Monday 4 July 2016

Tutorial 4th. July 2016

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4 July 2016.

30
EMQ. Confidentiality & consent
31
EMQ. Hepatitis B
32
EMQ. Haemophilia
33
EMQ. Education
34
Roleplay. Communication skills

30.   EMQ. Confidentiality & consent. 
Confidentiality.
Lead-in.
The following scenarios relate to confidentiality. For each, select the number that best fits the scenario.
Option list.
This EMQ has no option list. This is to make you decide your answers, which is what you are advised to do in the exam before you look at the option list.
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?
Scenario 14.
You are the SpR in theatre with your consultant. Mrs Mary White, age 45, has been listed for abdominal hysterectomy and bilateral salpingo-oophorectomy – she has a long history of menorrhagia that has not responded to conservative measures. Her mother had ovarian cancer diagnosed at 55 and died from the disease 3 years later. A 10 cm., solid tumour of the left ovary is found on opening the abdomen. Which of the following options is the correct course of action?
A
close the abdomen, see her to explain the findings and book a follow-up appointment in the gynaecological clinic to discuss further management
B
close the abdomen, arrange to see her to explain the findings and refer to the gynaecological oncologist to discuss further management
C
continue with the operation, but don’t remove the left ovary
D
continue with the operation, removing the uterus and both ovaries and tubes
E
continue with the operation, removing the uterus and both ovaries and tubes and obtaining peritoneal washings
F
ask the gynaecological oncologist to attend to perform definitive surgery on the basis that the cyst is likely to be malignant
G
phone the legal department for advice
H
phone the Court of Protection for advice
Scenario 15.
You are an SpR in theatre with your consultant.
Mrs Mary White, age 45, has been listed for abdominal hysterectomy and bilateral salpingo-oophorectomy – she has a long history of menorrhagia that has not responded to conservative measures. Her mother had ovarian cancer diagnosed at 55 and died from the disease 3 years later.
You perform examination under anaesthesia prior to the abdomen being opened. You find a 10 cm., mass to the left of the uterus. It feels solid. There is no evidence of ascites or other pathology.
 Which of the following options is the correct course of action?
A
Cancel the operation and arrange review in the gynaecology department in 6 weeks
B
Cancel the operation and arrange review by the oncology team
C
Cancel the operation and arrange an urgent scan
D
Continue with the planned procedure
E
Ask the gynaecological oncologist to attend theatre to examine the patient and advise
F
Perform laparoscopy to identify the nature of the mass
G
Phone the legal department

31.   EMQ. Hepatitis B.
Topic. Hepatitis B and pregnancy.
Lead-in.
These scenarios relate to hepatitis and pregnancy.
Instructions.
For each scenario, select the most appropriate option from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
HAV:           hepatitis A virus
HBcAg:       hepatitis B core antigen
HBeAg:       hepatitis B e antigen
HBsAg:       hepatitis B surface antigen
HBcAb:       antibody to hepatitis B core antigen
HBeAb:      antibody to hepatitis B e antigen
HBsAb:       antibody to hepatitis B surface antigen
HBIG:         hepatitis B immunoglobulin
HBV:           hepatitis B virus
HBcAg:       hepatitis B core antigen
HBeAg:       hepatitis B e antigen
HBsAg:       hepatitis B surface antigen
HBcAb:       antibody to hepatitis B core antigen
HBeAb:      antibody to hepatitis B e antigen
HBsAb:       antibody to hepatitis B surface antigen
HBIG:         hepatitis B immunoglobulin
HCV:           hepatitis C virus
HEV:           hepatitis E virus
HSV:           herpes simplex virus
VT:              vertical transmission

Option list.
A.       
acyclovir 
B.       
divorce
C.       
HBcAg +ve
D.       
HBeAg +ve
E.        
HbsAg +ve
F.        
HBsAg +ve; HBsAb –ve;  HBcAb –ve; HBeAg +ve
G.       
HBsAg +ve; HBsAb –ve on two tests six months apart
H.       
HBsAg -ve; HBsAb -ve on two tests six months apart
I.         
HBsAg -ve; HBsAb +ve; HBcAb –ve
J.         
HBsAg -ve; HBsAb +ve; HBcAb +ve
K.        
HBsAg -ve; HBsAb +ve
L.        
HBsAg +ve; HBcAg +ve
M.     
HBV vaccine
N.       
HBIG
O.      
HBV vaccine + HBIG
P.        
immune as a result of infection
Q.      
immune as a result of vaccination
R.       
not immune
S.        
chronic carrier of HBV infection
T.        
10%
U.       
30%
V.       
50%
W.     
60%
X.        
70-90%
Y.        
soap and boiling water
Z.        
10% dilution of bleach in water
AA.   
10% dilution of formaldehyde in alcohol
BB.   
ultraviolet irradiation
CC.   
yes
DD.  
no
EE.    
HAV
FF.     
HBV
GG.  
HCV
HH.  
HEV
II.       
HSV
JJ.       
none of the above
Scenario 1.
An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 4 months ago. What results on routine blood testing would indicate that she has an acute HBV infection?
Scenario 2.
An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 4 months ago. What results on routine blood testing would indicate that she is immune to the HBV as a result of infection?
Scenario 3.
An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 4 months ago. What results on routine blood testing would indicate that she is immune to the HBV as a result of HBV vaccine?
 Scenario 4.
An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 9 months ago. What results on routine blood testing would show that she is a chronic carrier of HBV infection?
Scenario 5.
Testing shows that he is positive for HBsAg, positive for HBcAb but negative for IgM HBcAb. What does this mean in relation to his HBV status?
Scenario 6.
Testing shows that he is negative for HBsAg, positive for HBcAb and positive for HBsAb.
What does this mean in relation to his HBV status?
Scenario 7.
How common is chronic HBV carrier status in UK pregnant women?
Scenario 8.
What is the risk of death from chronic HBV carrier status?
Scenario 9.
A primigravid woman at 8 weeks gestation is found to be non-immune to HBV. She has recently married and her husband is a chronic carrier. What should be done to protect her from infection?
Scenario 10.
A woman is a known carrier of HBV. What is the risk of vertical transmission in the first trimester?
Scenario 11.
What is the risk of the neonate who has been infected by vertical transmission becoming a carrier without treatment?
Scenario 12.
Should antiviral maternal therapy in the 3rd. trimester be considered for women with HBeAg or high viral load?
Scenario 13.
How effective is hepatitis B prophylaxis for the neonate in preventing chronic carrier status as a result of vertical transmission?
Scenario 14.
Can a woman who is a chronic HBV carrier breastfeed safely?
Scenario 15.
Hepatitis B infection is the most dangerous of the viral hepatitis infections in pregnancy.
Scenario 16.
A pregnant woman who is not immune to HBV has a partner who is a chronic carrier. Can HBV vaccine be administered safely in pregnancy?
Scenario 17.
A pregnant woman who is not immune has a partner with acute hepatitis due to HBV. He cuts his hand and bleeds onto the kitchen table. How should she clean the surface to ensure that she gets rid of the virus?
Scenario 18.
Is it true that the presence of HBeAg in maternal blood is a particular risk factor for vertical transmission? Not really a scenario, but never mind!
Scenario 19.
Does elective Cs before labour and with the membranes intact reduce the vertical transmission rate?
Scenario 20.
Which hepatitis virus normally produces a mild illness, but represents a major risk to pregnant women, with a mortality rate of up to 5%?
Scenario 21.
A pregnant woman has a history of viral hepatitis and informs the midwife at booking that she is a carrier and that she has a significant risk of cirrhosis and has been advised not to drink alcohol. Which is the most likely hepatitis virus?

Scenario 22.
Which hepatitis virus is an absolute contraindication to breastfeeding after appropriate treatment of the infected mother and prophylaxis for the baby?
Scenario 23.
Which hepatitis virus is linked to an increased risk of obstetric cholestasis?

32.   EMQ. Haemophilia.
Linguistics.
In relation to the possible genes, I use the terms “haemophilia gene” and “normal gene”. The use of the word “normal” in this way upsets some people. It can be taken to mean that the haemophilia gene is abnormal and that people with haemophilia are abnormal. This is not my intention and the use of “normal” just makes things easier rather than using “non-haemophilia gene” or some similar term, which could be confusing.
The key thing in answering these questions it to climb up the family tree to get to the common ancestor and then work back down to the individual we are talking about.
Lead-in.
The following scenarios relate to haemophilia A, factor VIII deficiency  (HA).
For each, select the most appropriate answer  from the option list.
Each option can be used once, more than once or not at all.
Scenario 1.
A woman attends for pre-pregnancy counselling. Her brother has haemophilia A. What is her risk of being a carrier?
Scenario 2.
A woman attends for pre-pregnancy counselling. Her father has haemophilia A. What is her risk of being a carrier?
Scenario 3.
If she is tested and found to be a carrier, what tests will you arrange for her partner?
Scenario 4.
If she is a carrier, what is the risk to her male offspring?
Scenario 5.
If she is a carrier, what is the risk to her female offspring?
Scenario 6.
If she is a carrier and her partner has haemophilia A, what are the risks to their female offspring?
Scenario 7.
If she is a carrier and her partner has haemophilia A, what are the risks to their male offspring?
Scenario 8.
A lady doctor  has a brother with haemophilia. The brother has a 20-year-old daughter who is planning pregnancy and phones his sister, the doctor,  to ask what the risk is of his daughter being a carrier.
Scenario 9.
A lady doctor  has a brother with haemophilia. The brother has a 20-year-old daughter who is planning pregnancy and phones his sister, the doctor,  to ask what the risk is of his daughter’s sons being affected.
Scenario 10.
A lady doctor  has a brother with haemophilia. The brother has a 20-year-old daughter who is planning pregnancy and phones his sister, the doctor,  to ask what the risk is of his daughter having an affected daughter.
Scenario 11.
A lady doctor  has a brother with haemophilia. She has a pregnancy with no testing. A son in born. What is the chance that he is affected?

Scenario 12.
A lady doctor  has a brother with haemophilia. She has a pregnancy with no testing. A son in born. What is the chance that he is not affected?
Scenario 13
A lady doctor  has a brother with haemophilia. She has a pregnancy with no testing. What is the chance that she will have an affected son?

33.   EMQ. Education
Lead-in.
The following scenarios relate to medical education
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
EMQ:    extended, matching question.
PBL:       problem-based learning.
Option list.
  1. brainstorming.
  2. brainwashing
  3. cream cake circle.
  4. Delphi technique.
  5. demonstration & practice using clinical model.
  6. doughnut round.
  7. interactive lecture with EMQs.
  8. lecture.
  9. 1 minute preceptor method.
  10. teaching peers / junior colleagues
  11. schema activation.
  12. schema refinement.
  13. small group discussion.
  14. snowballing.
  15. snowboarding.
  16. true
  17. false
Scenario 1.
A woman is admitted with an eclamptic seizure. The acute episode is dealt with and she is put on an appropriate protocol. You wish to use the case to outline key aspects of PET and eclampsia to the two medical students who are on the labour ward with you. Which would be the most appropriate approach?
Scenario 2.
You have been asked to provide a summary of the key aspects of the recent Maternal Mortality Meeting to the annual GP refresher course. There are likely to be 100 attendees. Which would be the most appropriate approach?
Scenario 3.
You have been asked to teach a new trainee the use of the ventouse. Which would be the most appropriate approach?
Scenario 4.
You have been asked to teach a group of medical students about PPH. To your surprise you find that they have good basic knowledge. Which technique will you apply to get the most from the teaching session?
 Scenario 5.
Your consultant has asked you to get the unit’s medical students to prepare some questions about breech delivery which they can ask of their peers when they next meet. Which technique will you use?
Scenario 6.
You have been asked to discuss 2ry. amenorrhoea with your unit’s medical students. You are uncertain about the amount of basic physiology and endocrinology they remember from basic science teaching. Which technique will you use?
Scenario 7
The RCOG has asked you to chair a Green-top Guideline development committee. You find that there is very little by way of research evidence to help with the process. The College has assembled a team of consultants with expertise and interest in the subject. Which technique would be best to reach consensus on the various elements of the GTG?
Scenario 8
Which of the listed teaching techniques is least likely to lead to deep learning?
Scenario 9
An interactive lecture with EMQs is the best method of teaching. True or false.
Scenario 10
Only 20% of what is taught in a lecture is retained. True or false.
Scenario 11.
The main role of the teacher is information provision. True or false.
Scenario 12.
The main role of the teacher is to be a role model.  True or false.

34.   Roleplay. Communication skills: X-linked recessive inheritance. You have been asked to go over the key aspects of recessive inheritance with a new FY1.



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