●
Routine investigations already done, including FBC, group, rubella, syphilis
●
Talks about Down’s screening
●
HIV screening
●
Cervical cytology (opportunistic)
●
Chlamydia
●
Hepatitis B and C
0
1
2
3
4
5
6
Global score
0
1
2
3
4
Total
/20
55
REVIEW STATIONS
Discussion
What does this question test?
This question tests the ability of the candidate to take a basic obstetric history and, in so doing, establish the risks for this patient and her pregnancy. Once the correct questions have been asked, any relevant investigations and appropriate management should ensue. It is looking at a patient who has a high risk of sexually transmitted disease, risk of an abnormal smear and also the possibility of drug abuse and the problems that may ensue in a pregnancy. The examination is taken to be normal and so there should be no interaction with the examiner, whose role is to mark according to the prescribed mark sheet. The role-player has been given a scenario and will answer questions when asked. She will have been briefed as to how much help to give candidates and in some cases will have specific questions to ask candidates in order to help them with the questions. If the question does not have a bear-ing on the scenario, the role-player will answer that all is normal.
What are the pitfalls?
The major pitfall in an obstetric history-taking station is that, in the UK, a midwife takes most full obstetric histories so the candidate is not in the routine of taking a history. Key points are not asked, e.g. whether this was a planned pregnancy, occupation, menstrual history and smear history. A lot of antenatal care involves routine screening and it is important to appreciate this fact when it comes to taking a history. It is important to elicit risk factors, including tobacco and alcohol consumption. It is important to ask about ‘recreational drugs’ and it is best asked in those terms. As with any pregnancy, a plan of action needs to be formulated and a decision arrived at as to whether the pregnancy is high or low risk. Another major pitfall that arises in many of the role-playing stations is the use of medical jargon and especially abbreviations. The role-players are non-medical, in order to simulate a real clinic setting, and they may not understand medical terms. They will pick you up on this, making you feel rather silly for using such words.
Advice
This patient may seem to be a nightmare patient but it is important to go back to the instructions and what is required. Get into the habit of taking routine obstetric histories and formulating plans for the pregnancy in the 14 minutes allocated. It is also useful to go through booking notes in antenatal clinic to assess risk factors.
Most history-taking questions are relatively straightforward, although in an OSCE situation there may be some kind of twist in the story. The role-player may have been primed to ask appropriate questions to steer you on track.
Be aware of the routine screening blood tests that are performed in the UK.
56
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Circuit A
58
Circuit A, Station 1
Breaking bad news – cancer
Candidate’s instructions
You are the registrar in the gynaecological outpatient clinic and you are about to see Ms Kylie Spears, a 40-year-old single woman who underwent a hysteroscopy and curettage 2 weeks ago and is here to obtain the results. She has had a history of heavy, irregular vaginal bleeding for the past 3 months and was treated by her GP
with a course of oral contraceptive pills with no relief. She was subsequently referred to this hospital for further investigation. Below is the histology report.
Please counsel Ms Spears. THIS IS A COUNSELLING STATION.
Four Mills District Hospital, Leicestershire Department of Pathology
Patient name: Kylie Spears
ID no.: T7785254
Age: 40
Date: 28 December 2004
Specimen: endometrial curettings
Histology report
Moderately differentiated adenocarcinoma of the endometrium Verified by:
……………………….
Dr Nisha Khan
MRC Path.
YOU WILL BE MARKED ACCORDING TO YOUR ABILITY TO EXTRACT
THE RELEVANT HISTORY AND EXPLAIN THE DIAGNOSIS AND TREATMENT
59
CIRCUIT A
Role-player’s instructions
●
You are Ms Kylie Spears, a 40-year-old primary school teacher.
●
You are single, not sexually active and will be married to your fiancé, Richard, in 6 months.
●
You love children and plan to have three.
●
You currently live with your parents and three brothers and you are close to your family.
●
Your menarche (first period) was at age 10. Your periods are irregular with each cycle lasting 1–6 months. Your periods last 4–5 days and are not heavy.
You have mild, tolerable dysmenorrhoea. You have always thought this pat-tern of periods was normal.
●
You have never used contraception and have never had a cervical smear.
●
You have not taken any regular medication except in the last 3 months.
●
You have not noticed any weight changes but have always been chubby. You have not noticed any increased hair growth.
●
You do not smoke, and drink socially occasionally.
●
Four months ago, your periods suddenly became frequent, occurring every few days and heavy with clots.
●
There was no abdominal pain.
●
You saw your GP, who prescribed a course of the combined oral contraceptive pill for the past 3 months.
●
The medication reduced the flow of the periods but there was still daily vaginal spotting.
●
You were then referred to this hospital for a hysteroscopy and D&C.
●
You are well after the D&C. There are no abdominal pains or vaginal discharge but you continue to have daily vaginal spotting.
●
You are worried about the result of the operation.
●
You are extremely upset about learning of the cancer, especially when you are to be married and plan to have children.
●
You are suspicious that your GP had treated your symptoms conservatively for 3 months and that that time had made a difference to the stage of the disease.
Prompt questions
●
What is the result of the operation, doctor?
●
Is it cancer? Is it curable?
●
Is there no way for me to have children in the future?
●
Why has this happened to me?
●
What are the risks of the surgery?
●
What are the risks and side-effects of radiotherapy?
●
Why didn’t my GP refer me earlier – I may not have got cancer?
60
BREAKING BAD NEWS – CANCER
Mark sheet
Relevant history
●
Menstrual history – previous irregular, long cycles, never took medication except the OCP in the last 12 months
●
Risk factors – no diabetes mellitus, non-smoker, non-drinker, nulliparous
●
No family history of any cancers
●
Fertility desires – to be married in 6 months. Wants to have children
●
Social support – financially stable. Good family support. Good relationship with parents and siblings
●
No previous medical/surgical history
0
1
2