Tutorial.
Contact.
Tonight we had 3 EMQs, one of them rather long, then 3 essays which we only had time to discuss briefly.
There will be an extra tutorial tomorrow night on urodynamics.
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. none of the above
Scenario 1.
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 completed a “return to work” programme. 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 2.
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 3.
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 4.
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 5.
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 6.
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 7.
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 8
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 9
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 10
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 11
You are an FY2 and assist the senior consultant at a hysterectomy. The operation goes well initially, but then there is a lot of bleeding and a ureter is cut. The consultant urologist attends and repairs the ureter. The woman bleeds vaginally that evening and is taken back to theatre by another consultant and ends up in the ICU. You became convinced during the operation that you could smell alcohol on the consultant gynaecologist’s breath. What are your responsibilities?
Scenario 12
When do you need to inform the Consultant on-call?
Scenario 13
When do you need to inform the Clinical Director?
Scenario 14
When do you need to inform the Medical Director?
Scenario 15
When do you need to inform the GMC?
Scenario 16
What are the roles of the BMA and MDU?
Scenario 17
What are the differences between verbal and written warnings?
Cervical smear management.
Lead-in.
There are too many scenarios and the option list is too long. And some of the “scenarios” are really MCQs. Don’t tell me – I know! I have tried to think of all the questions that could arise. At some point I’ll chop it into several bits to make the option list more sensible. A smaller option list would also allow me to introduce more “tempters” that sound as though they should be the correct answer.
The following scenarios relate to the management of cervical smears.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
ALOs: actinomyces-like organisms
BSCCP British Society for Colposcopy and Cervical Pathology. http://www.bsccp.org.uk/
CIN: cervical intraepithelial abnormality
CGIN: cervical glandular intraepithelial abnormality
FSRH: Faculty of Sexual and Reproductive Health: http://www.fsrh.org/
GUM clinic: genito-urinary medicine clinic
LBC: liquid-based cytology
LLETZ: large loop excision of the transformation zone
NEC: normal endometrial cell
NHSCSP: NHS Cervical Screening Programme: http://www.cancerscreening.nhs.uk/cervical/
POP: progesterone-only Pill
TZ: transformation zone
Option list.
a. repeat the test
b. repeat the test after 6 months
c. repeat the test at 6 and 12 months
d. repeat the test at 6 and 12 months and then annually until she has had 10 years’ follow-up followed by repeat tests at the normal intervals for her age
e. repeat the test after 3 or 5 years according to her age as per routine follow-up
f. repeat the test after HPV testing
g. repeat the test after giving an appropriate antibiotic
h. repeat the test after removing her IUCD.
i. repeat the test after removing the IUCD and giving an appropriate antibiotic
j. repeat the test after treating the TZ with diathermy
k. repeat the test after treating the TZ with cryocautery
l. discharge from follow-up
m. refer for colposcopy
n. refer for colposcopy within 2 weeks
o. refer for colposcopy within 8 weeks
p. refer for colposcopy within 12 weeks
q. refer for colposcopy only if she has other significant signs or symptoms
r. refer for cone biopsy
s. refer for fractional curettage
t. refer for “see and treat” LLETZ
u. refer to GUM clinic
v. recommend that she go back to America
w. there is insufficient information to formulate a management plan
x. false
y. true
z. none of the above
Scenario 1.
A woman with no previous abnormal smears has a routine smear showing an inadequate sample . What management will you suggest?
Scenario 2.
A woman with no previous abnormal smears has had a smear showing borderline nuclear changes. What management will you suggest?
Scenario 3.
A woman with no previous abnormal smears has had a smear showing borderline nuclear changes. Cervical ectopy is noted. What management will you suggest?
Scenario 4.
A woman with no previous abnormal smears has had a smear showing borderline cells of endocervical origin. What management will you suggest?
Scenario 5.
A woman with no previous abnormal smears has had a smear showing inflammatory changes. What management will you suggest?
Scenario 6.
A woman with no previous abnormal smears has had a smear showing inflammatory changes and ALOs. What management will you suggest?
Scenario 7.
A woman with no previous abnormal smears has had a smear showing inflammatory changes. She takes the COC for contraception. What management will you suggest?
Scenario 8.
A woman with no previous abnormal smears has had a smear showing inflammatory changes. She has a copper IUCD. What management will you suggest?
Scenario 9.
A woman with no previous abnormal smears has had a smear showing inflammatory changes and ALOs. She has had hysteroscopic sterilisation with ESSURE. What management will you suggest?
Scenario 10
A woman with no previous abnormal smears has had a smear showing borderline changes. A repeat smear after 6 months is normal. A repeat smear after 3 years shows inflammatory changes. A repeat smear after 6 months is normal. A repeat smear after 3 years shows borderline changes. What management will you suggest?
Scenario 11
A woman with no previous abnormal smears has had a smear showing mild dyskaryosis of squamous cells. What management will you suggest?
Scenario 12
A woman with no previous abnormal smears has had a smear showing moderate dyskaryosis of squamous cells. What management will you suggest?
Scenario 13
A woman with no previous abnormal smears has had a smear showing severe dyskaryosis of squamous cells. What management will you suggest?
Scenario 14
A woman with no previous abnormal smears has had a smear suggestive invasive disease. What management will you suggest?
Scenario 15
A woman with no previous abnormal smears has had a smear showing borderline nuclear changes in glandular cells. What management will you suggest?
Scenario 16
A woman with no previous abnormal smears has had a smear showing ? glandular neoplasia. What management will you suggest?
Scenario 17.
A woman with no previous abnormal smears has had a smear showing normal endometrial cells. What management will you suggest?
Scenario 18.
A woman with no previous abnormal smears has had a smear showing atypical endometrial cells. What management will you suggest?
Scenario 19
A woman with no previous abnormal smears has had a smear with a normal result. Contact bleeding was noted when the smear was taken. What management will you suggest?
Scenario 20
An American woman with no previous abnormal smears has been used to having annual smears. She has had a smear with a normal result and requests a repeat in 12 months. What management will you suggest?
Scenario 21
A woman with no previous abnormal smears is on renal dialysis and has had a smear with a normal result. What management will you suggest?
Scenario 22
A HIV +ve woman with no previous abnormal smears has had a smear with a normal result. What management will you suggest?
Scenario 23
A woman with no previous abnormal smears has had a smear with a normal result. She smokes 20 cigarettes daily and has a long history of recurrent genital warts. What management will you suggest?
Scenario 24.
A woman of 70 presents with postmenopausal bleeding. She had smears at the recommended intervals from the age of 22. All were normal. The last was taken at the age of 64. What is your management in relation to taking a smear?
Scenario 25.
A woman of 55 presents with hot flushes since her periods stopped at the age of 54. She wishes to go on HRT and there are no contraindications. She had smears at the recommended intervals from the age of 25. All were normal. The last was taken two years ago. What is your management in relation to taking a smear?
Scenario 26.
Women who have been treated for CIN are 2 – 5 times more likely to develop cancer than women who have not been treated. True or false?
Scenario 27.
More than 50% of women who develop cancer after treatment for CIN have been lost to follow-up. True or false?
Scenario 28.
Which of the following statements are true and which false?
a. cone biopsy is linked to ↓risk of recurrence compared to LLETZ.
b. excision margins that are not CIN-free ↑ the risk of recurrence, with endocervical margins that are not CIN-free posing a greater risk that similar ectocervical margins.
c. age > 35 years increases the risk of recurrent disease.
d. follow-up after treatment for CIN should start between 3 & 6 months from the time of treatment.
e. the initial examination should be with colposcopy plus cytology.
f. a failure to achieve negative results in the year after treatment means colposcopy should be done.
g. a required standard for treatment success is that ≥ 90% of women should have no evidence of dyskaryosis in the year after treatment.
h. a required standard for treatment success is that there should be ≤ 5% of histologically-confirmed treatment failures by 1 year after treatment.
Scenario 29
Women who have had normal follow-up results for 2 years after treatment of CIN 1 can revert to the routine recall.
Scenario 30.
Follow-up should continue with increased frequency for 5 years after treatment of CIN 2 & 3, after which recall at routine intervals is OK if all the follow-up has been normal. True or false?
Scenario 31.
A woman with LLETZ for CIN3 twelve months ago had a normal smear 6 months later. A smear taken 12 months after treatment is also normal. What management will you suggest?
Scenario 32.
A woman with LLETZ for CIN3 twelve months ago had a normal smear 6 months later. A smear taken 12 months after treatment shows mild dyskaryosis. What management will you suggest?
Scenario 33.
A woman on normal recall has hysterectomy for menorrhagia. There is no evidence of CIN on histology. What follow-up would you recommend?
Scenario 34.
A woman who was not on normal recall has hysterectomy for menorrhagia. There is no evidence of CIN on histology. What follow-up would you recommend?
Scenario 35.
Women who have had hysterectomy and require follow-up with vault smears cannot be managed within the NHSCSP. True or False?
Scenario 36.
A woman who was not on normal recall has hysterectomy for menorrhagia. There is evidence of completely excised CIN3 on histology. What follow-up would you recommend?
Scenario 37.
A woman who was not on normal recall has hysterectomy for menorrhagia. There is evidence of incompletely excised CIN3 on histology. What follow-up would you recommend?
Scenario 38.
A woman has conservative treatment for early stage cancer of the cervix. What follow-up should be recommended?
Scenario 39.
A woman is referred with severe dyskaryosis, but colposcopy is normal. What follow-up should be recommended?
Lead-in.
The following scenarios relate to some common drugs used in pregnancy.
Pick one option from the option list. Each option can be used once, more than once or not at all.
Abbreviations.
NSAID. non-steroidal anti-inflammatory drug.
Option list.
I have not given one to make you think! And, in the exam, you should be deciding your answer before you check the option list.
Scenario 1.
What is the generic name for Prostin?
Scenario 2.
What kind of drug is Prostin?
Scenario 3.
What is the generic name for Misoprostol?
Scenario 4.
What kind of drug is Misoprostol?
Scenario 5.
What is the generic name for Gemeprost?
Scenario 6.
What kind of drug is Gemeprost?
Scenario 7
What is the generic name for Mifepristone?
Scenario 8
What king of drug is Mifepristone?
Scenario 9
What are the constituents of a 1 ml. ampoule of Syntometrine?
Scenario 10
What is the generic name for Carbetocin?
Scenario 11
What kind of drug is Carbetocin?
Scenario 12
What is the generic name for Hemabate?
Scenario 13
What kind of drug is Hemabate?
Scenario 14
What is the generic name for Atosiban?
Scenario 15
What kind of drug is atosiban?
Scenario 16
What if the generic name for Cervagem?
Scenario 17
What kind of drug is Cervagem?
Scenarion 18
What is the cost of 1mg. of Prostin E2 gel and what are its storage requirements?
Scenarion 19
What is the cost of a 1mg. Gemeprost pessary and what are its storage requirements?
Scenarion 20
What is the cost of 200 mcg. of misoprostol and what are its storage requirements?
There has been a recent spate of requests for Caesarean section with no medical grounds. The Clinical Director has asked you to produce a provisional policy document on the subject for discussion at a Unit meeting with a view to formulating Unit policy.
Justify the issues and facts you will include in the paper.
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. 6 marks
3. Outline the subsequent management. 10 marks
With regard to adhesions.
1. Outline the incidence and possible adverse consequences of adhesion formation after gynaecological surgery.
8 marks.
2. How may the incidence of surgical adhesions be reduced? 12 marks.
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