Tutorial 3 July 2014

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We had the role-play to make you realise that the sooner you start to work on your communication skills the better. if you are in the UK, use every contact with a patient as an exam pratice. If you are not in the UK, you need to get together with other exam candidate and start to practise, though not so much that you don't pass the written!

8	EMQ. Hepatitis B.
27	You have been asked to give a lecture on the Mental Capacity Act 2005 to the junior staff of the department of O&G using illustrative examples. 1. What is the Court of Protection and what does it do?      6 marks 2. Describe the types of cases you will use and the key points you will make.  14 marks.
28	With regard to fetal welfare in labour. 1. Critically evaluate the methods available for monitoring the fetal condition.       14 marks 2. List the criteria recommended by NICE for continuous electronic fetal monitoring.  6 marks
29	Critically evaluate recent trends in the management of the 3rd. stage and its complications.
30	With regard to MBRRACE. 1. What is MBRRACE?                                                  2 marks 2. What is the role of MBRRACE?                              4 marks 3. How will MBRRACE differ from its precursor?   14 marks
3	Roleplay. PMB. Take a history and explain the initial investigation. See GP referral letter.

A 55 year old woman is referred by her General Practitioner.

Candidate’s Instructions.

You are an SpR in the “one-stop” PMB clinic. You are about to see a woman with bleeding some years since her menopause.

Your task is to take an appropriate history and advise her about the investigations you feel are appropriate.

Referral letter from the General Practitioner.

Manor Lodge,

High Street,

Bestown.

BE5 S00

Re: Mrs. Mary Smith,

5b High Street,

Bestown.

BE5 SO1

Dear Doctor,

Please see Mrs. Smith who has had postmenopausal bleeding.

Yours sincerely,

James Fewords,

General Practitioner.

Roleplayer’s instructions

You are Mary Smith. You had an episode of vaginal bleeding one week ago. It was bright red, slight in amount, but enough for you to wear a pad. It lasted for 4 hours. There was no provocative factor. It has not recurred.

You are 55 years of age. You reached the menopause at age 51. You have not taken HRT.

You health is good apart from type II diabetes which is well-controlled on diet. You have not had any major illness or operation. You are not taking any medicines.

You have two children. The pregnancies and deliveries were normal. The babies weighed 3 and 3.2 kg., were normal and are alive and well.

You have one sister. She is 5 years younger and has had bowel cancer. There is a history of bowel cancer in some of your father’s relatives, but you are not sure of the details. Your father died 10 years ago of a stroke at the age of 70 and you are out of touch with that side of the family. Your mother is alive and well, apart from Alzheimer’s disease at the age of 85.

Don’t provide information unless requested.

You are anxious because a close friend had an episode of PMB a few years ago, was found to have ovarian cancer and was dead within 3 months.

Hepatitis B and pregnancy.

Lead-in.

Each of the following scenarios relates to hepatitis B and pregnancy.

Instructions.

For each scenario, select the most appropriate option from the option list.

Each option can be used once, more than once or not at all.

Abbreviations.

HBcAg:  hepatitis B core antigen

HBeAg: hepatitis B e antigen      

HBsAg:  hepatitis B surface antigen

HBcAb: antibody to hepatitis B core antigen

HBeAb: antibody to hepatitis B e antigen

HBsAb: antibody to hepatitis B surface antigen

HBIG:    hepatitis B immunoglobulin

HBV:      hepatitis B virus

Option list.

A.      acyclovir

B.      divorce

C.      HBcAg +ve

D.      HBeAg +ve

E.       HbsAg +ve

F.       HBsAg +ve; HBsAb –ve; HBcAb -ve

G.     HBsAg +ve; HBsAb –ve on two tests six months apart

H.      HBsAG –ve; HBsAb -ve on two tests six months apart

I.        HBsAg –ve; HBsAb +ve; HBcAb –ve

J.        HBsAg –ve; HBsAb +ve; HBcAb +ve

K.      HBsAg –ve; HBsAb +ve

L.       HBsAg +ve; HBcAg +ve

M.    HBV vaccine.

N.     HBIG

O.     HBV vaccine + HBIG

P.      immune as a result of infection

Q.     immune as a result of vaccination

R.      not immune

S.       chronic carrier of HBV infection

T.       10%

U.     30%

V.      50%

W.    60%

X.      70 - 90%

Y.       soap and boiling water

Z.       10% dilution of bleach in water

AA. 10% dilution of formaldehyde in alcohol

BB.  ultraviolet irradiation

CC.  yes

DD. no

EE.   none of the above

Scenario 1.

An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 4 months ago. What results on routine blood testing would indicate that she has an acute infection?

Scenario 2.

An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 4 months ago. What results on routine blood testing would indicate that she is immune to the HBV as a result of natural infection?

Scenario 3.

An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 4 months ago. What results on routine blood testing would indicate that she is immune to the HBV as a result of HBV vaccine?

Scenario 4.

An asymptomatic primigravida books at 10 weeks. Her partner had an acute HBV infection 6 months ago. What results on routine blood testing would indicate that she is a chronic carrier of HBV infection?

Scenario 5.

Testing shows that he is positive for HBsAg, positive for HBcAb but negative for IgM HBcAb. What does this mean in relation to his HBV status?

Scenario 6.

Testing shows that he is negative for HBsAg, positive for HBcAb and positive for HBsAb.

What does this mean in relation to his HBV status?

Scenario 7

A primigravid woman at 8 weeks gestation is found to be non-immune to the HBV. She has recently married and her husband is a chronic carrier. What should be done to protect her from infection?

Scenario 8

A woman is a known carrier of Hepatitis B. What is the risk of vertical transmission in the first trimester?

Scenario 9

A woman is a known carrier of Hepatitis B. What is the risk of the neonate who has been infected by vertical transmission in the third trimester becoming a carrier without treatment?

Scenario 10

How effective is hepatitis B prophylaxis in preventing chronic carrier status developing in a neonate infected as a result of vertical transmission?

Scenario 11

Can a woman who is a chronic HBV carrier breastfeed safely?

Scenario 12.

Hepatitis B infection is the most dangerous of the viral hepatitis infections in pregnancy.

Scenario 13.

A pregnant woman who is not immune to HBV has a partner who is a chronic carrier. Can HBV vaccine be administered safely in pregnancy?

Scenario 14.

A pregnant woman who is not immune has a partner with acute hepatitis due to HBV. He cuts his hand and bleeds onto the kitchen table. How should she clean the surface to ensure that she gets rid of the virus?

Scenario 15.

Is it true that the presence of HBeAg in maternal blood is a particular risk factor for vertical transmission? Not really a scenario, but never mind!

Tutorial 30 June 2014

 

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30 June 2014

7	EMQ. Ulipristal.	30	June	2014
2	A nulliparous woman of 30 years attends for pre-pregnancy counselling. Her father is a carrier of the Fragile X pre-mutation. Her paternal uncle has Fragile X syndrome. Critically evaluate the management.	30	June	2014
2	A six year old girl is referred to the gynaecology clinic with a 2 month history of vaginal discharge. 1. Justify the history you will take.            5 marks 2. Justify the investigations you will do.                 5 marks 3. Critically evaluate the management. 10 marks	30	June	2014
2	Critically evaluate “Enhanced Recovery” in Obstetrics and Gynaecology.	30	June	2014
2	With regard to endometrial cancer. 1. Outline the key features of Type 1 and Type 2 cancers.        4 marks 2. Outline the FIGO histological grading system.                          2 marks 3. Critically evaluate the FIGO staging for endometrial cancer. 6 marks 4. Detail the FIGO staging system for endometrial cancer.        8 marks.	30	June	2014
7	Roleplay. Healthy, nulliparous woman referred for pre-pregnancy counselling. Brother has cystic fibrosis. You are asked to explain cystic fibrosis and the implications for her.	30	June	2014

EMQ  Ulipristal.

Lead-in.

The following scenarios relate to ulipristal. For each, select the most appropriate from the option list.

Each option can be used once, more than once or not at all.

Option list.

GnRH analogue.

Selective serotonin reuptake inhibitor.

19-nortestosterone derived progestagen.

21-hydroxyprogesterone-derived progestagen.

mifepristone derivative.

Selective oestrogen receptor modulator.

Selective progesterone receptor modulator.

Urinary excretion.

Metabolised by renal cytochrome P450 enzyme system.

Metabolised by hepatic cytochrome P450 enzyme system.

30 mg. with dose repeated if vomiting occurs within 3 hours.

100 mg. with dose repeated if vomiting occurs within 3 hours.

150 mg. with dose repeated if vomiting occurs within 3 hours.

phenobarbitone

valium

erythromycin

12 hours.

18 hours.

32 hours.

72 hours.

120 hours.

Depot-contraception.

Depression.

Emergency contraception.

Menorrhagia.

Termination of pregnancy.

Yes.

No.

Maybe.

Continue.

Discontinue for 36 hours.

Discontinue for 72 hours.

May interfere with contraception containing progestagen.

May interfere with contraception containing oestrogen.

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 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?

Tutorial 26 June 2014

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26 June  2014

6	EMQ Confidentiality & Consent.
19	A 30-year-old woman presents for booking at 8 weeks. Her father has recently been diagnosed with TB. She wishes to know what the risks are to her and the pregnancy and child of possible TB. 1. Critically evaluate the investigation.                                           4 marks 2. Outline the management in pregnancy.                                   2 marks 3. Critically evaluate the issues relating to the puerperium.  14 marks
20	In relation to diagnostic laparoscopy, critically evaluate: 1. the issues to be discussed in obtaining informed consent.             4 marks. 2. the factors that increase the incidence of entry-related injury      4 marks. 3. how entry-related injuries may be minimised                                                 12 marks
21	Critically evaluate the statement: “fortification of flour with folic acid is overdue in the UK”.
22	With regard to Systemic Lupus Erythematosis (SLE): 1.  outline the clinical manifestations of SLE.             4 marks. 2.  outline the implications of SLE for pregnancy .    4 marks. 3.  critically evaluate how the diagnosis is made.      4 marks. 4.  critically evaluate the management in the woman wishing to be       pregnant.        8 marks. 4a.critically evaluate the management of a woman booking at 8 weeks.                                  8 marks.

Confidentiality.

Lead-in.

The following scenarios relate to confidentiality.

For each, select the number that best fits the scenario.

Pick one option from the option list.

Each option can be used once, more than once or not at all.

Option list.

This EMQ has no 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?

Tutorial 23 June 2014

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5	EMQ. Coroner 1 – 3.
15	A 35-year-old woman plans to go to a malarial area of Africa to join her husband who works there. She is 6 weeks pregnant. Critically evaluate the advice you will give her.
16	With regard to ovarian hyperstimulation syndrome: a. Outline the risk factors. 4 marks b. Discuss the classification system. 6 marks c. Outline the key aspects of the management. 10 marks
17	Critically evaluate risk management in relation to shoulder dystocia.
18	With regard to precocious puberty. 1.            What is the definition?                               4 marks. 2.            Critically evaluate the main causes in a girl.           6 marks. 3.            Outline the investigation of a girl with PP.             4 marks. 4.            Outline the main issues in the management of a girl with PP.                                                                               6 marks.

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?