Thursday, 24 November 2016

Tutorial 24th. November 2016

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24 November 2016.

14
EMQ. Mental Capacity Act
15
EMQ. The Coroner
16
EMQ. Mode of inheritance
17
Air Travel & Pregnancy. How to read exercise & SBA. Extract the key facts for Qs. from SIP 1. 2013
18
Communication skills. Pre-pregnancy counselling

14    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.

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?

15. The Coroner. Question 1.
Lead-in.
The following scenarios relate to the role of the Coroner.
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.
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.
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?
Scenario 13.
A 65-year-old man dies 2 hours after admission to hospital with an apparent stroke. The coroner requests access to the notes. What access should be provided?
Option list.
A
provide access to the records by the Coroner in person
B
provide unrestricted access to the medical records by the coroner’s officers
C
provide a copy of the hospital records to the coroner or her officers
D
provide a medical report, but no access to the medical records
E
provide a copy of the letter to the GP about the recent admission
F
none of the above

16.         Mode of inheritance.
Lead-in.
The following questions relate to the mode of inheritance – some not quite to “mode”, but I am sure you will indulge me! Write what you think is the mode of inheritance or appropriate answer.
Option List. There is no option list.
Comment.
You are expected to know a lot of basic genetics and it is hard to remember the details. A list to go over in the days before the exam makes sense. Use this one and add anything else you can think of – and let me know of your additions so I can add them. Don’t add a load of rare syndromes – you will just end up confused. But add anything that you know has featured in the exam.
List of questions.
1.       achondrogenesis.
2.       achondroplasia.
3.       acute fatty liver of pregnancy (AFLP).
4.       adreno-genital syndrome
5.       adult polycystic kidney disease.
6.       androgen insensitivity syndrome.
7.       albinism.
8.       Angelman syndrome.
9.       Apert syndrome.
10.   Becker muscular dystrophy.
11.   Beckwith-Wiedemann syndrome.
12.   BRCA 1.
13.   BRCA2.
14.   Cavanan syndrome.
15.   Charcot-Marie-Tooth disease.
16.   chondrodystrophy.
17.   Christmas disease.
18.   congenital adrenal hyperplasia.
19.   Cowden syndrome.
20.   cri-du-chat syndrome. 
21.   cystic fibrosis.
22.   Dandy-Walker syndrome.
23.   developmental dysplasia of the hip.
24.   DiGeorge syndrome.
25.   Down’s syndrome.
26.   Duchenne muscular dystrophy
27.   Dwarfism. See isolated growth hormone deficiency.
28.   Edward’s syndrome.
29.   exomphalos.
30.   Ehlers-Danlos syndrome
31.   Fanconi anaemia
32.   Fitz-Hugh-Curtis syndrome.
33.   Fragile X syndrome.
34.   galactosaemia.
35.   gastroschisis.
36.   glucose-6-phosphatase deficiency. G6PD.
37.   glucose-6-phosphate dehydrogenase deficiency. G6PDD.
38.   haemochromatosis.
39.   haemosiderosis..
40.   haemophilia A:
41.   haemophilia B:
42.   Hunter syndrome.
43.   Huntington’s disease.
44.   ichthyosis.
45.   isolated growth hormone deficiency.
46.   juvenile polycystic kidney disease.
47.   Kallmann’s syndrome.
48.   Klinefelter’s syndrome.
49.   Lesch Nyhan syndrome.
50.   Lynch syndrome (HNPCC).
51.   Malignant hyperthermia.
52.   Maple syrup urine disease. 
53.   Marfan’s syndrome.
54.   Martin-Bell syndrome.
55.   Mayer-Rokitansky-Kuster-Hauser syndrome.
56.   McCune-Albright syndrome.
57.   Meckel-Gruber syndrome.
58.   Medium-chain acyl-CoA dehydrogenase deficiency.
59.   mucopolysaccharidosis type I.
60.   Myotonic dystrophy.
61.   neurofibromatosis.
62.   Niemann-Pick disease.
63.   Noonan syndrome.
64.   ocular albinism.
65.   osteogenesis imperfecta.
66.   osteoporosis.
67.   Patau’s syndrome.
68.   Perrault syndrome.
69.   phenyketonuria.
70.   polydactyly.
71.   porphyria.
72.   Potter’s syndrome.
73.   Prader-Willi syndrome. 
74.   Prune-belly syndrome
75.   pyruvate kinase deficiency.
76.   sickle cell disease.
77.   spherocytosis.
78.   Syndrome X.
79.   Tay-Sach’s disease.
80.   Thalassaemia.
81.   Thrombophilia.
82.   Triple X syndrome.
83.   Turner’s syndrome.
84.   Swyer’s syndrome.
85.   Uniparental disomy.
86.   VACTERL.
87.   vitamin D resistant rickets
88.   von Willebrand’s disease.
89.   A mother has spina bifida. What is the risk of a child being affected? 
90.   A mother has had a child with spina bifida, what is the risk of the next child being affected?   
91.   A mother has had two children with spina bifida. What is the risk of the next child being affected?
92.   A mother has grand-mal epilepsy. What is the risk of her child having epilepsy?
93.   A mother and her partner both have grand-mal epilepsy. What is the risk of their child having epilepsy?
94.   A mother has insulin-dependent diabetes mellitus. What is the risk of a child being affected?
95.   A mother has congenital heart disease. What is the risk of a child being affected? 
96.   A mother takes lithium for bi-polar disorder throughout her pregnancy. What is the risk of the child having congenital heart disease?
97.   A mother has a nuchal translucency scan at 11 weeks. The result is 6 mm. What is the risk of the fetus having congenital heart disease?

17.   Air travel & pregnancy. How to read exercise & SBA.
         Extract the key facts from SIP1 that you think could be used for an EMQ or SBA..

18.   Basic communication skills. Role-play.
Candidate's Instructions.
You are a 5th. year SpR. You are about to see Mrs. Jane Brown who has been referred for pre-pregnancy counselling as she is planning her first pregnancy and has a brother with cystic fibrosis.


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