Thursday, 7 May 2015

Tutorial 7th. May 2015

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The podcast is on Dropbox.
You need to be linked to the relevant folder to be able to download it.
Don't transfer it into your Dropbox - the podcasts are large files and would soon overload your Dropbox and have to buy more space.
If you want to be linked, send me an e-mail.

        
54
Viva. Risk management principles
55
Viva. Coeliac disease and O&G
56
Viva. Drug licensing.
57
Viva. Forceps
58
Viva. Pudendal block.
59
Viva. PPH.

54    Viva. Risk management principles
         Candidate’s instructions.
         Tell the examiner all you know about the principles of risk management.
         This is an unstructured viva and the examiner will not ask questions or respond in any way.

55    Viva. Coeliac disease and O&G
         Candidate’s instructions.
         The examiner will ask 8 questions.
        
56    Viva. Drug licensing.
         Candidate’s instructions.
         The examiner will ask a series of 10 questions.
         You can indicate when you wish to move to the next question.
         You are not allowed to return to a previous questions and no marks will be allocated if you do.
         The examiner will not communicate other than to ask the questions and whether you wish to move to the next question if you appear to have completed you answer to the current one.

57.   Viva. Forceps.
         The examiner will ask you to explain the differences in two types of forceps and their uses.

58    Viva. Pudendal block.
         Candidate’s instructions.
         Tell the examiner the key points in relations to:
              the anatomy of the pudendal nerve,
              when pudendal nerve blocks are clinically indicated,
              the risks and limitations of pudendal nerve block,
              how you would perform a pudendal nerve block.

58.   Viva. PPH.
         Candidate’s instructions.
         You have been asked to give a new batch of 4 trainees a teaching session.
         Tell the examiner how you will go about it and what you will include.



Monday, 4 May 2015

Tutorial 4th. May 2015

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50
Role-play. Stillbirth. Six week follow-up
51
Viva. Perinatal mortality
52
EMQ. Puerperal mental health.
53
Role-play. Fragile X syndrome

50.   Stillbirth.
Candidate’s instructions.
This is a roleplay station.
Mrs. Brown has come for follow-up 6/52 after delivery of a stillborn baby.
Reduced fetal movements had been noted at 38 weeks.
She was admitted and FDIU was confirmed.
The scan also showed IUGR.
She opted for induction of labour.
Prostin was used and she had a normal delivery 12 hours later.
Effective analgesia was provided by epidural anaesthesia.
There were no complications.
Full investigation, including PM, was normal apart from the birthweight, which was < 5th. centile. Your task is to explain the results and advise about the next pregnancy.

51.   Perinatal mortality.             
Candidate’s instructions.
This is a viva station about perinatal mortality.
The examiner will ask you X questions.
As you move from one question to the next, you are not allowed to go back to previous questions and will get no marks if you do.

52.   Puerperal mental health.
Lead-in.
The following scenarios relate to puerperal mental illness.
Pick one option from the option list.
Each option can be used once, more than once or not at all.
If I had put all the answers into the option list it would have been enormous. So there are quite a few where you need to decide what your answer would be. Opting for “none of the above” is not exercising your brain – make sure you come up with an answer.

Option list.
a.       arrange admission to hospital under Section 5 of the Mental Health Act
b.      send a referral letter to the perinatal psychiatrist requesting an urgent appointment.
c.       send an e-mail to the perinatal psychiatrist requesting an urgent appointment.
d.      phone the community psychiatric team.
e.       phone the on-call psychiatrist.
f.        arrange to see the patient in the next ante-natal clinic.
g.       arrange to see the patient urgently.
h.      send a referral letter to the social services department.
i.         phone the fire brigade.
j.         phone the police.
k.       there is no such thing.
l.         4 weeks
m.    6 weeks
n.      12 weeks
o.      26 weeks
p.      1 year
q.      <1%
r.        1-5%
s.       5-10%
t.        10-20%
u.      25%
v.       50%
w.     60%
x.       70%
y.       80%
z.       True
aa.   False
bb.  none of the above.

Scenario 1
What is the internationally agreed classification for postpartum psychiatric disease?
Scenario 2
What time limits does DSM-IV use for postpartum psychiatric disorders?
Scenario 3
What time limits does ICD-10 use pro postpartum psychiatric disorders?
Scenario 4
What clinical classification would you use in a viva or SAQ?
Scenario 5
What is the incidence of suicide in relation to pregnancy and the puerperium?
Scenario 6
What are the main conditions associated with suicide in pregnancy and the postnatal period?
Scenario 7
Most suicides occur in single women of low social class who have poor education. True / False
Scenario 8
The preferred method of suicide reported in recent MMRs was drug overdose.  True / False.
Scenario 9
When are women with Social Services involvement particularly at risk of suicide.
Scenario 10
Which women have the highest risk for puerperal psychosis and what is the risk?
Scenario 11.
What is the risk of puerperal psychosis for a primigravida with BPD?
Scenario 12
What is the risk of PP in a woman with no history of psychiatric illness but who has a FH of PP?
Scenario 13
Should screening include the identification of women with no history of psychiatric illness but who has a FH of PP?
Scenario 14
What do the Confidential Enquiries into Maternal Deaths say about the use of the term “postnatal depression”?
Scenario 15
Women with schizophrenia have a ≥ 25% risk of puerperal recurrence. True / False
Scenario 16
If lithium therapy for BPD is stopped in pregnancy, there is an increased risk of severe puerperal illness. True / False.
Scenario 17
You are the on-call SpR for obstetrics. A woman has just had a normal delivery of a 30 week baby that requires resuscitation. The mother says that the baby must be left alone and not resuscitated. The paediatric SpR and midwives are uncertain about what to do. What action will you take?
Scenario 18
You are the on-call SpR for obstetrics. The midwife on the postnatal ward phones for advice. A primigravida who delivered yesterday has stated that the baby is not hers and is refusing to care for it. What action will you take?
Scenario 19
You are the on-call Consultant in O&G. The community midwife has phoned for advice. She was asked to visit a primiparous woman who had a normal delivery seven days before. The husband reports that she has struck him several times. The woman tells her that voices have informed her that this man is not her husband and that she should drive him away in case he rapes her. What action will you take?
Scenario 20
You are the on-call Consultant in O&G. The community midwife has phoned. She has just been phoned by a woman who had a Caesarean section for breech presentation four weeks ago. She has been told by God that breech babies are the spawn of the Devil and she is going to the local multi-storey car park to jump off with the baby so that the baby cannot grow up and harm people and so that she cannot have more Devil babies. What action will you advise?

53.   Fragile X syndrome
Candidate's Instructions.
You are about to see Mary White who has been booked in with her first pregnancy by the midwife in the antenatal clinic. The midwife has asked you to see her as Mary has told her that there is a family history of Fragile X syndrome.
Your task is to discuss Fragile X syndrome and the implications for Mary.

Thursday, 30 April 2015

30th. April 2015

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46
Viva. Systematic review – question from the UHSM course
47
Role-play. Maternity Dashboard.
48
Viva. Cochrane.
49
Role-play. Caesarean section on maternal request.

46.   Viva. Systematic review. The UHSM course on the 29th. April had a station on systematic review.
         The UHSM course on the 29th. April had a station on systematic review and most people did badly. The candidate was told that they had been asked to do a systematic review of Ulipristal v. a GnRH analogue for use pre-hysterectomy in women with fibroids. There was a 15 minute preparatory station and the viva was unstructured – the examiner was supposed to say nothing!

47.   Role-play. Maternity Dashboard.
         Candidate’s instructions.
         You are an SpR5 and your consultant has asked you to explain the Maternity Dashboard to a new FY1 who hopes to train as a specialist in obstetrics and gynaecology.

48.   Viva.
Candidate’s instructions.
You are a SpR in year 5.
1.   You have been asked to explain the Cochrane Collaboration and Cochrane Reviews to a new trainee.
2.   And to explain the main elements and findings of the Forest plot below.
The trainee will ask 8 questions suggested by your Consultant.


49. Role-play. Caesarean section on maternal request.
Candidate’s instructions.
You are a SpR5 in the antenatal clinic.
Your consultant is feeling unwell and has gone to lie down.
The midwife has just seen a primigravid woman who has requested Caesarean section.
She is healthy, with no significant medical history and the pregnancy has been normal.
The gestation is 36 weeks, the head is engaged and the baby seems to be of an average size.
The midwife has done all the routine investigations and has asked you to see her to discuss the request for Caesarean section.
It is your task to discuss her request as you would in a normal clinic.



Sunday, 26 April 2015

Tutorial 26th. April 2015


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Today we covered the topics from yesterday's NW OSCE course.
After lunch we also dealt androgen insensitivity as a role-play, perhaps the most difficult role-play.
Worth practising in case it comes up and because it is so difficult.
Master it and most others are easy!

Thursday, 23 April 2015

Tutorial 23rd. April 2015

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40
Roleplay with preparatory station. Cs technicalities
41
Viva. MBRRACE
42
Roleplay. Pre-menstrual syndrome.
43
Role-play. Write a prescription
44
Role-play. Teach trainee fetal blood sampling.

40    Roleplay with preparatory station. Cs technicalities.
         Candidate’s instructions.
         You are a year 5 SpR and passed your membership 1st. time two years ago.
         You have been asked for help with OSCE preparation by a colleague who is sitting the OSCE for the first time in 1 month.
         The colleague went on the RCOG course last week and found the vivas especially difficult.
         Your consultant has suggested that you conduct a viva on the technical aspects of Cs: what should be done and what should not be done with some indication of the strength of the supporting evidence. To simplify things, you are to restrict the viva to singleton pregnancies, first Caesareans and elective procedures.
         You have 15 minutes in which to prepare a possible score sheet with all the topics you feel merit attention.
         If the colleague runs out of ideas for answers, ask for their opinion about the items on your list.

41    Viva. MBRRACE.
         The examiner will ask you 18 questions about MBRRACE.

42    Roleplay. Pre-menstrual syndrome.
Candidate's Instructions.
This is a roleplay station.
Your task is to take a history and advise about initial investigations and management.
GP Letter.
The Medical Centre,
Haversham Way,
Lasttown.
XS89 9JH.
Re Jenny Smith,
55 Town Street,
Lasttown.

Dear Doctor,
Please see this woman who complains of pre-menstrual syndrome. I don’t really believe in this condition so have not attempted to treat it.
Regards,
Dr. N. O. G. Ood.

43    Role-play. Write a prescription.
         You have seen Mary Smith who wishes is trying to conceive. She has had a full work-up and has very infrequent periods. PCOS has been diagnosed. She is not overweight. You have discussed her treatment with the consultant and a trial of clomifene has been agreed.

         Your task is to explain this to Mary and write her a prescription for a one-month supply.
         Mrs. Mary Smith, DoB: 15 March 90.
              5 Mansion Row,
              Richtown.
              Send me an e-mail for the prescription sheet to fill in.

44    Role-play. Teach trainee fetal blood sampling.
Candidate's Instructions.
This is a roleplay station.
Dr. Jones has recently joined your team as a new trainee in obstetrics & gynaecology.
The labour ward is quiet and the consultant has asked you to teach Dr. Jones about fetal blood sampling.





Monday, 20 April 2015

Tutorial 20th. April 2015

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20th. April 2015.

Topics discussed tonight were:

36
Viva. Write a model for taking an obstetric history.
37
Viva. Bullying, harassment and undermining.
38
Role-play. Abnormal cervical smear.
39
Viva. Uterine inversion.
Send me your answers and I'll send mine.
It is important to answer under exam conditions.
No preparation and within the allotted time.
This helps you develop exam technique which is essential.
Don't spend an hour or two reading your references - you are wasting your time and mine!

Monday, 13 April 2015

Tutorial 13 April 2015

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13th. April 2015.

31
Viva. Waiting list prioritisation.
32
Roleplay. Teach a FY1 about shoulder dystocia.
33
Role-play. Neonatal jaundice.
34
Viva. Adverse incident report. 4th. degree tear.
35
Viva. Whooping cough & pregnancy.

31    Viva. Waiting list prioritisation
Candidate’s instructions.
Your consultant is away.
The waiting-list manager comes to see you.
The following patients have been listed by junior staff.
The waiting-list manager wants you to:
         confirm the appropriateness of the proposed treatment,
         decide the degree of urgency,
         confirm the appropriateness of the proposed venue,
         decide any special requirement(s) for each patient.

Name
Age
Clinical Problem
Proposed operation
Venue
JK
5
chronic discharge.
? foreign body
EUA
Main theatre
JM
32
1ry. infertility
Laparoscopy + tubal patency tests
Main theatre
GN
77
Vulval cancer. Coronary thrombosis x 2. Unstable angina.
Radical vulvectomy agreed at MDT.
Main theatre
RU
55
PMB x1. Weight 20 stones. (127 kg.)
1 kg. = 2.2 lb.
1 stone = 14 lb.
D&C.

DCU.
LD
32
Menorrhagia. Fibroids. Anaemia.
Vaginal hysterectomy.

Main theatre.
DT
22
Does not want children.
Lap. Steril.
DCU
HB
14
Unwanted pregnancy at 10/52.
TOP
DCU. TOP list.
JY
44
GSI.
Anterior colporrhaphy.

Main theatre.
JS
23
Vaginal discharge. Cervical ectropion.
Diathermy to cervix.

DCU
DT
55
3 cm. ovarian mass.
Laparoscopy ? proceed to Hyst + BSO.

Main theatre.
EV
32
CIN3.
Cone biopsy.
DCU
UW
34
Endometriosis
Laparoscopic ablation
DCU
HT
88
Cystocoele/ rectocoele/ 2nd. degree uterine prolapse
Manchester Repair.

Main theatre.
KN
58
Haematuria
Cystoscopy
DCU
JW
18
Menorrhagia & copes badly with menstrual hygiene. Has Down’s syndrome. Sexually active.
Hysterectomy
Main theatre
TB
30
Menorrhagia. 2nd. degree uterine descent. Been sterilised. Jehovah’s witness.
Vaginal hysterectomy and repair.
Main theatre.
BM
55
Stage Ib cancer cervix. Been discussed at MDT. For Wertheim’s hysterectomy. Factor V Leiden. VTE on Pill. On warfarin.
Wertheim’s hysterectomy.
Main theatre.
NU
60
Recurrent rectocoele.
Posterior colporrhaphy.
Main theatre.


32    Roleplay. Shoulder dystocia
Candidate’s instructions.
You are a year 5 SpR. It is a quiet afternoon on the delivery unit and your consultant has asked to teach a newly-arrived FY1 about shoulder dystocia.

33    Roleplay. Neonatal jaundice.
         Candidate’s instructions.
         Explain the important issues relating to neonatal jaundice to a newly-arrived FY1.

34    Viva. Adverse incident report. 4th. degree tear.
Candidate’s instructions.
         Mrs Penelope Jane Brown sustained a 4th. degree tear after the delivery of her second baby.
         Dr. James Peter White conducted the delivery and was asked to write a statement for the Risk Management Team (RMT), to whom the incident has been reported as an adverse clinical incident.
         You have been asked to look at Dr. White’s report, comment on it and identify issues that the RMT needs to explore further. You have 15 minutes to read Dr. White’s report, after which you will have a viva with the examiner. The examiner will not lead the discussion and will simply listen to what you have to say.

         Dr. White’s Report.
         I am Dr. J. White. I have been SpR in obstetrics and gynaecology at the Royal Infirmary for over a year.
         On the 27th. September I was bleeped by a midwife on the labour ward and asked to see a Mrs Brown who needed to be delivered as there had been delay in the second stage and she was becoming exhausted.
         On arrival on the labour ward I felt that Mrs Brown was not trying very hard to deliver the baby naturally and that the midwives were not making much effort to encourage her. I advised that they should get her pushing properly and that I would go for a coffee and return in half an hour.
         I returned in 50 minutes, having had an important phone call from my wife about arrangements for our forthcoming holiday which was under threat of cancellation. The situation was unchanged and I was not impressed with either the woman’s endeavours or the midwives’ encouragement of her efforts..
         Examination showed the head to be mid-cavity. I felt that it could get it out using forceps. The midwives told me that her bladder was empty. I applied the forceps with ease. The baby delivered in good condition. I then noted that she had a 4th. degree tear. I repaired this in the usual way.
         I went on holiday the next day for two weeks and did not see this woman again.

35    Viva. Whooping cough and pregnancy.
         Candidate’s instructions.
         The examiner will ask you 4 questions about pertussis and pregnancy.