TN
82
Recent angina. Procidentia/lives
alone/incontinent (failed pessary)
TL
28
Laparoscopy for pain, previous laparotomy
(twice)
JB
22
Secondary subfertility – 3 years. Previous
ectopic
Examiner’s information
Waiting list for operations
Name
Age
Details
Operation and logical action
Venue
Special needs
Priority
JA
28
Deep dyspareunia, menorrhagia ovarian cyst
Hysteroscopy and laparoscopic
Day unit
Soon
(8 cm) (scan suggests benign cyst)
ovarian cystectomy
AB
42
Large pelvic mass. Likely ovarian cyst
Laparotomy. Consultant must
In-patient
Urgent
CA125 = 45 IU/mL
be present
JF
18
Recent abnormal smear. Cervical biopsy CIN3.
LLETZ
Day unit
Soon
Requests treatment under GA
PH
30
P3+1. Recent TOP. History of subacute-bacterial Laparoscopic sterilization,
Day unit
Soon
endocarditis and DVT. Wishes laparoscopic
antibiotic cover, anticoagulant
sterilization
PR
18
Primary amenorrhoea/cyclical pain. Ultrasound
Incise hymen
Day unit
Urgent
– distended vagina
KR
32
P5+0. Missing IUCD. Caring for invalid child
Laparoscopy? Proceed laparotomy
In-patient, but home
Good notice
Soon
(IUCD in abdominal cavity)
(consultant)
same day if possible
QT
44
Fibroid uterus. Menorrhagia. Haemoglobin 8.1,
LHRH analogues, iron tablets,
In-patient
Soon
Jehovah’s Witness
embolization, subtotal hysterectomy
TN
82
Recent angina (failed pessary). Procidentia/lives Vaginal hysterectomy, needs
In-patient
Arrange
Soon
alone/incontinent
preoperative assessment
postoperative care
TL
28
Laparoscopy for pain, previous laparotomy
Laparoscopy (consultant present)
In-patient
Warn re. risk
Routine
(twice)
of bowel damage
JB
22
Secondary subfertility – 3 years. Previous ectopic Laparoscopy dye, endometrial biopsy Day unit
Routine
OPERATING LIST – PRIORITIZATION
Mark sheet
Discuss each case briefly with regard to:
1. Logical action (operation and others)
2. Venue of proposed treatment
3. Special needs
4. Priority assignment
Global score
JA
0
1
2
3
4
AB
0
1
2
3
4
JF
0
1
2
3
4
PH
0
1
2
3
4
PR
0
1
2
3
4
KR
0
1
2
3
4
QT
0
1
2
3
4
TN
0
1
2
3
4
TL
0
1
2
3
4
JB
0
1
2
3
4
Totaclass="underline"
/40 → divide by 2
Final mark
/20
85
CIRCUIT A
Extra notes
The answers are not clear-cut so one needs to confirm that there is a common-sense approach, and this should be reflected in the global score for each case.
●
AB – it should be clear that a consultant must be present for this operation.
●
KR – this operation might be successfully done laparoscopically but if this proves impossible, a laparotomy may be necessary. The operative arrange-ments should reflect this, so it may be best to admit her as an in-patient on the understanding that, if a laparotomy proves unnecessary, she might go home on the same day. The special needs arrangement for the care of her invalid child would have to reflect the ‘worst’ scenario. Does she need the operation at all?
●
QT – the operation could include either TAH or subtotal TAH (not myomectomy). The candidate should discuss the preoperative treatment of the anaemia and the prerequisite of a normal blood count prior to surgery.
Although oral iron may be sufficient, the discussion should also include hormonal ovarian suppression if this fails. The special operation consent form is best done prior to admission.
●
TN – the use of anaesthetic preoperative assessment should be discussed.
●
TL – this patient is best admitted as an in-patient because of the possibility of bowel damage during laparoscopy. She should be warned of this risk.
●
JB – is this appropriate? Will need Chlamydia screening and prophylaxis.
●
JA – check CA125.
●
PH – mirena inserted under antibiotic cover may be a safer option.
86
Circuit A, Station 8
Bereavement
Candidate’s instructions
Mrs Tina Shoe was a 26-year-old primigravida who presented to the labour ward with a 24-hour history of decreased fetal movements at 39 weeks’ gestation. At that time her general observations were normal. Unfortunately the fetal heart could not be heard and an intrauterine fetal death was confirmed by ultrasound scan.
The pregnancy had been classed as ‘low risk’ and antenatal care provided by the community midwife and the GP. She had considered a home delivery. She was a bit of a worrier and had experienced some abdominal pain and had a CTG 24 hours prior to admission. At the time this was reported as normal, but on review it was less than optimal. She had been sent home.
Following the diagnosis of fetal demise, labour was induced and after 12 hours Mrs Shoe delivered a 2.3 kg macerated stillborn male infant with the cord wrapped tightly around the neck. The patient’s postnatal course was a little stormy, as her blood pressure was quite labile, rising to 140/100 with 2+ proteinuria. This settled after 36–48 hours.
At this station you will meet Mrs Shoe’s husband, who has come to see you 6 weeks after the event. His wife is physically well but has gone to stay with her mother in Bournemouth. The husband is very angry and is demanding an explanation for the death of his son.
Postmortem has shown an anatomically normal male infant weighing 2.3 kg. All fetal and maternal investigations were normal.
MARKS WILL BE AWARDED FOR YOUR ABILITY TO DEAL WITH A DIFFICULT SITUATION AND TO COUNSEL AN ANGRY BEREAVED
PERSON
87
CIRCUIT A
Role-player’s instructions
You are Mr Shoe and work as a window cleaner. You are at your wits end. Your wife has had a stillborn baby and she blames herself for it. She is a worrier and continued to smoke throughout the pregnancy but only 10 cigarettes/day. She has had to go to her mother’s house, as she cannot cope at home when you are out at work.
This event has put a real strain on the marriage and you feel she may never try for a baby again in case the same thing happens. Certainly sex is out of the question at the moment so you have to relieve yourself and you are getting fed up with it.
You cannot understand how this happened as the pregnancy had been considered low risk and you had even thought about a home delivery. You want to know if the midwife and GP did not provide the appropriate care. The baby seemed very small and you can’t understand why that wasn’t picked up – after all, she seemed to be down at the antenatal clinic for hours at a time. Why hadn’t she had more scans?