Contact us.
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16
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EMQ. Early pregnancy complications. Diagnoses to
exclude.
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17
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EMQ. Coroner.
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18
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SBA. Progestogen-only implants
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19
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EMQ. Headache.
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20
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Communication skills.
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16. Early pregnancy.
Diagnoses to exclude.
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.
17. 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.
Suggested reading.
I will put all you need to know into the answer to MCQ Paper 13,
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 and the coronial service?
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.
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 holidays
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
M. to play bagpipes at coronial funerals
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 there. His body is held at
the premises of a local funeral director. 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. 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 visited daily
until going on holiday three weeks before the death. 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 visited
daily up to the day of his death and attended to confirm the death, is on
holiday. 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 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 the 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 after 48 hours. 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 some hours later in a shocked condition. She is given the
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 minutes when the baby is
declared dead. What action should be taken with regard to the coroner?
18. Progestogen-only
Implants.
Abbreviations.
ENG: etonorgestrel
LNG: levonorgestrel
Question 1.
Lead-in
Pick the best option from the list below in relation to the
hormone in Nexplanon.
Option List
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68 mg. ENG
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100
mg. ENG
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100
mg. LNG
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150
mg. LNG
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50
mg. ENG + 100 mg. LVG
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Question 2.
Lead-in
How
does Nexplanon act as a contraceptive?
- mainly by inducing anovulation
- mainly by altering cervical mucus to the detriment of sperm transport
- mainly by thinning the endometrium, preventing implantation
- mainly by inducing loss of libido
Choose
the best option from the list below.
Option List
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I
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I
+ II
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I
+ III
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II
+ III
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III
+ IV
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Question 3.
Lead-in
What is the age range, if any, for which Nexplanon is licensed in
the UK?
Option List
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15 – 50 years
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18
– 40 years
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18
– 45 years
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20
– 50 years
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None
of the above.
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Question 4.
Lead-in
A
woman who is not in the licensed age range requests a Nexplanon. How should the
advising doctor proceed?
Option List
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Advise her about alternative licensed contraceptive methods, but
decline to insert Nexplanon
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Advise
her about alternative licensed contraceptive methods and insert Nexplanon
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Fit
her with a LNGIUS
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Refer
her to a colleague who fits anyone who asks with a Nexplanon
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None
of the above
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Question 5.
Lead-in
Which, if any, of the following statements about the pregnancy
rate for women using Nexplanon are true?
Option List
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The pregnancy rate is < 1 per 1,000 women during 3 years of
use
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The pregnancy rate is < 5 per 1,000 women during 3 years of
use
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The pregnancy rate is < 10
per 1,000 women during 3 years of use
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The
pregnancy rate is 10-20 per 1,000 women during 3 years of use
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None
of the above
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Question 6.
Lead-in
Which, if any, other implants are licensed in the UK?
Option List
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Implanon
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Norplant
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Norplant-2
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Jadelle
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None
of the above
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Question 7.
Lead-in
What are the main differences between Nexplanon and Implanon?
Pick
the most suitable answer from the list below.
Option List
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The dosage was increased from 60 to 68 mg. etonorgestrel
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The
dosage was increased from 150 – 175 mg. levonorgestrel
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Barium
sulphate was added to Nexplanon to make it radio-opaque
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The
number of rods was reduced to 2
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None
of the above
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Question 8.
Lead-in
What problems is the new applicator designed to minimise?
- non-insertion
- deep insertion
- difficulty with one-handed insertion
- difficulty with left-handed insertion
- difficulty with insertion in very thin women.
Option List
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I + II + III + IV
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I + II + III + IV + V
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II + III
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II + III + IV
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II + III + IV + V
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Question 9.
Lead-in
How long is Nexplanon licensed for?
Option List
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1 year
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2
years
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3
years
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5
years
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10
years
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Question 10.
Lead-in
What does NICE recommend that patients be told about bleeding
patterns with Nexplanon?
- menstrual bleeding may cease
- menstrual bleeding may become prolonged
- bleeding may become more frequent
- menstrual bleeding may become less frequent
- intermenstrual bleeding can be a problem in the first 6 months
Option List
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I + II + III
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I
+ II + III + IV
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II
+ III + IV + V
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I
+ III + IV
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I
+ III + IV + V
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Question 11.
Lead-in
What
information should women be given about the effect of Nexplanon on pain?
Option List
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Dysmenorrhoea may increase
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Dysmenorrhoea
may decrease
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Mittelschmerz is likely to cease
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Pain
due to endometriosis is likely to decrease
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Dyspareunia
is likely to be alleviated
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Question 12.
Lead-in
A
25-year old nulliparous woman has been found to have a few spots of endometriosis
in the pouch of Douglas at laparoscopy for pelvic pain. She wishes to avoid
pregnancy for 5 years but then wishes to have two children. She has read an
article suggesting that a progesterone-only implant provides high levels of
contraceptive efficacy and good results in suppressing endometriosis. What
advice will you give?
Option List
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Recommend a low-dose COC and tricycling as the best means of
suppressing endometriosis plus providing effective contraception
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Recommend a low-dose COC taken continuously as the best means of
suppressing endometriosis plus providing effective contraception
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Recommend
Nexplanon as the best means of suppressing endometriosis plus providing
effective contraception
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Recommend
Depot-Provera as the best means of suppressing endometriosis plus providing
effective contraception
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None
of the above
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Question 13.
Lead-in
When
can a Nexplanon be inserted with no need for additional contraception in a
woman with regular menstrual cycles and no contraindication to its use?
Option List
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Up to and including day 3 of menstruation
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Up
to and including day 5 of menstruation
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Up
to and including day 7 of menstruation
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Never
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None
of the above
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Question 14.
Lead-in
A
healthy 25 year-old-woman is recovering well from a normal delivery. She is not
breastfeeding and wishes to start Nexplanon.
Option List
Pick the best statement from the list below.
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No additional contraception is needed if Nexplanon is inserted
by day 7
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No
additional contraception is needed if Nexplanon is inserted by day 14
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No
additional contraception is needed if Nexplanon is inserted by day 21
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No
additional contraception is needed if Nexplanon is inserted by day 28
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No
additional contraception is needed if Nexplanon is inserted by day 42
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Question 15.
Lead-in
A
healthy 20-year-old woman wishes to switch from a COC to Nexplanon. What rules
apply to the need for additional contraception?
- If insertion takes place on day 1 of the hormone-free week, no additional contraception is needed.
- If insertion takes place on day 5 of the hormone-free week, additional contraception is needed for 7 days.
- If insertion takes place in week 2 after the hormone-free week, no additional contraception is needed.
- If insertion takes place in week 3 after the hormone-free week, no additional contraception is needed.
Option List
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I
|
|
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I
+ II
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I
+ II + III
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II
+ III + IV
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I
+ II + III + IV
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Question 16.
Lead-in
- Women switching from a POP to Nexplanon should be advised that additional contraception is required for 7 days.
- Women switching from a POP to Nexplanon should be advised that additional contraception is not required.
- Women switching from a LNGIUS to Nexplanon should be advised that additional contraception is required for 7 days.
- Women switching from a LNGIUS to Nexplanon, should be advised that additional contraception is not required.
Option List
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I + III
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I
+ IV
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II
+ III
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II
+ IV
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none
of the above
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19. Headache.
Lead-in.
The following
scenarios relate to headache in pregnancy.
Pick one option from the option list.
Each option can be used once, more than once or not at
all.
Option list.
1. abdominal migraine
2. analgesia overuse headache aka medication overuse headache
3. bacterial meningitis
4. benign intracranial hypertension
5. BP check
6. cerebral venous sinus thrombosis
7. chest X-ray
8. cluster headache
9. severe PET / impending eclampsia
10. malaria
11. meningococcal meningitis
12. methyldopa
13. methysergide
14. migraine
15. MRI brain scan
16. nifedipine
17. nitrofurantoin
18. pancreatitis
19. sinusitis
20. subdural haematoma
21. subarachnoid haemorrhage
22. tension headache
23. ultrasound scan of the abdomen
Scenario 1.
A 40-year-old para 3 is
admitted at 38 weeks by ambulance with severe headache of sudden onset. She
describes it as “the worst I’ve ever had”. Which diagnosis needs to be excluded
urgently?
Scenario 2.
A 32-year-old para 1 has
recently experienced headaches. They are worse on exercise, even mild exercise
such as walking up stairs. She experiences photophobia with the headaches. Which
is the most likely diagnosis?
Scenario 3.
A woman returns from a
sub-Saharan area of Africa. She develops severe headache, fever and rigors.
What diagnosis should particularly be in the minds of the attending doctors?
Scenario 4.
A woman at 37 weeks has developed headaches. They
particularly occur at night without obvious triggers. They occur every few days
and she then has
Scenario 5.
A primigravida has had headaches on a regular basis for
many years. They occur most days, are bilateral and are worse when she is
stressed. What is the most likely diagnosis?
Scenario 6.
A woman complains of recent
headaches at 36 weeks. The history reveals that the headaches started soon
after she began treatment with a drug prescribed by her GP. Which is the most
likely of the following drugs to be the culprit: 7. methyldopa, methysergide, nifedipine and Nitrofurantoin?
Scenario 7
A woman is booked for Caesarean
section and wishes regional anaesthesia. She had severe headache due to dural
tap after a previous Caesarean section. She wants to take all possible steps to
reduce the risk of having this again. Which of epidural and spinal anaesthesia
has the lower risk of causing dural tap headache?
Scenario 8
A 25-year-old primigravida
complains of headaches which started two weeks before when she attends for her
20 week scan. There is no significant history of previous headache. The pain
occurs behind her right eye and she describes it as severe and “stabbing” in
nature. The pain is so severe that she cannot sit still and has to walk about.
She has noticed that her right eye becomes reddened and “watery” during the
attack and her nose is “runny”. The attacks have no obvious trigger and mostly
occur a few hours after she has gone to sleep. The usually last about 20
minutes. She has no other symptoms. She smokes 20 cigarettes a day but does not
take any other drugs, legal or otherwise. What is the most likely diagnosis?
Scenario 9
A woman has a 5-year history of
unilateral, throbbing headache often preceded by nausea, visual disturbances,
photophobia and sensitivity to loud noise. What is the most likely diagnosis?
Scenario 10
A primigravida is admitted at 38 weeks complaining of
headache, abdominal pain and a sensation of flashing lights. What would be the
appropriate initial investigation?
Scenario 11
A woman with BMI of 35 attends for her combined Downs
syndrome screening test. She complains of pain behind her eyes. The pain is
worst last thing at night before she goes to sleep or if she has to get up in
the night. She has noticed she has noticed horizontal diplopia on several
occasions. She has no other symptoms. Examination shows papilloedema.
Scenario 12
A grande multip of 40 years experienced sudden-onset,
severe headache, vomited several times and then collapsed, all within the space
of 30 minutes. She is admitted urgently in a semi-comatose state. Examination
shows neck-stiffness and left hemi-paresis.
Scenario 13.
What did the MMR include as
“red flags” for headache in pregnancy?
