Monday, 8 June 2015

Tutorial 8 June 2015

8 June 2015.


16
Mental Capacity Act
17
MgSO4 : what points might feature in the exam? SIP 29
18
EMQ. Early pregnancy complications. Diagnoses to exclude.
19
EMQ. Coroner. 1 - 3
20
SBA. Progestogen-only implants

16. Mental Capacity Act.
       This was on the list for Thursday, but we did not get time to discuss it. A number of people have     
        written to say they are having problems with it, so we had better discuss it .
Mental Capacity Act 2005.

Lead-in.
The following scenarios relate to the Mental Capacity Act 2005.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Abbreviations.
CAD:     Court-appointed Deputy.
COP:     Court of Protection.
FGR:      fetal growth restriction.
LPA:      Lasting Power of Attorney.
MCA:    Mental Capacity Act 2005.
PoA:      Power of Attorney.

Option list.
A.        Yes
B.         No
C.         True
D.        False
E.         Does not exist
F.         The husband
G.        A parent
H.        The child
I.           the General Practitioner
J.          the Consultant
K.         the Registrar
L.          The Consultant treating the patient
M.      A Consultant not involved in treating the patient
N.        The Medical Director
O.        A person with Powers of Attorney
P.         The sheriff or sheriff’s deputy
Q.        Balance of probabilities
R.         Beyond reasonable doubt
S.         None of the above.

Scenario 1.
A person with LPA is normally not a family member.
Scenario 2.
A Sheriff’s Deputy is normally not a family member.
Scenario 3.
A person with PoA can consent to treatment for the patient who lacks capacity.
Scenario 4.
A Court-appointed Deputy can consent to treatment for the patient who lacks capacity, but must go back to the Court of Protection if further consent is required for additional treatment.
Scenario 5.
A person with PoA can authorise withdrawal of all care except basic care in cases of individuals with persistent vegetative states.
Scenario 6.
An advance decision can authorise withdrawal of all but basic care in cases of persistent vegetative states.
Scenario 7
A person with PoA cannot overrule an advance direction about withdrawal or withholding of life-sustaining care.
Scenario 8
A woman is seen in the antenatal clinic at 39 weeks’ gestation. Her blood pressure is 180/110 and she has +++ of proteinuria on dipstick testing. She has mild epigastric pain. A scan shows evidence of FGR with the baby on the 2nd. centile. Doppler studies of the umbilical artery are abnormal and a non-stress CTG shows loss of variability and variable decelerations. She is advised that she appears to have severe pre-eclampsia and is at risk of eclampsia and of intracranial haemorrhage. She is told of the associated risk of mortality and morbidity. She is also advised that the baby is showing evidence of severe FGR and has abnormal Doppler studies and CTG which could lead to death or hypoxic damage. She declines admission or treatment. She says she trusts in God and wishes to leave her fate and that of her baby in His hands. She is seen by a psychiatrist who assesses her as competent under the MCA and with no evidence of mental disorder. The obstetrician wants to apply to the COP for an order for compulsory treatment. Can he do this?
Scenario 9
A woman is admitted at 36 weeks’ gestation with evidence of placental abruption. She is semi-comatose and shocked. There is active bleeding and the cervical os is closed. Fetal heart activity is present but with bradycardia and decelerations. The consultant decides that Caesarean section is the best option to save her live and that of the baby. When reading the notes, the registrar comes across an advance notice drawn up by the woman and her solicitor. It states that she does not wish Caesarean section, regardless of the risk to her and the baby. The consultant tells the registrar that they can ignore it now that she is no longer competent and get on with the Caesarean section for which she will be thankful afterwards. The registrar says that the advance notice is binding. Who is correct?
Scenario 10
An 8 year old girl is admitted with abdominal pain. Appendicitis is diagnosed with peritonitis and surgery is advised. The parents decline treatment on religious grounds. Can the consultant in charge overrule the parents and give consent?

17. MgSO4 : what points might feature in the exam? SIP 29
      Read SIP 29 and list the key facts you need to know.

18. EMQ. Early pregnancy complications. Diagnoses to exclude.
Lead-in.
The following scenarios relate to early pregnancy.
For each, select the diagnosis you most want to exclude.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Scenario 1.
A 35-year-old primigravida is seen in the EPU with vaginal bleeding and severe left iliac fossa pain. The pregnancy occurred after four cycles of IVF and embryo transfer was performed six weeks ago. Her β-hCG is >1,000 iu/l. An ultrasound scan showed an intra-uterine pregnancy of an appropriate size for the gestation. Normal fetal heart activity was noted. No adnexal masses were seen.
Scenario 2.
A 25-year-old woman with known PCOS is seen in the early pregnancy unit after an episode of slight vaginal bleeding. Her LMP was 10 weeks ago. An ultrasound scan shows an intra-uterine pregnancy with CRL of 6 mm. No fetal heart activity is seen.
Scenario 3.
A GP phones for advice. She is conducting her morning surgery. A nulliparous woman at 6 weeks’ gestation has returned from France where she has enjoyed the local food, particularly unpasteurised soft cheese and pork meats. She has presented with diarrhoea and mild abdominal pain. A β-hCG is 25 iu/l. She is concerned about listeriosis and toxoplasmosis, about which she has read.
Scenario 4.
A 30-year-old parous woman attends the EPU with vaginal bleeding and lower abdominal pain. An ultrasound scan shows a 30 mm. intra-uterine sac but no evidence of fetal heart activity.
Scenario 5.
 A 45-year-old para 6 is admitted to the A&E department with 6 weeks’ amenorrhoea. A β-hCG is positive. She complains of retrosternal pain and has a history of heartburn and acid reflux. Her BMI is 30. She smokes 40 cigarettes daily and has COAD.

Option list.
Complete miscarriage.
Incomplete miscarriage.
Missed miscarriage.
Pregnancy in a uterine horn.
Ectopic pregnancy.
OHSS.
Ovarian torsion.
Ovarian cyst accident.
Hydatidiform mole.
Listeriosis.
Toxoplasmosis.
Crohn’s disease
Ulcerative colitis.
Duodenal ulceration.
Pulmonary embolism.
Pneumothorax.
Coronary thrombosis.
None of the above.

19. EMQ. Coroner. 1 - 3
The Coroner. Question 1.

Lead-in.
The following scenarios relate to the role of the Coroner.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Suggested reading.
I will put all you need to know into the answer to MCQ Paper 13, question 5.

Option list.
A.        an independent judicial officer
B.         a barrister acting for the Local Police Authority
C.         the regional representative of the Home Office
D.        the regional representative of the Queen.
E.         an employee of the High Court.
F.         the Local Authority
G.        the Local Police Authority
H.        the Home Office
I.           the High Court
J.          the Queen

Scenario 1.
What is the best description of the status of the Coroner?
Scenario 2.
Who appoints the Coroner?
Scenario 3.
Who pays for the Coroner and the coronial service?

The Coroner. Question 2.

Lead-in.
The following scenarios relate to the role of the Coroner.
Pick one option from the option list.
Each option can be used once, more than once or not at all.

Option list.
A.        must have had experience as a detective in the police force with  rank of Inspector or above
B.         must be a barrister, lawyer or doctor with at least 5 years’ experience
C.         must be a legally qualified individual with at least 5 years’ experience
D.        must be a trained bereavement counsellor
E.         must be able to play the bagpipes
F.         Monday -  Friday; 09.00 - 17.00 hours, including bank holidays
G.        Monday - Friday; 09.00 - 17.00 hours, excluding bank holidays
H.        All the time
I.           to arrest people suspected of unlawful killing
J.          to manage traffic in the vicinity of the Coroner’s court
K.         to make enquiries on behalf of the Coroner
L.          to make enquiries on behalf of the Coroner and provide administrative support
M.      to play bagpipes at coronial funerals

Scenario 1.
What qualifications must the Coroner have?
Scenario 2.
What are the hours of availability of the Coroner?
Scenario 3.
What is the role of the Coroner’s Officers?

The Coroner. Question 3.
Lead-in.
The following scenarios relate to the role of the Coroner.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Option list.
A.        the death must be reported to the Coroner
B.         the death does not need to be reported to the Coroner
C.         the Coroner must order the return of the body for an inquest
D.        the Coroner must order a post-mortem examination
E.         the Coroner must hold an inquest
F.         the Coroner should arrange for the death to be investigated by the Home Office
G.        the death must be reported to the authorities of the country in which it took place in order that a certificate of death can be issued
H.        a certificate of live birth
I.           a certificate of stillbirth
J.          a certificate of miscarriage
K.         yes
L.          no
M.      none of the above
Scenario 1.
A resident of Manchester dies suddenly while visiting the town of his birth in Scotland. His family decides that he will be buried there. His body is held at the premises of a local funeral director. What actions should be taken with regard to the Manchester coroner?
Scenario 2.
A resident of London dies suddenly while visiting Manchester, where he was born. His family decides that he will be buried in Manchester. His body is held at the premises of a Manchester funeral director. What actions should be taken with regard to the Manchester coroner?
Scenario 3.
A resident of Manchester dies on holiday in his native Greece. The family decide that he will be buried in Greece. What steps must be taken to obtain a valid death certificate?
Scenario 4.
A man of 65 dies of terminal lung cancer. The GP visited daily until going on holiday three weeks before the death. He has now returned and says that he will sign a death certificate, but needs to visit the funeral director to see the body first.  Will this be a valid death certificate?
Scenario 5.
A man of 65 dies of terminal lung cancer. The GP, who visited daily up to the day of his death and attended to confirm the death, is on holiday. He says that he will sign a death certificate and put it in the post, so that it will arrive in the morning. Will this be a valid death certificate?
Scenario 6.
A man of 65 dies of terminal lung cancer. The GP, who visited daily up to the day before his death, has been on holiday since. However, he says that he will sign a death certificate and put it in the post, so that it will arrive in the morning. Will this be a valid death certificate?

Scenario 7.
A 65-year-old man dies suddenly 12 hours after admission to the local coronary care unit with chest pain, despite the apparently satisfactory insertion of a coronary artery stent after a diagnosis of coronary artery thrombosis. What action should be taken with regard to the Coroner?
Scenario 8.
A 16-year-old girl is admitted at 36 weeks’  gestation in her first pregnancy with placental abruption. She is given the best possible care but develops DIC and hypovolaemic shock and dies after 48 hours. What action should be taken with regard to the coroner?
Scenario 9.
A 28-year-old woman is admitted with placental abruption at 36 weeks. She has bruising on the abdominal wall and the admitting midwife suspects that she has been the victim of domestic violence, though the woman denies it. Despite best possible care she dies as a consequence of bleeding. What action should be taken with regard to the coroner?
Scenario 10.
A 30-year-old woman delivers normally at home attended by her husband, but has a PPH. The husband practises herbal medicine. He applies various potions but her condition deteriorates. She is admitted to hospital by emergency ambulance some hours later in a shocked condition. She is given the best possible care and is admitted to the ICU. She dies 7 days later of multi-organ failure and ARDS attributed to hypovolaemic shock. What action should be taken with regard to the coroner?
Scenario 11.
A woman is admitted at 23 weeks in premature labour. There is evidence of fetal heart activity throughout the labour, with the last record being 5 minutes before the baby delivers. The baby shows no evidence of life at birth. The mother requests a death certificate so that she can register the birth and arrange a funeral. What form of certificate should be issued?
Scenario 12.
A woman is admitted at 26 weeks’ gestation in premature labour. The presentation is footling breech. At 8 cm. cervical dilatation the trunk is delivered and the cord prolapses. There is good evidence of fetal life with fetal movements and pulsation of the cord. The head is trapped and it takes 5 minutes to deliver it. The baby is pulseless, apnoeic and without visible movement at birth. Intubation and CPR are carried out for 20 minutes when the baby is declared dead. What action should be taken with regard to the coroner?
Scenario 13.
A 65-year-old man dies 2 hours after admission to hospital with an apparent stroke. The coroner requests access to the notes. What access should be provided?
Option list.
A
provide access to the records by the Coroner in person
B
provide unrestricted access to the medical records by the coroner’s officers
C
provide a copy of the hospital records to the coroner or her officers
D
provide a medical report, but no access to the medical records
E
provide a copy of the letter to the GP about the recent admission
F
none of the above


20. SBA. Progestogen-only implants.
Progestogen-only Implants.

Abbreviations.
ENG:              etonorgestrel
LNG:              levonorgestrel

Question 1.
Lead-in
Pick the best option from the list below in relation to the hormone in Nexplanon.

Option List
  1.  
68 mg. ENG
  1.  
100 mg. ENG
  1.  
100 mg. LNG
  1.  
150 mg. LNG
  1.  
50 mg. ENG + 100 mg. LVG

Question 2.
Lead-in
How does Nexplanon act as a contraceptive?
  1. mainly by inducing anovulation
  2. mainly by altering cervical mucus to the detriment of sperm transport
  3. mainly by thinning the endometrium, preventing implantation
  4. mainly by inducing loss of libido
Choose the best option from the list below.

Option List
  1.  
I
  1.  
I + II
  1.  
I + III
  1.  
II + III
  1.  
III + IV

Question 3.
Lead-in
What is the age range, if any, for which Nexplanon is licensed in the UK?

Option List
  1.  
15 – 50 years
  1.  
18 – 40 years
  1.  
18 – 45 years
  1.  
20 – 50 years
  1.  
None of the above.

Question 4.
Lead-in
A woman who is not in the licensed age range requests a Nexplanon. How should the advising doctor proceed?

Option List
  1.  
Advise her about alternative licensed contraceptive methods, but decline to insert Nexplanon
  1.  
Advise her about alternative licensed contraceptive methods and insert Nexplanon
  1.  
Fit her with a LNGIUS
  1.  
Refer her to a colleague who fits anyone who asks with a Nexplanon
  1.  
None of the above

Question 5.
Lead-in
Which, if any, of the following statements about the pregnancy rate for women using Nexplanon are true?

Option List
  1.  
The pregnancy rate is < 1 per 1,000 women during 3 years of use
  1.  
The pregnancy rate is < 5 per 1,000 women during 3 years of use
  1.  
The pregnancy rate is < 10  per 1,000 women during 3 years of use
  1.  
The pregnancy rate is 10-20 per 1,000 women during 3 years of use
  1.  
None of the above

Question 6.
Lead-in
Which, if any, other implants are licensed in the UK?

Option List
  1.  
Implanon
  1.  
Norplant
  1.  
Norplant-2
  1.  
Jadelle
  1.  
None of the above

Question 7.
Lead-in
What are the main differences between Nexplanon and Implanon?
Pick the most suitable answer from the list below.

Option List
  1.  
The dosage was increased from 60 to 68 mg. etonorgestrel
  1.  
The dosage was increased from 150 – 175 mg. levonorgestrel
  1.  
Barium sulphate was added to Nexplanon to make it radio-opaque
  1.  
The number of rods was reduced to 2
  1.  
None of the above

Question 8.
Lead-in
What problems is the new applicator designed to minimise?
  1. non-insertion
  2. deep insertion
  3. difficulty with one-handed insertion
  4. difficulty with left-handed insertion
  5. difficulty with insertion in very thin women.


Option List
  1.  
I + II + III + IV
  1.  
I + II + III + IV + V
  1.  
II + III
  1.  
II + III + IV
  1.  
II + III + IV + V

Question 9.
Lead-in
How long is Nexplanon licensed for?

Option List
  1.  
1 year
  1.  
2 years
  1.  
3 years
  1.  
5 years
  1.  
10 years

Question 10.
Lead-in
What does NICE recommend that patients be told about bleeding patterns with Nexplanon?
  1. menstrual bleeding may cease
  2. menstrual bleeding may become prolonged
  3. bleeding may become more frequent
  4. menstrual bleeding may become less frequent
  5. intermenstrual bleeding can be a problem in the first 6 months

Option List
  1.  
I + II + III
  1.  
I + II + III + IV
  1.  
II + III + IV + V
  1.  
I + III + IV
  1.  
I + III + IV + V

Question 11.
Lead-in
What information should women be given about the effect of Nexplanon on pain?

Option List
  1.  
Dysmenorrhoea may increase
  1.  
Dysmenorrhoea may decrease
  1.  
Mittelschmerz is likely to cease
  1.  
Pain due to endometriosis is likely to decrease
  1.  
Dyspareunia is likely to be alleviated

Question 12.
Lead-in
A 25-year old nulliparous woman has been found to have a few spots of endometriosis in the pouch of Douglas at laparoscopy for pelvic pain. She wishes to avoid pregnancy for 5 years but then wishes to have two children. She has read an article suggesting that a progesterone-only implant provides high levels of contraceptive efficacy and good results in suppressing endometriosis. What advice will you give?

Option List
  1.  
Recommend a low-dose COC and tricycling as the best means of suppressing endometriosis plus providing effective contraception
  1.  
Recommend a low-dose COC taken continuously as the best means of suppressing endometriosis plus providing effective contraception
  1.  
Recommend Nexplanon as the best means of suppressing endometriosis plus providing effective contraception
  1.  
Recommend Depot-Provera as the best means of suppressing endometriosis plus providing effective contraception
  1.  
None of the above

Question 13.
Lead-in
When can a Nexplanon be inserted with no need for additional contraception  in a woman with regular menstrual cycles and no contraindication to its use?

Option List
  1.  
Up to and including day 3 of menstruation
  1.  
Up to and including day 5 of menstruation
  1.  
Up to and including day 7 of menstruation
  1.  
Never
  1.  
None of the above

Question 14.
Lead-in
A healthy 25 year-old-woman is recovering well from a normal delivery. She is not breastfeeding and wishes to start Nexplanon.

Option List
Pick the best statement from the list below.
  1.  
No additional contraception is needed if Nexplanon is inserted by day 7
  1.  
No additional contraception is needed if Nexplanon is inserted by day 14
  1.  
No additional contraception is needed if Nexplanon is inserted by day 21
  1.  
No additional contraception is needed if Nexplanon is inserted by day 28
  1.  
No additional contraception is needed if Nexplanon is inserted by day 42

Question 15.
Lead-in
A healthy 20-year-old woman wishes to switch from a COC to Nexplanon. What rules apply to the need for additional contraception?
  1. If insertion takes place on day 1 of the hormone-free week, no additional contraception is needed.
  2. If insertion takes place on day 5 of the hormone-free week, additional contraception is needed for 7 days.
  3. If insertion takes place in week 2 after the hormone-free week, no additional contraception is needed.
  4. If insertion takes place in week 3 after the hormone-free week, no additional contraception is needed.
Option List
  1.  
I
  1.  
I + II
  1.  
I + II + III
  1.  
II + III + IV
  1.  
I + II + III + IV

Question 16.
Lead-in
  1. Women switching from a POP to Nexplanon should be advised that additional contraception is required for 7 days.
  2. Women switching from a POP to Nexplanon should be advised that additional contraception is not required.
  3. Women switching from a LNGIUS to Nexplanon should be advised that additional contraception is required for 7 days.
  4. Women switching from a LNGIUS to Nexplanon, should be advised that additional contraception is not required.
Option List
  1.  
I + III
  1.  
I + IV
  1.  
II + III
  1.  
II + IV
  1.  
none of the above





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