Thursday, 22 September 2016

Tutorial 22 September 2016



Contact us.

22 September 2016

15
Roleplay. Booking. Previous SB.
16
Viva. Breastfeeding.
17
Roleplay. Pre-pregnancy counselling. Phenylketonuria.
18
Roleplay. Pre-pregnancy counselling. Dad recently diagnosed with Huntington’s.

15. Roleplay. Previous stillbirth.
Candidate's Instructions.
You are an SpR in the booking clinic. You are about to see a woman who is at 10 weeks gestation in her second pregnancy. Her first baby was stillborn.
She has had all the routine booking, including investigations, dealt with by the midwife who has asked you to see her to advise about her first pregnancy and its implications for the management of this pregnancy.
Take an appropriate history, advise about the necessary investigations and how the history of stillbirth will influence the management of the pregnancy.

16. Viva. Breastfeeding.
Candidate’s instructions.
This is a viva station.
The examiner will ask you 7 questions.
                                                          
17. Viva. Phenylketonuria.
Candidate’s instructions.
You are the SpR in the pre-pregnancy clinic. Your consultant is off on sick leave and you are the most senior doctor in the clinic.
You are about to see Jane White who is planning her first pregnancy. Your task is to take a history and discuss the optimum management now and during pregnancy.

The GP letter reads:
Prime Health Practice,
Primetown,
Sussex.
0298766543.
Practice Manager:
Mrs Wilhelmina Bland.

Dear Doctor,
Please see Jane White, 35 years of age and planning her first pregnancy. Her health is good – she seems only to attend the Practice for routine checks such as cervical smears – the most recent of which was taken last year and was normal. From talking to her and examining her records, it is clear that she is very healthy and has always had good physical and mental health. Her social circumstances are good. The one thing of concern is that she told me she was on a diet in childhood supervised by the local paediatric team. She can’t recall what it was about and she stopped the diet at about the age of 14. Both of her parents are dead – her mother fifteen years ago at the age of 40 and her father two years ago in a RTA, so cannot shed light on what the diet was for. Fortunately, when I checked through her notes I came across correspondence indicating that the problem was phenylketonuria. I have told her that I am no expert in phenylketonuria and the implications for pregnancy, so have eschewed the temptation to provide any advice.
I look forward to receiving your expert report.
Dr. John Worthy.

18. Roleplay. Huntington’s chorea.
Candidate's Instructions.
You are the SpR in the pre-pregnancy counselling clinic.
Mary Smith has been referred.
The GP referral letter is brief. “Please see this woman who is considering becoming pregnant. Her father has Huntington’s chorea, about which I know very little.”
Your task is to take a history and advise about appropriate investigations.


Monday, 19 September 2016

Tutorial 19 September 2016


19 September 2016



11
Roleplay. Bleeding in early pregnancy.
12
Viva. Menozac website critique
13
Viva. Laboratory results
14
Roleplay. PMB.

11. Roleplay. Bleeding in early pregnancy.
Candidate's Instructions.
This is a role-play station. The role-player will act as the patient. An examiner will be present.
You are the SpR in the ante-natal clinic. The Consultant who was in clinic has been asked to assist her Consultant colleague in the labour ward theatre. She is unlikely to return for some time as the case is one of massive PPH and hysterectomy may be necessary.
One of the midwives asks you to see a patient who has just had a scan in the EPU.
She is primigravid and the gestation is 8 weeks. She has had some bleeding.
An ultrasound scan = IUP. CRL = 12 mm. No fetal heart activity. No adnexal masses.

12. Viva. Critique of HRT internet website.
Candidate's Instructions.
Patients may attend a consultation with information obtained from a website.
You must be able to provide a balanced critique of the information.
You have 12 minutes to read the document provided for this station.
Then you have 12 minutes with the examiner to detail your critique.
The document about the website is on Dropbox in the folder "Materials for the tutorials".

13. Viva. Laboratory results.
Candidate’s instructions.
Your consultant is on annual leave.
Her secretary has asked you to look through the following results and decide what administrative action should be taken in relation to each.

1
+ve MSSU at booking. No symptoms.
2
GTT at 34 weeks. Peak level 11.5.
3
FBC with ­ MCV at booking.
4
Thrombocytopenia at booking. 50,000.
5
Hydatidiform mole after evacuation of suspected miscarriage.
6
Histology after ERPC for incomplete miscarriage: no trophoblastic tissue.
7
Endometrial cancer: hysteroscopy: thickened endometrium. Histology: Anaplastic malignancy.
8
Endometrial cancer: MR scan: reaching serosa and upper endocervical canal.
9
Consultant does lap drainage of normal looking ovarian cyst. Malignant cells. Nulliparous. Wants children.
10
HVS: trichomonas.
11
Clue cells on smear. 12/52 pregnant.
12
Antenatal discharge: endocervical swab: chlamydia
13
Actinomyces on smear.
14
Herpes in pregnancy
15
Severe dyskaryosis on cervical smear at booking.
16
Primary infertility: FSH & LH ­ at 25 on day 3 of cycle.
17
Primary infertility. FSH 3, LH 12 on day 3 of cycle.
18
Treated with cabergoline for ­ prolactin and pituitary adenoma. 
19
3 cm. ovarian cyst. ­ Ca 125.

14. Roleplay. PMB.
Candidate’s Instructions.
You are an SpR in the “one-stop” PMB clinic. You are about to see a woman with bleeding some years since her menopause.
A 55 year old woman is referred by her General Practitioner.
Your task is to take an appropriate history and advise her about the investigations you feel are appropriate and why.
Referral letter from the General Practitioner.

Manor Lodge,
High Street,
Bestown. BE5 S00

Re: Mrs. Mary Smith,   Age 55.
5b High Street,
Bestown. BE5 SO1

Dear Doctor,
Please see Mrs. Smith who has had bleeding down below. It is a number of years since she reached the menopause.
Yours sincerely,
James Fewords,

General Practitioner.

Thursday, 15 September 2016

Tutorial 15 September 2016


15 September 2016

6
Viva. The examiner will ask you 2 questions about the part 3 exam.
7
Homework. Basic “blurbs” to write and practise. Setting the scene for breaking bad news, general pre-pregnancy counselling, dominant, recessive & x-linked inheritance etc.
8
Viva. Labour ward scenario 1.
9
Role-play. Woman attends for pre-pregnancy counselling as she plans her 1st. pregnancy. Her sister recently had a baby with Down’s syndrome.
10
Viva. The uses of MgSO4 in O&G.


8. 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. Early 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.

9. Roleplay. Pre-pregnancy counselling.
Candidate’s instructions.
You are the SpR in the gynaecology clinic. You have been asked to see Jenny Williams, who has come for pre-pregnancy counselling.
Letter from the General Practitioner.
5 High Street,
Deersworthy,
Kent.
DO9 1JY.

Re Mrs. J. Williams,
Manor Place,
Deersworthy.

Dear Dr.,
Please see this woman who is planning pregnancy. I understand that her sister has had a baby with Down’s syndrome.
Regards,
Dr. Jolly.

10. Viva. Use of MgSO4 in O&G
Candidate’s instructions.
This is a viva station about the uses of MgSO4 in O&G.
The examiner will not ask questions, prompt or otherwise assist. It is up to you to give as full an account of the uses as you can muster.


Monday, 12 September 2016

Tutorial 12th. September 2016



Welcome to the OSCE cycle as we prepare for the Part 3 exam in November.

12 September 2016

1
How to prepare. Picking a course. Communication skills partner
2
Urodynamics, CTG interpretation
3
Barriers to communication. What communication barriers exist between me and those attending the tutorial? We can use this as a basis to consider the communication problems between us, patients and colleagues.
4
Role-play: how to introduce oneself.
5
Role-play: Healthy, nulliparous. Brother with cystic fibrosis. Pre-pregnancy counselling.


Thursday, 25 August 2016

Tutorial 25th. August 2016.

Contact us.

If you want my versions of the answers, e-mail your answers to me. I'll then connect you to the answers, which are on Dropbox.

See "Contact us" above for my e-mail address.

25 August 2016.

80
EMQ. Puerperal mental illness
81
EMQ. Menopause. NG23. Definition & diagnosis
82
EMQ. Menopause. NG23. Management
83
SBA. Needle-stick and related injuries
84
SBA. Endometrial hyperplasia. GTG67

80.         EMQ.
Puerperal mental illness.
Lead-in.
The following scenarios relate to puerperal mental illness.
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 recent MMRs 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.
Scenario 17
You are the on-call SpR for obstetrics. A woman has just had a normal delivery of a 30 week baby that requires resuscitation. The mother says that the baby must be left alone and not resuscitated. The paediatric SpR and midwives are uncertain about what to do. What action will you take?
Scenario 18
You are the on-call SpR for obstetrics. The midwife on the postnatal ward phones for advice. A primigravida who delivered yesterday has stated that the baby is not hers and is refusing to care for it. What action will you take?
Scenario 19
You are the on-call Consultant in O&G. The community midwife has phoned for advice. She was asked to visit a primiparous woman who had a normal delivery seven days before. The husband reports that she has struck him several times. The woman tells her that voices have informed her that this man is not her husband and that she should drive him away in case he rapes her. What action will you take?
Scenario 20
You are the on-call Consultant in O&G. The community midwife has phoned. She has just been phoned by a woman who had a Caesarean section for breech presentation four weeks ago. She has been told by God that breech babies are the spawn of the Devil and she is going to the local multi-storey car park to jump off with the baby so that the baby cannot grow up and harm people and so that she cannot have more Devil babies. What action will you advise?

81. EMQ. Menopause NG23. Diagnosis & definitions.
Abbreviations.
AFC:      antral follicle count.
AMH:    anti-Müllerian hormone.
POF:      premature ovarian failure.
POI:       premature ovarian insufficiency.
Question 1.
Which adjective did NICE use in relation to ideal care in recommendation 1.1.1 of NG23?
Option List
A.       
best
B.       
holistic
C.       
individualised
D.       
personalised
E.        
privatised
Question 2.
What is the average age at the menopause?
Option List
A.       
49 years
B.       
50 years
C.       
51 years
D.       
52 years
E.        
53 years
Question 3.
What age limit is used for the diagnosis of premature ovarian insufficiency?
Option List
A.       
30 years
B.       
35 years
C.       
37 years
D.       
40 years
E.        
45 years
Question 4.
What is the approximate incidence of premature ovarian insufficiency?
Option List
A.       
0.1%
B.       
0.5%
C.       
1%
D.       
2%
E.        
5%
Question 5.
What is the definition of the perimenopause?
Question 6.
What is the definition of the postmenopause?
Question 7.
What is the definition of premature ovarian insufficiency?
Question 8.
A healthy physics teacher of 35 is diagnosed as menopausal. There is no obvious explanation. Which of the following conditions could be the undiagnosed hereditary cause?
Option List
A.       
Cystic fibrosis carrier status
B.       
Elliptocytosis
C.       
Fragile X carrier status
D.       
Galactosaemia
E.        
Polycythaemia vera
Question 9.
A healthy woman of 52 presents with amenorrhoea for 15 months and vasomotor symptoms. She is not taking any drugs. What tests should be done to confirm the diagnosis of the menopause.
Option List.
A.       
FSH
B.       
FSH & LH
C.       
FSH & oestradiol
D.       
AMH
E.        
None of the above
Question 10.
A healthy woman of 46 presents with vasomotor symptoms and irregular periods. She is not taking any drugs. What tests should be done to confirm the diagnosis of the menopause?
Option List.
A.       
FSH
B.       
FSH & LH
C.       
FSH & oestradiol
D.       
AMH
E.        
None of the above
Question 11.
Which tests does NICE say should not be used to diagnose the menopause and perimenopause in women > 45 years?
List of possible investigations.
A.       
AFCA
B.       
MH
C.       
CT scan of pituitary fossa
D.       
inhibin A
E.        
inhibin B
F.        
oestradiol
G.       
ovarian volume
H.       
prolactin
I.         
thyroid function tests
Question 12.
What does NICE recommend with regard to the use of FSH in relation to diagnosis of the menopause?
Question 13.
What does NICE recommend with regard to the use of FSH in relation to diagnosis of the perimenopause?
Question 14.
What does NICE say about the cost of FSH assay?
Question 15.
Which of the following statements, if any, are true in relation to the advice from NICE about the diagnosis of the menopause?
Option List
A
diagnose without lab tests in healthy women > 45 years with menopausal symptoms
B
diagnose without lab tests in healthy women > 50 years with menopausal symptoms
C
diagnose without lab tests in women > 50 years with amenorrhoea > 6/12 and not taking hormones
D
diagnose without lab tests in women > 55 years with amenorrhoea > 6/12 and not taking hormones
E
diagnose on symptoms without lab tests in women > 45 years who have had hysterectomy and are not taking hormones
F
none of the above
Question 16.
Which of the following statements is true in relation to the advice from NICE about the diagnosis of the perimenopause?
Option List
A
diagnose without lab tests in healthy women > 45 years with menopausal symptoms
B
diagnose without lab tests in healthy women > 50 years with menopausal symptoms
C
diagnose without lab tests in women > 50 years with amenorrhoea > 6/12 and not taking hormones
D
diagnose without lab tests in women > 55 years with amenorrhoea > 6/12 and not taking hormones
E
diagnose on symptoms without lab tests in women > 45 years who have had hysterectomy and are not taking hormones
F
none of the above
Question 17.
What does NICE recommend with regard to the use of oestradiol assay in relation to diagnosis of the menopause and perimenopause?
Question 18.
What does NICE recommend in relation to the diagnosis of POI?
Question 19.
NICE uses the term “urogenital atrophy” for the changes that may accompany the menopause. There is now a preferred term – what is it?

82.         EMQ.
Menopause NG23. Management.
This is a follow-on from the SBA on “Menopause. NG23. Diagnosis & definitions”.
Abbreviations.
POF:      premature ovarian failure.
POI:       premature ovarian insufficiency.
SJW:      St. John’s Wort.
Question 1.
What information should be given to menopausal women considering treatment?
Option List
There is none: this could be an OSCE station with no option list and you need to have the answers in your large brain.
Question 2.
How does NICE define “short-term” in relation to risks and benefits?
Option List
A
≤ 6 months
B
1 year
C
18 months
D
2 years
E
5 years
Question 3.
What does NG 23 say about how information should be provided?
Option List
A
orally
B
orally and written
C
orally, written and using intranet
D
orally, written and using internet
E
in different ways
Question 4.
Lead-in. What symptoms does NG23 include as associated with the menopause?
List of symptoms.
A
joint and muscle pain
B
menstrual cycle changes
C
mood changes
D
vaginal dryness
E
vasomotor symptoms
Question 5.
What information does NG23 say should be given to women about the available types of treatment for menopausal symptoms?
Question 6.
Which, if any, of the following are recommended in relation to review / follow-up for short-term symptoms.
A
review each treatment at 3/12 for efficacy / tolerability
B
review annually once established on treatment
C
review every 2 years once established on treatment
D
use NICE chart for documenting efficacy
E
none of the above
Question 7.
Which, if any, of the following should be advised in relation to starting / stopping HRT
A
unscheduled vaginal bleeding is common
B
unscheduled vaginal bleeding should be reported immediately
C
HRT should be stopped until unscheduled vaginal bleeding is investigated
D
HRT is best stopped in a regime of gradual reduction
E
none of the above
Question 8.
A woman with a high risk of breast cancer due to being a carrier of a BRCA1 mutation wishes to discuss HRT. Which of the following is true.
Option List
A
oestrogen-only HRT is safe for her to use in relation to breast cancer risk
B
HRT is contraindicated and should not be used
C
paroxetine should not be used when taking tamoxifen
D
fluoxetine is safe to use when taking tamoxifen
E
none of the above
Question 9.
Lead-in. A woman has a diagnosis of POI at the age of 35. She has no risk factors for oestrogen therapy and there is no family history of note. She wishes to discuss HRT. Which of the following are true and worthy of discussion.
Option List.
A
HRT or the COC protect against osteoporosis if taken to the average age at the menopause
B
HRT is less likely to be linked to the development of hypertension
C
combined HRT and the COC are linked to an increased risk of breast cancer, but the increase is small
D
contraception is not needed when she has gone 12 months from the diagnosis of POI
E
none of the above
Question 10.
Which, if any, of the following are true of transdermal oestrogen.
Option List.
A
transdermal HRT at standard doses ↑ the risk of diabetes, but < oral HRT
B
transdermal HRT at standard doses ↑ the risk of stroke, but < oral HRT
C
transdermal HRT at standard doses does not ↑ the risk of VTE
D
VTE risk is less with transdermal HRT than oral
E
none of the above

83.         EMQ.
Topic. Needle-stick, sharps and related risks.
Abbreviations.
CMV:    cytomegalovirus
GBCV:   GB virus C
HAV:     hepatitis A virus
HBV:     hepatitis B virus
HCV:     hepatitis C virus
HDV:     hepatitis D virus
SOE:      significant occupational exposure to blood-borne infective agent.
VL:         viral load.
Question 1.
Approximately how many SOEs are reported annually in the UK?
Option List
A
~    100
B
~    250
C
~    500
D
~ 1,000
E
~ 5,000
Question 2.
Who was Ignac Phillip Semmelweis?
Option List
A
the person credited with demonstrating the infective nature of puerperal sepsis
B
the horticulturist who first grew the white flower subsequently popularised in the musical, “The sound of music”, naming it after his first wife, Eidel.
C
the person who first used antisepsis in aerosol form to reduce the risk of infection during  C. section.
D
the inventor of catgut sutures
E
the inventor of the Dalkon shield
Question 3.
Why does the name of Semmelweis’s colleague Kotecha live on in medical history?
Option List
A
he was the first doctor to perform hysterectomy
B
he was the first doctor know to undergo transgender surgery
C
he died of infection akin to puerperal sepsis after a SOE
D
he performed the first successful repair of a 3rd. degree perineal tear
E
none of the above
Question 4.
Which of the following have been described as causing infection after a SOE.
Infective agents
1.        
hepatitis A virus
2.        
hepatitis B virus
3.        
hepatitis C virus
4.        
human T cell leukaemia virus
5.        
malaria parasites
Option List
A.       
1 + 2 + 3 + 4 + 5
B.       
1 + 2 + 3 + 5
C.       
2 + 3 + 4 + 5
D.       
2 + 3 + 4
E.        
2 + 3 + 5
Question 5.
Which are the main causes of infection to cause concern in the UK in relation to SOEs?
Infective agents.
1.        
hepatitis A virus
2.        
hepatitis B virus
3.        
hepatitis C virus
4.        
HIV
5.        
treponema pallidum
Option List
A.       
1 + 2 + 3 + 4 + 5
B.       
1 + 2 + 3 + 4
C.       
1 + 2 + 3 + 5
D.       
2 + 3 + 4 + 5
E.        
2 + 3 + 4
Question 6.
Which group features most in the list of those reporting SOEs?
Option List
A.       
doctors
B.       
midwives
C.       
phlebotomists
D.       
nurses
E.        
other healthcare workers.
Question 7.
Which clinical activity generates most SOEs?
Option List
A
acupuncture
B
assisting in the operating theatre
C
intramuscular drug / vaccine injection
D
subcutaneous drug / vaccine injection
E
venepuncture
Question 8.
Approximately how many cases of HIV seroconversion after SOE were recorded in the UK between 2004 and 2013?
Option List
A
0
B
1
C
20
D
100
E
500
Question 9.
Rate the following body fluids as: high or low risk in relation to infectivity.
Option List
A.       
amniotic fluid

B.       
blood

C.       
breast milk

D.       
cerebro-spinal fluid

E.        
faeces

F.        
peritoneal fluid

G.       
saliva

H.       
urine

I.         
urine – blood stained

J.         
vaginal fluid

K.        
vomit

Question 10.
Rate the following types of contact with body fluids as:
high-risk
low-risk
minimal or zero risk
Answer
A.       
exposure to faeces: not bloodstained

B.       
exposure to saliva: not bloodstained

C.       
exposure to urine: not bloodstained

D.       
exposure to vomit: not bloodstained

E.        
exposure via broken skin

F.        
exposure via intact skin

G.       
injury deep, percutaneous

H.       
exposure via mucosa

I.         
injury superficial

J.         
needle not used on source’s blood vessels

K.        
needle used on source’s blood vessels

L.        
sharps old

M.     
sharps recently used

N.       
sharps with blood not visible

O.      
sharps with blood visible sharps

Question 11.
Rate the following types of sources of potentially infective body fluids as:
high-risk
low-risk
minimal or zero risk
Answer
A.       
infected but VL and treatment details unknown

B.       
recent blood test negative for all relevant viruses

C.       
source has known risk factors but recent tests negative

D.       
viral status not known but source has known risk factors

E.        
viral status not known but source has no known risk factors

F.        
VL detectable

G.       
VL not detectable

H.       
VL unknown but on treatment with good adherence

Question 12.
Approximately how many cases of HBV seroconversion after SOE have been recorded in the UK since 1997?
Option List
A.       
0
B.       
1
C.       
20
D.       
100
E.        
500
Question 13.
Approximately how many cases of HCV seroconversion after SOE have been recorded in the UK since 1997?
Option List
A.       
0
B.       
1
C.       
20
D.       
100
E.        
500
Question 14.
What is the estimated risk of transmission of infection of HBV in a SOE involving sharps in a patient +ve for HBe antigen?
Option List

  1.  
1 in 2

  1.  
1 in 3

  1.  
1 in 30

  1.  
1 in 300

  1.  
 1 in 1,000 or less
Question 15.
What is the estimated risk of transmission of infection of HCV in a SOE involving sharps?
Option List

  1.  
1 in 2

  1.  
1 in 3

  1.  
1 in 30

  1.  
1 in 300

  1.  
 1 in 1,000 or less
Question 16.
What is the estimated risk of transmission of infection of HIV in a SOE involving sharps?
Option List

  1.  
1 in 2

  1.  
1 in 3

  1.  
1 in 30

  1.  
1 in 300

  1.  
 1 in 1,000 or less
Question 17.
What is the estimated risk of transmission of infection of HIV in a SOE involving mucosal splashing?
Option List

  1.  
1 in 2

  1.  
1 in 3

  1.  
1 in 30

  1.  
1 in 300

  1.  
 1 in 1,000 or less
Question 18.
Which of the following carries the highest risk of transmission of an infective agent after a SOE.
Option List
A.       
a bite on the bottom by an HIV-infected patient who finds your buttocks irresistible
B.       
deep injury from a scalpel wielded by a psychopathic surgeon
C.       
deep needle-stick after venepuncture
D.       
spitting by a patient with HIV
E.        
splash SOE from beating a disagreeable patient round the head with a frozen turkey because you are sick to death of their whingeing and perennial misery
Question 19.
List the steps you would take in relation to immediate first aid, including the things that might be suggested but you know are contraindicated.
Question 20.
Which tests should be performed on the source after obtaining consent?
List what you think should be done.
Option List
A.       
HBV surface antigen
B.       
HCV antibody
C.       
HCV RNA
D.       
HIV antigen and antibody (fourth generation HIV immunoassay)
E.        
TTV antibody
Question 21.
What consent is required from the source individual?
Option List
A.       
consent to having the tests
B.       
consent to having the results given to the occupational health department
C.       
consent to having the results given to the person who sustained the SOE
D.       
consent to having the results given to the hospital’s legal team
E.        
consent to notifying the hospital staff if the results are +ve.
Question 22.
What tests should be done on the person who has sustained the SOE and there is a significant risk of infection?
Option List
A.       
a baseline sample should be taken and stored for possible future use
B.       
HBV surface antibody
C.       
HCV antibody
D.       
HIV antigen and antibody
Question 23.
If there is a significant risk of HIV transmission, which of the following statements are correct in relation to when should PEP be given?
Option List
A.       
before the results of the tests done on the source are available
B.       
after the results of the tests done on the source are available
C.       
as soon as is practical
D.       
within 24 hours
E.        
within 72 hours
Question 24.
What are the recommended drugs for PEP in the UK?
Option List
A.       
Kaletra (200 mg lopinavir and 50 mg ritonavir)
B.       
Raltegravir 400 mg twice daily
C.       
Rifampicin 450-600mg daily as a single dose 
D.       
Tenofovir + lamivudine or emtricitabine
E.        
Truvada (245 mg tenofovir disoproxil fumarate and 200 mg emtricitabine)
Question 25.
Which of the following statements are correct in relation to PEP in early pregnancy
Option List
A.       
PEP is contraindicated until after 12 weeks
B.       
PEP should be started as for the non-pregnant
C.       
PEP should be started, but TOP should be offered
D.       
PEP should be started, but not until the puerperium
Question 26.
Which of the following statements is true in relation to reducing the risk of HCV infection.
Option List
A.       
HCV vaccine is safe in pregnancy and should be offered immediately
B.       
HCV vaccine is a live vaccine and contraindicated in pregnancy
C.       
acyclovir is an effective drug for prophylaxis
D.       
there is no known effective prophylactic drug
E.        
early treatment of HCV infection is effective, so SOE staff should be closely followed up for evidence of infection.

84.         SBA. Endometrial hyperplasia.
Abbreviations.
BSO:      bilateral salpingo-oophorectomy
c.f.         compared with
EC:         endometrial cancer
EH:        endometrial hyperplasia
ES:         endometrial surveillance
Question 1.
What is the definition of endometrial hyperplasia?
Option List
F.        
endometrial thickness ≥ twice that of proliferative endometrium
G.       
endometrial thickness ≥ twice that of proliferative endometrium in the absence of oestrogenic stimulation
H.       
premenopausal endometrial thickness ≥ 6 mm; postmenopausal thickness ≥ 4 mm.
I.         
proliferation of endometrial glands with ↑ gland to stroma ratio c.f. proliferative endometrium
J.         
proliferation of endometrial stroma with ↑ stroma to gland ratio c.f. proliferative endometrium
Question 2.
Approximately how many cases of endometrial cancer are diagnosed annually in the UK?
Option List

  1.  
≤ 1,000

  1.  
1,000 - ≤ 1,500

  1.  
1,500 - ≤ 3,000

  1.  
3,000 - ≤ 5,000

  1.  
5,000 - ≤ 10,000
Question 3.
Where does endometrial cancer rank in the list of gynaecological cancers by incidence?
Option List
A.       
1st.
B.       
2nd.
C.       
3rd.
D.       
4th.
E.        
5th.
Question 4.
Where does endometrial cancer rank in the list of gynaecological cancers causing death?
Option List
A
1st.
B
2nd.
C
3rd.
D
4th.
E
5th.
Question 5.
What is the prevalence of EH compared with that of EC.?
Option List
A.       
~ ¼
B.       
~ ½
C.       
similar
D.       
> double
E.        
> treble
Question 6.
What classification system does the RCOG recommend for EH?
Option List
A.       
BSGE 2015 classification based on endometrial thickness
B.       
FIGO 2000 classification based on risk of malignancy assessment
C.       
FIGO 2005 classification based on histological grading
D.       
WHO 2014 classification based on endometrial thickness
E.        
WHO 2014 classification based on cytological atypia
Question 7.
A 48-year-old woman presents with erratic bleeding and menopausal symptoms. Endometrial histology shows hyperplasia with no cytological anomaly. What is the risk of progression to endometrial cancer in the next 10 years?
Option List
A.       
< 1%
B.       
≤ 5%
C.       
5% - ≤ 10%
D.       
10% - ≤ 15%
E.        
> 15%
Question 8.
A 48-year-old woman presents with menopausal symptoms. Endometrial histology shows hyperplasia with no cytological anomaly. What is the chance of spontaneous regression of the endometrial hyperplasia?
Option List
A.       
< 1%
B.       
1% - ≤ 10%
C.       
10% - ≤ 15%
D.       
15% - ≤ 25%
E.        
> 25%
Question 9.
A 48-year-old woman presents with erratic bleeding and menopausal symptoms. An outpatient endometrial sample shows atypical hyperplasia. What is her lifetime risk of EC?
Option List
A.       
≤ 5%
B.       
5% - ≤ 10%
C.       
10% - ≤ 25%
D.       
25% - ≤ 50%
E.        
> 50%
Question 10.
Which of the following are risk factors for the development of endometrial hyperplasia?
Option List
A.       
aromatase inhibitors
B.       
clomiphene used for induction of ovulation
C.       
continuous combined HRT
D.       
obesity
E.        
tamoxifen
Question 11.
Which, if any, of the following should be used for the diagnosis of endometrial hyperplasia?
Option List
A.       
endometrial histology
B.       
CT scan
C.       
hystero-salpingography
D.       
MRI scan
E.        
trans-vaginal ultrasound scan
Question 12.
Which of the following are true of the management of endometrial hyperplasia without cytological abnormality?
Option List
A.       
identified risk factors should be discussed with the woman
B.       
observation with follow-up endometrial biopsies is acceptable
C.       
progestogens improve the chance of regression
D.       
progestogen should not be used when women show no regression after B
E.        
progestogen should not be used when women have abnormal bleeding
Question 13.
Which of the following are true of the management of endometrial hyperplasia without cytological abnormality?
Option List
A.       
brachytherapy is the recommended 1st. line treatment in the GTG
B.       
cyclical oral progestogen therapy is the recommended 1st. line treatment in the GTG
C.       
intra-cavity methotrexate is the recommended 1st. line treatment in the GTG
D.       
the COC is the recommended 1st. line treatment in the GTG
E.        
the LNG-IUS is the recommended 1st. line treatment in the GTG
Question 14.
Which of the following statements are true in relation to the management of endometrial hyperplasia without cytological abnormality?
Option List
A.       
treatment should be for a minimum of 6 months
B.       
women should be encouraged to continue with the LNG-IUS for at least 3 years
C.       
endometrial surveillance with biopsy should be provided at a minimum of 12 monthly
D.       
review schedules should be individualised
E.        
two consecutive 6-monthly biopsies should be negative before discharge is considered
Question 15.
Which of the following are true in relation to hysterectomy as management of endometrial hyperplasia without cytological abnormality?
Option List
A.       
treatment to achieve regression should be for at least 6 months before surgery is considered
B.       
treatment to achieve regression should be for at least 12 months before surgery is considered
C.       
treatment to achieve regression should be for at least 24 months before surgery is considered
D.       
recurrence of endometrial hyperplasia without cytological abnormality after progestogen therapy is grounds for considering hysterectomy
E.        
hysterectomy should be recommended to the woman who declines surveillance
Question 16.
 Which, if any, of the following statements are true in relation to women with endometrial hyperplasia without cytological atypia for whom hysterectomy is being considered?
Option List
A.       
post-menopausal women should have bilateral salpingo-oophorectomy
B.       
pre-menopausal women should have bilateral salpingo-oophorectomy
C.       
bilateral salpingectomy should be offered to all women not having BSO
D.       
laparoscopic hysterectomy should be offered in preference to abdominal
E.        
the GTG uses the term “total hysterectomy” which is really stupid
Question 17.
Which of the following is true in relation to the management of atypical hyperplasia of the endometrium?
Option List
A.       
endometrial ablation is satisfactory if ES can be done for at least 5 years
B.       
brachytherapy is satisfactory if ES can be done for at least 5 years
C.       
hysterectomy ± BSO or bilateral salpingectomy should be offered
D.       
frozen section should be done at the time of hysterectomy to determine the need for lymphadenectomy
E.        
continuous oral progestogen therapy should given for at least 12 months post-op
Question 18.
A woman with atypical hyperplasia of the endometrium wishes to retain her fertility. Which, if any of the following are true?
Option List
A.       
endometrial and ovarian cancer must be ruled out to start with
B.       
the MDT should decide management after reviewing the results of the histology, imaging and tumour markers
C.       
the woman should be advised is that medical advice is to have hysterectomy because of the risk of cancer
D.       
the LNG-IUS is the first-line preference for conservative management
E.        
oral progestogens should not be used
F.        
she should have at least one clear endometrial biopsy before conceiving
G.       
referral to a fertility specialist should be arranged to discuss ART
Question 19.
What follow-up should be offered to the woman with atypical hyperplasia of the endometrium who wishes conservative management?
Option List
A.       
surveillance includes endometrial biopsy
B.       
surveillance should be at intervals of not more than 6 months until 2 consecutive, clear biopsies have been obtained
C.       
surveillance should be at intervals of not more than 3 months until 2 consecutive, clear biopsies have been obtained
D.       
long-term follow-up after 2 consecutive, clear biopsies have been obtained can be at 6 – 12 month intervals
E.        
long-term follow-up after 2 consecutive, clear biopsies have been obtained can be at 12 – 24 month intervals
Question 20.
A woman who has had successful conservative treatment for atypical hyperplasia of the endometrium wishes to go onto HRT. Which, if any, of the following are true?
Option List
A.       
continuous progestogen therapy is necessary regardless of the type or mode of administration of oestrogen replacement
B.       
LNG-IUS or depot progestogens are preferred to oral therapy
C.       
hysterectomy should be recommended if not already done
D.       
six-months TV scans should be done for endometrial thickness
E.        
none of the above
Question 21.
Which, if any, of the following are true in relation to the woman with endometrial hyperplasia who has been treated for breast cancer and are taking tamoxifen or aromatase inhibitors.
Option List
A.       
she should be informed that tamoxifen ↑the risk of endometrial cancer
B.       
she should be informed that aromatase inhibitors ↑the risk of endometrial cancer
C.       
she should be informed that the LNG-IUS ↓ the risk of endometrial cancer for women on tamoxifen
D.       
she should be informed that the LNG-IUS ↓ the risk of endometrial cancer for women on aromatase inhibitors
E.        
she should be informed that the effect of the LNG-IUS on the risk of breast cancer recurrence is unknown and that it is not recommended as a result
Question 22.
A woman is found to have endometrial hyperplasia on an endometrial polyp. Which of the following are true of the best management?
Option List
A.       
complete removal of the polyp must be checked
B.       
hysteroscopy and curettage must be done to check the endometrium
C.       
an LNG-IUS should be recommended
D.       
hysterectomy should be recommended
E.        
none of the above.