2
3
4
5
Follow-up
●
Offers to meet mother ± father with the daughter, but would only talk about medical problems with the daughter’s consent and ideally in person. Verbal consent to mother is not adequate
●
Is explicit about the confidentiality aspect of the patient/doctor relationship 0
1
2
3
Global score (overall competency)
0
1
2
3
4
Totaclass="underline"
/20
143
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Circuit C, Station 2
Shoulder dystocia
Candidate’s instructions
Delivery unit emergency calclass="underline" ‘Doctor, please come to Room 4 immediately, as Mrs Pearson, gravida 2, para 1, has delivered the head but the shoulders are stuck.’
You are the doctor called to this delivery. Discuss with the examiner how you would proceed. A doll and mannequin have been provided for you to demonstrate the delivery.
YOU WILL BE MARKED ON YOUR ABILITY TO DEMONSTRATE YOUR
PRACTICAL SKILLS
You have 14 minutes.
145
CIRCUIT C
Examiner’s instructions
Say to the candidate: ‘Take me through what you would do, and how you would deliver.’ You should ask the candidate to deliver the doll.
After the candidate has finished, ask the following questions:
●
at what speed does the cord pH drop?
●
what are the predisposing factors to shoulder dystocia?
●
what is occurrence of shoulder dystocia in normal weight babies?
●
how would you repair the third-degree tear?
146
SHOULDER DYSTOCIA
Mark sheet
Management of shoulder dystocia
H
Call for help, anaesthetist, paediatrician
E
Evaluate for episiotomy and extend if possible
L
Legs McRoberts manoeuvre (hyperflexion of the hips) P
Pressure, external pressure, understanding of the direction of pressure, i.e. the posterior aspect of the shoulder
E
Enter Wood’s Screw Manoeuvre
R
Rotate posterior shoulder to anterior
R
Roll over onto all fours
Continue each for 30 seconds before moving onto the manoeuvre. Understands the importance of moving the shoulder anteriorly across the abdomen to narrow the diameter. Pushing it in the opposite direction increases the diameter.
0
1
2
3
4
5
6
7
8
9
After the candidate has finished, the following should be asked:
●
The speed at which the cord pH drops
●
The predisposing factors to shoulder dystocia
●
Occurrence in normal weight babies
– The cord pH falls 0.04 per minute
– 50% occur with a normal weight
– Predisposing factors GDM, raised BMI of mother, large baby, postmaturity 0
1
2
3
●
How do you repair the third degree tear and what postoperative management do you advise?
– Describes overlap method or end-to-end (no reliable evidence to show that either is superior)
– Preferably do repair in operating theatre under regional or general anaesthesia
– PDS is superior to catgut or polyglactin as it is associated with less infection and better long-term function of the anal sphincter complex. (Catgut no longer on UK market)
– Broad spectrum antibiotics should be given intra-operatively and postoperatively
– Post-operative laxatives are associated with less post-operative wound dehiscence
– Risk management form and needs postnatal follow-up appointment
– All women with a third degree tear should be seen at 6–12 months by a 147
CIRCUIT C
gynaecologist with an interest in anal-rectal dysfunction or a colorectal surgeon
0
1
2
3
4
Global score
0
1
2
3
4
Total Score:
/20
148
Circuit C, Station 3
Breaking bad news – ovarian cancer
Candidate’s instructions
The next patient has been sent down from the general surgical ward to your ‘fast-track’ clinic. She is Mrs Julie Dunlop, aged 45 years, and she was originally referred with a history of dyspepsia, flatulence, some weight loss and a slightly bloated abdomen. She was admitted via A&E with abdominal pain. On rectal examination she was found to have a mass in the pelvis.
An ultrasound scan of the abdomen and pelvis shows a complex mass 8 cm in diameter in the pelvis consistent with a lesion arising from the left ovary. There is a fair degree of free fluid, presumably ascites. A chest X-ray is normal. The CA125
level is 890, and the rest of her blood tests are normal. A CT scan is due to be performed after the clinic visit.
The most likely diagnosis is that of ovarian carcinoma until proved otherwise.
Mrs Dunlop is not aware of this tentative diagnosis and has been told that she ‘has a cyst that the gynaecology people will sort out for you’.
Your remit is to tell her the most likely diagnosis and outline her further management.
MARKS WILL BE AWARDED FOR:
●
Explanation of the possible diagnosis
●
Treatment of this presumptive diagnosis
You have 14 minutes.
149
CIRCUIT C
Role-player’s instructions
You are Mrs Julie Dunlop, a 45-year-old housewife with two children aged 12 and 14 years. You have been feeling run-down but felt that it was due to some sleepless nights with your 14-year-old. You have noticed some heartburn and increase in flatulence. You feel that you may have lost weight but your jeans and skirts seem tighter.
You initially thought you might have an ulcer and so were referred to the surgeons. The diagnosis as far as you are concerned is that of an ovarian cyst. The idea of cancer had never entered your head. You become panic-stricken at the thought of what is going to happen to your children.
You keep asking whether the doctor is sure of the diagnosis, and aren’t there tablets one can take. You are very apprehensive about surgery. You also mention that you knew someone in the street who had ovarian cancer and she was dead by the Christmas when her operation was in September.
When the doctor mentions chemotherapy, you keep asking whether you are going to lose your hair. You may at this stage ask about your outlook and you may be very specific about life expectancy.
150
BREAKING BAD NEWS – OVARIAN CANCER
Mark sheet
Explains the diagnosis is possible ovarian cancer
●
Explains the scan report
●
The significance of the CA125 – sensitive but not always specific
●
Avoids non-medical language and emphasizes keeping the patient informed
●
Acknowledges the difficulty of taking in the information
●
Explains that the good news is that something can be done and discusses outlook realistically
●
Treatment would be undertaken in a gynaecological cancer centre – mention cancer centre and unit
●
May discuss a differential diagnosis, including endometriosis, fibroma or a possible tumour elsewhere
●
Allows patient to ask questions
0
1
2
3
4
5
6
7
May need more imaging CT scan abdominal/pelvis and chest X-rays.
Treatment
●
Explains surgery, TAH, BSO and omentectomy, appendicectomy