Thursday, 1 December 2016

Tutorial 1st. December 2016

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1 December 2016.

22
EMQ. Early pregnancy complications. Diagnoses to exclude
23
SBA. Progestogen-only implants
24
SBA. Caldicott guardian
25
EMQ. Stolen notes
26
EMQ. Risk management

22.         EMQ Early pregnancy. Diagnoses to exclude.
Lead-in.
The following scenarios relate to early pregnancy.
For each, select the diagnosis you most want to exclude.
Pick one option from the option list.
Scenario 1.
A 35-year-old primigravida is seen in the EPU with vaginal bleeding and severe left iliac fossa pain. The pregnancy occurred after four cycles of IVF and embryo transfer was performed six weeks ago. Her β-hCG is >1,000 iu/l. An ultrasound scan showed an intra-uterine pregnancy of an appropriate size for the gestation. Normal fetal heart activity was noted. No adnexal masses were seen.
Scenario 2.
A 25-year-old woman with known PCOS is seen in the early pregnancy unit after an episode of slight vaginal bleeding. Her LMP was 10 weeks ago. An ultrasound scan shows an intra-uterine pregnancy with CRL of 6 mm. No fetal heart activity is seen.
Scenario 3.
A GP phones for advice. She is conducting her morning surgery. A nulliparous woman at 6 weeks’ gestation has returned from France where she has enjoyed the local food, particularly unpasteurised soft cheese and pork meats. She has presented with diarrhoea and mild abdominal pain. A β-hCG is 25 iu/l. She is concerned about listeriosis and toxoplasmosis, about which she has read.
Scenario 4.
A 30-year-old parous woman attends the EPU with vaginal bleeding and lower abdominal pain. An ultrasound scan shows a 30 mm. intra-uterine sac but no evidence of fetal heart activity.
Scenario 5.
 A 45-year-old para 6 is admitted to the A&E department with 6 weeks’ amenorrhoea. A β-hCG is positive. She complains of retrosternal pain and has a history of heartburn and acid reflux. Her BMI is 30. She smokes 40 cigarettes daily and has COAD.
Option list.
A.           Complete miscarriage.
B.           Incomplete miscarriage.
C.           Missed miscarriage.
D.          Pregnancy in a uterine horn.
E.           Ectopic pregnancy.
F.           OHSS.
G.          Ovarian torsion.
H.          Ovarian cyst accident.
I.            Hydatidiform mole.
J.            Listeriosis.
K.           Toxoplasmosis.
L.           Crohn’s disease
M.         Ulcerative colitis.
N.          Duodenal ulceration.
O.          Pulmonary embolism.
P.           Pneumothorax.
Q.          Coronary thrombosis.
R.           None of the above.

23.         Progestogen-only Implants.
Abbreviations.
ENG:  etonorgestrel
HFW: hormone-free week
LNG:   levonorgestrel
Question 1.
Lead-in
Pick the best option from the list below in relation to the hormone in Nexplanon.
Option List
A.       
68 mg. ENG
B.       
100 mg. ENG
C.       
100 mg. LNG
D.       
150 mg. LNG
E.        
50 mg. ENG + 100 mg. LVG
Question 2.
Lead-in
How does Nexplanon act as a contraceptive?
        I.            mainly by inducing anovulation
      II.            mainly by altering cervical mucus to the detriment of sperm transport
    III.            mainly by thinning the endometrium, preventing implantation
    IV.            mainly by inducing loss of libido
Choose the best option from the list below.
Option List
A.       
I
B.       
I + II
C.       
I + III
D.       
II + III
E.        
III + IV
Question 3.
Lead-in
What is the age range, if any, for which Nexplanon is licensed in the UK?
Option List
A.       
15 – 50 years
B.       
18 – 40 years
C.       
18 – 45 years
D.       
20 – 50 years
E.        
None of the above.
Question 4.
Lead-in
A woman who is not in the licensed age range requests a Nexplanon. How should the advising doctor proceed?
Option List
A.       
Advise her about alternative licensed contraceptive methods, but decline to insert Nexplanon
B.       
Advise her about alternative licensed contraceptive methods and insert Nexplanon
C.       
Fit her with a LNGIUS
D.       
Refer her to a colleague who fits anyone who asks with a Nexplanon
E.        
None of the above

Question 5.
Lead-in
Which, if any, of the following statements best describes the pregnancy rate for women using Nexplanon are true?
Option List
A.       
The pregnancy rate is < 1 per 1,000 women during 3 years of use
B.       
The pregnancy rate is < 5 per 1,000 women during 3 years of use
C.       
The pregnancy rate is < 10  per 1,000 women during 3 years of use
D.       
The pregnancy rate is 10-20 per 1,000 women during 3 years of use
E.        
None of the above
Question 6.
Lead-in
Which, if any, other implants are licensed in the UK?
Option List
A.       
Implanon
B.       
Norplant
C.       
Norplant-2
D.       
Jadelle
E.        
None of the above
Question 7.
Lead-in
What are the main differences between Nexplanon and Implanon?
Pick the most suitable answer from the list below.
Option List
A.       
The dosage was increased from 60 to 68 mg. etonorgestrel
B.       
The dosage was increased from 150 – 175 mg. levonorgestrel
C.       
Barium sulphate was added to Nexplanon to make it radio-opaque
D.       
The number of rods was reduced to 2
E.        
None of the above
Question 8.
Lead-in
What problems is the new applicator designed to minimise?
        I.            non-insertion
      II.            deep insertion
    III.            difficulty with one-handed insertion
    IV.            difficulty with left-handed insertion
      V.            difficulty with insertion in very thin women.
Option List
A.       
I + II + III + IV
B.       
I + II + III + IV + V
C.       
II + III
D.       
II + III + IV
E.        
II + III + IV + V
Question 9.
Lead-in
How long is Nexplanon licensed for?
Option List
A.       
1 year
B.       
2 years
C.       
3 years
D.       
5 years
E.        
10 years
Question 10.
Lead-in
What does NICE recommend that patients be told about bleeding patterns with Nexplanon?
        I.            menstrual bleeding may cease
      II.            menstrual bleeding may become prolonged
    III.            bleeding may become more frequent
    IV.            menstrual bleeding may become less frequent
      V.            intermenstrual bleeding can be a problem in the first 6 months
Option List
A.       
I + II + III
B.       
I + II + III + IV
C.       
II + III + IV + V
D.       
I + III + IV
E.        
I + III + IV + V
Question 11.
Lead-in
What information should women be given about the effect of Nexplanon on pain?
Option List
A.       
Dysmenorrhoea may increase
B.       
Dysmenorrhoea may decrease
C.       
Mittelschmerz is likely to cease
D.       
Pain due to endometriosis is likely to decrease
E.        
Dyspareunia is likely to be alleviated
Question 12.
Lead-in
A 25-year old nulliparous woman has been found to have a few spots of endometriosis in the pouch of Douglas at laparoscopy for pelvic pain. She wishes to avoid pregnancy for 5 years but then wishes to have two children. She has read an article suggesting that a progesterone-only implant provides high levels of contraceptive efficacy and good results in suppressing endometriosis. What advice will you give?
Option List
A.       
Recommend a low-dose COC and tricycling as the best means of suppressing endometriosis plus providing effective contraception
B.       
Recommend a low-dose COC taken continuously as the best means of suppressing endometriosis plus providing effective contraception
C.       
Recommend Nexplanon as the best means of suppressing endometriosis plus providing effective contraception
D.       
Recommend Depot-Provera as the best means of suppressing endometriosis plus providing effective contraception
E.        
None of the above
Question 13.
Lead-in
When can a Nexplanon be inserted with no need for additional contraception  in a woman with regular menstrual cycles and no contraindication to its use?
Option List
A.       
Up to and including day 3 of menstruation
B.       
Up to and including day 5 of menstruation
C.       
Up to and including day 7 of menstruation
D.       
Never
E.        
None of the above
Question 14.
Lead-in
A healthy 25 year-old-woman is recovering well from a normal delivery. She is not breastfeeding and wishes to start Nexplanon.
Option List
Pick the best statement from the list below.
A.       
No additional contraception is needed if Nexplanon is inserted by day 7
B.       
No additional contraception is needed if Nexplanon is inserted by day 14
C.       
No additional contraception is needed if Nexplanon is inserted by day 21
D.       
No additional contraception is needed if Nexplanon is inserted by day 28
E.        
No additional contraception is needed if Nexplanon is inserted by day 42
Question 15.
Lead-in
A healthy 20-year-old woman wishes to switch from a COC to Nexplanon. What rules apply to the need for additional contraception?
I
If insertion takes place on day 1 of the HFW, no additional contraception is needed.
II
If insertion takes place on day 5 of the HFW, additional contraception is needed for 7 days.
III
If insertion takes place in week 2 after the HFW, no additional contraception is needed.
IV
If insertion takes place in week 3 after the HFW, no additional contraception is needed.
Option List
A
I
B
I + II
C
I + II + III
D
II + III + IV
E
I + II + III + IV
Question 16.
Lead-in
I
Women switching from a POP to Nexplanon should be advised that additional contraception is required for 7 days.
II
Women switching from a POP to Nexplanon should be advised that additional contraception is not required.
III
Women switching from a LNGIUS to Nexplanon should be advised that additional contraception is required for 7 days.
IV
Women switching from a LNGIUS to Nexplanon, should be advised that additional contraception is not required.
Option List
A
I + III
B
I + IV
C
II + III
D
II + IV
E
none of the above
             
24.         Caldicott Guardian.
Question 1.
Lead-in
Which of the following statements is true of the Caldicott Guardian?
Option List
A
it is a large lizard, unique to the Galapagos Islands
B
it is the Trust Board member responsible for child safeguarding procedures
C
it is the Trust Board member responsible for complaint procedures
D
it is the person within a Trust responsible for patient confidentiality in relation to information
E
it is the person within a Trust responsible for dealing with bullying
Question 2.
Lead-in
The Caldicott Report identified 6 basic principles. What are they?
Option list.
There is none. Imagine that there is information about you stored on the computers of the local NHS Trust. What conditions would you want to lay down about sharing of that information within the Trust, with other NHS organisations and with non-NHS organisations?
Question 3.
Lead-in
The Caldicott Report made numerous recommendations. Which was particularly important for major NHS organisations such as Trusts?
Option List
A.       
the need to appoint a Caldicott Guardian
B.       
the need to create a Caldicott Register
C.       
the need to create a Caldicott Police Department
D.       
the need to create a link between the Caldicott Department and the DOH
E.        
none of the above.
Question 4.
Lead-in
What is the definition of the key role deriving from the answer to question 3?
Option List
There is none lest it give you the answer to question 3!

25.         Stolen case-notes.
Lead-in.
A SpR1 has been asked to carry out an audit and 50 sets of case-notes are to be used.
He is given 49 sets of notes and a day in which to go through them and extract the necessary data.
This he does in the hospital.
The final set of notes cannot be found initially, but are found two weeks later.
The doctor is given the notes on a Friday afternoon as he is leaving for home.
He decides to take the notes home to extract the data.
On the way home he stops at his favourite supermarket.
When he emerges, his car has been stolen with the notes inside.
He reports the theft to the police.
Abbreviations.
BMA:       British Medical Association
CG:           Caldicott Guardian
MDU:      Medical Defence Union
NPSA:      National Patient Safety Agency             
Question 1.
The SPR informs you, the Clinical Director, on the Monday when he returns to work.
What action will you take?
Option list.
A
Report events to the Caldicott Guardian
B
Report events to the Chief Executive
C
Report events to the General Medical Council
D
Report events to the NHSLA as a “never event”
E
Report events to the NHSLA as a “serious incident”
F
Report events to the NPHSLA as a “never event”
G
Report events to the NPSLA as a “serious incident”
H
Report events to the Risk Management Team
I
Report events to the Root Cause Analysis Team
J
Report events to the Trust Information Management Committee
K
Suspend the doctor until a full investigation has been done
Question 2.
What action will you take to deal with the SpR?
Option list.
A.       
Suspend the doctor until a full investigation has been done
B.       
Report the doctor to the Medical Director
C.       
Report the doctor to the Postgraduate Dean
D.       
Report the doctor to the General Medical Council
E.        
Report the doctor to the NHSLA
F.        
Report the doctor to the Caldicott Guardian
G.       
Report the doctor to the Trust Board member responsible for safeguarding
H.       
Report the doctor to the BMA
I.         
Report the doctor to the MDU
J.         
None of the above
Question 3.
What action will you take in relation to the patient whose notes are missing?
Option list.
A.       
Ask the Caldicott Guardian to deal with it
B.       
Ask the Chief Executive to deal with it
C.       
Ask the hospital’s legal team to deal with it
D.       
Ask the patient’s GP to deal with it
E.        
Discuss with the legal team, inform the patient, discuss the implications and keep her fully-up-to-date
F.        
Tell all those who know about the incident to discuss it with no one else, particularly the patient
G.       
None of the above

26.        
Lead-in.
The following scenarios relate to risk management / disciplinary procedures.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Abbreviations.
DOH:    Department of Health.
FY:         Foundation year trainee

Option list.
A.             allow the practice to continue
B.             stop the practice until a full investigation has been done
C.             stop the practice permanently
D.            arrange an investigation by a senior consultant from another hospital
E.             decide the practice does not involve added risk
F.              declare the risk to be acceptable
G.            cancel admissions for surgery
H.            arrange adverse incident analysis
I.               arrange audit
J.               arrange research
K.             arrange a formal warning for the doctor
L.              arrange retirement for the doctor
M.          arrange dismissal for the doctor
N.            consult the on-call consultant
O.            consult the Clinical Director
P.             consult the Educational Supervisor / College Tutor
Q.            consult the Medical Director
R.             consult the Chief Executive
S.              consult the Postgraduate Dean.
T.             consult the hospital’s lawyer
U.            write to Her Majesty at Buckingham Palace
V.             consult your Medical Defence Body
W.          consult the British Medical Association
X.             consult the RCOG
Y.             report the matter to the GMC
Z.              allow return to work
AA.        allow return to work, but offer support
BB.         arrange a “return to work” package specific to the doctor
CC.         none of the above

Scenario 1
You are the Clinical Director. 1 62-year-old Consultant colleague has been off work for 8 weeks with a broken arm sustained in a skiing accident. He sends you a certificate from his specialist to say that he is now fit to return to work. He indicates that he wishes to return to work immediately. What action will you take?
Scenario 2
You are the Clinical Director. 1 62-year-old Consultant colleague has been off work for 8 weeks with a severe bereavement reaction to the suicide of a family member. He sends you a certificate from his GP to say that he is now fit to return to work. He indicates that he wishes to return to work immediately. What action will you take?
Scenario 3
You are the Clinical Director. 1 62-year-old Consultant colleague has been off work for 6 months after having a coronary thrombosis. He sends you a certificate from his specialist to say that he is now fit to return to work. He indicates that he wishes to return to work immediately. What action will you take?
Scenario 4
You are the Clinical Director. A 62-year-old Consultant has returned to work after four months’ sick leave after a coronary thrombosis. He has three cases on his first operating list and all have complications reported by the Sister on the gynaecology ward. What action will you take?
Scenario 5.
A Consultant has been in her first consultant post for two months. Three of the four patients on a single operating list develop post-operative wound infections. What action will you take?
Scenario 6.
You have recently been appointed Clinical Director. A consultant has been in post for ten years and prefers to operate with the same nurse assistant. No complications have been reported. What action will you take?
Scenario 7.
You are the Clinical Director. A consultant has an operating  list in a peripheral unit 20 miles from the main hospital. There is no resident doctor with post-operative care being provided by nurses. The cases dealt with on the list traditionally were minor, day-cases.  You have been told that the consultant, who was appointed 6 months ago, has recently been doing hysterectomies and prolapse repairs to get the waiting list down.  What action will you take?
Scenario 8.
You are the Clinical Director. The blood bank informs you that there is a problem with supplies and fully cross-matched blood cannot be guaranteed for tomorrow’s arranged surgical cases.
What action will you take?
Scenario 9.
You are the on-call SpR. It is 8 pm. The blood bank informs you that there is a problem with supplies and fully cross-matched blood cannot be guaranteed for tomorrow’s arranged surgical cases.
What action will you take?
Scenario 10.
An SpR is half an hour late for starting his duties on three occasions in one week. His consultant wishes to have this dealt with as a disciplinary matter to “nip it in the bud” and teach him a lesson. He reports it to you, the Clinical Director asking you to discipline the doctor. What action will you take?
Scenario 11
An SpR gets into an argument with the senior midwife on the labour ward and in the heat of the moment slaps her across the face. You are the Clinical Director and the matter is reported to you next day.
Scenario 12
Your consultant is the Clinical Director and a nasty man. You apply 6 months in advance for study leave for the week before the written part of the Part Ii MRCOG exam. He tells you that he plans to go on holiday at that time and you are not going to get any leave. In addition, he tells you that if you complain about this he will give you a terrible reference and tell all his consultant friends that you are a waste of space in order to ruin your career. What action can you take?
Scenario 13
A SpR fails an OSATS, but falsifies his records to indicate that it has been completed satisfactorily. You are the Educational Advisor and this is brought to your attention. What action will you take ?>
Scenario 14
You are the Clinical Director. A SpR2 uploaded reflective practice putting himself in a good light after a case which had been handled sub-optimally by him. What action will you take?
Scenario 15
You are an FY2 and assist the senior consultant at a hysterectomy. The operation goes well initially, but then there is a lot of bleeding and a ureter is cut. The consultant urologist attends and repairs the ureter. The woman bleeds vaginally that evening and is taken back to theatre by another consultant and ends up in the ICU. You became convinced during the operation that you could smell alcohol on the consultant gynaecologist’s breath. What are your responsibilities?
Scenario 16
When do you need to inform the Consultant on-call? There is no answer on the option list – make your own list.
Scenario 17
When do you need to inform the Clinical Director? There is no answer on the option list – make your own list.
Scenario 18
When do you need to inform the Medical Director? There is no answer on the option list – make your own list.
Scenario 19
When do you need to inform the GMC? There is no answer on the option list – make your own list.
Scenario 20
What are the roles of the BMA and MDU? There is no answer on the option list – make your own list.
Scenario 21
What are the differences between verbal and written warnings? There is no answer on the option list – make your own list.
Scenario 22.
Lead-in.
You are the SpR for the delivery unit. During a quiet moment you head for the staff room adjacent to the operating theatre for a coffee. As you pass the anaesthetic room you hear loud snoring. You look in and find the on-call anaesthetic registrar unconscious on his back on the floor with an anaesthetic mask by his face attached to a cylinder of nitrous oxide.
What action will you take?
Pick one option from the option list.
Option list.
  1.  
call for help from the senior midwife
  1.  
go back to the labour ward and pretend that nothing has happened
  1.  
go back to the labour ward and inform the senior midwife
  1.  
phone the GMC
  1.  
phone the on-call consultant anaesthetist
  1.  
phone the on-call consultant obstetrician
  1.  
phone the police
  1.  
put the anaesthetist in the recovery position and remove the mask
  1.  
none of the above
Scenario 23.
Lead-in.
You are the SpR for the delivery unit. During a quiet moment you head for the staff room adjacent to the operating theatre for a coffee. As you pass the anaesthetic room you hear loud snoring. You look in and find the on-call anaesthetic registrar unconscious on his back on the floor with an anaesthetic mask by his face attached to a cylinder of nitrous oxide.
What action will you take next?
Pick one option from the option list.
Option list.
  1.  
call for help from the senior midwife
  1.  
go back to the labour ward and pretend that nothing has happened
  1.  
go back to the labour ward and inform the senior midwife
  1.  
phone the GMC
  1.  
phone the on-call consultant anaesthetist
  1.  
phone the on-call consultant obstetrician
  1.  
phone the police
  1.  
put the anaesthetist in the recovery position and remove the mask
  1.  
none of the above
Scenario 24.
Lead-in.
You are the Clinical Director. It is the morning after the events in scenarios 22 and 23.
The on-call consultant obstetrician comes to see you are reports what has happened.
What action will you take?
Pick one option from the option list.
Option list.
  1.  
discuss the case with the Chief Executive
  1.  
discuss the case with the Medical Defence Union
  1.  
discuss the case with the Medical Director
  1.  
discuss the case with the Medical Director
  1.  
discuss the case with the most senior person in the personnel department
  1.  
discuss the case with the Postgraduate Dean
  1.  
report the anaesthetic registrar to the GMC
  1.  
resign from being Clinical Director to avoid stress
  1.  
summon the anaesthetic registrar to give him a severe telling-off