Thursday 31 May 2012

Tutorial 31 May 2012

Tutorial
Website
Contact

Tonight we had an EMQ, or three, on the Coroner. This topic has featured in the exam and caused problems.
We then wrote 3 essay plans.
EMQs.
 
The Coroner. Question 1.
Lead-in.
The following scenarios relate to the role of the Coroner.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
Suggested reading.
I try will put all you need to know into the answer to MCQ13, question 5.
Option list.
A.        an independent judicial officer
B.        a barrister acting for the Local Police Authority
C.        the regional representative of the Home Office
D.        the regional representative of the Queen.
E.         an employee of the High Court.
F.         the Local Authority
G.       the Local Police Authority
H.        the Home Office
I.          the High Court
J.          the Queen
Scenario 1.
What is the best description of the status of the Coroner?
Scenario 2.
Who appoints the Coroner?
Scenario 3.
Who pays for the Coroner?

The Coroner. Question 2.
Lead-in.
The following scenarios relate to the role of the Coroner.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Suggested reading.
I try will put all you need to know into the answer to MCQ13, question 5.
Option list.
A.        must have had experience as a detective in the police force with  rank of Inspector or above
B.        must be a barrister, lawyer or doctor with at least 5 years’ experience
C.        must be a legally qualified individual with at least 5 years’ experience
D.        must be a trained bereavement counsellor
E.         must be able to play the bagpipes
F.         Monday -  Friday; 09.00 - 17.00 hours, including bank holidays
G.       Monday - Friday; 09.00 - 17.00 hours excluding bank holiday
H.        All the time
I.          to arrest people suspected of unlawful killing
J.          to manage traffic in the vicinity of the Coroner’s court
K.        to make enquiries on behalf of the Coroner
L.         to make enquiries on behalf of the Coroner and provide administrative support
Scenario 1.
What qualifications must the Coroner have?
Scenario 2.
What are the hours of availability of the Coroner?
Scenario 3.
What is the role of the Coroner’s Officers?

The Coroner. Question 3.
Lead-in.
The following scenarios relate to the role of the Coroner.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Option list.
A.        the death must be reported to the Coroner
B.        the death does not need to be reported to the Coroner
C.        the Coroner must order the return of the body for an inquest
D.        the Coroner must order a post-mortem examination
E.         the Coroner must hold an inquest
F.         the Coroner should arrange for the death to be investigated by the Home Office
G.       the death must be reported to the authorities of the country in which it took place in order that a certificate of death can be issued
H.        a certificate of live birth
I.          a certificate of stillbirth
J.          a certificate of miscarriage
K.        yes
L.         no
M.      none of the above
Scenario 1.
A resident of Manchester dies suddenly while visiting the town of his birth in Scotland. His family decides that he will be buried in the town of his birth. His body is held at the premises of a local funeral director to arrange the funeral and burial. What actions should be taken with regard to the Manchester coroner?
Scenario 2.
A resident of London dies suddenly while visiting Manchester, where he was born. His family decides that he will be buried in Manchester. His body is held at the premises of a Manchester funeral director who will arrange the funeral and burial. What actions should be taken with regard to the Manchester coroner?
Scenario 3.
A resident of Manchester dies on holiday in his native Greece. The family decide that he will be buried in Greece. What steps must be taken to obtain a valid death certificate?
Scenario 4.
A man of 65 dies of terminal lung cancer. The GP who had visited daily up to three weeks before the death has been on holiday for three weeks. He has now returned and says that he will sign a death certificate, but needs to visit the funeral director to see the body first.  Will this be a valid death certificate?
Scenario 5.
A man of 65 dies of terminal lung cancer. The GP who has visited daily up to the day of his death and attended to confirm the death is on holiday. However, he says that he will sign a death certificate and put it in the post, so that it will arrive in the morning. Will this be a valid death certificate?
Scenario 6.
A man of 65 dies of terminal lung cancer. The GP who has visited daily up to the day before his death has been on holiday since. However, he says that he will sign a death certificate and put it in the post, so that it will arrive in the morning. Will this be a valid death certificate?
Scenario 7.
A 65-year-old man dies suddenly 12 hours after admission to the local coronary care unit with chest pain, despite apparently satisfactory insertion of a coronary artery stent after a diagnosis of coronary artery thrombosis. What action should be taken with regard to the Coroner?
Scenario 8.
A 16-year-old girl is admitted at 36 weeks’  gestation in her first pregnancy with placental abruption. She is given the best possible care but develops DIC and hypovolaemic shock and dies. What action should be taken with regard to the coroner?
Scenario 9.
A 28-year-old woman is admitted with placental abruption at 36 weeks. She has bruising on the abdominal wall and the admitting midwife suspects that she has been the victim of domestic violence, though the woman denies it. Despite best possible care she dies as a consequence of bleeding. What action should be taken with regard to the coroner?
Scenario 10.
A 30-year-old woman delivers normally at home attended by her husband, but has a PPH. The husband practises herbal medicine. He applies various potions but her condition deteriorates. She is admitted to hospital by emergency ambulance. She is given best possible care and is admitted to the ICU. She dies 7 days later of multi-organ failure and ARDS attributed to hypovolaemic shock. What action should be taken with regard to the coroner?
Scenario 11.
A woman is admitted at 23 weeks in premature labour. There is evidence of fetal heart activity throughout the labour, with the last record being 5 minutes before the baby delivers. The baby shows no evidence of life at birth. The mother requests a death certificate so that she can register the birth and arrange a funeral. What form of certificate should be issued?
Scenario 12.
A woman is admitted at 26 weeks’ gestation in premature labour. The presentation is footling breech. At 8 cm. cervical dilatation the trunk is delivered and the cord prolapses. There is good evidence of fetal life with fetal movements and pulsation of the cord. The head is trapped and it takes 5 minutes to deliver it. The baby is pulseless, apnoeic and without visible movement at birth. Intubation and CPR are carried out for 20 when the baby is declared dead. What action should be taken with regard to the coroner?

The essays were:
5.
A nulliparous woman is admitted to the Early Pregnancy Unit with abdominal pain and bleeding. Her hCG is 2,000 i.u. per litre. An ultrasound scan shows an empty uterus and a left adnexal mass.
1.  Discuss the differential diagnosis.   4 marks.
2.  Discuss the treatment options.      10 marks.
3.  Discuss the advice you will give for when she has recovered.  6 marks.
6.
Critically evaluate the diagnosis and management of ectopic pregnancy not occurring in the peritoneal section of the Fallopian tubes.
7.
Critically evaluate the management of thrombocytopenia in pregnancy.
 
 You will note that we are now up to essay 7. I hope you are practising them all and under exam conditions.

Monday 28 May 2012

Tutorial 28 May 2012

Tutorial
Website
Contact

Tonight we had an EMQ on staging of cervical cancer. Definitely a topic for the last-minute-revision list if you are not an oncologist.

EMQ Paper 1 , Question 6 . Ca Cx staging.

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

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


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

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

Then two essays:
 A woman books at 8 weeks’ gestation in her first pregnancy. She is concerned because she works in a nursery where there has been an outbreak of cytomegalovirus infection. Critically evaluate the management.
 You have been asked to perform an audit. Outline the key issues involved in preparing and performing an audit.
In between we had a brief roleplay to illustrate the problems with explaining topics like recessive inheritance and the need to start to develop suitable approaches.

Thursday 24 May 2012

Tutorial 24 May 2012

Tutorial
Website
Contact

The cystic fibrosis EMQ from the previous tutorial caused mayhem. Most people messed it up. If you have not tackled it, I would suggest that you do so  and send it to me so that you get my answer and explanation. The feedback I have had is that it is similar to the EMQs in the exam on the subject. It is really easy once you understand the basics of what you are doing.

Tonight we had another EMQ. This time on early pregnancy.
The discussion showed up one or two problems with the option list, which is helpful as I might not have appreciated the problem if I had gone over it 50 times myself.

 
Early pregnancy complications.

Lead-in.
The following scenarios relate to early pregnancy. For each, select the most appropriate answer from the option list.
Each option can be used once, more than once or not at all.

Abbreviations.
AFC.         antral follicle count.
AMH.       anti-Mullerian hormone.
CRL.         crown-rump length.
EPU.         early pregnancy unit.
FSH.          follicle stimulating hormone.
GTD.         gestational trophoblastic disease.
GTG 17.    RCOG Green-top Guideline 17. ”Recurrent Miscarriage.”  2003.
GTG 25.    RCOG Green-top Guideline 25. ”The Management of Early Pregnancy Loss.“ 2006.
hCG.         human chorionic gonadotrophin
MEUC.     medical evacuation of uterine contents.
PUL.         pregnancy of unknown location.
PUV.         pregnancy of uncertain viability.
RM.          recurrent miscarriage.
SEUC.       surgical evacuation of uterine contents.
TVS.          trans-vaginal scan
USS.          ultrasound scan

Scenario 1.
A nulliparous woman attends the booking clinic at 8 weeks’ gestation. An ultrasound scan shows a missed miscarriage of a size commensurate with the gestation. What will be your management?

Scenario 2.
A nulliparous woman attends the booking clinic at 8 weeks’ gestation. An ultrasound scan shows a missed miscarriage of a size commensurate with the gestation. She has had two previous pregnancies; both resulted in 1st. trimester miscarriage. What will be your management?

Scenario 3.
A primigravid woman attends the A&E department with abdominal pain and vaginal bleeding. A home pregnancy test was +ve 1 week ago; the date of the LMP is uncertain. What will be your management?

Scenario 4.
A 40-year old woman is pregnant for the first time. Her periods have been erratic for 12 months and she has occasional hot flushes. She attends the A&E department with abdominal pain and vaginal bleeding. The bleeding is slight and her condition is good. An hCG is +ve and a TVS shows an incomplete miscarriage. What will be your management?

Scenario 5.
A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows endometrial thickening but no evidence of intra-uterine pregnancy. No pelvic abnormality is seen. What will be your management?

Scenario 6.
A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows a 15 mm. intra-uterine sac, but no fetus or yolk sac. What will be your management?

Scenario 7.
A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows a 30 mm. intra-uterine sac, but no fetus. What will be your management?

Scenario 8.
A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows an intra-uterine fetus with crown rump length of 5 mm., but no evidence of fetal heart activity. What will be your management?

Scenario 9.
A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows an intra-uterine fetus with crown rump length of 6 mm. Fetal heart activity is seen. What will be your management?

Scenario 10.
A 35-year-old woman attends the A&E department at 6 weeks’ gestation with pain and bleeding. She became pregnant after IVF. An ultrasound scan shows a viable intrauterine pregnancy of a size compatible with the gestation. What will be your management?

We decided that the option list would be better without “J”. So ignore it.
Option List.

A.    Admit as an emergency case.
B.    Counsel and arrange TVS in 1 week.
C.    Counsel and arrange TV colour Doppler scan.
D.    Counsel re expectant management.
E.    Explain diagnosis and counsel re MEUC and SEUC.
F.    Explain diagnosis and counsel re expectant management and MEUC and SEUC.
G.    Explain diagnosis and counsel re expectant management, MEUC and SEUC and refer to the EPU.
H.    Explain diagnosis and counsel re treatment options with accent on the relative merits of SEUC and refer to the EPU.
I.     Explain diagnosis and counsel re treatment options with accent on the relative merits of MEUC and refer to the EPU.
J.     EPU.
K.    Explain diagnosis and refer to the EPU for PUL protocol.
L.    Explain diagnosis and refer to the EPU for PUV protocol.
M.   Manage as ectopic pregnancy until proven otherwise.
N.    Arrange progesterone assay.
O.   Arrange AFC.
P.    Arrange AMH assay.
Q.   Arrange serial hCG monitoring for 48 hours.
R.    Administer anti-D immunoglobulin.
S.    Administer ergometrine 0.5 mg i.m.
T.    Prescribe mifepristone.
U.    Prescribe misoprostol for vaginal use.
V.    Continue with routine booking.

Then we wrote an essay plan: "Critically evaluate screening for gynaecological cancer".
 Then we did a roleplay: GP Letter. “Mrs Jones is planning to be pregnant. Her sister recently had a baby with Down’s syndrome. Please see and advise”.
It may seem daft to be doing OSCE  stuff when we are preparing for the written.
But it is good to start thinking about the words you are going to use e.g. to introduce yourself and to practise them over and over so that they are routine when you get to the OSCE.
Yes, we will practise them in the OSCE training, but it makes sense to have a good idea of what suits you by the time we get there.
Finally we wrote an essay plan for: "Critically evaluate the 10 Top Recommendations in the recent maternal mortality report".
I am sure that this will come as an essay or a viva one day. It would make a killer topic. Once the examiners have thought of it, I am sure they will introduce it.
It is also an important subject as they are the Report's top recommendations.
Put it on your last-minute revision list as it is difficult to remember for more than a few days.