The correct answer is C - Provide lifestyle advice

Freda’s blood pressure is not within the target range for patients with diabetes. However she does not have any complications from her diabetes and hypertension and her cholesterol is in a good range. This puts her at a low cardiovascular (CVD) risk – 2% using the Australian Absolute Cardiovascular Risk calculator.

Lowering BP below 120 mmHg systolic does reduce stroke risk but has no impact on other CVD risks.

Both angiotensin converting enzyme inhibitors (ACEI - Ramipril) and angiotensin receptor antagonists (ARA - Telmisartan) have reno protection properties (and both are used in the treatment of diabetic micro albuminuria). They are also used to treat hypertension and for endothelial protection. The National Heart Foundation guidelines identify that both ACEI and ARA are equally effective in blood pressure reduction and prevention of CVS risk overall. ACEI however, prevent onset of nephropathy and reduce early mortality in diabetes, while ARA prevent kidney failure in people with advanced diabetic nephropathy. Thus, if pharmacological treatment is considered then ACEI may have added benefit in this case. Randomised control trials (RCTs) report 10% patients develop cough on ACEIs but tis rate is only 2% in observational studies.

Calcium channel blockers and thiazide diuretics have been found to be equally effective in reducing blood pressure, but don’t have the same reno and cardioprotective benefits.

References

The correct answer is B – acute pulmonary embolism

The sudden onset of severe shortness of breath, pleuritic chest pain, tachycardia, low blood pressure and no fever make either acute pulmonary embolism or acute pneumothorax likely diagnoses. Pulmonary embolism is more likely because she is a smoker and is also on the combined oral contraceptive pill. The drospirenone is a 4th generation progestogen and has a further increased risk of venous thromboembolism compared with the older second generation oral contraceptives (e.g. levonogestrel). The risk is still very low and much lower than the risk of thromboembolism during pregnancy and post-partum.

Generally a spontaneous pneumothorax is more common in men.

References

The correct answer is C – IM 0.5ml adrenaline 1:1,000

Robert is showing signs of an anaphylactic reaction.

Adrenaline is the treatment of choice for anaphylaxis. Oral antihistamines are not appropriate and oral sedating antihistamine should be avoided as the side effects of drowsiness or lethargy may mimic some of the signs of anaphylaxis. Injectable sedating antihistamines are contraindicated as they can worsen hypotension and cause muscle necrosis. Prednisolone can be given for persistent wheeze but only after adrenaline has been given.

The correct concentration of adrenaline in an anaphylaxis setting is 1:1000; lower concentrations of 1:10,000 are used in cardiopulmonary resuscitation settings.

Anaphylaxis should be considered in:

• Any acute onset of hypotension or bronchospasm or upper airway obstruction where anaphylaxis is considered possible, even if typical skin features are not present

OR

• Any acute onset illness with typical skin features
• Urticarial rash
• Erythema/flushing and/or
• Angioedema

References

The correct answer is E – Giving pneumococcal vaccine last

There is strong evidence that giving the most painful vaccine last decreases distress. One mechanism suggested is that pain can escalate with each subsequent vaccine due to hyperalgesia, so starting with the most painful vaccination is not recommended. Painful vaccines include MMRII and pneumococcal conjugate vaccine.

There is strong evidence that partial or full swaddling can reduce pain and distress, but the child should be sitting upright or be held in a close comfortable position, rather than lying down. There is strong evidence that having a parent present for immunisation for children less than 10 years old is important. There is strong evidence for the use of oral sweeteners (directly on the tongue) but the evidence is for 20% sucrose or 30% glucose solution, not fructose. The mechanism is an orally mediated increase in endogenous opioid.

Injecting into the vastus lateralis muscle does lead to reduction of distress but has weaker evidence.

Other strategies with strong evidence include:

• Avoiding aspiration before IM injection
• Simultaneous rather than sequential injections
• Skin to skin contact (‘kangaroo care’) for babies up to one month
• Breast feeding during vaccine injection

Directed and non-directed distraction is effective but has weaker evidence that the other strategies.

References

The correct answer is D – Molluscum contagiosum

There is underlying eczema with evidence of intact and crusted molluscum contagiosum. The intact lesions are classically described as waxy and shiny or pearly papules with a central pit (umbilicated). They occur mainly in infants and children under 10 years of age.

Mullosca, however, can also induce a dermatitis around them which becomes pink, dry and itchy. As they resolve they may become inflamed, crusty or scabby.

The condition is caused by a pox virus and can spread by direct skin-to-skin contact, indirect contact e.g. via towels or through auto-inoculation by scratching or shaving. With auto-inoculation the mollusca often form in a row. In adults they can also be spread by sexual transmission.

Herpes simplex and chicken pox do not have the umbilicated appearance (which can be seen on close inspection of the lesions), rather the lesions are vesicular in appearance. As the lesions are spreading one would expect symptoms such as fever and itch if this were chicken pox, however Chloe is not troubled by these lesions.

References

The correct answer is D – Repeat the creatinine in another week

Commencing an Angiotensin Converting Enzyme inhibitor (perindopril) or an Angiotensin II Receptor Antagonist (irbesartan) can cause a significant in increase the serum creatinine in patients with renal artery stenosis. A small rise creatinine rises and of creatininel <25% of the baseline or raise in potassium (within normal range) should not prompt dose reduction or cessation of ARB.

Thus the most appropriate management step is to repeat the creatinine levels in a week to ensure that the creatinine has stabilised and is not continuing to rise (current increase is 20%). Discontinuing an appropriate medication that can treat his hypertension and could also assist in slowing the progression of his chronic renal disease is not required at this point.

References

The correct answer is B – Referral to the emergency department

Neonates with an acutely sticky eye may have ophthalmia neonatorum caused by chlamydia or gonococcus and so immediate referral is required for identification of the causative organism. If Chlamydia is identified, then treatment is with oral antibiotics; if gonococcus is identified then the child may need a septic workup and systemic ceftriaxone. Severe purulent discharge and conjunctival and lid oedema are suggestive of gonococcal conjunctivitis. All other common organisms e.g. staphylococcus, streptococcus and haemophilus can be treated with topical chloramphenicol.

Blocked nasolacrimal ducts are not usually associated with any upper lid swelling (mild lower lid swelling may be present) or redness of the conjunctivae. This condition often affects both eyes, although can be unilateral; it is treated with saline eye rinses and nasolacrimal duct massage

References

The correct answer is B – Arrange transvaginal ultrasound

While heavy irregular periods are likely to be due to anovulatory cycles it is important to exclude intrauterine pathology in a woman >45 years and who is having irregular uterine bleeding for 6 months or longer. The first step would be to organize a transvaginal ultrasound, ideally performed on days 5-10 of the menstrual cycle. Endometrial biopsy will be important if the ultrasound demonstrates endometrial thickening.

If not seeking to conceive, the treatment options include:

1. 52mg levonorgesterel-releasing IUD – most effective drug therapy
2. Tranexamic acid, non-steroidal anti-inflammatory drugs (NSAIDs), or combined hormonal contraception (second line). Tranexamic acid is more effective than NSAIDS.
3. Oral progestogens or depot medroxyprogesterone, if other options contraindicated or patient preference

While hypothyroidism can cause abnormal uterine bleeding there are no clinical indicators for a thyroid disorder and so it not the most appropriate next step.

References

The correct answer is C – Perform a microscopic examination of the urine

The most likely diagnosis in this case is Henoch-Schonlein purpura (HSP) with the classic presentation of:

• rash
• arthritis
• abdominal pain

The rash is present in virtually all cases and can begin as red spots or weals (urticarial-like) which within 24 hours change to a palpable purpura. The commonest sites of the rash are the buttocks, lower legs, elbows and knees. It is the most common vasculitis of childhood.

The most appropriate investigation (and only investigation required) in a classical presentation of HSP is urine analysis to identify if there is haematuria or proteinuria and therefore renal involvement. Further investigations may be required if the diagnosis is unclear, abdominal symptoms are severe or there is evidence of significant renal involvement e.g. macroscopic haematuria or significant proteinuria.

The cause of HSP is unknown, but there may be a history of a recent URTI.  In a general practice setting, urgent specialist opinion should be sought (usually in a paediatric emergency department) and treatment with prednisone 1 mg/kg is often given to reduce the duration of abdominal and joint pain, and may reduce the risk of abdominal complications.

References

The correct answer is C – 20%

Absolute risk reduction (ARR or risk difference) when the experimental treatment reduces the risk of a bad event is calculated as CER – EER (the Control Event Rate (CER) minus the Experimental Event Rate (EER)).

The Control Event Rate is 40%. The Experimental rate is 20%. So, 40% - 20% = 20%, which is the Absolute risk reduction (ARR).

Therefore, Heartprev will save 20% of patients already at risk of heart disease, from an AMI in the next five years.

NB. When the experimental treatment increases the probability of a good event, the ARR is EER-CER.

The Relative risk is EER/CER – 20/40 = 50%.

References

The correct answer is C – Help him identify his options and potential obstacles

Based on the Prochaska and DiClemente stages of change David is likely to be in the preparation phase as he is seriously considering and planning to change behaviour (usually within 30 days).

In this phase the practitioner’s tasks are to:

• praise the decision to change behaviour,
• prioritize the behaviour change opportunities,
• to identify obstacles and assist in problem-solving,
• encourage small, initial steps and
• assist the individual in identifying social supports

The remaining strategies are useful in other stages and it is important not to mismatch stages and processes.

References

The correct answer is C – Internal hordeolum

This is an internal hordeolum. It is an acute, localised infection or abscess of the Meibomian gland, and is usually due to Staphylococcus.

A chalazion is a Meibomian cyst caused by obstruction of the gland and is not usually painful. Granulomatous inflammation can occur from extravasation of the lipid material in the gland.

Although a chalazion and hordeolum are similar clinically, the underlying pathology is different. An internal hordeolum is an acute, painful, inflamed lesion near the eyelid margin caused by infection (predominantly staphylococcal) of the tarsal meibomian glands, which leads to a small abscess.

A stye is an external hordeolum due to an infection of an eyelash follicle and adjacent glands of an infection. It is located externally along the lid margin.  

Dacrocystitis is an infection of the lacrimal gland and any lump developing would arise at the inner canthus.

In an older person the differential diagnosis of a chalazion includes a sebaceous cell carcinoma.

References

The correct answer is C – Commence doxycycline and prednisolone as per her COPD plan

While there are many causes for her delirium the most likely is infection, specifically a COPD exacerbation. A urinary tract infection (UTI) is possible but less likely. As she has end stage COPD it would be reasonable for her to be managed according to the plan, especially as she has someone at home with her at present.

If living alone the most appropriate next step, even though it might aggravate the delirium, would be admission for further investigation.

Increasing her oxygen rate because she is short of breath is likely to worsen her condition leading to hypercapnic respiratory failure.

It would be appropriate to review her medications as part of her treatment plan especially once she is stabilised as she is at risk of complications from polypharmacy, in particular serotonin syndrome from the combination of a tricyclic antidepressant, a selective serotonin reuptake inhibitor and tramadol.

References

The correct answer is E – Tennis

The most osteogenic exercise for prevention of osteoporosis is exercise that involves either high impact e.g. basketball, netball, volleyball, jump rope, or multidirectional impact e.g. tennis and squash. These are appropriate for a person who does not already have osteoporosis.

Jogging, running and brisk or hill walking and resistance training are examples of moderately osteogenic exercise. Swimming, cycling and kayaking are non-osteogenic but preserve strength and appropriate for cardiovascular fitness.

References

The correct answer is B - Biceps tendinopathy

Biceps tendinopathy causes anterior shoulder pain. The patient usually complains of a 'clicking' or audible 'popping', which indicates that the tendon is subluxing. Palpation over the patient's bicipital groove elicits a painful response. Internal rotation can cause pain as can resisted flexion.

Speed's test: A positive test consists of pain elicited in the bicipital groove when the patient attempts to forward elevate the shoulder against examiner resistance; the elbow is slightly flexed, and the forearm is supinated. Proximal biceps pathology is often associated with concomitant shoulder pathologies. Thus, it is important to differentiate the primary sources of patient-reported pain and symptoms clinically.

Shoulder rotator cuff syndrome and subacromial bursitis typically causes a painful arc and pain on resisted shoulder abduction; passive range of motion is often normal. Painful weakness and atrophy of muscles suggest significant tendon tears.

Acromioclavicular joint dislocation will typically cause pain localised to the AC joint with associated swelling and bruising; sufferers will typically have poor range of motion in all directions and pain on any passive movement. Early adhesive capsulitis has similar features but passive movement through the arc produces pain (unlike rotator cuff syndrome).

References

The correct answer is E – Prescribe prophylactic antibiotics after sexual intercourse

This is recurrent urinary tract infection, not relapsed infection. It is common in young women. Antibiotic prophylaxis should be considered for women who have 2 or more infections in 6 months or 3 or more infections in 12 months. Strategies for antibiotic prophylaxis include:

• Intermittent self-treatment
• Intermittent prophylaxis (within 2 hours after sexual intercourse)
• Continuous antibiotics

Advice to void after sexual intercourse is a good preventive measure. Intravaginal oestrogen does reduce recurrent UTI, but only in postmenopausal women. Cranberry products are not recommended for prevention.

In the setting of recurrent UTI in young women, an MSU should be performed when asymptomatic, as well as serum renal function and renal ultrasound; if all of these are normal then no further investigation is generally necessary.

References

The correct answer is A – Idiopathic thrombocytopenic purpura

Idiopathic thrombocytopenic purpure (ITP) is a condition in which circulating platelets are decreased, resulting in a bleeding tendency.  Typically FBE is normal and platelets reduced, with autoimmune markers negative.  Splenomegaly is not generally a feature of the condition. 

Other options:

• Sickle cell disease is a genetic disorder resulting from the presence of a mutated form of haemoglobin, and is characterised by anaemia and splenomegaly. 
• Non-accidental injury should not result in thrombocytopenia.
• SLE will often cause a normocytic anaemia but does not typically cause a bleeding tendency although can be associated with reduced platelets; ANA will generally be positive.
• Patients with myelodysplastic syndrome may present with clinical manifestations of anaemia, thrombocytopenia, and/or neutropenia. Usually there is some combination of dysplastic cell morphology, increased marrow blasts, and a karyotypic abnormality.

References

The correct answer is D – Part of a multinodular goitre

While apparently a solitary nodule on clinical examination, most nodules are part of a multinodular goitre (70%).  Between 4-7% of the general population have a palpable thyroid nodule, while around 30-50% of adults have a nodule visible on ultrasound scan.

Only 4-7% of thyroid nodules are malignant, rising to 15% in nodules greater than 10 mm in size.

References

The correct answer is C – Hepatitis A serology

Men who have sex with men (MSM) should have their immunity to Hepatitis A and B established, and be offered vaccination if not immune. 

Urethral gonorrhoea is rare in men without urethral symptoms so urethral swab testing is not recommended in asymptomatic men– anorectal and pharyngeal swabs and first pass urine should be done every 3 months in MSM. Herpes viral swabs are collected only if there is evidence of an ulcer, and a urethral swab for chlamydia is not required.

In addition to Hepatitis A and B serology, asymptomatic patients should have 3-monthly testing (and at least yearly testing if not sexually active or are in a monogamous relationship) with:

• first pass urine, anorectal and throat swabs for chlamydia and gonorrhoea (NAAT/PCR),
• serum testing for syphilis and HIV.

Serology testing for Hepatitis C would be required if the patient was HIV +ve, on PrEP or there was concurrent intravenous drug use. Hepatitis C is not considered an STI except between HIV infected men having unprotected anal sex.

References

The correct answer is B – Cluster headache

Cluster headaches comprise at least five attacks of headache lasting 15-180 minutes. They are always unilateral with severe pain around or above the eye and/or in the temporal region. There is usually at least one of the following: conjunctival injection +/- lacrimation, nasal congestion, eyelid oedema, forehead and facial seating or flushing, sense of fullness in the ear, miosis and/or ptosis.

Cervicogenic headaches are thought to arise from the spinal trigeminal nucleus, and typically are very similar clinically to tension headaches.  They usually produce tight gripping pressure type pain and can be bi-temporal, occipital or generalised.  They can be associated with sleep disturbance, and are often worse at the end of the day.   Migraine is typically unilateral, throbbing or pulsating in nature, associated with nausea/vomiting/photophobia, and often has an aura.  It is commonly triggered by stress, hormonal changes or certain foods.  Temporal arteritis would be suspected in older patients with persistent headache, visual symptoms and jaw claudication; patients will often have a prominent temporal artery on examination. 

References

The correct answer is E – Organise an electrocardiogram (ECG)

ECG should be performed as soon as possible to look for presence of atrial fibrillation (AF), which would indicate a higher level of risk for Barry. Evidence of AF can be missed on examination, and AF can be paroxysmal.

The current guidelines indicate that “in pre-hospital settings, high risk indicators (e.g. crescendo TIA, current or suspected AF, current use of anticoagulants, carotid stenosis or high ABCD² score) can be used to identify patients for urgent specialist assessment”.

The provisional diagnosis is a transient ischaemic attack (TIA) and rapid further assessment and management should be undertaken, ideally with transfer to a stroke unit initially.  Medication would not usually be commenced until some brain imaging has been done (computed tomography or magnetic resonance imaging) to ensure there is no intracranial haemorrhage.  A mini mental state examination is unlikely to change management initially.  Checking INR and coagulation studies would be important at some stage, but would not be the highest initial priority.

References

The correct answer is C – Offer 2-yearly PSA testing

The PSA can be used as a risk predictor in those younger than 50 years (it is not screening) but should only be considered in those >45 years at average risk after discussion of risks and benefits.

The PSA result is >75th percentile but < 95th percentile for age. This indicates he has a 3-4 fold increased risk of prostate cancer and should be offered 2-yearly PSA testing.

A PSA <75th percentile indicates no increased risk and therefore no further testing until 50 years.

Investigation would only be appropriate if the PSA was >95th percentile for age. The guidelines do not recommend the use of PSA velocity or PHI test, except in the context of research, as it does not improve the specificity of the PSA test. There is very little evidence for whether free-to-total PSA% improves specificity in men aged under 50 years of age. A repeat PSA and free-to-total PSA is only required if the PSA is between 3 ng/ml and 5.5 ng/ml in men ≥50 years.

References

The correct answer is D – Streptoccocal pneumonia

The clinical presentation suggests community acquired pneumonia (CAP), which is in the majority of cases is caused by streptococcus pneumonia. The other diagnoses are all possible.

Usually there are risk factors present for legionella e.g. chronic lung disease, smoking, diabetes, end-stage kidney disease etc, or there may be evidence of an outbreak locally. It often presents as severe CAP.

Melioidosis (Burkholderia pseudomallei) and Acinetobacter baumanii are important causes of CAP in tropical Australia but usually are associated with risk factors including alcoholism, diabetes, chronic renal disease or chronic obstructive pulmonary disease (COPD).

Atypical pneumonia especially Mycoplasma pneumonia is common in adolescents and young adults, and is often associated with upper respiratory tract symptoms. 

Viral pneumonia is usually identified by culture and influenza needs to be considered based on season.

References

The correct answer is C – Echocardiograph

While a usual workup should include an ECG and CXR, the echocardiograph is the definitive test for the diagnosis of chronic heart disease.

An echocardiogram is an essential investigation in patients with a diagnosis of heart failure, to evaluate cardiac chamber volumes, LV wall thickness, LV systolic and diastolic function, RV systolic function, intracardiac filling pressures, valve structure and function, pulmonary artery pressure, and pericardial disease. However, if the diagnosis is unclear following initial clinical assessment and an echocardiogram cannot be arranged in a timely fashion, measurement of plasma natriuretic peptide levels is recommended. It is often used in Emergency departments to distinguish between heart failure and non-heart failure shortness of breath. It is a useful 'rule-out' test.

Clinical symptoms are not sufficient to make the diagnosis of chronic heart failure, and clinical signs (if present) are unreliable, especially in the obese, elderly and those with pulmonary disease. The ECG is seldom normal, but changes can be non-specific, and a normal chest X-Ray does not exclude the diagnosis.

References

The correct answer is B – Recurrence does occur in approximately 30-40% of children with simple febrile convulsions

Recurrence rates of febrile convulsions depend on the age of the child at the time of first convulsion 12-month-old - 50% recurrence rate, 2 years old - 30% recurrence rate.

The risk of epilepsy is approximately 1% (similar to population risk). Risk factors for epilepsy include a family history of epilepsy, any neurodevelopmental delay, prolonged or focal febrile seizures or febrile status epilepticus. The risk of epilepsy with one risk factor present is 2% and rises to 10% with more than one risk factor.

Reduction of fever using paracetamol or tepid sponging has not been shown to reduce the risk of further febrile convulsions. Paracetamol may be used for pain or discomfort, but is not a preventive measure. Tepid sponging for the treatment of fever is not recommended because it causes discomfort and can also induce cutaneous vasoconstriction, shivering and sympathetic activation.

Referral to a paediatrician may be appropriate if the parents are very anxious, but is usually not necessary. It should be considered for complex febrile convulsions.

References

The correct answer is E – Progesterone subcutaneous implant ('Implanon')

Long acting reversible contraception (LARC) options have the lowest real-life failure rates. This includes the hormonal IUD (Mirena), copper IUDs, and the hormonal implant (Implanon). The Contraceptive CHOICE project showed that women who used non-LARC were 20 times more likely to have an unintended pregnancy.

In Australia in 2015, a study identified that there was a low uptake of LARC. Barriers include norms, misconceptions, bodily consequences, access issues, lack of control of hormones entering the body and health professionals’ confidence and available support in LARC insertions.  (Garrett C et al. 2015)

References

The correct answer is D – She should have another chlamydia test 3 months after treatment to detect re-infection

Chlamydia is commonly asymptomatic in women, and immunity to new infection is not provided by previous infection.  It is recommended that another chlamydia test is performed at 3 months to check the patient has not become re-infected.

Other options:

• All sexual partners from the past 6 months should be traced and treated (not 2 months).
• Non pregnant patients should be treated with azithromycin 1g PO stat OR doxycycline 100mg bd for 7 days, and should abstain from sex until 7 days after treatment is complete. 
• Test of cure is not generally necessary unless patient is pregnant, or in the case of rectal chlamydia.  

References

The correct answer is D – Take a detailed dive history

This is likely to be barotrauma of the ear, which is divided into:

1. outer ear – due to a canal stenosis from blocked cerumen, foreign body, tight fitting wetsuit or drysuit hood. A relative vacuum is created on descent causing oedema and haemorrhagic vesiculation of the canal
2. middle ear - occurs when there is dysequilibrium between the middle ear and ambient pressure or as alternobaric vertigo (AV) which is thought to arise from asymmetrical equalization of middle ear pressure transmitted via the oval and round window membranes.
3. inner ear - occurs when pressure changes are transmitted to the inner ear from the middle ear space or cerebral spinal fluid (CSF), resulting in inner ear haemorrhage, labyrinthine membrane tear, or perilymphatic fistula (PLF). It may result from either an 'explosive' or 'implosive' force

Inner ear decompression sickness (IEDCS) can resemble inner ear barotrauma but is a much more severe condition which is likely to require recompression.

A more detailed dive history will help clarify if this is barotrauma or IEDCS.

The treatments provided are all appropriate for types of different barotrauma:

• Outer ear barotrauma - Reassurance and restricted diving and/or flying
• Middle ear barotrauma - Advise the use of topical nasal steroids and decongestants
• Inner ear barotrauma - Arrange hospital admission +/- surgery

References

The correct answer is A – Arrange Helicobacter pylori antibody testing

Vitamin B12 deficiency is common in refugees, and there is also an increased risk in strict vegans, and patients with autoimmune gastritis, gastrectomy and other bowel surgery.  The presence of Helicobacter pylori infection should be checked as infection is common in refugees and can lead to B12 malabsorption. Testing can be by serum H. Pylori antibodies (if they haven’t had treatment), breath test or stool antigen. Giardia lamblia infection should also be tested as it too can give rise to B12 deficiency in refugees with chronic infection.

Treatment consists of IM hydroxycobalamin 1000 mg at least weekly for 3 weeks (some sources say 2nd daily for 2 weeks) then maintenance dose would generally be 1000 mg then monthly for 3 months with monitoring to assess if B12 levels return to normal after any treatment for H Pylori or Giardia lamblia. If pernicious anaemia is diagnosed then treatment is lifelong. Oral supplementation can be effective but much higher doses are needed and it is generally less practical than intramuscular replacement. It is not known if these preparations would be appropriate for refugees who are Vitamin B12 deficient.

Patients should be encouraged to eat animal source food (meat, seafood, dairy, eggs) if possible and fortified cereals for dietary Vitamin B12.

Potassium should be monitored during treatment as hypokalaemia can occur. Reticulocyte response will generally be evident on bloods in 7-10 days, and mean cell volume will usually normalise by 8 weeks so it is suggested that FBC and reticulocytes be checked at 7-10 days then again at 8 weeks.

References

The correct answer is B – Decrease oestrogen dose

Strategies to reduce breast tenderness with the combined oral contraceptive pill are to reduce oestrogen and/or reduce the progesterone dose. A change of the progesterone used to drospirenone can also be effective.

Generally, the combined pill should be taken for three cycles to allow for common adverse effects to settle, however Heidi has been on the combined pill for 4 months now and her symptoms are unlikely to resolve after this time without a change to the pill combination.

References