Monday, 17 November 2014

Tutorial 17th. November 2014


17 November 2014.

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1.        
How to prepare
17
November
2014
2.        
RCOG sample obstetric SBA
17
November
2014
3.        
RCOG sample gynaecological SBA
17
November
2014
4.        
Mode of inheritance EMQ
17
November
2014
5.        
Cancer staging EMQ
17
November
2014

How to prepare.
This is on the website:
You need to start thinking about OSCE preparation. Read the stuff on the website about communication skills and start practising.
I mentioned the Bolton OSCE course and its particular merits. What I had not checked was its pass rate, which was 100%.
This is even better than the 90% for those who used the tutorials.
Practice SBAs from the RCOG website.
We went through the sample SBAs from the RCOG website. These tend to turn up in the exam, so make sure you can answer them.
You will learn most by answering the questions before reading the answers.
I put them on to highlight the fact that most of the EMQs and SBAs will come from guidelines, both Green-tops and NICE, SIPs and other stuff from the RCOG website and recent TOG articles.
You can find the sample SBAs here:

EMQs.

I chose these EMQs to make a couple of points: last-minute revision and having a good revision system.
Detail such as cancer staging tends to fade fast from memory, highlighting the need to have a week before the exam for last-minute revision.
You can't start doing a lot of new work at this time - do it now, so that you are revising it then.
Information such as rare syndromes is also hard to remember - you need a good revision system so that you can go over it time and again until it sticks.

Send you answers for the following and I will send mine.

Ca Cx staging.

Lead-in.
The following scenarios relate to cervical cancer staging.
For each, select the most appropriate staging.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Scenario 1.
A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 2 mm and 6 mm in width. The resection margins are tumour-free. There is no evidence of spread outside the uterus. She is nulliparous and wishes to retain her fertility.
Scenario 2.
A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 5 mm and 6 mm in width. The resection margins are tumour-free. There is no evidence of spread outside the uterus. She is nulliparous and wishes to retain her fertility.
Scenario 3.
A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 5 mm and 6 mm in width. The resection margins are not tumour-free. There is no evidence of spread outside the uterus. She is nulliparous and wishes to retain her fertility.
Scenario 4.
A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 6 mm and 3 cm in width. The resection margins are tumour-free. There is no evidence of extension outside the uterus. She is nulliparous and wishes to retain her fertility.
Scenario 5.
A woman of 25 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 6 mm and 5 cm in width. The resection margins are tumour-free. She is nulliparous and wishes to retain her fertility.
Scenario 6.
A woman of 38 has a cone biopsy. The histology report shows squamous cell carcinoma penetrating to a depth of 4 mm and 6mm in width. The resection margins are tumour-free. An MR scan shows involvement of the lymphatic nodes in the left of the pelvis.
Scenario 7.
A woman of 45 has carcinoma of the cervix. It extends into the parametrium, but not to the pelvic side-wall. It involves the upper 1/3 of the vagina. There is MR evidence of para-aortic node involvement.
Scenario 8.
A woman of 55 has carcinoma of the cervix. It extends to the pelvic side-wall. It involves the upper 1/3 of the vagina. She has a secondary on the end of her nose.
Scenario 9.
A woman of 55 has carcinoma of the cervix. It involves the bladder mucosa.
Scenario 10.
A woman of 35 has a proven cancer of the cervix with extension into the right parametrium, but not to the pelvic side-wall. Left hydroureter and left non-functioning kidney are noted on IVP and there is no other explanation for the findings. Cystoscopy shows bullous oedema of the bladder mucosa.
Scenario 11.
A woman of 25 has a cone biopsy. It shows malignant melanoma. The lesion invades to a depth of 3 mm and is 5 mm in width. The margins of the biopsy are clear. There is evidence of lymphatic vessel involvement. There is no evidence of spread outside the uterus.

Option list.
Micro-invasive cervical cancer.
Stage Ia1
Stage Ia2
Stage Ia3
Stage Ib1
Stage Ib2
Stage Ib3
Stage IIa
Stage IIb
Stage IIc
Stage IIIa
Stage IIIb
Stage IIIc
Stage IVa
Stage IVb
Stage IVc
Stage Va
Stage Vb
Stage Vc
None of the above.

This question illustrates the problems surrounding staging. If you are not a cancer specialist, it is not something that you think about very often, if ever. So you have to put it into your list of things to revise in the days before the exam. If you haven’t started this list, do so now.

Mode of inheritance.

Lead-in.
The following questions relate to the mode of inheritance – some not quite to “mode”, but I am sure you will indulge me!
For each question, write what you think is the mode of inheritance or appropriate answer. There is no option list.
Comment.
You are expected to know a lot of basic genetics and it is hard to remember the details. A list to go over in the days before the exam makes sense. Use this one and add anything else you can think of – and let me know of your additions so I can add them to this list. Don’t add a load of rare syndromes – you will just end up confused. But add anything that you know has featured in the exam.

List of questions.
1.       achondrogenesis.
2.       achondroplasia.
3.       acute fatty liver of pregnancy (AFLP).
4.       adreno-genital syndrome
5.       adult polycystic kidney disease.
6.       androgen insensitivity syndrome.
7.       albinism.
8.       Angelman syndrome.
9.       Apert syndrome.
10.   Becker muscular dystrophy.
11.   Beckwith-Wiedemann syndrome.
12.   BRCA 1.
13.   BRCA2.
14.   Cavanan syndrome.
15.   Charcot-Marie-Tooth disease.
16.   chondrodystrophy.
17.   Christmas disease.
18.   congenital adrenal hyperplasia.
19.   Cowden syndrome.
20.   cri-du-chat syndrome. 
21.   cystic fibrosis.
22.   Dandy-Walker syndrome.
23.   developmental dysplasia of the hip.
24.   Down’s syndrome.
25.   Duchenne muscular dystrophy
26.   Dwarfism. See isolated growth hormone deficiency.
27.   Edward’s syndrome.
28.   exomphalos.
29.   Ehlers-Danlos syndrome
30.   Fanconi anaemia
31.   Fitz-Hugh-Curtis syndrome.
32.   Fragile X syndrome.
33.   galactosaemia.
34.   gastroschisis.
35.   glucose-6-phosphatase deficiency. G6PD.
36.   glucose-6-phosphate dehydrogenase deficiency. G6PDD.
37.   haemochromatosis.
38.   haemosiderosis..
39.   haemophilia A:
40.   haemophilia B:
41.   Hunter syndrome.
42.   Huntington’s disease.
43.   ichthyosis.
44.   isolated growth hormone deficiency.
45.   juvenile polycystic kidney disease.
46.   Kallmann’s syndrome.
47.   Klinefelter’s syndrome.
48.   Lesch Nyhan syndrome.
49.   Lynch syndrome (HNPCC).
50.   Malignant hyperthermia.
51.   Maple syrup urine disease. 
52.   Marfan’s syndrome.
53.   Martin-Bell syndrome.
54.   Mayer-Rokitansky-Kuster-Hauser syndrome.
55.   McCune-Albright syndrome.
56.   Meckel-Gruber syndrome.
57.   Medium-chain acyl-CoA dehydrogenase deficiency.
58.   mucopolysaccharidosis type I.
59.   Myotonic dystrophy.
60.   neurofibromatosis.
61.   Niemann-Pick disease.
62.   Noonan syndrome.
63.   ocular albinism.
64.   osteogenesis imperfecta.
65.   osteoporosis.
66.   Patau’s syndrome.
67.   Perrault syndrome.
68.   phenyketonuria.
69.   polydactyly.
70.   porphyria.
71.   Potter’s syndrome.
72.   Prader-Willi syndrome. 
73.   Prune-belly syndrome
74.   pyruvate kinase deficiency.
75.   sickle cell disease.
76.   spherocytosis.
77.   Syndrome X.
78.   Tay-Sach’s disease.
79.   Thalassaemia.
80.   Thrombophilia.
81.   Triple X syndrome.
82.   Turner’s syndrome.
83.   Swyer’s syndrome.
84.   Uniparental disomy.
85.   VACTERL.
86.   vitamin D resistant rickets
87.   von Willebrand’s disease.
88.   A mother has spina bifida. What is the risk of a child being affected? 
89.   A mother has had a child with spina bifida, what is the risk of the next child being affected?  
90.   A mother has had two children with spina bifida. What is the risk of the next child being affected?
91.   A mother has grand-mal epilepsy. What is the risk of her child having epilepsy?
92.   A mother and her partner both have grand-mal epilepsy. What is the risk of their child having epilepsy?
93.   A mother has insulin-dependent diabetes mellitus. What is the risk of a child being affected?
94.   A mother has congenital heart disease. What is the risk of a child being affected? 
95.   A mother takes lithium for bi-polar disorder throughout her pregnancy. What is the risk of the child having congenital heart disease?
96.   A mother has a nuchal translucency scan at 11 weeks. The result is 6 mm. What is the risk of the fetus having congenital heart disease?


Monday, 3 November 2014

Tutorial 2 November 2014

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I have not had time to write answers for all of the following, but will do my best to do so this week. Keep an eye on Dropbox.

We talked about forceps. We got distracted talking about Kielland’s forceps and did not discuss the “wandering” method of application. We had discussed this on the 6th. October, so you can listen to that. Basically you apply the forceps as though it was an OA position. So, the first blade goes over the face or the back of the head and is gradually “wandered” during the process to that it lies over the side of the head. The question is whether to go round the face or the back of the head. The obvious answer is to avoid the face, but it is the wrong answer. Look at the head of a baby born after being OP or OT. The moulding is all at the back of the head which is greatly extended. So you don’t go via that route.


54
Viva. Systematic Review.
55
Role-play. Caesarean section on maternal request.
56
Viva. Drug licensing.
57
Role-play. Optimising patient benefit from surgery.
58
Role-play. Pudendal block.

54.   Viva. Systematic Review.
Candidate's Instructions.
This is a viva station.
You are to tell the examiner what systematic review is and how it is done.

55.   Role-play. Caesarean section on maternal request.
         This is a role-play station.

56.   Viva. Optimising patient benefit from surgery.
         Candidate’s instruction.
         
57.   Viva. Drug licensing.
 Candidate's Instructions.
This is a viva station.
The examiner will ask you 10 questions.

58.   Role-play.
         Candidate’s instruction.
 This is a role-play station.
         You are an SpR in year 5. You have been asked to instruct a new FY1 about pudendal block.  This is a follow-on from a teaching session she had with you about instrumental delivery.



Tutorial 30 October 2014

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49
EMQ. Puerperal mental health.
50
Role-play. Maternity Dashboard.
51
Viva. Risk management. Laparoscopic injury.
52
Role-play. Laparoscopic injury.
53
Role-play. Androgen insensitivity syndrome.

49.   Puerperal mental health.
             
Lead-in.
The following scenarios relate to puerperal mental illness.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
If I had put all the answers into the option list it would have been enormous. So there are quite a few where you need to decide what your answer would be. Opting for “none of the above” is not exercising your brain – make sure you come up with an answer.

Option list.
a.         arrange admission to hospital under Section 5 of the Mental Health Act
b.         send a referral letter to the perinatal psychiatrist requesting an urgent appointment.
c.          send an e-mail to the perinatal psychiatrist requesting an urgent appointment.
d.         phone the community psychiatric team.
e.         phone the on-call psychiatrist.
f.          arrange to see the patient in the next ante-natal clinic.
g.         arrange to see the patient urgently.
h.         send a referral letter to the social services department.
i.           phone the fire brigade.
j.           phone the police.
k.         there is no such thing.
l.           4 weeks
m.       6 weeks
n.         12 weeks
o.         26 weeks
p.         1 year
q.         <1%
r.          1-5%
s.          5-10%
t.          10-20%
u.         25%
v.         50%
w.       60%
x.         70%
y.         80%
z.          True
aa.     False
bb.     none of the above.

Scenario 1
What is the internationally agreed classification for postpartum psychiatric disease?
Scenario 2
What time limits does DSM-IV use for postpartum psychiatric disorders?
Scenario 3
What time limits does ICD-10 use pro postpartum psychiatric disorders?
Scenario 4
What clinical classification would you use in a viva or SAQ?
Scenario 5
What is the incidence of suicide in relation to pregnancy and the puerperium?
Scenario 6
What are the main conditions associated with suicide in pregnancy and the postnatal period?
Scenario 7
Most suicides occur in single women of low social class who have poor education. True / False
Scenario 8
The preferred method of suicide reported in the MMR was drug overdose.  True / False.
Scenario 9
When are women with Social Services involvement particularly at risk of suicide.
Scenario 10
Which women have the highest risk for puerperal psychosis and what is the risk?
Scenario 11.
What is the risk of puerperal psychosis for a primigravida with BPD?
Scenario 12
What is the risk of PP in a woman with no history of psychiatric illness but who has a FH of PP?
Scenario 13
Should screening include the identification of women with no history of psychiatric illness but who has a FH of PP?
Scenario 14
What do the Confidential Enquiries into Maternal Deaths say about the use of the term “postnatal depression”?
Scenario 15
Women with schizophrenia have a ≥ 25% risk of puerperal recurrence. True / False
Scenario 16
If lithium therapy for BPD is stopped in pregnancy, there is an increased risk of severe puerperal illness. True / False.

50.   Maternity Dashboard.
         This is a role-play station.
         You are a 5th. year SpR. You have been asked to explain the Maternity Dashboard and its uses to a new FY1.

51.   Viva. Risk management. Laparoscopic injury.
Candidate’s instructions.
You performed laparoscopy yesterday. On inserting the laparoscope you realized that the bowel had been injured. You have been asked to write a report about the incident for the risk management committee.
You have 15 minutes to prepare the contents of your report. Then you will present them to an examiner at the next station.

52.   Role-play. Laparoscopic injury.
Candidate’s instructions.
You are the SpR from the previous question. You are seeing the patient the following morning. Your task is to explain what happened and anything else you feel is relevant.

53.   Role-play. Androgen insensitivity syndrome.
       This is a role-play station.
The patient is Euphemia Johnstone. She is 17 years old. She attended the gynaecology clinic 1 month ago with primary amenorrhoea.
Clinical examination showed an apparently normal young woman with normal breast development but absent pubic and axillary hair. The external genitalia appeared normal. Vaginal examination was not attempted.
She has come today for the results of the ultrasound scan and blood results.
The scan has shown absence of the uterus. There are no ovaries in the pelvis. There are bilateral groin masses that could be gonads.
The blood tests which were done are reported as:
FSH: normal.
LH:   normal.
Prolactin: normal.
Karyotype. 46XY.

Your tasks are to explain the results and their implications and to answer her questions.

Monday, 27 October 2014

Tutorial 27 October 2014

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Tonight we are having a tutorial on how to criticise a paper by Julie Morris.
The papers she will discuss have been e-mailed and are on Dropbox.
She usually takes about an hour.
Depending on the time remaining, we will try to get through the following topics.

45
How to criticise a paper. Julie Morris.
46
Viva. Non-medical skills.
47
Role-play. Write a prescription
48
Role-play. Fragile X syndrome.

45.   How to criticise a paper. Julie Morris.
         Julie talks about 2 papers that I will send in advance of the tutorial. You won’t get much from the session unless you have read the papers and tried to do a critique.

46.   Candidate's Instructions. Non-medical skills.
         This is a viva station.
It is an unstructured viva and the examiner will not ask any questions other than to confirm your candidate number.
Trainees spend years developing the medical skills necessary to perform well as a consultant. But there are other skills that a good consultant possesses. Outline your views on what these are and how they may be acquired.

47.   Write a prescription.
See separate sheet.

48.   Fragile X syndrome.            
Candidate’s instructions.
You are about to see Mary White who has been booked in with her first pregnancy by the midwife in the antenatal clinic. The midwife has asked you to see her as Mary has told her that there is a family history of Fragile X syndrome.
Your task is to discuss Fragile X syndrome and the implications for Mary, the pregnancy and her father.



Thursday, 23 October 2014

Tutorial 23 October 2014

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40
Viva.          Uterine inversion.
41
Role-play. Stillbirth. 6/52 follow-up.
42
Role-play. Sterilisation request.
43
Role-play. Cochrane.
44
Role-play. Neonatal screening.

40.   Uterine inversion.
Candidate's Instructions.
This is a viva station.
The examiner will ask you 7 questions.
1.     What are the risk factors for uterine inversion?
2.     What are the clinical features?
3.     What is the differential diagnosis?
4.     What are the diagnostic features?
5.     What would be your immediate management?
6.     What would be your subsequent management?
7.     What would be your management after the uterus has been replaced and the woman has been resuscitated?

41.   Role-play. Stillbirth. 6/52 follow-up.
Candidate's Instructions.
This is a role-play station.
This is a roleplay station.
Mrs. Brown has come for follow-up 6/52 after delivery of a stillborn baby.
Reduced fetal movements had been noted at 38 weeks.
She was admitted and FDIU was confirmed.
The scan also showed IUGR.
She opted for induction of labour.
Prostin was used and she had a normal delivery 12 hours later.
Effective analgesia was provided by epidural anaesthesia.
There were no complications.
Full investigation, including PM, was normal apart from the birthweight, which was < 5th. centile.
Your task is to explain the results and advise about the next pregnancy.

42.   Role-play. Sterilisation request.
Candidate's Instructions.
You are a 5th. year SpR. You are about to see Mrs. Mary Fecund in the gynaecology clinic. There is a referral letter from the GP.
Read the letter and then conduct the consultation with Mrs. Fecund as you would do in the clinic in your hospital.

Perfect Health Centre,
Paradise Lane,
Slagheap.
SLH 678.
Your ref: BRI 07/54843.

Re. Mary Fecund,
The Shoe, High Street, Slagheap.
Dear Doctor,
Please see Mrs Fecund who has too many children. She wishes to be sure she has no more and has asked to be sterilised – one of her friends was sterilised recently which has put her in the mood to have it done.
Yours sincerely,
Dr. John Williams.

43. Role-play. Cochrane.            
Candidate’s instructions.
You are a SpR in year 5.
1.     You have been asked to explain the Cochrane Collaboration and Cochrane Reviews to a new trainee. The trainee will ask 7 questions suggested by the Consultant.
2.     Explain the main elements and findings of the Forest plot below.



44.   Role-play. Neonatal screening.
Candidate’s instructions.
You are a SpR in year 5.
You are in the antenatal booking clinic and about to see Mary Eccles. She has been booked in by a midwife at 10 weeks’ gestation and all is well. She has recently arrived in the UK from the USA and asked about the routine neonatal screening that is done in the UK. She will be having the baby in the UK.