Friday, 15 August 2014

Tutorial 14 August 2014

Website.
Contact us.

There was no tutorial. These are the topics we would have covered.
Don't waste time researching. Just write the answers using what you already know.
I'll try to ensure all the necessary facts are in my answers.

21
EMQ. Cervical smear management & referral.
14
August
2014
22
EMQ. Antepartum haemorrhage.
14
August
2014
23
EMQ. Ca Cx staging.
14
August
2014
24
EMQ. Drugs in O&G 1.
14
August
2014
71
With regard to the Human Fertilisation and Embryology Act:
1. When was the latest update of the Act and what were the key amendments .       4 marks
2. With regard to the body that oversees the implementation of the Act:
               What is it called?                   1 mark
               What kind of body is it?       1 mark
3. What are the main functions of the body that oversees implementation of the Act?   14 marks
14
August
2014
72
There has been a recent spate of requests for Caesarean section with no medical grounds. The Clinical Director has asked you to produce a provisional policy document on the subject for discussion at a Unit meeting with a view to formulating Unit policy.
14
August
2014
73
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
14
August
2014
74
With regard to UKOSS.
1. What is UKOSS?                                                                                 2 marks
2. Who is responsible for UKOSS and how does it work?               4 marks
3. Critically evaluate the work of UKOSS.                                       14 marks
14
August
2014

Cervical smear management & referral.
Lead-in.
There are too many scenarios and the option list is too long. And some of the “scenarios” are really MCQs. Don’t tell me – I know! I have tried to think of all the questions that could arise. At some point I’ll chop it into several bits to make the option list more sensible. A smaller option list would also allow me to introduce more “tempters” that sound as though they should be the correct answer.

The following scenarios relate to the management of cervical smears.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Abbreviations.
ALOs:              actinomyces-like organisms
BSCCP            British Society for Colposcopy and Cervical Pathology. http://www.bsccp.org.uk/
CIN:                 cervical intraepithelial abnormality
CGIN:             cervical glandular intraepithelial abnormality
FSRH:              Faculty of Sexual and Reproductive Health: http://www.fsrh.org/
GUM clinic:  genito-urinary medicine clinic
LBC:                 liquid-based cytology
LLETZ:             large loop excision of the transformation zone
NEC:                normal endometrial cell
NHSCSP:        NHS Cervical Screening Programme: http://www.cancerscreening.nhs.uk/cervical/
                         http://www.cancerscreening.nhs.uk/cervical/index.html
POP:               progesterone-only Pill
TZ:                   transformation zone

Option list.
a.         repeat the test
b.        repeat the test after 6 months
c.         repeat the test at 6 and 12 months
d.        repeat the test at 6 and 12 months and then annually until she has had 10 years’ follow-up followed by repeat tests at the normal intervals for her age
e.        repeat the test after 3 or 5 years according to her age as per routine follow-up
f.          repeat the test after HPV testing
g.         repeat the test after giving an appropriate antibiotic
h.        repeat the test after removing her IUCD.
i.           repeat the test after removing the IUCD and giving an appropriate antibiotic
j.          repeat the test after treating the TZ with diathermy
k.         repeat the test after treating the TZ with cryocautery
l.           discharge from follow-up
m.      refer for colposcopy
n.        refer for colposcopy within 2 weeks
o.        refer for colposcopy within 8 weeks
p.        refer for colposcopy within 12 weeks
q.        refer for colposcopy only if she has other significant signs or symptoms
r.          refer for cone biopsy
s.         refer for fractional curettage
t.          refer for “see and treat” LLETZ
u.        refer to GUM clinic
v.         recommend that she go back to America
w.       there is insufficient information to formulate a management plan
x.         false
y.         true
z.         none of the above
Scenario 1.
A woman with no previous abnormal smears has a routine smear showing an inadequate sample . What management will you suggest?
Scenario 2.
A woman with no previous abnormal smears has had a smear showing borderline nuclear changes.  What management will you suggest?
Scenario 3.
A woman with no previous abnormal smears has had a smear showing borderline nuclear changes. Cervical ectopy is noted.  What management will you suggest?
Scenario 4.
A woman with no previous abnormal smears has had a smear showing borderline cells of endocervical origin. What management will you suggest?
Scenario 5.
A woman with no previous abnormal smears has had a smear showing inflammatory changes.  What management will you suggest?
Scenario 6.
A woman with no previous abnormal smears has had a smear showing  inflammatory changes and ALOs. What management will you suggest?
Scenario 7.
A woman with no previous abnormal smears has had a smear showing  inflammatory changes. She takes the COC for contraception. What management will you suggest?
Scenario 8.
A woman with no previous abnormal smears has had a smear showing  inflammatory changes. She has a copper IUCD. What management will you suggest?
Scenario 9.
A woman with no previous abnormal smears has had a smear showing  inflammatory changes and ALOs. She has had hysteroscopic sterilisation with ESSURE. What management will you suggest?
Scenario 10
A woman with no previous abnormal smears has had a smear showing borderline changes. A repeat smear after 6 months is normal. A repeat smear after 3 years shows inflammatory changes. A repeat smear after 6 months is normal. A repeat smear after 3 years shows borderline changes. What management will you suggest?
Scenario 11
A woman with no previous abnormal smears has had a smear showing mild dyskaryosis of squamous cells. What management will you suggest?
Scenario 12
A woman with no previous abnormal smears has had a smear showing moderate dyskaryosis of squamous cells. What management will you suggest?
Scenario 13
A woman with no previous abnormal smears has had a smear showing severe dyskaryosis of squamous cells. What management will you suggest?
Scenario 14
A woman with no previous abnormal smears has had a smear suggestive invasive disease. What management will you suggest?
Scenario 15
A woman with no previous abnormal smears has had a smear showing borderline nuclear changes in glandular cells. What management will you suggest?
Scenario 16
A woman with no previous abnormal smears has had a smear showing ? glandular neoplasia. What management will you suggest?
Scenario 17.
A woman with no previous abnormal smears has had a smear showing normal endometrial cells. What management will you suggest?
Scenario 18.
A woman with no previous abnormal smears has had a smear showing atypical endometrial cells. What management will you suggest?
Scenario 19
A woman with no previous abnormal smears has had a smear with a normal result. Clinical examination was normal, but contact bleeding was noted when the smear was taken. What management will you suggest?
Scenario 20
An American woman with no previous abnormal smears has been used to having annual smears. She has had a smear with a normal result and requests a repeat in 12 months. What management will you suggest?
Scenario 21
A woman with no previous abnormal smears is on renal dialysis and has had a smear with a normal result. What management will you suggest?
Scenario 22
A HIV +ve woman with no previous abnormal smears has had a smear with a normal result. What management will you suggest?


Scenario 23
A woman with no previous abnormal smears has had a smear with a normal result. She smokes 20 cigarettes daily and has a long history of recurrent genital warts. What management will you suggest?
Scenario 24.
A woman of 70 presents with postmenopausal bleeding. She had smears at the recommended intervals from the age of 22. All were normal. The last was taken at the age of 64. What is your management in relation to taking a smear?
Scenario 25.
A woman of 55 presents with hot flushes since her periods stopped at the age of 54. She wishes to go on HRT and there are no contraindications. She had smears at the recommended intervals from the age of 25. All were normal. The last was taken two years ago. What is your management in relation to taking a smear?
Scenario 26.
Women who have been treated for CIN are 2 – 5 times more likely to develop cancer than women who have not been treated. True or false?
Scenario 27.
Scenario 27.
More than 50% of women who develop cervical cancer have been lost to follow-up. True or false?
Scenario 28.
Which of the following statements are true and which false?
a.   cone biopsy is linked to ↓risk of recurrence compared to LLETZ.
b.  excision margins that are not CIN-free ↑ the risk of recurrence, with endocervical margins that are not CIN-free posing a greater risk that similar ectocervical margins.
c.   age > 35 years increases the risk of recurrent disease.
d.  follow-up after treatment for CIN should start between 3 & 6 months from the time of treatment.
e.  the initial examination should be with colposcopy plus cytology.
f.   a failure to achieve negative results in the year after treatment means colposcopy should be done.
g.   a required standard for treatment success is that ≥ 90% of women should have no evidence of dyskaryosis in the year after treatment.
h.  a required standard for treatment success is that there should be ≤ 5% of histologically-confirmed treatment failures by 1 year after treatment.
Scenario 29
Women who have had normal follow-up results for 2 years after treatment of CIN 1 can revert to the routine recall.
Scenario 30.
Follow-up should continue with increased frequency for 5 years after treatment of CIN 2 & 3, after which recall at routine intervals is OK if all the follow-up has been normal. True or false?
Scenario 31.
A woman with LLETZ for CIN3 twelve months ago had a normal smear 6 months later. A smear taken  12 months after treatment is also normal. What management will you suggest?
Scenario 32.
A woman with LLETZ for CIN3 twelve months ago had a normal smear 6 months later. A smear taken  12 months after treatment shows mild dyskaryosis. What management will you suggest?
Scenario 33.
A woman on normal recall has hysterectomy for menorrhagia. There is no evidence of CIN on histology. What follow-up would you recommend?
Scenario 34.
A woman who was not on normal recall has hysterectomy for menorrhagia. There is no evidence of CIN on histology. What follow-up would you recommend?

Scenario 35.
Women who have had hysterectomy and require follow-up with vault smears cannot be managed within the NHSCSP. True or False?
Scenario 36.
A woman who was not on normal recall has hysterectomy for menorrhagia. There is evidence of completely excised CIN3 on histology. What follow-up would you recommend?
Scenario 37.
A woman who was not on normal recall has hysterectomy for menorrhagia. There is evidence of incompletely excised CIN3 on histology. What follow-up would you recommend?
Scenario 38.
A woman has conservative treatment for early stage cancer of the cervix. What follow-up should be recommended?
Scenario 39.
A woman is referred with severe dyskaryosis, but colposcopy is normal. What follow-up should be recommended?

Antepartum haemorrhage.
Lead-in.
The following scenarios relate to APH.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Abbreviations.
ART:       assisted reproduction technology
FGR:      fetal growth restriction
GTG:      Green-top guideline no 62
PET:       pre-eclampsia

Option list.
genital tract bleeding ≥ 500 ml. from 24 weeks until the delivery of the baby
genital tract bleeding ≥ 500 ml. from 24 weeks until the delivery of the placenta.
genital tract bleeding ≥ 500 ml. from 24 weeks, or earlier if the baby is live-born, until the delivery of the baby.
1
2
3
4
5
6
7
8
9
10
15
20
30
50
100
500
1,000
true
false
none of the above

Scenario 1.
What is the definition of APH?
Scenario 2.
What is the upper limit in ml. for minor APH
Scenario 3.
What is the upper limit in ml. of major haemorrhage
Scenario 4.
What is the % risk of recurrence after 1 abruption?
Scenario 5.
What is the % risk of recurrence after 2 abruptions?
Scenario 6.
What is the major risk factor for placental abruption.
Scenario 7
List 10 risk factors for placental abruption.
Scenario 8
List 6 risk factors for placenta previa.
Scenario 9
In what % of pregnancies does APH occur?
Scenario 10
With regards to steps that can be taken to reduce the incidence of APH, what things would you include in an essay?

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.

Lead-in.
The following scenarios relate to drugs & hypertension in pregnancy.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Abbreviations.
ACE:                angiotensin-converting enzyme.
ACEI:               angiotensin-converting enzyme inhibitor.
ARA:               angiotensin II receptor antagonist.
BNF:                British National Formulary.
CNP:               Handbook of Obstetric Medicine. 4th. Edition. Catherine Nelson-Piercy. Informa. 2010
Dewhurst:    Dewhurst’s  Textbook of O&G. Edmonds. 8th. Edition. 2012.  Wiley-Blackwell
DDPL:             Drugs during pregnancy and lactation. Schaeffer et al. 2nd. Edition. 2007. Academic Press.
eMC:              electronic Medicines Compendium UK.
GCE:                German Commission E
L&B:                Obstetrics and Gynaecology: An Evidence-Based Text for MRCOG (2nd edition). Luesley & Baker. 2010.
MAOI:            monoaminoxidase inhibitor.
SAC16:           Vitamin Supplementation in Pregnancy. Scientific Advisory Committee.
Opinion Paper 16. 2009

Option list.
a)        False.
b)        True.
c)         5
d)        10
e)        15
f)         18
g)        20
h)        24
i)          contraindicated in the months before pregnancy
j)          contraindicated in the 1st. trimester
k)        contraindicated in the 2nd. trimester
l)          contraindicated in the 3rd. trimester
m)      contraindicated in all trimesters
n)        not contraindicated in pregnancy
o)        contraindicated in breastfeeding
p)        not contraindicated in breastfeeding
q)        an acute, severe illness like rheumatoid arthritis
r)         an acute, severe illness with encephalopathy and acute fatty liver
s)         an acute, severe illness with gastro-intestinal tract bleeding.


Scenario 1.
When are ACE inhibitors contraindicated in pregnancy?
Scenario 2.
When are ARAs contraindicated in pregnancy?
Scenario 3.
Can St. John’s Wort (SJW) be used in pregnancy?
Scenario 4.
Methyl dopa is an acceptable option for the treatment of gestational hypertension. True / False.
Scenario 5.
Spironolactone is contraindicated in pregnancy. True/False
Scenario 6.
Furosemide is an acceptable option in the management of gestational hypertension. True / False.
Scenario 7.
When are thiazide diuretics contraindicated in pregnancy?
Scenario 8.
Salbutamol is contraindicated for the management of premature labour. True / False.
Scenario 9.
Ergometrine is an integral part of active management of the 3rd. stage.  True / False.
Scenario 10.
When is aspirin contraindicated in pregnancy & the puerperium?
Scenario 11.
When are NSAID’s contraindicated in pregnancy and why?
Scenario 12.
Pethidine:       adverse neonatal effects are most likely if the drug is administered in the six hours before birth. True / False.
Scenario 13.
Pethidine:       what is the half-life in the mature neonate?
Scenario 14.
Pethidine:       is contraindicated in those taking MOAIs or who have taken them in the previous 2 months.
Scenario 15.
Pethidine:       is relatively contra-indicated when there is significant blood loss.
Scenario 16.
Pethidine:       has greater analgesic effect in labour than Diamorphine.
Scenario 17.
What is Reye’s syndrome?




No comments:

Post a comment