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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Sprache: Englisch
Part 2 MRCOG: SBA Questions contains invaluable preparation and practice for candidates undertaking the Royal College of Obstetricians and Gynaecologists Part 2 MRCOG examination. It contains 400 practice questions written by a highly experienced team of MRCOG question writers, alongside detailed answers referencing each question to either an RCOG, NICE or WHO guideline, or an article in the professional journal ‘The Obstetrician & Gynaecologist’. This will enable candidates to understand the reasoning and knowledge base behind the question, as well as giving them a clear reference should they wish to read further around the subject.
The first part of the book introduces and explains the new format of the Part 2 MRCOG exam, giving insightful advice on the skills required to write a good SBA question. The second part of the book contains chapters matched to the 15 of the 19 modules of the core curriculum, giving a comprehensive range of questions and answers with detailed explanations and references. For anyone preparing for the Part 2 MRCOG exam, this book will provide extensive and comprehensive practice and guidance from an expert author team.
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Table of Contents
Cover
Title Page
Copyright
Notes on Authors
Andrew Sizer
Chandrika Balachandar
Nibedan Biswas
Richard Foon
Anthony Griffiths
Sheena Hodgett
Banchhita Sahu
Martyn Underwood
Foreword
Preface
Acknowledgments
List of Abbreviations
Introduction
Format of the Part 2 MRCOG Written Examination
Why Have SBAs Been Introduced?
References
Questions
Module 3: IT, Governance and Research
Module 5: Core Surgical Skills
Module 6: Postoperative Care
Module 7: Surgical Procedures
Module 8: Antenatal Care
Module 9: Maternal Medicine
Module 10: Management of Labour
Module 11: Management of Delivery
Module 12: Postnatal Care
Module 13: Gynaecological Problems
Module 14: Subfertility
Module 15: Sexual and Reproductive Health
Module 16: Early Pregnancy Problems
Module 17: Gynaecological Oncology
Module 18: Urogynaecology and Pelvic Floor Problems
Explanations
Module 3: IT, Governance and Research
Module 5: Core Surgical Skills
Module 6: Postoperative Care
Module 7: Surgical Procedures
Module 8: Antenatal Care
Module 9: Maternal Medicine
Module 10: Management of Labour
Module 11: Management of Delivery
Module 12: Postnatal Care
Module 13: Gynaecological Problems
Module 14: Subfertility
Module 15: Sexual and Reproductive Health
Module 16: Early Pregnancy Problems
Module 17: Gynaecological Oncology
Module 18: Urogynaecology and Pelvic Floor Problems
End User License Agreement
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Guide
Cover
Table of Contents
Foreword
Preface
Begin Reading
List of Illustrations
Introduction
Figure 1 Millers Pyramid (see Miller, 1990)
Part 2 MRCOG: Single Best Answer Questions
Andrew Sizer
Shrewsbury and Telford Hospital NHS Trust, Shropshire, UK
Chandrika Balachandar
Walsall Healthcare NHS Trust, West Midlands, UK
Nibedan Biswas
Shrewsbury and Telford Hospital NHS Trust, Shropshire, UK
Richard Foon
Shrewsbury and Telford Hospital NHS Trust, Shropshire, UK
Anthony Griffiths
University Hospital of Wales, Glamorgan, UK
Sheena Hodgett
Shrewsbury and Telford Hospital NHS Trust, Shropshire, UK
Banchhita Sahu
Shrewsbury and Telford Hospital NHS Trust, Shropshire, UK
Martyn Underwood
Shrewsbury and Telford Hospital NHS Trust, Shropshire, UK
This edition first published 2016 © 2016 by John Wiley & Sons Ltd
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Library of Congress Cataloging-in-Publication Data
Names: Sizer, Andrew, author.
Title: Part 2 MRCOG : single best answer questions / Andrew Sizer, Chandrika Balachandar, Nibedan Biswas, Richard Foon, Anthony Griffiths, Sheena Hodgett, Banchhita Sahu, Martyn Underwood.
Other titles: Part two MRCOG
Description: Chichester, West Sussex ; Hoboken, NJ : John Wiley & Sons, Inc., 2016. | Includes bibliographical references and index.
Identifiers: LCCN 2015047746 | ISBN 9781119160618 (pbk.)
Subjects: | MESH: Obstetrics | Gynecology | Great Britain | Examination Questions
Classification: LCC RG111 | NLM WQ 18.2 | DDC 618.10076—dc23 LC record available at http://lccn.loc.gov/2015047746
Paperback ISBN: 9781119160618
A catalogue record for this book is available from the British Library.
Wiley also publishes its books in a variety of electronic formats. Some content that appears in print may not be available in electronic books.
Cover image: © selensergen/Gettyimages′
Notes on Authors
Andrew Sizer
Andrew Sizer completed specialist training in 2005 and was appointed as Consultant Obstetrician & Gynaecologist at Shrewsbury and Telford Hospital NHS Trust in 2007 and as Senior Lecturer at Keele University School of Medicine in 2008.
He is currently Clinical Director for Gynaecology and Lead Medical Appraiser for the Trust. He is the Chair of Intermediate training (ST3-5) at the West Midlands Deanery.
At the RCOG, he was a member of the Part 1 exam sub-committee from 2008 to 2011. At the end of this time he wrote ‘SBAs for the Part 1 MRCOG’ (RCOG Press) in conjunction with Neil Chapman.
From 2011 to 2014 he was Convenor of Part 1 revision courses. In 2014, he was appointed as Chair of the Part 1 exam sub-committee. He is an examiner for the Part 2 MRCOG.
Chandrika Balachandar
Chandrika Balachandar has been a Consultant Obstetrician and Gynaecologist at Walsall Healthcare NHS Trust since 1995. She has been Director of Postgraduate Medical Education for the Trust since 2010 and has established simulation training following training and certification as an instructor from the Center for Medical Simulation, Harvard, Cambridge MA. She is an examiner for Part 2 MRCOG since 2007 and coordinates the DRCOG examinations in Birmingham. She is a faculty member of the RCOG Part 2 revision courses, was a moderator for the RCOG Enhanced Revision Programme in 2013 and 2014 and member of the RCOG Assessment sub-committee from 2009 to 2012. From June 2015 she has taken on the role of Chair – Part 2 MRCOG Extended Matching Questions sub-committee. Mrs Balachandar is a generalist with special interests in High Risk Obstetrics, Colposcopy and Paediatric and Adolescent Gynaecology.
Nibedan Biswas
Nibedan Biswas completed his specialist training in Wessex Deanery in 2011 and worked as a locum Consultant at Poole hospital before joining Shrewsbury and Telford Hospital NHS Trust in 2012 as Consultant Obstetrics and Gynaecology. He is the audit lead for the department and led the team that was successful in obtaining CNST level 3 status.
He is an undergraduate tutor for Keele University School of Medicine.
Richard Foon
Richard Foon started his professional career as a secondary school teacher before entering medical school.
He completed his training in Obstetrics and Gynaecology in 2012, which included 3 years of Subspecialty training in Urogynaecology in Bristol/Plymouth.
He has been a Consultant in Obstetrics and Gynaecology (with a special interest in Urogynaecology) at the Shrewsbury and Telford Hospital NHS Trust, since April 2012.
Currently, he is the Urogynaecology lead for the unit, the lead for Practical Obstetric Multi-Professional training and also the RCOG College Tutor.
Anthony Griffiths
Anthony Griffiths completed his specialist training in 2006 and was appointed as Consultant Obstetrician and Gynaecologist at the University Hospital of Wales the same year. He works closely with Cardiff University delivering postgraduate training for an MSc programme in ultrasound.
He holds postgraduate diplomas in both medical education and advanced endoscopy. He was awarded fellowship of the higher education academy in 2007.
Previously he served as an RCOG college tutor during 2006–2012 and is now Clinical Director for Obstetrics and Gynaecology. He is a preceptor for the ATSM in advanced laparoscopic surgery.
At the RCOG he was a member of the Part 1 examination sub-committee during 2011–2014. At that time he wrote an MRCOG Part 1 SBA resource. Since 2014 he has been convenor for the RCOG London Part 1 revision course. He also teaches on several international MRCOG courses.
Sheena Hodgett
Sheena Hodgett was appointed Consultant Obstetrician and Gynaecologist in 2000, and was initially at University Hospitals of Leicester prior to her appointment at Shrewsbury and Telford Hospital NHS Trust in 2009.
Her specialist areas of interest are intrapartum care and maternal and fetal medicine. She is the departmental lead for obstetric guidelines and for clinical research.
She is an examiner for Part 2 MRCOG having previously been a DRCOG examiner and undergraduate examiner at the University of Leicester. She has participated in MRCOG Part 2 courses in the United Kingdom and abroad.
Banchhita Sahu
Banchhita Sahu is a Consultant in Obstetrics and Gynaecology at the Shrewsbury and Telford Hospital NHS Trust. She completed specialist training in Obstetrics and Gynaecology in India and the United Kingdom.
She complemented her clinical training by working as a Clinical Research Fellow at University College London, a post with a substantial teaching and research commitment.
She has several first author publications in peer reviewed journals.
Her special interests include minimal access surgery, gynaecological oncology and simulation training in obstetrics and gynaecology.
Martyn Underwood
Martyn Underwood was appointed as Consultant Obstetrician and Gynaecologist to the Shrewsbury and Telford Hospital NHS Trust in 2014. He has interests in Ambulatory Gynaecology, Colposcopy and Minimal Invasive Surgery. He has taught on the RCOG Part 1 revision course for several years and also on the ACE Courses MRCOG Part 1 course in Birmingham. More recently, he has contributed to the Part 2 MRCOG course led by Andrew Sizer in Birmingham.
He has an interest in research in field of Gynaecology and Early Pregnancy and has recently contributed to several books in the field of Gynaecological Surgery.
Foreword
The RCOG's decision to add a Single Best Answer component to the Part 2 MRCOG examination was taken with the aim of making the examination more valid and relevant to clinical practice. I am therefore delighted to introduce this extremely useful and timely resource for candidates preparing for the new format of the examination.
The book's helpful layout mirrors that of the Curriculum to ensure full coverage of the relevant topics and their ease of reference by readers.
Candidates will find this book an invaluable aid to revision and examination practice when professional lives are increasingly busy and time is short. The authors have extensive experience of preparing candidates for MRCOG examinations and also of writing questions as members of the various College examination committees. As practising clinicians the authors are fully aware of the need to match theory to practice, and this book reflects the important role of the MRCOG in setting professional standards.
Dr Michael MurphyDeputy Chief ExecutiveRoyal College of Obstetricians and Gynaecologists
Preface
In 2014, cognizant of the introduction of single best answer (SBA) questions into the Part 2 MRCOG examination, a group of us, predominantly based in the West Midlands Deanery, decided to produce an SBA question resource.
Our aim was to produce questions mapped across the relevant modules of the curriculum and to use the following sources as our primary references:
RCOG Green top guidelines
NICE guidelines
Articles in ‘The Obstetrician & Gynaecologist’
Between us we have produced 400 questions. The styles of the questions are different, but we envisage this will mimic the actual examination since many authors have contributed to the RCOG SBA question bank.
At the time of writing, very little was known about the actual style and content of SBA questions for the Part 2 MRCOG. We have used our experience and knowledge of medical education to develop questions that we feel are appropriate.
Knowledge accumulates, practice alters and guidelines change. We will be grateful for feedback.
We hope that candidates for the Part 2 MRCOG find this book helpful in their preparation for the examination.
For further examination practice for the Part 2 MRCOG, please visit www.andragog.co.uk
Acknowledgments
We would like to thank the following trainees for being our ‘guinea pigs’ in our initial attempts at question writing and for their useful feedback.
Dr Kiri Brown MRCOG
Dr Guy Calcott MRCOG
Dr Will Parry-Smith MRCOG
Dr Dorreh Charlesworth MRCOG
List of Abbreviations
BASHH
British Association for Sexual health and HIV
BHIVA
British HIV Association
CGA
RCOG Clinical Governance Advice
FSRH
Faculty of Sexual and Reproductive Healthcare
GTG
RCOG Green Top Guideline
NICE
National Institute for Health and Care Excellence
NICE CG
NICE Clinical Guideline
NICE IPG
NICE Interventional Procedure Guidance
RCOG
Royal College of Obstetricians & Gynaecologists
RCOG CA
RCOG Consent Advice
SIGN
Scottish Intercollegiate Guidelines Network
TOG
The Obstetrician and Gynaecologist
Introduction
Attainment of the membership to the Royal College of Obstetricians and Gynaecologists (MRCOG) is an essential component of specialist training in Obstetrics and Gynaecology in the United Kingdom. Possession of the MRCOG is also highly prized by specialists working in many countries worldwide.
In March 2015, there were some significant changes to the format of the written component of the Part 2 MRCOG examination, although there was no change in the syllabus.
Previously, the examination had consisted of short answer questions (SAQs), true-false (TF) questions and extended matching questions (EMQs). However, in order to keep abreast of modern thinking in medical assessment, the SAQs and TF questions were dropped in favour of single best answer questions (SBAs).
SBAs had already been introduced into the Part 1 MRCOG examination in 2012, so many candidates were familiar with them. From March 2015, the Part 1 exam consisted solely of SBAs.
Format of the Part 2 MRCOG Written Examination
The exam consists of two written papers with a short break (approximately 30 minutes) between them.
The two papers are identical in format and carry the same amount of marks.
Each paper consists of 50 SBAs and 50 EMQs, but the weighting between the two question types (reflecting the different format and time taken to answer) is different.
The SBA component is worth 40% of the marks and the EMQ component is 60%.
Each paper is of 3 hours duration, but in view of the weighting the RCOG recommends that candidates spend approximately 70 minutes on the SBA component and 110 minutes on the EMQ component. There are however, no buzzers or warning regarding this, so candidates are responsible for their own time management.
Traditionally, Paper 1 is mainly Obstetrics and Paper 2 mainly Gynaecology, but there is no guarantee that this is the case and theoretically, any type of question or subject could appear in either paper.
Why Have SBAs Been Introduced?
SBA questions have been used as a form of written assessment for decades in a variety of subjects at a variety of levels, but have found increasing use in undergraduate and postgraduate medical examinations over the past 15 years as well as in the General Medical Council (GMC) assessment of poorly performing doctors.
SBAs allow much wider coverage of the syllabus when compared to SAQs and questions can be mapped to the entire syllabus using a blueprinting grid.
Compared to TF questions, SBAs are considered to be a higher level form of assessment. When considering their assessment ability according to Millers pyramid, they can assess ‘knows how’ and ‘knows’ as opposed to ‘knows’ alone (see Figure 1).
Figure 1 Millers Pyramid (see Miller, 1990)
An SBA question usually consists of an introductory stem, which in a clinical question could recount a clinical history or scenario. There is then a lead-in question that should ask a specific question. Following this, there will be five options, one of which is the correct, or best, answer.
There are therefore two variations of SBAs: single ‘best’ answer where one of the answer stems is clearly more appropriate or better than the rest, although the other answer stems are plausible, and the single ‘correct’ or single ‘only’ type of question where only one stem is correct and the remaining are incorrect.
Where SBAs are used for basic science questions in medical examinations the single ‘correct’ type of question tends to predominate, since the answers are generally very clear-cut. However, when SBAs are used to assess clinical knowledge, the single ‘best’ type of question predominates since clinical scenarios and their management tend to be more open to interpretation, or, indeed, there may be more than one type of management that is perfectly reasonable.
A good SBA question should pass the ‘cover test’, meaning that in a properly constructed question a good candidate should be able to cover the answer options and deduce the answer merely from the information in the stem and the lead-in question. In practice this can be difficult, and question writers often resort to a ‘which of the following…’ style of questioning. However, this is not a true SBA and is really a true-false question in the guise of an SBA.
Our advice would be always to apply the cover test. In other words, read the question with the five options covered. If you feel you know the answer and it appears in the list of options, your answer is almost certainly correct. A well-constructed question will have plausible ‘distractors’ that could make you doubt yourself. Therefore, it is best to try and answer the question without initially looking at all the options.
There are a number of potential flaws in SBA questions, which the well-prepared candidate could possibly use to their advantage. Many of these (with examples) are summarised in Hayes and McCrorie (2010). In addition to these, numerical questions will have a preponderance of answer ‘C’ being correct. This is because it is more common to spread the ‘distractors’ around the correct answer. However, the wily question writer can use this phenomenon to his advantage and place the correct numerical answer at either end of the spectrum.
We hope that our 400 questions give a broad coverage of the syllabus and that you will find the different styles of question writing useful. However, as Obstetrics & Gynaecology is such a vast subject, it is impossible to cover everything unless the questions run into several volumes.
We have not included questions in core modules 1, 2, 4 and 19 as we do not feel these subjects lend themselves to the SBA format and can be better assessed by other assessment tools. The number of questions in the included core modules represent what we consider to be an appropriate weighting.
We hope you find this book helpful as part of your exam preparation.
References
Hayes, K and McCrorie P (2010) The principles and best practice of question writing for postgraduate examinations.
Best practice & research Clinical Obstetrics and Gynaecology
,
24
, 783–794.
Miller, GE (1990) The assessment of clinical skills/competence/performance.
Academic Medicine
,
65
, S63–S67.
Questions
Module 3
IT, Governance and Research
1
If involved in a serious incident requiring investigation (SIRI), initial steps would involve completing an incident form, ensuring completion of notes accurately and participating in team debrief.
If a trainee is involved in an SIRI, what action should be taken as soon as possible?
A.
Discuss with the medical defence organisation
B.
Engage fully with the investigation
C.
Meet with the educational supervisor to discuss the case
D.
Write a formal statement
E.
Write a reflection of the vent
2
In surrogacy arrangement, the commissioning couple need to obtain parental orders. Within what time frame after delivery must these be made?
A.
6 months
B.
12 months
C.
18 months
D.
24 months
E.
36 months
When managing a patient with surrogate pregnancy, who decides about the treatment required for any clinical situation that may affect the pregnancy?
A.
The binding agreement
B.
The commissioning father
C.
The commissioning mother
D.
The surrogate mother
E.
The unborn child
4
A primigravida at 24 weeks gestation has come to the antenatal clinic with a fear of childbirth and is asking for elective caesarean section as a mode of delivery.
What would be the recommended management?
A.
Adequate exploration of the fears with counselling by trained personnel
B.
Discharging the patient to midwife care with advise for vaginal delivery
C.
Enlisting the patient for elective caesarean section
D.
Referral to another obstetrician for second opinion
E.
Referral to the supervisor of midwife
5
Women requesting caesarean section on maternal request might have posttraumatic stress disorder (PTSD) after previous childbirth.
What is the incidence of PTSD after childbirth?
A.
0–1%
B.
6–7%
C.
12–13%
D.
24–25%
E.
36–37%
6
Among those receiving gynaecological treatment, what is the reported incidence of domestic violence in the United Kingdom?
A.
11%
B.
21%
C.
31%
D.
41%
E.
51%
7
When obtaining consent for a procedure, a doctor should take reasonable care in communicating with the patients, as their inability to recall from such discussion is often evident.
What percentage of the information that is discussed during the process of obtaining consent before surgery is retained at 6 months?
A.
10%
B.
20%
C.
30%
D.
40%
E.
50%
8
One of the main challenges faced by clinical trials is a lower than expected rate of recruitment.
What is the key to successful recruitment?
A.
Collaboration and collective effort in multicentric trials
B.
Do nothing, as clinical trials are not important
C.
Provide incentives for participation in medical studies
D.
Wait for colleagues to publish clinical trials
E.
Withhold care to patients if they do not agree to participate in clinical trials
9
Improved outcomes are often observed in women participating in a clinical trial.
What is the reason behind this improved outcome, irrespective of study findings?
A.
Positive change in the behaviour of clinicians and participants along with improved delivery of care
B.
There is no difference in the outcome of care
C.
Treatment is provided in a new hospital with latest technology
D.
Treatment is provided in a tertiary hospital
E.
Treatment is usually based on postal delivery of medication
10
On completing a consent form with a patient for a diagnostic laparoscopy, you mention that the chance of suffering a bowel injury is ‘uncommon’.
How would you define ‘uncommon’ in this context in numerical terms?
A.
1/1–1/10
B.
1/10–1/100
C.
1/100–1/1000
D.
1/1000–1/10,000
E.
<1/10,000
Module 5
Core Surgical Skills
11
A medical student asks you how to measure blood pressure.
What maximum pressure should you inflate the cuff to measure systolic blood pressure in pregnancy?
A.
Always initially inflate to 200 mmHg then deflate
B.
Patient's palpated diastolic blood pressure
C.
Patient's palpated systolic blood pressure
D.
Patients palpated systolic blood pressure + 20–30 mmHg
E.
Patients palpated systolic blood pressure + 5 mmHg
12
A healthy 39-year-old woman with no significant past medical history attends a preoperative assessment clinic.
She is due to undergo a total abdominal hysterectomy for heavy menstrual bleeding following a local anaesthetic endometrial ablation that was unsuccessful.
She is fit and well.
What preoperative investigation is required?
A.
Chest X-ray
B.
Coagulation screen
C.
Electrocardiogram
D.
Full blood count
E.
Renal function tests
13
On deciding where to place your secondary lateral ports at laparoscopy, care should be taken to avoid the inferior epigastric vessels.
Where can these be found?
A.
∼2 cm from the midline
B.
Lateral to the lateral umbilical ligaments
C.
Lateral to the medial umbilical ligaments
D.
Medial to the lateral umbilical ligaments
E.
Medial to the medial umbilical ligaments
14
Your hospital has recently had an increase in postoperative infections. As a result, you are formulating a new guideline that includes information on skin preparation and hair removal prior to surgery.
What is the most appropriate method of hair removal prior to surgery?
A.
Electric clippers
B.
Electrolysis
C.
Laser
D.
Shaving
E.
Waxing
15
Following delivery, a woman is found to have a third degree tear and a trainee wishes to do the repair under supervision.
Which two suture materials have equivalent efficacy when repairing the external anal sphincter?
A.
Polydiaxanone (PDS) and chromic catgut
B.
Polydiaxanone (PDS) and nylon (Prolene)
C.
Polydiaxanone (PDS) and Polyglactin (Vicryl)
D.
Polyglactin (Vicryl) and chromic catgut
E.
Polyglactin (Vicryl) and nylon (Prolene)
16
A 45-year-old woman is undergoing an abdominal hysterectomy for a history of heavy menstrual bleeding that has not responded to medical treatment. The patient has a past history of pelvic pain and the operation notes from a previous laparoscopy comments that the patient had ‘pelvic adhesions’
What is the most appropriate action in terms of protecting the ureter?
A.
Identify the ureter tracing it from the pelvic brim and mobilise the ureter by incising the peritoneum and sweeping the tissues laterally
B.
Mobilise the entire ureter with the aid of electrosurgery to reduce the blood loss
C.
Perform a preoperative MRI
D.
Perform a preoperative MRI and Intravenous urogram to assess the ureters
E.
Perform preoperative ureteric stenting
17
A 45-year-old asthmatic patient attends the gynaecology clinic with heavy menstrual bleeding and an ultrasound scan suggests the presence of an endometrial polyp.
The patient is booked for an outpatient hysteroscopy.
What analgesia should be prescribed at least 1 hour before the procedure?
A.
Buprenorphine
B.
Diclofenac
C.
Ibuprofen
D.
Paracetamol
E.
Tramadol
18
What is the preferred distension medium for outpatient diagnostic hysteroscopy?
A.
Carbon dioxide
B.
Dextran
C.
Glycine
D.
Icodextrin
E.
Normal saline
19
At what pressure should the pneumoperitoneum be maintained during the insertion of secondary ports for a laparoscopic procedure?
A.
5–10 mmHg
B.
12–15 mmHg
C.
20–25 mmHg
D.
30–35 mmHg
E.
>35 mmHg
20
What is the background rate of venous thromboembolism in healthy non-pregnant non-contraceptive using women?
A.
0.5/10,000/year
B.
2/10,000/year
C.
5/10,000/year
D.
10/10,000/year
E.
20/10,000/year
Module 6
Postoperative Care
21
What proportion of patients having a surgical procedure will develop a surgical site infection?
A.
5%
B.
10%
C.
15%
D.
20%
E.
25%
22
What is the most common source of microorganisms causing surgical site infection?
A.
Anaesthist
B.
Contaminated surgical equipment
C.
Patient
D.
Postoperative nursing staff
E.
Surgeon
23
A 54-year-old patient has had an insertion of a mid urethral retropubic tape and following the procedure there was a significant fall in the haemoglobin levels from 12.3 g/dl to 7.8 g/dl. Imaging investigations show the presence of retropubic hematoma. A decision is made to evacuate the hematoma. The most appropriate incision would be:
A.
Cherney incision
B.
Kustner incision
C.
Maylard incision
D.
Midline (median) incision
E.
Pfannenstiel incision
24
A postoperative patient who had a hysterectomy received morphine in recovery and then again in the gynaecology ward. Her respiratory rate is suppressed; she is drowsy and has pinpoint pupils.
What medication would you give to reverse this potential morphine overdose?
A.
Atropine
B.
Buprenorphine
C.
Flumazenil
D.
Naloxone
E.
Pethidine
25
A patient who is frail, old and overweight has undergone a midline laparotomy and pelvic clearance for an endometrial cancer.
On postoperative day 4, the nursing staff notice that she has a pressure ulcer with full thickness skin loss, but the bone, tendon and muscle are not exposed.
What type of pressure ulcer grade is this?
A.
Grade 1
B.
Grade 2
C.
Grade 3
D.
Grade 4
E.
Grade 5
26
A woman had an emergency caesarean section for a pathological CTG and pyrexia in labour. She was discharged on postoperative day 4 but re-admitted on day 6 with pyrexia, tachypnoea, tachycardia and hypotension. Haemoglobin is 105 g/l.
Septic shock is the main differential diagnosis.
Following the Sepsis 6 bundle, along with antibiotics and blood cultures, which other important blood test needs to be taken?
A.
C-Reactive protein
B.
Fibrinogen
C.
Lactate
D.
Urea and electrolytes
E.
White Cell Count
27
A patient undergoes a challenging hysterectomy. A drain is left in the pelvis. You are called to review the patient eight hours later as the nurses have noted a high serous drain output and poor urinary output.
What finding would identify if the drain fluid is urine (suggestive of a bladder/ureteric injury) or normal peritoneal fluid?
A.
Peritoneal creatinine > urine nitrogen
B.
Peritoneal urea > urine urea
C.
Serum creatinine > peritoneal creatinine
D.
Serum nitrogen > drain fluid nitrogen levels
E.
Urine nitrogen > peritoneal nitrogen
28
A patient has a ventouse delivery. Two days later she reports general malaise, fever and feeling unwell.
With sepsis, which is the first clinical sign to deteriorate, which can be detected through the use of early warning scores?
A.
Altered consciousness
B.
Hypotension
C.
Hypoxia
D.
Tachycardia
E.
Tachypnoea
29
Oral fluids and food are often delayed following major gynaecological surgery.
Which gastrointestinal complication is improved by early postoperative feeding?
A.
Abdominal distension
B.
Incidence of diarrhoea
C.
Need for nasogastric tube placement
D.
Recovery of bowel function
E.
Rectal bleeding
30
Following a difficult hysterectomy, a 65-year old woman has returned to the gynaecology ward. She had large amounts of morphine in the recovery area for pain relief and is also connected to a patient-controlled analgesia device.
The nurses note that she is drowsy and her respiratory rate is low.
The anaesthetist decides to perform arterial blood gas sampling.
What disturbance of acid–base balance is this most likely to show?
A.
Metabolic acidosis
B.
Metabolic alkalosis
C.
No disturbance
D.
Respiratory acidosis
E.
Respiratory alkalosis
Module 7
Surgical Procedures
31
Which type of ureteric injury is most commonly reported at laparoscopy?
A.
Crush
B.
Laceration
C.
Ligation
D.
Thermal
E.
Transection
32
During laparoscopic pelvic surgery, which visceral structure is most likely to be damaged?
A.
Aorta
B.
Bladder
C.
Ileum
D.
Rectum
E.
Ureter
33
Theoretically, what kind of injury related to laparoscopic entry should be reduced by the Hasson (open) technique, compared to a Veress needle entry?
A.
Bladder injury
B.
Bowel injury
C.
Major vessel injury
D.
Splenic injury
E.
Ureteric injury
34
An 18-year-old nulliparous girl presents as a gynaecological emergency with severe left-sided pelvic pain, tachycardia and vomiting. A pregnancy test is negative. An ultrasound scan is performed in the emergency department, which appears to demonstrate a left adnexal cyst.
In theatre, a laparoscopy is performed which shows an ovarian torsion that has twisted three times on its pedicle. The left tube and ovary appear purple and congested.
What is the most appropriate surgical management?
A.
Convert to laparotomy and perform a left salpingo-oophorectomy
B.
Laparoscopic left salpingo-oophorectomy
C.
Untwist the tube and ovary and perform a laparoscopic ovarian cystectomy
D.
Untwist the tube and ovary and perform a oophoropexy
E.
Untwist the tube and ovary, drain the ovarian cyst and leave the tube and ovary in situ
35
A patient undergoes a laparoscopic cystectomy for a dermoid cyst and some spillage of the contents occurs into the peritoneal cavity. What will be the incidence of chemical peritonitis?
A.
5%
B.
15%
C.
25%
D.
35%
E.
45%
36
When comparing robotic-assisted surgery to conventional laparoscopic surgery for gynaecological procedures, what would be the major drawback?
A.
Intraoperative complication rate
B.
Length of hospital stay
C.
Operative time
D.
Postoperative complication rate
E.
Safety and effectiveness in gynaecological cancer
37
A 19-year-old is undergoing a laparoscopy for pelvic pain.
What is the estimated risk of death due to a patient undergoing a laparoscopy?
A.
1 in 100
B.
1 in 1000
C.
1 in 10,000
D.
1 in 100,000
E.
1 in 1,000,000
38
A 22-year-old is undergoing a laparoscopy for suspected endometriosis.
What is the estimated risk of bowel, bladder or blood vessel injury?
A.
1.2:10,000
B.
2.4:10,000
C.
1.2:1000
D.
2.4:1000
E.
4.8:1000
39
Consent is being obtained from a 24-year-old for a diagnostic laparoscopy and it is correctly documented that there is a risk of laparotomy if any injury to bowel, bladder or blood vessels were to occur during the procedure.
The patient wishes to know what proportion of cases would be converted to a laparotomy should an injury occur?
A.
17%
B.
31%
C.
48%
D.
67%
E.
92%
40
A healthy 54-year-old lady is due to attend the outpatient postmenopausal bleeding hysteroscopy clinic.
Which medication should she be advised to consider taking prior to her attendance at the clinic?
A.
Benzodiazepines
B.
non-steroidal anti-inflammatory agents (NSAIDs)
C.
Opioids
D.
Paracetamol
E.
Prostaglandins
41
A 62-year-old is due to undergo a hysteroscopy due to a thickened endometrium detected as part of her investigations for postmenopausal bleeding.
Which medication should be used to ‘prime’ the cervix prior to the hysteroscopy?
A.
Mifepristone
B.
Misoprostol
C.
No medication required
D.
Non-steroidal anti-inflammatory
E.
Vaginal oestrogen
42
A 43-year-old lady with a history of heavy menstrual bleeding and a scan suggesting a polyp is due to undergo an outpatient hysteroscopy.
Which distension medium is routinely recommended due to its improved quality of image and speed of the procedure?
A.
Carbon dioxide
B.
Gelofusin
C.
Normal saline 0.9%
D.
Purosol
E.
5% glucose
43
A 32 year old is due to undergo a laparoscopic operation for investigation and management of an ovarian cyst detected on scan.
What is the expected serious complication rate following a laparoscopy?
A.
1:500
B.
1:1000
C.
1:2500
D.
1:5000
E.
1:10,000
44
With respect to instrumentation of the uterus, which operation has the highest risk of perforation?
A.
Division of intrauterine adhesions
B.
Outpatient hysteroscopy
C.
Postpartum suction evacuation for haemorrhage
D.
Second generation endometrial ablation
E.
Surgical termination of pregnancy
45
What is the most frequently encountered complication of suction evacuation of the uterus for first trimester miscarriage?
A.
Haemorrhage
B.
Pelvic infection
C.
Perforation
D.
Retained products of conception
E.
Significant Cervical Injury
46
A 19-year-old woman is to undergo a laparoscopy for pelvic pain.
How would you describe the correct technique for entry with the veress needle?
A.
Enter below the umbilicus horizontally and then pass the needle at 45° to the skin
B.
Enter below the umbilicus transverse plane and then pass the needle at 45° to the skin
C.
Enter below the umbilicus vertical to the skin
D.
Enter at the base of the umbilicus and pass the needle at ∼60° to the skin
E.
Enter the base of the umbilicus vertical to the skin
47
What is the most common complication of the bottom up single-incision retropubic tape procedure?
A.
Bladder perforation
B.
De novo urinary urgency
C.
Retention
D.
Tape erosion
E.
Voiding dysfunction
48
You have attempted to perform a direct entry for your laparoscopy and opted to undertake a Palmer's point entry.
Where would you find Palmers point?
A.
1 cm below the left costal margin in the mid-clavicular line
B.
1 cm below the right costal margin in the mid-clavicular line
C.
3 cm below the left costal margin in the mid-axilla
D.
3 cm below the left costal margin in the mid-clavicular line
E.
3 cm inferior to the right intercostal margin
49
A laparoscopic hysterectomy has been completed and several port sizes have been used.
When the port is in the midline, what size of port requires closure of the rectus sheath?
A.
<5 mm
B.
5 mm
C.
7 mm
D.
>10 mm
E.
All midline ports
50
A laparoscopy oophorectomy has been completed and the port sites are about to be closed.
What diameter of nonmidline port site required closure of the rectus sheath?
A.
No nonmidline port
B.
<5 mm
C.
5 mm
D.
>7 mm
E.
All midline ports
51
A woman is due to undergo an outpatient hysteroscopy and is concerned about pain.
Which hysteroscope is associated with the least discomfort in the outpatient setting?
A.
All are the same
B.
Flexible Hysteroscope
C.
Rigid Hysteroscope 0°
D.
Rigid Hysteroscope 15°
E.
Rigid Hysteroscope 30°
52
A woman is due to undergo an outpatient hysteroscopic polypectomy using a bipolar resectoscope.
Which distension medium should be used?
A.
Glucose 5%
B.
Glycine
C.
Manitol
D.
Normal Saline
E.
Purisol
53
A woman is due to undergo a routine diagnostic laparoscopy.
According to RCOG data what is the expected incidence of bowel injury during a laparoscopy?
A.
<0.1/1000
B.
0.36/1000
C.
3.6/1000
D.
3.6/10,000
E.
3.6/100,000
54
A woman with a stage 3 uterine prolapse is considering a variety of surgical options.
She understands the potential benefits of a mesh repair but is concerned about the risk of mesh erosion.
What is the risk of mesh erosion for a patient undergoing a subtotal hysterectomy with sacrocolpopexy?
A.
4%
B.
7%
C.
14%
D.
18%
E.
24%
55
A woman had a total abdominal hysterectomy in the past using a lower transverse incision.
She has now developed a persistent ovarian cyst and is due to have a laparoscopic bilateral salpingo-oophorectomy.
What will be the incidence of adhesions in the region of the umbilicus in this scenario?
A.
11%
B.
17%
C.
23%
D.
31%
E.
45%
56
A morbidly obese woman is due to undergo a total laparoscopic hysterectomy for endometrial cancer.
What type of complication is more common compared to traditional open hysterectomy in this situation?
A.
Bowel injury
B.
Hernia
C.
Infection
D.
Urinary tract injury
E.
Venous thrombosis
57
A woman has been offered a sacrocolpopexy for a vault prolapse. Her friend had a similar operation but developed stress incontinence following the procedure.
What is the incidence of de novo stress incontinence after a sacrocolpopexy?
A.
1–5%
B.
7–12%
C.
14–19%
D.
21–26%
E.
27–32%
58
A woman presents with a history of dysuria, postmicturition dribble and vaginal discharge.
On examination, a tender mass anteriorly inside the introitus is found. You suspect a urethral diverticulum.
What investigation would you use to diagnose the presence of a urethral diverticulum?
A.
Urethroscopy using a 0° endoscope
B.
Urethroscopy using a 12° endoscope
C.
Urethroscopy using a 30° endoscope
D.
Urethroscopy using a 70° endoscope
E.
Urodynamics
59
A 45-year-old multiparous woman is due to have a hysterectomy for heavy menstrual bleeding. The patient is considering having a subtotal hysterectomy as she has had normal cervical smears history.
When comparing a subtotal hysterectomy to a total hysterectomy, which perioperative complication is reduced?
A.
Bowel injury
B.
Cyclical vaginal bleeding
C.
Intraoperative blood loss
D.
Pyrexia
E.
Urinary retention
60
At the end of a total laparoscopic hysterectomy (in which the woman was placed in a steep Trendelenburg position) you observe that the woman's shoulder brace was placed too laterally.
What type of nerve injury may present in the postoperative period?
A.
Femoral nerve injury
B.
Lower brachial plexus injury
C.
Radial nerve injury
D.
Ulnar nerve injury
E.
Upper brachial nerve injury
Module 8
Antenatal Care
61
A nulliparous woman with a dichorionic diamniotic twin pregnancy presents at 32 weeks gestation with severe pruritis and an erythematous papular rash on her abdomen with periumbilical sparing. The most likely diagnosis is:
A.
Atopic eruption of pregnancy
B.
Eczema
C.
Obstetric cholestatsis
D.
Pemphigoid gestationis
E.
Polymorphic eruption of pregnancy
62
A woman presents at 34 weeks gestation with a sudden onset of severe headache and altered consciousness following an episode of vomiting and diarrhoea. What is the most appropriate imaging technique?
A.
Cerebral angiography
B.
Computerised tomography (CT scan)
C.
Magnetic resonance imaging (MRI scan)
D.
Magnetic resonance venography (MRV scan)
E.
Skull X-ray
63
A woman attends for a dating ultrasound scan at 12 weeks gestation. Doppler ultrasound identifies tricuspid regurgitation and a reversed A-wave in the ductus venosus (DV). She is at increased risk of which condition?
A.
Early onset fetal growth restriction (FGR)
B.
Early onset pre-eclampsia
C.
Fetal anaemia
D.
Fetal aneuploidy
E.
Late onset pre-eclampsia
64
A woman is referred by the community midwife with suspected small for dates pregnancy at 33 weeks gestation. Ultrasound assessment confirms a small for gestation (SGA) fetus with reduced liquor volume and reversed end diastolic flow on umbilical artery (UA) Doppler. Cardiotocograph (CTG) is normal. What is the most appropriate management?
A.
Antenatal steroids and delivery within 1 week
B.
Elective delivery at 37 weeks gestation
C.
Immediate delivery by caesarean section
D.
Repeat Doppler ultrasound in 1 week
E.
Repeat ultrasound growth assessment in 2 weeks
65
What proportion of pre-eclampsia can be predicted by risk assessment from maternal history alone in the first trimester of pregnancy?
A.
10–20%
B.
20–30%
C.
30–40%
D.
40–50%
E.
50–60%
66
When aspirin is used to reduce risk of pre-eclampsia in woman at high risk, at what gestation should it be commenced for maximum efficacy?
A.
Before 12 weeks
B.
Before 16 weeks
C.
Before 20 weeks
D.
Before 24 weeks
E.
Before 28 weeks
67
When calcium supplementation is used to reduce the risk of pre-eclampsia in women at high risk, at what gestation should it be commenced?
A.
12 weeks
B.
16 weeks
C.
20 weeks
D.
24 weeks
E.
28 weeks
68
What proportion of pregnant women in the United Kingdom is estimated to take the recommended dose of periconceptual folic acid supplementation?
A.
less than 5%
B.
5–10%
C.
10–20%
D.
20–50%
E.
50–70%
69
What is the incidence of red cell antibodies in pregnancy?
A.
1 in 500
B.
1 in 300
C.
1 in 160
D.
1 in 80
E.
1 in 40
70
In the presence of anti-c red cell antibodies in pregnancy, which additional red cell antibody increases the risk of fetal anaemia?
A.
Anti-D
B.
Anti-e
C.
Anti-E
D.
Anti-Fy
a
E.
Anti-K
71
A woman attends the antenatal clinic following a scan at 36 weeks gestation in her fourth pregnancy, which identifies an anterior placenta previa. She has had three previous caesarean births. What is the risk of placenta accreta?
A.
3%
B.
11%
C.
40%
D.
61%
E.
67%
72
What proportion of pregnant women in paid employment require time off work due to nausea and vomiting of pregnancy (NVP)?
A.
10%
B.
20%
C.
30%
D.
40%
E.
50%
73
What is the incidence of acute appendicitis in pregnancy?
A.
1 in 400 to 1 in 800
B.
1 in 800 to 1 in 1500
C.
1 in 1500 to 1 in 2000
D.
1 in 2000 to 1 in 2500
E.
1 in 3000
74
A 21-year-old woman is admitted at 22 weeks gestation in her first pregnancy with suspected appendicitis. She has a low grade pyrexia with a leucocytosis and a mildly elevated C reactive protein level. Abdominal ultrasound is inconclusive. What imaging technique is the most appropriate subsequent investigation?
A.
Abdominal X-ray
B.
Computed tomography (CT) scan of the abdomen
C.
Magnetic resonance imaging (MRI) scan of the abdomen
D.
Repeat abdominal ultrasound in 24 hours
E.
Transvaginal ultrasound scan of the pelvis
75
What is the risk of serious neonatal infection associated with prelabour rupture of membranes (PROM) at term?
A.
0.5%
B.
1%
C.
1.5%
D.
2%
E.
2.5%
76
A women in her first trimester scores more than 3 in the 2-item Generalized Anxiety Disorder scale (GAD-2) used to identify anxiety disorders in pregnancy.
What is the best plan of care?
A.
Further assess using the GAD-10 scale
B.
Further assess using the GAD-7 scale
C.
Reassure
D.
Repeat the GAD-2 scale in 4 weeks
E.
Repeat the GAD-2 scale in second trimester
77
Women suffer from various anxieties in pregnancy.
What is tokophobia?
A.
Fear of baby dying in utero
B.
Fear of extreme pain
C.
Extreme fear of childbirth
D.
Fear of heights
E.
Fear of spiders
78
What vitamin should women be advised to be taken throughout pregnancy and also while breastfeeding?
A.
Folic acid
B.
Vitamin A
C.
Vitamin C
D.
Vitamin D
E.
Vitamin K
79
