Monday, 22 September 2014

Tutorial 22 September 2014

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7
Abusive GP letter.
22
September
2014
8
Roleplay. Break bad news. Primigravida. 8 weeks. Some bleeding.
Scan = IUP. CRL = 12 mm. No fetal heart activity. Counsel.
22
September
2014
9
Roleplay. Woman attends for pre-pregnancy counselling as she plans her 1st. pregnancy. Her sister recently had a baby with Down’s syndrome.
22
September
2014
10
Viva station.
You are a year 4 SpR and have been asked by your consultant to assess Mrs Mimi Dresden on the orthopaedic ward.
She is 85 years old and has been admitted from the nursing home where she lives with a hip fracture after a fall. She has Alzheimer’s disease. The nursing staff have noted blood on her underwear.
The examiner will ask you a series of questions:
   what history will you take?
   what examination will you perform and your reasoning?
   what investigations will you arrange?
   what management will you propose?
22
September
2014

The Medical Centre,
Green Lane,
Broadforth-on-Sea.

Your ref: BRI 07/54843.
Re. Jennifer Houseside,
45 The Maltings,
Broadforth-on-Sea.

Dear John,
It was wonderful to see you and Mary again on Saturday and so kind of you to invite us. The meal was up to Mary’s high standards and the company convivial. We may be getting older, but Mary’s fragrant beauty does not diminish.
Please see this woman who complains of unacceptably heavy periods. She is huge, malodorous and is more like a whale than a human being. One can see how the family name originated! I do not envy you the task if you feel that you have to examine her.
She is as stupid as she is fat. I doubt that she has more than one brain cell. If she has, they are not inter-connected. She talks incessantly and brings complete sense of the old adage “empty vessels make most sound”. Despite the vacuum in her cranium she is awash with idiotic ideas most of which she gets from her monumentally stupid mother. She is too thick for logical reasoning to have any impact on her ridiculous views – you might as well attempt a philosophical discussion with your dog.
The father is a dirty, unpleasant sort and I would not be surprised if incest had contributed to their low IQs. If the human race has advanced though evolution and natural selection, what on earth were their ancestors like?
They are social parasites. None of the family has ever worked and they live off Social Security payments. I have had the misfortune to have to do the occasional home visit to various members of the family. They live in disgusting squalor. If they were pigs their living conditions would give the species a bad name. Theirs are houses in which you wipe your feet on the mat as you leave and not as you enter and pray that you never have to visit again. I am sure the Court of Human Rights would regard a second visit as a cruel and unnatural punishment. They always ask you to sit, but I would not wish to ruin my clothes. Their hospitality also extends to offering cups of tea. Perish the thought! I would rather take my chance with neat hemlock.
Despite living on Social Security payments, they have the latest widescreen TVs and associated DVD equipment. The husband looks to me as though he indulges in low-level crime, probably shoplifting. He is a shifty character whom you would not trust and I strongly advise you to make sure that all valuables are locked up and out of sight when he or any of her family is around. One brother is in prison for theft to feed a heroin habit, which typifies the contribution this family makes to the greater good. Her sister is said to be a prostitute and I would think it true. Certainly she has a lot of children and I doubt that any of them have the same father or that she would be able to enlighten them as to who their fathers might be. She (the sister) is a regular visitor to the Sexually Transmitted Diseases clinic where she displays a surprising range of conditions needing treatment. She is a one-woman update course for the staff ensuring they are abreast of all aspects of STDs. I was going to say she was a one-woman refresher course, but there is nothing refreshing about her. The sister is as fat and ugly as my patient, making one marvel at the mentality of her clients. I cannot imagine how anyone would want to come within smelling distance of her, far less have sexual relations and pay for the privilege. Some exotic form of masochism, I guess.
I wish you well in your dealings with her and apologise for sending such an unpleasant lump to your clinic. This is a family that makes you wish the Abortion Act could be made retrospective!
Please do your best not to send her back to see me.


Yours sincerely,

Candidate’s instruction.
You are the SpR in the gynaecology clinic.
List the things that are wrong with this letter.
What action would you take after seeing the patient with regard to the letter?

Examiner’s instructions.
If the candidate says the would take the letter to the consultant, ask what action they would take if they were the consultant.

































Thursday, 18 September 2014

Tutorial 18 September 2014

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Send your answers and I'll send mine.

OSCE topics. Autumn 2014


1.
How to prepare. Picking a course.
10
March
2014
2.
Barriers to communication. What communication barriers exist between me and the trainees attending the tutorial? We can use this as a basis to consider the communication problems between us, patients and colleagues.
10
March
2014
3.
Roleplay: how to introduce oneself.
10
March
2014
4.
Labour ward scenario 1.
10
March
2014
5.
Labour ward scenario 2.
10
March
2014
6.
Roleplay: Healthy, nulliparous. Brother with cystic fibrosis. Pre-pregnancy counselling.
10
March

Labour Ward Scenario 1. Sunday 13.00 hours.

Labour Ward.

1
Mrs JH
Primigravida. T+8. In labour. 6 cms.
2
Mrs AH
Primigravida at T. In labour. 5 cms.
3
Mrs. BH
Para 2. 30 days post delivery. 2ry. PPH > 1,000 ml. Hb. 9.3.
4
Mrs SB
Primigravida. 32/52 gestation. Admitted 30 minutes ago. Abdominal pain + 200 ml. bleeding. Nephrostomy tube in situ - not draining since this morning. Low placenta on 20 week scan.
5
Mrs KW
Para 1. In labour. Cx. 5 cm. Ceph at spines.
6
Mrs KT
Para 0+1. 38 weeks. SROM. Ceph 2 cm. above spines. Clear liquor.
7
Mrs TB
Para 1. T+4. Clinically big baby. Cx fully dilated for 1 hour. Type 1 decelerations.
8
Mrs RJ
Primigravida. Epidural. RIF pain. Cx fully dilated for 1 hour. Shallow late decelerations. OT position. Distressed ++. BP /105. ++ protein. Urine output 50 ml in past 4 hours.
9
Mrs KC
Transfer from ICU. 13 days after delivery of 32 week twins. Laparotomy on day 7 for pelvic pain and fever. Infected endometriotic cyst removed. IV antibiotics changed to oral.

Gynaecology ward.

8 major post operative cases who have been seen on the morning ward round and are stable. Husband of patient who has had Wertheim's hysterectomy asking to see a doctor for a report on the operation.

1
Mrs JB
10 week incomplete miscarriage. Hb. 10.8. Moderate fresh bleeding.
2
Ms AS
19 years old. Nulliparous. Just admitted with left iliac fossa pain. Scan shows unilocular 5 cm. ovarian cyst.

Medical staff:

Consultant at home. Registrar - you.
Senior House Officer with 12 months experience.
Registrar in Anaesthesia.
Consultant Anaesthetist on call at home.

Midwifery staff:
Senior Sister.           Trained to take theatre cases. Able to site IV infusions and suture episiotomies and tears.
3 staff midwives. 1 trained to take theatre cases. Two able to site IV infusions.
1 Community midwife looking after Mrs. KW.
2 Pupil Midwives.


Scenario 2.

Monday. 0900 hours.  You have just come on duty.

1
Mrs A
Para 0+0
25 yrs
41 weeks. In labour 12 hours. Cx 8 cm. No progress for 4 hours. "Dips" reported on CTG
2
Mrs B
Para 1+2
31 yrs
28 weeks. Just admitted. "Show" + contractions
3
Mrs C
Para 5+3
40 yrs
In labour 8 hours. Cx 6 cm. dilated
4
Mrs D
Para 1+3
27 yrs
37 weeks. Diabetes. Admitted ½ hour previously. Previous Caesarean section.
5
Mrs E
Para 1+2
32 yrs
40 weeks. Previous 9 lb. baby. In the second stage for 1 ½ hours.
6
Miss F
Para 0+0
15 yrs
34 weeks. Concealed pregnancy. In labour. Just admitted. Breech presentation
7
Mrs G
Para 1+2

26 weeks. Admitted with severe abdominal pain
8
Mrs H
Para 2+1

39 weeks. In early labour.
9
Mrs I
Para 1+0

Delivered two hours previously by Caesarean section for severe pre-eclampsia. Diastolic BP / 110. Urine output 50 ml. since delivery
10
Mrs J
Para 1+0

Normal delivery + PPH >1,500 ml. one hour ago


Medical staff:

Consultant:               in his Rooms.
You:                            Registrar.
Foundation Year 2  six months’ experience.
Registrar in anaesthetics.

Midwifery staff:

Senior Sister.
Two staff midwives.
One community midwife.
Two student midwives.

Thursday, 21 August 2014

Tutorial 21 August 2014

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31
EMQ. Germ cell and sex cord tumours
32
EMQ. Gestational Trophoblastic Disease (GTD)
33
EMQ. Haemophilia
34
EMQ. Headache
35
EMQ. Obstetric cholestasis 1
36
EMQ. Obstetric cholestasis 2
37
EMQ. PPH
38
EMQ. Puerperal mental illness
39
EMQ. Risk management 1
37
EMQ. Vulval conditions
79
A woman attends the A&E Department complaining that she has been raped. The A&E consultant says he has no experience in dealing with this problem and asks you to take care of the woman.
1. Discuss the risk management issues relating to such a case for the average DGH.  4 marks
2. Justify your immediate management.                                                                              10 marks 
3. Outline the subsequent management.                                                                               6 marks
80
With regard to Gestational Trophoblastic Neoplasia.
Outline the factors influencing prognosis.
81
A 73-year-old woman is referred with vault prolapse 5 years after hysterectomy.
1. Discuss the steps that can be taken during and after hysterectomy to reduce the risk of vault prolapse.                                           4 marks
2. Justify the history you will obtain.      4 marks
3. Evaluate the management options. 12 marks
82
A nulliparous woman notices reduced fetal movements at 37 weeks and phones the delivery unit for advice.
1. Outline the immediate management.    14 marks
2. Justify the subsequent management.       6 marks.
83
Home birth.
A woman books at 10 weeks’ gestation and states that she is keen to have a home birth.
1. What are the key legal issues in relation to home birth?                                            2 marks
2. Justify the history you will take.                                                                                           4 marks
3. Critically evaluate the advice you will give re the risks & benefits of home birth.   6 marks
4. Justify your management plan.                                                                                            8 marks
84
A primigravid woman attends the antenatal booking clinic at 5 weeks’ gestation. She smells strongly of alcohol. She admits to consuming at least ½ bottle of vodka each day.
1. Critically evaluate the public health advice available in the UK about alcohol and pregnancy.       
                                                                                                                   4 marks.
2. Critically evaluate screening for alcohol abuse in pregnancy.    4 marks.                                               
3. Critically evaluate the risks to the fetus and child of the mother who abuses alcohol in pregnancy.                                                                                                 6 marks.
4. Justify the management you would arrange for this patient.      6 marks.
85
Read the RCOG’s document on the maternity dashboard http://www.rcog.org.uk/womens-health/clinical-guidance/maternity-dashboard-clinical-performance-and-governance-score-card. I doubt it will come as an essay but it could be in the MCQs and EMQs.
Germ cell and sex cord tumours and substances secreted.
Lead-in.
The following scenarios relate to the substances that ovarian cell tumours usually secrete.
For each, select the most appropriate substance from the option list.
Each option can be used once, more than once or not at all.

Option List.
A.        None.
B.        a-fetoprotein.
C.        a-fetoprotein + hCG.
D.        a1-antitrypsin
E.         Androgen.
F.         Ascites.
G.       Walthard
H.        Ca125
I.          hCG.
J.          β-hCG
K.        Follicle stimulating hormone.
L.         Luteinising hormone.
M.      Oestrogen.
N.       Prolactin.
O.       Thyroxine sufficient to produce hyperthyroidism.
P.        Pleuritic fluid.
Q.       None of the above.

Scenario 1.
Mature cystic teratoma.
Scenario 2.
Granulosa cell tumour.
Scenario 3.
Sertoli-Leydig tumours.
Scenario 4 .
Brenner tumour.
Scenario 5.
Struma ovarii.
Scenario 6.
Embryonal carcinoma.
Scenario 7.
Polyembryoma.
Scenario 8.
Endodermal sinus tumour (Yolk sac tumour).
Scenario 9.
Dysgerminoma.
Scenario 10.
Primary ovarian choriocarcinomas.

Gestational Trophoblastic Disease (GTD)

Lead-in.
The following scenarios relate to gestational trophoblastic disease.
For each, select the number that best fits the scenario.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Scenario 1.
What is the incidence of GTD in the UK pregnant population?
Scenario 2.
A woman had a complete mole in her first pregnancy. She is pregnant for the second time. What is the risk that it is another molar pregnancy?
Scenario 3.
A woman has had two molar pregnancies. What is the risk of molar pregnancy if she becomes pregnant again?
Scenario 4.
What is the risk of persistent GTD after a complete mole?
Scenario 5.
 What is the risk of requiring chemotherapy after a complete mole?
Scenario 6.
What is the risk of persistent GTD after a partial mole?
Scenario 7
What is the risk of requiring chemotherapy after a partial mole?
Scenario 8
What is the risk of requiring chemotherapy with hCG level > 20,000 i.u. one month after evacuation?
Scenario 9
What is the overall risk of requiring chemotherapy after molar pregnancy in the UK?
Scenario 9
What is the risk of requiring chemotherapy in the USA compared with the UK?
Scenario 10
What is the risk of molar pregnancy at age 15 compared to age 30?
Scenario 11
What is the risk of molar pregnancy at age 45 compared to age 30?

Option list.

  1.  
100%

  1.  
20%

  1.  
< 20%

  1.  
15%

  1.  
<15%

  1.  
< 10%

  1.  
10%

  1.  
5%

  1.  
2.5%

  1.  
1.5%

  1.  
0.5%

  1.  
1 in 35

  1.  
1 in 55

  1.  
1 in 65

  1.  
1 in 700

  1.  
1 in 1,000

  1.  
Ö64

  1.  
pr2

  1.  
increased

  1.  
reduced

  1.  
increased by a factor of 2

  1.  
increased by a factor of 5

  1.  
increased by a factor of 10

  1.  
increased by a factor of 20

  1.  
increased by a factor of 30

  1.  
increased by a factor of > 100


Haemophilia.

Lead-in.
The following scenarios relate to haemophilia A, factor VIII deficiency  (HA).
For each, select the most appropriate answer  from the option list.
Each option can be used once, more than once or not at all.

Scenario 1.
A woman attends for pre-pregnancy counselling. Her brother has haemophilia A. What is her risk of being a carrier?
Scenario 2 .
A woman attends for pre-pregnancy counselling. Her father has haemophilia A. What is her risk of being a carrier?
Scenario 3.
If she is tested and found to be a carrier, what tests will you arrange for her partner?
Scenario 4.
If she is a carrier, what is the risk to her male offspring?
Scenario 5.
If she is a carrier, what is the risk to her female offspring?
Scenario 6.
If she is  a carrier and her partner has haemophilia A, what are the risks to their female offspring?
Scenario 7.
If she is a carrier and her partner has haemophilia A, what are the risks to their male offspring?

Headache in pregnancy.

Lead-in.
The following scenarios relate to headache in pregnancy.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Option list.
  1. abdominal migraine
  2. analgesia overuse headache aka medication overuse headache
  3. bacterial meningitis
  4. benign intracranial hypertension
  5. BP check
  6. cerebral venous sinus thrombosis
  7. chest X-ray
  8. cluster headache
  9. severe PET / impending eclampsia
  10. malaria
  11. meningococcal meningitis
  12. methyldopa
  13. methysergide
  14. migraine
  15. MRI brain scan
  16. nifedipine
  17. nitrofurantoin
  18. pancreatitis
  19. sinusitis
  20. subdural haematoma
  21. subarachnoid haemorrhage
  22. tension headache
  23. ultrasound scan of the abdomen

Scenario 1.
A 40-year-old para 3 is admitted at 38 weeks by ambulance with severe headache of sudden onset. She describes it as “the worst I’ve ever had”. Which diagnosis needs to be excluded urgently?
Scenario 2.
A 32-year-old para 1 has recently experienced headaches. They are worse on exercise, even mild exercise such as walking up stairs. She experiences photophobia with the headaches. Which is the most likely diagnosis?
Scenario 3.
A woman returns from a sub-Saharan area of Africa. She develops severe headache, fever and rigors. What diagnosis should particularly be in the minds of the attending doctors?
Scenario 4.
A woman at 37 weeks has developed headaches. They particularly occur at night without obvious triggers. They occur every few days and she then has
Scenario 5.
A primigravida has had headaches on a regular basis for many years. They occur most days, are bilateral and are worse when she is stressed. What is the most likely diagnosis?
Scenario 6.
A woman complains of recent headaches at 36 weeks. The history reveals that the headaches started soon after she began treatment with a drug prescribed by her GP. Which is the most likely of the following drugs to be the culprit: 7.                methyldopa, methysergide, nifedipine and Nitrofurantoin?
Scenario 7
A woman is booked for Caesarean section and wishes regional anaesthesia. She had severe headache due to dural tap after a previous Caesarean section. She wants to take all possible steps to reduce the risk of having this again. Which of epidural and spinal  anaesthesia has the lower risk of causing dural tap headache?
Scenario 8
A 25-year-old primigravida complains of headaches which started two weeks before when she attends for her 20 week scan. There is no significant history of previous headache. The pain occurs behind her right eye and she describes it as severe and “stabbing” in nature. The pain is so severe that she cannot sit still and has to walk about. She has noticed that her right eye becomes reddened and “watery” during the attack and her nose is “runny”. The attacks have no obvious trigger and mostly occur a few hours after she has gone to sleep. The usually last about 20 minutes. She has no other symptoms. She smokes 20 cigarettes a day but does not take any other drugs, legal or otherwise. What is the most likely diagnosis?
Scenario 9
A woman has a 5-year history of unilateral, throbbing headache often preceded by nausea, visual disturbances, photophobia and sensitivity to loud noise. What is the most likely diagnosis?
Scenario 10
A primigravida is admitted at 38 weeks complaining of headache, abdominal pain and a sensation of flashing lights. What would be the appropriate initial investigation?
Scenario 11
A woman with BMI of 35 attends for her combined Downs syndrome screening test. She complains of pain behind her eyes. The pain is worst last thing at night before she goes to sleep or if she has to get up in the night. She has noticed she has noticed horizontal diplopia on several  occasions. She has no other symptoms. Examination shows papilloedema.
Scenario 12
A grande-multip of 40 years experienced sudden-onset, severe headache, vomited several times and then collapsed, all within the space of 30 minutes. She is admitted urgently in a semi-comatose state. Examination shows neck-stiffness and left hemi-paresis.
Scenario 13.
What did the MMR include as “red flags” for headache in pregnancy?

Obstetric cholestasis. (OC). Definition & Diagnosis.
Lead-in.
The following scenarios relate to the definition and diagnosis.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Abbreviations.
gamma GT: gamma-glutamyl transferase
GTG:      RCOG’s Green-top Guideline No. 43. April 2011.
OC:         obstetric cholestasis.

Suggested reading.
The GTG is “must read”.  It is also dealt with in MCQ paper 1, question 41. I don’t think you need to read anything more.

Option list.
A.             true
B.             false
C.             don’t be daft
D.             pruritus of pregnancy with no other explanation which is associated with abnormal LFTs, raised bile acids and pale stools, all of which resolve postnatally
E.              pruritus of pregnancy with no other explanation which is associated with abnormal LFTs, ± raised bile acids and pale stools, all of which resolve postnatally
F.              pruritus of pregnancy with no other explanation which is associated with abnormal LFTs, ± raised bile acids, all of which resolve postnatally
G.            pruritus of pregnancy with no other explanation which is associated with abnormal LFTs (using pregnancy-specific ranges), ± raised bile acids and pale stools, all of which resolve postnatally
H.             pruritus of pregnancy with no other explanation which is associated with abnormal LFTs (using pregnancy-specific ranges), ± raised bile acids, all of which resolve postnatally
I.               levels do not usually rise in pregnancy
J.               mostly originates in the placenta
K.             levels vary with the time of day
L.              no information in the GTG
M.           none of the above

Scenario 1.
The international definition of OC was agreed at a conference in Tokyo in 1985.
Scenario 2.
What is the GTG’s definition of OC?
Scenario 3.
What is the incidence of pruritus in pregnancy?
Scenario 4.
Hepatitis B and C, but not hepatitis A, may cause pruritus and abnormal LFTs in pregnancy.
Scenario 5.
Infection with the Ebstein Barr virus may cause pruritus and abnormal LFTs in pregnancy.
Scenario 6.
The cytomegalovirus may cause pruritus and abnormal LFTs in pregnancy.
Scenario 7.
The herpes zoster virus may cause pruritus and abnormal LFTs in pregnancy.
Scenario 8.
Chronic active hepatitis and secondary biliary cirrhosis are included in the GTG’s list of conditions to be considered in the differential diagnosis.
Scenario 9.
Bilirubin levels are normally elevated in the early stages of OC and remain elevated until the condition resolves after delivery.
Scenario 10.
Liver function tests become abnormal as soon as the pruritus is noted.
Scenario 11.
Levels of bile acids commonly rise significantly after meals making fasting levels mandatory for diagnosis.
Scenario 12.
The upper limit of normal for transaminases, gamma GT and bile acids is about 20% lower in pregnancy.
Scenario 13.
Once a diagnosis of OC has been made, tests of liver function should not be repeated until the puerperium
Scenario 14.
LFTs should be checked weekly until they have returned to normal after delivery of the baby in a case of OC.
Scenario 15.
Once a diagnosis of OC has been made, the activated partial thromboplastin time (APTT) should be measured and a full coagulation screen done if it is prolonged.
Scenario 16.
Delivery at 37 weeks should be recommended because of the risk of FDIU in the later weeks of pregnancy.
Scenario 17.
What additional pre-labour monitoring of fetal welfare is advisable in the third trimester?
Scenario 18.
Prophylactic steroids should be offered at 28 weeks because of the risk of spontaneous premature labour.


Obstetric cholestasis. (OC). Prevalence.

Lead-in.
The following scenarios relate to the prevalence of OC.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Abbreviations.
GTG:     RCOG’s Green-top Guideline No. 43. April 2011.
OC:        obstetric cholestasis.

Option list.
A.        0.1%
B.        0.5%
C.        0.7%
D.        1 – 1.2%
E.         1.2% to 1.5%
F.         1.5 – 2%
G.       2.4%
H.        3 – 3.5%
I.          5%
J.          7%
K.        15%
L.         white
M.      brown
N.       blue-green
O.       red-brown, striped
P.        no information in the GTG
Q.       none of the above

Scenario 1.
What is the overall prevalence in the UK population?
Scenario 2.
What is the overall prevalence in the Indian and Pakistani Asian populations?
Scenario 3.
What is the overall prevalence in Scandinavia?
Scenario 4.
What is the overall prevalence in Chile?
Scenario 5.
What is the overall prevalence in Araucanian Indians?
Scenario 6.
What is the overall prevalence in Eskimos?
Scenario 7.
What is the incidence of pruritus in pregnancy?
Scenario 8.
What colour of eggs do Araucanian chickens lay?

Postpartum haemorrhage.
Lead-in.
The following scenarios relate to post-partum haemorrhage.
For each, select the appropriate answer.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Abbreviations.
APH:      antepartum haemorrhage.
GTG:      Green-top Guideline No 52. “Prevention and Management of PPH.”
i.m.        intramuscularly.
PPH:      postpartum haemorrhage.
s.c.         subcutaneously.

Scenario 1.
A 34 year-old, para 4 delivers the first twin and bleeds loses 250 ml. of fresh blood. A further 300 ml. is lost after the delivery of the second baby. What is the classification of the bleeding?
Scenario 2.
A 25 year-old nulliparous woman delivers a stillborn baby at 22 weeks. 1,000 ml. of fresh bleeding occurs in the next 2 hours. What is the classification of the bleeding?
Scenario 3.
A 45 year-old primigravid woman is readmitted at 10 weeks post-delivery as she has bled continuously for 3 weeks. What is the classification of the bleeding?
Scenario 4.
A 34 year-old woman passes placental tissue and 500 ml. of fresh blood 14 weeks after delivery of her second child. What is the classification of the bleeding?
Scenario 5.
Which drug is recommended by the GTG for routine use in the active management of the 3rd. stage?
Scenario 6.
By what amount does active management using syntometrine reduce the risk of 1ry. PPH?
Scenario 7.
What is the definition of primary PPH?
Scenario 8.
What is the definition of secondary PPH?

Option list.
Bleeding from the birth canal ≥ 500 ml.
Bleeding from the birth canal ≥ 500 ml. up to 24 hours after delivery of the placenta.
Bleeding from the birth canal ≥ 500 ml. from 24 hours after delivery of the placenta until 6 weeks later.
Bleeding from the birth canal ≥ 1,000 ml. from 24 hours after delivery of the placenta until 6 weeks later.
Bleeding from the birth canal ≥ 500 ml. from 24 hours after delivery of the baby until 12 weeks later.
Bleeding from the birth canal ≥ 1,000 ml. from 24 hours after delivery of the baby until 12 weeks later.
Abnormal bleeding from the birth canal from 24 hours after delivery of the baby until 12 weeks later.
APH.
1ry. PPH.
Major primary PPH.
2ry. PPH.
Syntocinon 5 i.u. i.m.
Syntometrine 5 mg. i.m.
Misoprostol 10 mg. orally.
Gemeprost 40 mg. rectally.
Vasopressin 5 i.u. s.c.
20%
40%
60%
80%
None of the above.

Puerperal mental illness.
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.

Risk Management / Disciplinary procedures.

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.

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
A SpR2 uploaded reflective practice putting him in a good light after a case which had been handled sub-optimally by him.
Scenario 15
You are a  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?
Scenario 17
When do you need to inform the Clinical Director?
Scenario 18
When do you need to inform the Medical Director?
Scenario 19
When do you need to inform the GMC?
Scenario 20
What are the roles of the BMA and MDU?
Scenario 21
What are the differences between verbal and written warnings?

Vulval conditions.
Lead-in.
The following scenarios relate to vulval conditions.
Choose the most likely vulval condition from the option list.
Each option can be used once, more than once or not at all.

Scenario 1.
A 22 year-old woman attends the colposcopy clinic after 2 smears showing minor atypia. The cervical appearances are of aceto-white with punctation. 
Scenario 2.
A 60-year old woman has an erythematous rash of the vulva extending to the inner thighs. A similar rash is noted under the breasts. She is not known to have diabetes.
Scenario 3.
A woman attends the gynaecology clinic with a vulval rash. It has a “lacy” appearance. 
Scenario 4.
A 35-year old woman attends is noted to have a vulval fistula. She has a history of episodic diarrhoea. 
Scenario 5.
A 25-year old woman attends the gynaecology clinic with a history of intense vulval itching and soreness. The appearances are of diffuse erythema with excoriation. Diabetes, candidiasis and other local infections have been eliminated by the GP. 
Scenario 6.
A 35-year old woman attends the gynaecology clinic with vulvitis. She also has a scalp rash. Clinical examination shows scaly, pink patches with signs of excoriation. Skin samples grow Malassezia ovalis.
Scenario 7.
A 40-year old woman has evidence of chronic vulval ulceration. She has recently been seen by a dermatologist for mouth ulceration and has been started on thalidomide.
Scenario 8.
An African woman of 35 years attends the gynaecology clinic. She has a ten-year history of chronic vulval ulceration. Examination shows multiple, tender vulval and pubic subcutaneous nodules, some of which have ulcerated.
Scenario 9.
A Caucasian woman of 29 years attends the gynaecology clinic with a chronic vulval rash. Examination shows erythematous areas with clearly defined margins and white scaly patches. 
Scenario 10.
A 30-year old woman attends the gynaecology clinic with vulval itching. Examination shows erythema of the labia minora and perineum. Full-thickness biopsy shows abnormal cell maturation throughout the epithelium with increased mitotic activity.


Option list.
A.
Acne.
B.
Behçet’s syndrome.
C.
Candidiasis.
D.
CIN 3
E.
CIN1
F.
Crohn’s disease.
G.
Dermatitis.
H.
Eczema.
I.
Genital warts.
J.
Hidradenitis suppurativa.
K.
Leprosy.
L.
Lichen planus
M.
Lichen sclerosis
N.
Lymphogranuloma venereum
O.
Normal skin.
P.
Psoriasis.
Q.
Seborrhoeic dermatitis.
R.
Type 1 diabetes mellitus
S.
Type 2 diabetes mellitus
T.
Ulcerative colitis.
U.
VIN III.