|
16 |
Role-play. Anencephaly |
|
17 |
Structured conversation. Labour ward
scenario |
|
18 |
EMQ. Hepatitis B |
|
19 |
EMQ. Montgomery & consent |
16. Role-play. Anencephaly.
Candidate’s instructions.
You are an SpR5 and running the ante-natal clinic – your
consultant has been called to help a consultant colleague with an emergency on
the labour unit and is not available for advice.
You are about to see Jean Hathersage. She is 25 years old
and had a 10-week scan last week that showed anencephaly. She stated that she
did not want TOP. She was counselled, given information leaflets and asked to
return to the antenatal clinical today for further discussion.
Your task is to conduct that discussion.
17. Structured
conversation. Labour ward scenario.
You are the registrar on duty and responsible
for the labour and gynae wards. You have just had the handover. Your task is to
discuss the overall management of the wards with the examiner, to prioritise
the patients and decide the allocation of staff to care for them.
This station was written for the first
tutorial I ran for the OSCE exam when it was introduced more than 20 years ago.
There are phrases and concepts that reveal this distant origin, but I have
retained them for nostalgic reasons. I ran the tutorial on a Sunday afternoon
when I was on-call and using what was happening on the labour and gynae wards
that day. You won’t be asked about gynae patients in a labour ward station!
Labour Ward. Sunday 13.00 hours.
|
1 |
Mrs JH |
Primigravida. T+8. In labour. 6
cms. |
|
2 |
Mrs AH |
Primigravida at T. In labour. 5 cms. |
|
3 |
Mrs. BH |
Para 2. 30 days post delivery. 2ry. PPH >
1,000 ml. Hb. 9.3. |
|
4 |
Mrs SB |
Primigravida. 32/52 gestation. Admitted 30
minutes ago. Abdominal pain + 200 ml. bleeding. Nephrostomy tube in situ -
not draining since this morning. Low placenta on 20 week scan. |
|
5 |
Mrs KW |
Para 1. In labour. Cx. 5 cm. Ceph at spines. |
|
6 |
Mrs KT |
Para 0+1. 38 weeks. SROM. Ceph 2
cm. above spines. Clear liquor. |
|
7 |
Mrs TB |
Para 1. T+4. Clinically big baby.
Cx fully dilated for 1 hour. Early decelerations. |
|
8 |
Mrs RJ |
Primigravida. Epidural. RIF pain. Cx fully
dilated for 1 hour. Shallow late decelerations. OT position. Distressed ++.
BP /105. ++ protein. Urine output 50 ml in past 4 hours. |
|
9 |
Mrs KC |
Transfer from ICU. 13 days after delivery of
32 week twins. Laparotomy on day 7 for pelvic pain and fever. Infected
endometriotic cyst removed. IV antibiotics changed to oral. |
Gynaecology ward.
8 major post-operative cases who have been
seen on the morning ward round and are stable. The husband of a patient who had
Wertheim
|
1 |
Mrs JB |
10 week incomplete miscarriage. Hb. 10.8.
Moderate fresh bleeding. |
|
2 |
Ms AS |
19 years old. Nulliparous. Just admitted
with left iliac fossa pain. Scan shows unilocular 5 cm. ovarian cyst. |
Medical staff:
Consultant at home. Registrar - you.
Senior House Officer with 12 months
experience.
Registrar in Anaesthesia. Consultant Anaesthetist
on call at home.
Midwifery staff:
Senior Sister. Trained to take theatre cases. Able to site IV infusions and
suture episiotomies and tears.
3 staff midwives. 1 trained to take theatre
cases. Two able to site IV infusions.
1 Community midwife looking after Mrs. KW.
2 Pupil Midwives.
18. EMQ.
Hepatitis B.
Abbreviations.
GDM: gestational
diabetes mellitus.
HAV: hepatitis
A virus
HBcAg: hepatitis
B core antigen
HBeAg: hepatitis
B e antigen
HBsAg: hepatitis
B surface antigen
HBcAb: antibody
to hepatitis B core antigen
HBeAb: antibody
to hepatitis B e antigen
HBsAb: antibody
to hepatitis B surface antigen
HBIG: hepatitis
B immunoglobulin
HBV: hepatitis
B virus
HCV: hepatitis
C virus
HEV: hepatitis
E virus
HSV: herpes
simplex virus
Question 1.
An asymptomatic primigravida books at 10 weeks. Her partner had an
acute HBV infection 4 months ago. What results on routine blood testing would
indicate that she has an acute HBV infection?
Question 2.
An asymptomatic primigravida books at 10 weeks. Her partner had an
acute HBV infection 4 months ago. What results on routine blood testing would
indicate that she is immune to the HBV as a result of infection?
Question 3.
An asymptomatic primigravida books at 10 weeks. Her partner had an
acute HBV infection 4 months ago. What results on routine blood testing would
indicate that she is immune to the HBV as a result of HBV vaccine?
Question 4.
An asymptomatic primigravida books at 10 weeks. Her partner had an
acute HBV infection 9 months ago. What results on routine blood testing would show
that she is a chronic carrier of HBV infection?
Question 5.
Testing
shows that he is positive for HBsAg, positive for HBcAb but negative for IgM HBcAb.
What does this mean in relation to his HBV status?
Question 6.
Testing
shows that he is negative for HBsAg, positive for HBcAb and positive for
HBsAb. What does
this mean in relation to his HBV status?
Question 7.
How common is chronic HBV carrier status in UK pregnant women?
Question 8.
What is the risk of death from chronic HBV carrier status?
Question 9.
A primigravid woman at 8 weeks gestation is found to be non-immune
to HBV. She has recently married and her husband is a chronic carrier. What
should be done to protect her from infection?
Question
10. A woman is a known carrier of
HBV. What is the risk of vertical transmission in the first trimester?
Question 11.
What is the risk of the neonate who has been infected by vertical
transmission
becoming
a carrier without treatment?
Question 12.
Should antiviral maternal therapy in the 3rd. trimester
be considered for women with HBeAg or high viral load?
Question 13.
How effective is hepatitis B prophylaxis for the neonate in
preventing chronic carrier status as a result of vertical transmission?
Question 14.
Can a woman who is a chronic
HBV carrier breastfeed safely?
Question 15.
Hepatitis B infection is the most dangerous of
the viral hepatitis infections in
pregnancy.
Question 16.
A pregnant woman who is not immune to HBV has a partner who is a
chronic carrier. Can HBV vaccine be administered safely in pregnancy?
Question 17.
How long can HBV survive outside the body?
Question 18.
A pregnant woman who is not immune has a partner with acute
hepatitis due to HBV. He cuts his hand and bleeds onto the kitchen table. How
should she clean the surface to ensure that she gets rid of the virus?
Question 20.
What does 5 log10 copies /mL mean?
|
A |
> 10 copies / mL |
|
B |
> 100 copies / mL |
|
C |
> 1,000 copies / mL |
|
D |
> 10,000 copies / mL |
|
E |
> 100,000 copies / mL |
|
F |
this has scared me witless and I am
going straight home to complain to my Mum |
Question 21.
Which, if any, of the following statements are true about
amniocentesis and CVS and the risk of vertical transmission if the mother is
HbsAg+ve?
Option list.
|
A |
they are contraindicated |
|
B |
they should be done with cover
with HBIG |
|
C |
they should be done with
cover with a drug that is effective
for HBV and safe in pregnancy. |
|
D |
none of the above |
Question 22.
Which, if any, of the
following statements are true about treatment in the third trimester to reduce
the risk of vertical transmission?
Option list.
|
A |
women
who are HbsAg+ve should be offered testing for HBV DNA levels in the 3rd.
trimester |
|
B |
there
is no effective treatment for HBV in the 3rd. trimester |
|
C |
the
risks of treatment for HBV in the 3rd. trimester outweigh the
benefits |
|
D |
drug
treatment for HBV in the 3rd. trimester adds nothing beneficial to
the normal use of HBIG + HB vaccination of the neonate |
|
E |
none
of the above. |
Question 23.
Which, if any, of the following drugs is recommended for use in
the third trimester to reduce the risk of vertical transmission?
Option list.
|
A |
acyclovir |
|
B |
lamivudine |
|
C |
telbivudine |
|
D |
tenofovir |
Question 24.
Does elective Cs before labour and with the membranes intact
reduce the vertical transmission rate?
Question 25.
Which hepatitis virus normally produces a mild illness, but
represents a major risk to pregnant women, with a mortality rate of up to 5%?
Question 26.
A pregnant woman has a history of viral hepatitis and informs the
midwife at booking that she is a carrier and that she has a significant risk of
cirrhosis and has been advised not to drink alcohol. Which is the most likely
hepatitis virus?
Question 27.
Which hepatitis virus is an absolute contraindication to
breastfeeding after
appropriate
treatment of the infected mother and prophylaxis for the baby?
Question 28.
Which hepatitis virus is linked to an increased risk of obstetric
cholestasis?
Question 29.
Which, if any, of the following statements is true in relation to
HepB and the risk of GDM?
Option list.
|
A |
the
risk is about the same |
|
B |
the
relative risk is about 0.1. |
|
C |
the
relative risk is about 0.2. |
|
D |
the
relative risk is about 0.5. |
|
E |
the
relative risk is about 1.2. |
|
F |
the
relative risk is about 1.5. |
|
G |
the
relative risk is about 2.0 |
|
H |
the
relative risk is about 3.0 |
|
I |
the
risk is unknown |
19. EMQ. Montgomery & consent.
BMA: British
Medical Association.
GMC: General
Medical Council.
Question 1.
Which, if any, of the following statements is most accurate?
|
A |
The
Montgomery ruling largely replaces the Bolam ruling |
|
B |
The Montgomery ruling largely replaces the Chester
ruling |
|
C |
The Montgomery ruling largely replaces the Sidaway
ruling |
|
D |
The Montgomery ruling is being contested in the
European Court by the GMC as it infringes the rights of doctors |
|
E |
The Montgomery ruling is being contested in the
European Court by the BMA as it infringes the rights of doctors |
Question
2.
Which, if any, of the following statements are true?
|
A |
the
level of risk, however small, must be disclosed if a patient requests it |
|
B |
the level of risk of damage from a procedure need not
be disclosed if < 1% |
|
C |
the level of risk of damage from a procedure need not
be disclosed if < 10% |
|
D |
a material risk is one that would be reflected in
damages > £100,000 if negligence were proved in court |
|
E |
a material risk is one that would be reflected in
damages > £1,000,000 if negligence were proved in court |
|
F |
a material risk is one that involves anatomical damage,
not emotional or psychological |
|
G |
a material risk is one that a reasonable person in the
patient’s situation would be likely to regards as significant |
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