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5 January 2015.
|
EMQ. Confidentiality
& Consent
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5
|
January
|
2015
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SBA. MBRRACE
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5
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January
|
2015
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SBA. NICE Clinical
Guideline 132. Caesarean
section.
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5
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January
|
2015
|
|
EMQ. COC. Starting
& missed pills.
|
5
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January
|
2015
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|
Communication
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5
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January
|
2015
|
26. Confidentiality.
Lead-in.
The following scenarios relate to confidentiality.
Option list.
This EMQ has not option list. This is to make you decide
your answers. Send them to me and I’ll send my version including what I think
an option list might have looked like.
Scenario 1.
A 15-year-old girl attends the
TOP clinic requesting TOP. She is assessed as Fraser competent. After full
discussion arrangements are made for her admission for TOP. She does not wish
her parents to be informed. Her mother attends clinic 1 hour after the child
has left. She demands full information about her daughter. The consultant has
delegated you to deal with her. Which option best fits the action you
will take?
Scenario 2.
A 17-year-old A-level student
attends the gynaecology clinic requesting TOP. She is accompanied by her
30-year-old mathematics teacher, who is her lover and wishes to give consent. Which
option best fits the action you will take?
Scenario 3.
A 12-year-old girl attends the
gynaecology clinic with her mother seeking contraceptive advice. She has an
18-year-old boyfriend whom the parents like and she wishes to start having sex.
Which option best fits the action you will take?
Scenario 4.
A 15-year-old girl who is Fraser competent is referred to
the gynaecology clinic with a complaint of vaginal discharge. She reveals that
she has been having consensual sexual intercourse for six months with her
18-year-old boyfriend. She asks for advice about suitable contraception as she
is happy in the relationship and wants to continue to have sex. Which option
best fits the action you will take?
Scenario 5.
You are the new oncology consultant and have just
operated on the wife of a local General Practitioner for suspected ovarian
cancer. The diagnosis is confirmed and you proceed with appropriate surgery. On
completion of the operation you go to the surgeon’s room for a coffee. The
senior consultant anaesthetist who was not involved in theatre but is the
Medical Director and tells you he is a close friend of the woman, asks what the
diagnosis and prognosis are. Which option best fits the action you will take?
Scenario 6.
You are phoned by a doctor
looking for information about his wife’s results from the booking clinic she
attended two weeks ago. He says that she has given consent for disclosure. She
has given a history of 2 terminations but no other pregnancies. She is Rhesus
negative, but has Rhesus antibodies. Which option best fits the action
you will take?
Scenario 7
You are phoned by a doctor
looking for information about his wife’s results from the booking clinic she
attended two weeks ago. He says that she has given consent for disclosure. Her
serology tests have proved +ve for syphilis. You have spoken to the consultant
bacteriologist who says that they have run confirmatory tests and they are +ve
too. He is sure the woman has active syphilis. Which option best fits
the action(s) you will take?
Scenario 8
A 15-year-old girl attends the
TOP clinic requesting TOP. She is assessed as Fraser competent. After full
discussion arrangements are made for her admission for TOP. She does not wish
her parents to be informed despite your best efforts to persuade her. Who will
give consent for the procedure?
Scenario 9
An immature 15-year-old girl
attends the gynaecology clinic requesting TOP. She is accompanied by her
25-year-old sister who is a lawyer with whom she has been staying since she
knew she was pregnant. She does not want her parents to be informed. The girl
is assessed as not Fraser competent. The sister says that she is happy to act
in loco parentis and to give consent. Which option best fits the
action(s) you will take?
Scenario 10
A 25-year-old woman with Down’s syndrome attends the
clinic accompanied by her mother. She has menorrhagia and copes badly with the
hygiene aspects. The menorrhagia is bad enough for her now to be on treatment
for iron-deficiency anaemia. She has tried all the standard medical methods. To
complicate the problem, she has become close friends with a young man she has
met at College, to which she travels independently each weekday. Her mother
fears that she may already be involved in sexual activity and cannot get an
accurate answer from her about it. The mother is keen for her to have
hysterectomy to deal with both problems. If you agree that the surgery is
appropriate, who can give consent?
Scenario 11
A 25-year-old woman with Down’s syndrome is admitted from
College after collapsing. The clinical features are of ectopic pregnancy and
she states that she has UPSI with her boyfriend of six months. She has
tachycardia and hypotension and it is felt that she should have urgent surgery.
You reckon that she is not competent to consent for surgery. Who can give
consent?
Scenario 12
A 25-year-old woman with Down’s syndrome is admitted from
College after collapsing. The clinical features are of ectopic pregnancy and
she states that she has UPSI with her boyfriend of six months. She has
tachycardia and hypotension and it is felt that she should have urgent surgery.
You reckon that she is not competent to consent for surgery. What limits are
there on the surgery?
Scenario 13.
You are the SpR on call and are asked to see a
10-year-old child in the A&E department. She has been brought because of
vaginal bleeding. She is accompanied by her parents who give a story of her
injuring herself falling of her bike. Examination shows vaginal bleeding and
you think the hymen looks torn. You suspect sexual abuse and don’t believe the
parents’ story. When this is discussed with the parents they say it is
impossible and that they do not want involvement of police or social workers. What
action will you take?
27. MBRRACE.
Lead-in.
The following scenarios relate to MBRRACE.
Option list.
There is none!
Scenario 1.
What is the meaning of the acronym MBRRACE-UK”?
Scenario 2.
Which organisation does it replace?
Scenario 3.
How does it differ structurally from its predecessor?
Scenario 4.
How will its reports differ from those of its predecessor?
Scenario 5.
When was its first Report published?
Scenario 6.
What geographical innovation was included in its first Report?
Scenario 7.
What was the latest MMR reported in its first Report?
Scenario 8.
How did this compare with the final MMR reported by CMACE?
Scenario 9.
Which topics were reviewed in detail in the first Report?
Scenario 10.
What was the leading direct cause of death in the first Report?
Scenario 11.
What was the leading indirect cause of death in the first Report?
Scenario 12.
What is the definition of a maternal death?
Scenario 13.
What is the
definition of a direct maternal death?
Scenario 14.
What is the
definition on indirect maternal death?
Scenario 15.
What observation was made in the first Report about deaths due to
hypertensive disease.
Scenario 16.
Which condition was linked to 1 in 11 maternal deaths?
Scenario 17.
What were the 5 top causes of direct maternal death in the years 2009 –
2011?
Scenario 18.
What key messages were singled out in the first Report?
28. SBA. NICE Clinical Guideline 132. Caesarean section.
Lead-in.
The following scenarios relate to Caesarean section.
Abbreviations.
Option list.
There is none, to make you think!
Scenarios.
1)
MPA is suspected on a routine 20 week scan
in a woman who has had two LSCSs. What advice should she be given in relation
to the value of colour Doppler US and MRI?
2)
What advice is
given about women who are infected with hepatitis B?
3)
What advice is
given about women who are infected with hepatitis C
4)
What advice is
given about women who are infected with HIV?
5)
What advice is given about women who are
infected with HIV + hepatitis B?
6)
What advice is
given about women who are infected with HIV + hepatitis C
7)
A woman with HIV
takes HAART and has a PVL < 50 copies per ml. She wishes Caesarean section
for non-obstetric reasons. She has been counselled and Caesarean section has
been agreed. At what gestation should it be done?
8)
What advice should
be given to the woman with HSV infection in pregnancy?
9)
What is the risk
of MTCT after primary HSV infection in the 3rd. trimester?
10)
A woman presents
with genital herpes at 36 weeks’ gestation in her first pregnancy. As far as
she is aware, this is her first episode of HSV infection. What is the chance
that it is a recurrent infection?
11)
A woman presents
with genital herpes at 36 weeks’ gestation in her third pregnancy. As far as
she is aware, this is her first episode of HSV infection. What is the chance
that it is a recurrent infection?
12)
A woman presents with genital herpes at 36
weeks’ gestation in her first pregnancy. As far as she is aware, this is her
first episode of HSV infection. What test should be done to clarify whether it
is a 1ry. or recurrent infection?
13)
A woman presents with genital herpes at 36
weeks’ gestation in her first pregnancy. As far as she is aware, this is her first
episode of HSV infection. Swabs are taken from the skin lesions and blood is
taken for HSV type-specific antibodies. She goes into labour at 38 weeks before
the results of the HSV type specific antibody tests are available. What advice
should be given re mode of delivery?
14)
A woman presents
with genital herpes at 36 weeks’ gestation in her first pregnancy. As far as
she is aware, this is her first episode of HSV infection. Swabs are taken from
the skin lesions and blood is taken for HSV type-specific antibodies and
confirm 1ry. infection. She goes into labour with intact membranes at
38 weeks and declines Cs. What action should be taken with regard to anti-viral
treatment?
15)
A woman presents
in labour at 38 week’s gestation, 2 weeks after a 1ry. infection
with genital HSV. She declines Caesarean section, but opts for antiviral
treatment for her and the baby. Which drug should be considered and in what
doses?
16)
A woman presents
in labour at 38 week’s gestation, 2 weeks after a 1ry. infection
with genital HSV. She had SRPM 6 hours before.
17)
A woman presents
in early labour at 38 weeks’ gestation. She has a history or recurrent genital
HSV. She has a typical herpetic blister on the vulva. What risk of neonatal
infection will you quote in the discussion?
18)
A woman presents
in labour at term with lesions and a history that are typical of 1ry.
genital HSV infection. Which invasive procedures, if any, should be avoided?
19)
A woman with a
history of recurrent genital herpes presents in labour at 40 weeks with a
typical vulval herpetic blister. Which invasive procedure, if any, should be avoided?
20)
A baby is born by
Caesarean section after maternal 1ry. genital herpes one month
before. Which, if any, of the following are appropriate.
Option
list.
A. liaise with the neonatal unit
B. normal postnatal care of the baby with examination at 24
hours, then discharge if well and feeding is established.
C. swabs of skin, conjunctiva, oropharynx and rectum for HSV
PCR
D. lumbar puncture for evidence of HSV
E. parents to be educated re good hand hygiene
F. i.v. acyclovir, 20 mg/kg 8 hourly until active infection is
ruled out.
G. strict infection control procedures should be put in place
for both mother and baby.
H. breastfeeding should be discouraged because of the presence
of HSV in breast milk.
I.
parents advised to
seek medical help if they have concerns, in particular, skin, eye or mucous
membrane lesions, lethargy, irritability or poor feeding
21)
A baby is born by
Caesarean section after maternal 1ry. genital herpes one month
before. Which, if any, of the following are appropriate.
Option list.
J.
liaise with the
neonatal unit
K.
normal postnatal care
of the baby with examination at 24 hours, then discharge if well and feeding is
established.
L.
swabs of skin,
conjunctiva, oropharynx and rectum for HSV PCR
M. lumbar puncture for evidence of HSV
N.
parents to be educated
re good hand hygiene
O. i.v. acyclovir, 20 mg/kg 8 hourly until active infection is
ruled out.
P.
strict infection
control procedures should be put in place for both mother and baby.
Q. breastfeeding should be discouraged because of the presence
of HSV in breast milk.
R.
parents advised to
seek medical help if they have concerns, in particular, skin, eye or mucous
membrane lesions, lethargy, irritability or poor feeding
22)
A baby is born by
Caesarean section after maternal 1ry. genital herpes one month
before. Which, if any, of the following are appropriate.
Option list.
S.
liaise with the
neonatal unit
T.
normal postnatal care
of the baby with examination at 24 hours, then discharge if well and feeding is
established.
U.
swabs of skin,
conjunctiva, oropharynx and rectum for HSV PCR
V.
lumbar puncture for
evidence of HSV
W. parents to be educated re good hand hygiene
X.
i.v. acyclovir, 20
mg/kg 8 hourly until active infection is ruled out.
Y.
strict infection
control procedures should be put in place for both mother and baby.
Z.
breastfeeding should
be discouraged because of the presence of HSV in breast milk.
AA. parents advised to seek medical help if they have concerns,
in particular, skin, eye or mucous membrane lesions, lethargy, irritability or
poor feeding
23)
What proportion of
neonatal HSV infection is thought to be due to infection after birth?
24)
What steps should
be taken to reduce the risk of neonatal HSV infection?
25)
A primigravida
attends for booking. She requests Caesarean section. There are no clinical
grounds. Outline your management.
26)
A woman with BMI
> 50 should be offered Caesarean section. True/ False.
27)
When should prophylactic
antibiotics in relation to the timing of the operation?
28)
A woman has had
her 3rd. Caesarean section. She wants to know the advice you would
give re the risks of subsequent vaginal delivery.
29) What are the key aspects of induction of general anaesthesia
for unplanned Cs?
30) What should be done about thromboprophylaxis for women
having Cs?
29. COC Missed pills.
Starting the Pill.
Lead-in.
The following scenarios relate to the combined oral
contraceptive (COC) and missed pills.
For each, select the option that best fits the scenario.
Each option can be used once, more than once or not at
all.
Abbreviations.
UPSI: unprotected
sexual intercourse.
Option list.
A.
pill that is ≥ 12
hours late.
B.
pill that is > 12
hours late.
C.
pill that is ≥ 24
hours late.
D.
pill that is > 24
hours late.
E.
two missed pills at
any time in a single cycle.
F.
the first pill taken
in one’s first love affair, now recalled with fond nostalgia for its
effectiveness in preventing pregnancy, the Prince having been truly a loathsome
toad.
G.
no additional
contraception required.
H.
additional
contraception required for 7 days.
I.
emergency
contraception should be considered.
J.
emergency
contraception should be recommended.
K.
take the missed pill
immediately, but not if it means 2 pills in one day; no additional
contraception needed; pill-free interval as normal.
L.
take the missed pill
immediately, even if it means 2 pills in one day; no additional contraception
needed; pill-free interval as normal.
M. take the missed pill immediately, even if it means 2 pills
in one day; additional contraception for 7 days; pill-free interval as usual.
N.
take one of the missed
pills immediately, discard the other missed pills, use extra contraception for
7 days and discuss emergency contraception with your doctor.
O.
take the missed pills
immediately, use extra contraception for 7 days and discuss emergency
contraception with your doctor.
P.
continuous combined
preparation.
Q.
bi-phasic preparation.
R.
quadriphasic
preparation.
S.
cannot be answered
from the data given.
T.
none of the above.
Scenario 1.
What is the definition of a
missed pill?
Scenario 2.
What is the definition of two
missed pills?
Scenario 3.
A COC is begun on day 1 of menstruation. What advice
should be given about temporary additional contraception?
Scenario 4.
A COC is begun 5 days after day 1 of menstruation. What
advice should be given about temporary additional contraception?
Scenario 5.
A COC is begun for the first time on day 1 of
menstruation. The fifth pill is missed. What advice should be given?
Scenario 6.
A pill is missed on day 14 of a
21-day pack. What advice should be given?
Scenario 7
A pill is missed on day 21 of a
21-day pack. What advice should be given?
Scenario 8
Two pills are missed in the
first week of a 21-day pack. What advice should be given?
Answer:
Scenario 9
Two pills are missed in the
second week of a 21-day pack. What advice should be given?
Scenario 10
Two pills are missed in the third week of a 21-day pack.
What advice should be given?
Scenario 11
What kind of preparation is
Qlaira?
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