Thursday, 17 December 2015

Tutorial 17th. December 2015




17th. December 2015.

27
EMQ. Mental Capacity Act.
28
MgSO4 : what points might feature in the exam?
29
SBA. Progestogen-only implants
30
EMQ. COC: starting and missed pills.
31
Communication skills.

27.         EMQ. Mental Capacity Act.
Lead-in.
The following scenarios relate to the Mental Capacity Act 2005.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
CAD:     Court-appointed Deputy.
COP:      Court of Protection.
FGR:      fetal growth restriction.
LPA:       Lasting Power of Attorney.
PoA:      Power of Attorney.
Option list.
A.       
Yes
B.       
No
C.       
True
D.       
False
E.        
Does not exist
F.        
The husband
G.       
A parent
H.       
The child
I.         
the General Practitioner
J.         
the Consultant
K.        
the Registrar
L.        
The Consultant treating the patient
M.     
A Consultant not involved in treating the patient
N.       
The Medical Director
O.      
A person with Powers of Attorney
P.        
The sheriff or sheriff’s deputy
Q.      
Balance of probabilities
R.       
Beyond reasonable doubt
S.        
None of the above.
T.        
Scenario 1.
U.       
A person with LPA is normally not a family member.
V.       
Scenario 2.
W.     
A Sheriff’s Deputy is normally not a family member.
X.        
Scenario 3.
Y.        
A person with PoA can consent to treatment for the patient who lacks capacity.
Z.        
Scenario 4.
AA.   
A Court-appointed Deputy can consent to treatment for the patient who lacks capacity, but must go back to the Court of Protection if further consent is required for additional treatment.

Lead-in.
The following scenarios relate to the Mental Capacity Act 2005.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
CAD:     Court-appointed Deputy.
COP:     Court of Protection.
FGR:      fetal growth restriction.
LPA:      Lasting Power of Attorney.
PoA:      Power of Attorney.
Option list.
A.        Yes
B.         No
C.         True
D.        False
E.         Does not exist
F.         The husband
G.        A parent
H.        The child
I.           the General Practitioner
J.          the Consultant
K.         the Registrar
L.          The Consultant treating the patient
M.      A Consultant not involved in treating the patient
N.        The Medical Director
O.        A person with Powers of Attorney
P.         The sheriff or sheriff’s deputy
Q.        Balance of probabilities
R.         Beyond reasonable doubt
S.         None of the above.

Scenario 1.
A person with LPA is normally not a family member.
Scenario 2.
A Sheriff’s Deputy is normally not a family member.
Scenario 3.
A person with PoA can consent to treatment for the patient who lacks capacity.
Scenario 4.
A Court-appointed Deputy can consent to treatment for the patient who lacks capacity, but must go back to the Court of Protection if further consent is required for additional treatment.
Scenario 5.
A person with PoA can authorise withdrawal of all care except basic care in cases of individuals with persistent vegetative states.
Scenario 6.
An advance decision can authorise withdrawal of all but basic care in cases of persistent vegetative states.
Scenario 7
A person with PoA cannot overrule an advance direction about withdrawal or withholding of life-sustaining care.
Scenario 8
A woman is seen in the antenatal clinic at 39 weeks’ gestation. Her blood pressure is 180/110 and she has +++ of proteinuria on dipstick testing. She has mild epigastric pain. A scan shows evidence of FGR with the baby on the 2nd. centile. Doppler studies of the umbilical artery are abnormal and a non-stress CTG shows loss of variability and variable decelerations. She is advised that she appears to have severe pre-eclampsia and is at risk of eclampsia and of intracranial haemorrhage. She is told of the associated risk of mortality and morbidity. She is also advised that the baby is showing evidence of severe FGR and has abnormal Doppler studies and CTG which could lead to death or hypoxic damage. She declines admission or treatment. She says she trusts in God and wishes to leave her fate and that of her baby in His hands. She is seen by a psychiatrist who assesses her as competent under the MCA and with no evidence of mental disorder. The obstetrician wants to apply to the COP for an order for compulsory treatment. Can he do this?
Scenario 9
A woman is admitted at 36 weeks’ gestation with evidence of placental abruption. She is semi-comatose and shocked. There is active bleeding and the cervical os is closed. Fetal heart activity is present but with bradycardia and decelerations. The consultant decides that Caesarean section is the best option to save her live and that of the baby. When reading the notes, the registrar comes across an advance notice drawn up by the woman and her solicitor. It states that she does not wish Caesarean section, regardless of the risk to her and the baby. The consultant tells the registrar that they can ignore it now that she is no longer competent and get on with the Caesarean section for which she will be thankful afterwards. The registrar says that the advance notice is binding. Who is correct?
Scenario 10
An 8 year old girl is admitted with abdominal pain. Appendicitis is diagnosed with peritonitis and surgery is advised. The parents decline treatment on religious grounds. Can the consultant in charge overrule the parents and give consent?

28.         EMQ. MgSO4 use in O&G.
Write down all the things about the use of MgSO4 in O&G that you think might come in the exam. Think EMQ, SBA and viva.

29.         EMQ. Progestogen-only implants.
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
A.       
68 mg. ENG
B.       
100 mg. ENG
C.       
100 mg. LNG
D.       
150 mg. LNG
E.        
50 mg. ENG + 100 mg. LVG
Question 2.
Lead-in
How does Nexplanon act as a contraceptive?
        I.            mainly by inducing anovulation
      II.            mainly by altering cervical mucus to the detriment of sperm transport
    III.            mainly by thinning the endometrium, preventing implantation
    IV.            mainly by inducing loss of libido
Choose the best option from the list below.
Option List
A.       
I
B.       
I + II
C.       
I + III
D.       
II + III
E.        
III + IV
Question 3.
Lead-in
What is the age range, if any, for which Nexplanon is licensed in the UK?
Option List
A.       
15 – 50 years
B.       
18 – 40 years
C.       
18 – 45 years
D.       
20 – 50 years
E.        
None of the above.
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
A.       
Advise her about alternative licensed contraceptive methods, but decline to insert Nexplanon
B.       
Advise her about alternative licensed contraceptive methods and insert Nexplanon
C.       
Fit her with a LNGIUS
D.       
Refer her to a colleague who fits anyone who asks with a Nexplanon
E.        
None of the above
Question 5.
Lead-in
Which, if any, of the following statements about the pregnancy rate for women using Nexplanon are true?
Option List
A.       
The pregnancy rate is < 1 per 1,000 women during 3 years of use
B.       
The pregnancy rate is < 5 per 1,000 women during 3 years of use
C.       
The pregnancy rate is < 10  per 1,000 women during 3 years of use
D.       
The pregnancy rate is 10-20 per 1,000 women during 3 years of use
E.        
None of the above
Question 6.
Lead-in
Which, if any, other implants are licensed in the UK?
Option List
A.       
Implanon
B.       
Norplant
C.       
Norplant-2
D.       
Jadelle
E.        
None of the above
Question 7.
Lead-in
What are the main differences between Nexplanon and Implanon?
Pick the most suitable answer from the list below.
Option List
A.       
The dosage was increased from 60 to 68 mg. etonorgestrel
B.       
The dosage was increased from 150 – 175 mg. levonorgestrel
C.       
Barium sulphate was added to Nexplanon to make it radio-opaque
D.       
The number of rods was reduced to 2
E.        
None of the above
Question 8.
Lead-in
What problems is the new applicator designed to minimise?
        I.            non-insertion
      II.            deep insertion
    III.            difficulty with one-handed insertion
    IV.            difficulty with left-handed insertion
      V.            difficulty with insertion in very thin women.
Option List
A.       
I + II + III + IV
B.       
I + II + III + IV + V
C.       
II + III
D.       
II + III + IV
E.        
II + III + IV + V
Question 9.
Lead-in
How long is Nexplanon licensed for?
Option List
A.       
1 year
B.       
2 years
C.       
3 years
D.       
5 years
E.        
10 years
Question 10.
Lead-in
What does NICE recommend that patients be told about bleeding patterns with Nexplanon?
        I.            menstrual bleeding may cease
      II.            menstrual bleeding may become prolonged
    III.            bleeding may become more frequent
    IV.            menstrual bleeding may become less frequent
      V.            intermenstrual bleeding can be a problem in the first 6 months
Option List
A.       
I + II + III
B.       
I + II + III + IV
C.       
II + III + IV + V
D.       
I + III + IV
E.        
I + III + IV + V
Question 11.
Lead-in
What information should women be given about the effect of Nexplanon on pain?
Option List
A.       
Dysmenorrhoea may increase
B.       
Dysmenorrhoea may decrease
C.       
Mittelschmerz is likely to cease
D.       
Pain due to endometriosis is likely to decrease
E.        
Dyspareunia is likely to be alleviated
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
A.       
Recommend a low-dose COC and tricycling as the best means of suppressing endometriosis plus providing effective contraception
B.       
Recommend a low-dose COC taken continuously as the best means of suppressing endometriosis plus providing effective contraception
C.       
Recommend Nexplanon as the best means of suppressing endometriosis plus providing effective contraception
D.       
Recommend Depot-Provera as the best means of suppressing endometriosis plus providing effective contraception
E.        
None of the above
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
A.       
Up to and including day 3 of menstruation
B.       
Up to and including day 5 of menstruation
C.       
Up to and including day 7 of menstruation
D.       
Never
E.        
None of the above
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.
A.       
No additional contraception is needed if Nexplanon is inserted by day 7
B.       
No additional contraception is needed if Nexplanon is inserted by day 14
C.       
No additional contraception is needed if Nexplanon is inserted by day 21
D.       
No additional contraception is needed if Nexplanon is inserted by day 28
E.        
No additional contraception is needed if Nexplanon is inserted by day 42
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?
        I.            If insertion takes place on day 1 of the hormone-free week, no additional contraception is needed.
      II.            If insertion takes place on day 5 of the hormone-free week, additional contraception is needed for 7 days.
    III.            If insertion takes place in week 2 after the hormone-free week, no additional contraception is needed.
    IV.            If insertion takes place in week 3 after the hormone-free week, no additional contraception is needed.
Option List
A.       
I
B.       
I + II
C.       
I + II + III
D.       
II + III + IV
E.        
I + II + III + IV
Question 16.
Lead-in
        I.            Women switching from a POP to Nexplanon should be advised that additional contraception is required for 7 days.
      II.            Women switching from a POP to Nexplanon should be advised that additional contraception is not required.
    III.            Women switching from a LNGIUS to Nexplanon should be advised that additional contraception is required for 7 days.
    IV.            Women switching from a LNGIUS to Nexplanon, should be advised that additional contraception is not required.
Option List
A.       
I + III
B.       
I + IV
C.       
II + III
D.       
II + IV
E.        
none of the above

30.         EMQ. COC: starting and missed pills.
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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