|
62 |
EMQ. Headache |
|
63 |
Role-play. You are called to A&E. Further details on the night. |
|
Structured
conversation. Topic with
which you should be familiar |
|
|
65 |
SBA. Lynch syndrome |
62. EMQ. Headache.
|
1 |
abdominal migraine |
|
2 |
analgesia overuse, aka medication overuse |
|
3 |
bacterial meningitis |
|
4 |
benign intracranial hypertension |
|
5 |
BP check |
|
6 |
cerebral venous sinus thrombosis |
|
7 |
chest X-ray |
|
8 |
cluster |
|
9 |
impending eclampsia / severe PET |
|
10 |
malaria |
|
11 |
meningococcal meningitis |
|
12 |
methyldopa |
|
13 |
methysergide |
|
14 |
migraine |
|
15 |
MRI brain scan |
|
16 |
nifedipine |
|
17 |
nitrofurantoin |
|
18 |
pancreatitis |
|
19 |
sinusitis |
|
20 |
subdural haematoma |
|
21 |
subarachnoid haemorrhage |
|
22 |
tension |
|
23 |
ultrasound scan of the abdomen |
Scenario 1. A 405-year-old para 3 is admitted at 38 weeks by ambulance
with severe headache of sudden onset. She
d6escribes it as “the worst I’ve ever had”. Which diagnosis needs to be
excluded urgently?
Scenario 2. A 32-year-old para 1 has recently experienced headaches. They are worse on exercise, even mild exercise such as
walking up stairs. She experiences photophobia with the headaches. Which is the most likely diagnosis?
Scenario 3. A woman returns from a sub-Saharan area of Africa. She
develops severe headache, fever and rigors.
What diagnosis should particularly be in the minds of the attending doctors?
Scenario 4. A
woman at 37 weeks has s. They particularly occur at night without obvious
triggers. They occur every few days.
Scenario 5. A
primigravida has had s on a regular basis for many years. They occur most days,
are bilateral and are worse when she is stressed. What is the most likely
diagnosis?
Scenario 6. A woman complains of recent headaches at 36 weeks. The history reveals that they started soon
after she began treatment with a drug prescribed by her GP. Which is the most
likely of the following drugs to be the culprit: methyldopa, methysergide, nifedipine
or nitrofurantoin?
Scenario 7. A woman is booked for Caesarean section and wishes regional
anaesthesia. She had severe headache due to dural tap after a previous
Caesarean section. She wants to take all possible steps to reduce the risk of
having this again. Which of epidural / spinal anaesthesia has the lower risk of
causing dural tap?
Scenario 8. A 25-year-old primigravida attends for her 20-week scan and
complains of headache which started two weeks before. There is no significant
history. The pain occurs behind her right eye and she describes it as severe
and “stabbing” in nature. The pain is so severe that she cannot sit still and
has to walk about. She has noticed that her right eye becomes reddened and
“watery” during the attack and her nose is “runny”. The attacks have no obvious
trigger and mostly occur a few hours after she has gone to sleep. The usually
last about 20 minutes. She has no other symptoms. She smokes 20 cigarettes a
day but does not take any other drugs, legal or otherwise. What is the most
likely diagnosis?
Scenario 9. A woman has a 5-year history of unilateral, throbbing
headache often preceded by nausea, visual disturbances, photophobia and
sensitivity to loud noise. What is the most likely diagnosis?
Scenario 10. A
primigravida is admitted at 38 weeks complaining of headache, abdominal pain
and a sensation of flashing lights. What would be the appropriate initial
investigation?
Scenario 11. A
woman with BMI of 35 attends for her combined Downs syndrome screening test.
She complains of pain behind her eyes. The pain is worst last thing at night
before she goes to sleep or if she has to get up in the night. She has noticed
she has noticed horizontal diplopia on several occasions. She has no other
symptoms. Examination shows papilloedema.
Scenario 12. A
grande multip of 40 years experienced sudden-onset, severe headache, vomited
several times and then collapsed, all within the space of 30 minutes. She is
admitted urgently in a semi-comatose state. Examination shows neck-stiffness
and left hemi-paresis.
Scenario 13. What did the MMR include as “red flags” for headache in pregnancy? These are not on the option list – you need
to dig them out of your head.
Option list.
|
A |
asthma |
↔ |
↑ |
↓ |
|
B |
developmental dysplasia of the hip in child |
↔ |
↑ |
↓ |
|
C |
diabetes |
↔ |
↑ |
↓ |
|
D |
Down’s syndrome in child |
↔ |
↑ |
↓ |
|
E |
hypertension |
↔ |
↑ |
↓ |
|
F |
ischaemic heart disease |
↔ |
↑ |
↓ |
|
G |
PET |
↔ |
↑ |
↓ |
|
H |
stroke |
↔ |
↑ |
↓ |
Scenario 15.
Which of the following drugs is
contraindicated in the prophylaxis of migraine in pregnancy?
Option list.
|
A |
amitriptyline
|
|
B |
ß-blockers |
|
C |
ergotamine |
|
D |
low-dose aspirin |
|
E |
pizotifen |
|
F |
pregabalin |
|
G |
tricyclic antidepressants |
|
H |
verapamil |
Scenario 16. Which, if any, of the following
statements is true about posterior reversible encephalopathy syndrome. This is
not a true EMQ as there may be > 1 true answer.
Option list.
|
A |
‘thunderclap’ headache is typical |
|
B |
‘handclap’ headache is typical |
|
C |
classically occurs in the early puerperium
and is recurrent |
|
D |
classically occurs in the early puerperium
and is not recurrent |
|
E |
arterial beading is typically seen on MRI |
|
F |
arterial beating is typically seen on MRI |
|
G |
arterial bleeding is typically seen on MRI |
|
H |
venous beading is typically seen on MRI |
|
I |
venous beating is typically seen on MRI |
|
J |
venous bleeding is typically seen on MRI |
|
K |
diagnosis requires lumbar puncture and
evidence of ↑
CSF pressure |
|
L |
treatment is with nimodipine |
Scenario 17. Which, if any, of the following
statements is true about reversible cerebral vasoconstriction syndrome. This is
not a true EMQ as there may be > 1 true answer.
Option list.
|
A |
‘thunderclap’ headache is typical |
|
B |
‘handclap’ headache is typical |
|
C |
classically occurs in the early puerperium
and is recurrent |
|
D |
classically occurs in the early puerperium
and is not recurrent |
|
E |
arterial beading is typically seen on MRI |
|
F |
arterial beating is typically seen on MRI |
|
G |
arterial bleeding is typically seen on MRI |
|
H |
venous beading is typically seen on MRI |
|
I |
venous beating is typically seen on MRI |
|
J |
venous bleeding is typically seen on MRI |
|
K |
diagnosis requires lumbar puncture and
evidence of ↑
CSF pressure |
|
L |
treatment is with nimodipine |
Questions from TOG article by Revell & Moorish. 2014. They
are open access.
Red flag features
for headaches include:
1. headache
that changes with posture True / False
2. associated
vomiting True / False
3. occipital
location True / False
4. associated
visual disturbance. True / False
Migraine is
classically,
5. bilateral.
True / False
6. pulsating.
True / False
7. aggravated
by physical exercise. True / False
With regard to
migraine headaches in pregnancy,
8. there
is an increase in the frequency of attacks without aura. True / False
9. women
who suffer from this have not been shown to have an increase in the risk of
pre-eclampsia. True / False
10. the
5HT1-receptor sumatriptan has been shown to be teratogenic. True / False
11. women
presenting with an aura for the first time are not at an increased risk of
intracranial disease. True / False
Posterior reversible
encephalopathy syndrome,
12. is
associated with an impairment of the autoregulatory mechanism which maintains
constant cerebral blood flow where there are blood pressure fluctuations. True / False
13. when
it is associated with pre-eclampsia, management should follow the pathway for
managing severe pre-eclampsia. True / False
With regard to
cerebral venous thrombosis,
14. the
incidence in western countries in pregnancy ranges from 1 in 2500 deliveries to
1 in 10 000 deliveries. True / False
15.
the greatest risk in pregnancy is mainly in the last four weeks. True / False
16. the
most common site is the sagittal sinus. True / False
17. a
plain computed tomography is a highly sensitive investigation. True / False
18. T2-weighted
magnetic resonance imaging has been shown to have limited value in diagnosis.
True / False
19. the
outcome is better when it is associated with pregnancy and the puerperium
compared to that occurring outside pregnancy. True / False
20. when
it occurs in pregnancy, it is a contraindication for future pregnancies. True / False
63. Role-play. You are called to A&E. Further
details given on the night.
64.
Structured conversation. Topic with which you should be familiar.
The examiner
will ask a series of questions.
65. SBA.
Lynch syndrome.
Abbreviations
CRC: colorectal
cancer.
EC: endometrial
cancer.
IBD: inflammatory
bowel disease: Crohn’s & ulcerative colitis.
IDDM: insulin-dependent
diabetes mellitus.
Ls: Lynch
syndrome.
MLH: mutL-homolog
family of DNA, mismatch repair genes.
MMR: mismatch
repair.
MSH: mutS
homolog family of DNA, mismatch repair genes.
Question 1.
What is Lynch syndrome?
Option List
|
A |
auto-immune
condition leading to reduced factor X levels in blood |
|
B |
hereditary condition which increases the risk of many
cancers, particularly breast |
|
C |
hereditary
condition which increases the risk of many cancers, particularly breast &
colorectal |
|
D |
hereditary
condition which increases the risk of many cancers, particularly colorectal
& endometrial |
|
E |
none of
the above |
Question 2.
How is Lynch syndrome inherited?
Option List
|
A |
it is an
autosomal dominant condition |
|
B |
it is an autosomal recessive condition |
|
C |
it is an X-linked dominant condition |
|
D |
it is an X-linked recessive condition |
|
E |
none of the above |
Question 3.
Which, if any, of the following genes can cause Lynch syndrome?
Option List
|
A |
MLH1 +
MLH2 + MOH1 |
|
B |
MLH1 + MLH2 + MSH1 |
|
C |
MLH1 + MLH2 + MSH6 |
|
D |
MLH1 + MSH2 + MSH6 |
|
E |
None of the above |
Question 4.
Mutations of which 2 of the following genes cause most cases of Lynch
syndrome?
Option List
|
A |
MLH1 +
MLH2 |
|
B |
MLH1 + MSH1 |
|
C |
MLH1 + MSH2 |
|
D |
MLH2 + MSH1 |
|
E |
MLH2 + MSH2 |
Question 5.
What is the approximate prevalence of Ls in the UK population?
Option List
|
A |
1 in 50 |
|
B |
1 in 100 |
|
C |
1 in
1,000 |
|
D |
3 in
1,000 |
|
E |
none of the above |
Question 6.
Approximately what % of individuals with Ls have had the diagnosis
established?
Option List
|
A |
< 5% |
|
B |
5 -10% |
|
C |
10-20% |
|
D |
20-30% |
|
E |
>30% |
Question 7.
Which, if any, of the following conditions are associated with an ↑
risk of Ls?
Option List
|
A |
acromegaly
+ Addison’s disease + coeliac disease + IBD + IDDM |
|
B |
acromegaly
+ disease + anosmia + coeliac disease + IBD |
|
C |
acromegaly
+ IBD + IDDM |
|
D |
acromegaly
+ IBD |
|
E |
Addison’s
disease + anosmia + coeliac disease + IBD + IDDM |
|
F |
acromegaly
+ Addison’s disease + anosmia + coeliac disease + IBD + IDDM |
|
G |
none of the above |
Question 8.
Which 2 cancers are most likely in women with Lynch syndrome?
Option List
|
A |
breast +
bowel |
|
B |
breast + pancreas |
|
C |
breast + endometrium |
|
D |
bowel + cervix |
|
E |
bowel + endometrium |
|
F |
bowel + ovary |
|
G |
bowel + pancreas |
|
H |
endometrium + ovary |
Question 9.
What does NICE recommend about screening for Lynch syndrome for the
population
with no
personal history of colorectal cancer?
Option List
|
A |
offer screening to those aged < 50 years with ≥ 1 affected 1st.O
relative |
|
B |
offer screening to those aged < 60 years with ≥ 1
affected 1st.O relative |
|
C |
offer screening to those with ≥ 1 affected 1st.O
relative aged < 50 years at diagnosis |
|
D |
offer screening to those with ≥ 1 affected 1st.O
relative aged < 60 years at diagnosis |
|
E |
none of the above |
Question 10.
What does NICE recommend in relation to screening for Lynch syndrome in
those with
a new
diagnosis of colorectal cancer?
Option List
|
A |
offer
screening to everyone, regardless of age and family history |
|
B |
offer screening to those aged < 50 years at diagnosis |
|
C |
offer screening to those aged < 60 years at
diagnosis |
|
D |
offer screening to those aged < 50 years at
diagnosis with + ≥ 1 affected 1st.O relative |
|
E |
offer screening to those aged < 60 years at
diagnosis with + ≥ 1 affected 1st.O relative |
Question 11.
What does NICE recommend about screening for Lynch syndrome for the
population
with no
personal history of thyroid cancer?
Option List
|
A |
offer screening to those aged < 50 years with ≥ 1 affected 1st.O
relative |
|
B |
offer screening to those aged < 60 years with ≥ 1
affected 1st.O relative |
|
C |
offer screening to those with ≥ 1 affected 1st.O
relative aged < 50 years at diagnosis |
|
D |
offer screening to those with ≥ 1 affected 1st.O
relative aged < 60 years at diagnosis |
|
E |
none of the above |
Question 12.
What does NICE recommend in relation to screening for Lynch syndrome in
those
with a new
diagnosis of thyroid cancer?
Option List
|
A |
offer
screening to everyone, regardless of age and family history |
|
B |
offer screening to those aged < 50 years at
diagnosis |
|
C |
offer screening to those aged < 60 years at
diagnosis |
|
D |
offer screening to those aged < 50 years at
diagnosis with + ≥ 1 affected 1st.O relative |
|
E |
none of the above |
Question 13.
What does NICE recommend about screening for Lynch syndrome for the population
with no personal history of endometrial
cancer?
Option List
|
A |
offer screening to those aged < 50 years with ≥ 1 affected 1st.O
relative |
|
B |
offer screening to those aged < 60 years with ≥ 1
affected 1st.O relative |
|
C |
offer screening to those with ≥ 1 affected 1st.O
relative aged < 50 years at diagnosis |
|
D |
offer screening to those with ≥ 1 affected 1st.O
relative aged < 60 years at diagnosis |
|
E |
none of the above |
Question 14.
What does NICE recommend in relation to screening for Lynch syndrome in
those with
a new
diagnosis of endometrial cancer?
Option List
|
A |
offer screening to those aged < 50 years with ≥ 1 affected 1st.O
relative |
|
B |
offer screening to those aged < 60 years with ≥ 1
affected 1st.O relative |
|
C |
offer screening to those with ≥ 1 affected 1st.O
relative aged < 50 years at diagnosis |
|
D |
offer screening to those with ≥ 1 affected 1st.O
relative aged < 60 years at diagnosis |
|
E |
none of the above |
Question 15.
What does NICE recommend about screening for Lynch syndrome for the
population
with no
personal history of colorectal cancer?
Option List
|
A |
offer screening to those aged < 50 years with ≥ 1 affected 1st.O
relative |
|
B |
offer screening to those aged < 60 years with ≥ 1
affected 1st.O relative |
|
C |
offer screening to those with ≥ 1 affected 1st.O
relative aged < 50 years at diagnosis |
|
D |
offer screening to those with ≥ 1 affected 1st.O
relative aged < 60 years at diagnosis |
|
E |
none of the above |
Question 16.
What does NICE recommend in relation to screening for Lynch syndrome in
those with
a new
diagnosis of colorectal cancer?
Option List
|
A |
offer
screening to everyone, regardless of age and family history |
|
B |
offer screening to those aged < 50 years at diagnosis |
|
C |
offer screening to those aged < 60 years at
diagnosis |
|
D |
offer screening to those aged < 50 years at
diagnosis with + ≥ 1 affected 1st.O relative |
|
E |
offer screening to those aged < 60 years at
diagnosis with + ≥ 1 affected 1st.O relative |
Question 17.
What relationship, if any, exists between Ls and acromegaly?
Option List
|
A |
the risk
of Ls is ↓
in those with acromegaly compared with the general population |
|
B |
the risk
of Ls is ↑
in those with acromegaly compared with the general population |
|
C |
the risk
of Ls is unchanged in those with acromegaly compared with the general
population |
|
D |
the risk
of Ls in unknown in those with acromegaly |
|
E |
|
Question 18.
What is the effect of aspirin consumption on the risk of EC and CRC?
Option List
|
A |
aspirin
reduces the risk of EC and CRC |
|
B |
aspirin
reduces the risk of EC but not CRC |
|
C |
aspirin
reduces the risk of CRC but not EC |
|
D |
aspirin
does not reduce the risk of EC or CRC |
|
E |
aspirin reduces the risk of EC and CRC, but the risks
outweigh the benefits |
Question 19.
A healthy woman of 35 years is diagnosed with Ls? What are the key
elements of the
National
Screening Programme for people with Ls?
There is
no option list – just write down everything you know.
Question
20. Which, if any, of the following were
recommendations made by Monahan et al, the 30
experts who wrote to the BMJ in 2017.
Option List
|
A |
creation of a national register of
people with Ls |
|
B |
creation of a
post of Consultant in Ls for each NHS Trust |
|
C |
creation of a
post of Clinical Champion for Ls in each NHS Region. |
|
D |
creation of a
post of Clinical Champion for Ls in the DOH. |
|
E |
none of the
above |
With regard to Lynch
syndrome,
1. loss of mismatch repair protein expression
on immunohistochemistry of cancer is diagnostic.
True/False
2. most carriers of the mutation associated
with the syndrome know they have the condition.
True/False
3. the first cancers associated with the
syndrome are predominantly endometrial or ovarian cancers. True/False
4. when cancers occur, they have in them an unusually
high immune infiltrate. True/False
With regard to testing for Lynch syndrome,
5. consent must be sought before definitive germline
testing for Lynch syndrome by a trained professional. True/False
6. immunohistochemical staining of tumours for
the mismatch repair proteins or microsatellite instability analysis are recognised
ways of screening cancers for characteristics suggestive of the syndrome. True/False
7. the National Institute for Health and Care Excellence
endorses universal screening of colorectal cancer patients for Lynch syndrome. True/False
8. most gynaecological cancers found to have aberrant
mismatch repair immunohistochemical staining will be in those with the
syndrome. True/False
9. the addition of MLH1 promotor hypermethylation
testing in a Lynch syndrome diagnostic pathway improves specificity. True/False
Regarding gynaecological surveillance in women with Lynch
syndrome,
10. there is strong evidence to recommend its use.
True/False
11. this should be offered to women around 25 years
of age. True/False
12. counselling should include education on red flag
symptoms of cancer and risk-reducing surgery.
True/False
With regard to risk-reducing strategies for women with Lynch
syndrome,
13. hysterectomy is strongly recommended for all those
with the syndrome. True/False
14. the timing of risk-reducing surgery depends on
the syndrome gene. True/False
15. where possible, a laparoscopic approach is
recommended. True/False
16. aspirin is not recommended as a means of reducing
their overall cancer risk. True/False
Regarding Lynch syndrome-associated gynaecological
cancers,
17. endometrial types that arise as a result of
the syndrome have a poorer prognosis than sporadic types. True/False
18. checkpoint inhibition of the PD-1/PD-L1 pathway
has been shown to be very effective in mismatch repair-deficient cancers. True/False
19. vaccination against these cancers is currently
the focus of research. True/False
20. the Manchester International Consensus guideline
is a useful reference for gynaecologists managing women with these cancers. True/False
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