Tutorial 30th. September 2019

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28	Role-play. Explain, dyskaryosis, dysplasia, CIN etc.
29	Viva. Laboratory results
30	Role-play. Sterilisation request.
31	Viva. Waiting list prioritisation
32	Viva. Clinical governance

28. Roleplay.  Explain, dyskaryosis, dysplasia, CIN etc..

Candidate's Instructions.

This is a role-play station. You are a 4^th. year SpR.

Jane Smith is a 1^st. year student nurse who has joined the department. She has heard the following terms used in the gynaecology and colposcopy clinics:

mild, moderate and severe dyskaryosis in relation to cervical smears,

mild, moderate and severe dysplasia and CIN 1 – 3,

simple, complex and atypical endometrial hyperplasia,

She would like to know what they mean and their significance as the explanations given by the medical staff in the clinics were not clear and patients asked her for clarification. Her knowledge was insufficient for her to provide this, which she found very unsatisfactory for the patients and her. Your consultant has delegated the explanation to you.

29. Structured discussion. Laboratory results.

Candidate’s instructions.

Your consultant is on annual leave.

Her secretary has asked you to look through the following results and decide what administrative action should be taken in relation to each.

1.     +ve MSSU at booking. No symptoms.

2.     GTT at 34 weeks. Peak level 11.5.

3.     FBC with ­ MCV at booking.

4.     Thrombocytopenia at booking. 50,000.

5.     Hydatidiform mole after evacuation of suspected miscarriage.

6.     Histology after ERPC for incomplete miscarriage: no trophoblastic tissue.

7.     Endometrial cancer: hysteroscopy: thickened endometrium. Histology: Anaplastic malignancy.

8.     Endometrial cancer: MR scan: reaching serosa and upper endocervical canal.

9.     Consultant does lap drainage of normal looking ovarian cyst. Malignant cells. Nulliparous. Wants children.

10.   HVS: trichomonas.

11.   Clue cells on smear. 12/52 pregnant.

12.   Antenatal discharge: endocervical swab: chlamydia

13.   Actinomyces on smear.

14.   Herpes in pregnancy

15.   Severe dyskaryosis on cervical smear at booking.

16.   Primary infertility: FSH & LH ­ at 25 on day 3 of cycle.

17.   Primary infertility. FSH 3, LH 12 on day 3 of cycle.

18.   Treated with cabergoline for ­ prolactin and pituitary adenoma. +ve beta HCG.

19.   3 cm. ovarian cyst. ­ Ca 125.

30. Roleplay.  Sterilisation request.

Candidate’s Instructions.

You are a 5^th. year SpR. You are about to see Mrs. Mary Fecund in the gynaecology clinic. There is a referral letter from the GP.

Read the letter and then conduct the consultation with Mrs. Fecund as you would do in the clinic in your hospital.

Referral letter.

Perfect Health Centre,

Paradise Lane,

Slagheap. SLH 678.

Your ref: BRI 07/54843.

Re. Mary Fecund,

The Shoe,

High Street,

Slagheap.

Dear Doctor,

Please see Mrs Fecund who has too many children. She wishes to be sure she has no more and has asked to be sterilised – one of her friends was sterilised recently which has put her in the mood to have it done.

Yours sincerely, Dr. John Williams.

31. Structured discussion.  Waiting list prioritisation.

Candidate’s instructions

Your consultant is away. The waiting-list manager comes to see you.

The following patients have been listed by junior staff.

The waiting-list manager wants you to:

confirm the appropriateness of the proposed treatment,

decide the degree of urgency,

confirm the appropriateness of the proposed venue,

decide any special requirement(s) for each patient.

Name    Age         Clinical problem                                         Proposed operation

JK	5	chronic discharge. ? foreign body	EUA
JM	32	1ry. infertility	Laparoscopy + tubal patency tests
GN	77	Vulval cancer. Coronary thrombosis x 2. Unstable angina.	Radical vulvectomy agreed at MDT.
RU	55	PMB x1. BMI 35.	D&C.
LD	32	Menorrhagia. Fibroids. Anaemia.	Vaginal hysterectomy.
DT	22	Does not want children.	Lap. Steril.
HB	14	Unwanted pregnancy at 10/52.	TOP
JY	44	GSI.	Anterior colporrhaphy.
JS	23	Discharge. Cervical ectropion.	Diathermy to cervix.
DT	55	3 cm. ovarian mass.	Laparoscopy ? proceed to Hyst + BSO.
EV	32	CIN3.	Cone biopsy.
UW	34	Endometriosis	Laparoscopic ablation
HT	88	Cystocoele/ rectocoele/ 2nd. degree uterine prolapse	Manchester Repair.
KN	58	Haematuria	Cystoscopy
JW	18	Menorrhagia & copes badly with menstrual hygiene. Has Down’s syndrome. Sexually active.	Hysterectomy
TB	30	Menorrhagia. 2nd. degree uterine descent. Been sterilised. Jehovah’s witness.	Vaginal hysterectomy and repair.
BM	55	Stage Ib cancer cervix. Been discussed at MDT. For Wertheim’s hysterectomy. Factor V Leiden. VTE on Pill. On warfarin.	Wertheim’s hysterectomy.
NU	60	Recurrent rectocoele.	Posterior colporrhaphy.

32. Structured discussion. Clinical governance.

Candidate’s instructions.

This is a structured clinal discussion station about clinical governance. The examiner will ask you 5 questions.

When you have finished a question, you will not be allowed to return to it as later questions may indicate the answer. If you return, no marks will be awarded, even for correct answers.

Tutorial 26th. September 2019

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23	EMQ. Pertussis.
24	Role-play. PMB. Explain investigation etc. in one-stop clinic
25	Viva. Obstetric surveillance systems
26	Role-play. Mechanisms of normal labour & delivery.
27	Structured discussion. Cochrane Collaboration

23. EMQ. Pertussis.

Question  1.       

Lead-in. Why is pertussis of current concern in obstetrics?

Option List

A	Research has linked pertussis in the 1st. trimester with an ↑ risk of congenital heart disease
B	A mini-epidemic since 2011 has caused ↑ deaths of mothers & of babies < 3 months
C	A mini-epidemic since 2011 has caused ↑ deaths of babies < 3 months
D	The infecting organism has become increasingly drug-resistant
E	The infecting organism has become increasingly virulent

Question  2.       

Lead-in

Which organism causes whooping cough?

Option List

A	Bordella pertussis
B	Bacteroides pertussis
C	Rotavirus whoopoe
D	Respiratory syncytiovirus pertussis
E	None of the above

Question  3.       

Lead-in

Which, if any, of the following statements is true about the organism what causes whooping cough? This is not a true SBA as I have condensed several questions into one to save space, there are more than 5 options and there may be more than one correct answer.

Option List

A	the organism is aerobic
B	the organism is anaerobic
C	the organism is capsulated
D	the organism is flagellate
E	the organism is an obligate intra-cellular parasite
F	the organism is a Gram -ve diplococcus
G	the organism is a Gram +ve diplococcus
H	the organism requires special transport media
I	no one is going to ask me any of this stuff

Question  4.            

Lead-in

Which of the following statements is true?

Option List

A	Pertussis is no longer a significant threat to infants
B	Pertussis remains a significant threat to infants
C	The risk of death from pertussis is eliminated by timely antibiotic therapy
D	the risk of death from pertussis is eliminated by timely antiviral therapy
E	None of the above

Question  5.       

Lead-in

Which of the following statements is true?

Option List

A	Pertussis is not a notifiable disease
B	Pertussis is a notifiable disease
C	Pertussis is not a notifiable disease, but cases should be reported to the local bacteriologist
D	Pertussis is not a notifiable disease, but cases should be subject to audit

Question  6.       

Lead-in

What is the main mode of spread of the organism that causes pertussis?

Option List

A	contact with contaminated surfaces
B	contaminated food
C	contaminated water
D	respiratory droplets
E	none of the above

Question  7.            

Lead-in

What is the main reservoir of the organism that causes pertussis?

Option List

A	budgerigars
B	cats
C	dogs
D	humans
E	pigeons
F	pigs
G	none of the above

Question  8.       

Lead-in

What is the epidemiology of pertussis?

Option List

A	the condition is endemic
B	the condition is endemic with mini-epidemics every 3-5 years
C	the condition is endemic with mini-epidemics most years in the winter months
D	the condition is epidemic, with outbreaks at roughly three-year intervals
E	the condition is epidemic, with outbreaks at unpredictable intervals

Question  9.            

Lead-in

What is the incubation period for pertussis?

Option List

A	3-6     days
B	7-10   days
C	11-14 days
D	15-18 days
E	none of the above.

Question  10.         

Lead-in

What is the duration of infectivity of someone with pertussis?

Option List

A	2 days from exposure → 5 days after onset of paroxysms of coughing
B	3 days from exposure → 10 days after onset of paroxysms of coughing
C	4 days from exposure → 14 days after onset of paroxysms of coughing
D	6 days from exposure → 21 days after onset of paroxysms of coughing
E	none of the above

Question  11.         

Lead-in

What % of non-immune, close contacts of pertussis will develop the disease?

Option List

A	50%
B	60%
C	70%
D	80%
E	90%

Question  12.   

Lead-in

What practical issues are current for obstetrician in relation to pertussis?

Option List

A	The DOH advises that all pregnant women be immunised to ↓maternal death rates.
B	The DOH advises that all pregnant women be immunised to ↓ deaths in babies < 3 months.
C	The DOH advises that all babies be immunised at birth.
D	The DOH advised that “Boostrix- IPV” should replace “Repevax” from July 2014.
E	The DOH advises that immunisation of pregnant women be continued until 2019

Question  13.         

Lead-in

Which, if any, of the following statements is true in relation to average annual number of deaths due to pertussis in the years before routing child immunisation was introduced?

Option List

A	the number was 10,000
B	the number was    5,000
C	the number was    4,000
D	the number was    3,500
E	the number was <1,000

Question  14.   

Lead-in

Which, if any, of the following statements are true in relation to pertussis vaccine.

Option List

A	“Boostrix- IPV” is a vaccine for pertussis only
B	“Repevax” is a vaccine for pertussis only
C	“Boostrix- IPV” & “Repevax” are live, attenuated vaccines
D	“Boostrix- IPV” & “Repevax” act against diphtheria, tetanus and polio as well as pertussis
E	“Boostrix- IPV” & “Repevax” are acellular

Question  15.   

Lead-in

Which, if any, of the following statements are true in relation to the JCVI’s advice of the best time to administer pertussis vaccine in pregnancy?

Option List

A	20 - 24 weeks
B	25- 28 weeks
C	28 - 32 weeks
D	28 - 34 weeks
E	none of the above

Question  16.         

Lead-in

A woman has suspected pertussis in early pregnancy. Should she still be offered vaccination?

Option List

A	Yes
B	No
C	I don’t know
D	I don’t know
E	I hate this subject now

Question  17.         

Lead-in

A woman has proven pertussis in early pregnancy. Should she still be offered vaccination?

Option List

A	Yes
B	No
C	I don’t know
D	I don’t know
E	I hate this subject now

Question  18.         

Lead-in

A pregnant woman misses out on vaccination as part of the TIPP. Should vaccination still be offered in the puerperium?

Option List

A	Yes
B	No
C	I don’t know
D	I don’t know
E	I hate this subject now

24. Role-play. PMB

Candidate’s Instructions.

This is a follow-on from the station we did in the previous tutorial. You are an SpR in the “one-stop” PMB clinic. You saw Mary Smith, age 55 years, who had had a single, unprovoked episode of postmenopausal bleeding. You have taken her history, which is unremarkable apart from the bleeding, which was unprovoked and not associated with other symptoms. Her health is good apart from Type II diabetes which is well-controlled on diet. She has no other history of significant illness or surgery. She has never taken HRT and is not on any medicines. She does not take anticoagulants or aspirin.

Your tasks are to take a family history to explain the reason for advising further investigation and the investigations you recommend be done today. You will also explain how the results of these investigations will affect the situation and the possibilities for further management.

25. Viva. Obstetric surveillance systems

Candidate's Instructions.

This is a structured discussion station.

The examiner will ask you 2 questions about surveillance systems used in obstetrics.

The first question has 4 marks; the second 16 marks.

The examiner will ask if you wish to move to the second question when you appear to have completed the first to ensure that you have time for the remaining answers. But it is for you to decide when you move on.

26. Role-play.  Mechanisms of normal labour & delivery

Candidate's Instructions.

Explain the mechanisms of normal labour & delivery to the role-player, who is a medical student and keen to learn how to do a normal delivery. Your consultant has said that she needs a clear understanding of the mechanisms before considering conducting a delivery.

27. Structured discussion. Cochrane Collaboration.

Candidate’s instructions.

This is a viva about the Cochrane Collaboration.

The examiner will ask 8 questions and give one instruction.