Tutorial 28 June 2012

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Tonight we had an EMQ and 4 essays.
As usual, send me your answers and I'll send mine.
 

Confidentiality.

Lead-in.

The following scenarios relate to confidentiality.

For each, select the number that best fits the scenario.

Pick one option from the option list.

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

Option list.

This EMQ has not option list. This is to make you decide your answers. Send them to me and I’ll send my version including what I think an option list might have looked like.

Scenario 1.

A 15-year-old girl attends the TOP clinic requesting TOP. She is assessed as Fraser competent. After full discussion arrangements are made for her admission for TOP. She does not wish her parents to be informed. Her mother attends clinic 1 hour after the child has left. She demands full information about her daughter. The consultant has delegated you to deal with her. Which option best fits the action you will take?

Scenario 2.

A 17-year-old A-level student attends the gynaecology clinic requesting TOP. She is accompanied by her 30-year-old mathematics teacher, who is her lover and wishes to give consent. Which option best fits the action you will take?

Scenario 3.

A 12-year-old girl attends the gynaecology clinic with her mother seeking contraceptive advice. She has an 18-year-old boyfriend whom the parents like and she wishes to start having sex. Which option best fits the action you will take?

Scenario 4.

A 15-year-old girl who is Fraser competent is referred to the gynaecology clinic with a complaint of vaginal discharge. She reveals that she has been having consensual sexual intercourse for six months with her 18-year-old boyfriend. She asks for advice about suitable contraception as she is happy in the relationship and wants to continue to have sex. Which option best fits the action you will take?

Scenario 5.

You are the new oncology consultant and have just operated on the wife of a local General Practitioner for suspected ovarian cancer. The diagnosis is confirmed and you proceed with appropriate surgery. On completion of the operation you go to the surgeon’s room for a coffee. The senior consultant anaesthetist who was not involved in theatre but is the Medical Director and tells you he is a close friend of the woman, asks what the diagnosis and prognosis are. Which option best fits the action you will take?

Scenario 6.

You are phoned by a doctor looking for information about his wife’s results from the booking clinic she attended two weeks ago. He says that she has given consent for disclosure. She has given a history of 2 terminations but no other pregnancies. She is Rhesus negative, but has Rhesus antibodies. Which option best fits the action you will take?

Scenario 7

You are phoned by a doctor looking for information about his wife’s results from the booking clinic she attended two weeks ago. He says that she has given consent for disclosure. Her serology tests have proved +ve for syphilis. You have spoken to the consultant bacteriologist who says that they have run confirmatory tests and they are +ve too. He is sure the woman has active syphilis. Which option best fits the action(s) you will take?

Scenario 8

A 15-year-old girl attends the TOP clinic requesting TOP. She is assessed as Fraser competent. After full discussion arrangements are made for her admission for TOP. She does not wish her parents to be informed despite your best efforts to persuade her. Who will give consent for the procedure?

Scenario 9

An immature 15-year-old girl attends the gynaecology clinic requesting TOP. She is accompanied by her 25-year-old sister who is a lawyer with whom she has been staying since she knew she was pregnant. She does not want her parents to be informed. The girl is assessed as not Fraser competent. The sister says that she is happy to act in loco parentis and to give consent. Which option best fits the action(s) you will take?

Scenario 10

A 25-year-old woman with Down’s syndrome attends the clinic accompanied by her mother. She has menorrhagia and copes badly with the hygiene aspects. The menorrhagia is bad enough for her now to be on treatment for iron-deficiency anaemia. She has tried all the standard medical methods. To complicate the problem, she has become close friends with a young man she has met at College, to which she travels independently each weekday. Her mother fears that she may already be involved in sexual activity and cannot get an accurate answer from her about it. The mother is keen for her to have hysterectomy to deal with both problems. If you agree that the surgery is appropriate, who can give consent?

Scenario 11

A 25-year-old woman with Down’s syndrome is admitted from College after collapsing. The clinical features are of ectopic pregnancy and she states that she has UPSI with her boyfriend of six months. She has tachycardia and hypotension and it is felt that she should have urgent surgery. You reckon that she is not competent to consent for surgery. Who can give consent?

Scenario 12

A 25-year-old woman with Down’s syndrome is admitted from College after collapsing. The clinical features are of ectopic pregnancy and she states that she has UPSI with her boyfriend of six months. She has tachycardia and hypotension and it is felt that she should have urgent surgery. You reckon that she is not competent to consent for surgery. What limits are there on the surgery?

1. 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.          

2. With regard to cervical cancer:

1. Describe the FIGO staging.                                            12 marks

2. Critically evaluate the FIGO staging classification.      8 marks    

3. With regard to fetal welfare in labour.

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

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

4.  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.      

Tutorial 25 June 2012

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Tonight we had four essays and an EMQ.

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 definition and main causes of premature ovarian failure.   10 marks

2.  Critically evaluate the management options.           10 marks   

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

A 23-year-old primigravida with no known risk factors for premature delivery presents at 26 weeks' gestation with a history of uterine contractions and vaginal fluid loss.

1. Describe your assessment. 10 marks

2. Discuss your management assuming premature rupture of the membranes is confirmed.

With regard to ovarian hyperstimulation syndrome:

1.            Outline the risk factors.                                                   4 marks

2.            Discuss the classification system.                                6 marks

3.  Outline the key aspects of the management.                10 marks

 

EMQ. Early pregnancy.

Lead-in.

The following scenarios relate to early pregnancy.

For each, select the diagnosis you most want to exclude.

Pick one option from the option list.

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

Scenario 1.

A 35-year-old primigravida is seen in the EPU with vaginal bleeding and severe left iliac fossa pain. The pregnancy occurred after four cycles of IVF and embryo transfer was performed six weeks ago. Her β-hCG is >1,000 iu/l. An ultrasound scan showed an intra-uterine pregnancy of an appropriate size for the gestation. Normal fetal heart activity was noted. No adnexal masses were seen.

Scenario 2.

A 25-year-old woman with known PCOS is seen in the early pregnancy unit after an episode of slight vaginal bleeding. Her LMP was 10 weeks ago. An ultrasound scan shows an intra-uterine pregnancy with CRL of 6 mm. No fetal heart activity is seen.

Scenario 3.

A GP phones for advice. She is conducting her morning surgery. A nulliparous woman at 6 weeks’ gestation has returned from France where she has enjoyed the local food, particularly unpasteurised soft cheese and pork meats. She has presented with diarrhoea and mild abdominal pain. A β-hCG is 25 iu/l. She is concerned about listeriosis and toxoplasmosis, about which she has read.

Scenario 4.

A 30-year-old parous woman attends the EPU with vaginal bleeding and lower abdominal pain. An ultrasound scan shows a 30 mm. intra-uterine sac but no evidence of fetal heart activity.

Scenario 5.

 A 45-year-old para 6 is admitted to the A&E department with 6 weeks’ amenorrhoea. A β-hCG is positive. She complains of retrosternal pain and has a history of heartburn and acid reflux. Her BMI is 30. She smokes 40 cigarettes daily and has COAD.

Option list.

Complete miscarriage.

Incomplete miscarriage.

Missed miscarriage.

Pregnancy in a uterine horn.

Ectopic pregnancy.

OHSS.

Ovarian torsion.

Ovarian cyst accident.

Hydatidiform mole.

Listeriosis.

Toxoplasmosis.

Crohn’s disease

Ulcerative colitis.

Duodenal ulceration.

Pulmonary embolism.

Pneumothorax.

Coronary thrombosis.

None of the above.

Tutorial 7 June 2012

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Tonight we had an EMQ and 3 essays.

 

EMQ: Turner’s  syndrome.

This is supposed to be an EMQ, but some of the questions are MCQs with “True” and “False” answers, so I have put these in the answer list. But it includes everything I think you might be asked about Turner’s.

Option list

1 in   500

1 in 1,000

1 in 1,500

1 in 2,000

1 in 2,500

1 in 3,000

1 in 10,000

1 in 50,000

0%

0.1%

1 %

2%

5%

10%

15%

20%

25%

30%

40%

50%

60%

70%

80%

90%

> 90%

Most common

2^nd. most common

True

False

Answer not on this option list.

Questions.

1.      TS is due to 45XO.                                                

2.      What is the incidence of TS?                                  

3.      The incidence of TS rises with maternal age?           .

4.      Most cases of TS are due to loss of a paternal chromosome. 

5.      How common in monosomy X in TS?                     

6.      How common is monosomy Y in TS?                     

7.      What % of miscarriages are due to TS?                  

8.      What % of TS pregnancies miscarry?                     

9.      ↑ NT is a feature of TS                                           

10.    ↑ NT is a feature of congenital heart disease           

11.    Low birth weight is a feature of TS.                         .

12.    If TS is suspected, but the neonate’s karyotype from blood testing is normal, the diagnosis is Noonan’s syndrome.                               .

13.    Neonates are at normal risk of developmental dysplasia of the hip. 

14.    Immune hydrops is more common in TS.                

15.    Cystic hygroma is more common in TS.                 

16.    What is the approximate risk of malignancy if there is XY mosaicism in TS?

17.    How common is webbing of the neck in TS?                       

18.    How common is an occipital hairline in TS?             

19.    How common is congenital heart disease in TS?     

20.    Dissecting aortic aneurysm is more common in TS.

21.    How common is lymphoedema in TS?                    

22.    How common is kidney disease in TS?                   

23.    Short stature in TS has been linked to the TS gene. 

24.    What % of adolescents with TS have scoliosis.       .

25.    Inverted nipples are more common in TS.               

26.    1ry. amenorrhoea occurs in all cases.                     

27.    Adrenarche occurs at a normal time.                       

28.    Cubitus valgus is more common in TS.                   

29.    Cleft palate if a feature of TS.                                

30.    Micrognathia is a feature of TS.                             

31.    Abnormalities of teeth and nails are more common in TS.    

32.    Otitis media is more common in TS.                                   

33.    Intelligence is usually lower in TS, especially verbal skills.   

34.    Women with TS have higher mortality rates than other women..

35.    Oestrogen should be started on diagnosis to promote bone growth.  .

36.    Oestrogen-only HRT is appropriate for bone protection.      

37.    Women with TS have an ↑ risk of hypertension.      

38.    Women with TS have an ↑ risk of coeliac disease.  

39.    Women with TS have an increased risk of Crohn’s disease and ulcerative colitis. 

40.    Women with TS have an ↑ risk of diabetes              

41.    Women with TS have an ↑ risk of hyperthyroidism.  

42.    Women with TS have an ↑ risk of deafness. .

43.    Women with TS have an ↑ risk of osteoporosis.

44.    Women with TS have similar rates of red-green colour blindness as men.  

45.    Women with TS have a normal incidence of ptosis. 

46.    Women with TS cannot have children.

47.    The “short stature homeobox” (SHOX) gene has been implicated in TS

A 25-year-old primigravida attends the antenatal clinic at 36 weeks. She has read a magazine article about delayed cord clamping. DCC.

1. Outline the factors that make DCC unwise.                                         6 marks.

2. Justify the advice you will give about the risks & benefits of DCC.  8 marks.

3. Outline the arrangements necessary for DCC.                                    6 marks.          

In relation to coeliac disease and pregnancy.

1.            What is coeliac disease?                                                                                                            2 marks

2.            What are the clinical features in the non-pregnant?                                       4 marks.

3.            How is coeliac disease diagnosed?                                                               4 marks.

4.            What are the implications of coeliac disease for the pregnant woman?    6 marks.

5.            Evaluate the management options in relation to pregnancy.                     4 marks              

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.

Tutorial 4 June 2012

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Tonight we had an EMQ and 4 essays.
 

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.
To make you use correct EMQ technique, the option list is not there.
So, you have to come up with an answer.

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?

 

A 35-year-old woman plans to go to a malarial area of Africa to join her husband who works there. She is 6 weeks pregnant. Critically evaluate the advice you will give her.

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.

Critically evaluate the non-contraceptive benefits of the COC.

Critically evaluate asymptomatic bacteruria in relation to pregnancy.

Send me your answers, written under exam conditions and I'll respond with mine.