice?

            *delay the pregnancy, have a good control

            *prescribe a reliable method of contraception

3. If in good control, what advice would you give?

            *Need for referral to a neurologist

            *Consider possibility of stopping medication – if long fit free interval

            *possibility of changing drug/s to less teratogenic drugs

            *possibility to manage with single drug with minimum effective dose

            *Counselling regarding the effects of disease/ drugs to the fetus

                        - Increased risk of epilepsy two folds.

                        - Major  teratogenic effects –oro fascial clefts, Ht disease, NTD

                        - minor teratogenic effects- neuro development delay

                        To mother-

                        -1/3 gets increased seizer frequency

                        -may need increasing drug dose/ frequency

                        -drug levels in blood to be monitored

                        -Need frequent ANC visits, blood investigations

                        -Importance of compliance

                        -High dose folic acid (5mg/d) reduces the risk of NTD

4. How to minimize adverse outcomes due to drugs?

            *If long fit free period à stop mediation

            *Pre pregnancy folic acid

            *manage on single drug, minimum effective dose

            *Change to a less teratogenic agent

            *Screaning for diformitiesà USS – NTD, Ht disease, orofascial clefts

                                                      àacetyle choline esterase – open NTD

5. Why do some women experience increased seizer frequency in pregnancy?

            *Reduced compliance

            *Increased plasma volume reduces drug concentration

            *Reduced plasma proteinsà increased clearance (due to reduced bound fraction)

6. What important steps would you consider during labor and delivery?

            *Continue antiepileptic Rx

            *Good pain relief – epidural/ opioids

            *one to one care

            *Inform paediatric team

            *Maintain good hydration

            *None precipitous labor environment

7. How do you manage status epilepticus?

            *Call for help

            *Patient put in left lateral position, suck out secretions, and give O₂

            *IV line, medosolam or diazepam iv, if not possible give rectally

            *If no response paralyse and ventilate

8. What is the importance of vit K within last 4 weeks of delivery?

            *Reduces risk of PPH

            *Reduces risk of haemorrhagic disease of new born

9. What advice would you give on discharge?

            *Breast feeding not contraindicated, some drugs excreat in breast milk, if the baby is               excessively sleepy need medical attention

            *Breast feed before taking drugs

            *Stress and lack of sleep can provoke fits

            *Need help/ supervision at baby caring, bathing and breast feeding

            *Drugs can be changed to pre pregnancy drugs/ doses

10. What advice would you give regarding contraception?

*Enzyme inducing drugs increase metabolism of hormonal contraception, reducing their efficacy

*If taking OCP need high dose pills, cannot follow conventional missed pill rule

*DMPA- needs increased frequency

*IUCD good option

MCQ with answers for final MBBS

1. True or false
a. Complain of involuntary leakage of certain urine during certain activity is only called as urinary incontinence
b.Leakage of urine during cough is called as genuine stress urinary incontinence
c.Overactive bladder (OAB) is defined as frequency  that occurs with or without UI 
d.Detrusor overactivity is characterized by involuntary contractions during the filling phase of cystometry which may be spontaneous or provoked .
e.Urinary tract infection must me excluded in any woman with urinary incontinence

answers - FTFTT

2. Recognized risk factors for urinary incontinence

a.Older age

b.Increased estrogen level 

c.Pregnancy

d Vaginal delivery

e. Menopause 

answers  TFTTT

3.True or false

a.Loss of support to the bladder neck leads primarily to urge incontinence

b.Urodynamic tests are necessary to confirm the presence of stress incontinence

c.Urinary tract infection can cause urgency and stress incontinence

d.Urethral stricture is a cause for stress incontinence

e.Vesico vaginal fistula can present with urinary incontinence

answers FFTFT

4.True or false

a. Pelvic floor exercise is successful only in less severe cases of stress incontinence

b. Severe Stress incontinence is primarily treated by surgery

c. Advanced urodynamic studies are recommended before proceeding for surgery in any kind of urinary incontinence

d.Surgery is the best option for a patient with urge incontinence who failed to respond to conservative measure

e.Non invasive vaginal surgeries are the 1st line of surgical option for stress incontinence 

answers TTTFT

URINARY INCONTINENCE MADE EASY

1.What is the definition of urinary incontinence?

            ` Complain of any involuntary loss of urine`

2.What are the types of  urinary incontinence?

1. Stress incontinence (Urodynamic stress incontinence): Urine leakage associated with increased abdominal pressure from laughing, sneezing, coughing, climbing stairs, or other physical stressors on the abdominal cavity and, thus, the bladder.

` patient pass urine when she coughs or laughs`

2. Urge incontinence: Involuntary leakage accompanied by or immediately preceded by urgency

` patient feel the urge to pass urine but unable to control it until reaching wash room/toilet`

3. Mixed: A combination of stress and urge incontinence, marked by involuntary leakage associated with urgency and also with exertion, effort, sneezing, or coughing

4. Functional: The inability to hold urine due to reasons other than neuro-urologic and lower urinary tract dysfunction (eg, delirium, psychiatric disorders, urinary infection, reduced mobility

3.What are the risk factors for urinary incontinence?

1.Age

2.Race – white women had a prevalence of urodynamic incontinence 2.3 times higher than african american women

3.Pregnancy – aggravated physiological response

4.Child birth – damage to pelvic floor muscle       pudendal and pelvic nerves.

                            Increase with parity

5. Menopause – estrogen deficiency

4. What are the causes for stress incontinence?

Urethral hypemobility

   Urogenital prolapse

Pelvic floor damage or denervation

    parturition

    pelvic surgery

    menapause

Urethral scarring

    vaginal/urethral surgery

     incontinence surgery

     urethral dilatation

      recurrent UTI

     radiotherapy

Raised intraabdominal pressure

      pregnancy

       chronic cough

       abdominal /pelvic mass

       fecal impaction

       ascitis

       (obesity)

 `support to the bladder neck is lost` is the main reason for SI

5. What is detrusor over activity?

Urodynamic observation characterized by involuntary contractions during the filling phase which may be spontaneous or provoked .

It can cause urge incontinence 

6. What is over active bladder ?

Overactive bladder (OAB) is defined as urgency that occurs with or without UI and usually with frequency and nocturia.

7. What are points to be assessed  in the history taking ?

1.Severity and quantity of urine lost and frequency of incontinence episodes

2.Duration of the complaint and whether problems have been worsening

3.Triggering factors or events (eg, cough, sneeze, lifting, bending, feeling of urgency, sound of running water, sexual activity/orgasm)

4.Constant versus intermittent urine loss

5.Associated frequency, urgency, dysuria, pain with a full bladder

6.History of urinary tract infections (UTIs)

7.Concomitant fecal incontinence or pelvic organ prolapse

8.Coexistent complicating or exacerbating medical problems

9.Obstetrical history, including difficult deliveries, grand multiparity, forceps use, obstetrical lacerations, and large babies

10.History of pelvic surgery, especially prior incontinence procedures, hysterectomy, or pelvic floor reconstructive procedures

11.Other urologic procedures

12.Spinal and central nervous system surgery

13.Lifestyle issues, such as smoking, alcohol or caffeine abuse, and occupational and recreational factors causing severe or repetitive increases in intra-abdominal pressure

14.Medications

8.What are the medical problems can excerbate the incontinence?

·         Chronic cough

·         Chronic obstructive pulmonary disease (COPD)

·         Congestive heart failure

·         Diabetes mellitus

·         Obesity

·         Connective tissue disorders

·         Postmenopausal hypoestrogenism

·         CNS or spinal cord disorders

·         Chronic UTIs

·         Urinary tract stones

·         Benign prostatic hyperplasia

·         Cancer of pelvic organs

9. What are the medications that may be associated with urinary incontinence ?

·         

      Cholinergic or anticholinergic drugs

·         Alpha-blockers

·         Over-the-counter allergy medications

·         Estrogen replacement

·         Beta-mimetics

·         Sedatives

·         Muscle relaxants

·         Diuretics

·         Angiotensin-converting enzyme (ACE) inhibitors

10 .What are the investigation for the incontinence?

General practioner/outpatient

Midstream specimen of urine

Frequency volume chart

Pad test

Basic urodynamics study

Uroflowmetry

Cystometry

Videocysto urethrography

Specialized urodynamics study

Urethral pressure profilometry

Cystourethroscopy

Ultrasound

Cystourethrography

Intravenous urography

Electromyography

Ambulatory urodynamic

11. What are the management options for stress incontinence? 

Stress incontinence

Conservative

Pharmacological

Surgical

12. What are the conservative managements for stress incontinence?

PFMT(pelvic floor muscle training/ pelvic floor exercise)

Vaginal cones

electric stimulation

Biofeedback

13. What are the indication for conservative management?

Mild disease

Medically unfit for surgery

Does not wish to undergo surgery

Fertility wish

Pregnancy

14. How Pelvic floor muscle training is practiced? 

Women learn to consciously precontract the pelvic floor muscles before and during increases in abdominal pressure to prevent leakage

Strength training builds up long lasting muscle volume and thus provides structural support

Abdominal muscle training indirectly strengthens the pelvic floor muscles .

Mechanical compression of urethra posterior to the symphysis

PFMT is more effective if patients are given a structured programme to follow rather than simple verbal instruction.

It is unusual for anything more than mild urodynamic stress incontinence to be completely cured by the conservative measures and most women require surgery eventually

15 what are the surgical options available for stress incontinence?

Surgery is usually the most effective way of curing urodynamic stress incontinence and a 90% cure rate can be expected for an appropriate properly performed primary procedure .

1st operative procedure offers the best chance of cure and therefore it is very important to select the appropriate procedure for each  patient .

Vaginal surgeries

Urethral bulking agents

Retropubic midurethral tape procedures

Transobturator mid urethral tape procedures

Abdominal

Burch colposuspencion                                              

Laparascopic

Burch colposuspencion                                               

combined 

sling procedure 

Complex

 Neourethra

artificial sphincter

 urinary diversion

Burch colposuspension

   corrects both SI and cystocele

   may not be suitable if vagina is scarred/narrowed

   Detrusor overactivity may occur de novo or may be

   unmasked by the procedure .

   Rectoenterocele may be excerbated .

    Overall cure rate 70%.

Retro pubic mid urethral tape procedure

Tension free vaginal tape(TVT)

Polypropylene mesh is inserted vaginally at   midurethral level

Under local, spinal and general anesthesia

Complication –short term voiding difficulties

                           bladder perforation

                           de novo urgency

                            bleeding

 90% cure rate  

Trans obturator Tape(TOT)

Local ,regional or general anesthesia

Complication – nerve /vessel injurry

                                bladder injury

                                 vaginal erosion

                         

15. What is Urethral bulking agents?

intramural bulking agents (silicone, carbon-coated zirconium beads or hyaluronic acid/dextran copolymer) for the management of stress incontinence  if conservative management has failed. 

Although success rates with urethral bulking agents are generally lower than those with conventinonal continence surgery ,they are minimally invasive and have lower complication rates meaning that they remain a useful alternative in selected cases

16. What are the initial conservative management of urge incontinence due to detrusor over activity?

Regime suggested by Jarvis

Exclude pathology

Explain rationale to patient

void every 1.5h-  await or be incontinent

Increase interval by 30min(bladder re training)

Normal volume of fluids

Keep fluid balance chart

Give encouragement 

17. What are the management option available if conservative treatment for UI failed ?

DRUG treatment 

Drugs with mixed action – oxybutynin

                                                             propiverine

Antimuscarinic drugs – tolterodine

                                                       trospium

                                                       solifenacin

                                                       fesoterodine

Antidepressants     -    imipramine

Prostaglandin synthetase inhibitors

Anti diuretic agents – desmopressin

Tolterodine is as effective as oxybutynin,although since it has fewer adverse effects,patient tolerability and compliance are improved

commonly used drugs in srilanka are oxytocin and tolterodine.

Intravesical therapy

Intravesical therapy –capsaicin

                                          resiniferatoxin

                                          botulinum toxin

Botulinum toxin A

offer bladder wall injection with botulinum toxin A[7] to women with OAB caused by proven detrusor overactivity that has not responded to conservative management (including OAB drug therapy).

Neuro modulation

Peripheral neuromodulation

Sacral neuromodulation

Surgery

Clam cystoplasty

Urinary diversion

Detrusor myectomy

MCQs with answers

1. Regarding cardiac diseases during pregnancy,
a.Rheumatic Heart Disease (RHD) is the commonest  heart disease in developing countries.
b.anticoagulation should be ommited during pregnacy of a woman with mechanical heart valve
c.Fetal growth restriction and preterm birth are more common in pregnancies complicated by cyanotic congenital heart disease
d.pregnancy is contraindicated in Eisenmengers syndrome
e.caesarean section is the preferred method of delivery for majority of women with cardiac disease 

Answers- a-T   b- F   c- C  d- T   e - F

2.cardiac disease during pregnacy,
a. multidisciplinary team approach is necessary
b.adequate hydration by excessive administration of fluid should be given during labour
c.instrumental delivery during second stage of labour is contra indicated
d.epidural is better choice for intrapartum  pain management
e.ergometrine is better drug for active management of 3rd stage


Answers  - a- T  b-F    c- F   d - T      e- F

3.a women 49 year old woman presented with painless vaginal bleeding after 2 year history of amennorhea,
a. it cannot be labbelled as post menaupausal bleeding as she is only 49 years old
b.speculum examination is necessary for this women
c. endometrial thickness of 8mm is normal for this woman
d.ultasound identified a submucoasal fibroid in the woman, which may be the most likely cause for her bleeding
e.pippel biopsy need hospital admission and spinal aneasthesia

Answers - a- F   b - T    c- F       d- F      e- F

4 Regarding .postmenaupasal bleeding and investigation
a. 10 % of cases associated with malignacy
b.endometrial biopsy is considered only if woman has 3 or more episode of bleeding
c.hysterescopy has more sensitivity to diagnose endometrial malignacy than D and C
d.rare case of ovarian malignancy can present with postmenauposual bleeding
e.cervical malignacy is a known cause 




Answers - a- T   b- F    c- T   d- T    e- T

MCQs for final MBBS with answers

1, which of the following may be attributed as normal symptoms of pregnancy?

a.amenorrhea
b.bleeding PV
c.nausea and vomiting
d.breast tenderness
e.urinary frequency

2,which may be the normal finding in the abdominal examination of the pregnant women? 
a. fundus at umbilicus at 32 weeks
b.fundus at xiphoid sternum only at term
c.head not engaged after 37 weeks in a multiparous women 
d.breech presentation at 28 weeks
e.incisional hernia 

3.regarding diabetis complicating pregnancy,
a.screening for diabetes done only in high risk woman in srilanka
b.oral glucose tolerance test is the gold standard test
c.women with gestational diabetis mellitus is at increased risk for PIH
d.all oral hypoglycemic drugs are contraindicated 
e shoulder dystocia is a known complication 


4.Regarding hypertensive disorder in pregnancy ,
a.Primi mothers are having more risk for PIH than a pregnant women with second pregnancy
b.Poor trophoblastic invasion is implicated as a pathogenesis for PIH
c.Asprin is recommended as a prophylaxis for women high risk for PIH
d.Fetal growth retardation (FGR) is a well associated complication
e.Captopril is a ideal drug to control blood pressure during pregnancy 


Answers
1.True - A,C D E
2.True -C,D
3.True -B,C,E
4.True - A,B,C,D

Preinvasive cervical disease - CIN

CIN1       mild dysplasia       

CIN2       moderate dysplasia

CIN3       severe dysplasia           

CIN 1 - low grade

CIN 2 and 3 – high grade     

Bethesda classification

Low grade squamous intraepithelial lesion (LSIL) – mild dysplasia

High grade squamous intra epithelial lesion        - moderate/severe dyplasia

CIN3   - 30 -50% progress to invasive cancer if left alone

Mild dykaryosis – 16-47 fold increased risk for cancer compare to general female population.

HPV DNA virus

Chromosome contains  early and late gene region

Early region – codes functional proteins

Late gene – codes protein coat

E6 transforming protein binds p53 tumor suppressor gene

E7 major transforming protein binds the RB tumor suppressor

Higher risk subtypes – HPV -16,-18,31.-33,-35,-45,56,etc

Low risk subtypes – HPV  -6,-11

Impaired cell mediated immunity – increased risk

Impaired humoral immunity – risk is not increased

Vaccines

Quadravalent vaccine – directed against HPV 6 11 16 18

Bivalent vaccine          - HPV 16 18

Both types increase specific IgG

Both vaccine exploits the ability of viral capsid proteins to self-assemble into virus like particle .

Virus like particle same antigenic signature as a real virus but as they don’t have DNA - non infective or non-transforming

Pitfall of vaccine

30% of cancers are due to non HPV 16 and 18

Duration of effect is only 4.5 yrs.

No protection for already infected people

Immortalization and transformation

Most cells have life span of 50 – 60 cell division .HPV increase life span, and prevent differentiation  which cause cells to carry on dividing . Which is called as immortalization .

Immortalization  allows DNA damage to accumulate .

NHS (UK) screening programme

25 – 49 years every 3 year

50 -65 years every 5 years

< 25 years – high prevalence but most are transient infection – so only opportunistic screening offered

Coverage  is defined as  percentage of women in the target age group 25 -64 years who is screened in the last 5 years.

If coverage 80%                                reduction of death rate 95%.

The proportion of normal smears increases in older women but so does the proportion of abnormalities representing the invasive cancer.

Specificity 98%

Sensitivity 51%

Further investigation

CIN 1 – repeat in 6 month

CIN 2 3 – further evaluation by colposcopy

Colposcopy

Low power binocular microscope

Magnification 4- 25 times

Before colposcopy,

 Brief history  of LMP, smoking and contraception

Bimanual examination

Colposcopic  Examination done in lithotomy position

Moisten the epithelium with saline soaked cotton wool

Examine underlying vessels with high magnification 16-25

Green filter makes capillaries more clear

Shape of capillaries and intercappillary distance is measured

 Acetic acid apply acetic acid by spray or cotton wool

Mucolytic effect helps more clear examination

Acetowhiteness is noted

Cytoplasm goes reversible changes

High nuclear cytoplasm ratio – nuclei become crowded

Hyperkeratosis /leukoplakia appear white before application

Not all acetowhiteness are CIN

Other causes of acetowhiteness

regenerating epithelium

subclinical HPV infection

immature metaplasia

Classical vessel pattern of CIN – punctuation and mosaic

Malignancy – bizarre vessel pattern.

lugol iodine

Not effected by acetic acid test

Premalignant ,malignant cells – no  glycogen or liitle glycogen

schillers positive – areas non staining with iodine

schillers negative  - areas take up iodine

Treatments for high grade lesions

Excisional technique – abnormal tissue is removed – specimen available for bipsy

Ablative – abnormal tissue is destroyed- no specimen – need punch biopsy beforehand

All achieve cure rate 90-95% except cryocautery which has 85%