Monday, 5 December 2016

Tutorial 5th. December 2016

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5 December 2016.

27
EMQ. Ulipristal
28
EMQ. COC. Starting and missed pills
29
EMQ. Headache
30
MgSO4 use in O&G. List all the points you think might get a mark in the exam. Think main headings for uses then key points for each. Think EMQ, SBA and viva.
31
SBA. Ovarian reserve

27.         EMQ. Ulipristal
Option list.
A
GnRH analogue.
B
Selective serotonin reuptake inhibitor.
C
19-nortestosterone derived progestagen.
D
21-hydroxyprogesterone-derived progestagen.
E
mifepristone derivative.
F
Selective oestrogen receptor modulator.
G
Selective progesterone receptor modulator.
H
Urinary excretion.
I
Metabolised by renal cytochrome P450 enzyme system.
J
Metabolised by hepatic cytochrome P450 enzyme system.
K
30 mg. with dose repeated if vomiting occurs within 3 hours.
L
100 mg. with dose repeated if vomiting occurs within 3 hours.
M
150 mg. with dose repeated if vomiting occurs within 3 hours.
N
phenobarbitone
O
valium
P
erythromycin
Q
12 hours.
R
18 hours.
S
32 hours.
T
72 hours.
U
120 hours.
V
Depot-contraception.
W
Depression.
X
Emergency contraception.
Y
Menorrhagia.
Z
Termination of pregnancy.
AA
Yes.
AB
No.
AC
Maybe.
AD
Continue.
AE
Discontinue for 36 hours.
AF
Discontinue for 72 hours.
AG
May interfere with contraception containing progestagen.
AH
May interfere with contraception containing oestrogen.
AI
No action if LARC being used.
Scenario 1.
What type of drug is ulipristal?

Scenario 2.
How is ulipristal broken down / excreted?
Scenario 3.
What is the half-life of ulipristal?
Scenario 4.
Which drug (erythromycin, phenobarbitone, Valium)  may prolong the half-life of ulipristal?
Scenario 5.
What is the main use of ulipristal?
Scenario 6.
What is the dose of ulipristal?
Scenario 7.
What time-scale applies to the licensed use of ulipristal?
Scenario 8.
What contraceptive advice is given to those using ulipristal?
Scenario 9.
What advice is given to women who are breast-feeding?
Scenario 10.
Can treatment with ulipristal be repeated within 1 month?
Scenario 11.
Which medical conditions are contraindications to ullipristal use ? – these are not on the option list.

28.         EMQ. COC Missed pills. Starting the Pill.
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?

29.         EMQ. Headache.
Option list.
1.       abdominal migraine
2.       analgesia overuse headache aka medication overuse headache
3.       bacterial meningitis
4.       benign intracranial hypertension
5.       BP check
6.       cerebral venous sinus thrombosis
7.       chest X-ray
8.       cluster headache
9.       severe PET / impending eclampsia
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 headache
23.   ultrasound scan of the abdomen
Scenario 1.
A 40-year-old para 3 is admitted at 38 weeks by ambulance with severe headache of sudden onset. She describes 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 headaches. They particularly occur at night without obvious triggers. They occur every few days.
Scenario 5.
A primigravida has had headaches 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 the headaches started soon after she began treatment with a drug prescribed by her GP. Which of the following drugs is most likely to be the culprit: methyldopa, methysergide, nifedipine and 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 and spinal  anaesthesia has the lower risk of causing dural tap headache?
Scenario 8
A 25-year-old primigravida complains of headaches which started two weeks before when she attends for her 20 week scan. There is no significant history of previous headache. 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.

30.         EMQ. MgSO4 use in O&G.
List all the points you think might get a mark in the exam. Think main headings for uses then key points for each. Think EMQ, SBA and viva.

31.         SBA. Ovarian reserve.
Abbreviations.
AFC:            antral follicle count
AMH:         anti-Mullerian hormone.
OR:             ovarian reserve.
Question 1.
Lead-in
What is the definition of ovarian reserve?
Option List
A.       
Sex-hormone-induced female shyness.
B.       
the number of functional oocytes per cubic centimetre of ovarian tissue
C.       
the number of oocytes per cubic centimetre of ovarian tissue
D.       
the number of remaining oocytes
E.        
the proportion of residual to primordial oocytes
Question 2.
Lead-in
What is the definition of the menopause?
Option List
A.       
the end of menstruation
B.       
the end of menstruation, but not if hysterectomy is the cause
C.       
the end of menstruation, but not if endometrial ablation is the cause
D.       
the time when periods become infrequent and finally cease
E.        
the climacteric
Question 3.
Lead-in
How many periods must be missed for the menopause to be diagnosed?
Option List
A.       
6
B.       
9
C.       
12
D.       
24
E.        
none of the above
Question 4.
Lead-in
What is the definition of the climacteric?
Option List
A.       
the same as “menopause”
B.       
the same as the “perimenopause”
C.       
the time from the start to the end of vasomotor symptoms
D.       
the time from the start of menopausal symptoms to one year after the LMP
E.        
I am never going to use this term again, so don’t ask me about it!
F.        
none of the above
Question 5.
Lead-in
What is the definition of premature menopause?
Option List
A.       
menopause occurring at an earlier age in successive generations
B.       
menopause occurring < 50 years
C.       
menopause occurring < 45 years
D.       
menopause occurring < 40 years
E.        
menopause occurring < 35 years
Question 6.
Lead-in
Which of the following conditions is not associated with premature menopause.
Conditions.
1.        
45XO/XX mosaicism
2.        
Fragile X pre-mutation carrier status
3.        
Fragile X full mutation carrier status
4.        
galactosaemia
5.        
Mayer – Rokitansky – Kuster - Hauser syndrome
6.        
Swyer’s syndrome.
Option List
A.       
1 + 2 + 4
B.       
1 + 2 +  4 + 5
C.       
1 + 2 + 4 + 6
D.       
1 + 3 + 4
E.        
3 + 4 + 5
F.        
 3 + 5 + 6
G.       
all of the conditions
H.       
some of the conditions, but I don’t know which
I.         
none of the conditions
Question 7.
Lead-in
A woman is a carrier of the Fragile X pre-mutation. What is her risk of premature ovarian failure?
Option List
A.       
5%
B.       
10%
C.       
15%
D.       
20%
E.        
25%
Question 8.
Lead-in
Where is FSH produced?
Option List
A.       
granulosa cells
B.       
hypothalamus
C.       
pineal gland
D.       
anterior pituitary
E.        
posterior pituitary
Question 9.
Lead-in
Where is LH produced?
Option List
A.       
granulosa cells
B.       
hypothalamus
C.       
pineal gland
D.       
anterior pituitary
E.        
posterior pituitary
Question 10.
Lead-in
Where is Inhibin A produced?
Option List
A.       
granulosa cells
B.       
granulosa cells of small developing follicles
C.       
granulosa cells of the dominant follicle and corpus luteum
D.       
ovarian stroma
E.        
adrenal gland
Question 11.
Lead-in
Where is Inhibin B produced?
Option List
A.       
granulosa cells
B.       
granulosa cells of small developing follicles
C.       
granulosa cells of the dominant follicle and corpus luteum
D.       
ovarian stroma
E.        
adrenal gland
Question 12.
Lead-in
Where is AMH produced?
Option List
A.       
granulosa cells
B.       
granulosa cells of small antral follicles
C.       
granulosa cells of the pre-antral follicles
D.       
dominant follicle and corpus luteum
E.        
ovarian stroma
Question 13.
Lead-in
Which if any of the following statements are true?
Statements.
1.        
AFC is based on antral follicles up to 2 mm in diameter
2.        
AFC is based on antral follicles up to 5 mm in diameter
3.        
AFC is based on antral follicles up to 10 mm in diameter
4.        
AFC is of proven superiority to AMH assay in assessing OR
5.        
AFC + AMH assay is a superior test to AMH assay alone in assessing OR
Option List
A.       
1 + 5
B.       
2 + 5
C.       
3 + 5
D.       
4
E.        
4 + 5
F.        
none of the above
Question 14.
Lead-in
Which is the best test to measure ovarian reserve?
Option List
A.       
early follicular FSH levels
B.       
luteal follicular FSH levels
C.       
early follicular-phase FSH + LH levels
D.       
early follicular-phase AMH levels
E.        
early follicular-phase AFC
F.        
none of the above







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