Tutorial 29 December 2011

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Tonight's materials were as follows. The EMQs caused a bit of headache so make sure you do them as there are bound to be some like them in the exam.
In most of the questions, if one partner was affected or a carrier, it was assumed that the other was not affected. I will need to re-write the questions to tighten this up, but assume if for the answers unless the question specifically spells out that both are affected.
Haemophilia A. Question 1.

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?

  

Haemophilia A. Question 2. Pre-pregnancy counselling.

Lead-in.

The following scenarios relate to haemophilia A and pre-pregnancy counselling.

For each, select the most appropriate risk from the option list.

Pick one option from the option list.

Each option can be used once, more than once or not at all.

Scenario 1.

A nulliparous 20-year-old wishes to know the risk of her being a carrier as her father has mild haemophilia A.

Scenario 2.

A nulliparous 20-year-old wishes to know the risk of her being a carrier as her father has severe haemophilia A.

Scenario 3.

A para 3, 30-year-old wishes to know the risk of her being a carrier as her mother is a carrier.

Scenario 4.

A para 0+⁴, 25-year-old wishes to know the risk of her being a carrier as her sister has an affected son.

Scenario 5.

 A para 6, 40-year-old wishes to know the risk of her being a carrier as her daughter has had an affected baby.

Scenario 6.

 A nulliparous woman wishes to know the risk of a son having haemophilia as she is a carrier.

Scenario 7.

A nulliparous woman wishes to know the risk of a son having haemophilia as her husband has haemophilia A.

Scenario 8.

A nulliparous woman wishes to know the risk of a daughter being a carrier as she is a carrier.

Scenario 9.

A nulliparous woman wishes to know the risk of a daughter being a carrier as her husband has haemophilia A.

Scenario 10.

A nulliparous woman wishes to know the risk of a son having haemophilia as her paternal grandfather had haemophilia A.

Scenario 11.

A nulliparous woman wishes to know the risk of a son having haemophilia as her maternal grandfather had haemophilia A.

Scenario 12.

A nulliparous woman wishes to know the risk of a son having haemophilia as her husband’s paternal grandfather had haemophilia A.

Scenario 13.

A nulliparous woman wishes to know the risk of a son having haemophilia as her husband’s maternal grandfather had haemophilia A.

Scenario 14.

A nulliparous woman wishes to know the risk of a son having haemophilia as her mother’s brother has haemophilia A.

Scenario 15.

A nulliparous woman wishes to know her risk of being a carrier as she has read about it in a magazine. There is no family history of haemophilia A.

Option list.

A.	0 %
B.	0.1 %
C.	1 %
D.	12.5 %
E.	13.3%
F.	20 %
G.	25 %
H.	33 %
I.	50 %
J.	66.6%
K.	68 %
L.	75 %
M.	80 %
N.	90 %
O.	100 %
P.	200 %

 

Essays 29 December 2011.

1. A nulliparous woman of 20 years attends the A&E department with abdominal pain and vaginal discharge. The A&E SpR suspects acute pelvic inflammatory disease and has asked you to see her. Justify:

1.  the history you will take.                                      6 marks.

2.  the investigations you will arrange.                     4 marks.

3.  the immediate management.                              6 marks.

4.  the follow-up arrangements you will discuss.     4 marks.

2. A six year old girl is referred to the gynaecology clinic with a 2 month history of vaginal discharge.

1. Justify the history you will take.                  5 marks

2. Justify the investigations you will do.          5 marks

3. Critically evaluate the management.        10 marks

3. A woman is found to have a temperature of 39.⁰ C. on the second day after a normal delivery.

1. what is the definition of puerperal pyrexia?            2 marks.

2. is puerperal pyrexia a notifiable disease?  2 marks.

3. critically evaluate the investigation.           8 marks.

4. critically evaluate the management.          8 marks.

4. Critically evaluate neonatal screening.

Tutorial 22 December 2011

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Soundcloud is struggling to upload the tutorial, so this may be published before the tutorial.
If the tutorial does not upload soon, it will need to wait until tomorrow as I am going to bed!
The materials we used were as follows:
 

1. Critically evaluate the statement: “fortification of flour is overdue in the UK”.

2. With regard to epidural anaesthesia:

1.    Outline the main differences between it and spinal anaesthesia.      4 marks.

2.    Outline the main techniques and drugs used.      6 marks.

2.    Evaluate the main contraindications.                  4 marks.

3.    Discuss the main uses.                                      6 marks.

3.    Your consultant is on leave. The Secretary gives you an histology report relating to a

24-year-old woman who had suction evacuation for incomplete miscarriage 10 days before. The histology report is diagnostic of a complete hydatidiform mole.

1.  Justify your immediate management.     8 marks

2.  Detail the subsequent management.    12 marks.

4.    A woman with sickle cell disease is referred to the pre-pregnancy counselling clinic.

1.    Justify the history you will take.                      6 marks

2.    Justify the investigations you will perform.       4 marks

3.  Outline the strategy for managing pregnancy.  10 marks

Lead-in.

The following scenarios relate to epidural anaesthesia.

For each, select the answer 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.

Which spinal level(s) conduct pain sensation from the uterus and cervix?

Scenario 2.

Which spinal level(s) conduct pain from the perineum?

Scenario 3.

Which spinal level(s) conduct pain from the left big toe and what does it signify?

Scenario 4.

Maternal pyrexia is a complication of epidural anaesthesia.

Scenario 5.

Spinal anaesthesia is effective more rapidly than epidural anaesthesia.

Scenario 6.

Adding an opioid to the local anaesthetic drug increased the potency of epidural anaesthesia.

Scenario 7

Epidural anaesthesia increases the Caesarean section rate.

Scenario 8

Epidural anaesthesia increases the length of labour.

Scenario 9

What is the rate of incomplete block with epidural anaesthesia?

Option list.

A.        True

B.        False

C.        ≥ 1 in 10

D.        1 in 10 to 1 in 100.

E.         1 in 100 to 1 in 1,000

F.         1 in 1,000 to 1 in 50,000

G.       1 in 50,000 to 1 in 100,000

H.        1 in 100,000 or less

I.          T₈ - T₁₂

J.          T₁₀ – L₁

K.        L₂ - L₈.

L.         L₈ - S₁

M.      S₁ – S₄

N.       S₂ – S₄

O.       S₃ – S₅

P.        10%

Q.       20%

R.        20 – 50%

S.         50 – 70%

T.      80 – 90%

U.     90 – 100%

V.     I have no idea, I don’t care and I am going to the pub to drown my sorrows!

W.    None of the above.

Tutorial 19 December 2011

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1. You are the SpR in the antenatal clinic. The consultant is absent due to illness and no other consultant is available. A midwife asks you to see a woman whose scan has shown anencephaly.

1. What steps will you take before seeing the woman?       6 marks

2. Justify the approach you will use during the interview.   10 marks

3. What will you do when the interview is over?                  4 marks         

2. In relation to diagnostic laparoscopy, critically evaluate:

1. the issues to be discussed in obtaining informed consent       4 marks.

2. the factors that increase the incidence of entry-related injury   4 marks.

3. how entry-related injuries may be minimised                         12 marks.

3.Critically evaluate HPV vaccine and its uses.

 4. A woman attends the antenatal clinic at 10 weeks. Her son developed chickenpox two days ago. Her sister is 38 weeks pregnant. Critically evaluate the management.

 

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.

Tutorial 15 December 2011

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We managed 1 EMQ and 4 essays.
The EMQ was on Ulipristal, which you need to know about as it is sure to be in the exam databases by now.
The questions are below the essays, which come next.
I am still getting essays that have been written with the Green-top guidelines and textbooks open.
This is a complete waste of time!

1. A 32 year-old woman with learning difficulty attends the gynaecology clinic with her mother. The referral is because of severe dysmenorrhoea and menorrhagia. The mother is keen for her to have hysterectomy and is prepared to give her consent.

1.  What factors will you take into consideration before offering treatment? 8 marks.

2.  Outline the treatment options, not including hysterectomy, that you will discuss. 6 marks.

3.  If it is concluded that hysterectomy is the best option, justify the steps you will take to arrange this. 6 marks.

2. Endometriosis & fertility

A 32 year-old woman attends the clinic with her partner. A recent laparoscopy for pelvic pain and dyspareunia revealed endometriosis. The have not used contraception for 12 months but have not conceived. Neither has had a child before.

1.      Outline the history you will take.                6 marks

2.      Outline the investigations you will arrange.  6 marks

3.      Outline the information you will wish to discuss with the couple. 12 marks

3. A woman of 18 attends the A&E Department requesting emergency contraception.

1.  Outline the history you will take.               4 marks.

2.  Justify the investigations you will arrange.   2 marks.

3.  Outline the methods of emergency contraception and their pros and cons. 8 marks
4.  Justify your management.     8 marks.

4. A 25-year-old primigravida attends for a routine scan and echogenic bowel is noted.

1. What is the advice of the National Screening Committee in relation to “soft markers”?  6 marks.

2. What conditions are linked to echogenic bowel?    6 marks.

3. Justify your management.                                    12 marks.

 

Lead-in.

The following scenarios relate to ulipristal. For each, select the most appropriate from the option list.

Each option can be used once, more than once or not at all.

Scenario 1.

What type of drug is ulipristal?

Scenario 2.

How is ulipristal broken down / excreted?

Scenario 3.

What is the half life of ulipristal?

Scenario 4.

Which drug may prolong the half life of ulipristal?

Scenario 5.

What is the main use of ulipristal?

Scenario 6.

What is the dose of ulipristal?

Scenario 7.

What time-scale applies to the licensed use of ulipristal?

Scenario 8.

What contraceptive advice is given to those using ulipristal?

Scenario 9.

What advice is given to women who are breast-feeding?

Scenario 10.

Can treatment with ulipristal be repeated within 1 month?

Option list.

GnRH analogue.

Selective serotonin reuptake inhibitor.

19-nortestosterone derived progestagen.

21-hydroxyprogesterone-derived progestagen.

mifepristone derivative.

Selective oestrogen receptor modulator.

Selective progesterone receptor modulator.

Urinary excretion.

Metabolised by renal cytochrome P450 enzyme system.

Metabolised by hepatic cytochrome P450 enzyme system.

30 mg. with dose repeated if vomiting occurs within 3 hours.

100 mg. with dose repeated if vomiting occurs within 3 hours.

150 mg. with dose repeated if vomiting occurs within 3 hours.

phenobarbitone

valium

erythromycin

12 hours.

18 hours.

32 hours.

72 hours.

120 hours.

Depot-contraception.

Depression.

Emergency contraception.

Menorrhagia.

Termination of pregnancy.

Yes.

No.

Maybe.

Continue.

Discontinue for 36 hours.

Discontinue for 72 hours.

May interfere with contraception containing progestagen.

May interfere with contraception containing oestrogen.

No action if LARC being used.

Tutorial 12 December 2011

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Tonight we managed 4 essay topics and an EMQ.

1. With regard to endometrial cancer.

1. Outline the key features of Type 1 and Type 2 cancers.             4 marks

2. Outline the FIGO histological grading system.                            2 marks

3. Critically evaluate the FIGO staging for endometrial cancer.       6 marks

4. Detail the FIGO staging system for endometrial cancer.             8 marks.

2. With regard to fetal welfare in labour.

1.   Critically evaluate the methods available for monitoring the fetal condition.                14 marks

2.   List the criteria recommended by NICE for continuous electronic fetal monitoring.   
6 marks

3. With regard to hyperemesis gravidarum.

1.  Outline how the diagnosis is made.                                                   2 marks

2.  Outline the immediate consequences.                                               6 marks

3.  Outline the consequences in later pregnancy.                                    6 marks

4.  Justify your management of a woman seen with HG at 10 weeks.     6 marks.

4. You have been asked to give a lecture on the Mental Capacity Act 2005 to the junior staff of the department of O&G using illustrative examples.

Describe the types of cases you will use and the key points you will make.           

 

Lead-in.

The following scenarios relate to endometrial cancer.

Pick one option from the option list.

Each option can be used once, more than once or not at all.

Option list.

Scenario 1.

A histology report on endometrial curetting is of 95% adenocarcinoma with 5% solid, non-squamous areas. What is the FIGO grade?

Scenario 2.

A histology report on endometrial curetting is of 90% adenocarcinoma with 10% solid, non-squamous areas. What is the FIGO grade?

Scenario 3.

A histology report on endometrial curetting is of 50% adenocarcinoma with 50% solid, non-squamous areas. What is the FIGO grade?

Scenario 4.

A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the body of the uterus with 5% myometrial invasion. What is the FIGO staging?

Answer.

Scenario 5.

A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the body of the uterus with 25% myometrial invasion. What is the FIGO staging?

Scenario 6.

A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the body of the uterus with 60% myometrial invasion. What is the FIGO staging?

Scenario 7

A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the uterus. There is no myometrial invasion, but there is extension to the endocervical endothelium. What is the FIGO staging?

Scenario 8

A woman undergoes surgery for carcinoma of the endometrium. Histology shows the tumour is confined to the uterus. There is no myometrial invasion, but there is extension to the stroma of the cervix. What is the FIGO staging?

Scenario 9

A woman undergoes surgery for carcinoma of the endometrium. Peritoneal washings are +ve but there is no other evidence of spread outside the uterus. There is no myometrial invasion. There is extension to the stroma of the cervix. What is the FIGO staging?

Scenario 10

A woman undergoes surgery for carcinoma of the endometrium. There is no evidence of extension outside the uterus. There is myometrial invasion through to and including the serosa. What is the FIGO staging?

Scenario 11

A woman undergoes surgery for carcinoma of the endometrium. There is myometrial invasion. Tumour is noted in the vagina. There is no evidence of disease elsewhere. What is the FIGO staging?

Scenario 12

A woman undergoes surgery for carcinoma of the endometrium. There is myometrial invasion. Tumour is noted in the vagina. Positive pelvic nodes are found, but no other lymphatic involvement. There is no distant spread. What is the FIGO staging?

Scenario 13

A woman undergoes surgery for carcinoma of the endometrium. There is myometrial invasion. Tumour is noted in the vagina. The tumour involves the mucosa of the bladder. There is no lymphatic or distant spread. What is the FIGO staging?

Tutorial 8th. December 2011

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Tonight we managed to deal with 1 EMQ and four essays.
The first essay was about essay-writing and prompted by the fact that quite a lot of people still seem confused by what we are trying to do with the essays.
The main idea is to move from being pretty hopeless at essay-writing now to being really good in the exam hall.
This will only come with lots of practice - and practice is no good unless it is done under exam conditions.
There was a bit of a digression into MDU and BMA membership, which was not really necessary.

Antenatal steroids and the neonate.

Lead-in.

The following scenarios relate to antenatal steroid use and the neonate.

Pick one option from the option list.

Each option can be used once, more than once or not at all.

Abbreviations.

ANS:      antenatal steroids.

FGR:      fetal growth restriction.

GTG:     Green-Top Guideline No 7 from the RCOG. “Antenatal Corticosteroids to Reduce Neonatal Morbidity and Mortality.”

RDS:      respiratory distress syndrome. Now better known as “surfactant-deficient lung disease of the new-born”.

Option list.

As before, there is no option list.

I want you to come up with your answers.

I’ll produce one and send it once I have seen your answers.

Scenario 1.

What are the benefits to the neonate of appropriate administration of antenatal steroids?

Scenario 2.

At what gestations should antenatal steroids be offered to women with singleton pregnancies who are at risk of premature labour?

Scenario 3.

At what gestations should antenatal steroids be offered to women with multiple pregnancies who are at risk of premature labour?

Scenario 4.

What advice is contained in the GTG in relation to very early gestations, threatened premature labour and the use of antenatal steroids.

Scenario 5.

What advice is contained in the GTG in relation to antenatal steroids and Caesarean section?

Scenario 6.

What advice is given in the GTG about ANS in relation to the fetus with FGR at risk of premature delivery?

Scenario 7

What advice is given in the GTG in relation to ANS for women with IDDM?

Scenario 8

What advice is in the GTG in relation to adverse effects of ANS on the fetus?

Scenario 9

What advice is in the GTG in relation to short-term maternal adverse effects?

Scenario 10

What contraindications to ANS are cited in the GTG?

Scenario 11

What is the recommended drug regime for ANS administration?

Scenario 12.

What is the time-scale for maximum effect of ANS in reducing RDS?

Scenario 13.

When should repeat courses of ANS be given?

 

Question1.

You have been asked to give a tutorial on essay-writing for MRCOG part II candidates.

Outline the key aspects of the advice you will wish to convey.

Question2.

With regard to the Clinical Negligence Scheme for Trusts.

1.   What it the CNST?                                                                      4 marks

2.   Describe the impact of the CNST on obstetric practice.    16 marks

Question3.

A 28-year-old woman is referred to the gynaecology clinic with suspected premature ovarian failure. She has “hot flushes”, has not menstruated for 8 months and a FSH level was found to be 40 iu/l.

1.  Outline the main causes of premature ovarian failure.   10 marks

2.  Critically evaluate the management options.                    10 marks

Question4.

A nulliparous woman of 30 years attends for pre-pregnancy counselling. Her father is a carrier of the Fragile X premutation. Her paternal uncle has Fragile X syndrome.

Critically evaluate the management.