3
4
Explanation of histological report
●
Malignancy of lining of womb
●
Extent of disease unknown. Will need MRI prior to surgery
●
Need for total hysterectomy and bilateral salpingo-oophorectomy, possible lymph node dissection
●
Surgery procedure – GA, midline or phannenstiel incision and risks of surgery, i.e. anaesthetic risks, venous thromboembolism, bladder, bowel injury, bleeding, infection
0
1
2
3
4
Discusses consequences of treatment
●
No further fertility, menopause and consequent risk of osteoporosis, climacteric symptoms
●
Risk of HRT
●
Prognosis depends on staging. Varies from 95 per cent in stage 1 to 10 per cent in stage 4
●
May need postoperative radiotherapy depending on histology
●
Will need co-management with gynae-oncologist and treatment in a gynaecological cancer centre or unit dependent on MDT review 0
1
2
3
4
5
61
CIRCUIT A
Counselling
●
Addresses patient’s concern about GP’s initial conservative management
●
Offers counselling to cope with news
0
1
2
3
Global score
0
1
2
3
4
Total mark:
/20
62
Circuit A, Station 2
Preoperative ward round
Candidate’s instructions
You are the registrar responsible for the following morning’s operating list. Your consultant will be in the hospital but has an important meeting and would prefer not to be disturbed. You now have to do the preoperative ward round. There are three patients on the list:
●
Mrs Andrews – a 42-year-old for a total abdominal hysterectomy
●
Mrs Devine – a 35-year-old for a diagnostic laparoscopy
●
Mrs Norman – a 35-year-old for a resection of a submucosal fibroid.
You are about to meet the examiner. He will ask you some questions about what you would normally do with each patient preoperatively.
63
CIRCUIT A
Examiner’s instructions
Please ask the candidate the following:
●
Mrs Andrews is 42 years old with a 20-week fibroid uterus for a total abdominal hysterectomy.
– What relevant history do you want to know?
– what symptoms she is having?
– is she still premenopausal?
– previous surgery?
– has subtotal been discussed?
– What results of investigations would you like to know?
– USS
– Hb
– pregnancy test
– cervical smear
– What would you discuss with her?
– does she know what operation she is having?
– confirm ovarian conservation has been discussed
– discuss incision – vertical
– What would you warn her of?
– haemorrhage
– bowel/bladder trauma
– catheter postop
– i.v. line
– drain
– Anything else you would do?
– examine her abdomen
– ask if she had any questions
0
1
2
3
4
5
6
●
Mrs Devine is a 33-year-old woman who is having a laparoscopy for right-sided pelvic pain (? endometriosis).
– What relevant history do you want to know
– nature of pain
– exact site of pain
– past O&G history
– past surgery
– What results of investigations would you like to know?
– USS
– Hb
– pregnancy test
– cervical smear
– What would you discuss with her?
– does she know what operation she is having?
– if endometriosis is found diathermy would be useful 64
PREOPERATIVE WARD ROUND
– What would you warn her of?
– bowel/bladder trauma
– where incisions will be
– Anything else you would do?
– examine her abdomen
– ask if she had any questions
– go through consent form with her
0
1
2
3
4
5
●
Mrs Norman is a 35-year-old woman who has a 3-cm-diameter submucosal fibroid that has been causing her regular heavy periods.
– Any relevant history you would like to know?
– any previous O&G history
– any previous surgery
– What results of investigations would you like to know?
– Hb
– USS
– pregnancy test
– cervical smear
– What would you check she has had preoperatively?
– GnRH agonists
– What would you warn her of?
– uterine perforation which would then require a laparoscopy
– Anything else you would do?
– examine her abdomen
– ask if she had any questions
– go through consent form with her
0
1
2
3
4
5
Global scale
0
1
2
3
4
Total score
/20
65
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Circuit A, Station 3
Obstetric history and management
The patient, Shirley Wright, you are about to see has just been admitted to your maternity unit. The midwife is concerned about her and no other doctor is available to see her at present. You have 14 minutes to obtain a history from the patient and outline the plan of management.
THIS STATION TESTS YOUR ABILITY TO TAKE AN OBSTETRIC HISTORY
AND YOUR COMMUNICATION SKILLS WITH REGARD TO MANAGEMENT
67
CIRCUIT A
Role-player’s instructions
●
You are 39 years old and this is your second pregnancy and you have reached 26 weeks’ gestation:
LMP = 29 weeks earlier
EDD = 11 weeks later
●
This pregnancy is the result of in vitro fertilization and intracytoplasmic sperm injection (third attempt) after 5 years of infertility due to severe problems with the quality of your partner’s sperm.
●
Your first pregnancy was at the age of 17 and you had a termination.
●
You booked at the maternity hospital at 12 weeks’ gestation.
●
Triple test at 15 weeks, risk of Down’s syndrome 1 in 175.
●
Serum AFP within normal range.
●
Chorionic villous sampling at 11 weeks uneventful. Result – normal male karyotype.
●
Ultrasound at 18 weeks normal.
●
The day before admission you felt generally unwell, (feverish, tired). Several hours prior to admission you experienced a gush of fluid vaginally and there has been persistent vaginal dampness since.
●
Now aware of lower abdominal cramps.
●
Personal – married, secretary.
●
Family – mother has IDDM.
●
Sister with spina bifida, sister had DVT while on OCP.
●
Social – smoke 10 cigarettes/day.
●
< 5 units of alcohol per week.
●
Drugs – folic acid.
●
PMH – congenital dislocation of the hip as a baby, and have had recurring hip problems since.
Role-player’s attitude
You are very worried about your situation and fear that you are going to lose your baby. You continually seek reassurance from the doctor.
68
OBSTETRIC HISTORY AND MANAGEMENT
Mark sheet
History
●
Personal details – TOP
●
Family history:
– IDDM
– NTD
– DVT
●