You have 14 minutes to obtain a history from the patient. You seek information relevant to her current pregnancy, determine the reason for her admission and formulate a management plan.
Examination reveals normal vital signs, her urine is normal. On abdominal palpation, the uterus is equivalent to her dates with a breech presentation. On vaginal examination, the cervix is effaced but not dilated, presenting part at the level of spines with intact membranes. An obstetric calculator is supplied.
YOU WILL BE AWARDED MARKS FOR YOUR ABILITY TO:
●
Take a history
●
Make a diagnosis
●
Formulate a management plan
105
CIRCUIT B
Role-player’s instructions
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Disinterested attitude and awkward to the point of being obstructive, but in pain.
●
You are 21 years old; this is your second pregnancy, which has reached 29
weeks.
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LMP – date of exam minus 29 weeks, giving appropriate EDD.
●
This pregnancy is unplanned, resulting from a casual relationship and failed barrier contraception. Your previous pregnancy was terminated at 8 weeks as you were then 15 years old and still at school.
●
You booked at the maternity unit at 16 weeks.
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All the blood tests were normal.
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Antenatal care has been shared with your general practitioner.
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Ultrasound at 18 weeks showed a normally grown fetus equivalent to your dates. The ultrasonographer noted the presence of a choroid plexus cyst. You were seen by the consultant and reassured. Rescan at 24 weeks did not show any choroid plexus cyst.
●
The day before admission you had felt generally unwell with crampy abdominal pains. Several hours prior to admission you developed abdominal pains that were intermittent and are now lasting about 30 seconds with 2–3 minutes in between. You have also had some vaginal discharge that is slimy with some bloodstaining.
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Personal – single, unemployed live at home with parents, three brothers and two sisters. You are the eldest.
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Family – mother is a non-identical twin.
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Social – you smoke 20 cigarettes per day, and drink alcohol at the weekends (six to seven bottles of lager), depending on the cash flow situation.
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Drugs – occasional ecstasy tablet but not since you found out you were pregnant. Never used i.v. drugs. Use inhalers (becotide and ventolin) for asthma.
●
You ask the candidate, ‘What is the cause of the pain?’
106
ABDOMINAL PAIN – PREMATURE LABOUR
Mark sheet
History
Presenting complaint
●
Duration of pregnancy
●
Contractions – sequence and timing
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‘Show’
Current pregnancy
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Unplanned
●
Shared care
●
LMP/EDD
●
Scan result
Past history
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Obstetric
●
Social
●
Drugs
●
Family
●
Medical
0
1
2
3
4
5
6
Provisional diagnosis
●
Preterm labour
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Investigate cause
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Infection
●
Differential diagnosis urine tract infection (UTI), appendicitis, concealed abruption or bowel problems
0
1
2
3
4
5
Treatment plan
●
Admit; discuss aims of treatment to prolong the pregnancy
●
Try to stop contractions
●
Steroids
●
Discuss with paeds
●
Mode of delivery
0
1
2
3
4
5
Global score
0
1
2
3
4
Total
/20
107
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Circuit B, Station 3
Urinary incontinence
Candidate’s instructions
The patient you are about to see was referred to your outpatient clinic by her general practitioner. A copy of the referral letter is given below. You should accept the GP’s examination findings as correct.
You have 14 minutes to read the letter and obtain a relevant history from the patient. You should discuss any relevant investigations and treatment that you feel may be indicated with the patient.
Dear Doctor
Please see Mrs Martha Black who is a part-time schoolteacher and who has been experiencing urinary incontinence for 4–5 years.
She can feel a lump coming down and it is affecting her lifestyle.
She is overweight and her current body mass index (BMI) is 32. General physical examination was normal, but she has a moderate cystourethrocele. A recent cervical smear test was normal, and an MSU showed E. coli.
Please see and treat as required.
Yours sincerely
Dr Beattie
YOU WILL BE AWARDED MARKS FOR:
●
Obtaining a relevant history from the patient
●
Discussing relevant investigations
●
Discussing appropriate management options
109
CIRCUIT B
Role-player’s instructions
●
You are Mrs Martha Black, a 53-year-old woman who works as a part-time schoolteacher. Your main problems are as follows:
– urinary frequency, passing urine eight to 10 times per day
– passing urine at night (nocturia) – two to three times per night
– no bedwetting
– when you’ve got to go, you’ve got to go, with occasional accidents of not getting there on time
– you leak when you cough, laugh, sneeze and run for a bus, and so do not do much exercise to try to reduce your weight as it is too embarrassing
– occasional stinging on passing urine.
●
You went through the menopause at age 48 years, with no gynaecological problems. You have had three children, all normal deliveries and all weighing over 4 kg. You remain sexually active.
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The rest of the history is unremarkable, although you smoke 20 cigarettes per day and seem to be always ‘chesty’.
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You are overweight but claim not to eat very much at all; you drink at least 10 cups of tea/coffee per day and have a cuppa just before going to bed.
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Whenever the doctor suggests investigations, you need to ask exactly what does it involve. Ask about how the bladder pressure studies are performed and why they are done.
110
URINARY INCONTINENCE
Mark sheet
Relevant history
●
Basic symptoms, frequency, nocturia, urgency, dysuria
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Incontinence type
●
Basic gynaecological history
●
Obstetric history, deliveries and size of babies
●
Food intake, especially quantity and timing of tea
●
Family and social history, including smoking
0
1
2
3
4
5
Relevant investigations
●
Repeat MSU to ensure it has been treated
●
Random blood sugar, or possibly a fasting one
●
Urodynamics – needs to explain what is done with a catheter in the bladder, transducer in the rectum and filling the bladder and looking at the voiding.
Not dignified but not painful. Need to ensure MSU negative before undertaking it
0
1
2
3
4
5