Postoperative care/future pregnancy (thromboprophylaxis, ELP no use, decision re.
mode of subsequent delivery)
0
1
2
Global score
0
1
2
3
4
Total
/20
119
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Circuit B, Station 6
Abnormal smear
Candidate’s instructions
The general practitioner has referred the patient you are about to see to your colposcopy clinic. A copy of the referral letter is given below. 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.
The Surgery
High Rd
Buckhurst Hill
Dear Doctor
Re: Mrs Joan Starr (23.10.74)
I would be pleased if you could see this patient whose recent cervical smear result showed severe dyskaryosis with wart viral infection.
She is nulliparous and the rest of her medical history is unremarkable.
Yours sincerely
Dr S. White
MARKS WILL BE AWARDED FOR:
●
Relevant history-taking
●
Explaining result
●
Discussion of relevant treatment options
You have 14 minutes.
121
CIRCUIT B
Role-player’s instructions
You are Joan Sturr, a 30-year-old woman who works as a secretary. You have been completely freaked out by your abnormal smear result and have two things on your mind:
●
You think this result means that you have got cancer.
●
Your partner (husband) has been unfaithful and has given you the wart virus, and this is entirely his fault.
You are completely asymptomatic; you have never been pregnant and have never had any sexually transmitted diseases. You have only ever had three sexual partners and do not really like talking about sexual matters. You are, however, taking the pill but no other medication and have no other medical history of note. You smoke 20
cigarettes per day but this has recently increased since discovering the smear result.
You are anxious to know more about the procedure of colposcopy: will it hurt and how long will it take for the results? You want to know the treatment options and might consider alternative therapies because you are afraid of hospitals. Your mother died from breast cancer at the age of 54 years. You are also anxious about your fertility as you were planning to stop the pill to try for a pregnancy and only had the smear taken to check all was well before doing so. This is your first smear.
122
ABNORMAL SMEAR
Examiner’s instructions
At this station, the candidate will have 14 minutes to obtain a history relevant to the patient’s complaint. The candidate should also discuss with the patient what colposcopy entails and that a biopsy may be necessary.
The candidate needs to explain to the patient that cytology is looking for a premalignant lesion, and to sensibly explain what the term ‘wart virus infection’
means.
123
CIRCUIT B
Mark sheet
History
●
Symptoms IMB/PCB
●
Basic gynaecological history/contraception
●
Obstetric history
●
Genital tract infections
●
Family and social history, including smoking
●
Allergies, especially to iodine and peanut oil if sultrin cream to be used 0
1
2
3
4
5
6
Colposcopy counselling
●
Explains what happens – looking at the transformation zone and why
●
Biopsy needed
●
Usually gives a good idea of what is going on by the end of the procedure
●
Explains that the screening programme is looking for premalignant disease
●
This smear result is suggestive of precancer
●
More than likely needs treatment
●
Avoids blaming any particular partner
0
1
2
3
4
5
Treatment
●
Advises stopping smoking and why
●
Explains about LLTZ and that it could be done as an outpatient or GA
●
Could see and treat at this procedure but would depend on colposcopic findings
●
Need for follow-up after treatment
●
At some point explains that this should not affect her fertility 0
1
2
3
4
5
Global score
0
1
2
3
4
Totaclass="underline"
/20
124
Circuit B, Station 7
CTG abnormality
You are called to see Mrs Dunne in Room 4. She is a 22-year-old primip who is now term + 7 days in an otherwise uneventful first pregnancy. She was booked for induction of labour in 4 days’ time. She has presented with some irregular contractions, decreased fetal movements and a show. The midwife is worried about the CTG which she shows you.
You are asked to counsel the patient and her partner about the management of the labour. Her vital signs are normal. The cervix is 2 cm dilated but fully effaced and the head is 2 cm above the spines.
MARKS WILL BE AWARDED FOR:
●
Discussing the CTG
●
Discussing further management of this labour
You have 14 minutes at this station.
125
CIRCUIT B
Role-player’s brief
You are 22 years old and you live with your partner who works for Greenpeace. You had initially wanted a home birth with as little intervention as possible. You have been well throughout the pregnancy and noticed some tightenings during the night with a show and slight decrease in the baby’s movements. You are convinced it is a girl and keep calling her Flora.
Your partner is devoted to you and you are constantly looking to him for support. You are reluctant to be monitored and do so grudgingly for Flora’s sake, but feel that the whole of the medical profession is male-dominated and wants to do Caesarean sections on everyone.
You are concerned about the welfare of your baby and want the registrar to be very explicit about why he is worried about the trace. If he does not pick up on the severity of the trace, you need to get him to explain why it doesn’t look like the one in your pregnancy book.
126
CIRCUIT B
Mark sheet
Discusses CTG under broad headings
●
Define risk, decreased fetal movements and past due date
●
Contraction regularity
●
Baseline rate – tachycardia
●
Variability – reduced
●
Accelerations – none
●
Decelerations – shallow
●
Opinion – non-reassuring/abnormal
0
1
2
3
4
5
6
7
Concern about status of baby
●
Early stage of labour
●
Unable to do FBS
●
Possible diagnosis of abruptio or feto-maternal transfusion 0
1
2
3
4
Discusses LSCS
●
Type of anaesthesia (spinal vs. GA), allows partner to be present
●
Consent
●
Portrays the urgency of the situation
0
1
2
3
4
5
Global score
0
1
2
3
4
Totaclass="underline"
/20
128
Circuit B, Station 8
Down’s syndrome