Monday, 5 January 2015

Tutorial 5 January 2015

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5 January 2015.

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EMQ. Confidentiality & Consent
5
January
2015
SBA. MBRRACE
5
January
2015
SBA. NICE Clinical Guideline 132. Caesarean section.
5
January
2015
EMQ. COC. Starting & missed pills.
5
January
2015
Communication
5
January
2015

26. Confidentiality.
Lead-in.
The following scenarios relate to confidentiality.
Option list.
This EMQ has not option list. This is to make you decide your answers. Send them to me and I’ll send my version including what I think an option list might have looked like.
Scenario 1.
A 15-year-old girl attends the TOP clinic requesting TOP. She is assessed as Fraser competent. After full discussion arrangements are made for her admission for TOP. She does not wish her parents to be informed. Her mother attends clinic 1 hour after the child has left. She demands full information about her daughter. The consultant has delegated you to deal with her. Which option best fits the action you will take?
Scenario 2.
A 17-year-old A-level student attends the gynaecology clinic requesting TOP. She is accompanied by her 30-year-old mathematics teacher, who is her lover and wishes to give consent. Which option best fits the action you will take?
Scenario 3.
A 12-year-old girl attends the gynaecology clinic with her mother seeking contraceptive advice. She has an 18-year-old boyfriend whom the parents like and she wishes to start having sex. Which option best fits the action you will take?
Scenario 4.
A 15-year-old girl who is Fraser competent is referred to the gynaecology clinic with a complaint of vaginal discharge. She reveals that she has been having consensual sexual intercourse for six months with her 18-year-old boyfriend. She asks for advice about suitable contraception as she is happy in the relationship and wants to continue to have sex. Which option best fits the action you will take?
Scenario 5.
You are the new oncology consultant and have just operated on the wife of a local General Practitioner for suspected ovarian cancer. The diagnosis is confirmed and you proceed with appropriate surgery. On completion of the operation you go to the surgeon’s room for a coffee. The senior consultant anaesthetist who was not involved in theatre but is the Medical Director and tells you he is a close friend of the woman, asks what the diagnosis and prognosis are. Which option best fits the action you will take?
Scenario 6.
You are phoned by a doctor looking for information about his wife’s results from the booking clinic she attended two weeks ago. He says that she has given consent for disclosure. She has given a history of 2 terminations but no other pregnancies. She is Rhesus negative, but has Rhesus antibodies. Which option best fits the action you will take?
Scenario 7
You are phoned by a doctor looking for information about his wife’s results from the booking clinic she attended two weeks ago. He says that she has given consent for disclosure. Her serology tests have proved +ve for syphilis. You have spoken to the consultant bacteriologist who says that they have run confirmatory tests and they are +ve too. He is sure the woman has active syphilis. Which option best fits the action(s) you will take?
Scenario 8
A 15-year-old girl attends the TOP clinic requesting TOP. She is assessed as Fraser competent. After full discussion arrangements are made for her admission for TOP. She does not wish her parents to be informed despite your best efforts to persuade her. Who will give consent for the procedure?
Scenario 9
An immature 15-year-old girl attends the gynaecology clinic requesting TOP. She is accompanied by her 25-year-old sister who is a lawyer with whom she has been staying since she knew she was pregnant. She does not want her parents to be informed. The girl is assessed as not Fraser competent. The sister says that she is happy to act in loco parentis and to give consent. Which option best fits the action(s) you will take?
Scenario 10
A 25-year-old woman with Down’s syndrome attends the clinic accompanied by her mother. She has menorrhagia and copes badly with the hygiene aspects. The menorrhagia is bad enough for her now to be on treatment for iron-deficiency anaemia. She has tried all the standard medical methods. To complicate the problem, she has become close friends with a young man she has met at College, to which she travels independently each weekday. Her mother fears that she may already be involved in sexual activity and cannot get an accurate answer from her about it. The mother is keen for her to have hysterectomy to deal with both problems. If you agree that the surgery is appropriate, who can give consent?
Scenario 11
A 25-year-old woman with Down’s syndrome is admitted from College after collapsing. The clinical features are of ectopic pregnancy and she states that she has UPSI with her boyfriend of six months. She has tachycardia and hypotension and it is felt that she should have urgent surgery. You reckon that she is not competent to consent for surgery. Who can give consent?
Scenario 12
A 25-year-old woman with Down’s syndrome is admitted from College after collapsing. The clinical features are of ectopic pregnancy and she states that she has UPSI with her boyfriend of six months. She has tachycardia and hypotension and it is felt that she should have urgent surgery. You reckon that she is not competent to consent for surgery. What limits are there on the surgery?
Scenario 13.
You are the SpR on call and are asked to see a 10-year-old child in the A&E department. She has been brought because of vaginal bleeding. She is accompanied by her parents who give a story of her injuring herself falling of her bike. Examination shows vaginal bleeding and you think the hymen looks torn. You suspect sexual abuse and don’t believe the parents’ story. When this is discussed with the parents they say it is impossible and that they do not want involvement of police or social workers. What action will you take?

27. MBRRACE.
Lead-in.
The following scenarios relate to MBRRACE.
Option list.
There is none!
Scenario 1.          What is the meaning of the acronym MBRRACE-UK”?
Scenario 2.          Which organisation does it replace?
Scenario 3.          How does it differ structurally from its predecessor?
Scenario 4.          How will its reports differ from those of its predecessor?
Scenario 5.          When was its first Report published?
Scenario 6.          What geographical innovation was included in its first Report?
Scenario 7.          What was the latest MMR reported in its first Report?
Scenario 8.          How did this compare with the final MMR reported by CMACE?
Scenario 9.          Which topics were reviewed in detail in the first Report?
Scenario 10.      What was the leading direct cause of death in the first Report?
Scenario 11.      What was the leading indirect cause of death in the first Report?
Scenario 12.      What is the definition of a maternal death?
Scenario 13.      What is the definition of a direct maternal death?
Scenario 14.      What is the definition on indirect maternal death?
Scenario 15.      What observation was made in the first Report about deaths due to hypertensive disease.
Scenario 16.      Which condition was linked to 1 in 11 maternal deaths?
Scenario 17.      What were the 5 top causes of direct maternal death in the years 2009 – 2011?
Scenario 18.      What key messages were singled out in the first Report?

28. SBA. NICE Clinical Guideline 132. Caesarean section.
Lead-in.
The following scenarios relate to Caesarean section.
Abbreviations.

Option list.
There is none, to make you think!

Scenarios.
1)      MPA is suspected on a routine 20 week scan in a woman who has had two LSCSs. What advice should she be given in relation to the value of colour Doppler US and MRI? 
2)      What advice is given about women who are infected with hepatitis B?
3)      What advice is given about women who are infected with hepatitis C
4)      What advice is given about women who are infected with HIV?
5)      What advice is given about women who are infected with HIV + hepatitis B?
6)      What advice is given about women who are infected with HIV + hepatitis C
7)      A woman with HIV takes HAART and has a PVL < 50 copies per ml. She wishes Caesarean section for non-obstetric reasons. She has been counselled and Caesarean section has been agreed. At what gestation should it be done?
8)      What advice should be given to the woman with HSV infection in pregnancy?
9)      What is the risk of MTCT after primary HSV infection in the 3rd. trimester?
10)   A woman presents with genital herpes at 36 weeks’ gestation in her first pregnancy. As far as she is aware, this is her first episode of HSV infection. What is the chance that it is a recurrent infection?
11)   A woman presents with genital herpes at 36 weeks’ gestation in her third pregnancy. As far as she is aware, this is her first episode of HSV infection. What is the chance that it is a recurrent infection?
12)   A woman presents with genital herpes at 36 weeks’ gestation in her first pregnancy. As far as she is aware, this is her first episode of HSV infection. What test should be done to clarify whether it is a 1ry. or recurrent infection?
13)   A woman presents with genital herpes at 36 weeks’ gestation in her first pregnancy. As far as she is aware, this is her first episode of HSV infection. Swabs are taken from the skin lesions and blood is taken for HSV type-specific antibodies. She goes into labour at 38 weeks before the results of the HSV type specific antibody tests are available. What advice should be given re mode of delivery?
14)   A woman presents with genital herpes at 36 weeks’ gestation in her first pregnancy. As far as she is aware, this is her first episode of HSV infection. Swabs are taken from the skin lesions and blood is taken for HSV type-specific antibodies and confirm 1ry.  infection.  She goes into labour with intact membranes at 38 weeks and declines Cs. What action should be taken with regard to anti-viral treatment?
15)   A woman presents in labour at 38 week’s gestation, 2 weeks after a 1ry. infection with genital HSV. She declines Caesarean section, but opts for antiviral treatment for her and the baby. Which drug should be considered and in what doses?
16)   A woman presents in labour at 38 week’s gestation, 2 weeks after a 1ry. infection with genital HSV. She had SRPM 6 hours before.
17)   A woman presents in early labour at 38 weeks’ gestation. She has a history or recurrent genital HSV. She has a typical herpetic blister on the vulva. What risk of neonatal infection will you quote in the discussion?
18)   A woman presents in labour at term with lesions and a history that are typical of 1ry. genital HSV infection. Which invasive procedures, if any, should be avoided?
19)   A woman with a history of recurrent genital herpes presents in labour at 40 weeks with a typical vulval herpetic blister. Which invasive procedure, if any, should be avoided?
20)   A baby is born by Caesarean section after maternal 1ry. genital herpes one month before. Which, if any, of the following are appropriate.
Option list.
A.      liaise with the neonatal unit
B.      normal postnatal care of the baby with examination at 24 hours, then discharge if well and feeding is established.
C.      swabs of skin, conjunctiva, oropharynx and rectum for HSV PCR
D.      lumbar puncture for evidence of HSV
E.       parents to be educated re good hand hygiene
F.       i.v. acyclovir, 20 mg/kg 8 hourly until active infection is ruled out.
G.      strict infection control procedures should be put in place for both mother and baby.
H.      breastfeeding should be discouraged because of the presence of HSV in breast milk.
I.        parents advised to seek medical help if they have concerns, in particular, skin, eye or mucous membrane lesions, lethargy, irritability or poor feeding
21)   A baby is born by Caesarean section after maternal 1ry. genital herpes one month before. Which, if any, of the following are appropriate.
Option list.
J.        liaise with the neonatal unit
K.       normal postnatal care of the baby with examination at 24 hours, then discharge if well and feeding is established.
L.       swabs of skin, conjunctiva, oropharynx and rectum for HSV PCR
M.    lumbar puncture for evidence of HSV
N.      parents to be educated re good hand hygiene
O.     i.v. acyclovir, 20 mg/kg 8 hourly until active infection is ruled out.
P.       strict infection control procedures should be put in place for both mother and baby.
Q.     breastfeeding should be discouraged because of the presence of HSV in breast milk.
R.      parents advised to seek medical help if they have concerns, in particular, skin, eye or mucous membrane lesions, lethargy, irritability or poor feeding
22)   A baby is born by Caesarean section after maternal 1ry. genital herpes one month before. Which, if any, of the following are appropriate.
Option list.
S.       liaise with the neonatal unit
T.       normal postnatal care of the baby with examination at 24 hours, then discharge if well and feeding is established.
U.      swabs of skin, conjunctiva, oropharynx and rectum for HSV PCR
V.      lumbar puncture for evidence of HSV
W.    parents to be educated re good hand hygiene
X.       i.v. acyclovir, 20 mg/kg 8 hourly until active infection is ruled out.
Y.       strict infection control procedures should be put in place for both mother and baby.
Z.       breastfeeding should be discouraged because of the presence of HSV in breast milk.
AA.  parents advised to seek medical help if they have concerns, in particular, skin, eye or mucous membrane lesions, lethargy, irritability or poor feeding
23)   What proportion of neonatal HSV infection is thought to be due to infection after birth?
24)   What steps should be taken to reduce the risk of neonatal HSV infection?
25)   A primigravida attends for booking. She requests Caesarean section. There are no clinical grounds. Outline your management.   
26)   A woman with BMI > 50 should be offered Caesarean section. True/ False.
27)   When should prophylactic antibiotics in relation to the timing of the operation?
28)   A woman has had her 3rd. Caesarean section. She wants to know the advice you would give re the risks of subsequent vaginal delivery.
29)   What are the key aspects of induction of general anaesthesia for unplanned Cs?
30)   What should be done about thromboprophylaxis for women having Cs?

29.  COC Missed pills. Starting the Pill.
Lead-in.
The following scenarios relate to the combined oral contraceptive (COC) and missed pills.
For each, select the option that best fits the scenario.
Each option can be used once, more than once or not at all.
Abbreviations.
UPSI:     unprotected sexual intercourse.
Option list.
A.        pill that is ≥ 12 hours late.
B.         pill that is > 12 hours late.
C.         pill that is ≥ 24 hours late.
D.        pill that is > 24 hours late.
E.         two missed pills at any time in a single cycle.
F.         the first pill taken in one’s first love affair, now recalled with fond nostalgia for its effectiveness in preventing pregnancy, the Prince having been truly a loathsome toad.
G.        no additional contraception required.
H.        additional contraception required for 7 days.
I.           emergency contraception should be considered.
J.          emergency contraception should be recommended.
K.         take the missed pill immediately, but not if it means 2 pills in one day; no additional contraception needed; pill-free interval as normal.
L.          take the missed pill immediately, even if it means 2 pills in one day; no additional contraception needed; pill-free interval as normal.
M.      take the missed pill immediately, even if it means 2 pills in one day; additional contraception for 7 days; pill-free interval as usual.
N.        take one of the missed pills immediately, discard the other missed pills, use extra contraception for 7 days and discuss emergency contraception with your doctor.
O.        take the missed pills immediately, use extra contraception for 7 days and discuss emergency contraception with your doctor.
P.         continuous combined preparation.
Q.        bi-phasic preparation.
R.         quadriphasic preparation.
S.         cannot be answered from the data given.
T.         none of the above.
Scenario 1.
What is the definition of a missed pill?
Scenario 2.
What is the definition of two missed pills?
Scenario 3.
A COC is begun on day 1 of menstruation. What advice should be given about temporary additional contraception?
Scenario 4.
A COC is begun 5 days after day 1 of menstruation. What advice should be given about temporary additional contraception?
Scenario 5.
A COC is begun for the first time on day 1 of menstruation. The fifth pill is missed. What advice should be given?
Scenario 6.
A pill is missed on day 14 of a 21-day pack. What advice should be given?
Scenario 7
A pill is missed on day 21 of a 21-day pack. What advice should be given?
Scenario 8
Two pills are missed in the first week of a 21-day pack. What advice should be given?
Answer:
Scenario 9
Two pills are missed in the second week of a 21-day pack. What advice should be given?
Scenario 10
Two pills are missed in the third week of a 21-day pack. What advice should be given?
Scenario 11
What kind of preparation is Qlaira?


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