23
|
EMQ. Mode of inheritance
|
24
|
EMQ. BRCA1&2
and breast & ovarian cancer risk
|
25
|
EMQ. Borderline
ovarian tumours
|
26
|
EMQ. Stolen notes
|
27
|
EMQ. Headache
|
28
|
EMQ. Risk
management
|
29
|
EMQ. COC. Starting and missed pills
|
23. 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! For each
question, write what you think is the mode of inheritance or appropriate
answer. 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 to this
list. Don’t add a load of very 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. Holt-Oram syndrome.
43. Hunter syndrome.
44. Huntington’s
disease.
45. ichthyosis.
46. isolated
growth hormone deficiency.
47. juvenile
polycystic kidney disease.
48. Kallmann’s
syndrome.
49. Klinefelter’s
syndrome.
50. Lesch Nyhan syndrome.
51. Lynch syndrome (HNPCC).
52. Malignant hyperthermia.
53. Maple syrup urine disease.
54. Marfan’s syndrome.
55. Martin-Bell syndrome.
56. Mayer-Rokitansky-Kuster-Hauser syndrome.
57. McCune-Albright
syndrome.
58. Meckel-Gruber syndrome.
59. Medium-chain acyl-CoA dehydrogenase deficiency.
60. mucopolysaccharidosis type I.
61. Myotonic
dystrophy.
62. neurofibromatosis.
63. Niemann-Pick
disease.
64. Noonan syndrome.
65. ocular albinism.
66. osteogenesis imperfecta.
67. osteoporosis.
68. Patau’s
syndrome.
69. Perrault syndrome.
70. phenyketonuria.
71. polydactyly.
72. porphyria.
73. Potter’s syndrome.
74. Prader-Willi syndrome.
75. Prune-belly syndrome
76. pyruvate kinase deficiency.
77. sickle cell disease.
78. spherocytosis.
79. Syndrome
X.
80. Tay-Sach’s disease.
81. Thalassaemia.
82. Thrombophilia.
83. Triple X syndrome.
84. Turner’s syndrome.
85. Swyer’s syndrome.
86. Uniparental disomy.
87. VACTERL.
88. vitamin D resistant rickets
89. von Willebrand’s disease.
90. A
mother has spina bifida. What is the risk of a child being affected?
91. A
mother has had a child with spina bifida, what is the risk of the next child
being affected?
92. A mother has had two children with spina bifida. What is
the risk of the next child being affected?
93. A mother has grand-mal epilepsy. What is the risk of her
child having epilepsy?
94. A mother and her partner both have grand-mal epilepsy. What
is the risk of their child having epilepsy?
95. A mother has insulin-dependent diabetes mellitus. What is
the risk of a child being affected?
96. A
mother has congenital heart disease. What is the risk of a child being
affected?
97. A mother takes lithium for bi-polar disorder throughout her
pregnancy. What is the risk of the child having congenital heart disease?
98. 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?
24. BRCA1&2
and breast & ovarian cancer risk
Option lists. Most of the questions have no option list to make you
work harder.
Abbreviations.
BSO: bilateral
salpingo-oophorectomy
EOC: epithelial ovarian
cancer
HGSOG: high-grade serous ovarian
cancer
LGSOG: low-grade serous ovarian
cancer
Scenario 1.
Which, if any, of the following statements are true?
A
|
EOC is the most common gynaecological cancer in the
developed world
|
B
|
EOC is the leading cause of death from gynaecological
cancer in the developed world
|
C
|
50% of EOC is mucinoid
|
D
|
HGSOG is 20 times more common than LGSOG
|
E
|
HGSOG is the main cause of death from ovarian cancer
|
F
|
overall life time risk of EOC is 1 in 70
|
G
|
the main risk factors for EOC are cigarette smoking
& older age
|
H
|
5% of ovarian cancer is due to identified hereditary
genetic factors
|
I
|
BRCA1 is linked to an ↑ risk of breast, ovarian,
pancreatic and prostate cancer
|
J
|
BRCA2 is linked to an ↑risk of breast, ovarian,
pancreatic and prostate cancer & melanoma
|
K
|
The prevalence of BRCA1 & 2 mutations is about 1 in
400 in the general population
|
L
|
The prevalence of BRCA1 & 2 mutations is about 1 in
40 in the Ashkenazi Jewish population
|
M
|
The risk of developing ovarian cancer by 75 years is
BRCA1: 50% and BRCA2: 25%
|
N
|
EOC associated with BRCA1 &2 is mostly low-grade
mucinous in type
|
O
|
The risk of male breast cancer is about 7% with BRCA2,
higher than with BRCA1
|
P
|
BRCA1 & 2 are DNA repair genes
|
Q
|
male breast, pancreatic and prostate cancer are more common
with BRCA2 than BRCA1
|
Scenario 2.
A woman of 30 has two sisters who developed breast cancer
before the age of 40. They and she have been proved to be carriers of BRCA1.
She attends the gynaecology clinic requesting information
about her lifetime risk of breast cancer.
What is the approximate figure?
Scenario 3.
A woman of 30 has two sisters who developed breast cancer
before the age of 40. They and she have been proved to be carriers of BRCA1.
She attends the gynaecology clinic requesting information
about her lifetime risk of ovarian cancer.
What is the approximate figure?
Scenario 4.
A woman of 30 has two sisters who developed breast cancer
before the age of 40. They and she have been proved to be carriers of BRCA2.
She attends the gynaecology clinic requesting information
about her lifetime risk of breast cancer.
What is the approximate figure?
Scenario 5.
A woman of 30 has two sisters who developed breast cancer
before the age of 40. They and she have been proved to be carriers of BRCA2.
She attends the gynaecology clinic requesting information
about her lifetime risk of ovarian cancer.
What is the approximate figure?
Scenario 6.
The woman asks for the overall figure for lifetime risk
of breast cancer in UK women for comparison with her risk. What is the
approximate figure?
Scenario 7.
The woman asks for the overall UK figure for lifetime
risk of ovarian cancer for comparison with her risk. What is the approximate
figure?
Scenario 8
Which of
the following genes have mutations that increase the risk of breast cancer?
A
|
ATM
|
B
|
CDH1
|
C
|
CHEK1
|
D
|
FATHEAD
|
E
|
MARBELLA.
|
F
|
NBENE
|
G
|
p45
|
H
|
p53.
|
I
|
PALB2
|
J
|
PNINE
|
K
|
PTEN
|
L
|
RADON50
|
M
|
RINT1
|
Scenario 9
A man of 30 has two sisters who developed breast cancer before
the age of 40. They and he have been proved to be carriers of BRCA2.
His GP phones to ask about his lifetime risk of breast cancer.
What is the approximate figure?
Scenario 10
A man of 30 has two sisters who developed breast cancer before
the age of 40. They and he have been proved to be carriers of BRCA2.
His GP phones to ask about his lifetime risk of ovarian cancer.
What is the approximate figure?
Scenario 11
A woman of 30 has two sisters who developed breast cancer
before the age of 40. They and she have been proved to be carriers of BRCA2.
She attends the gynaecology clinic requesting information
about the value of prophylactic mastectomy. What advice will you give about
efficacy?
Scenario 12
A woman of 30 has two sisters who developed breast cancer
before the age of 40. They and she have been proved to be carriers of BRCA2.
She attends the gynaecology clinic requesting information
about the benefits of prophylactic salpingo-oophorectomy – her family is
complete and her husband has had vasectomy. What is the approximate figure for
the efficacy of BSO in relation to cancer?
Scenario 13.
Which, if any, of the following statements is true in
relation to the findings by Kuchenbaecker in relation to the incidence of
breast cancer in carriers of a BRCA1 mutation?
Pick one option from the option list.
Option list.
A.
|
it rises rapidly until the age of 30-40, then stays
constant until age 80
|
B.
|
it rises rapidly from puberty until the age of 30-40,
then stays constant until age 80
|
C.
|
it rises rapidly from young adulthood until the age of 30-40, then stays constant
until age 80
|
D.
|
it rises rapidly from puberty until the age of 40-50,
then stays constant until age 80
|
E.
|
it rises rapidly from young adulthood until the age of 40-50, then stays constant
until age 80
|
F.
|
it rises rapidly from puberty until the menopause, then
stays constant until age 80
|
G.
|
it rises rapidly from young adulthood until the menopause, then stays constant
until age 80
|
H.
|
none of the above
|
Scenario 14.
Which, if any, of the following statements is true in
relation to the findings by Kuchenbaecker in relation to the incidence of
breast cancer in carriers of a BRCA2 mutation?
Pick one option from the option list.
Option list.
A.
|
it rises rapidly until the age of 30-40, then stays
constant until age 80
|
B.
|
it rises rapidly from puberty until the age of 30-40,
then stays constant until age 80
|
C.
|
it rises rapidly from young adulthood until the age of 30-40, then stays constant
until age 80
|
D.
|
it rises rapidly from puberty until the age of 40-50,
then stays constant until age 80
|
E.
|
it rises rapidly from young adulthood until the age of 40-50, then stays constant
until age 80
|
F.
|
it rises rapidly from puberty until the menopause, then
stays constant until age 80
|
G.
|
it rises rapidly from young adulthood until the menopause, then stays constant
until age 80
|
H.
|
none of the above
|
Scenario 15.
A woman of 30 has two sisters who developed breast cancer
before the age of 40. They and she have been proved to be carriers of BRCA1.
She attends the gynaecology clinic requesting information
about the benefits of prophylactic salpingo-oophorectomy. What are the
disadvantages of BSO?
Scenario 16
A woman of 30 has two sisters who developed breast cancer
before the age of 40. They and she have been proved to be carriers of BRCA1.
She attends the gynaecology clinic requesting information
about the benefits of prophylactic salpingo-oophorectomy. What alternatives should be discussed?
Scenario 17
A woman of 25 years is a known carrier of BRCA1. She has
no family history of breast cancer. She has a friend who is similar in age and
has similar risk factors for breast cancer, including being a BRCA1 carrier,
apart from having two 1st. degree relatives with breast cancer.
Which, if any of the following statements is true in relation to the risk of
breast cancer for the friend compared with the woman?
A.
|
her risk is the same
|
B.
|
her risk is 2 x that of the woman
|
C.
|
her risk is 5x that of the woman
|
D.
|
her risk is ½ of that of the woman
|
E.
|
none of the
above
|
Scenario 18
A woman of 25 years is a known carrier of BRCA2. She has
no family history of breast cancer. She has a friend who is similar in age and
has similar risk factors for breast cancer, including being a BRCA2 carrier,
apart from having two 1st. degree relatives with breast cancer.
Which, if any of the following statements is true in relation to the risk of
breast cancer for the friend compared with the woman?
A.
|
her risk is the same
|
B.
|
her risk is 2 x that of the woman
|
C.
|
her risk is 5x that of the woman
|
D.
|
her risk is ½ of that of the woman
|
E.
|
none of the
above
|
25. Borderline
ovarian tumours
Some of these are not true EMQs
– they have more than one answer. I do this as it makes the document shorter
and saves me some typing.
Abbreviations.
Bagade: “Management of borderline ovarian tumours”: Bagade
P., Edmondson R. & Nayar A.
BOT: borderline ovarian tumour.
Ca125: Ca125 as iu/ml.
COC: combined oral contraceptive.
EOT: epithelial ovarian tumour.
IOC: invasive ovarian cancer.
MOV: mean ovarian volume.
MS: menopause score.
POI: premature ovarian insufficiency.
RMI: Risk of Malignancy Index.
SOT: serous ovarian tumour.
US: ultrasound score.
Scenario 1.
Which, if any, of the following
statements are true in relation to BOTs?
Option list.
A
|
show more proliferation than benign ovarian tumours
|
B
|
stromal invasion is absent
|
C
|
stromal invasion is < 5 mm from the ovarian surface
|
D
|
comprise 10-15% of EOTs
|
E
|
comprise 10-15% of GCTOs
|
F
|
comprise 10-15% of SOTs
|
Scenario 2.
Which, if any, of the following
statements are true?
Option list.
A
|
BOTs constitute
5-10% of ovarian epithelial neoplasia
|
B
|
BOTs constitute 10-15% of ovarian epithelial neoplasia
|
C
|
BOTs constitute 15-20% of ovarian epithelial neoplasia
|
D
|
BOTs constitute
5-10% of ovarian germ-cell neoplasia
|
E
|
BOTs constitute 10-15% of ovarian germ-cell neoplasia
|
F
|
BOTs constitute 15-20% of ovarian germ-cell neoplasia
|
Scenario 3.
Which, if any, of the following
statements are true?
Option list.
A
|
BOTs are less common in women who have taken the COC
for > 5 years
|
B
|
BOTs are less common in women with a history of
lactation
|
C
|
BOTs are more common after the menopause
|
D
|
BOTs are more common in multiparous women
|
E
|
BOTs are more common in women with BRCA1 & 2
mutations
|
Scenario 4.
Which, if any, of the following
statements are true in relation to BOTs.
Option list.
A
|
p53 mutations are more common than in invasive ovarian
tumours
|
B
|
BRAF/KRAS mutations are common than in invasive ovarian
tumours
|
C
|
BRCA 1 & 2 mutations are more common in women with
BOTs
|
D
|
BOTs are more common in women from a Lynch syndrome
family with a known MSH6 mutation
|
E
|
BOTs are more common in women with red hair
|
Scenario 5.
Which, if any, of the following
statements are true in relation to BOTs.
Option list.
A
|
Brenner tumours are the most common
|
B
|
endometrioid tumours are the most common
|
C
|
mucinous tumours are the most common
|
D
|
serous tumours are the most common
|
E
|
< 10% are bilateral
|
Scenario 6.
Which, if any, of the following
statements are true in relation to mucinous BOTs.
Option list.
A
|
are subdivided into endocervical / Müllerian or
intestinal categories
|
B
|
are subdivided into endocervical / Müllerian,
intestinal or renal categories
|
C
|
are subdivided into endometrial or intestinal
categories
|
D
|
pseudomyxoma peritonei occurs in < 1% of cases
|
E
|
pseudomyxoma peritonei occurs in about 10% of cases
|
Scenario 7.
Which, if any, of the following
statements are true in relation to BOTs.
Option list.
A
|
↑ Ca
125 levels are rare, normally indicating malignancy
|
B
|
Ca 19-9 levels are often ↑ in mucinous BOTs
|
C
|
CEA levels are often ↑ in serous tumours
|
D
|
Ca 15-3 is commonly ↑ in both mucinous and serous BOTs
|
E
|
TVS and MRI are useful in the assessment of BOTs
|
Scenario 8.
Which, if any, of the following
statements are true in relation to BOTs.
Option list.
A
|
the 5-year survival rate is approximately 80% for stage
I disease
|
B
|
the 5-year survival rate is approximately 95% for stage
I disease
|
C
|
the 5-year survival rate is approximately 50% for stage
III disease
|
D
|
the 5-year survival rate is approximately 60% for stage
III disease
|
E
|
the overall 10-year survival rate is approximately 75%
|
Scenario 9.
Which, if any, of the following
statements is true in relation to calculation of the RMI score?
Option list.
A
|
uses the formula age x Ca125 x US
|
B
|
uses the formula Ca125 x MS x MOV
|
C
|
uses the formula (Ca125 + MS) x US
|
D
|
uses the formula Ca125 + MS + US
|
E
|
uses the formula Ca125 x MS x US
|
F
|
none of the above
|
Scenario 10.
Which, if any, of the following
describes the formula used for the calculation of the MOV as used in the RMI
score?
Option list.
A
|
total ovarian volume / 2
|
B
|
total ovarian volume / average ovarian number
|
C
|
total ovarian volume /
ovarian number
|
D
|
total volume of the larger ovary
|
E
|
p
x (mean diameter)3 / 4 of the larger ovary
|
F
|
none of the above
|
Scenario 11.
Which, if any, of the following
as used in the calculation of the MS as used in the RMI score
Option list.
A
|
prepubertal:
score = 0
|
B
|
1ry. amenorrhoea:
score = 1
|
C
|
POI: score = 2
|
D
|
perimenopausal:
score = 3
|
E
|
menopausal:
score = 4
|
F
|
none of the above
|
Scenario 12.
Which, if any, of the following
statements is true in relation to calculation of the RMI score?
Option list.
A
|
uses the formula age x Ca125 x US
|
B
|
uses the formula Ca125 x MS x MOV
|
C
|
uses the formula (Ca125 + MS) x US
|
D
|
uses the formula Ca125 + MS + US
|
E
|
uses the formula Ca125 x MS x US
|
F
|
none of the above
|
Scenario 13.
Which, if any, of the following
statements are true in relation to the RMI and BOTs.
Option list.
A
|
the RMI is particularly useful and should always be
considered in the early assessment
|
B
|
the RMI is not particularly useful in the majority of
possible BOTs
|
C
|
the strength of the RMI in the assessment of possible
BOTs lies with the elevated Ca125 levels
|
D
|
weakness of the RMI in the assessment of possible BOTs
is, in part, due to the wide range of Ca125 levels found with BOTs
|
E
|
none of the above
|
Scenario 14.
Which, if any, of the following
statements are true in relation to the measurement of Ca125 in calculating a
RMI score.
Option list.
A
|
the units used are mg/L
|
B
|
the units used are mg/mL
|
C
|
the units used are mol/L
|
D
|
the units used are mol/mL
|
E
|
the units used are iu/L
|
E
|
the units used are iu/ml
|
Scenario 15.
Which, if any, of the following
are part of the measurement of US?
Option list.
A
|
ascites
|
B
|
hydrothorax
|
C
|
multilocular cysts
|
D
|
↑
ovarian blood flow
|
E
|
↑ ovarian number
|
E
|
↑ ovarian volume
|
Scenario 16.
Which, if any, of the following
statements describes the best management of BOTs.
Option list.
A
|
the best management is hysterectomy + BSO + infracolic
omentectomy + lymphadenectomy + appendicectomy + excision of extra-ovarian
lesions
|
B
|
the best management is hysterectomy + BSO + infracolic
omentectomy + appendicectomy
|
C
|
the best management is hysterectomy + BSO +
appendicectomy
|
D
|
the best initial management is ovarian cystectomy +
histology of frozen section
|
E
|
chemotherapy should be offered when the stage is > I
|
F
|
none of the above
|
Scenario 17.
Which, if any, of the following
statements describes the recommended management of BOT in the woman who does
not wish to retain her fertility?
Option list.
A
|
the best management is hysterectomy + BSO + infracolic
omentectomy + lymphadenectomy + appendicectomy + excision of extra-ovarian lesions
|
B
|
the best management is hysterectomy + BSO + infracolic
omentectomy + appendicectomy
|
C
|
the best management is hysterectomy + BSO +
appendicectomy
|
D
|
the best initial management is ovarian cystectomy +
histology of frozen section
|
E
|
none of the above
|
Scenario 18.
Which, if any, of the following
statements describes the recommended additional management of BOT in the woman
who does not wish to retain her fertility and whose tumour is mucinous?
Option list.
A
|
appendicectomy
|
B
|
appendicectomy after histology of frozen section
|
C
|
removal of the other ovary
|
D
|
removal of the other ovary after histology of frozen
section
|
E
|
bilateral salpingectomy
|
Scenario 19.
What advice is usually given in
relation to the use of clomifene in women treated for BOTs?
Option list.
A
|
clomifene is contraindicated
|
B
|
only offer treatment to women < 35 years
|
C
|
only offer treatment to women who have screened –ve for
BRCA 1 & 2
|
D
|
only offer treatment to women with stage 1 & 2
disease
|
E
|
restrict the number of treatment cycles
|
Scenario 20.
What is the role of
chemotherapy in the management of women with BOTs?
Option list.
A
|
chemotherapy should be offered routinely after surgery
as for invasive disease
|
B
|
pre-operative chemotherapy reduces recurrence rates
|
C
|
routine chemotherapy is of unproven benefit
|
D
|
the main role for chemotherapy is for recurrent disease
|
E
|
the main role for chemotherapy is for recurrent disease
unsuitable for surgery
|
Scenario 21.
Which, if any, of the following
statements are true in relation to restaging in the management of women with BOTs?
Option list.
A
|
should be offered routinely if definitive surgery is
not performed initially
|
B
|
restaging improves 5-year recurrence rates
|
C
|
restaging improves 10-year survival
|
D
|
restaging may be appropriate for those with invasive
implants
|
E
|
restaging may be appropriate for those with DNA
aneuploidy
|
Scenario 22.
What advice is usually given in
relation to the management of women found unexpectedly to have a BOT on
histology?
Option list.
A
|
further surgery, if needed, to remove the ovary and
tube
|
B
|
adjuvant chemotherapy
|
C
|
pelvic radiotherapy
|
D
|
close follow-up
|
E
|
none of the above
|
Scenario 23.
What is the role of laparoscopy
in women with actual or suspected BOT?
Option list.
A
|
laparoscopy has replaced laparotomy in most cases
|
B
|
concerns about the risk of recurrence limit its use
|
C
|
concerns about worse survival limit its use
|
D
|
concerns about port metastasis limit its used
|
E
|
none of the above
|
Scenario 24.
What is the definition of
conservative surgery in the management of
BOTs?
Option list.
A
|
surgery with conservation of uterus and at least one
ovary
|
B
|
surgery with conservation of uterus and at least part
of one ovary
|
C
|
surgery with complete staging + conservation of uterus
and at least one ovary
|
D
|
surgery with complete staging + conservation of uterus
and at least part of one ovary
|
E
|
complete staging + omentectomy + conservation of uterus
and at least part of one ovary
|
Scenario 25.
A nulliparous 24-year-old woman
has a right-sided BOT. She has opted for conservative surgery with conservation
of the uterus and left ovary and tube. She has asked about the advisability of
biopsy of the left ovary at the time of surgery. Which of the following options
would reflect your advice.
Option list.
A
|
biopsy of the apparently normal ovary is recommended
|
B
|
biopsy of the apparently normal ovary is not
recommended
|
C
|
biopsy of the apparently normal ovary is decided on an
ad hoc basis by the MDT
|
D
|
biopsy of the apparently normal ovary is a matter for
informed consent
|
E
|
none of the above
|
Scenario 26.
A nulliparous 24-year-old woman
has a right-sided BOT. She has conservative surgery with conservation of the
uterus and left ovary and tube. She has asked about the advisability of removal
of the left ovary and tube once she has completed her family.
Option list.
A
|
LSO is recommended once her family is complete
|
B
|
LSO is not recommended
|
C
|
LSO once her family is complete is decided on an ad hoc
basis by the MDT
|
D
|
LSO once her family is complete is a matter for
informed consent
|
E
|
none of the above
|
Scenario 27.
What advice can be given about
fertility rates after conservative surgery for a BOT?
Option list.
A
|
about half of women conceive spontaneously
|
B
|
fertility rates are unimpaired by conservative surgery
|
C
|
fertility rates are improved by conservative surgery
|
D
|
fertility rates after conservative surgery are unknown
|
E
|
none of the above
|
26. Stolen
notes.
Lead-in.
A SpR1 has been asked to carry out an audit and 50 sets
of case-notes are to be used.
He is given 49 sets of notes and a day in which to go
through them and extract the necessary data.
This he does in the hospital. The final set of notes
cannot be found initially, but are found two weeks later. The doctor is given
the notes on a Friday afternoon as he is leaving for home. He decides to take
the notes home to extract the data. On the way home he stops at his favourite
supermarket.
When he emerges, his car has been stolen with the notes
inside. He reports the theft to the police.
Abbreviations.
BMA: British
Medical Association
CG: Caldicott
Guardian
MDU: Medical
Defence Union
NHSLA: NHS Litigation Authority
Question 1.
The SPR informs you, the Clinical Director, on the Monday
when he returns to work.
What action will you take?
Option list.
A
|
Report events to the Caldicott Guardian
|
B
|
Report events to the Chief Executive
|
C
|
Report events to the General Medical Council
|
D
|
Report events to the NHSLA as a “never event”
|
E
|
Report events to the NHSLA as a “serious incident”
|
F
|
Report events to the NPHSLA as a “never event”
|
G
|
Report events to the NPSLA as a “serious incident”
|
H
|
Report events to the Risk Management Team
|
I
|
Report events to the Root Cause Analysis Team
|
J
|
Report events to the Trust Information Management
Committee
|
K
|
Suspend the doctor until a full investigation has been
done
|
Question 2.
What action will you take to deal with the SpR?
Option list.
A.
|
Suspend the doctor until a full investigation has been
done
|
B.
|
Report the doctor to the Medical Director
|
C.
|
Report the doctor to the Postgraduate Dean
|
D.
|
Report the doctor to the General Medical Council
|
E.
|
Report the doctor to the NHSLA
|
F.
|
Report the doctor to the Caldicott Guardian
|
G.
|
Report the doctor to the Trust Board member responsible
for safeguarding
|
H.
|
Report the doctor to the BMA
|
I.
|
Report the doctor to the MDU
|
J.
|
None of the above
|
Question 3.
What action will you take in relation to the patient whose
notes are missing?
Option list.
A.
|
Ask the Caldicott Guardian to deal with it
|
B.
|
Ask the Chief Executive to deal with it
|
C.
|
Ask the hospital’s legal team to deal with it
|
D.
|
Ask the patient’s GP to deal with it
|
E.
|
Discuss with the legal team, inform the patient,
discuss the implications and keep her fully-up-to-date
|
F.
|
Tell all those who know about the incident to discuss
it with no one else, particularly the patient
|
G.
|
None of the above
|
27. Headache
Lead-in.
Pick one option from the option list.
Option list.
1. abdominal migraine
2. analgesia overuse
aka medication overuse
3. bacterial meningitis
4. benign intracranial hypertension
5. BP check
6. cerebral venous sinus thrombosis
7. chest X-ray
8. cluster
9. severe PET / impending eclampsia
10. malaria
11. meningococcal meningitis
12. methyldopa
13. methysergide
14. migraine
15. MRI brain scan
16. nifedipine
17. nitrofurantoin
18. pancreatitis
19. sinusitis
20. subdural haematoma
21. subarachnoid haemorrhage
22. tension
23. ultrasound scan of the abdomen
Scenario 1.
A 40-year-old para 3 is
admitted at 38 weeks by ambulance with severe
of sudden onset. She describes it as “the worst I’ve ever had”. Which
diagnosis needs to be excluded urgently?
Scenario 2.
A 32-year-old para 1 has
recently experienced s. They are worse on exercise, even mild exercise such as
walking up stairs. She experiences photophobia with the s. Which is the most
likely diagnosis?
Scenario 3.
A woman returns from a
sub-Saharan area of Africa. She develops severe , fever and rigors. What
diagnosis should particularly be in the minds of the attending doctors?
Scenario 4.
A woman at 37 weeks has s. They particularly occur at
night without obvious triggers. They occur every few days.
Scenario 5.
A primigravida has had s on a regular basis for many
years. They occur most days, are bilateral and are worse when she is stressed.
What is the most likely diagnosis?
Scenario 6.
A woman complains of recent s
at 36 weeks. The history reveals that the s started soon after she began
treatment with a drug prescribed by her GP. Which is the most likely of the
following drugs to be the culprit: methyldopa, methysergide, nifedipine or
Nitrofurantoin?
Scenario 7
A woman is booked for C section
and wishes regional anaesthesia. She had severe headache due to dural tap after
a previous C section. She wants to take all possible steps to reduce the risk
of having this again. Which of epidural and spinal anaesthesia has the lower risk of causing
dural tap?
Scenario 8
A 25-year-old primigravida
complains of s which started two weeks before when she attends for her 20 week
scan. There is no significant history of previous . The pain occurs behind her
right eye and she describes it as severe and “stabbing” in nature. The pain is
so severe that she cannot sit still and has to walk about. She has noticed that
her right eye becomes reddened and “watery” during the attack and her nose is
“runny”. The attacks have no obvious trigger and mostly occur a few hours after
she has gone to sleep. The usually last about 20 minutes. She has no other
symptoms. She smokes 20 cigarettes a day but does not take any other drugs,
legal or otherwise. What is the most likely diagnosis?
Scenario 9
A woman has a 5-year history of
unilateral, throbbing often preceded by
nausea, visual disturbances, photophobia and sensitivity to loud noise. What is
the most likely diagnosis?
Scenario 10
A primigravida is admitted at 38 weeks complaining of ,
abdominal pain and a sensation of flashing lights. What would be the
appropriate initial investigation?
Scenario 11
A woman with BMI of 35 attends for her combined Downs
syndrome screening test. She complains of pain behind her eyes. The pain is
worst last thing at night before she goes to sleep or if she has to get up in
the night. She has noticed she has noticed horizontal diplopia on several occasions. She has no other symptoms. Examination
shows papilloedema.
Scenario 12
A grande multip of 40 years experienced sudden-onset,
severe , vomited several times and then collapsed, all within the space of 30
minutes. She is admitted urgently in a semi-comatose state. Examination shows
neck-stiffness and left hemi-paresis.
Scenario 13.
What did the MMR include as
“red flags” for in pregnancy? These are
not on the option list – you need to dig them out of your head.
28. Risk
management
Lead-in.
The following scenarios relate to risk management /
disciplinary procedures.
Pick one option from the option list.
Abbreviations.
DOH: Department
of Health.
Option list.
A.
allow the practice to
continue
B.
stop the practice
until a full investigation has been done
C.
stop the practice
permanently
D.
arrange an
investigation by a senior consultant from another hospital
E.
decide the practice
does not involve added risk
F.
declare the risk to be
acceptable
G.
cancel admissions for
surgery
H.
arrange adverse
incident analysis
I.
arrange audit
J.
arrange research
K.
arrange a formal
warning for the doctor
L.
arrange retirement for
the doctor
M.
arrange dismissal for
the doctor
N.
consult the on-call
consultant
O.
consult the Clinical
Director
P.
consult the
Educational Supervisor / College Tutor
Q.
consult the Medical
Director
R.
consult the Chief
Executive
S.
consult the
Postgraduate Dean.
T.
consult the hospital’s
lawyer
U.
write to Her Majesty at
Buckingham Palace
V.
consult your Medical
Defence Body
W.
consult the British
Medical Association
X.
consult the RCOG
Y.
report the matter to
the GMC
Z.
allow return to work
AA.
allow return to work,
but offer support
BB.
arrange a “return to
work” package specific to the doctor
CC.
none of the above
Scenario 1
You are the Clinical Director.
1 62-year-old Consultant colleague has been off work for 8 weeks with a broken
arm sustained in a skiing accident. He sends you a certificate from his
specialist to say that he is now fit to return to work. He indicates that he
wishes to return to work immediately. What action will you take?
Scenario 2
You are the Clinical Director.
1 62-year-old Consultant colleague has been off work for 8 weeks with a severe
bereavement reaction to the suicide of a family member. He sends you a
certificate from his GP to say that he is now fit to return to work. He
indicates that he wishes to return to work immediately. What action will you
take?
Scenario 3
You are the Clinical Director.
1 62-year-old Consultant colleague has been off work for 6 months after having
a coronary thrombosis. He sends you a certificate from his specialist to say
that he is now fit to return to work. He indicates that he wishes to return to
work immediately. What action will you take?
Scenario 4
You are the Clinical Director.
A 62-year-old Consultant has returned to work after four months’ sick leave
after a coronary thrombosis. He has three cases on his first operating list and
all have complications reported by the Sister on the gynaecology ward. What
action will you take?
Scenario 5.
A Consultant has been in her
first consultant post for two months. Three of the four patients on a single
operating list develop post-operative wound infections. What action will you
take?
Scenario 6.
You have recently been
appointed Clinical Director. A consultant has been in post for ten years and
prefers to operate with the same nurse assistant. No complications have been
reported. What action will you take?
Scenario 7.
You are the Clinical Director. A consultant has an operating list in a peripheral unit 20 miles from the
main hospital. There is no resident doctor with post-operative care being
provided by nurses. The cases dealt with on the list traditionally were minor,
day-cases. You have been told that the
consultant, who was appointed 6 months ago, has recently been doing
hysterectomies and prolapse repairs to get the waiting list down. What action will you take?
Scenario 8.
You are the Clinical Director.
The blood bank informs you that there is a problem with supplies and fully
cross-matched blood cannot be guaranteed for tomorrow’s arranged surgical
cases.
What action will you take?
Scenario 9.
You are the on-call SpR. It is
8 pm. The blood bank informs you that there is a problem with supplies and
fully cross-matched blood cannot be guaranteed for tomorrow’s arranged surgical
cases.
What action will you take?
Scenario 10.
An SpR is half an hour late for
starting his duties on three occasions in one week. His consultant wishes to
have this dealt with as a disciplinary matter to “nip it in the bud” and teach
him a lesson. He reports it to you, the Clinical Director asking you to
discipline the doctor. What action will you take?
Scenario 11
An SpR gets into an argument
with the senior midwife on the labour ward and in the heat of the moment slaps
her across the face. You are the Clinical Director and the matter is reported
to you next day.
Scenario 12
Your consultant is the Clinical
Director and a nasty man. You apply 6 months in advance for study leave for the
week before the written part of the Part Ii MRCOG exam. He tells you that he
plans to go on holiday at that time and you are not going to get any leave. In
addition, he tells you that if you complain about this he will give you a terrible
reference and tell all his consultant friends that you are a waste of space in
order to ruin your career. What action can you take?
Scenario 13
A SpR fails an OSATS, but
falsifies his records to indicate that it has been completed satisfactorily.
You are the Educational Advisor and this is brought to your attention. What
action will you take ?>
Scenario 14
You are the Clinical Director. A
SpR2 uploaded reflective practice putting himself in a good light after a case
which had been handled sub-optimally by him. What action will you take?
Scenario 15
You are an FY2 and assist
the senior consultant at a hysterectomy. The operation goes well initially, but
then there is a lot of bleeding and a ureter is cut. The consultant urologist
attends and repairs the ureter. The woman bleeds vaginally that evening and is
taken back to theatre by another consultant and ends up in the ICU. You became
convinced during the operation that you could smell alcohol on the consultant
gynaecologist’s breath. What are your responsibilities?
Scenario 16
When do you need to inform the Consultant on-call? There
is no answer on the option list – make your own list.
Scenario 17
When do you need to inform the Clinical Director? There
is no answer on the option list – make your own list.
Scenario 18
When do you need to inform the Medical Director? There is
no answer on the option list – make your own list.
Scenario 19
When do you need to inform the GMC? There is no answer on
the option list – make your own list.
Scenario 20
What are the roles of the BMA and MDU? There is no answer
on the option list – make your own list.
Scenario 21
What are the differences between verbal and written
warnings? There is no answer on the option list – make your own list.
Scenario 22.
Lead-in.
You are the SpR for the delivery unit. During a quiet moment
you head for the staff room adjacent to the operating theatre for a coffee. As
you pass the anaesthetic room you hear loud snoring. You look in and find the
on-call anaesthetic registrar unconscious on his back on the floor with an
anaesthetic mask by his face attached to a cylinder of nitrous oxide.
What action will you take?
Pick one option from the option list.
Option list.
|
|
call for help from the senior midwife
|
|
|
go back to the labour ward and pretend that nothing has
happened
|
|
|
go back to the labour ward and inform the senior midwife
|
|
|
phone the GMC
|
|
|
phone the on-call consultant anaesthetist
|
|
|
phone the on-call consultant obstetrician
|
|
|
phone the police
|
|
|
put the anaesthetist in the recovery position and remove
the mask
|
|
|
none of the above
|
Scenario 23.
Lead-in.
You are the SpR for the delivery unit. During a quiet moment
you head for the staff room adjacent to the operating theatre for a coffee. As
you pass the anaesthetic room you hear loud snoring. You look in and find the
on-call anaesthetic registrar unconscious on his back on the floor with an
anaesthetic mask by his face attached to a cylinder of nitrous oxide.
What action will you take next?
Pick one option from the option list.
Option list.
|
|
call for help from the senior midwife
|
|
|
go back to the labour ward and pretend that nothing has
happened
|
|
|
go back to the labour ward and inform the senior midwife
|
|
|
phone the GMC
|
|
|
phone the on-call consultant anaesthetist
|
|
|
phone the on-call consultant obstetrician
|
|
|
phone the police
|
|
|
put the anaesthetist in the recovery position and remove
the mask
|
|
|
none of the above
|
Scenario 24.
Lead-in.
You are the Clinical Director. It is the morning after the
events in scenarios 22 and 23.
The on-call consultant obstetrician comes to see you are
reports what has happened.
What action will you take?
Pick one option from the option list.
Option list.
|
|
discuss the case with the Chief Executive
|
|
|
discuss the case with the Medical Defence Union
|
|
|
discuss the case with the Medical Director
|
|
|
discuss the case with the Medical Director
|
|
|
discuss the case with the most senior person in the
personnel department
|
|
|
discuss the case with the Postgraduate Dean
|
|
|
report the anaesthetic registrar to the GMC
|
|
|
resign from being Clinical Director to avoid stress
|
|
|
summon the anaesthetic registrar to give him a severe
telling-off
|
29. COC.
Starting and missed pills
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.
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?
Scenario 12
What advice does the FSRH give
in relation to CHC use by women who are breastfeeding?
Option list.
A.
|
UKMEC 1
|
B.
|
UKMEC 1 until 6 weeks then
UKMEC 2
|
C.
|
UKMEC 2 until 6 weeks then
UKMEC 1
|
D.
|
UKMEC 3
|
E.
|
UKMEC 4
|
Scenario 13
At what age does the FSRH
advise that women should stop using CHC?
Pick the statement from the
option list that best reflects the FSRH’s advice
Option list.
F.
|
there is no age limit if the
woman has no risk factors for VTE or medical contraindications
|
G.
|
the age limit is 50 if the
woman has no risk factors for VTE or medical contraindications
|
H.
|
the age limit is 55 if the
woman has no risk factors for VTE or medical contraindications
|
I.
|
contraception is not needed
for women ≥ 55 years.
|
J.
|
none of the above
|
Scenario 14
Add the risk of VTE per 10,000
women years to the right column for each category.
Category
|
Risk per 10,000 women per year
|
Reproductive age not using
CHC
|
|
Pregnancy
|
|
Puerperium
|
|
CHC progestogens 1
|
|
CHC progestogens 2
|
|
“Evra” transdermal patch (
|
|
“NuvaRing” vaginal ring
|
Progestogens 1 are:
levonorgestrel, norethisterone & norgestimate
Progestogens 2 are:
desogestrel, Dienogest, drospirenone, gestodene & nomegestrol
List of possible risks.
Risk per 10,000 women per year
|
2
|
15
|
29
|
300-400
|
500-600
|
5 - 7
|
6 - 12
|
9 - 12
|
9 - 15
|
Scenario 15
What is the risk of death for a
woman having a VTE on CHC?
Option list
A.
|
0.1%
|
B.
|
1%
|
C.
|
2%
|
D.
|
5%
|
E.
|
10%
|
The
document has 10 MCQs at the end. As these are picked out as important facts, it
is likely that the exam committee will have woven them into EMQs or SBAs, so
you should know the answers.
1 The bleed
experienced during the pill-free week is a natural menstrual bleed. T
F
2 Contraceptive
efficacy of the combined transdermal patch (CTP) may be decreased in women
weighing >90 kg. T
F
3 CHC can be
started at any time in the cycle if the clinician is reasonably certain the
woman is not pregnant. T F
4 If switching
from the POP to CHC, additional contraceptive protection is not required. T
F
5 The CTP can be
detached for 48 hours before contraceptive efficacy is decreased. T F
6 Lamotrigine
affects contraceptive efficacy of CHC. T F
7 The risk of
venous thromboembolism (VTE) when using CHC is highest in the first few months
of use. T F
8 UK Medical
Eligibility Criteria for Contraceptive Use states that having a 1st.-degree
relative with a history of VTE under the age of 45 years is UKMEC 3. T F
9 CHC can be used
if there is a family history of breast cancer without genetic mutation. T F
10 CHC is not
thought to cause weight gain. T F
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