Tutorial 6th. March 2023

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6 March 2023.

 

20	Role-play. Difficult patient. Wishes to complain.
21	Structured conversation. Waiting list prioritisation
22	SBA. McCune Albright syndrome
23	EMQ. ARRIVE trial

 

20.         Role-play. Difficult patient. Wishes to complain.

Candidate’s instructions.

You are an ST5 and are in the gynaecology clinic. Anne Dezibel, a patient, has been aggressive towards the reception and nursing staff, insisting that she must see the consultant, not a junior doctor. She shouted at both the receptionist and the nurses, saying: ‘I want to see the organ grinder, not the bloody monkey’.

The consultant says that she has no intention of seeing her and that you need to learn to deal with difficult patients. The GP referral letter has gone missing. Your task is to deal with the patient.

 

21.         Structured conversation. 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	Venue	Special Needs	Urgency
JK	5	chronic discharge. ? foreign body	EUA	Main theatre
JM	32	1ry. infertility	Laparoscopy + tubal patency tests	Main theatre
GN	77	Vulval cancer. Coronary thrombosis x 2. Unstable angina.	Radical vulvectomy agreed at MDT.	Main theatre
RU	55	PMB x1. Weight 20 stones. (127 kg.) 1 kg. = 2.2 lb. 1 stone = 14 lb.	D&C.	DCU.
LD	32	Menorrhagia. Fibroids. Anaemia.	Vaginal hysterectomy.	Main theatre.
DT	22	Does not want children.	Lap. Steril.	DCU
HB	14	Unwanted pregnancy at 10/52.	TOP	DCU. TOP list.	.
JY	44	GSI.	Anterior colporrhaphy.	Main theatre.
JS	23	Vaginal discharge. Cervical ectropion.	Diathermy to cervix.	DCU
DT	55	3 cm. ovarian mass.	Laparoscopy ? proceed to Hyst + BSO.	Main theatre.
EV	32	CIN3.	Cone biopsy.	DCU
UW	34	Endometriosis	Laparoscopic ablation	DCU
HT	88	Cystocoele/ rectocoele/ 2nd. degree uterine prolapse	Manchester Repair.	Main theatre.
KN	58	Haematuria	Cystoscopy	DCU
JW	18	Menorrhagia & copes badly with menstrual hygiene. Has Down’s syndrome. Sexually active.	Hysterectomy	Main theatre
TB	30	Menorrhagia. 2nd. degree uterine descent. Been sterilised. Jehovah’s witness.	Vaginal hysterectomy and repair.	Main theatre.
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.	Main theatre.
NU	60	Recurrent rectocoele.	Posterior colporrhaphy.	Main theatre.

 

22.         SBA. McCune Albright syndrome.

Abbreviations.

CPP:      central precocious puberty.

MCA:    McCune Albright syndrome.

PFD:      polyostotic fibrous dysplasia.

PP:         precocious puberty.

Scenario 1.    Which, if any, of the following are components of the classical triad of MCA?

Option List

A	albinism
B	“cafè Cubano” spots
C	“Coast of California” pigmented areas
D	lentigo
E	macroorchidism
F	osteomalacia
G	polyostotic fibrous dysplasia
H	precocious puberty
I	premature menopause
J	primary amenorrhoea

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

Option List

A	it is an example of central primary amenorrhoea
B	it is an example of central secondary amenorrhoea
C	it is an example of central precocious puberty
D	it is an example of peripheral primary amenorrhoea
E	it is an example of peripheral secondary amenorrhoea
F	it is an example of peripheral precocious puberty
G	none of the above

Scenario 3.    Which, if any, of the following are believed to be true in relation to the abnormality of

onset of puberty associated with MCA?

Option List

A	it is due to abnormal FSH production
B	it is due to abnormal LH production
C	it may be due to abnormal androgen production
D	it may be due to abnormal oestrogen production
E	it is linked to ovarian cysts with ↑ malignant potential
F	none of the above

Scenario 4.    Which, if any, of the following are true in relation to polyostotic fibrous dysplasia?

Option List

A	polyostotic means resembling parrot bone
B	polyostotic means resembling pigeon bone
C	polyostotic means affecting long bones
D	fibrous dysplasia refers to replacement of marrow by fibrous tissue
E	PFD is a variant of osteomalacia
F	PFD may be unilateral
G	PFD is associated with a 1% risk of malignancy

Scenario 5.    Which, if any, of the following are true in relation to MCA?

Option List

A	hyperthyroidism is common
B	hypothyroidism is common
C	thyroid function is similar to those without MCA

Scenario 6.    Which, if any, of the following are true in relation to MCA?

Option List

A	excess growth hormone production  is common
B	inadequate growth hormone production is common
C	growth hormone production is similar to those without MCA

Scenario 7.    Which, if any, of the following is true in relation to MCA?

Option List

A	inheritance is autosomal dominant
B	inheritance is autosomal recessive
C	inheritance is X-linked dominant
D	inheritance is X-linked recessive
E	inheritance is multifactorial
F	it is not a hereditary disorder
G	it is not genetic
H	none of the above

Scenario 8.    Which, if any, of the following are true in relation to MCA?

Option List

A	renal artery stenosis is more common
B	renal cortex wasting is more common
C	renal phosphate wasting is more common
D	renal waisting is more common
E	none of the above.

Scenario 9.    Approximately what % of children born to women with MCAS will have MCAS?

Option List

A	0
B	1 in 105 - 106
C	1 in 104
D	1 in 100
E	1 in 50
F	1 in 10
G	1 in 2
H	All

 

TOG includes MCAS in CPD Questions for volume 14, number 2, 2012, which are open access, so reproduced here. There are only two questions on MCAS. Note that the second includes CPP.

McCune–Albright syndrome

1. is caused by activating mutations of the GNAS1 gene.                                            True / False

2. is characterised by polyostotic fibrous dysplasia, café-au-lait spots and CPP.      True / False

 

23.         EMQ. ARRIVE trial.

Abbreviations.

EBL:    estimated blood loss.

IOL:    induction of labour.

SGA:   small for gestational age.

Question 1.             What does the acronym ‘ARRIVE’ mean?

Option list.

A	a randomised review of intravenous ergometrine for the prevention of PPH
B	a randomised review of IVF efficacy
C	a retrospective review of IVF efficacy
D	a randomised review of IOL at term versus expectant management of high-risk pregnancy
E	a randomised review of IOL at 39 weeks versus expectant management of high-risk pregnancy
F	a randomised trial of IOL at term versus expectant management of low-risk pregnancy
G	a randomised trial of IOL at 39 weeks versus expectant management of low-risk pregnancy
H	none of the above

Question 2.        What was the primary outcome of the trial?

Option list.

A	C section and instrumental delivery rates versus the spontaneous delivery rate
B	cost-effectiveness of IVF
C	composite outcome of perinatal death or severe neonatal complications
D	estimated blood loss using low-dose ergometrine versus oxytocin for the 3rd. stage
E	frequency and severity of perineal trauma
F	length of labour
G	maternal satisfaction
H	urinary incontinence severity score at 3 months postpartum
I	none of the above

Question 3.        Which, if any, of the following were the important conclusions of the trial?

Option list.

A	C section and instrumental delivery rates were significantly ↓ with IOL at 39/52
B	C section rate but not instrumental delivery rate was significantly ↓with IOL at 39/52
C	instrumental delivery rate but not C section rate was significantly ↓ with IOL at 39/52
D	C section and instrumental delivery rates were significantly ↑ with IOL at 39/52
E	C section rate but not instrumental delivery rate was significantly ↑ with IOL at 39/52
F	instrumental delivery rate but not C section rate was significantly ↑ with IOL at 39/52
G	C section and instrumental delivery rates were unchanged
H	IVF was cost-effective
I	IVF was not cost-effective
J	composite perinatal outcome was better with IOL
K	composite perinatal outcome was unchanged with IOL
L	composite perinatal outcome was worse with IOL
M	EBL using low-dose ergometrine versus oxytocin for the 3rd. stage was ↓↓
N	EBL using low-dose ergometrine versus oxytocin for the 3rd. stage was ↓↓ but with ↑↑ BP
O	frequency and severity of perineal trauma ↑ with IOL
P	length of labour was ↑↑ with IOL
Q	maternal satisfaction was higher with IOL
R	urinary incontinence at 3 months was reduced by IOL
S	none of the above