|
EMQ. Semmelweis, Gordon and Holmes |
|
|
44 |
EMQ. Cytomegalovirus and Pregnancy. CMV |
|
45 |
EMQ. Risk
management |
|
46 |
EMQ. Relugolix |
|
47 |
EMQ. Kell antibodies |
|
48 |
EMQ. Listeriosis and pregnancy |
Try to answer all the questions before the tutorial –
doing this helps facts stick in long-term memory.
Don’t look up any facts – just use ‘intelligent
guessing’ if you don’t know the answer. This is what you will rely on in the
exam.
43. EMQ. Semmelweis, Gordon and Holmes.
Scenario
1.
Which, if any, of
the following statements are true in relation to Semmelweis?
Option list.
|
A |
his full name was
Ignác Fülöp Semmelweis, but he was known to friends as "Naci". |
|
B |
he lived from
1818 to 1865 |
|
C |
he
revolutionised understanding of ‘childbed fever’ |
|
D |
he
revolutionised understanding of rheumatic fever |
|
E |
he
revolutionised understanding of tuberculosis |
|
F |
he pioneered
proton beam therapy |
|
G |
his
professional ‘Damascene moment’ came after the death of his colleague,
Kolletschka, at the hands of a medical student in 1847 |
|
H |
his work was
vilified by the majority of his professional contemporaries |
|
I |
he died in a
lunatic asylum |
|
J |
he died in a
road traffic accident |
|
K |
he died at
home in bed with his mistress |
Scenario
2.
Which, if any, of
the following statements are true in relation to Gordon?
Option list.
|
A |
his full name was
Hamish Gordon, but he was known to friends as "Hamy". |
|
B |
he lived from
1801 to 1864 |
|
C |
he
revolutionised understanding of ‘childbed fever’ |
|
D |
he
revolutionised understanding of rheumatic fever |
|
E |
he
revolutionised understanding of tuberculosis |
|
F |
he pioneered
proton beam therapy |
|
G |
his
professional ‘Damascene moment’ came after epidemics of erysipelas and
puerperal fever in Aberdeen in the late 18th. century |
|
H |
his work was
vilified by the majority of his professional contemporaries |
|
I |
he died in a
lunatic asylum |
|
J |
he died in a
road traffic accident |
|
K |
he died at
home in bed with his mistress |
Scenario 3.
Which, if any, of
the following statements are true in relation to Wendell Holmes?
Option list.
|
A |
his full name was Wendell Holmes, but he was known to
friends as "Wellie". |
|
B |
he lived from 1801 to 1864 |
|
C |
he revolutionised understanding of ‘childbed fever’ |
|
D |
he revolutionised understanding of rheumatic fever |
|
E |
he revolutionised understanding of tuberculosis |
|
F |
he pioneered proton beam therapy |
|
G |
he was a fan of the work of Gordon. |
|
H |
his work on childbed fever was vilified by the majority
of his professional contemporaries |
|
I |
he died in a lunatic asylum |
|
J |
he died in a road traffic accident |
|
K |
he died at home in bed with his mistress |
44. EMQ. Cytomegalovirus and Pregnancy. CMV.
Abbreviations.
AI: avidity
index.
CMV: cytomegalovirus.
CNS: central
nervous system.
FGR: fetal
growth restriction.
HIG: hyperimmunoglobulin.
IUFD: intrauterine fetal death.
Scenario 1.
What does the term
“cytomegalovirus” mean?
Option list.
|
A |
it is an unusually large virus |
|
B |
it is the largest known virus |
|
C |
the viral cytoplasm is increased in volume |
|
D |
infected cells are enlarged and have enlarged nuclei |
|
E |
none of the above |
Scenario 2.
Which of the
following terms is used in relation to CMV infected cells?
Option list.
|
A |
almond-eyed |
|
B |
apple of my eye |
|
C |
cross-eyed |
|
D |
doe-eyed |
|
E |
owl-eyed |
Scenario 3.
Which family of
viruses does CMV belong to?
Option list.
|
A |
Adenoviridae |
|
B |
Arachnoviridae |
|
C |
Enteroviridae |
|
D |
Herpesviridae |
|
E |
Poxviridae |
Scenario 4.
What kind of virus
is CMV?
Option list.
|
A |
bacteriophage |
|
B |
DNA virus |
|
C |
RNA virus |
|
D |
none of the above |
Scenario 5.
What is the
structure of the herpes virus?
Option list.
|
A |
double-stranded DNA core, surrounded by three layers:
capsid, tegument and envelope |
|
B |
single-stranded DNA core, surrounded by two layers:
capsid and envelope |
|
C |
double-stranded RNA core, surrounded by three layers:
capsid, tegument and envelope |
|
D |
single-stranded RNA core, surrounded by two layers:
capsid and envelope |
|
E |
none of the above |
Scenario 6.
How many herpes
viruses have been described?
Option list.
|
A |
>1,000 |
|
B |
> 500 |
|
C |
> 250 |
|
D |
> 100 |
|
E |
none of the above. |
Scenario 7.
How many herpes
viruses are of relevance to human infection?
Option list.
|
A |
8 |
|
B |
10 |
|
C |
12 |
|
D |
14 |
|
E |
20 |
Scenario 8.
Write the list of
herpes viruses which affect humans and the conditions they cause?
Option list. There is
none. You have to write your own list.
Scenario 9.
Where does CMV
rank in the list of the most common causes of congenital viral
infection?
Option list.
|
A |
1 |
|
B |
2 |
|
C |
3 |
|
D |
4 |
|
E |
5 |
Scenario 10.
Which of the
following statements is the most accurate in relation to CMV?
Option list.
|
A |
CMV can lie dormant after 1ry. infection, usually in
bone marrow |
|
B |
CMV can lie dormant after 1ry. infection, usually in
dorsal root ganglia |
|
C |
CMV can lie dormant after 1ry. infection, usually in
the lungs |
|
D |
CMV can lie dormant after 1ry. infection, usually in
the salivary glands |
|
E |
CMV does not lie dormant after 1ry. infection |
Scenario 11.
Which, if any, of
the following statements is true of CMV & pregnancy in the UK?
Option list.
|
A |
approximately 10-20% of women are immune before their 1st.
pregnancy |
|
B |
approximately 20-30% of women are immune before their 1st.
pregnancy |
|
C |
approximately 30-50% of women are immune before their 1st.
pregnancy |
|
D |
approximately 40-60% of women are immune before their 1st.
pregnancy |
|
E |
none of the above |
Scenario 12.
Which of the
following statements is true in relation to vertical transmission?
Option list.
|
A |
it is mainly transplacental |
|
B |
it is mainly due to feto-maternal haemorrhage |
|
C |
it mainly occurs during labour and delivery |
|
D |
it mainly occurs during lactation |
|
E |
none of the above |
Scenario 13.
What is the
approximate incidence of 1ry. CMV infection in pregnancy?
Option list.
|
A |
< 1% |
|
B |
< 5% |
|
C |
< 7.5% |
|
D |
< 10% |
|
E |
≥ 10% |
Scenario 14.
What is the
biggest source of CMV infection for women of reproductive age?
Option list.
|
A |
contaminated food or water |
|
B |
blood transfusion |
|
C |
infected sexual partner |
|
D |
infected small children |
|
E |
undercooked meat, particularly pork |
Scenario 15.
What proportion of
1ry. maternal CMV infection in pregnancy is asymptomatic?
Option list.
|
A |
up to 10% |
|
B |
11 – 29% |
|
C |
30 – 49% |
|
D |
50 – 79% |
|
E |
80 – 89% |
|
F |
≥ 90% |
Scenario 16.
What is the
approximate prevalence of CMV infection in UK neonates?
Option list.
|
A |
0.10- 0.25% |
|
B |
0.10- 0.50% |
|
C |
0.20- 0.50% |
|
D |
0.20- 1.00% |
|
E |
0.20- 2.25% |
Scenario 17.
Where does CMV
rank in the non-genetic causes of SNHL in children?
Option list.
|
A |
1 |
|
B |
2 |
|
C |
3 |
|
D |
4 |
|
E |
none of the above |
Scenario 18.
When does vertical
transmission carry the greatest risk of inflicting neurological
damage on the fetus?
Option list.
|
A |
with 1ry infection during the 1st. trimester |
|
B |
with 2ry infection during the 1st. trimester |
|
C |
with 1ry infection during the 2nd. trimester |
|
D |
with 2ry infection during the 2nd. trimester |
|
E |
with 1ry infection during the 3rd. trimester |
|
F |
with 2ry infection during the 3rd. trimester |
|
G |
with 1ry infection during labour / delivery |
|
H |
with 2ry infection during labour / delivery |
|
I |
none of the above |
Scenario 19.
What is the risk
of vertical transmission after CMV infection in the immediate
preconception period?
Option list.
|
A |
< 1% |
|
B |
1-5% |
|
C |
6-10% |
|
D |
11-15% |
|
E |
16-20% |
|
F |
21-30% |
Scenario 20.
A fetus is
infected with CMV at the time of highest risk for neurological damage. What
is the approximate upper limit
for the risk that the child will have neurological damage?
Option list.
|
A |
up to 1% |
|
B |
up to 5% |
|
C |
up to 7.5% |
|
D |
up to 10% |
|
E |
up to 12.5% |
|
F |
up to 15% |
|
G |
up to 20% |
|
H |
none of the above |
Scenario
21. Approximately what % of cerebral palsy is thought
attributable to fetal CMV?
Option list.
|
A |
1% |
|
B |
5% |
|
C |
7.5% |
|
D |
10% |
|
E |
12.5% |
|
F |
15% |
|
G |
20% |
|
H |
25% |
Scenario 22.
Approximately what
% of SNHL is thought attributable to fetal CMV infection?
Option list.
|
A |
1% |
|
B |
5% |
|
C |
7.5% |
|
D |
10% |
|
E |
12.5% |
|
F |
15% |
|
G |
20% |
|
H |
25% |
Scenario 23.
Which, if any, of
the following statements is true of CMV?
Option list.
|
A |
1ry. infection is followed by life-long latent
infection |
|
B |
1ry. infection is followed by life-long latent infection
in a minority of cases |
|
C |
life-long latent infection is characteristic of CMV but
not other herpes viruses |
|
D |
life-long latent infection only occurs after 2ry.
infection |
|
E |
none of the above. |
Scenario 24.
How is 1ry.
maternal CMV infection best diagnosed?
Option list.
|
A |
by the regional laboratory |
|
B |
IgM to IgG conversion |
|
C |
presence of IgM with low avidity IgG |
|
D |
religious conversion |
|
E |
sero-conversion from IgG -ve to IgG +ve |
Scenario 25.
Which, if any, of
the following is true in relation to ‘avidity’ in CMV infection?
Option list.
|
A |
avidity declines directly with the interval from 1ry
infection to the test |
|
B |
avidity is an indirect measure of viral load |
|
C |
avidity measures the determination of the obstetrician
to make a diagnosis |
|
D |
avidity measures the enthusiasm of the laboratory for
maximising the cost of testing |
|
E |
avidity measures the strength of binding of CMV
antibody to the virus |
Scenario 26.
Which, if any, of
the following is true in relation to the CMV ‘avidity index’?
Option list.
|
A |
the AI is the ratio of free: albumin-bound CMV IgG in
maternal serum |
|
B |
the AI is the IgG antibody titre in maternal serum |
|
C |
the AI is the percentage of IgG that is bound to the
antigen |
|
D |
the AI is the amount of IgG bound to the antigen
expressed as micrograms / gram |
|
E |
none of the above |
Scenario 27.
Which, if any, of
the following is true in relation to the CMV ‘avidity index’?
Option list.
|
A |
an AI < 30 is indicative of old infection |
|
B |
an AI < 30 is indicative of recent 1ry infection |
|
C |
an AI < 30 suggests a faulty assay |
|
D |
the AI assay used in the NHS is standard across all
laboratories |
|
E |
none of the above |
Scenario 28.
Which, if any, of the following
statements is true in relation to identifying women at greatest risk of having
a baby with severe congenital infection?
Option list.
|
A |
a low AI < 18 weeks indicates high risk |
|
B |
a high AI < 18 weeks indicates high risk |
|
C |
a high IgM titre indicates low risk |
|
D |
a high IgG titre indicates high risk |
|
E |
none of the above |
Scenario 29.
What is UK policy
in relation to routine screening for CMV in pregnancy?
Option list.
|
A |
routine screening was introduced in 2018 |
|
B |
routine screening is not advocated because of cost |
|
C |
routine screening is not advocated because of the lack
of an accurate test |
|
D |
routine screening is not advocated because of cross-reaction
with EBV |
|
E |
none of the above |
Scenario 30.
What is UK policy
in relation to routine screening of the neonate for CMV?
Option list.
|
A |
routine screening was introduced in 2015 |
|
B |
routine screening is not advocated because of cost |
|
C |
routine screening is not advocated because of the lack
of an accurate test |
|
D |
routine screening is not advocated because of cross-reaction
with EBV |
|
E |
none of the above |
Scenario
31. Pick the true statements from the list below.
Option list.
|
A |
avidity testing
is not done on CMV IgM antibodies |
|
B |
CMV IgG is a
maverick and does not play by the usual rules |
|
C |
CMV IgM is a
maverick and does not play by the usual rules |
|
D |
CMV IgG
persists for many years |
|
E |
CMV IgM
persists for 1 year or more |
|
F |
none of the
above |
Scenario 32.
A woman has been
shown to have had CMV infection in pregnancy. It is decided to
check for evidence of fetal
infection. What does SIP56 say is the mainstay of diagnosing fetal CMV
infection.?
Option list.
|
A |
amniocentesis and PCR for evidence of CMV |
|
B |
amniocentesis and electron microscopy for evidence of
CMV |
|
C |
amniocentesis and light microscopy for evidence of CMV |
|
D |
amniocentesis and viral culture |
|
E |
MRI |
|
F |
ultrasound – abdominal |
|
G |
ultrasound - transvaginal |
Scenario 33.
A woman has been
shown to have had CMV infection in pregnancy. Which, if any of
the following statements best
describe the role of MRI scanning in assessing the fetus? This is not a true
EMQ as more than one statement may be true.
Option list.
|
A |
it should be offered in conjunction with ultrasound |
|
B |
it should be offered if ultrasound examination suggests
fetal infection |
|
C |
it should be offered if ultrasound examination does not
suggest fetal infection |
|
D |
it should be offered if there is sufficient funding to
pay for it |
|
E |
the role of MRI scanning is not yet clear |
|
F |
none of the above |
Scenario 34.
A pregnant woman
is HIV+ve? Which of the following statements is true?
Option list.
|
A |
the risk of vertical transmission in pregnancy is ↑ |
|
B |
the risk of vertical transmission in pregnancy is ↓ |
|
C |
the risk of vertical transmission in pregnancy is the
same as in HIV-ve women |
Scenario 35.
A pregnant woman
is HIV+ve? Which of the following statements is true?
Option list.
|
A |
her neonate is at ↑
risk of acquiring CMV perinatally |
|
B |
her neonate is at ↓
risk of acquiring CMV perinatally |
|
C |
her neonate is at normal risk of acquiring CMV
perinatally |
|
D |
none of the above |
Scenario 36.
A pregnant woman
is HIV+ve? Her neonate is +ve for both CMV and HIV. Which of the
following statements is true?
Option list.
|
A |
the child has a ↓
risk of HIV progression and ↓
risk of CNS damage from CMV |
|
B |
the child has a ↓
risk of HIV progression and ↑
risk of CNS damage from CMV |
|
C |
the child has a ↓
risk of HIV progression and normal risk of CNS damage from CMV |
|
D |
the child has an ↑
risk of HIV progression and ↓
risk CNS damage from CMV |
|
E |
the child has an ↑
risk of HIV progression and ↑
risk CNS damage from CMV |
|
F |
the child has an ↑
risk of HIV progression and normal risk of CNS damage from CMV |
|
G |
the child has a normal risk of HIV progression and ↓ risk of CNS damage from CMV |
|
H |
the child has a normal risk of HIV progression ↑ risk of CNS damage from CMV |
|
I |
the child has a normal risk of both HIV progression and
CNS damage from CMV |
Scenario 37.
Which of the
following treatments in pregnancy is of proven efficacy and safety in
reducing the risk of vertical
transmission to the fetus?
Option list.
|
A |
acyclovir |
|
B |
CMV vaccine |
|
C |
ganciclovir |
|
D |
HIG |
|
E |
valaciclovir |
|
F |
none of the above |
TOG CPD
Comprehensive review and update of
cytomegalovirus infection in pregnancy
Regarding cytomegalovirus (CMV),
1. it is a double-stranded RNA herpes
virus. True False
2. it is the commonest congenital viral
infection in
the developed world. True False
3. prevalence is most common in social
class V. True False
Regarding CMV morbidity,
4. it is the leading genetic cause of
sensorineural deafness. True False
5. maternal infection occurring in the
third
trimester carries the highest risk to
the
fetus. True False
6. previous infection confers complete
future
immunity to the mother. True False
Regarding feto-maternal transmission of
CMV,
7. there is good evidence to suggest
that
gestational age has no apparent influence
on
risk of transmission. True False
8. breastfeeding is a route of
transmission. True False
9. for healthy mature babies, an
infection with
the CMV through breastmilk does not pose
significant danger. True False
10. transmission can be reduced by
appropriate
hand washing after nappy changes and
exposure to bodily fluids, avoiding
kissing
young children on mouth and cheeks and
by
avoiding sharing food, drinks or
utensils with
young children. True False
11. primary infection, reactivation and
reinfection
with different CMV strains during
pregnancy
has been shown to lead to congenital
CMV. True False
Regarding maternal CMV in pregnancy,
12. diagnosis of maternal CMV based on
symptoms is reliable with over 70% of
women
presenting with classic symptoms. True False
13. viral reactivation is more common in
HIV
positive pregnant women. True False
Regarding diagnosis of CMV infection in
pregnancy,
14. seroconversion of CMV specific
immunoglobulin G (IgG) in paired acute
and
convalescent sera is diagnostic of a new
acute infection. True False
15. When prepregnancy status is unknown,
detection of immunoglobulin M (IgM)-
specific antibody is diagnostic of
primary infection. True False
16. IgM serology is imprecise for
determining
primary infection as it has been shown
to
remain positive for up to a year
following
acute infection. True False
17. The presence of IgG and IgM CMV
antibodies
with low CMV antibody avidity is
diagnostic
of primary infection. True False
Concerning congenital CMV infection,
18. 85% are asymptomatic at birth. True False
19. 30% of affected infants will develop
neurological sequelae. True False
20. 15% of infants born to mothers with
recurrent
CMV infection are overtly symptomatic. True False
These derive from the TOG
article by Navti et al. The article is from 2016 and is open-access.
TOG. Volume
18, Issue 4 October 2016 Pages 301–7.
Some of the questions are badly
written – I would expect exam questions to be better.
Regarding cytomegalovirus
(CMV),
1. it is a double-stranded RNA herpes virus. True False
2. it is the commonest congenital viral
infection in the developed world. True False.
3. prevalence is most common in social class
V. True False
Regarding CMV morbidity,
4. it is the leading genetic cause of
sensorineural deafness. True False
5. maternal infection occurring in the 3rd.
trimester carries the highest risk to the fetus. True False
6. previous infection confers complete future
immunity to the mother. True False
Regarding feto-maternal transmission of CMV,
7. there is good evidence to suggest that
gestational age has no apparent influence on risk of transmission. True False
8. breastfeeding is a route of transmission. True False
9. for healthy mature babies, an infection
with the CMV through breastmilk does not pose significant danger. True False
10. transmission can be reduced by appropriate
hand washing after nappy changes and exposure to bodily fluids, avoiding
kissing young children on mouth and cheeks and by avoiding sharing food, drinks
or utensils with young children. True False
11. primary infection, reactivation and
reinfection with different CMV strains during pregnancy has been shown to lead
to congenital CMV. True False
Regarding maternal CMV in pregnancy,
12. diagnosis of maternal CMV based on symptoms
is reliable with over 70% of women presenting with classic symptoms. True Fa
13. viral reactivation is more common in HIV
positive pregnant women. True False
Regarding diagnosis of CMV infection in pregnancy,
14. seroconversion of CMV specific immunoglobulin
G (IgG) in paired acute and convalescent sera is diagnostic of a new acute
infection. True False
15. When prepregnancy status is unknown, detection
of immunoglobulin M (IgM)- specific antibody is diagnostic of primary
infection. True False
16. IgM serology is imprecise for determining
primary infection as it has been shown to remain positive for up to a year
following acute infection. True
17. The presence of IgG and IgM CMV antibodies
with low CMV antibody avidity is diagnostic of primary infection. True False
Concerning congenital CMV infection,
18. 85% are asymptomatic at birth. True False
19. 30% of affected infants will develop
neurological sequelae. True False
20. 15% of infants born to mothers with recurrent
CMV infection are overtly symptomatic.
True False
45. EMQ. Risk management.
Lead-in. The following scenarios relate to risk management
/ disciplinary procedures.
Abbreviations.
BMA: British
Medical Association
DOH: Department of Health.
Option list.
A.
allow the practice to
continue
B.
stop the practice
until a full investigation has been done
C.
stop the practice
permanently
D.
arrange an
investigation by a senior consultant from another hospital
E.
decide the practice
does not involve added risk
F.
declare the risk to be
acceptable
G.
cancel admissions for
surgery
H.
arrange adverse
incident analysis
I.
arrange audit
J.
arrange research
K.
arrange a formal
warning for the doctor
L.
arrange retirement for
the doctor
M.
arrange dismissal for
the doctor
N.
consult the on-call
consultant
O.
consult the Clinical
Director
P.
consult the
Educational Supervisor / College Tutor
Q.
consult the Medical
Director
R.
consult the Chief
Executive
S.
consult the
Postgraduate Dean.
T.
consult the hospital’s
lawyer
U.
write to Her Majesty
at Buckingham Palace
V.
consult your Medical
Defence Body
W.
consult the British
Medical Association
X.
consult the RCOG
Y.
report the matter to
the GMC
Z.
allow return to work
AA.
allow return to work,
but offer support
BB.
arrange a “return to
work” package specific to the doctor
CC.
none of the above
Scenario 1. You are the
Clinical Director. A 62-year-old Consultant colleague has been off work for 8
weeks with a broken arm sustained in a skiing accident. He sends you a
certificate from his specialist to say that he is now fit to return to work. He
indicates that he wishes to return to work immediately. What action will you
take?
Scenario 2. You are the
Clinical Director. A 62-year-old Consultant colleague has been off work for 8
weeks with a severe bereavement reaction to the suicide of a family member. He
sends you a certificate from his GP to say that he is now fit to return to
work. He indicates that he wishes to return to work immediately. What action
will you take?
Scenario 3. You are the
Clinical Director. A 62-year-old Consultant colleague has been off work for 6
months after having a coronary thrombosis. He sends you a certificate from his
specialist to say that he is now fit to return to work. He indicates that he
wishes to return to work immediately. What action will you take?
Scenario 4. You are the
Clinical Director. A 62-year-old Consultant has returned to work after four
months’ sick leave after a coronary thrombosis. He has three cases on his first
operating list and all have complications reported by the Sister on the
gynaecology ward. What action will you take?
Scenario 5. A
Consultant has been in her first consultant post for two months. Three of the
four patients on a single operating list develop post-operative wound
infections. What action will you take?
Scenario 6. You have
recently been appointed Clinical Director. A consultant has been in post for
ten years and prefers to operate with the same nurse assistant. No
complications have been reported. What action will you take?
Scenario 7. You are the
Clinical Director. A consultant has an
operating list in a peripheral unit 20 miles from the main hospital. There is
no resident doctor with post-operative care being provided by nurses. The cases
dealt with on the list traditionally were minor and day-cases. You have been told that the consultant, who
was appointed 6 months ago, has recently been doing hysterectomies and prolapse
repairs to get the waiting list down. What action
will you take?
Scenario 8. You are the
Clinical Director. The blood bank informs you that there is a problem with
supplies and fully cross-matched blood cannot be guaranteed for tomorrow’s
arranged surgical cases. What action will you take?
Scenario 9. You are the
on-call SpR. It is 8 pm. The blood bank informs you that there is a problem
with supplies and fully cross-matched blood cannot be guaranteed for tomorrow’s
arranged surgical cases. What action will you take?
Scenario 10. A SpR is
half an hour late for starting his duties on three occasions in one week. His
consultant wishes to have this dealt with as a disciplinary matter to “nip it
in the bud” and teach him a lesson. He reports it to you, the Clinical Director,
asking you to discipline the doctor. What action will you take?
Scenario 11, A SpR gets
into an argument with the senior midwife on the labour ward and in the heat of
the moment slaps her across the face. You are the Clinical Director and the
matter is reported to you next day.
Scenario 12, Your
consultant is the Clinical Director and a nasty man. You apply 6 months in
advance for study leave for the week before the written part of the Part Ii
MRCOG exam. He tells you that he plans to go on holiday at that time and you
are not going to get any leave. In addition, he tells you that if you complain
about this he will give you a terrible reference and tell all his consultant
friends that you are a waste of space in order to ruin your career. What action
can you take?
Scenario 13, A SpR
fails an OSATS, but falsifies his records to indicate that it has been
completed satisfactorily. You are the Educational Advisor and this is brought
to your attention. What action will you take?
Scenario 14. You are
the Clinical Director. A SpR2 uploaded reflective practice putting himself in a
good light after a case which had been handled sub-optimally by him. What
action will you take?
Scenario 15. You are an FY2 and assist
the senior consultant at a hysterectomy. The operation goes well initially, but
then there is a lot of bleeding and a ureter is cut. The consultant urologist
attends and repairs the ureter. The woman bleeds vaginally that evening and is
taken back to theatre by another consultant and ends up in the ICU. You became
convinced during the operation that you could smell alcohol on the consultant
gynaecologist’s breath. What are your responsibilities?
Scenario 16. When do you need to inform the
Consultant on-call?
Scenario 17. When do you need to inform the
Clinical Director?
Scenario 18. When do you need to inform the
Medical Director?
Scenario 19. When do you need to inform the GMC?
Scenario 20. What are the roles of the BMA and
MDU?
Scenario 21. What are the differences between
verbal and written warnings?
Scenario 22. A SpR1 has been asked to carry out
an audit and 50 sets of case-notes are to be used.
He is given 49 sets of notes and a day in which to go
through them and extract the necessary data.
This he does in the hospital. The final set of notes cannot
be found initially, but are found two weeks later. The doctor is given the
notes on a Friday afternoon as he is leaving for home. He decides to take the
notes home to extract the data. On the way home he stops at his favourite
supermarket.
When he emerges, his car has been stolen with the notes
inside. He reports the theft to the police.
He informs you, the Clinical Director, on the Monday when he
returns to work. What action will you take?
Scenario 23. You are the SpR for the delivery
unit. During a quiet moment you head for the staff room adjacent to the
operating theatre for a coffee. As you pass the anaesthetic room you hear loud
snoring. You look in and find the on-call anaesthetic registrar unconscious on
his back on the floor with an anaesthetic mask by his face attached to a
cylinder of nitrous oxide. What action will you take?
Option list.
|
A |
call for help |
|
B |
go back to the labour ward and pretend that nothing has
happened |
|
C |
go back to the labour ward and inform the senior
midwife |
|
D |
phone the GMC |
|
E |
phone the on-call consultant anaesthetist |
|
F |
phone the on-call consultant obstetrician |
|
G |
phone the police |
|
H |
put the anaesthetist in the recovery position and
remove the mask |
|
I |
none of the above |
Scenario 24. This is a follow-on from the previous station. What action will you take next?
Scenario 25. You are the Clinical Director. It is
the morning after the events in scenarios 22 and 23.
The on-call consultant obstetrician comes to see you and
reports what has happened.
What action will you take?
Option list.
|
A |
discuss the case with the Chief Executive |
|
B |
discuss the case with the Medical Defence Union |
|
C |
discuss the case with the BMA |
|
D |
discuss the case with the Medical Director |
|
E |
discuss the case with the most senior person in the
personnel department |
|
F |
discuss the case with the Postgraduate Dean |
|
G |
report the anaesthetic registrar to the GMC |
|
H |
resign from being Clinical Director to avoid stress |
|
I |
summon the anaesthetic registrar to give him a severe
telling-off |
46. EMQ. Relugolix.
Abbreviations.
DEXA: dual-energy x-ray absorptiometry for
bone density.
RON: relugolix + oestradiol + norethisterone
Question
1. Which, if any, of the following are correct about relugolix?
Option list.
|
A |
it is a FSH agonist |
|
B |
it is a FSH antagonist |
|
C |
it is a GnRH agonist |
|
D |
it is a GnRH antagonist |
|
E |
is an oestrogen receptor modulator |
|
F |
is a progestogen receptor modulator |
Question 2.
Which, if
any, of the following are true about the preparation recommended by NICE for
the use of relugolix in gynaecology?
Option list.
|
A |
it contains relugolix as the only active component |
|
B |
it contains relugolix and
ibuprofen |
|
C |
it contains relugolix with ethinylestradiol and
desogestrel |
|
D |
it contains relugolix with oestradiol and
norethisterone |
|
E |
it is administered intramuscularly |
|
F |
it is administered orally |
|
G |
it is administered nasally as a spray |
|
H |
it is administered subcutaneously |
|
I |
it is administered daily |
|
J |
it is administered monthly |
|
K |
it is administered three-monthly |
|
L |
it is in the form of a rod which can be removed easily |
|
M |
the proprietary preparation in called ‘Ryegg’ |
|
N |
the proprietary preparation in called ‘Ryego’ |
|
O |
the proprietary preparation in called ‘Wryegg’ |
|
P |
the proprietary preparation in called ‘Wryego’ |
Question 3.
Which, if any, of
the following were described by NICE as proven benefits from the use of RON?
Option list.
|
A |
↓
menstrual bleeding compared with GnRH agonists |
|
B |
↓
menstrual bleeding compared with placebo |
|
C |
↓ size of fibroids compared with GnRH agonists |
|
D |
↓ size of fibroids compared with
placebo |
|
E |
↓
rate of expulsion of submucous fibroids compared with GnRH agonists |
|
F |
↓ rate
of expulsion of submucous fibroids compared with placebo |
Question 4.
Which, if any, of
the following are described by NICE as likely benefits from the use of
relugolix preparation available in the UK?
Option list.
|
A |
is effective long-term |
|
B |
is safe long-term |
|
C |
is well-tolerated |
|
D |
has no adverse effect on fertility |
|
E |
↓ the risk of breast cancer |
|
F |
↓ the risk of cervical cancer |
|
G |
↓
the risk of endometrial cancer |
Question 5.
For which of the
following is the UK relugolix preparation licensed?
Option list.
|
A |
breast cancer |
|
B |
cervical cancer |
|
C |
endometrial cancer |
|
D |
ovarian cancer |
|
E |
prostate cancer |
|
F |
endometriosis |
|
G |
fibroids |
|
H |
premenstrual syndrome |
|
I |
puerperal psychosis |
Which, if any, of the following are listed as
contraindications to the use of the relugolix preparation available in the UK?
Option list.
|
A |
asthma |
|
B |
breast cancer |
|
C |
breastfeeding |
|
D |
osteoporosis |
|
E |
protein C
deficiency |
|
F |
von
Willebrand’s disease |
Question 7.
Which, if any, of
the following are listed as side-effects by the manufacturer?
Option list.
|
A |
acne |
|
B |
alopecia |
|
C |
angina |
|
D |
anxiety |
|
E |
asthma |
|
F |
breast cysts |
|
G |
breast pain |
|
H |
depression |
|
I |
dyspepsia |
|
J |
expulsion of fibroid |
|
K |
hot flushes |
|
L |
hyperhidrosis |
|
M |
night sweats |
|
N |
red degeneration of fibroid |
|
O |
reduced libido |
|
P |
uterine bleeding |
Question 8.
Which, if any, of the following
are correct in relation to long-term contraception while taking RON?
Option list.
|
A |
barrier methods are recommended |
|
B |
depot and implant progestogens are recommended |
|
C |
IUDs are recommended |
|
D |
combined oral contraception is contraindicated |
|
E |
RON provides adequate contraception, but additional
contraception should be used for 3/12 |
|
F |
RON may delay recognition of an unplanned pregnancy |
Question 9.
Which, if any, of
the following are advised prior to prescribing RON?
Option list.
|
A |
clotting screen |
|
B |
DEXA scan |
|
C |
endometrial histology |
|
D |
full blood count |
|
E |
liver function tests |
|
F |
pregnancy test |
|
G |
thyroid function tests |
Question 10.
Which, if any, of
the following are true in relation to the potential for the preparation
available in the UK to react adversely with other drugs?
Option list.
|
A |
use with P-glycoprotein
inhibitors is not recommended |
|
B |
use with CYP3A4 inducers in not recommended |
|
C |
use with penicillin in not recommended |
|
D |
use with aspitin is not recommended |
|
E |
use with St John’s wort is not recommended |
Question 11.
What advice should
be given after missed pills?
Option list.
|
A |
non-hormonal contraception for 7 days after
1 missed pill |
|
B |
non-hormonal contraception for 10 days after 1 missed pill |
|
C |
non-hormonal contraception for 14 days after 1 missed pill |
|
D |
non-hormonal contraception for 7 days after
2 consecutive missed pills |
|
E |
non-hormonal contraception for 10 days after 2 consecutive missed pills |
|
F |
non-hormonal contraception for 14 days after 2 consecutive missed pills |
|
G |
non-hormonal contraception for 7 days after
≥ 3 consecutive
missed pills |
|
H |
non-hormonal contraception for 10 days after ≥
3 consecutive missed pills |
|
I |
non-hormonal contraception for 14 days after ≥
3 consecutive missed pills |
47. EMQ. Kell antibodies.
Lead-in. The following scenarios relate to risk
management / disciplinary procedures.
Abbreviations.
BMA: British
Medical Association
DOH: Department of Health.
Option list.
DD.
allow the practice to
continue
EE.
stop the practice
until a full investigation has been done
FF.
stop the practice
permanently
GG.
arrange an
investigation by a senior consultant from another hospital
HH.
decide the practice
does not involve added risk
II.
declare the risk to be
acceptable
JJ.
cancel admissions for
surgery
KK.
arrange adverse
incident analysis
LL.
arrange audit
MM. arrange research
NN.
arrange a formal
warning for the doctor
OO.
arrange retirement for
the doctor
PP.
arrange dismissal for
the doctor
QQ.
consult the on-call
consultant
RR.
consult the Clinical
Director
SS.
consult the
Educational Supervisor / College Tutor
TT.
consult the Medical
Director
UU.
consult the Chief
Executive
VV.
consult the
Postgraduate Dean.
WW. consult the hospital’s lawyer
XX.
write to Her Majesty
at Buckingham Palace
YY.
consult your Medical
Defence Body
ZZ.
consult the British
Medical Association
AAA. consult the RCOG
BBB. report the matter to the GMC
CCC. allow return to work
DDD. allow return to work, but offer support
EEE. arrange a “return to work” package specific to the doctor
FFF. none of the above
Scenario 1. You are the
Clinical Director. A 62-year-old Consultant colleague has been off work for 8
weeks with a broken arm sustained in a skiing accident. He sends you a
certificate from his specialist to say that he is now fit to return to work. He
indicates that he wishes to return to work immediately. What action will you
take?
Scenario 2. You are the
Clinical Director. A 62-year-old Consultant colleague has been off work for 8
weeks with a severe bereavement reaction to the suicide of a family member. He
sends you a certificate from his GP to say that he is now fit to return to
work. He indicates that he wishes to return to work immediately. What action
will you take?
Scenario 3. You are the
Clinical Director. A 62-year-old Consultant colleague has been off work for 6
months after having a coronary thrombosis. He sends you a certificate from his
specialist to say that he is now fit to return to work. He indicates that he
wishes to return to work immediately. What action will you take?
Scenario 4. You are the
Clinical Director. A 62-year-old Consultant has returned to work after four
months’ sick leave after a coronary thrombosis. He has three cases on his first
operating list and all have complications reported by the Sister on the
gynaecology ward. What action will you take?
Scenario 5. A
Consultant has been in her first consultant post for two months. Three of the
four patients on a single operating list develop post-operative wound
infections. What action will you take?
Scenario 6. You have
recently been appointed Clinical Director. A consultant has been in post for
ten years and prefers to operate with the same nurse assistant. No
complications have been reported. What action will you take?
Scenario 7. You are the
Clinical Director. A consultant has an
operating list in a peripheral unit 20 miles from the main hospital. There is
no resident doctor with post-operative care being provided by nurses. The cases
dealt with on the list traditionally were minor and day-cases. You have been told that the consultant, who
was appointed 6 months ago, has recently been doing hysterectomies and prolapse
repairs to get the waiting list down. What action
will you take?
Scenario 8. You are the
Clinical Director. The blood bank informs you that there is a problem with
supplies and fully cross-matched blood cannot be guaranteed for tomorrow’s
arranged surgical cases. What action will you take?
Scenario 9. You are the
on-call SpR. It is 8 pm. The blood bank informs you that there is a problem
with supplies and fully cross-matched blood cannot be guaranteed for tomorrow’s
arranged surgical cases. What action will you take?
Scenario 10. A SpR is
half an hour late for starting his duties on three occasions in one week. His
consultant wishes to have this dealt with as a disciplinary matter to “nip it
in the bud” and teach him a lesson. He reports it to you, the Clinical Director,
asking you to discipline the doctor. What action will you take?
Scenario 11, A SpR gets
into an argument with the senior midwife on the labour ward and in the heat of
the moment slaps her across the face. You are the Clinical Director and the
matter is reported to you next day.
Scenario 12, Your
consultant is the Clinical Director and a nasty man. You apply 6 months in
advance for study leave for the week before the written part of the Part Ii
MRCOG exam. He tells you that he plans to go on holiday at that time and you
are not going to get any leave. In addition, he tells you that if you complain
about this he will give you a terrible reference and tell all his consultant
friends that you are a waste of space in order to ruin your career. What action
can you take?
Scenario 13, A SpR
fails an OSATS, but falsifies his records to indicate that it has been
completed satisfactorily. You are the Educational Advisor and this is brought
to your attention. What action will you take?
Scenario 14. You are
the Clinical Director. A SpR2 uploaded reflective practice putting himself in a
good light after a case which had been handled sub-optimally by him. What
action will you take?
Scenario 15. You are an FY2 and assist
the senior consultant at a hysterectomy. The operation goes well initially, but
then there is a lot of bleeding and a ureter is cut. The consultant urologist
attends and repairs the ureter. The woman bleeds vaginally that evening and is
taken back to theatre by another consultant and ends up in the ICU. You became
convinced during the operation that you could smell alcohol on the consultant gynaecologist’s
breath. What are your responsibilities?
Scenario 16. When do you need to inform the
Consultant on-call?
Scenario 17. When do you need to inform the
Clinical Director?
Scenario 18. When do you need to inform the
Medical Director?
Scenario 19. When do you need to inform the GMC?
Scenario 20. What are the roles of the BMA and
MDU?
Scenario 21. What are the differences between
verbal and written warnings?
Scenario 22. A SpR1 has been asked to carry out
an audit and 50 sets of case-notes are to be used.
He is given 49 sets of notes and a day in which to go
through them and extract the necessary data.
This he does in the hospital. The final set of notes cannot
be found initially, but are found two weeks later. The doctor is given the
notes on a Friday afternoon as he is leaving for home. He decides to take the
notes home to extract the data. On the way home he stops at his favourite
supermarket.
When he emerges, his car has been stolen with the notes
inside. He reports the theft to the police.
He informs you, the Clinical Director, on the Monday when he
returns to work. What action will you take?
Scenario 23. You are the SpR for the delivery
unit. During a quiet moment you head for the staff room adjacent to the
operating theatre for a coffee. As you pass the anaesthetic room you hear loud
snoring. You look in and find the on-call anaesthetic registrar unconscious on
his back on the floor with an anaesthetic mask by his face attached to a
cylinder of nitrous oxide. What action will you take?
Option list.
|
A |
call for help |
|
B |
go back to the labour ward and pretend that nothing has
happened |
|
C |
go back to the labour ward and inform the senior
midwife |
|
D |
phone the GMC |
|
E |
phone the on-call consultant anaesthetist |
|
F |
phone the on-call consultant obstetrician |
|
G |
phone the police |
|
H |
put the anaesthetist in the recovery position and
remove the mask |
|
I |
none of the above |
Scenario 24. This is a follow-on from the previous station. What action will you take next?
Scenario 25. You are the Clinical Director. It is
the morning after the events in scenarios 22 and 23.
The on-call consultant obstetrician comes to see you and
reports what has happened.
What action will you take?
Option list.
|
A |
discuss the case with the Chief Executive |
|
B |
discuss the case with the Medical Defence Union |
|
C |
discuss the case with the BMA |
|
D |
discuss the case with the Medical Director |
|
E |
discuss the case with the most senior person in the
personnel department |
|
F |
discuss the case with the Postgraduate Dean |
|
G |
report the anaesthetic registrar to the GMC |
|
H |
resign from being Clinical Director to avoid stress |
|
I |
summon the anaesthetic registrar to give him a severe
telling-off |
48. EMQ. Listeriosis and pregnancy.
Lm: Listeria monocytogenes.
TOC: test of cure.
Scenario
4.
Which organism is
responsible for human listeriosis?
|
A |
Listeria diogenys |
|
B |
Listeria frigidaire |
|
C |
Listeria hominis |
|
D |
Listeria monocytogenes |
|
E |
Listeria xenophylus |
Scenario
5.
Which, if any, of
the following statements are true about Lm?
Option list.
|
A |
it is a small, Gram -ve rod |
|
B |
it is a Gram +ve coccus |
|
C |
it is flagellated |
|
D |
it has no cell wall |
|
E |
it is an obligate aerobe |
|
F |
it functions within host cells |
|
G |
it can easily be mistaken for commensal organisms |
|
H |
none of the above |
Scenario
6.
Which of the
following are associated with an increased risk of contracting LM?
|
A |
age > 60 years |
|
B |
age < 1 year |
|
C |
blond hair |
|
D |
pregnancy |
|
E |
strabismus |
Scenario 7.
Which of the
following are true of the susceptibility of pregnant women to Lm?
Option list.
|
A |
they are not more susceptible |
|
B |
they are more susceptible x 2 |
|
C |
they are more susceptible x 5 |
|
D |
they are more susceptible x 10 |
|
E |
they are more susceptible x 20 |
|
F |
they are > 20 times more susceptible |
|
G |
none of the above. |
Scenario
8.
When does Lm most
often occur?
Option list.
|
A |
1st. trimester |
|
B |
2nd. trimester |
|
C |
3rd trimester |
|
D |
1st. + 2nd. trimesters |
|
E |
2nd. + 3rd trimesters |
|
F |
all trimesters equally |
|
G |
puerperium |
|
H |
none of the above |
Scenario
9.
What is the
incubation period for Lm?.
Option list.
|
A |
7±3 days |
|
B |
7±5 days |
|
C |
10±3 days |
|
D |
10±5 days |
|
E |
14±3 days |
|
F |
14±5 days |
|
G |
none of the above. |
Scenario
10. What is the significance of Granulomatosis Infantisepticum
?
Option list.
|
A |
it is a
fabrication by the author and of no significance |
|
B |
it is
pathognomonic of Lm infection |
|
C |
it is the cause
of vertical transmission of Lm |
|
D |
I refuse to
answer Latin questions as they make me think of Boris Johnson |
|
E |
none of the above |
Scenario
11. Which of the following are accurate about cervico-vaginal
infection? This is not a true
EMQ as there may be >1 correct answer.
Option list.
|
A |
Lm is as often found in the cervix as in the bowel. |
|
B |
Lm is as often found in the vagina as in the bowel. |
|
C |
Lm is less often
found in the cervix than in the bowel. |
|
D |
Lm is less often
found in the vagina than in the bowel. |
|
E |
Lm is more often
found in the cervix than in the bowel. |
|
F |
Lm is more often
found in the cervix than in the bowel. |
|
G |
no one knows and no one cares |
Scenario
12.
A GP phones about
a primigravida at 28 weeks. She has possibly ingested food
contaminated by Lm. She is asymptomatic and afebrile. What
advice will you give?
Option list.
|
A |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 2 weeks |
|
B |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 4 weeks |
|
C |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 6 weeks |
|
D |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 8 weeks |
|
E |
prescribe appropriate antibiotic(s) for 7 days with
follow-up for TOC |
|
F |
prescribe appropriate antibiotic(s) for 7 days with
follow-up for TOC |
|
G |
prescribe appropriate antibiotic(s) for 7 days with
follow-up for TOC |
|
H |
admit to hospital for investigation and intensive
treatment if Lm infection found |
|
I |
none of the above |
Scenario
13. A GP phones about a primigravida at 28 weeks. She has
possibly ingested food
contaminated by Lm. She has mild symptoms but is afebrile.
What advice will you give?
Option list.
|
A |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 2 weeks |
|
B |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 4 weeks |
|
C |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 6 weeks |
|
D |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 8 weeks |
|
E |
prescribe appropriate antibiotic(s) for 7 days with
follow-up for TOC |
|
F |
prescribe appropriate antibiotic(s) for 7 days with
follow-up for TOC |
|
G |
prescribe appropriate antibiotic(s) for 7 days with
follow-up for TOC |
|
H |
admit to hospital for investigation and intensive
treatment if Lm infection found |
|
I |
none of the above |
Scenario
14. A GP phones about a primigravida at 28 weeks. She has
possibly ingested food
contaminated by Lm. She is symptomatic and her temperature
is 38.2oC. What advice will you give?
Option list.
|
A |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 2 weeks |
|
B |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 4 weeks |
|
C |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 6 weeks |
|
D |
reassure and advise her about avoiding exposure and to
reattend if she develops signs or symptoms within 8 weeks |
|
E |
prescribe appropriate antibiotic(s) for 7 days with
follow-up for TOC |
|
F |
prescribe appropriate antibiotic(s) for 7 days with
follow-up for TOC |
|
G |
prescribe appropriate antibiotic(s) for 7 days with
follow-up for TOC |
|
H |
admit to hospital for investigation and intensive
treatment if Lm infection found |
|
I |
none of the above |
Scenario
15. Which, if any, of the following would be appropriate for
consideration as 1st. line
treatment of Lm in pregnancy? This is not a true EMQ as
there may be more than 1 correct answer.
Option list.
|
A |
ampicillin |
|
B |
ampicillin + gentamycin |
|
C |
ampicillin + streptomycin |
|
D |
amoxicillin + clavulanic acid |
|
E |
clarithromycin |
|
F |
erythromycin |
|
G |
erythromycin + metronidazole |
|
H |
trimethoprim |
|
I |
none of the above |
Scenario
16. Is listeriosis a notifiable infection in the UK? Yes/No.
