Social history – smoker
●
Previous menstrual history
– CDH
– infertility
0
1
2
3
4
Presenting complaint
●
Gestation
●
Premature rupture of membranes
●
Contractions?
●
Sequence/timing
Current pregnancy
●
IVF + ICSI
●
LMP/EDD
●
AFP/triple test
●
CVS
●
Ultrasound scan
0
1
2
3
4
Management
●
Admit
●
Steroids
●
Regular scan
●
Monitor WBC, CRP
●
CTG
●
Expectant management
●
Antibiotics
0
1
2
3
4
69
CIRCUIT A
Communication
●
Empathetic
●
Concise but clear information
●
Arranges neonatal paediatrician to visit
●
Allows patient to express anxieties
0
1
2
3
4
Global score
0
1
2
3
4
Total score
/20
70
Circuit A, Station 4
Management problem – gynaecology
Candidate’s instructions
A 45-year-old nulliparous female solicitor, Ms Marianne Brighton, has been referred to you by the GP complaining of painful heavy periods. She bleeds for 10
days every month and has so much pain that she is bedridden throughout her period. She has regular cervical smears, all of which have been normal.
Four years ago she had a lumpectomy for breast cancer and is now on tamoxifen.
She smokes 20 cigarettes a day and is otherwise well. She is fed up and wants something done.
You have examined her and found:
●
BMI = 30 kg/m2
●
Soft, obese, distended abdomen
●
18-week-sized irregular abdomino-pelvic mass, confirmed to be fibroids on ultrasound scan – anterior fundal fibroid (12 × 8 × 6 cm); submucosal fibroid (3 × 4 × 4 cm).
You are about to see the patient. Ask her relevant questions and then outline the options, discussing any risks involved.
MARKS WILL BE AWARDED FOR YOUR ABILITY TO TAKE A RELEVANT
HISTORY AND DESCRIBE MANAGEMENT OPTIONS
71
CIRCUIT A
Role-player’s instructions
●
You are Ms Marianne Brighton, a 45-year-old solicitor.
●
For the last 3 years you have had very heavy menstrual periods, bleeding for 10 days every month and the pain throughout the periods is unbearable. You even go to bed during your periods as the pain is so bad.
●
Periods are regular.
●
You have been told that your womb is enlarged and sometimes you feel that there is pressure on your bladder as you have to pass urine frequently.
●
You have never tried to get pregnant as you still have not met the right man.
You have had partners in the past but none at the moment. You accept that you may not get pregnant and will consider a hysterectomy.
●
You are pretty well but 4 years ago had breast cancer and had a lumpectomy and you have been on tamofixen ever since.
●
You have had regular Pap smears, which were normal.
●
You smoke 20 cigarettes a day.
●
Allergic to amoxil – you get a rash.
●
Family history of ovarian cancer – mother and maternal aunt.
72
MANAGEMENT PROBLEM – GYNAECOLOGY
Mark sheet
Enquires about the relevant past history
●
Past obstetric and gynaecological history – nulliparous
●
Other treatments that have been tried?
●
Stable relationship?
●
Prospects for children? Is family complete?
●
Pressure symptoms?
0
1
2
3
4
Which surgical procedure (need endometrial biopsy first)?
●
Hysteroscopy – resection of submucosal fibroid may be an option
●
Myomectomy
●
Subtotal hysterectomy ± Bilateral salpingo oopherectomy (BSO)
●
Total abdominal hysterectomy ± BSO
●
Other options:
– arterial embolization
– do nothing
0
1
2
3
4
Risk of procedures
Immediate
●
Anaesthetic
●
Bladder/bowel injury
●
Haemorrhage
●
Risk of unwanted hysterectomy (for hysteroscopy and myomectomy) Intermediate
●
DVT/PE
●
Bladder problems
●
Infection
Long term
●
DVT/PE
●
Bladder problems
●
Psychosexual – loss of womanhood
0
1
2
3
4
73
CIRCUIT A
Advantages and disadvantages of procedures
●
Hysteroscopy – less invasive but may need further procedure as pressure symptoms won’t be improved
●
Myomectomy – will preserve fertility but must understand chance of hysterectomy and massive bleeding
●
Subtotal hysterectomy – (+ total abdominal) both may have premature menopause; subtotal is the easier operation, there are fewer bladder problems postoperatively and ?better sexual function; however, cervix remains – potential site of cancer, ? may still bleed
●
Other options – still in research arena
0
1
2
3
4
Global score
0
1
2
3
4
Totaclass="underline"
/20
74
Circuit A, Station 5
Prenatal counselling
Candidate’s instructions
You are the registrar in the antenatal clinic. Please see Ms Anna Reid, a 35-year-old Caucasian woman who has been married for the past year and is planning her first pregnancy. She is keen to find out more about genetic testing for cystic fibrosis. You are asked to take a relevant history from this patient and address her concerns.
YOU WILL BE MARKED ON YOUR COMMUNICATION SKILLS AND
YOUR ABILITY TO EXPLAIN TO HER ABOUT THE DISEASE OF CYSTIC
FIBROSIS AND THE RISKS OF HER BABY BEING AFFECTED WITH
CYSTIC FIBROSIS
75
CIRCUIT A
Role-player’s instructions
Profile
●
You are Ms Anna Reid. You are 35 years old, married for the past year and are now keen to start a family. You have never been pregnant before.
●
You are Roman Catholic by religion.
●
A few months ago, your mother revealed to you that she had a brother who was affected with cystic fibrosis before she was born and passed away at age 6
years, before you were born.
●
Your periods are regular, normal flow, no dysmenorrhoea. Your last cervical smear was 12 months ago and was normal. You have not used any form of contraception.
●
You have no medical/surgical history of note.
●
Your husband, Alan, is aged 40 and is a Caucasian. He is Protestant by religion.
●
As far as you know, his family has no history of cystic fibrosis.
Concerns about the disease which need to be addressed
●
You are worried about the possibility of your child being affected with cystic fibrosis.
●
You would like to know more about the disease.