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11 Cards in this Set
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.Ensuring that things are done in the right way, by the right person, in the right place, with the right result.Clinical effectivenes
Ensuring that health records are accurate and up-to-date, that confidentiality is maintained in respect of patient data and that all available sources of data are mined to produce intelligent information for improving quality = information Mx
A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. Clinical audit
Litigation
Hysteroscopy
Litigation in part is related to a failure of clinicians to adapt tothe demands of newer technologies, lack of adequate expertisewhen performing complicated procedures and failure torecognise complications during relatively simple procedures.
Clinical negligence claims related to hysteroscopic proceduresinclude complications related to uterine perforation andsubsequent internal organ injury.
The failure to recognise thecomplication is the commonest cause of litigation. When therehas been internal organ damage, such as bowel, patients mayremain asymptomatic for 2–10 days before the nature of theinjury, often thermal, becomes apparent.
Factors that increase the risk of perforation includecervical stenosis, acute anteversion or retroversion,lower-segment fibroids or intrauterine synechiae andoperator inexperience.
Uterine injury without the useof an electrical source can usually be managed by observationof signs of vaginal or intraperitoneal bleeding.
However,where an electrical source has been used, laparoscopy isadvised to rule out bowel injury.Fatal complications to which the clinician should be alertduring hysteroscopy include: fluid overload causing hyponatraemia and subsequentrespiratory arrest and seizures, air embolism leading to collapse and death.
Though relatively rare, this has been recorded and both the surgeonand anaesthetist must be alert to the signs suggestive of this rare but fatal complication.
How many appraisals should a doctor have in one revalidation cycle?
One Two Three Four Five. 5
Options for Questions
A CA 125 B Chemotherapy C Computed tomography (CT) D Magnetic resonance imaging (MRI) E Ovarian cyst aspiration F Ovarian cystectomy G Oophorectomy H Ovarian transposition I Repeat scan not necessary J Repeat the transabdominal ultrasoundscan K Repeat the transvaginal scan (TVS) L Refer to the colposcopy clinic M Refer to the cancer centre N Refer to the gynaecology clinic O Staging laparotomy
.26. A 20-year-old woman attends the emergency department with acute abdominal pain. The surgeon suspects appendicitis and performs a diagnostic laparoscopy.You are the on-call registrar for that night and the surgeon calls you to give an opinion on an incidentally found large solid ovarian mass in the right adnexa withpapillary projections on the surface. There is some free fluid in the pelvis and the other ovary appears normal. ?A
27. A 58-year-old woman presents to her general practitioner with gradual distension of the abdomen for the last 6 months. She is then referred to the gynaecology clinic for suspected ovarian cancer. An ultrasound scan of the pelvis reveals a large multilocular ovarian cyst on the right side. Her tumour markers are reported as:(a) CA 125 2000 U/mL, (b) CEA 1.2 ng/mL, and (c) CA 19.9 1 U/mL. ?M
28. A 39-year-old woman is reviewed in the gynaecology clinic with symptoms of pelvic pain for the last 2 years. She was treated for endometriosis 5 years ago with laparoscopic laser ablation. Her ultrasound scan 2 months ago revealed a left-sided ovarian cyst (5.8 cm) with diffuse low-level internal echoes with one thininternal septae. Her CA 125 level is raised (61 U/mL). F
29. A 28-year-old woman is referred to the gynaecology clinic with symptoms of menorrhagia with no intermenstrual and postcoital bleeding. Her pelvic examination is normal. However, an ultrasound scan of the pelvis shows an incidental finding of a simple ovarian cyst (size 3 × 3 × 3 cm) on the right side. A serum CA 125 level is 15 U/mL. Her recent cervical smear was normal. I
30. A 50-year-old woman is referred to the gynaecology clinic with two ultrasound scan reports: (a) a current one showing a simple left ovarian cyst of 3 × 4 cm in size,and (b) the previous one performed 4 months ago showing a simple left ovariancyst of 5 × 4 cm in size. Her CA 125 is 6 U/mL. She is otherwise asymptomatic andwell. K
Options for Questions 6–10
A Benign teratoma glial= tissue B Choriocarcinoma C Dysgerminoma= LDH & placental alkaline phosphatase D Endodermal sinus tumour E Embryonal carcinoma F Epithelial ovarian tumour G Granulosa cell tumour H Gynandroblastoma I Gonadoblastoma J Leydig cell tumour K Malignant teratoma L Sertoli cell tumourInstructions
6. A 19-year-old girl is referred to the gynaecology clinic with a scan report of a bilateral ovarian mass. An MRI scan confirms a bilateral solid ovarian tumour. The blood test results show an increase in lactate dehydrogenase and placental alkaline phosphatase. She is referred to an oncology centre for further management,following which she undergoes staging for ovarian cancer and bilateral oophorectomy. Her final histology shows marked lymphocytic infiltration in the stroma surrounding the tumour cells. C
7. A 20-year-old woman presents to the emergency department with abdominal distention and pain. Clinical examination reveals a palpable abdomino-pelvic mass and an ultrasound scan shows a unilateral solid ovarian mass on the rightside. Her tumour marker alpha fetoprotein was 300 U/mL and CA 125 45 U/mL.She was then referred to the gynaecology oncology centre for further management. She had further imaging in the form of MRI and CT scans and underwent staging laparotomy and right-sided oophorectomy. The histology revealed a Schiller–Duvalbody. D
8. An 18-year-old girl presents to her general practitioner with distention of the abdomen. An ultrasound scan reveals a unilateral solid/cystic mass on the left side. An MRI scan confirms that the ovarian tumour is confined to the left ovary and the right ovary looks normal. However, her tumour markers, beta humanchorionic gonadotropin (beta hCG) and alpha fetoprotein, were normal. She is then referred to the gynaecology oncology centre for further management,following which she undergoes staging laparotomy and left-sided oophorectomy.One of the components of the histology shows elements of glial tissue. A or E
9. A 55-year-old menopausal woman presents to the emergency department with irregular vaginal bleeding. An abdominal scan shows a large pelvic mass on the right side and a thickened endometrium (20 mm). An MRI scan reveals similarfindings. The blood test shows a raised a subunit of inhibin and CA 125 48 U/mL. She gives a family history of breast cancer and is currently on tamoxifen. G
10. A 58-year-old woman presents to the emergency department with abdominal bloating and a decreased appetite. She had opened her bowels 2 days ago. Clinical examination reveals a distended abdomen with signs of subacute bowelobstruction. A CT scan of the abdomen and pelvis revealed a large complex pelvic mass (size 15 × 12 × 12 cm) with raised CA 125 (1000 U/mL) and normal carcinoembryonic antigen (CEA) (2 U/mL). F |
Litigation
Good communication
Possibly more important than high standards of care is good communication with the patient and valid informed consent.
Informed consent is a dialogue, not a lecture. It requires physicians to discuss: risks of the treatment, benefits of the treatment, and alternatives to the treatment including doing nothing aswell as pros and cons of the individual treatment options.
Any risks associated with serious long-term sequelae,must be discussed, even if the probability of the risk occurring is remote. |
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STATISTICS T/FRandomized controlled studies. a)Are observational studies b)Are the gold standard of clinical research c)An intervention under investigation is compared with standard treatment d)An intervention under investigation is compared with a placebo e)In such studies, patients are allocated in random fashion to the two groups Key E
T/FRegarding sterilisation,medicolegal law states that parents are entitled to the cost of bringing up a child if it is born as a result of failed sterilisation. Key F for healthy child True for disabled child Key #F parents of healthy children born after sterilisation were not entitled to the costs of bringing up the child. However, a valid claim can be made following the birth of child with disabilities, based on the additional cost of raising a child with those disabilities |
Stats
Correlation measures the strength of the association between variables. T
Regression quantifies the association. It should only be used if one of the variables is thought to precede or cause the other. T |
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StatsT/F
In a set of observations with skewness to the right, the median is:
a) less than the mode.
b) the value that half of the data points fall above it and half below it.
c) a better representative of the data than the mean is.
d) the best measure of central tendency in ordinal data
e) always represented by one of the data points. FTFTT |
A test is “positive” in 231 of 258 patients with disease and “negative in54 of 86 patients without disease.
•What is the test sensitivity?
What is the test specificity?
Sensitivity =231/258×100=89% Specificity=54/86×100=62%
Caldicrt gardian is to protect ot confidentiality. |
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CLINICAL GOVERNANCE STRATOG EMQS SET NO.1
Select the most appropriate answer to each of these statements from the list below.
A: Saving Mothers' Lives B: Patient Advice and Liaison Service (PALS) C: Root cause analysis D: Data Protection Act 1998 E: National Perinatal Epidemiology Unit F: Continuing professional development G: Risk register H: Early warning score I: Clinical audit J: Communication tool K: Patient focus L: Clinical effectiveness M: Patient safety incident N: The Parliamentary and Health Service Ombudsman O: Non-technical skills
1.A continuing process, outside formal undergraduate and postgraduate training, that enables individual doctors to maintain and improve standards of medical practice through the development of knowledge, skills, attitudes and behaviour. 🔶F✔The answer is continuing professional development.
2.A quality improvement process that seeks to improve patient care and outcomes through systematic review of care against explicit criteria and the implementation of change. 🔶I✔The answer is clinical audit.
3.A source of audit data that could be used to improve antenatal, intrapartum and neonatal care. 🔶E✔The answer is the National Perinatal Epidemiology Unit.
4.Next port of call if local resolution of a complaint is not achieved. 🔶N✔The answer is The Parliamentary and Health Service Ombudsman.
5.Ensuring that the right person does the right thing in the right way to get the right outcome. 🔶L✔The answer is clinical effectiveness.
6.One of the seven domains by which health care is evaluated. 🔶K✔The answer is patient focus.
7.Looks at task factors, patient factors, team factors and communication. 🔶C✔The answer is root cause analysis.
8.Recognising and responding appropriately to early signs of deterioration in hospitalised patients. 🔶H✔The answer is early warning score. |
Litigation Bolam v Friern Hospital ManagementThe Bolam principle formulated that a medical professional isnot considered negligent if his practice reflects that of anaccepted body of responsible medical opinion at that time. Bolitho v City and Hackney Health AuthorityThe Bolitho principle subjects expert evidence to close judicialscrutiny. The court is not bound to accept that a doctorescapes liability for a treatment or diagnosis purely on thegrounds that other medical experts are of the opinion thatthe defendant’s actions were in accordance with soundmedical practice. Roe v Minister of HealthThe Roe ruling stated that a defendant may not be liableprovided he acted in accordance with medical knowledgeavailable at the time of theincident rather than the time of the trial. Ashcroft v Mersey RHAThe burden of proof lies with the claimant to prove that onthe balance of probabilities the defendant was negligent. Hunter v HanleyDeparture from routine practice does not automaticallyconstitute negligence. Crawford v Board of Governors of Charing CrossHospitalThe standard of medical knowledge and its applicationwill not be judged on the basis of publication in isolatedmedical journals. Wilsher v Essex Area Health AuthorityThe standard of care is reliant on the post occupied by adoctor, not the level of training. Where multiple causesresulted in an adverse outcome it is for the claimant to provethat “But For” the defendant’s actions the damage would nothave occurred. Chester v AfsharPatients should be told of any possible significant adverseoutcomes of a proposed treatment. A patient has a primafacie right to be informed by a surgeon of a small, butwell-established, risk of serious injury as a result of surgery;even if it would not have changed the claimant’s decision toproceed with the treatment. Janaway v Salford Health AuthorityDoctors who object to participating or being involved in theprocess of termination of pregnancies should make theseopinions known to patients and give them an opportunity tosee another clinician without undue delay if that is what thepatient desires. The General MedicalCouncil (GMC), in the current edition of GoodMedicalPractice goes on to state ‘the doctor must ensure thatarrangements are made for another suitably qualifiedcolleague to take over this role so that the patient’s caredoes not suffer’. |
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T/FWith regard to litigation in gynaecology n obstetrics claims should be made within 5 years of injury ? F 3 yr |
Stats facts The “HR” is the ratio of the hazard (chance ofsomething harmful happening) of an event in onegroup of observations divided by the hazard of anevent in another group. A HR of 1 means the risk is1 × that of the second group, i.e. the same. A HR of2 implies twice the risk. |
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Process of defining a level of care set as a goal to be attained is benchmarking ??Key T |
Stats Examples of nominal data include: a) ethnic origin data. b) gender data. c) cancer staging data. d) serum uric acid data. e) height data. TT FFF |
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Risk mx
Risk score is commonly derived by multiplying the severity of the incident by the likelihood of its occurance. (T) |
Risk mx The seven domains of healthcare include all except A)safety B)clinical cost effectiveness C)governance D)patient focus E)accessible and responsive care F)care environment and facilities G)clinical audit H)public health key G |
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All of the following are trigger for incident reporting in gynaecology except
A)anesthetic complications B)operative blood loss greater than 200ml C)omission of planned procedures D)missed diagnosis E)unplanned intensive care admission Key B 500 ml |
Stats What are the requirements of the screening test? a) The test should have a high sensitivity b) The test should have a high specificity c) The test should be cost-effective d) The test should be safe to apply to the whole population e) There should be a latent period in disease progression ALL T |
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Stats
In any set of observations:
a) the mean is always less than the mode. b) half of the observations are greater than the median. c) if the data is skewed to the right, the median is less than the mean. d) the mode is always the most frequently occurring value. e) the variance is the square root of the standard deviation. F ttt F |
STATs A double-blind clinical trial can be used to compare: a) labetalol and methyldopa in the treatment of pre-eclampsia. b) hysterectomy and endometrial resection in the treatment of menorrhagia. c) out-patient and in-patient management of asymptomatic placenta praevia. d) cervical cerclage and no treatment in suspected cervical incompetence. e) aspirin and placebo in the prevention of pre-eclampsia. T fff T
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consent
A 12-year-old girl, who lives in a care home, attends the Sexual Health Clinic requesting contraception. After taking a thorough sexual history you discover that her partner is 16 years old and she does not feel they are doing anything wrong. She has asked you not to share her information with your Safe guarding team because she is afraid of getting her partner in trouble. What should you do? 1. Agree with her request for confidentiality and issue the contraceptive 2. Agree with her request for confidentiality but refuse to give her any contraceptives as she is under the age of consent for intercourse. 3. Inform the police 4. immediatelyIssue a contraceptive and involve the Safeguarding team Not issue the contraceptive but involve the Safeguarding Team
Key ? A |
Stats In a set of data with normal (Gaussian) distribution:
a) the mean is equal to the median. b) 99% of value would be expected to lie within the mean+3 standard deviation. c) the coefficient of variation expresses the standard deviation as a percentage of the mean. d) the skewness is usually ≥+5. e) Parametric significant tests can be used TT?FT |
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ETHICS
Mrs A suffers with severe dementia and develops pneumonia, which worsens to the extent that she now requires ventilation. Her respiratory function deteriorates despite ventilation. A decision needs to be made regarding continuation of ventilation. Who is able to make the final decision?
A. An advance directive from Mrs A before the onset of dementia which does not specifically mention mechanical ventilation
B. Her consultant, using best interest principles
C. Her daughter, to whom Mrs A once confided that she did not want to suffer if placed in such a situation
D. Her son, who has lasting power of attorney
E. Her husband |
ETHICS The parents of a 22-year-old mentally handicapped woman come to see you in the gynaecology clinic requesting sterilisation for their daughter. The woman had recently become sexually active and she describes it as 'very nice' and 'fun'. Her partner is a member of the care home she lives in. She does not understand that her actions may lead to a pregnancy and she thinks it will be nice to have a baby to take for walks in the garden. The lady will not allow a pelvic examination and an implant inserted a few months ago was removed with her fingernails and a fork.How would you manage this case? Offer long-acting forms of contraception, such as the levonorgestrel intrauterine system under general anaesthesia Perform sterilisation as the lady does not understand the implications of getting pregnant Refer the case to a court for judgement
Refuse to perform sterilisation as the woman is not in a position to consent to the treatment
Suggest moving care homes to prevent further sexual activity |
