Tutorial 21 February 2013

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This was the last tutorial before the written exam: next week is for last-minute-revision.
We usually re-start on the Monday after the exam, which will be Monday  11th. March.
I'll e-mail nearer the time.
It is important to start your OSCE practice straight away as there is a lot to do.
Don't leave it until the results of the written are published.
We managed 4 essay topics, bringing the total to 81.
We usually find that at least half of the SAQs have been covered in the tutorials.
We also managed an EMQ.
The subject matter may seem a bit specialist, but the questions are based on things that people have remembered from the exam.

With regard to uterine rupture:

1. how is uterine rupture graded?                                 2 marks

2. critically evaluate the risk factors for uterine rupture.  6 marks

3. critically evaluate the diagnosis of uterine rupture.     6 marks

4. outline the management.                                         6 marks   

You see a 25-year-old primigravida at 30 weeks’ gestation in the antenatal clinic after referral by the community midwife who feels that the uterus is large-for-dates.

1. Justify your immediate management.                                6 marks.

2. Justify the management of the remainder of the pregnancy. 4 marks

3. Justify the management of the delivery.                              6 marks

4. Justify the advice you will give post-delivery.                       4 marks    

A 53-year-old woman is referred by her GP. She wishes to discuss HRT. She is recovering well from treatment for endometrial cancer.

1. Outline the history you will take.                      4 marks

2. Justify the investigations you will arrange.         2 marks

3. Critically evaluate your management.              14 marks              

A 35 year-old woman books at 6 weeks. She has noted a left breast mass. Breast cancer is suspected.

1. What is the life-time risk of female breast cancer.         1 mark.

2. How does pregnancy affect the risks of breast cancer.  4 marks.

3. Outline the investigation.                                            5 marks.

4. Critically evaluate the management.                          10 marks.              

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 14 February 2013

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Tonight we managed an EMQ and 4 essay topics.

Essays 14 February 2013.

EMQ. Down syndrome screening.           

A 55 year old woman is referred with loss of libido.

1. Outline the key points in the history.              8 marks

2. Outline the investigations you will arrange.     4 marks

3. Critically evaluate the management.               8 marks               

Discuss the contra-indications to the use of the COC.    

An 88-year-old woman with severe Alzheimer’s disease has been admitted to the orthopaedic ward after a fall. Vaginal bleeding has been noted. You have been asked to see her.

1. Justify the history you will take.                         6 marks

2. Justify the investigations you will arrange.           2 marks

3. Justify your management.                                12 marks   

It is Saturday morning.  You are the on-call SpR for gynaecology and have been asked for help by the locum Registrar in A&E.

A man has returned from Africa on a surprise visit home. On arrival he cut his finger on a kitchen knife and has attended A&E for treatment.  He is accompanied by his wife. His finger has been cleaned and two sutures have been inserted. Prior to treatment he mentioned that he was found to be HIV+ve as a result of extra-marital heterosexual activity in Africa and was started on anti-retroviral therapy there. He refuses to disclose his HIV status to his wife as she would “go mad” if she were to discover his infidelity. She has asked for contraceptive advice as he was not due to return for several months and she stopped contraception when he left 3 months before. The A&E Consultant has gone out to a major road traffic accident and is not expected to be available for about an hour. The husband is not prepared to await his return. The sexually-transmitted disease STD clinic is closed and will not open until Monday. You have spoken to your Consultant who has said he doesn’t want to know and that you have to “get on with it”. Outline and justify your management.

Lead-in.

The following scenarios relate to screening for Down’s syndrome.

Pick one option from the option list.

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

Scenario 1.

a.              What is the age-related risk of DS at 20 years?

Scenario 2.

b.             What is the age-related risk of DS at 30 years?

Scenario 3.

c.              What is the age-related risk of DS at 35 years?

Scenario 4.

d.             What is the age-related risk of DS at 40 years?

Scenario 5.

e.             What is the age-related risk of DS at 45 years?

Scenario 6.

AFP levels are lower in Ds.

Scenario 7

Inhibin levels are raised in DS.

Scenario 8

Oestriol levels are raised in DS.

Scenario 9

β-hCG levels are raised in DS.

Scenario 10

1^st. trimester PAPP-A levels are lower in DS.

Scenario 11

2^nd. trimester PAPP-A levels are normal in DS.

                

Tutorial 11 February 2013

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Tonight we had a shorter tutorial than usual.
Only James and Patrice came and James was on call and had to leave early.
We discussed the EMQ and first essay.
Write your answers for all the essays and EMQ and send them.

EMQ. Mental Capacity Act.

A 16-year-old virgin is referred with dysmenorrhoea. You are the SpR and see her in the gynaecology clinic. She is accompanied by her mother.

a.         justify the history you will take.                      8 marks

b.         justify the investigations you will arrange.    4 marks

c.         critically evaluate your management.           8 marks.                     

A woman is referred after her third consecutive miscarriage at 10 weeks.

1. outline the key features in the history you will take.                                 4 marks

2. list the main causes of recurrent miscarriage.                                          4 marks

3. critically evaluate the investigations you will arrange.                             6 marks

4. critically evaluate the available treatments for recurrent miscarriage.              6 marks                                                                

           

A girl of 15 is referred to the gynaecology clinic. She is concerned because she has not started to menstruate although all her friends have.

1. Justify the history you will take.                 6 marks

2. Justify the investigations you will arrange.            6 marks

3. Justify your management                              8 marks       

With regard to vulval cancer.

1. critically evaluate screening.                                                       2 marks.

2. outline the FIGO staging system.                                                6 marks.

3. critically evaluate the modern approach to management.  12 marks     

 Mental Capacity Act 2005.

Lead-in.

The following scenarios relate to the Mental Capacity Act 2005.

Pick one option from the option list.

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

Abbreviations.

CAD:      Court-appointed Deputy.

COP:      Court of Protection.

FGR:      fetal growth restriction.

LPA:       Lasting Power of Attorney.

MCA:    Mental Capacity Act 2005.

PoA:      Power of Attorney.

Option list.

A.        Yes

B.        No

C.        True

D.        False

E.         Does not exist

F.         The husband

G.       A parent

H.        The child

I.          the General Practitioner

J.          the Consultant

K.        the Registrar

L.         The Consultant treating the patient

M.      A Consultant not involved in treating the patient

N.       The Medical Director

O.       A person with Powers of Attorney

P.        The sheriff or sheriff’s deputy

Q.       Balance of probabilities

R.        Beyond reasonable doubt

S.         None of the above.

Scenario 1.

A person with LPA is normally not a family member.

Scenario 2.

A Sheriff’s Deputy is normally not a family member.

Scenario 3.

A person with PoA can consent to treatment for the patient who lacks capacity.

Scenario 4.

A Court-appointed Deputy can consent to treatment for the patient who lacks capacity, but must go back to the Court of Protection if further consent is required for additional treatment.

Scenario 5.

A person with PoA can authorise withdrawal of all care except basic care in cases of individuals with persistent vegetative states.

Scenario 6.

An advance decision can authorise withdrawal of all but basic care in cases of persistent vegetative states.

Scenario 7

A person with PoA cannot overrule an advance direction about withdrawal or withholding of life-sustaining care.

Scenario 8

A woman is seen in the antenatal clinic at 39 weeks’ gestation. Her blood pressure is 180/110 and she has +++ of proteinuria on dipstick testing. She has mild epigastric pain. A scan shows evidence of FGR with the baby on the 2^nd. centile. Doppler studies of the umbilical artery are abnormal and a non-stress CTG shows loss of variability and variable decelerations. She is advised that she appears to have severe pre-eclampsia and is at risk of eclampsia and of intracranial haemorrhage. She is told of the associated risk of mortality and morbidity. She is also advised that the baby is showing evidence of severe FGR and has abnormal Doppler studies and CTG which could lead to death or hypoxic damage. She declines admission or treatment. She says she trusts in God and wishes to leave her fate and that of her baby in His hands. She is seen by a psychiatrist who assesses her as competent under the MCA and with no evidence of mental disorder. The obstetrician wants to apply to the COP for an order for compulsory treatment. Can he do this?

Scenario 9

A woman is admitted at 36 weeks’ gestation with evidence of placental abruption. She is semi-comatose and shocked. There is active bleeding and the cervical os is closed. Fetal heart activity is present but with bradycardia and decelerations. The consultant decides that Caesarean section is the best option to save her live and that of the baby. When reading the notes, the registrar comes across an advance notice drawn up by the woman and her solicitor. It states that she does not wish Caesarean section, regardless of the risk to her and the baby. The consultant tells the registrar that they can ignore it now that she is no longer competent and get on with the Caesarean section for which she will be thankful afterwards. The registrar says that the advance notice is binding. Who is correct?

7 February 2013

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Tonight we had a tutorial on medical statistics by Julie Morris.
The questions she discussed were:

1.      Weight gain in pregnancy was measured in a sample of 1000 women. Summary statistics of the weight gain were calculated.  (Answer yes/no to each statement)-

A      The median is the weight gain value which occurs most frequently

B      If weight gain was found to have a positively skewed distribution, the mean will be less than the median.

C      The interquartile range is unaffected by outliers

D     A large positive outlier will increase the mean

E      The median is affected by outliers

2.      For a cohort of babies, birthweight was considered to be Normally distributed with a mean of 3000g and a standard deviation of 500g. It follows that: (Answer yes/no to each statement)-

A      All birthweights must be less than 4500g

B      The distribution of birthweights is skewed

C      About 50% of birthweights are above 3000g

D     About 2.5% of birthweights are below 2000g

E      About 95% of birthweights are between 2500g and 3500g

3.      Theme: Summary statistics

         A     mean                                               E          interquartile range

         B      standard deviation                           F          percentage

         C      range                                               G          mode

         D     median                                            H          standard error

        

         For each type of data description given below choose the SINGLE most appropriate summary statistic. Each option may be used once, more than once, or not at all.   

1.     The variability of length of hospital stay for 230 mothers following a caesarean, where length of stay is Normally distributed.

2.     The extremes of length of hospital stay for 230 mothers following a caesarean, where length of stay is Normally distributed

3.       The elective caesarean section rate in a hospital for 2011

4.      To assess the effectiveness of a new antenatal screening test, 100 pregnant women over 45 years of age, were screened.  25 women subsequently had babies with mild congenital problems. 20 of these 25 women had a positive screening test result. 65 of those with normal babies had a negative test result. (Answer yes/no to each statement).

A      The predictive value of a positive test result  as a marker for congenital problems is 20/35

B      The sensitivity of the test will not depend upon the prevalence of congenital problems in the cohort of women to which it is applied

C      The sensitivity of the screening test is 20/100

D     The specificity of the screening test is 65/75

E      Specificity=1-sensitivity

5.      In a study looking at the relationship between blood pressure during pregnancy and fetal growth, 130 women had their 24-hour blood pressure readings taken in mid-pregnancy. The size of the baby was recorded at birth. The Pearson correlation between blood pressure and birthweight was found to equal -0.70 with an associated p-value of  p<0.001.

         (Answer yes/no to each statement):

A      Blood pressure  explains 70% of the variability in birthweight

B      We can conclude that increasing blood pressure is a cause of low birthweight

C      A correlation of zero is interpreted as showing no association between two variables

D     The correlation between blood pressure and birthweight can be different from the correlation between birthweight and blood pressure

E      There is a significant negative linear  relationship between blood pressure and birthweight

6.      In a study of 75 infants with median gestational age 30 weeks (range 25 to 42 weeks), lung area was calculated from chest radiographs and lung volume from measurements of FRC. The aim of the study was to see whether lung area would predict lung volume in neonates.  (choose just one).

A      Chi-square test

B      Correlation coefficient

C      Mann-Whitney U-test

D     Regression analysis

         E      Two-sample t-test

7.      A cohort of women experiencing nausea and vomiting in pregnancy were given acid-reducing medication. The Pregnancy-Unique Quantification of Emesis and nausea (PUQUE) score was recorded before and after treatment. The clinical effect of the medication could be evaluated using: (Answer yes or no to each statement):

A      The Student paired t-test

B      The Spearman correlation coefficient

C      The Wilcoxon matched-pairs test

D     The Sign test

E      The Mann-Whitney U-test

8.      Theme: Statistical significance tests

         A     Chi-square test                                F          Spearman correlation

         B      Two-sample t-test                            G          Mann-Whitney U-test

         C      Pearson correlation                          H          Wilcoxon test

         D     Fisher’s Exact test                            I           Paired t-test

         E      Linear regression                             J           ANOVA

         For each of the studies described below choose the SINGLE most appropriate statistical test. Each option may be used once, more than once, or not at all.   

1.        A comparison of two audits (2011 vs 2006) of smoking habits of pregnant women looking at the percentage of current smokers.

2.       In a cohort of 500 pregnant women, maternal cotinine levels (an indicator of exposure to cigarette smoke) were measured. The aim of the study was to see whether high maternal cotinine levels were related to subsequent birthweight. It was assumed that cotinine levels would have a highly skewed distribution.

3.       Adrenaline concentrations were measured in 30 mechanically-ventilated babies at 1 hour and 24 hours to assess whether there had been a significant change. The adrenaline concentrations cannot be assumed to follow a Normal distribution.

9.      In a study of diet and epithelial ovarian cancer, 128 women with cancer and 251 women without cancer were asked about their consumption of dairy products. 50% of cancer patients and 10% of controls reported consuming yoghurt regularly: (Answer yes or no to each statement):

A      This is a cohort study

B      The odds ratio is 9

C      The odds ratio is 5

D     The relative risk can be estimated by an odds ratio if the disease is rare and the cases and controls are random samples from the same population.

E      An odds ratio of 0 indicates no difference between cancer patients and controls in the consumption of yoghurt.

10.    In a study of the effect of a new antibiotic therapy for bacterial vaginosis in pregnancy, the infection response rate for women on the new antibiotics was 0.4, whereas it was 0.2  in the control group (p=0.03). (Answer yes or no to each statement):

A      The infection response rate was significantly lower in the control group.

B      The NNT is the difference in the number of infection-free women in the treated group compared to the control group

C      The NNT=5

D     The NNT=2

E      The NNT is the number of women needed to receive the intervention to see one additional occurrence of the outcome in the treatment group

We then discussed a couple of essay topics:

A nulliparous woman notices reduced fetal movements at 37 weeks and phones the delivery unit for advice.

1.  Outline the immediate management.    6 marks

2.  Justify the subsequent management.  12 marks. 

A woman attends the antenatal clinic at 36 weeks. She has read an article in a woman’s magazine about the merits of umbilical cord blood banking and would like to have this done.

1. Justify the history you will take.                       4 marks

2. Justify the investigations you will arrange.     2 marks

3. Justify your management.                               14 marks