Tutorial 14th. February

Contact us.

Website.

14 February 2022.

 

26	Role-play. Androgen insensitivity syndrome
27	Role-play. Suspected domestic abuse
28	EMQ. Coroner and Medical Examiner
29	EMQ. Kangaroo care
30	EMQ. Mycoplasma genitalium
31	EMQ. Education
32	SBA. Ospemifene

 

26.         Androgen insensitivity syndrome.

Candidate's Instructions.

The patient is Anastasia Johnstone. She is 17 years old. She attended the gynaecology clinic 1 month ago with primary amenorrhoea. Clinical examination showed an apparently normal young woman with normal breast development but absent pubic and axillary hair. The external genitalia appeared normal. Vaginal examination was not attempted.

She has come today for the results of an ultrasound scan and blood tests. The scan shows absence of the uterus. There are no ovaries in the pelvis. There are bilateral groin masses. The karyotype is 46XY.

Your tasks are to explain the results and their implications and to answer her questions.

 

27.         Suspected domestic abuse.

Candidate's Instructions.

You are a 5^th. year SpR in the antenatal clinic. The Consultant in the clinic has been feeling unwell and has gone off sick, leaving you in charge. The senior midwife comes to see you. One of the midwives has reviewed a patient at 36 weeks in her first pregnancy. She was referred by her community midwife who noted extensive bruising for which the patient could give no explanation. The GP ran tests to exclude a bleeding disorder, which were normal. Both the community and hospital midwives suspect domestic abuse, but the patient has not admitted that this has occurred despite being asked on several occasions.

Your task is to see the patient and manage the situation.

 

28.         EMQ. Coroner and Medical Examiner.

The Coroner.

This topic has featured in the exam and makes for easy marks if you know the basics.

Abbreviations.

CC:                Chief Coroner.

CJA9:             Coroners and Justice Act 2009.

MCCD:          medical certificate of the cause of death.

NOD:             notification of deaths.        

SB:                 stillbirth

Option list 1.

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

Use option list 1 for scenarios 1 - 3.

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?

Scenario 4.             Which, if any, are current titles for coroners?

Option list.

A	area coroner
B	assistant coroner
C	district coroner
D	deputy coroner
E	lead coroner
F	national coroner

Scenario 5.             Which, if any, of the following is a function of the Chief Coroner?

Option list.

A	to appoint coroners
B	to approve coronial appointments
C	to negotiate coroners’ salaries
D	to negotiate coroners’ terms and conditions
E	to oversee the disciplinary procedures for coroners
F	to keep an eye on coronial investigations that have taken too long
G	to organise advice from coroners about how deaths may be prevented

Option list 2. Use for scenarios 6-8.

A.   must have had experience as a detective in the police force with the 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 holiday

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

Scenario 6.             What qualifications must the Coroner have?

Scenario 7.             What are the hours of availability of the Coroner?

Scenario 8.              

What are the roles of the Coroner’s Officers?

Scenario 9.             Who or what is responsible for appointing medical examiners?

Option list.

A	Local authorities
B	the Chief Coroner
C	the Chief Medical Examiner
D	the local Senior Coroner
E	the Lord Chancellor
F	NHS Trusts
G	the Queen

Scenario 10.          Which, if any, of the following are applicable to the role of medical examiner?

Option list.

A	to decide if a post-mortem is required
B	notification of deaths to the coroner
C	supervision of the quality of MCCDs
D	attendance at post-mortems
E	performance of post-mortems

Scenario 11.          When was the 1^st. Chief Medical Examiner for England & Wales appointed?

Option list.

A	2005
B	2010
C	2015
D	2017
E	2019
F	the post does not exist
G	none of the above

Scenario 12.          What was the specialty of the 1^st. appointee to the post of the lead medical examiner for England & Wales?

Option list.

A	accident and emergency medicine
B	forensic medicine
C	forensic pathology
D	forensic psychiatry
E	obstetrics & gynaecology
F	pathology

Scenario 13.          Which, if any, of the following are requirements for those wishing to become a medical examiner?

Option list.

A	full registration with the General Medical Council
B	consultant status
C	> 10 years’ experience as a fully-registered doctor
D	to have the Diploma of the Faculty of Medical Examiners
E	to have membership of the RCP
F	none of the above

Option list 3. Use for the remaining scenarios, unless they have an 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 14.          A resident of Manchester dies suddenly while visiting the town of his birth in Scotland. His family decides that he will be buried in the town of his birth. His body is held at the premises of a local funeral director to arrange the funeral and burial. What actions should be taken with regard to the Manchester coroner?

Scenario 15.          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 who will arrange the funeral and burial. What actions should be taken with regard to the Manchester coroner?

Scenario 16.          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 17.          A man of 65 dies of terminal lung cancer. The GP who had visited daily up to three weeks before the death has been on holiday for three weeks. 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 18.          A man of 65 dies of terminal lung cancer. The GP, who has visited daily up to the day of his death and attended to confirm the death, is on holiday. 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 19.          A man of 65 dies of terminal lung cancer. The GP who has 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 20.          A 65-year-old man dies suddenly 12 hours after admission to the local coronary care unit with chest pain, despite 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 21.           

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 22.          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 23.          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. She is given 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 24.          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 25.          A woman is admitted at 26 weeks’ gestation in premature labour after being kicked in the abdomen by her partner. 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 26.          A woman is admitted at 26 weeks’ gestation in premature labour after being kicked in the abdomen by her partner. She says that he did not want the pregnancy to continue.

Pick the best option from the option list.

Option list.

A.  dial 999

B.  get advice from the BMA

C.  get advice from the Department of Health

D.  get advice from the legal department

E.  get advice from the police

F.  none of the above.

Scenario 27.          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

Scenario 28.          You have been swimming in the sea at Broad Beach, Rhosneigr. As you walk back to the shore your foot hits something in the sand. You explore and find a number of gold coins that look ancient. What should you do?

Option list.

A	put them back as they may have been an offering to the Gods
B	put them in a safe place with a view to having them valued and sold
C	take them to the local museum for identification and advice about informing the coroner
D	take them to the nearest police station for advice
E	take them to your favourite pub and trade them for a meal and round of drinks

 

29.         EMQ. Kangaroo care.

Question  1.          Which, if any, of the following are true in relation to kangaroo care?

Option list.

A.	skin-to-skin contact between mother and baby is a key component
B.	rooming-in is a key component
C.	exclusive breastfeeding is a key component
D.	carrying the baby in a sling anterior to the maternal chest is a key component
E.	carrying the baby in a sling on the mother’s back is a key component
F.	carrying the baby in a sling on the mother’s chest or back is a key component
G.	carrying the baby in a sling with skin-to-skin contact with the mother is a key component

 

Question  2.          Which, if any,  of the following are proven benefits of Kc?

Option list.

A.	↓ neonatal mortality
B.	↓ neonatal morbidity
C.	↑ breastfeeding rates
D.	↑ head circumference growth
E.	↓ hypothermia
F.	↑ mother-baby bonding
G.	↓ necrotising enterocolitis
H.	↓ neonatal intra-ventricular haemorrhage
I.	↓ neonatal sepsis
J.	↑ neonatal weight gain
K.	↓ postnatal depression
L.	↑ psychomotor development at 12 months

 

30.         EMQ. Mycoplasma genitalium.

BASSH launched a new, “NICE-accredited” guideline on MG in July 2018 This makes it a hot topic and it is one that most people will know nothing about. There are enough “buzz words” to catch the attention of MRCOG examiner sand make its inclusion in the exam databases irresistible! It would be a killer “structured discussion” in the Part 3 and would sink most candidates in the Part 2.

Abbreviations.

BASHHMG:  British Association for Sexual Health and HIV’s “National guideline for the management of infection with Mycoplasma genitalium”. 2018

MG:               Mycoplasma genitalium.

MP:               Mycoplasma pneumoniae.

NHSCS:         NHS Cervical Screening Programme

PCB:              postcoital bleeding.

PMB:             postmenopausal bleeding.

PID:               pelvic inflammatory disease.

PTB:              preterm birth.

SARA:            Sexually-Acquired Reactive Arthritis.

Scenario 1.             Which, if any, of the following statements are true in relation to MG?

Option list.

A	MG was first isolated in 2001
B	MG was first isolated from men with non-gonococcal urethritis (NGU)
C	MG belongs to the Cutemollies class
D	MG is the smallest known yeast with the ability to self-replicate
E	MG is the smallest known bacterium with the ability to self-replicate
F	MG has an unusual, double-layered cell wall
G	MG has an unusual protrusion at one end
H	MG’s protrusion enables it to adhere to epithelial cells
I	MG’s protrusion enables it to invade epithelial cells
J	MG is best seen on a Gram stain

Scenario 2.             Which, if any, of the following statements are true in relation to Mycoplasmas?

Option list.

A	are the largest known bacteria
B	have no cell wall
C	have no nuclei
D	are resistant to ß-lactam antibiotics
E	are resistant to sulphonamides
F	colonies show a ‘scrambled egg’ appearance on culture on agar
G	particularly affect mucosal surfaces

Scenario 3.             Which, if any, of the following statements are true in relation to Mg?

Option list.

A	when the organism was originally found, culture took 50 days
B	Mg is facetious
C	Mg is a facultative aerobe
D	Mg is a facultative anaerobe
E	Mg is a facultative aerobe & anaerobe
F	Mg is fastidious

Scenario 4.             Which, if any, of the following are true about the approximate prevalence of MG?

Option list.

A	it is ~ 0.1%
B	it is ~ 1.0%
C	it is ~ 5.0%
D	it is ~ 5-10%
E	it is > 10%
F	none of the above

Scenario 5.             Which, if any, of the following is true in relation to screening for MG?

Option list.

A	screening for MG is now included in the NCSP
B	screening for MG is now offered as part of the NHSCS
C	screening should be offered to all sexually active women < 30 years old
D	screening should only be offered to those with symptoms suggestive of infection
E	screening should be offered to all partners of those with MG infection
F	none of the above

Scenario 6.             Which, if any, of the following are included in BASHHMG as risk factors for MG?

Option list.

A	Cigarette smoking
B	Multiple dancing partners
C	Multiple sexual partners
D	Non-white ethnicity
E	Younger age
F	None of the above

Scenario 7.             Which of the following statements is true in relation to MG and co-infection?

Option list.

A	MG excretes bactericidal toxins and co-infection is rare
B	MG co-infection is most often with chlamydia
C	MG co-infection is most often with E. coli
D	MG co-infection is most often with HIV
E	MG co-infection is most often with TB
F	None of the above

Scenario 8.             Which of the following statements is true in relation to MG and men?

Option list.

A	It is the most common cause of NGU
B	It is the most common cause of epididymitis
C	It is the most common cause of prostatitis
D	It is a well-recognised cause of male sub-fertility
E	Most men with MG infection are asymptomatic
E	None of the above

Scenario 9.             Which, if any, of the following statements are true in relation to MG and women?

Option list.

A	MG is linked to an ↑ risk of cervicitis
B	MG is linked to an ↑ risk of endometritis
C	MG is linked to an ↑ risk of female infertility
D	MG is linked to an ↑ risk of miscarriage
E	MG is linked to an ↑ risk of otitis media
F	MG is linked to an ↑ risk of pelvic inflammatory disease
G	MG is linked to an ↑ risk of postcoital bleeding
H	MG is linked to an ↑ risk of postmenopausal bleeding
I	MG is linked to an ↑ risk of preterm birth
J	MG is linked to an ↑ risk of damage to Fallopian tube cilia
K	MG is linked to an ↑ risk of puerperal psychosis
L	MG is linked to an ↑ risk of puerperal sepsis
M	Most infected women are asymptomatic
N	None of the above

Scenario 10.           Which, if any, of the following are true about current concerns about Mg?

Option list.

A	It could become a ‘superbug’, resistant to most antibiotics, within a decade
B	Infection is often misdiagnosed as chlamydia with ↑ risk of antibiotic resistance
C	‘superbug’ status would be likely to lead to an ↑ in renal failure
D	‘superbug’ status would be likely to lead to an ↑ in female infertility
E	‘superbug’ status would be likely to lead to an ↑ in male infertility

Scenario 11.          Which, if any, of the following are used in the recommended test for MG infection in women?

Option list.

A	blood testing for MG IgG
B	blood testing for MG IgM
C	cervical smears checked microscopically for the diagnostic intracellular inclusion bodies
D	culture and sensitivity of cervical swab specimens using MG-specific culture medium
E	culture and sensitivity of 1st. void MSSU using MG-specific culture medium
F	culture and sensitivity of vaginal swab specimens using MG-specific culture medium
G	NAATs that detect the MG G-antigen
H	NAATs that detect MG DNA
I	NAATs that detect MG RNA
J	serum testing for MG-specific antigen
K	vaginal swabs taken by the woman
L	none of the above

Scenario 12.          Which, if any, of the following statements are true in relation to testing for antibiotic resistance after initial tests are +ve for MG?

Option list.

A	test for resistance to cephalosporins
B	test for resistance to macrolides
C	test for resistance to penicillin
D	test for resistance to quinolones
E	test for resistance to macrolides
F	test for resistance to streptomycin
F	test for resistance to sulphonamides
F	test for resistance to tetracyclines
G	None of the above

Scenario 13.          Which, if any, of the following statements are true in relation to estimates of antibiotic resistance in current strains of MG in the UK?

Option list.

A	20% are resistant to cephalosporins
B	40% are resistant to macrolides
C	50% are resistant to penicillin
D	50% are resistant to quinolones
E	10% are resistant to streptomycin
F	90% are resistant to sulphonamides
F	40% are resistant to tetracyclines
F	None of the above

Scenario 14.          Which, if any, of the following is BASHHMG’s recommended 1^st. line treatment of uncomplicated MG?

Option list.

A	azithromycin 1 gram daily for 7 days
B	doxycycline 100 mg twice daily for 7 days
C	doxycycline 100 mg twice daily for 10 days
D	doxycycline 100 mg twice daily for 7 days
E	doxycycline 100 mg twice daily for 7 days then azithromycin 1 gram daily for 2 days
F	moxifloxacin 400mg orally once daily for 7 days
G	moxifloxacin 400mg orally once daily for 10 days
H	none of the above

Scenario 15.          Which, if any, of the following is BASHHMG’s recommended 1^st. line treatment of complicated MG?

Option list.

A	doxycycline 100 mg twice daily for 10 days
B	doxycycline 100 mg twice daily for 14 days
C	moxifloxacin 400mg orally once daily for 10 days
D	moxifloxacin 400mg orally once daily for 14 days
E	none of the above

Scenario 16.          This is not an EMQ or SBA! Fill in the gaps in the table below, using option list.

Option list.

A	aminoglycoside
B	cephalosporin
C	macrolide
D	penicillin
E	quinolone
F	tetracycline

Table.

Drug name	Category of drug
azithromycin
doxycycline
moxifloxacin

Scenario 17.          Which, if any, of the following statements is true in about relation to test of cure (TOC) after treatment of MG?

Option list.

A	TOC should be offered to everyone who has been treated for MG
B	TOC should only be offered to those who had signs of infection before treatment
C	TOC should only be offered to those who had symptoms of infection before treatment
D	TOC should only be offered to those who had signs and symptoms before treatment
E	TOC should only be offered to those who continue to have signs or symptoms two weeks or more after the start of treatment
F	none of the above

Scenario 18.          Which, if any, of the following statements are true in relation to the timing of test of cure (TOC) after treatment of MG?

Option list.

A	TOC is best done at 3 weeks after start of treatment
B	TOC is best done at 4 weeks after start of treatment
C	TOC is best done at 5 weeks after start of treatment
D	TOC is best done at 6 weeks after start of treatment
E	TOC should not be done < 2 weeks from the start of treatment
F	TOC should not be done < 3 weeks from the start of treatment
G	TOC should not be done < 4 weeks from the start of treatment

 

31.         EMQ. Education.

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

Question 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?

Question 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?

Question 3. You have been asked to teach a new trainee the use of the ventouse. Which would be the most appropriate approach?

Question 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?

Question 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?

Question 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?

Question 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?

Question 8. Which of the listed teaching techniques is least likely to lead to deep learning?

Question 9. An interactive lecture with EMQs is the best method of teaching. True or false.

Question 10. Only 20% of what is taught in a lecture is retained. True or false.

Question 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.

 

32.         SBA. Ospemifene.

Abbreviations.

CYP:            cytochrome P450 enzyme.

DVT:           deep vein thrombosis.

ER:              oestrogen receptor.

SERM:        selective oestrogen receptor modulator.

VTE:           venous thrombo-embolism.

Question 1. What type of drug is ospemifene?

Option List

A	GnRH analogue
B	selective androgen receptor modulator
C	selective oestrogen receptor modulator
D	selective progestogen receptor modulator
E	selective serotonin reuptake inhibitor antagonist

Question 2. What condition is it licensed for in the UK?

Option List

A	genito-urinary syndrome of the menopause (GSOM)
B	oligomenorrhoea
C	oligospermia
D	osteoporosis
E	vulvo-vaginal atrophy

Question 3. What is its effect on bone ERs?

Option List

A	agonist
B	antagonist
C	unknown

Question 4. Which, of the following statements is most accurate about the use of ospemifene for women who have had breast cancer or at increased risk of being affected by it?

Option List

A	it is an agonist for breast ERs and is contraindicated
B	it is an antagonist for breast ERs and its use is safe
C	there is insufficient data to be certain of its risks

Question 5. What is its effect on endometrial ERs?

Option List

A	it has a strong agonist effect
B	it has a weak agonist effect
C	it has a strong antagonist effect
D	it has a weak ant agonist effect
E	its effect is unknown

Question 6. What is its effect on DVT risk?

Option List

A	the risk is decreased
B	the risk is increased
C	the risk is unknown

Question 7. Which, if any, of the following statements are true?

A	it is mainly excreted in urine
B	it is metabolised by hepatic enzymes including CYPs
C	it should not be used with acyclovir
D	it should not be used with fluconazole
E	it should not be used with metformin
F	it should not be used with oestrogen
G	it should not be used with other SERMS