Thursday, 25 May 2017

Tutorial 25th. May 2017

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7
EMQ. Maternal Mortality definitions
8
EMQ. Coroner 1-3
9
EMQ. Antepartum haemorrhage
10
EMQ. Cystic fibrosis.
11
Communication skills. Pre-pregnancy. Brother has cystic fibrosis.

7.     Maternal mortality definitions.
You need to know these as they are often asked.
Lead-in.
Pick the option that best answers the task in each scenario from the option list.
Option List.
A.   Death of a woman during pregnancy and up to 6 weeks later, including accidental and incidental causes.
B.    Death of a woman during pregnancy and up to 6 weeks later, excluding accidental and incidental causes.
C.    Death of a woman during pregnancy and up to 52 weeks later, including accidental and incidental causes.
D.   Death of a woman during pregnancy and up to 52 weeks later, excluding accidental and incidental causes.
E.    A pregnancy going to 24 weeks or beyond.
F.    A pregnancy going to 24 weeks or beyond + any pregnancy resulting in a live-birth.
G.   Maternal deaths per 100,000 maternities.
H.   Maternal deaths per 100,000 live births.
I.      Direct + indirect deaths per 100,000 maternities.
J.     Direct + indirect deaths per 100,000 live births.
K.    Direct death.
L.     Indirect death.
M. Early death.
N.   Late death.
O.   Extra-late death.
P.    Fortuitous death.
Q.   Coincidental death.
R.    Accidental death.
S.    Maternal murder.
T.    Not a maternal death.
U.   Yes
V.   No.
W. I have no idea.
X.    None of the above.
Abbreviations.
MMR:      Maternal Mortality Rate.
MMRat:  Maternal Mortality Ratio.
SUDEP:    Sudden Unexplained Death in Epilepsy.           
Scenario 1.
What is a Maternal Death?
Scenario 2.
A woman dies from a ruptured ectopic pregnancy at 10 weeks’ gestation. What kind of death is it?
Scenario 3.
A woman dies from a ruptured appendix at 10 weeks’ gestation. What kind of death is it?
Scenario 4.
A woman dies from suicide at 10 weeks’ gestation. What kind of death is it?
Scenario 5.
A woman with a 10-year-history of coronary artery disease dies of a coronary thrombosis at 36 weeks’ gestation. What kind of death is it?
Scenario 6.
A woman has gestational trophoblastic disease, develops choriocarcinomas and dies from it 24 months after the GTD was diagnosed and the uterus evacuated. What kind of death is it?
Scenario 7
A woman develops puerperal psychosis from which she makes a poor recovery. She kills herself when the baby is 18 months old. What kind of death is it?
Scenario 8
A woman develops puerperal psychosis from which she makes a poor recovery. She kills herself when the baby is 6 months old. What kind of death is it?
Scenario 9
What is a “maternity”.
Scenario 10
What is the definition of the Maternal Mortality Rate?
Scenario 11
What is the Maternal Mortality Ratio?
Scenario 12
A woman is diagnosed with breast cancer. She has missed a period and a pregnancy test is +ve. She decides to continue with the pregnancy. The breast cancer does not respond to treatment and she dies from secondary disease at 38 weeks. What kind of death is it?
Scenario 13
A woman who has been the subject of domestic violence is killed at 12 weeks’ gestation by her partner. What kind of death is it?
Scenario 14
A woman is struck by lightning as she runs across a road. As a result she falls under the wheels of a large lorry which runs over abdomen, rupturing her spleen and provoking placental abruption. She dies of haemorrhage, mostly from the abruption. What kind of death is it?
Scenario 15
A woman is abducted by Martians who are keen to study human pregnancy. She dies as a result of the treatment she receives. As this death could only have occurred because she was pregnant, is it a direct death?
Scenario 16
Could a maternal death from malignancy be classified as “Direct”.
Scenario 17
Could a maternal death from malignancy be classified as “Indirect”.
Scenario 18
Could a maternal death from malignancy be classified as “Coincidental”?

8.     EMQ. Coroner 1-3.
This may seem obscure, but it has come several times in the exam. This and MCQ Paper 13, question 5 give you all the facts you need.
The Coroner. Question 1.
Lead-in.
The following scenarios relate to the role of the Coroner.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

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.
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

9.     EMQ. Antepartum haemorrhage.
Lead-in.
Pick one option from the option list. Each option can be used once, more than once or not at all.
Some of the questions don’t have answers on the option list – you have to dig them out of your brain.
Abbreviations.
ART:      assisted reproduction technology
FGR:      fetal growth restriction
PET:      pre-eclampsia
Option list.
A.        genital tract bleeding ≥ 500 ml. from 24 weeks until the delivery of the baby
B.         genital tract bleeding ≥ 500 ml. from 24 weeks until the delivery of the placenta.
C.         genital tract bleeding ≥ 500 ml. from 24 weeks, or earlier if the baby is live-born, until the delivery of the baby.
D.        1
E.         2
F.         3
G.        4
H.        5
I.           6
J.          7
K.         8
L.          9
M.      10
N.        15
O.        20
P.         30
Q.        50
R.         100
S.         500
T.         1,000
U.        true
V.        false
W.      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 a viva in the OSCE?

10.   EMQ. Cystic fibrosis.
This question is about cystic fibrosis.
And, to make you behave in a model fashion, there is no option list, so you have to decide the correct answer.
Question 1.
A woman is 8 weeks pregnant and known to be a carrier of cystic fibrosis.
Her husband is Caucasian.
What is the risk of the child having cystic fibrosis?
Question 2.
A healthy woman attends for pre-pregnancy counselling.
Her brother has cystic fibrosis. Her husband is Caucasian.
He has been screened for cystic fibrosis. The test was negative.
What is the approximate risk of them having a child with cystic fibrosis?
Question 3.
A healthy woman is a known carrier of cystic fibrosis.
She attends for pre-pregnancy counselling. Her husband has cystic fibrosis.
What is the risk of them having a child with CF?
Question 4.
A healthy woman attends for pre-pregnancy counselling. Her sister has had a child with cystic fibrosis.
What is her risk of being a carrier?
Question 5.
A woman attends for pre-pregnancy counselling. Her mother has cystic fibrosis.
What is the risk that she is a carrier?
Question 6.
A woman attends for pre-pregnancy counselling. Her mother has cystic fibrosis.
The partner’s risk of being a carrier is 1 in X.
What is the risk that she will have a child with CF?
Question 7.
A healthy Caucasian woman is 10 weeks pregnant.
Her husband is a known carrier of cystic fibrosis.
Which test would you arrange?
Question 8.
A woman attends for pre-pregnancy counselling. She has read about diagnosing CF using cffDNA from maternal blood. Is it possible to test for CF in this way?
Question 9.
A woman and her husband are known carriers of cystic fibrosis.
What is the risk of them having an affected child?
Question 10.
A woman and her husband are known carriers of cystic fibrosis.
What can they do to reduce the risk of having an affected child?
Question 11.
A woman and her husband are known carriers of cystic fibrosis.
Can CVS exclude an affected pregnancy?
Question 12.
A woman with cystic fibrosis is planning pregnancy. Her husband is a carrier of cystic fibrosis. What is the risk of having an affected child?
Question 13.
A woman with cystic fibrosis has a normal delivery of a healthy, 3.2 kg. baby at term. She has been advised not to breastfeed because her breast milk will be protein-deficient due to malabsorption.
Is this advice correct?
Question 14.
A woman with cystic fibrosis has a normal delivery of a healthy, 3.2 kg. baby at term. She has been advised not to breastfeed because her breast milk will contain abnormally low levels of sodium.
Is this advice correct?

11.   Communication skills. Prepregnancy counselling. Brother has cystic fibrosis.
Candidate's Instructions.
This is a roleplay station. You are a year 4 SpR and are in the gynaecology clinic.
The consultant has just left you in charge as she is feeling unwell and has gone to lie down.
Your task is to deal with the patient as you would in real life.
GP referral letter.
Best Medical Centre,
High Road,
Anytown.
Phone: 01882 78998.
Practice Manager: Mary Wright. B.SC., RGN.
Phone: 01882 78998 ext. 23.
Re. Mrs. Bonnie Black,
25 Low Road,
Anytown.
DOB: 28 January 1990.
Phone: 07889 888 132.
Dear Doctor,
Please see Mrs Black who is planning her first pregnancy. Her main concern is that her brother has cystic fibrosis.
This was the first time I had met her although she has been registered with us for 5 years – her health is good and she has no history of serious illness or surgery.
I have explained that I don’t know much about the implications of the brother’s cystic fibrosis for her potential pregnancies and that she needs to talk to an expert.
Yours sincerely,
John P. Clatter.


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