●
You would like to know whether you are a carrier.
●
You would like to know if the disease can be detected in the baby and how it can be tested.
●
You would like to know how accurate is the testing.
76
PRENATAL COUNSELLING
Mark sheet
Relevant history
●
Age, parity and religion – 35 years old, para 0, Roman Catholic
●
Family history – mother has revealed to her that she had a brother who was affected with cystic fibrosis before she was born and passed away at age 6
●
No medical/surgical history of note
●
Husband’s age and race – aged 40 and is a Caucasian
●
History of cystic fibrosis in husband’s family – none of note 0
1
2
3
4
Explanation of the disease
●
Inherited disease, inherited in an autosomal recessive manner
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Affects lungs, digestion and reproduction
●
Basic problem is in the production of mucus and saliva, which leads to recurrent chest infections, indigestion and malnutrition. Intelligence is normal
●
Chronic condition requiring prolonged care and multiple hospital visits
●
Life expectancy – 20s to 30s
0
1
2
3
4
Chance of baby being affected
●
A child is affected if he or she inherits one affected gene from each parent and has two abnormal genes
●
With the history of her brother being affected, Ms Reid is either normal with no affected genes or a carrier with one affected gene
●
If she and her husband are both carriers, then the risk of the baby being affected is 25 per cent. The risk of the baby being a carrier is 50 per cent and the baby has a 25 per cent chance of being normal 0
1
2
3
Genetic testing
●
In a Caucasian population, the chance of a person being affected is 1 in 25.
●
Parental testing can be done to determine if a person is a carrier
●
Genetic testing identifies up to 90 per cent of all cystic fibrosis gene spontaneous mutations and may miss 10 per cent of mutations 77
CIRCUIT A
●
Testing if the baby is affected allows the parents to know if the pregnancy is affected and, if so, allows termination of the pregnancy if they are not prepared to care for such a child
●
Fetal testing can be done by testing the baby’s cells via one of two methods: amniocentesis or chorionic villous sampling
0
1
2
3
4
5
Global score
0
1
2
3
4
Totaclass="underline"
/20
78
Circuit A, Station 6
Obstetric emergency – uterine inversion
Candidate’s instructions
You are the registrar in charge of the labour ward. You are urgently called by the midwife. She has just discovered that a patient who had a vaginal delivery has collapsed.
YOU WILL BE MARKED ON YOUR ABILITY TO ANSWER THE
EXAMINER’S QUESTIONS REGARDING THE EMERGENCY OUTLINED
AND TO EXPLAIN HOW YOU WOULD SYSTEMATICALLY MANAGE IT
79
CIRCUIT A
Mark sheet
You arrive in the room and the midwife is there with the uterus inverted and placenta attached. The examiner’s questions are as follows:
‘What are your immediate management actions?’
●
This is an obstetric emergency and the candidate will go and see the patient immediately
●
Activate emergency code to mobilize SHO, anaesthetist, charge midwife
●
Establish and maintain airway of patient, begin chest compression if asystole.
An intravenous line should be started and blood for FBC, urea/electrolytes, liver function test, coagulation profile, uric acid level, hypocount, group and save should be taken
0
1
2
3
4
‘What is the subsequent management of this patient?’
●
Prompt gentle replacement of the uterine inversion manually – last out/first in method
●
Use of uterine relaxant, e.g. i.v. terbutaline 0.25 mg, or general anaesthesia in the operating theatre
●
Hydrostatic method (O’Sullivan’s method) – the inverted uterus is held within the vagina and warm saline infused (about 2 L is infused rapidly into the vagina)
●
If still unsuccessful, may need emergency laparotomy and replacement of uterus by traction on round ligaments
●
As a last resort, a Caesarean hysterectomy may be necessary
●
Once stable, correction of anaemia or coagulopathy with blood and fresh frozen plasma, if necessary
●
Use of oxytocin drip should be started to maintain uterine contractility
●
Observation in high-dependency unit for hourly BP, HR and urine output measurements
●
Antibiotic cover should be started
●
TED stockings
0
1
2
3
4
5
6
7
8
80
OBSTETRIC EMERGENCY – UTERINE INVERSION
‘Other management steps?’
●
Inform consultant
●
Inform patient’s partner or next of kin and warn them of preventive steps at next delivery, i.e. controlled cord traction with fundal guarding in the third stage of labour
●
Record the events systematically and chronologically in the case notes
●
Record the events in an ‘incident report’ form
0
1
2
3
4
Global score
0
1
2
3
4
Totaclass="underline"
/20
81
Circuit A, Station 7
Operating list – prioritization
Candidate’s instructions
You are asked to go through a consultant’s gynaecology waiting list and advise the waiting list manager on:
●
appropriate procedure(s) (operation and others)
●
venue of proposed treatment (outpatients department, day unit, in-patient)
●
special needs (if any)
●
priority of assignment – routine (within 6 months), soon (within 12 weeks), urgent (within 4 weeks).
Please describe your action and offer an explanation wherever appropriate. You will have 15 minutes to review this list and will discuss it at the next station with the examiner.
YOU WILL BE AWARDED MARKS FOR YOUR ABILITY TO MANAGE AND
PRIORITIZE THE CASES
82
Waiting list for operations (candidate’s information) Name
Age
Details
Operation and logical action
Venue
Special needs
Priority
JA
28
Deep dyspareunia, menorrhagia, ovarian cyst
(8 cm) (scan suggests benign cyst)
AB
42
Large pelvic mass. Likely ovarian cyst
CA125 = 45 IU/mL
JF
18
Recent abnormal smear. Cervical biopsy CIN3.
Requests treatment under GA
PH
30
P3+1. Recent TOP. History of subacute-bacterial endocarditis and DVT. Wishes laparoscopic
sterilization
PR
18
Primary amenorrhoea/cyclical pain. Ultrasound
– distended vagina
KR
32
P5+0. Missing IUCD. Caring for invalid child
(IUCD in abdominal cavity)
QT
44
Fibroid uterus. Menorrhagia. Haemoglobin 8.1,
Jehovah’s Witness