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This MCQ is about paediatric A&E, written by Dr Nagi Barakat

 

 

1-The following features are true for children presented with status asthmaticus

 

a-                      Able to talk   

b-                      Respiratory rate of more than 40 breaths per minute

c-                      Capillary refill time is usually less than 2 seconds

d-                      Using accessory muscles

e-                      No wheezes on auscultation

 

2-In respiratory acidosis associated with acute respiratory failure, the following are correct

 

a-                                  PH is less than 7.35 Kpa

b-                                 PCO2 is low

c-                                  PO2 is normal

d-                                 PH is more than 7.36 kpa

e-                                  HCO3 is low or normal

 

3-The alpha-adrenergic affect of adrenaline is

 

a-                      Elevates the systolic blood pressure   

b-                     Increases renal blood flow     

c-                      Increases myocardial contractility       

d-                     Relaxes bronchial muscles      

e-                      Enhances delivery of oxygen to the heart        

 

4-True or false about history of excessive bleeding in children

 

a-                      Bleeding into skin or muscle may be an indication of intrinsic factor problem

b-                      Spontaneous bleeding mucus membrane could be due to extrinsic factor problem

c-                      Spontaneous bleeding into skin is often due to platelets defect

d-                      Isolated bleeding from gastrointestinal tract is usually an indication of bleeding disorders

e-                      Brisk bleeding from mucocutaneous membrane is criteria of DIC

 

5-Children presented to A&E with purpuric rashes may suffer from

 

a-                      ITP

b-                      Septicaemia

c-                      SLE

d-                      Viral infection

e-                      NAI

 

6-In anaphylactic reaction

 

a-                      It only affects organ systems when mast cells concentration are abundant

b-                      Upper and lower respiratory tract are affected

c-                      Intravenous epinephrine of 1:1000 should be given with dramatic improvement

d-                      Intravenous aminophylline is contraindicated

e-                      Shock is due to intravascular fluid loss

 

 

 

 

 

7-Electro-physiological changes occurring in pyloric stenosis include

 

a-       Urea increased  

b-      Metabolic acidosis

c-       Hypocalcaemia

d-      Hypercholraemia   

e-       Hypokalaemia  

 

8-These are true about acute appendicitis in children

 

a-                      Abdominal pain & tenderness are almost always present

b-                      Presence of leucocytes in mid-stream urine is an indication of perforation

c-                      Rectal examination should be performed in all children

d-                      Blood glucose test is not required in children presented with suspected appendicitis

e-                      Inflamed appendicitis lies posterior to caecum and peritoneum may not show rebound tenderness

 

9-True or false about burns in children

 

a-                      Children with 10% burns of body surface area should not be admitted to hospital

b-                      Involvement of both arms and posterior trunk will be calculated as 36% burns

c-                      Intravenous colloids can be given as % of burns x body weight over 8 hours

d-                      Silver nitrate dressing is contraindicated for burns affecting the face

e-                      Dextrose/saline intravenous fluid is not recommended as a resuscitating fluid

 

10- These are good indicators for lead poisoning

 

a-                      Basophilic stippling of RBCs

b-                      Detection of urinary coproprophyrin

c-                      Raised transaminase

d-                      Raised serum aminolevulinic acid level

e-                      Target cells on blood film

 

11-In children with sequestration crisis of sickle cell disease, which of the following occur:

 

a-                      Increased RBCs destruction

b-                      Sudden enlargement of spleen

c-                      Raised transaminase

d-                      Abdominal pain

e-                      Profound decline in circulating RBCs

 

12- Which of the following statements are true about acute mesenteric lymphadenitis

 

a-                      Associated with gram negative organism infection

b-                      Rebound and tenderness is often present

c-                      Leucocytosis is uncommon

d-                      Pain and tenderness is more diffuse than with appendicitis

e-                      Usually associated with large inflamed tonsils

 

13-Migrain in children is often associated with the following

 

a-                      Bilateral headache

b-                      Headache is often described as a band round the head

c-                      Diplopia

d-                      Abdominal pain

e-                      Hallucination

 

14-The common causes of hypernatraemic dehydration in children are

 

a-                      Nephrogenic diabetes insipidus

b-                      Diabetic ketoacidosis

c-                      Profuse sweating

d-                      Salicylate poisoning

e-                      Congenital adrenal hyperplasia

 

15-The commonest organisms causing meningitis in children at all ages are

 

a-                      H. Influenza

b-                      N. Meningitides

c-                      E. Coli

d-                      Streptococcal pneumonia

e-                      Mycobacterium

 

16-In Salicylate poisoning, metabolic acidosis develops as result of which of the following

 

a-                      Salicylic acid

b-                      Increase in organic ketoacids

c-                      Hypoglycaemia

d-                      Loss of fixed base

e-                      Renal tubular leakage

 

17-Low CSF sugar in bacterial meningitis is due to which of following

 

a-                      Increased glucose utilisation by the brain

b-                      Defective glucose transport from blood to CSF

c-                      Increased glucose utilisation by bacteria in the CSF

d-                      Increased insulin production

e-                      Increased glucose utilisation by RBCs

 

18-The following organisms are causing purulent otitis media in children

 

a-                      Staph aureus

b-                      H. Influenza

c-                      Beta haemolytic streptococcus

d-                      Streptococcal pneumonia

e-                      Adenovirus

 

19-Renal calculi in children is often presented with

 

a-                      Iliac fossa or abdominal pain

b-                      Haemturia

c-                      Proteinuria

d-                      Urinary tract infection

e-                      Vomiting

 

20-These are true about hypoglycaemia in children

 

a-                      Increase in plasma glucagons

b-                      Increase in plasma cortisol level

c-                      Increase in C-peptides

d-                      Decrease in growth hormone level

e-                      Increase in insulin level

 

21-These are the most common causes of haemturia in children

 

a-                      Urinary tract infection

b-                      Postural hypotension

c-                      Sickle cell anaemia

d-                      Acute golmerulonephritis

e-                      Rota virus infection

 

22-The following drugs can be used in management of acute supraventricular tachycardia in infants

 

a-                      Digitalis

b-                      Flecanide

c-                      Morphine

d-                      Adenosine

e-                      Verapamil

 

23-The most common causes of stridor of 2 weeks old newborn are

 

a-                      Laryngeal web

b-                      Vascular ring

c-                      Tracheal Haemangioma

d-                      Hypocalcaemia

e-                      Thyroglossal duct remnant

 

24-Rectal bleeding in 3 years old child may be due to

 

a-                      Anal fissure

b-                      Child sexual abuse

c-                      Haemorrhoids

d-                      Milk allergy

e-                      Meckel’s diverticulum

 

25- The following statements are true about Diabetic Ketoacidosis (DKA) in children

 

a-                      Can be presented with nausea and vomiting

b-                      Abdominal pain is always one of the associated features

c-                      Insulin sliding scale is the current management

d-                      Addition of potassium chloride is not required in first two hours of DKA management.

e-                      Deficit and maintenance fluid should be given in first 24 hours.

 

26-Which of the following are good clinical markers of Child Sexual Abuse (CSA)

 

a-                      Ano-genital warts

b-                      Anal fissure

c-                      UTI in girls

d-                      Herpes simplex vagnitis

e-                      Laceration of penis

 

27- The following statements are true about status epilepticus in children

 

a-                      It can be defined if seizure lasts more than 30 minutes

b-                      The commonest cause is bacterial meningitis

c-                      Intravenous Lorazepam is superior to IV diazepam

d-                      Intravenous phenytoin may cause skin burns in young children only

e-                      EEG is often normal following febrile status epilepticus

 

 

PLAB two questions by seven sisters.

100 questions.

 

 

 

 

History, Physical Examination & Counselling:
Q.1: IDDM: Annual Check up.
1. Measure Body Weight.
2. Examine the eyes:
a. Xanthelasma and arcus.
b. Visual acuity (maculopathy).
c. Test eye movements (Mononeuritis multiplex, III, IV, VI CN).
d. Ophthalmoscopy (cataract, rubeosis iridis, retinopathy, vitrous haemorrhage).
3. Mouth: candidiasis.
4. Neck: listen for carotid bruit (atherosclerosis).
5. Upper limb:
a. Blood pressure (sitting and standing for postural hypotension, and hypertension).
b. Radial pulse (for resting tachycardia).
c. Inspect hand for wasting of thenar (carpal tunnel syndrome), hypothenar and interossei muscles (ulnar nerve palsy). Index for infection of prick site, ask the patient to do prayer sign (joint contracture).
6. Chest: auscultate for signs of TB, pneumonia, or CCF.
7. Examine lower limb:
a. Inspection:
i. Foot for ulcer, gangrene, callus, infection at prick site. In between toes and look for small muscle wasting, pes cavus, claw toes.
ii. Ankle: for deformity (charcot joint, OHCS, 5th ed. p668)
iii. Leg: for muscle wasting.
iv. Knee: for deformity (charcot joint).
v. Thigh: for injection sites (infection, lipo-atrophy, lipo-hypertrophy), muscle wasting (especially quadriceps for diabetic amyotrophy).
b. Foot pulses:
i. Dorsalis pedis: on dorum of foot just lateral to extensor hallucis tendon
ii. Posterior tibial: 1-2cm below and behind medial malleolus
c. Tendon reflexes:
i. Ankle jerk (S1): lower limb flexed at knee and extended at ankle by hand of examiner and ankle put at dorsum of opposite foot (can be abscent in elderly)
ii. Knee jerk (L3, L4): lower limb flexed at knee to 60° and carried by hand.
iii. Plantar reflex (S1, S2): rake with blunt object along lateral border of foot from heel to little toe (can be extended in Diabetic amyotrophy).
d. Sensory exam:
i. Joint position: ask the patient to close eyes. Show him up and down positions first. Then start form interphalangeal (IP) joint of hallux holding proximal and moving distal phalanx. If sensation is impaired, move to metatarso-phalangeal (MP) joint, ankle and knee.
ii. Vibration: ask the patient to close eyes, apply tuning fork to sternum, to establish baseline sensation. Test base of big toe, medial malleolus, tibial shaft and tuberus of anterior iliac crest.
iii. Touch: ask the patient to close eyes, use cotton piece. Ask the patient to respond verbally. Examine segments in turn and compare.
iv. Pain: Ask the patient to close eyes and to respond verbally. Use disposable pin, establish baseline sensation at the sternum. Test segments in turn and compare. Ask patient to report if quality of sensations changes (hypo or hyper-aesthesia).
v. Temperature: ask the patient to close eyes. Use two containers of warm and cool water; or use a cold subject (e.g. tuning fork). And ask the patient about quality of sensation (test segments in turn and compare).
vi. Deep pain: ask the patient to close eyes. Apply firm pressure to nail or squeeze the calf belly. And ask the patient to report pain.
e. Power (motor system): Test from proximal to distal.
i. Flex, extend, abduct, and adduct hip joint.
ii. Flex, and extend knee joint.
iii. Dorsiflex (L5), plantarflex (S1), invert, and evert foot.
iv. Flex, and extend toes.
f. Sensory loss in DM:
i. Early: vibration, deep pain, and temperature.
ii. Later: joint position sensation.
g. Investigations:
i. Glycosylated Hb (HbA1c): relates to blood glucose level over 6-8 weeks (normal: 2.3-6.5%).
ii. Glycosylated plasma proteins (fructosamine): relates to blood glucose level over 1-3 weeks.
iii. Urine for glucose, Ketones, and Albumin (macro and micro-albuminuria).
iv. Blood for plasma creatinine, and lipids.
h. Questions to ask:
i. Review of self-monitoring results and injection techniques.
ii. Review of eating habit.
iii. Ask about symptoms of hypoglycemia.
iv. Talk about general and specific problems.
v. Education.

Q.2: Examine the lower limbs of a diabetic patient.
Introduction, and then you may say: “As far as I know you have high glucose level, I would like to examine your legs. Can you please slip off cloths from your bottom half to your underwear?”
1. Observe patient's gait.
2. Inspection:
a. Foot: for ulcer, gangrene, infection, callus at prick sites (heel and heads of metatarsals). And look for small muscle wasting, pes cavus, claw toes, loss of hair, and trophic (waxy) changes.
b. Ankle: for deformity (charcot joint).
c. Leg: for muscle wasting.
d. Knee: deformity (charcot joint).
e. Thigh: for injection sites (lipo-atrophy, lipo-hypertrophy, infection). Quadriceps (diabetic amyotrophy).
3. Palpation:
a. Pulses: (always compare bilaterally)
i. Dorsalis pedis: on dorsum of foot, just lateral to extensor hallucis tendon.
ii. Posterior tibial: 1-2cm below and behind medial malleolus.
iii. Popliteal: flex knee to 30°, press firmly with thumbs in front, and four fingers of both hands posteriorly over popliteal artery below knee.
iv. Femoral: midway between anterior superior iliac spine and pubic tubercle (lateral extension of pubic hair).
b. Palpate for temperature changes, with dorsum of hand.
c. Palpate hind foot, mid foot, and fore foot (MP, IP joints). Compress fore foot for tenderness.
d. Reflexes:
i. Ankle jerk (S1): lower limb is slightly flexed at knee, and extended at ankle, which is placed on the dorsum of opposite foot.
ii. Knee jerk (L3, L4): lower limb is flexed at knee to 60آ؛, and held by hand of examiner.
iii. Plantar reflexes (S1, S2): rake, with blunt object, lateral border of foot. (extension is noted in amyotrophy).
e. Sensory:
i. Joint position: show the patient up and down and then ask him/her to close eyes. Start from IP of big toe. Hold the proximal part and move the distal one, if impaired then move downwards to MP, ankle, knee.
ii. Vibration: ask the patient to close eyes, and apply TF to sternum for baseline sensation. Test base of big toe, medial malleolus, tibial shaft, tibial tuberosity, and anterior iliac crest.
iii. Touch: ask the patient to close eyes. Use cotton piece. Examine segments in turn.
iv. Pain: ask the patient to close eyes. Use disposable pins and start from sternum for baseline sensation. Test segments in turn and ask the patient to report if quality of sensation changes (hypo-, or hyper-aesthesia).
v. Temperature: ask the patient to close eyes. Use two containers of warm and cool water. Or you may use cold object (e.g. TF). And ask the patient about quality of sensation he/she felt. Test segments in turn.
vi. Deep pain: ask the patient to close eyes. Apply firm pressure to toe nail and squeeze calf belly. Ask the patient to report pain.
f. Motor System:
i. Power:
• Flex, extend, abduct, and adduct hip joint.
• Flex, and extend knee joint.
• Dorsiflex (L5), plantar flexion (S1), invert and evert foot.
• Flex, and extend toes.
ii. Tone:
• Rotate the foot (ask the patient to relax).
• Rotate the leg, internally and externally, with knee extended.
• Flex and extend knee.
For segment distribution, dermatomes check OHCM, 4th Ed, p 410.

Q.3: Diabetic coma (M. X.). Explain to examiner.
1. Hypoglycemia:
a. Blood Glucose <2.5 mmol/L.
b. Clinical Findings: autonomic symptoms (sweating, tremor, pallor). Neurological symptoms (irritablity, abnormal behaviour, drowsiness, convulsion, focal neurological sings, and coma). None specific symptoms like nausea, tiredness, and headache.
c. Management: if in doubt, take blood sample for test and give glucose bolus injection before results are out. (50 ml 50% Dextrose IV, followed by Normal Saline flushing. Or give Glucagone 1mg IM).
2. Diabetic Ketoacidosis(DKA):
a. Clinical findings: nausea, vomiting, abdominal pain. Signs of dehydration. Hyperventilation (Kussmall Breathing). Ketotic (acetone) breath smells. Neurological symptoms (confusion, stupor, coma).
b. Management:
i. Insulin: 10 u IV stat, then by pump according to Insulin sliding scale. If no pump available 10 u IM stat, then 6 u IM/hr.
ii. Fluid: 1L N/S over ½ hr, 1L /1hr, 1L /2hrs, 1L /4hrs, 1L /6hrs, till when blood glucose < 15 mmol/L then change to 4% Dextrose, 0. 18% N/S.
iii. Add KCL 20 mmol to all fluid except the first liter (Contraindicated in Renal Failure, and if K+ >6)
iv. Before starting treatment take blood for glucose, U & E, Osmolality, Blood Gases, FBC, Blood C/S, urine for Ketones and C/S. Then measure Blood Glucose and U & E hourly.
v. Insert N/G tube. Chart vital signs, B. Glucose, coma level, Input/Output.
vi. Consider cathetrisation if no urine for 4 hours.
vii. Treat infections with antibiotics.
viii. Shift to SC Insulin and allow by mouth intake when Ketones level <1+.

Differences between Hypoglycemia and DKA coma:

Hypoglycemia DKA
Moist skin and tongueFull pulseNormal, or high blood pressureNormal breathingHyper-reflexia Dry skin and mouthWeak pulseLow blood pressureHyper-ventilationHypo-reflexia

3. Hyperosmolar Non-Ketotic Coma:
a. Clinical findings: typically affects elderly NIDDM, severe dehydration, no acidosis, focal neurological signs may be found, increased risk of DVT.
b. Management:
i. Fluid: N/S half rate of fluid given in DKA.
ii. Insulin: wait after fluid correction, since insulin may not be needed then. But, if needed give 1 u/hr.
iii. Heparin: prophylactic for DVT risk.

Q.4 A 24 year-old female patient presents with vaginal bleeding and 8 weeks of secondary amenorrhea. Take history, make a diagnosis, and discuss management plan.
Introduce yourself. And you may, then, start by saying: ” As far as I know, you didn’t have your periods for the last 8 weeks, and now you have bleeding from your down below. I would like to ask you some questions, and then I will explain to you what we will do”. (You may ask her if it is ok, then proceed with your questions).
When did the bleeding happen? (Or you may ask) when did you first notice the bleeding? Can you describe the bleeding for me? Is it bright red? (Abortion). Or dark red or brown? (Ectopic pregnancy). Is it heavy bleeding with clots? Or just slight blood loss? Have you felt any pain in your tummy? (Site, and character). Have you always had regular periods? Do you think you might be pregnant?
Do you feel sick? Is there any pain in your breasts? Did you notice if your breasts enlarged lately?
Do you use any contraceptive method? What kind you use? IUCD, pills? (IUCD, Progesteron Only Pill risk ectopic pregnancy).
Have you ever had ectopic pregnancy? Have you ever had previous miscarriages? Have you ever had vaginal discharge? Any recurrent pain in the lower part of your tummy? (PID).
Have you ever had any previous operation in your tummy? (appendectomy,C/S).
How have you been feeling in yourself recently? Any stress in job or at home?
Have you experienced any pain between shoulder blades?
Do you have any pain when passing water? Any burning sensation?
How is your bowel motion?
Do you have any medical problem? Do take any medication?
Do you have any bleeding from other sites?
Have you suffered any dizziness? Have you fainted?
After finishing the History taking, you may proceed by saying: “Now I would like to examine you, and after exam we need to run some tests especially pregnancy test to make sure if you are pregnant or not. And we need to do ultrasound examination (ask the patient if she knows what U/S is about, and shortly explain if necessary) to be sure that the possible pregnancy is in the right place, which is in your womb”.
Don’t worry, you will be all right, we will look after you.

Q.5 A young lady presenting with vaginal bleeding and left iliac fossa pain. Take history, and establish differential diagnosis.
Introduce yourself, and you may continue by saying: “As far as I know, you have bleeding from your down below, and you feel pain in the left lower part of your tummy. I would like to ask you a few questions about your condition”.
Can you describe the bleeding for me? Is it bright red? (Miscarriage). Or dark red or brown? (Ectopic pregnancy). Is it heavy bleeding with clots? How many tampons (or pad) you use? Is it heavy bleeding (miscarriage), or slight blood loss? (Ectopic pregnancy).
Can you tell exactly where the pain is? Can you tell what it feels like? Did the pain started before bleeding? (Ectopic pregnancy). Or you saw bleeding before feeling pain? (Miscarriage).
How was your periods? Regular, irregular?
Have you ever had unprotected sexual contact? Do you think you are pregnant? Do you feel sick? Is there any breast discomfort, pain, or enlargement?
Do you use contraception? What kind? (IUCD & progesterone only pills® Ectopic pregnancy).
Have you ever had ectopic pregnancy before? Any miscarriages?
Have you ever had vaginal discharges before? Or recurrent pain in lower part of your tummy? Have you ever had any operation before, especially in your tummy (ask about appendectomies, Cesarean section).
Differential diagnosis:
1. Ectopic pregnancy
2. Miscarriage (Threatened or Inevitable).
3. Chronic PID.
4. Dysfunctional Uterine Bleeding.

Q.6 Amenorrhoea of nine months, Take history to reach a diagnosis.
Introduce yourself, and then you may say: “As far as I have been told, you did not have your periods for the last nine months. I would like to ask you few questions about your condition”.
How old were you when you had your first period? Were your periods regular before? Have you become pregnant before? How many times? When was the last time? Have you ever had miscarriages before? Have you ever had problems during your pregnancies? Have you ever had any kind of Termination Of Pregnancy? Any D&C? (think of Ascherman Syndrome).
Were your deliveries normal? Any difficulties? Any bleeding following deliveries? (Sheehan Syndrome.).
Do you use contraception? What kind do you use? (Post pill amenorrhea and amenorrhea after injectables).
Do you feel tired, sleepy? Have you had any (temperature) fever recently? (General illness).
Did you notice any change in weight? Are you on any kind of diet? (Decreased in Anorexia Nervosa, general illness, increased in Polycystic Ovary Syndrome).
Any recent dislike of hot weather, sweating, tremor, diarrhoea? (Hyperthyroidism).
Any recent increase in hair growth in your face, on your breasts or on your tummy? Did you notice any deepening of your voice? (Virilization).
Have you notice any milky discharge from nipple recently? Any disturbance of vision? (Hyperprolactinoma).
How have you been feeling in yourself for the last year? Any stress in job or at home? Any change of environment? (Stress may cause amenorrhoea).
Are you on any medication? Do you feel any mass in your tummy?

Differential diagnosis:
1. Ectopic pregnancy.
2. Miscarriage (Threatened, inevitable).
3. Chronic PID.
4. Dysfunctional Uterine Bleeding.

Q.7 Hormone Replacement Therapy (HRT): Counseling.
Introduction, then you may begin by saying: “I have heard that you are here to discuss HRT. You know every woman goes through the menopause. This occurs when a woman’s ovaries produce no more the female sex hormones, which are oestrogen and progesterone. Oestrogen has an effect on every cell in the body, whether it is in the skin, bone, blood vessels, womb and vagina. So when the level of oestrogen in the body fall, women get features of hot flushes, night sweats, mood changes, forgetfulness, sleep disturbances, and loss of concentration. In addition, lack of oestrogen causes a type of protein, called collagen, to be gradually lost from the skin, so the skin become thinner, drier, and easily bruised. Also the vagina becomes thinner, less flexible, drier leading to painful sexual intercourse, and less resistant to infections. But the most important effect of oestrogen lack, is on the bones causing what we call osteoporosis, which means that the bones loose mass so they become weak, brittle, and much more likely to break causing number of minor injury such as a fall. Another important effect is on the heart, where before menopause women rarely get heart diseases, while after menopause, the possibility of getting heart attack increases. And within 10 years they catch up with the heart attack incidence in men. Fortunately, there is an effective way of dealing with the problem that is the use of HRT, which consists of these lacking hormones, oestrogen and progesterone.
There are many ways of taking HRT; the first is tablets, which are taken by mouth every day, the second is patches that stick to the skin and should be changed twice weekly. Another way is implants that are inserted under the skin under local anesthesia and their effect lasts for 3-6 months. The fourth way is the gel, which is applied to the skin daily. But you should not bath after application for 1 hour. If vaginal dryness is the main problem, we could give you cream or pessary to place inside the vagina.
With HRT, hot flushes usually disappear within few weeks. It also helps dryness of vagina, improves mood, and sleep disturbances. And the most important effect of HRT is that it can dramatically decrease the risk of osteoporosis, hence fractures. And substantially decreases the risk of heart attacks.
There are very few reasons why a woman cannot take HRT, such as in liver disease, cancer of the womb, or cancer of the breast, and in case of abnormal bleeding from vagina that has no obvious cause. Like any other medication HRT has some side effects, most of them are minor and often disappear if you stop the treatment. Some women feel sick, that is with tablets. Some may put on weight, some may get breast pain and mood changes before periods, which will re-appear with HRT. Some may get skin irritation with the usage of patches. With the use of oestrogen hormone there is a slight increased risk of womb cancer and to decrease that risk we add progesterone, which has protective effect on the womb. Therefore, in women who have had their womb removed this combination of drug is not necessary. The most common reason people are worried about in HRT, is breast cancer, however if you use HRT for five years the risk still minimal. But once you get beyond that e.g. 10-15years then risk tends to increase bit more and we usually teach women how to do self-examination of the breast. Also, we tell them to report, immediately, any vaginal bleeding if happens. One more thing is that HRT is not a contraception method and the woman should continue to use her usual contraception method for one year after the last menstrual period.
Patches, implants, and gel can be taken with liver disease.





Q.8 a female patient asks for permanent sterilization. Take history & counsel her.
Introduction, then you may say: “As far as I know you want to do permanent sterilization. I would like to ask you a few questions, and discuss the condition with you.
How old are you? Do you have children? How many? Do you have a partner? Does he know about your decision? Does he agree?
Why do you want to be sterilized? Do you know about contraception methods available, such as OCP, coils, condoms, diaphragm and cups?
Female sterilization is a procedure by which the fallopian tubes that are the tubes between the womb and ovaries are cut, sealed or blocked. This stops eggs moving down them to meet sperms. The operation can be done in several ways; the most common method is by the use of laparoscopy. This is usually done with the use of General Anesthesia, where you will be put to sleep; a doctor will make two tiny cuts, one just below your navel and the other and the other just above the bikini line in the lower part of your tummy, they will then insert a laparoscope which is a thin telescope-like instrument with magnifying lenses to look at your reproductive organs. The second way is by what we call it mini-laporatomy, usually done under General Anesthesia, the doctor will make a small cut in your tummy, just below the bikini line to reach the Fallopian Tubes. The third way is to reach the reproductive organs through the vagina. The fallopian tubes are then blocked either by tying (ligation), or by removal of a small piece, and then sealed by heat, Or by applying clips or rings.
The period you need to stay in hospital depends on type of anesthesia and operation. It is usually around couple of days. After operation if you have General Anesthesia you may feel unwell for few days and you may have some bleeding and pain, which are slight. You must consider sterilization as permanent method of contraception.
However, there is an operation to reverse sterilization, but it is complicated and may not work. The failure rate of female fertilization is 1-3 per 1000. Pregnancy rate after reversal is around 50% with high risk of ectopic pregnancy.
The advantage is that it does not interfere with sex; your womb and ovaries will remain in place. Ovaries will still release an egg every month. Your sex drive and enjoyment will not be affected. Actually they may improve, as fear of pregnancy is no more an issue. Occasionally some women find their periods to be heavier, but it is usually because of their age and stopping contraceptive pills. You can start sex as soon as comfortable. You must continue contraception until time of operation and if you use ICUD, it should be left till the next period. You should contact your doctor if you think that you are pregnant, of if you missed a period and especially it’s accompanied with tummy pain.
Q.9 A girl on the pills. Explain.
Introduction, I have heard that you are here to discuss OCP. There are two main types of OCP.
The first type is Combined Oral Contraceptives (COP): Where the tablet contains two hormones, Oestrogen and Progesterone. This type stops woman releasing an egg each month.
Advantages: A very reliable method of contraception with less than 1/100 will get pregnant in a year. It does not interrupt sex, often decreases bleeding, period pain and Premenstrual Tension. It also protects against cancer of womb and ovaries.
Disadvantages: The most important disadvantages are the risk of vascular diseases as clot in the leg, heart attack, and stroke. That is why it should not be given to women at risk of these diseases. Women with cardiac diseases, liver diseases, some cases of migraine, gross obesity and immobility also abnormal vaginal bleeding. It should be stopped in a smoker at age of 30 yrs and should not be used by breast-feeding mothers.
How to take the pills: they should be taken daily for 21 days, and stopped then for 7 days. Taking pills should starts on the first day of cycle (the first day when blood is seen), on the day of Termination Of Pregnancy, 3 weeks postpartum (if the mother is not breast-feeding the baby), and 2 weeks after major surgery (if the patient is immobilized). If the pills are forgotten for more then 12 hrs, you should keep taking the pills as usual thereafter, but you should use another type of contraception for seven days. This is also applied in case of diarrhea where you should use another type of contraception on the day of diarrhea and for another 7 days thereafter. It is also applied in case of taking of drugs known to interfere in the action of Combined Oral Contraceptive pills like anticonvulsants, and antibiotics.
If you start taking OCP you have to come for follow up every 6 months to check your BP, and do Breast exam (if >35 yrs).
OCP should be stopped in case of severe headache, severe chest pain, and tummy pain.
The second type is POP (Progesterone Only Pills): this type contains only the Progesterone hormone which causes changes making it difficult for sperm to enter the womb or for womb to accept a fertilized egg, and in some women it prevents the release of eggs.
Advantages: it is a reliable method, with careful use; the failure rate is 1/100 per year. It does not interrupt sex. It is useful for women who smoke and those who cannot take COP for any cause. Also it can be taken in breast-feeding mothers.
Disadvantages: it has some side effects like headache, acne, putting on weight. The periods may be irregular with some bleeding in between. And it is less reliable than COP.
How to take the pill: the same as COP, and should be taken at the same time of everyday. If you miss by 3 hours, you should use another type of contraception for a week and also if you get diarrhea, use another type of contraception for the period of diarrhea and for one week thereafter.
Any woman on OCP should have every 6 months check of: BP, breast exam, cervical smear.

Q.10 Vasectomy, explain the operation and the side effects.
Introduction, then you may say: “As far as I know you asked about sterilization that is what we call vasectomy.
Vasectomy is the procedure by which tubes that carry sperms from your testicles to the penis are cut and blocked. This operation is usually done under local anesthesia. That is the type of anesthesia that numbs the (sac) scrotal area. So you will be awake during the procedure but you will not feel pain. The doctor will make a small cut in the skin of the scrotum, which is the sac of the testicle to reach the tubes, then will remove a small piece of each tube and close the ends.
The cuts will be very small and you may not need any stitch, but if needed, dissolvable stitches will be used. The operation takes 10-15 minutes and you will be able to leave the hospital shortly afterward. But you should not drive yourself home; you should rest for the remainder of the day. The stitches used are dissolvable and will disappear within a week. After the operation the scrotum may feel bruised, swollen and painful. You can help that by wearing tight-fitting underpants to support your scrotum day and night for one week. Avoid heavy exercise for at least a week.
Some men may get bleeding or infections. If this happens you should contact your doctor. You can have sex after the operation as soon as it is comfortable; however, you have to use another method of contraception until sperms disappear from your seminal fluid, and this may take up to 2-3 months. We have to have 2 clear semen tests so that you can rely on vasectomy for contraception. Your testicle will continue to produce male hormone as before, your sex drive, ability to have erection and climax will not be affected. The appearance and amount of semen should be the same as before. There is a suggestion about link between vasectomy and cancer of testicle and prostate but it is not yet proven.
You should consider vasectomy as a permanent method of contraception. Reversal is complicated and may not work. Failure rate is 1/1000-2000 and reversal rate is as 50%. You should not attempt vasectomy if you are not sure that you don’t want more children and you should discuss it carefully with your partner as well as the possibility of the use of available method of contraception.
It doesn’t protect against STD.

Q.11 a 30 years old with cervical smear results of severe dyscaryosis (CIN-III). Counsel, give explanation and advice about colposcopy, and biopsy
Introduction, then you may start as follows: “Now we have had the results of your cervical smear test back and it showed some changes in the lower part of your womb, that is the neck of your womb.
Now we need to do further exam called colposcopy, which is a simple exam that allows the doctor to have a closer look at the changes on the neck of your womb. You will lie comfortably on bed, and the doctor will gently insert a speculum into your vagina just as when you had your cervical smear done. After that the doctor will look by a colposcope that is a specially adapted type of microscope. It is just a large magnifying glass with a light source attached to it. It does not touch you nor gets inside you. The doctor will then dab liquids onto the neck of your womb, which helps the area with changes to appear white and if any such area appears then the doctor will take a sample of tissue (which is just a size of pin head). The exam takes about 15 minutes it should not be painful, may be a bit uncomfortable. You may feel a slight stinging during the tissue sample taking.
After colposcopy, if you have had a biopsy, you may have a light blood stained discharge for few days, this is nothing to worry about and should clear by itself and it is better to avoid sexual intercourse for 5 days to allow site to heal.
You will get the results back of your biopsy after one or two weeks, they will tell you about that. If the result showed any condition that needs treatment, the doctor will tell you about the treatment, which is simple, and virtually 100% effective. The treatment is usually carried out with the use of colposcopy and the procedure is similar to your initial exam. There are several ways of treatment, either to apply heat or freeze the area or apply laser. All treatment types aim at destroying the cells with changes. After treatment you may need to have blood stained discharge for 2-4 weeks during which and with periods you will need to use sanitary towels rather than tampons and it is better to avoid heavy exercise and sexual intercourse to allow the area to heal.
The treatment will have little or no effect on your further fertility, nor on risk of having miscarriages. After treatment you will have a follow up visit after 6 months during which you will have a cervical smear and colposcopy exam and if everything is satisfactory you will have a follow up smears every year for the following 4-5 years.
NB: you are welcome to arrange for a friend or relative to come with you for colposcopy. You may need to bring a sanitary towel with you just in case some discharge appears.
Intercourse does not make the condition worse, enjoy sex as usual but use effective contraception, it is important not to get pregnant until the condition is dealt with. This is because hormones during pregnancy make treatment more difficult. You cannot pass changes or abnormal cells to your partner.
Abnormal smear does not mean cancer, it is very common 1/12, it is just a warning sign and the treatment is simple and virtually 100% effective.
Colposcopy is performed in lithotomy position and liquid used is 5% acetic acid.

Q.12/A A patient is diagnosed to have ectopic pregnancy. You decided to do laparoscopy. Explain that to her.
Introduction, then you may start by saying: “Now, we have had a good look at your tests that we run. And according to the results of the tests, the examination, and what you complained of, there is a high possibility that you have what we call ectopic pregnancy that is a pregnancy outside your womb. This can be in the tubes between your womb and ovaries as in most cases, or at the ovary or inside the tummy, which is very rare.
And since the pregnancy is not in the usual place, it cannot continue to term. In addition, it may bleed suddenly or even cause damage to the tube, which could cause you some harm.
To avoid these problems, we have first to be sure that you have ectopic pregnancy and the best way to do this is by laparoscope. That is the procedure by which we insert a tube with lenses within a small incision in your tummy, after we put you into sleep. So we could look at your womb and tubes. And to treat the condition, there are two ways. Either by laparoscopy, where we could either, inject a medication called methotrexate or remove the pregnancy by incision. The second way to deal with this condition is by operation to remove the pregnancy. And in either ways of treatment we will try to conserve the tube, but if it is damaged by this condition, then the only way to deal with it, is to remove the tube.
Is everything clear or do you want me to repeat anything for you?
Are there any questions that you would like to ask me?
You will remain for 2-3 days in the hospital.
You can return to work after 6 weeks (sick leave).
The doctor will make 2 incisions, one just below the navel and the second above the bikini line.

Q.12/B a female patient with left lower abdominal pain with vaginal bleeding, suspected to have ectopic pregnancy. You want to do investigation, and the patient wants to go home. Counsel her.
Introduction, then you may begin by saying: “According to what you complain of and the examination, there is a high possibility that you have what we call it ectopic pregnancy, which is a pregnancy outside the normal place that is the womb. And this could be either in the tube between the womb and ovaries or less commonly on the ovaries or inside the tummy. And the pregnancy in these positions could not go to term and what is important is that it could bleed suddenly or even cause tear to the tube with bleeding inside your tummy. And these conditions could be avoided by early treatment.
So first, we have to confirm ectopic pregnancy, so we want you to do pregnancy test on sample of your urine. Then we would arrange ultrasound of your tummy and we might need to do laparoscopy, which is a tube passed inside your tummy through small incisions to look at your womb and tubes.
There are 2 ways to deal with this condition by laparoscopy with injection of medication called methotrexate or removal of pregnancy. The secon