●
Accepts her wish for non-manipulation of the uterus 0
1
2
3
4
5
Communication
●
Explains that persistent ectopics can occur with laparoscopic conservative surgery for tubal ectopics
●
Does not blame previous surgeon for supposed negligence
●
Diffuses situation as much as can
●
Discusses IVF for future pregnancies
0
1
2
3
4
5
6
Global score
0
1
2
3
4
Totaclass="underline"
/20
27
REVIEW STATIONS
Discussion
What is this station testing?
This is a difficult situation where a previous operation has not been correctly performed. This station tests your ability to diffuse a situation where a woman is clearly very angry while at the same time not ‘bad-mouthing’ one of your colleagues. With regard to her anger, it is better to allow her to get angry at you and get it off her chest, and it is best for you to be a passive listener.
However, you do have to manage the case and you need to be quite clear in telling her what needs to be done, but you also need to accept her wish for a more conservative approach with regard to instrumenting the uterus and conservative surgery on the tubes. You also need to be quite clear that if she opts for conservative surgery again, not only is there a very small chance of the trophoblastic tissue persisting, but also, in the future, she has a further chance of an ectopic. If she was going for IVF then it is in her interests to have this tube removed.
What are the pitfalls?
It is very easy to say that the previous operation was not done correctly but you need to avoid saying this. You must take a focused history, as her past pregnancy history is very important here. There are therefore three aspects to this station and one of the pitfalls is not to cover them all. You need to take a focused history, explain what needs to be done now and discuss the prognosis for future pregnancies and how you can help her.
Preparation
These stations are difficult to prepare for because they do involve patients who are quite angry because something has gone wrong. The best way to practise this station is to ask a colleague to role-play the angry patient and try to deflate the situation.
28
Review station 6
Premenstrual syndrome
Candidate’s instructions
The patient you are about to see has been referred to your outpatient 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 any relevant investigations and treatment that you feel may be indicated.
Dear Gynaecologist
Re: Mrs Jodie Revell – DOB 23.06.70
I would be pleased if you would see this patient who has coerced me into referring her for a gynaecological opinion. She says that she has severe premenstrual symptoms. She does not seem to have responded to anything that I have prescribed her.
Many thanks.
Yours sincerely
Dr A. N. Other
YOU WILL BE MARKED ON YOUR ABILITY TO TAKE A RELEVANT
GYNAECOLOGY HISTORY AND DISCUSS INVESTIGATIONS AND
TREATMENT OPTIONS
29
REVIEW STATIONS
Role-player’s instructions
You are Jodie Revell, currently 34 years old, and you are completely fed up. You have terrible premenstrual symptoms and you have been to your GP many times for this but he just tries to fob you off. Your main symptoms are mood swings, irri-tability, pelvic pain and sometimes violent behaviour. Your relationship is almost in tatters because your partner is fed up with your behaviour. You are perfectly lovely for 3 weeks out of 4, but for 7 days before your period you turn into a completely different person.
You have had an episode of depression in the past but you don’t believe that there is anything psychiatrically wrong with you. You have been violent in the past and certainly have hit your partner on numerous occasions. You have tried the odd vitamin for premenstrual syndrome (PMS) but nobody has ever really explained it to you and you are just very fed up. You work as an assistant to a dental surgeon and you do find it extremely stressful as the practice is a very busy private practice and, as well as working very hard, you have to be sweet and nice to everybody all of the time otherwise your boss gets upset because his private practice, and therefore his income, is also dependent on your personality.
You had an unwanted pregnancy 6 years ago and you had a termination. You are currently using the mini-pill for contraception but you appear to have regular periods. You had chlamydia about 3 years ago and you have been with your current partner for 5 years. It always worried you that he had deviated when you found out that you had chlamydia.
You have no past medical or surgical history of note. Medications you take are Neurofen Extra premenstrually for the pelvic pain. You smoke 20 cigarettes a day and drink about 20 units of alcohol per week. You enjoy the odd joint of marijuana and have about three per week.
Family history – your mother suffered from severe depression and has been on antidepressants for some years.
30
PREMENSTRUAL SYNDROME
Examiner’s instructions
At this station, candidates will have 14 minutes to obtain a history relevant to the patient’s complaint. They should ask about clinical examination and then investigations that they think may be relevant, explaining them to the patient along the way. They should also discuss possible treatments.
31
REVIEW STATIONS
Mark sheet
History
●
History taking to elicit the actual symptoms
●
Important to establish that the symptoms are definitely premenstrual and disappear by the end of the period
●
Elicits the patient’s concerns about how the symptoms are affecting her home and professional life
0
1
2
3
4
5
Investigations
●
appreciates that there are no relevant investigations
●
explains this to patient
0
1
2
Management
●
Establishing the diagnosis by a symptom/visual analogue diary
●
Hierarchy of treatments
– counselling/education/reassurance/stress management and relaxation techniques
– pyridoxine/essential fatty acids
– selective serotonin reuptake inhibitors (SSRIs) – ensure that used specifi-cally for PMS and not depression in this case
– OCP/progesterone/danazol
– oestradiol patches (or implants) + cyclical progesterone
– gonadotrophin-releasing hormone (GnRH) analogues ± back therapy
– total abdominal hysterectomy (TAH) and bilateral salpingo-ophorectomy (BSO) followed by oestrogen hormone replacement therapy (HRT) 0
1
2
3
4
5
6
7
Communication
●
Discusses management in a non-confrontational and empathic way
●
Emphasizes attempts at stopping ovulation
0
1
2
Global score
0
1
2
3
4
Totaclass="underline"
/20
32
PREMENSTRUAL SYNDROME
Discussion
What is the station testing?
As with the station concerning antenatal history-taking, this station is testing your communication skills and ability to take a comprehensive gynaecology history of a difficult problem. In the referral letter, the GP has stated that he was not happy to refer her on to a specialist, so there are clearly problems in the interaction between the patient and her GP. This indicates that this will not be an easy consultation and you will need to be particularly good at communicating and being empathetic.