Tutorial 30 May 2013

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We started with an EMQ.

EMQ Paper 1, Question 1.

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.

Then we discussed plans for 3 essays.

3	Critically evaluate screening for gynaecological cancer.
4	Cytomegalovirus infection. 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.
5	Audit. You have been asked to perform an audit. Outline the key issues involved in preparing and performing an audit.

Tutorial 27 May 2013

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We started with a chat about how to prepare.
Then we had an EMQ, to illustrate the need to start a last-minute-revision list right away.
And to book a week or study leave immediately before the exam.

EMQ 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 and there is no other explanation for the findings. Cystoscopy shows bullous oedema of the bladder mucosa.

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 we had a short role-play about discussing screening for Down syndrome.
This was meant to highlight the need to start practising communication skills now.
Every patient you see in clinic could be viewed as giving practise in role-play skills or in essay-writing.

Finally we had two essays. These demonstrated the need to develop technique and the only way to do this is by writing lots of essays under exam conditions.

Discuss the non-contraceptive benefits of the combined oral contraceptive.

A 55 year old woman is referred by her General Practitioner after a single episode of post-menopausal vaginal bleeding. Critically evaluate the management.

Please don't waste your time by sitting down for an hour with your books and Greentops.
Send my your versions of the answers and I'll send mine.
Regards,
Tom.