13 April 2023.
|
EMQ.
Medical Examiner |
|
|
Viva. Late pregnancy
ultrasound and undiagnosed breech |
|
|
61 |
Role-play. Uterine perforation during ERPC |
|
62 |
EMQ. Headache |
59. EMQ.
Medical Examiner.
Abbreviations.
MCCD: medical
certificate of the cause of death.
ME: medical
examiner.
Do I really need to know
this stuff? This
is ‘hot’: MEs were an innovation in 2018. Easy EMQ or viva if you know the
basic facts. These are not true EMQs as there may be > 1 correct answer.
Question
1.
Which, if any, of
the following are included in the role of the ME?
Option list.
|
A |
scrutiny of all death certificates from the NHS Trust |
|
B |
scrutiny of all death certificates from the local area |
|
C |
scrutiny of non-coronial death certificates from the
local area |
|
D |
deciding if postmortem examination is appropriate |
|
E |
supervision of postmortem examination |
|
F |
deciding on and arranging further investigations to
establish the cause of death |
|
G |
liaison with the coroner |
|
H |
discussing the cause of death with the family of the
deceased |
|
I |
directing police investigations in cases of suspicious
death |
Question
2.
What
qualifications must a ME have?
Option list.
|
A |
be registered with the GMC |
|
B |
be licensed to practise or be < 5 years into
retirement |
|
C |
be a member or fellow of a Royal Medical College |
|
D |
be a member or fellow of the Royal College of
Pathologists |
|
E |
none of the above. |
Question
3.
Which, if any, of
the following are included in the role of the medical examiner?
Option list.
|
A |
discussing the case with the doctor who provided care
during the final illness |
|
B |
reviewing the medical records |
|
C |
deciding the cause of death to be put on the
certificate of death |
|
D |
discussing the cause of death with next of kin |
|
E |
identifying any concerns the next of kin may have about
the care |
|
F |
providing medical advice to the coroner |
|
G |
identifying deaths that should trigger a mortality case
record review |
Question
4.
Which, if any, of
the following are included in the role of the National ME?
Option list.
|
A |
being a member of the medical team responsible for the
King’s health |
|
B |
appointing Trust MEs |
|
C |
disciplining errant MEs |
|
D |
producing reports |
|
E |
arbitrating in disputes between MEs and coroners about
the cause of death |
|
F |
dealing with appeals by families who are dissatisfied
with the MCCD or the care |
60. Viva.
Late pregnancy ultrasound and undiagnosed breech.
The examiner will ask a series of questions.
61. Role-play.
Uterine perforation during ERPC.
Candidate’s instructions.
You are a ST5 in the gynaecology clinic. Joan Read had
her first baby two months ago. She had Caesarean section for failure to
progress. She was readmitted on day 14 with PPH, had ERPC under spinal block,
made a good recovery and was discharged the next morning. The histology report
arrived in the department yesterday. The products of conception showed blood
clot and cells that appeared to have originated in bowel wall. The on-call
registrar was notified, phoned Joan, found that she was well and arranged for
her to attend today’s gynaecology clinic. Your tasks are to take a history and
advise about management.
62. EMQ.
Headache.
|
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 |
impending eclampsia / severe PET |
|
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 405-year-old para 3 is admitted at 38 weeks by ambulance
with severe headache of sudden onset. She
d6escribes 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 headaches. They are worse on exercise, even mild exercise such as
walking up stairs. She experiences photophobia with the headaches. Which is the most likely diagnosis?
Scenario 3. A woman returns from a sub-Saharan area of Africa. She
develops severe headache, 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 headaches at 36 weeks. The history reveals that they 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 Caesarean section and wishes regional
anaesthesia. She had severe headache due to dural tap after a previous
Caesarean section. She wants to take all possible steps to reduce the risk of
having this again. Which of epidural / spinal anaesthesia has the lower risk of
causing dural tap?
Scenario 8. A 25-year-old primigravida attends for her 20-week scan and
complains of headache which started two weeks before. There is no significant
history. 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
headache 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 headache, 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 headache, 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 headache in pregnancy? These are not on the option list – you need
to dig them out of your head.
Option list.
|
A |
asthma |
↔ |
↑ |
↓ |
|
B |
developmental dysplasia of the hip in child |
↔ |
↑ |
↓ |
|
C |
diabetes |
↔ |
↑ |
↓ |
|
D |
Down’s syndrome in child |
↔ |
↑ |
↓ |
|
E |
hypertension |
↔ |
↑ |
↓ |
|
F |
ischaemic heart disease |
↔ |
↑ |
↓ |
|
G |
PET |
↔ |
↑ |
↓ |
|
H |
stroke |
↔ |
↑ |
↓ |
Scenario 15.
Which of the following drugs is
contraindicated in the prophylaxis of migraine in pregnancy?
Option list.
|
A |
amitriptyline
|
|
B |
ß-blockers |
|
C |
ergotamine |
|
D |
low-dose aspirin |
|
E |
pizotifen |
|
F |
pregabalin |
|
G |
tricyclic antidepressants |
|
H |
verapamil |
Scenario 16. Which, if any, of the following
statements is true about posterior reversible encephalopathy syndrome. This is
not a true EMQ as there may be > 1 true answer.
Option list.
|
A |
‘thunderclap’ headache is typical |
|
B |
‘handclap’ headache is typical |
|
C |
classically occurs in the early puerperium
and is recurrent |
|
D |
classically occurs in the early puerperium
and is not recurrent |
|
E |
arterial beading is typically seen on MRI |
|
F |
arterial beating is typically seen on MRI |
|
G |
arterial bleeding is typically seen on MRI |
|
H |
venous beading is typically seen on MRI |
|
I |
venous beating is typically seen on MRI |
|
J |
venous bleeding is typically seen on MRI |
|
K |
diagnosis requires lumbar puncture and
evidence of ↑
CSF pressure |
|
L |
treatment is with nimodipine |
Scenario 17. Which, if any, of the following
statements is true about reversible cerebral vasoconstriction syndrome. This is
not a true EMQ as there may be > 1 true answer.
Option list.
|
A |
‘thunderclap’ headache is typical |
|
B |
‘handclap’ headache is typical |
|
C |
classically occurs in the early puerperium
and is recurrent |
|
D |
classically occurs in the early puerperium
and is not recurrent |
|
E |
arterial beading is typically seen on MRI |
|
F |
arterial beating is typically seen on MRI |
|
G |
arterial bleeding is typically seen on MRI |
|
H |
venous beading is typically seen on MRI |
|
I |
venous beating is typically seen on MRI |
|
J |
venous bleeding is typically seen on MRI |
|
K |
diagnosis requires lumbar puncture and
evidence of ↑
CSF pressure |
|
L |
treatment is with nimodipine |
Questions from TOG article by Revell & Moorish. 2014. They
are open access.
Red flag features
for headaches include:
1. headache
that changes with posture True / False
2. associated
vomiting True / False
3. occipital
location True / False
4. associated
visual disturbance. True / False
Migraine is
classically,
5. bilateral.
True / False
6. pulsating.
True / False
7. aggravated
by physical exercise. True / False
With regard to
migraine headaches in pregnancy,
8. there
is an increase in the frequency of attacks without aura. True / False
9. women
who suffer from this have not been shown to have an increase in the risk of
pre-eclampsia. True / False
10. the
5HT1-receptor sumatriptan has been shown to be teratogenic. True / False
11. women
presenting with an aura for the first time are not at an increased risk of
intracranial disease. True / False
Posterior reversible
encephalopathy syndrome,
12. is
associated with an impairment of the autoregulatory mechanism which maintains
constant cerebral blood flow where there are blood pressure fluctuations. True / False
13. when
it is associated with pre-eclampsia, management should follow the pathway for
managing severe pre-eclampsia. True / False
With regard to
cerebral venous thrombosis,
14. the
incidence in western countries in pregnancy ranges from 1 in 2500 deliveries to
1 in 10 000 deliveries. True / False
15.
the greatest risk in pregnancy is mainly in the last four weeks. True / False
16. the
most common site is the sagittal sinus. True / False
17. a
plain computed tomography is a highly sensitive investigation. True / False
18. T2-weighted
magnetic resonance imaging has been shown to have limited value in diagnosis.
True / False
19. the
outcome is better when it is associated with pregnancy and the puerperium
compared to that occurring outside pregnancy. True / False
20. when
it occurs in pregnancy, it is a contraindication for future pregnancies. True / False
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