The major pitfall in all counselling questions is that the candidate fails to read the question properly and consequently does not answer it. When in doubt candidates revert to history-taking with which they feel comfortable. No history is required here; it is not relevant. There is no doubt about the diagnosis, but there is a tendency for candidates to give erroneous information to the role-player. It is also important to know the local protocol and apply it to the scenario. It is necessary to empathize with the role-player, but important information needs to be communicated and candidates should always be mindful of what exactly they are being asked to do, as the marking scheme will reflect those tasks. A good candidate will be aware of the distress a diagnosis like this may cause – termination may not necessarily occur with the first course of cervagem as the patient is a primigravida, and continuation of the pregnancy is not without its risks. A good candidate is likely to draw a diagram to explain the diagnosis to illustrate to the patient exactly what is the problem.
38
BREAKING BAD NEWS – ANENCEPHALY
Advice and preparation
There are three parts to this question, the main one dealing with whether to terminate or continue this pregnancy. It is important, as with all the OSCEs, to utilize your time appropriately. In the examination you are given a pad to take round with you, and in this situation drawing a diagram may be a very useful way of conveying some of the information, as it can be difficult to get the role-player to take it on board from a solely verbal explanation. It is important to remember that this news can be devastating for the patient, and one should avoid ‘okay’ and ‘all right’ and keep checking that the role-player understands the significance of what you are saying.
This station is very much the ‘appliance of science’, i.e. the application of your obstetric knowledge to deal with a bad news scenario. Imagine this is a clinic situation and do what you would do there. Prior to the OSCE part of the MRCOG, it would be useful to sit in with a senior colleague when they are breaking bad news if you have no experience of doing so. It is important to allow the role-player to have time to speak as she may furnish you with valuable information. Do not be afraid of silences, providing they do not go on for too long. The role player will have been briefed to ask questions if you have come to a halt.
What variations are possible for this question?
Breaking bad news in the obstetric scenario can be very variable, from fetal abnormality (fatal or non-fatal), intrauterine fetal death or stillbirth. In all these scenarios there will be no doubt about the diagnosis and marks will be awarded for dealing with the situation and not history-taking.
39
Review station 8
Infertility – case notes
Candidate’s instructions
This is a preparatory station and you have 15 minutes to review the notes and results of the patient you will see in the next station.
The patient and her partner were referred to your outpatient clinic by her general practitioner. They were originally seen in the clinic 3 months ago and some baseline investigations were undertaken. The original notes have been lost. A copy of the original referral letter has been found plus a copy of the original clinic letter.
Copies of the results have also been placed in the notes.
YOU WILL BE AWARDED MARKS FOR:
●
Discussing appropriate supplementary history
●
Discussing results of investigations
●
Discussing appropriate treatment options
40
INFERTILITY – CASE NOTES
The Surgery,
Blackhorse Rd,
London E44
Dear Doctor
Can you please see Susan Pesh who has a history of infertility over the past 3
years?
Susan is 27 years old with a history of mild endometriosis, which was diagnosed laparoscopically 2 years ago. The endometriotic spots were found on the uterosacral ligaments only and these were diathermied. The rest of the pelvis appeared normal. Susan has been on a course of Provera for 6 months and is now asymptomatic.
Regards
Dr Twort
41
REVIEW STATIONS
Dear Dr Twort
Re: Susan PESH (7.7.73)
26, Victoria Gardens, E44
Thank you for referring this patient to my gynaecological outpatients’ clinic with a history of primary infertility. She commenced her periods at the age of 13 years and appears to have a regular 28-day cycle with bleeding for 5 days.
The rest of her gynaecological history is unremarkable except for a previous history of endometriosis that appears to have been successfully treated with ?
at the time of laparoscopy and Provera. She is now asymptomatic. Her coital frequency appears to be satisfactory. Her smears are up to date and normal.
The rest of her medical history is unremarkable and she is not taking any medication.
General physical examination was unremarkable with a BP of 110/70 and a normal BMI. Pelvic examination was normal.
I have organized some routine investigations and plan to see her again in 3
months’ time when the results should be available. I will keep you informed of her progress.
With best wishes
Yours sincerely
Mr A Sherman
42
INFERTILITY – CASE NOTES
Day 21 progesterone (Susan PESH 7.7.73)
60 IU/L
(follicular 0–15 IU/L)
(luteal > 25 IU/L)
Hysterosalpingogram (Susan PESH 7.7.73)
●
The uterus is normal anteverted and mobile. Both uterine tubes fill and the isthmus and ampullary portions appear normal
●
There is free spill of contrast into the peritoneal cavity bilaterally with little retention of dye
Pelvic USS (Susan PESH 7.7.73)
●
Normal anteverted uterus, with normal looking ovaries
●
No pelvic pathology seen and no evidence of PCO
●
Small amount of fluid in the POD
HVS result (Susan PECK 7.4.62.)
Normal commensals plus Candida spp.
Endocervical swab (Susan PESH 7.7.73)
Negative for Chlamydia
Semen analysis (Brian PESH, partner of Susan PESH 7.7.73) Collection
Masturbation
Days abstinence
1 day
Time since production
90 minutes
Volume
2.8 mL
Viscosity
Normal
Motility
30%
Sperm concentration
0.6 million/mL
Abnormal form
50%
Non-sperm cell conc’n
0.3 million/mL
Total motile sperm
0.5 million
Tray agglutination test
No antisperm antibody detected
Repeat semen analysis (Brian PESH, partner of Susan PESH 7.7.73 – 2 months later) Collection
Masturbation
Days abstinence
5 days
Time since production
30 minutes
Volume
4 mL
Viscosity
Normal
Motility
35%
Sperm concentration
0.9 million/mL
Abnormal form
55%
Non sperm cell conc’n
0.1 million/mL
Total motile sperm
2.4 million
43
REVIEW STATIONS
Role-player’s instructions
You are a 27-year-old woman called Susan Pesh who works as a sales assistant. You commenced your periods at the age of 13 years and now have a regular 28-day cycle with bleeding for 5 days. You are unsure about when you ovulate but only volun-teer this information if asked. You have been with Richard, your husband, for 5
years and have regular intercourse, three times a week.
Apart from a laparoscopy as an investigation for pain on intercourse you have had no other surgical procedures. You were treated for mild endometriosis, although you are a little unsure about the nature of it. The rest of your history is unremarkable, you are a non-smoker and you are not taking any medication. Your last smear was prior to your referral and the result was normal. You have used the oral contraceptive pill in the past but at the age of 21 for 9 months only.