MRCOGManchester

Monday, 12 October 2020

12 October 2020

92	Role-play. Complaint. Mis-filed combined Ds test report.
93	Viva. Diathermy
94	Role-play. Optimising surgical outcomes.
95	EMQ. Case notes lost in stolen car

92. Role-play. Mis-filed DS screening report.

Candidate's Instructions.

You are the SpR in the ante-natal clinic. The consultant has been called to the labour ward to help with a case of placenta accreta and you have been put in charge of the clinic.

Mrs Jones had a “combined test” at 11 weeks which gave a risk of Down’s syndrome of 1: 40. The report was filed in the notes in error by a clerk without being shown to any of the medical or midwifery staff.

She attended today for the routine 20-week scan. The ultrasonographer found the report in the notes, realised that no action had been taken, informed the patient and made arrangements for her to see you urgently.

93. Structured conversation. Diathermy.

Candidate's Instructions.

This is a viva station about diathermy and its uses and complications.

The examiner will ask you 8 questions.

When you have completed an answer you are not allowed to return.

94. Role-play. Improving surgical outcomes.

Candidate’s instruction.

Use your own name. You are an enthusiastic new consultant and are running the labour ward. It is an unusual day as there are no women in labour. You were chatting to the on-call staff over coffee and the SpR, who is planning to sit the Part 2, mentioned reading about improving surgical outcomes and didn’t know where to start. You decide to give a tutorial on the subject. Proceed!

95. EMQ. Case notes lost in stolen car.

A SpR1 has been asked to carry out an audit and 50 sets of case-notes are to be used. He is given 49 sets of notes and a day in which to go through them and extract the necessary data. This he does in the hospital.

The final set of notes cannot be found initially, but are found two weeks later. The doctor is given the notes on a Friday afternoon as he is leaving for home. He decides to take the notes home to extract the data. On the way home he stops at his favourite supermarket. When he emerges, his car has been stolen with the notes inside. He reports the theft to the police.

Abbreviations.

BMA: British Medical Association

CG: Caldicott Guardian

MDU: Medical Defence Union

NHSLA: NHS Litigation Authority

NPSA: National Patient Safety Agency

Question 1.

The SPR informs you, the Clinical Director, on the Monday when he returns to work.

What action will you take?

Option list.

A	Report events to the Caldicott Guardian
B	Report events to the Chief Executive
C	Report events to the General Medical Council
D	Report events to the NHSLA as a “never event”
E	Report events to the NHSLA as a “serious incident”
F	Report events to the NPHSLA as a “never event”
G	Report events to the NPSLA as a “serious incident”
H	Report events to the Risk Management Team
I	Report events to the Root Cause Analysis Team
J	Report events to the Trust Information Management Committee
K	Suspend the doctor until a full investigation has been done

Question 2.

What action will you take to deal with the SpR?

Option list.

A.	Suspend the doctor until a full investigation has been done
B.	Report the doctor to the Medical Director
C.	Report the doctor to the Postgraduate Dean
D.	Report the doctor to the General Medical Council
E.	Report the doctor to the NHSLA
F.	Report the doctor to the Caldicott Guardian
G.	Report the doctor to the Trust Board member responsible for safeguarding
H.	Report the doctor to the BMA
I.	Report the doctor to the MDU
J.	None of the above

Question 3.

What action will you take in relation to the patient whose notes are missing?

Option list.

A.	Ask the Caldicott Guardian to deal with it
B.	Ask the Chief Executive to deal with it
C.	Ask the hospital’s legal team to deal with it
D.	Ask the patient’s GP to deal with it
E.	Discuss with the legal team, inform the patient, discuss the implications and keep her fully-up-to-date
F.	Tell all those who know about the incident to discuss it with no one else, particularly the patient
G.	None of the above

Thursday, 1 October 2020

Tutorial 1st. October 2020

Website

84	Viva. Tentorium cerebelli
85	Roleplay. Pre-pregnancy counselling. Phenylketonuria
86	Viva. Obstetric surveillance systems
87	Roleplay. Teach junior colleague re postnatal depression

84. Viva. Tentorium cerebelli.

Candidate’s instructions.

This is an old-fashioned viva, which is harder than the new ‘structured discussion’. Do the origami and make the model. Tell the examiner what you know about the mechanics of tentorial tears. The examiner will just listen and not guide you in any way.

85. Role-play. Phenylketonuria.

Candidate’s instructions.

You are the SpR in the pre-pregnancy clinic. Your consultant is off on sick leave and you are the most senior doctor in the clinic.

You are about to see Jane White who is planning her first pregnancy. Your task is to take a history and discuss the optimum management now and during pregnancy.

The GP letter reads:

Prime Health Practice,

Primetown,

Sussex.

0298766543.

Practice Manager:

Mrs Wilhelmina Bland.

Dear Doctor,

Please see Jane White, 35 years of age and planning her first pregnancy. Her health is good – she seems only to attend the Practice for routine checks such as cervical smears – the most recent of which was taken last year and was normal. From talking to her and examining her records, it is clear that she is very healthy and has always had good physical and mental health. Her social circumstances are good. The one thing of concern is that she told me she was on a diet in childhood supervised by the local paediatric team. She can’t recall what it was about and she stopped the diet at about the age of 14. Both of her parents are dead – her mother fifteen years ago at the age of 40 and her father two years ago in a RTA, so cannot shed light on what the diet was for. Fortunately, when I checked through her notes, I came across correspondence indicating that the problem was phenylketonuria. I have told her that I am no expert in phenylketonuria and the implications for pregnancy, so have eschewed the temptation to provide any advice.

I look forward to receiving your expert report.

Dr. John Worthy.

86. Viva. Obstetric surveillance systems.

Candidate's Instructions.

This is a viva station.

The examiner will ask you 2 questions about surveillance systems used in obstetrics.

The first question is less important than the second, so don’t spend too much time on it.

The examiner will ask if you wish to move to the second question when you appear to have completed the first, but it is for you to decide when you move on.

87. Role-play. Teach junior colleague re postnatal depression.

Candidate's Instructions.

This is a role-play station. You are an SpR5 and in charge of running the labour ward.

There are only two women in labour, both are healthy and without complication. This is the second pregnancy for both and they had uncomplicated 1^st. pregnancies and normal deliveries. They are being looked after by the midwives who are happy that all is well and good progress is being made.

One of the midwives has mentioned that one lady had postnatal depression and asked if anything different should be done for her.

The consultant has suggested that you give a tutorial to your new colleague and any midwives who are interested.

Wednesday, 16 September 2020

Tutorial 17 September 2020.

Website

80	Tutorial. Julie Morris. Medical statistics
81	EMQ. Phenylketonuria
82	EMQ. Headache

81. Julie Morris. Medical statistics tutorial.

82. EMQ. Phenylketonuria.

Abbreviations.

PA: phenylalanine.

PAH: phenylalanine hydroxylase.

PAHD: phenylalanine hydroxylase deficiency.

PKU: phenylketonuria.

Tyr: tyrosine.

Option list.

A.	autosomal dominant
B.	autosomal recessive
C.	X-linked dominant
D.	X-linked recessive
E.	1 in 100,000
F.	1 in 50,000
G.	1 in 10,000
H.	1 in 5,000
I.	deficiency in phenylalanine hydroxylase
J.	deficiency in phenylalanine oxidase
K.	deficiency in phenylalanine transferase
L.	deficiency in phenylketone hydroxylase
M.	deficiency in phenylketone oxidase
N.	raised PA levels
O.	reduced PA levels
P.	raised tyrosine levels
Q.	reduced tyrosine levels
R.	normal tyrosine levels
S.	No
T.	Yes
U.	unknown

Question 1.

What is PKU? Write your answer – there is no option list.

Question 2.

What is PKU due to? Use the option list.

Question 3.

What levels of PA and Tyr are typical in PKU? Use the option list. This is not a real EMQ as there are two answers.

Question 4.

Is PKU subdivided into different categories? If “yes”, what are the categories? Write your answer – there is no option list.

Question 5.

Which, if any, of the following statements is true about hyperphenylalaninaemia? This is not a true EMQ as more than one answer may be correct.

Option List

A.	it blocks growth hormone
B.	it destroys astrocyte miosis
C.	it disrupts folic acid activity
D.	it enhances vitamin A activity
E.	it interferes with myelin synthesis
F.	it negates the effects of vitamin C
G.	nobody knows, nobody cares; especially me

Question 6.

How is PKU inherited? Use the option list.

Question 7.

Which chromosome houses the gene related to PKU transmission?

Question 8.

How many mutations of the gene related to PKU have so far been identified?

Question 9.

Is a person with PKU likely to have one or two mutations of the relevant gene?

Question 10.

What is BH4?

Question 11.

What is pegvaliase?

Question 12.

What is the approximate prevalence of PKU in Caucasians?

Question 13.

What is the approximate prevalence of PKU carrier status in Caucasians?

Question 14.

The prevalence of PKU varies between ethnic groups.

Match each of the following ethnic groups to the closest prevalence given in the option list.

Option List

H.	1 in 1,000
I.	1 in 2,500
J.	1 in 5,000
K.	1 in 10,000
L.	1 in 100,000
M.	1 in 150,000
N.	1 in 200,000
O.	1 in 1,000,000

Ethnic group	Prevalence
Turkish	1 in 2,600
Irish	1 in 4,500
Caucasian	1 in 10,000
East Asian	1 in 10,000
Japanese	1 in 143,000
Finnish	1 in 200,000

Question 15.

Which, if any, of the following are characteristic of PKU?

Option list.

A.	alopecia
B.	angst
C.	facial dysmorphism
D.	facial hair in females and pre-pubertal males
E.	kyphosis
F.	macroorchidism in post-pubertal males

Question 16.

Are fetal PKU levels higher or lower than maternal? There is no option list.

Question 17.

Which, if any, of the following are true in relation to the maternal phenylketonuria syndrome? This is not a true EMQ as there may be more than correct answer.

Option list.

A.	asymptomatic bacteruria is more common
B.	cholestasis of pregnancy is more common
C.	early onset gestational hypertension is more common
D.	eczema is more common
E.	gallstones are more common
F.	miscarriage is more common
G.	MPKUS is usually due to non-adherence to a low phenylalanine diet
H.	porphyria is more common
I.	reversible posterior cerebral syndrome is more common
J.	urinary tract urea stones are more common
K.	none of the above

Question 18.

What are the main consequences for the offspring of untreated PKU in the mother?

Question 19.

Is screening for PKU a routine part of the neonatal screen in the UK?

Question 20.

The test for PKU used to be known by the name of its inventor. Who was he and why did he have a particular interest? There is no option list and no one is going to ask you except me!

Question 21.

What conditions are included in the routine neonatal ‘heelprick’ screening test? There is no option list.

Question 22.

Is neonatal screening for PKU still done using Guthrie’s bacterial inhibition method? If not, what method is used? There is no option list.

Question 23.

What is the main treatment of PKU and what problems are associated with it? There is no option list.

Question 24.

How long should the main treatment of PKU be continued and why? There is no option list.

Question 25.

Lead-in

A woman with PKU is planning her first pregnancy at the age of 22. She has been off the PKU-restricted diet since the age of 10 and can barely remember being on it. Should she be advised to re-start the diet? If ‘yes’, when should she start and what explanation would you give for the advice?

Question 26.

Lead-in

Which if any of the following statements are true about screening for PKU and its effects in the neonate born to a woman with PKU ?

Option list.

A.	routine bloodspot screening alone is required
B.	the neonate should be examined by a paediatrician for signs of PKU
C.	the baby should have developmental assessment, even if it does not have PKU
D.	an ultrasound scan should be done because of the increased risk of developmental dysplasia of the hip
E.	the baby should be started on a low PA diet until all assessments are complete
F.	none of the above.

Question 27.

Lead-in

Is breast-feeding advisable for women with PKU?

Question 28.

Lead-in

Are any other therapeutic approaches available? If ‘yes’, what are they and how do they work? If ‘yes’ use the option list for the mode of action.

Option List

A.	it binds PA to circulating plasma proteins, reducing its free levels
B.	it increases hepatic metabolism of PAH.
C.	it increases renal excretion of PA
D.	it is a co-factor for PAH, increasing its efficacy in reducing PA levels
E.	it is phenylalanine ammonia lyase, capable of breaking down PA
F.	it is a synthetic PAH enzyme
G.	it reduces absorption of PA from the small bowel

TOG CPD questions. These are open-access, so reproduced here.

Regarding phenylketonuria (PKU):

1. it is a deficiency of the amino acid phenylalanine (Phe). True False

2. it is an X-linked recessive inherited metabolic disease. True False

3. it results in a deficiency in the amino acid tyrosine. True False

4. it is treated with a low-phenylalanine restricted diet. True False

5. the incidence is approximately 1:1000. True False

6. the Newborn Screening Programme has been a great success in the diagnosis and management of children with PKU. True False

7. neonates with fetal alcohol syndrome and PKU are clinically difficult to distinguish at birth. True False

8. in utero exposure to very high levels of phenylalanine results in reversible neurological damage to the fetus. True False

9. pregnancy outcome is improved substantially when treatment results in low maternal phenylalanine concentrations ideally before conception. True False

10. oral methods of contraception should be switched to barrier methods at least 12 months before conception. True False

11. the risk of congenital heart defects is estimated to be 7–10%. True False

12. it is an indication for early delivery by caesarean section. True False

13. neonates born to mothers with PKU should be offered screening for PKU as per the routine national screening programme. True False

14. breastfeeding is contraindicated in women with PKU. True False

With regard to the biochemistry of PKU:

15. Phe is passively transported across the placenta. True False

16. fetal Phe levels are approximately 1.25-2.5 times > than maternal levels. True False

Children born to women with PKU:

17. tend to have blue eyes. True False

18. are fair skinned. True False

With regard to the effect of high Phe levels on loss of IQ or behavioural changes:

19. these changes are reversible in utero. True False

20. they are reversible with resumption of diet deficient of Phe. True False

83. EMQ. Headache.

Option list.

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. 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

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 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.

Scenario 14.

This is not an EMQ. It relates to the incidence of various conditions in women who have migraine. Choose the appropriate arrow for each.

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. These are open access.

You can find the questions here.

Headaches in pregnancy

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