Monday 29 July 2013

Tutorial 29 July 2013

Tutorial.
Website.
Contact us.

You can click on the title or "Tutorial" above to go to Soundcloud and access and download the tutorials.
I am also putting them on Dropbox.
If you want to access the ones on Dropbox, you need a Dropbox account.
You also need to let me know the e-mail address you use for the account.
I can then link your account to my Dropbox files and you can access them whenever you want.

I was a bit late starting the recording, so the first couple of EMQ scenario discussions are missing.
Send me your answer and you will get my written version.
You will note that we are up to essay number 53.
How many have you written?



14
EMQ. Cystic fibrosis
50
You have been asked to give a tutorial on essay-writing to MRCOG part II candidates.
Outline the key aspects of the advice you will wish to convey.
51
You are the SpR in the antenatal clinic. The consultant is absent due to illness and no other consultant is available. A midwife asks you to see a woman whose scan has shown anencephaly.
1. What steps will you take before seeing the woman?         6 marks
2. Justify the approach you will use during the interview.   10 marks
3. What will you do when the interview is over?                     4 marks
52
A 25 year-old woman books at 8 weeks. She has one child, aged 3 years. He has recently had chickenpox diagnosed. Her sister is 38 weeks pregnant.
1.  Justify your initial management.                                            8 marks.
2.  Justify your management for the rest of the pregnancy.  8 marks.
3.  Justify the advice you will give with regard to her sister.  4 marks.
53
Question. Critically evaluate HPV vaccine and its uses.




This question is about cystic fibrosis.
For each scenario choose the option that gives the best answer.
Each option can be used once, more than once or not at all.
And, to make you behave in a model fashion, there is no option list, so you have to decide the correct answer.
Scenario 1.
A woman is 8 weeks pregnant and known to be a carrier of cystic fibrosis.
Her husband is Caucasian.
What is the risk of the child having cystic fibrosis?
Scenario 2.
A healthy woman attends for pre-pregnancy counselling.
Her brother has cystic fibrosis. Her husband is Caucasian.
He has been screened for cystic fibrosis. The test was negative.
What is the risk of them having a child with cystic fibrosis?
Scenario 3.
A healthy woman is a known carrier of cystic fibrosis.
She attends for pre-pregnancy counselling. Her husband has cystic fibrosis.
What is the risk of them having a child with CF?
Scenario 4.
A healthy woman attends for pre-pregnancy counselling. Her sister has had a child with cystic fibrosis.
What is her risk of being a carrier?
Scenario 5.
A woman attends for pre-pregnancy counselling. Her mother has cystic fibrosis.
What is the risk that she is a carrier?
Scenario 6 .
A woman attends for pre-pregnancy counselling. Her mother has cystic fibrosis.
The partner’s risk of being a carrier is 1 in X.
What is the risk that she will have a child with CF?
Scenario 7.
A healthy Caucasian woman is 10 weeks pregnant.
Her husband is a known carrier of cystic fibrosis.
Which test would you arrange?
Scenario 8.
A woman attends for pre-pregnancy counselling. She has read about diagnosing CF using cffDNA from maternal blood. Is it possible to test for CF in this way?
Scenario 9.
A woman and her husband are known carriers of cystic fibrosis.
What is the risk of them having an affected child.
Scenario 10.
A woman and her husband are known carriers of cystic fibrosis.
What can they do to reduce the risk of having an affected child?
Scenario 11.
A woman and her husband are known carriers of cystic fibrosis.
Can CVS exclude an affected pregnancy?
Scenario 12.
A woman with cystic fibrosis has a normal delivery of a healthy, 3.2 kg. baby at term. She has been advised not to breastfeed because her breast milk will be protein-deficient due to malabsorption.
Is this advice correct?
Scenario 13.
A woman with cystic fibrosis has a normal delivery of a healthy, 3.2 kg. baby at term. She has been advised not to breastfeed because her breast milk will contain abnormally low levels of sodium.
Is this advice correct?




Thursday 25 July 2013

Tutorial 25 July 2013

Tutorial.
Website.
Contact us.

The last five minutes of this tutorial are blank. I went to let those attending out of my house and got chatting to one of them.
You can turn off as soon as they are obviously leaving.



Obstetric cholestasis. (OC). 1.
 Lead-in.
The following scenarios relate to the prevalence of OC.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Abbreviations.
GTG:     RCOG’s Green-top Guideline No. 43. April 2011.
OC:        obstetric cholestasis.

Option list.
A.        0.1%
B.        0.5%
C.        0.7%
D.        1 – 1.2%
E.         1.2% to 1.5%
F.         1.5 – 2%
G.       2.4%
H.        3 – 3.5%
I.          5%
J.          7%
K.        15%
L.         white
M.      brown
N.       blue-green
O.       red-brown, striped
P.        no information in the GTG
Q.       none of the above

Scenario 1.
What is the overall prevalence in the UK population?
Scenario 2.
What is the overall prevalence in the Indian and Pakistani Asian populations?
Scenario 3.
What is the overall prevalence in Scandinavia?
Scenario 4.
What is the overall prevalence in Chile?
Scenario 5.
What is the overall prevalence in Araucanian Indians?
Scenario 6.
What is the overall prevalence in Eskimos?
Scenario 7.
What is the incidence of pruritus in pregnancy?
Scenario 8.
What colour of eggs do Araucanian chickens lay?



Obstetric cholestasis. (OC). 2.
Lead-in.
The following scenarios relate to the definition and diagnosis.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Some of the answers are more MCQ than EMQ, i.e. “true” or “false”.

Abbreviations.
gamma GT: gamma-glutamyl transferase
GTG:      RCOG’s Green-top Guideline No. 43. April 2011.
OC:         obstetric cholestasis.

Suggested reading.
The GTG is “must read”.  It is also dealt with in MCQ paper 1, question 41. I don’t think you need to read anything more.

Option list.
A.             true
B.             false
C.             don’t be daft
D.             pruritus of pregnancy with no other explanation which is associated with abnormal LFTs, raised bile acids and pale stools, all of which resolve postnatally
E.              pruritus of pregnancy with no other explanation which is associated with abnormal LFTs, ± raised bile acids and pale stools, all of which resolve postnatally
F.              pruritus of pregnancy with no other explanation which is associated with abnormal LFTs, ± raised bile acids, all of which resolve postnatally
G.            pruritus of pregnancy with no other explanation which is associated with abnormal LFTs (using pregnancy-specific ranges), ± raised bile acids and pale stools, all of which resolve postnatally
H.             pruritus of pregnancy with no other explanation which is associated with abnormal LFTs (using pregnancy-specific ranges), ± raised bile acids, all of which resolve postnatally
I.               levels do not usually rise in pregnancy
J.               mostly originates in the placenta
K.             levels vary with the time of day
L.              no information in the GTG
M.           none of the above

Scenario 1.
The international definition of OC was agreed at a conference in Tokyo in 1985.
Scenario 2.
What is the GTG’s definition of OC?
Scenario 3.
What is the incidence of pruritus in pregnancy?
Scenario 4.
Hepatitis B and C, but not hepatitis A, may cause pruritus and abnormal LFTs in pregnancy.
Scenario 5.
Infection with the Ebstein Barr virus may cause pruritus and abnormal LFTs in pregnancy.
Scenario 6.
The cytomegalovirus may cause pruritus and abnormal LFTs in pregnancy.
Scenario 7.
The herpes zoster virus may cause pruritus and abnormal LFTs in pregnancy.
Scenario 8.
Chronic active hepatitis and secondary biliary cirrhosis are included in the GTG’s list of conditions to be considered in the differential diagnosis.
Scenario 9.
Bilirubin levels are normally elevated in the early stages of OC and remain elevated until the condition resolves after delivery.
Scenario 10.
Liver function tests become abnormal as soon as the pruritus is noted.
Scenario 11.
Levels of bile acids commonly rise significantly after meals making fasting levels mandatory for diagnosis.
Scenario 12.
The upper limit of normal for transaminases, gamma GT and bile acids is about 20% lower in pregnancy.
Scenario 13.
Once a diagnosis of OC has been made, tests of liver function should not be repeated until the puerperium
Scenario 14.
LFTs should be checked weekly until they have returned to normal after delivery of the baby in a case of OC.
Scenario 15.
Once a diagnosis of OC has been made, the activated partial thromboplastin time (APTT) should be measured and a full coagulation screen done if it is prolonged.
Scenario 16.
Delivery at 37 weeks should be recommended because of the risk of FDIU in the later weeks of pregnancy.
Scenario 17.
What additional pre-labour monitoring of fetal welfare is advisable in the third trimester?
Scenario 18.
Prophylactic steroids should be offered at 28 weeks because of the risk of spontaneous premature labour.



46
Critically evaluate palliative treatment in gynaecological oncology.
47
With regard to epidural anaesthesia:
1.  Outline the main differences between it and spinal anaesthesia.  4 marks.
2.   Outline the main techniques and drugs used.     6 marks.
2.  Evaluate the main contraindications.                  4 marks.
3.  Discuss the main uses.                                      6 marks.
48
A woman with BMI of 35 attends for pre-pregnancy counselling.
1. Outline the reasons that obesity is causing concern in relation to pregnancy.   6 marks
2. Justify the investigations you will arrange.  2 marks
3.  Justify your management.                         6 marks
4. Outline the key aspects of antenatal care.   6 marks.  
49
A woman of 48 is referred with erratic vaginal bleeding for six months. She has had an intra-uterine contraceptive in place for five years. She has occasional hot flushes.
1. Justify the things you will focus on in taking her history.  6 marks
2. Justify the investigations you will perform.                      6 marks
3. Justify the advice you will give.                                      8 marks