Questions/remarks
●
‘Why did this happen when she had some monitoring the day before and the doctor at that time said everything was all right?’
●
‘Who is to blame and what are you going to do about it?’
●
‘I’m going to complain and go to the papers. This shouldn’t happen in this day and age. I am going to sue this hospital.’
●
‘I want to see the boss man.’
88
BEREAVEMENT
Mark sheet
Communication skills
●
Appropriate introduction
●
Sympathetic approach – not responding aggressively
●
Expression of sympathy
●
Allowing husband to talk – not interrupting
●
Asking about his wife and how they are coping as a couple
●
Maintaining eye contact
●
Trying to defuse anger
0
1
2
3
4
5
6
Dealing with the case
●
Recognizing IUGR
●
Fetal demise may have been due to IUGR which may have been PET-induced
●
Cord around fetus may be causal or incidental
●
Explanation of postmortem findings, avoiding medical jargon
●
Advice for future pregnancy, including aspirin, folic acid, serial scans 0
1
2
3
4
5
Advice/comments
●
Not incriminating colleagues
●
Not becoming agitated at mention of suing
●
Explain access to complaints procedure
●
Offer to meet again with his wife and the carers
●
Offer to discuss management in a further pregnancy 0
1
2
3
4
5
Global score
0
1
2
3
4
Totaclass="underline"
/20
89
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Circuit A, Station 9
Emergency contraception
Candidate’s instructions
The patient you are about to see has attended the gynaecological ward for emergency contraception. She is Ruth Hale and is 31 years old. You are the registrar on call and the staff on the ward would like you to see her as they are short-staffed and, due to bed shortages, the ward is full of elderly patients. They are very busy and unable to deal with this patient unless she waits a considerable time.
MARKS WILL BE AWARDED FOR:
●
Taking an appropriate history
●
Counselling her appropriately
●
Discussing appropriate examinations
91
CIRCUIT A
Role-player’s instructions
You are Ruth Hale, a 31-year-old librarian. You live at home with your aged parents but were coerced into going out on a hen party last night. You got a bit drunk and became quite disinhibited. Your friends set you up with the male stripper who had been the entertainment at the party, which was held in one of your colleague’s houses. One thing led to another and you had unprotected intercourse with him.
This is unusual behaviour for you as you have only had one sexual partner in the past, and that was soon after you finished university.
Your last period was 2 weeks ago, your cycle is usually about 28–30 days and you usually bleed for 5 days. You have never had any pregnancies or gynaecological problems in the past. You do, however, suffer intermittently from migraine. You have no known allergies and are not taking any medication.
It is now about 12 hours since you had intercourse and you are still a little hung over and also disinhibited, so may be a bit crude and graphic about what happened.
You do not feel you could cope with the embarrassment of being pregnant at this stage in your life, although you would love to become pregnant at some stage.
Questions
●
‘What methods are there?’
●
‘What is the failure rate?’
●
‘What happens if it fails, would it affect the baby?’
●
‘You won’t have to examine me will you?’
●
‘This is confidential isn’t it?’
92
EMERGENCY CONTRACEPTION
Examiner’s instructions
History
●
LMP and check it was normal
●
Patient’s cycle
●
Calculate date of ovulation
●
Hasn’t had sex for many years
●
Days in the cycle of unprotected sex
●
Number of hours since episode of unprotected sex
●
Current method of contraception
●
Any potential contraindications
0
1
2
3
4
5
6
Counselling
●
Methods available, mode of action and risks
●
Levonelle better efficacy than PC4, 0.75 mg × 2, 12 hours apart, or IUD time limit 5 days
●
Failure rate and implications
●
Attitude to possible pregnancy if method fails
●
Importance of follow-up
●
Make final decision about PCC
●
Warn about action if vomiting occurs (if within 2 hours with levonelle then take second dose and get a repeat prescription)
●
Discuss contraception in current cycle
●
Long-term contraception needs
●
Keep accurate records, time and date
●
Discuss STD screening
0
1
2
3
4
5
6
7
Vaginal examination
●
May reveal concealed pregnancy
●
May reveal possible infection
●
Do microbiological swabs
●
IUD suitability
0
1
2
3
Global score
0
1
2
3
4
Totaclass="underline"
/20
93
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Circuit A, Station 10
Intermenstrual bleeding
Candidate’s instructions
The patient you are about to see has been referred to your outpatients clinic by her general practitioner. A copy of the referral letter is given below.
Read the letter and obtain a relevant history from the patient. You should discuss with the patient any relevant investigations and management options that you feel may be indicated.
The Surgery
Lauriston Rd,
Hackney
London E9
Dear Doctor
Re: Hetty Buckingham
23-07-70
Would you please see this patient who seems to have been getting some intermenstrual bleeding over the last 12 months. She has a BMI of 23 and pelvic examination was normal and, in particular, the cervix looked normal.
Yours sincerely
Dr A.P. Rilfool MRCGP
MARKS WILL BE AWARDED FOR:
●
Taking an appropriate history
●
Discussing appropriate investigations
●
Discussing appropriate management options
95
CIRCUIT A
Role-player’s instructions
●
You are Hetty Buckingham, a 34-year-old accountant in a stable relationship.
You have a 4-year-old son who was a normal delivery and he weighed 3.2 kg.
●
You have been on the OCP (microgynon) for many years and it has always suited you. You were recently diagnosed as epileptic and started on some medication for this condition. You are vague about the epilepsy and only mention it if asked. You are currently taking carbamazepine 200 mg daily.
You have noticed recently that you have become a bit forgetful and occasionally forget to take the odd OCP.