Thursday, 19 March 2015

Tutorial 19 March 2015

Viva. Critique of Menozac website extract
Role-play. PMB.
Basic “blurbs” to write and practise.
Viva. You are a year 4 SpR and are to assess Mrs Mimi Dresden on the orthopaedic ward.
Viva. Critique RCOG Pt. Info leaflet Genital Herpes.

9. Critique of extract from Menozac website.
Candidate's Instructions.
You are to provide a critique of this extract from a website.
You have 15 minutes to read the document provided for the station.
Then you have 15 minutes with the examiner to detail your critique.
The examiner will not lead the discussion or provide prompts or other assistance.

Websites dedicated to medical matters can come up in a number of ways. You could be asked just to do a critique. The materials we are using were taken from the Menozac website a few years ago and chosen because the website site was a polished example of the genre and showed a lot of the techniques common to websites of this kind. I use the past tense as I have not visited the website recently and it has probably evolved.
You could also have a patient who has visited a website and has some information she wishes to discuss, a test or treatment she wishes to have provided etc.
You have to be able to do this is a way that persuades the patient that you are giving sensible, objective advice.

10. Role-play. PMB.
A 55 year old woman is referred by her General Practitioner.
Candidate’s Instructions.
You are an SpR in the “one-stop” PMB clinic. You are about to see a woman with bleeding some years since her menopause.
Your task is to take an appropriate history and advise her about the investigations you feel are appropriate.
Referral letter from the General Practitioner.
Manor Lodge,
High Street,
BE5 S00

Re: Mrs. Mary Smith,   Age 55.
5b High Street,
Dear Doctor,
Please see Mrs. Smith who has had bleeding down below. It is a number of years since she reached the menopause.
Yours sincerely,
James Fewords, General Practitioner.

11. Basic “blurbs” to write and practise.
There are a number of building blocks that commonly feature in the stations that you should practise until you are confident and fluent. These include:
your introduction,
what the GP letter says,
creating an agenda for a role-play,
setting the scene for breaking bad news,
what words to use when breaking bad news,
general pre-pregnancy counselling,
chromosomes, genes, recessive inheritance, x-linked inheritance,
performing in a viva with an examiner behaving like a Sphinx,
complaint handling,  etc.
If you think of any others, please let me know.

12. Viva station. Assessment of old patient on the orthopaedic ward.
This time it is a structured viva: the examiner will ask 4 questions. You may be told that when you have answered a question you are not allowed to go back to it if subsequent questions trigger further thoughts.
Candidate’s instructions
You are a year-4 SpR and have been asked by your consultant to assess Mrs Mimi Dresden on the orthopaedic ward.
She is 85 years old and has been admitted from the nursing home where she lives with a hip fracture after a fall. She has Alzheimer’s disease. The nursing staff have noted blood on her underwear.
The examiner will ask you a series of questions:
         what history will you take?
         what examination will you perform and your reasoning?
          what investigations will you arrange and why?
         what management will you propose?

13. Viva. Critique RCOG Pt. Info leaflet Genital Herpes.

    This is not the latest version of this PIF, but it illustrates a number of errors and the new one is much better - if we get time we will do a comparison in a future tutorial.
    This is an unstructured viva. The examiner will just sit there and do nothing! This is very daunting and needs to be practised

Genital herpes in pregnancy
First published in February 2005 Revised in February 2009 Information for you
What is genital herpes? Genital herpes is a common sexually transmitted infection caused by the herpes simplex virus (HSV). There are two types, HSV1 and HSV2. Both types can be found in the genital and anal area (genital herpes). Herpes simplex can also occur around the mouth and nose (cold sores) and fingers and hand (herpetic whitlows). This information is mainly about genital herpes in pregnancy.
In women, genital herpes can occur in the skin in and around the vagina, the vulva (lips around the opening of the vagina), the urethra (tube through which urine empties out of the bladder) and the anus (back passage). In men, it can occur in the skin of the penis, the urethra and in the anal area.
How is genital herpes passed on? Genital herpes is usually passed from one person to another during sexual contact. Both women and men can get the virus. The herpes simplex virus enters the body through small cracks in the skin or through the soft, moist mucous membranes in the mouth or genital area. Once you have the virus it stays in your body for life.
You may only get one attack (known as an episode) or you may have repeated episodes (known as recurrent episodes). The herpes simplex virus is most likely to be passed on just before, during and straight after an episode. It can be passed on: ● through skin to skin contact. ● by having vaginal, oral or anal sex or sharing sex toys. ● at the time of birth by a mother to her baby.
What are the symptoms of genital herpes? Some people get genital herpes mildly, some notice no signs or symptoms and for some, the symptoms are very painful. When you have an episode of genital herpes for the first time you may feel unwell and may notice painful sores or watery blisters in your genital area. Many people have an early-warning tingling sensation before an episode occurs.
Symptoms can occur within a short time of coming into contact with the virus or it may be many weeks, months or years before any signs or symptoms appear.
What should I do if I think I have genital herpes? If you and/or your partner have symptoms which you think are unusual, you should seek further advice. Contact your general practice or a clinic that specialises in sexually transmitted infections (called genitourinary medicine clinics or sexual health clinics). You should have a check-up which may include testing, treatment and advice.
It is possible to have more than one sexually transmitted infection at the same time. You may be offered testing to check for this too. For information about clinics see Useful organisations.
What could genital herpes mean for my baby? Most women who have genital herpes have healthy babies by vaginal birth. Genital herpes can be safely treated during pregnancy. If you get genital herpes before you become pregnant, your immune system will provide protection to your baby when you become pregnant. Recurrent episodes of genital herpes during pregnancy do not affect the baby. If you get genital herpes for the first time after you become pregnant, this can be more serious. ● If you get genital herpes in the first 3 months of pregnancy, there is a small chance of miscarriage. ● If you get genital herpes for the first time late in your pregnancy (within 6 weeks of birth), there will not be time for your immune system to provide enough protection to your baby. If you then give birth vaginally, there will be about a 4 in 10 (40%) chance of passing the virus to your baby.
If a baby catches the herpes simplex virus at birth, this is known as neonatal herpes. It can be serious but it is very rare in the UK (1–2 out of every 100,000 newborn babies).
Neonatal herpes can cause infections in the baby’s skin and eyes. It may also cause infection of the brain (herpes meningitis) and other body organs. The baby may become seriously ill or die in the first 7 days after birth. Treatment with drugs designed to treat virus infections may help prevent or reduce damage to the baby.
How can I reduce the risk to my baby? Tell your midwife at your first antenatal appointment if you and/or your partner have ever had the herpes simplex virus (cold sores, whitlows or genital herpes). If you are not sure whether you have the herpes simplex virus, ask for a check-up.
Your can reduce the risk to your baby in the following ways. ● If your partner is having an episode of the herpes simplex virus (cold sores, genital herpes or herpetic whitlows), you should avoid skin-to-skin contact with the affected area. This might include avoiding: vaginal intercourse anal intercourse oral intercourse. ● As there is a very small risk that a sexual partner who has genital herpes can pass on the infection even when there are no signs or symptoms, you may consider using condoms throughout your pregnancy, particularly in the last 3 months. ● Avoid skin-to-skin contact between your baby and anyone with an active herpes simplex infection, such as a cold sore on the mouth or nose or herpetic whitlow on the hand. ● Ensure that you wash your hands after touching any sores.
What treatment will I be offered? If your doctor or midwife thinks you have got genital herpes for the first time while you are pregnant, you should be referred to a specialist genitourinary medicine clinic. You will be offered appropriate testing, treatment and support.
If you have genital herpes for the first time when you are pregnant, you may be offered antiviral tablets called aciclovir and you may be admitted to hospital if it is very painful or you cannot pass urine.
If you have frequent recurrent episodes of genital herpes during pregnancy, you may be given continuous aciclovir treatment from 36 weeks of pregnancy to birth.
The aim of treatment is to help reduce the length and severity of your symptoms.
Are there any risks in treatment? Aciclovir has been used for many years and when used in pregnancy it has not been shown to harm the baby. It can be used safely during breastfeeding.
Will I need a caesarean delivery?
Most women with genital herpes will have a normal vaginal birth. ● If you were infected with genital herpes before you became pregnant, you will not need a caesarean delivery. ● If you develop genital herpes for the first time in the last 6 weeks of pregnancy, you will be offered a planned caesarean delivery. ● If you get a recurrent episode of genital herpes at the onset of labour, you will not normally need a caesarean delivery. Your doctor or midwife will discuss this with you to help you decide how you would like your baby to be born. A glossary of all medical terms is available on the RCOG website:
Useful organisations
Herpes Viruses Association 41 North Road London N7 9DP Helpline: 0845 123 2305 Email: Website:
fpa 50 Featherstone Street London EC1Y 8QU Helpline: 0845 122 8690 Website: Visit the ‘Find a clinic’ section of the fpa website for details of your nearest sexual health clinic.
Sources and acknowledgements This information is based on the Royal College of Obstetricians and Gynaecologists (RCOG) guideline Management of Genital Herpes in Pregnancy (originally published by the RCOG in 2002 and revised in September 2007). This information will also be reviewed, and updated if necessary, once the guideline has been reviewed. The guideline contains a full list of the sources of evidence we have used. You can find it online at:
Clinical guidelines are intended to improve care for patients. They are drawn up by teams of medical professionals and consumer representatives who look at the best research evidence available and make recommendations based on this evidence.
This information has been developed by the Patient Information Subgroup of the RCOG Guidelines Committee, with input from the Consumers’ Forum and the authors of the clinical guideline. It has been reviewed before publication by women attending clinics in Burton on Trent, London and Oxford. The final version is the responsibility of the Guidelines Committee of the RCOG.
The RCOG consents to the reproduction of this document providing that full acknowledgement is made.
A final note The Royal College of Obstetricians and Gynaecologists produces patient information for the public. This is based on guidelines which present recognised methods and techniques of clinical practice, based on published evidence. The ultimate judgement regarding a particular clinical procedure or treatment plan must be made by the obstetrician or other attendant in the light of the clinical data presented and the diagnostic and treatment options available.
© Royal College of Obstetricians and Gynaecologists 2009

Monday, 16 March 2015

Tutorial 16 March

16 March 2015.

Contact us.

We planned to do the following, but did not have time for number 9 - we will do it on Thursday.

Critique of GP letter.
Role-play. Healthy primigravida. 8 weeks. Some bleeding.
Scan = IUP. CRL = 12 mm. No fetal heart activity. Counsel.
Role-play. Woman attends for pre-pregnancy counselling as she plans her 1st. pregnancy. Her sister recently had a baby with Down’s syndrome.
Viva station.
You are a year-4 SpR and have been asked by your consultant to assess Mrs Mimi Dresden on the orthopaedic ward.
She is 85 years old and has been admitted with a hip fracture after a fall from the nursing home where she lives. She has Alzheimer’s disease. The nursing staff have noted blood on her underwear.
The examiner will ask you a series of questions:
   what history will you take?
   what examination will you perform and your reasoning?
   what investigations will you arrange?
   what management will you propose?

6. Critique of GP letter.
You have a 15 minute preparatory station to read the following letter and prepare yourself to deliver a critique to the examiner you will meet at the next station.
The examiner will not ask questions or guide you in any way. It is up to you to decide what you need to say.
GP letter.
The Medical Centre,
Green Lane,
Your ref: BRI 07/54843.

Re. Jennifer Houseside,
45 The Maltings,

Dear John,
It was wonderful to see you and Mary again on Saturday and so kind of you to invite us. The meal was up to Mary’s high standards and the company convivial. We may be getting older, but Mary’s fragrant beauty does not diminish.
Please see this woman who complains of unacceptably heavy periods. She is huge, malodorous and is more like a whale than a human being. One can see how the family name originated! I do not envy you the task if you feel that you have to examine her.
She is as stupid as she is fat. I doubt that she has more than one brain cell. If she has, they are not inter-connected. She talks incessantly and brings complete sense of the old adage “empty vessels make most sound”. Despite the vacuum in her cranium she is awash with idiotic ideas most of which she gets from her monumentally stupid mother. She is too thick for logical reasoning to have any impact on her ridiculous views – you might as well attempt a philosophical discussion with your dog.
The father is a dirty, unpleasant sort and I would not be surprised if incest had contributed to their low IQs. If the human race has advanced though evolution and natural selection, what on earth were their ancestors like?
They are social parasites. None of the family has ever worked and they live off Social Security payments. I have had the misfortune to have to do the occasional home visit to various members of the family. They live in disgusting squalor. If they were pigs their living conditions would give the species a bad name. Theirs are houses in which you wipe your feet on the mat as you leave and not as you enter and pray that you never have to visit again. I am sure the Court of Human Rights would regard a second visit as a cruel and unnatural punishment. They always ask you to sit, but I would not wish to ruin my clothes. Their hospitality also extends to offering cups of tea. Perish the thought! I would rather take my chance with neat hemlock.
Despite living on Social Security payments, they have the latest widescreen TVs and associated DVD equipment. The husband looks to me as though he indulges in low-level crime, probably shoplifting. He is a shifty character whom you would not trust and I strongly advise you to make sure that all valuables are locked up and out of sight when he or any of her family is around. One brother is in prison for theft to feed a heroin habit, which typifies the contribution this family makes to the greater good. Her sister is said to be a prostitute and I would think it true. Certainly she has a lot of children and I doubt that any of them have the same father or that she would be able to enlighten them as to who their fathers might be. She (the sister) is a regular visitor to the Sexually Transmitted Diseases clinic where she displays a surprising range of conditions needing treatment. She is a one-woman update course for the staff ensuring they are abreast of all aspects of STDs. I was going to say she was a one-woman refresher course, but there is nothing refreshing about her. The sister is as fat and ugly as my patient, making one marvel at the mentality of her clients. I cannot imagine how anyone would want to come within smelling distance of her, far less have sexual relations and pay for the privilege. Some exotic form of masochism, I guess.
I wish you well in your dealings with her and apologise for sending such an unpleasant lump to your clinic. This is a family that makes you wish the Abortion Act could be made retrospective!
Please do your best not to send her back to see me.

Yours sincerely,

7. Role-Play.
Candidate’s instructions.
You are the SpR on-call for the Early Pregnancy Unit. You have been called to see a patient. The phone message summoning gave you the following information:
“Healthy primigravida. Presents with some bleeding at 8 weeks. Scan = IUP. CRL = 12 mm. No fetal heart activity”.
Your task is to counsel her as you would normally in the EPU.

8. Role-play. Booking clinic counselling.
Candidate’s instructions.
You are the SpR running the booking clinic – the consultant is on leave.
You have been asked to see Susan Sharpe who has attended for booking.
The GP letter reads as follows.
Dr. J. Mills,
25 High Street,
Re: Mrs S. Sharpe, 28 High Street, Lowtown.
Please see Mrs. Sharpe who wants to talk about amniocenteses.
J. Mills.
Your task is to counsel her as you would such a patient in a booking clinic

9. Viva station.
Candidate’s instructions
You are a year-4 SpR and have been asked by your consultant to assess Mrs Mimi Dresden on the orthopaedic ward.
She is 85 years old and has been admitted with a hip fracture after a fall from the nursing home where she lives. She has Alzheimer’s disease. The nursing staff have noted blood on her underwear.
The examiner will ask you a series of questions:
   what history will you take?
   what examination will you perform and your reasoning?
   what investigations will you arrange and why?
   what management will you propose?

Monday, 9 March 2015

Tutorial 9 March 2015

Contact us.

There is some information on the website about communication.

How to prepare. Picking a course.
Barriers to communication. What communication barriers exist between me and the trainees attending the tutorial? We can use this as a basis to consider the communication problems between us, patients and colleagues.
Role-play: how to introduce oneself.
Labour ward scenario 1.
Role-play: Healthy, nulliparous. Brother with cystic fibrosis. Pre-pregnancy counselling.

Labour Ward Scenario 1.

Sunday 13.00 hours.

Labour Ward.

Mrs JH
Primigravida. T+8. In labour. 6 cms.
Mrs AH
Primigravida at T. In labour. 5 cms.
Mrs. BH
Para 2. 30 days post delivery. 2ry. PPH > 1,000 ml. Hb. 9.3.
Mrs SB
Primigravida. 32/52 gestation. Admitted 30 minutes ago. Abdominal pain + 200 ml. bleeding. Nephrostomy tube in situ - not draining since this morning. Low placenta on 20 week scan.
Mrs KW
Para 1. In labour. Cx. 5 cm. Ceph at spines.
Mrs KT
Para 0+1. 38 weeks. SROM. Ceph 2 cm. above spines. Clear liquor.
Mrs TB
Para 1. T+4. Clinically big baby. Cx fully dilated for 1 hour. Type 1 decelerations.
Mrs RJ
Primigravida. Epidural. RIF pain. Cx fully dilated for 1 hour. Shallow late decelerations. OT position. Distressed ++. BP /105. ++ protein. Urine output 50 ml in past 4 hours.
Mrs KC
Transfer from ICU. 13 days after delivery of 32 week twins. Laparotomy on day 7 for pelvic pain and fever. Infected endometriotic cyst removed. IV antibiotics changed to oral.

Gynaecology ward.

8 major post operative cases who have been seen on the morning ward round and are stable. Husband of patient who has had Wertheim's hysterectomy asking to see a doctor for a report on the operation.

Mrs JB
10 week incomplete miscarriage. Hb. 10.8. Moderate fresh bleeding.
19 years old. Nulliparous. Just admitted with left iliac fossa pain. Scan shows unilocular 5 cm. ovarian cyst.

Medical staff:

Consultant at home. Registrar - you.
Senior House Officer with 12 months experience.
Registrar in Anaesthesia.
Consultant Anaesthetist on call at home.

Midwifery staff:
Senior Sister.          Trained to take theatre cases. Able to site IV infusions and suture episiotomies and tears.
3 staff midwives. 1 trained to take theatre cases. Two able to site IV infusions.
1 Community midwife looking after Mrs. KW.
2 Pupil Midwives.

We did not get a chance to discuss labour ward scenario 2, but you can use it for practice.

 Scenario 2.

Monday. 0900 hours.  You have just come on duty.

Mrs A
Para 0+0
25 yrs
41 weeks. In labour 12 hours. Cx 8 cm. No progress for 4 hours. "Dips" reported on CTG
Mrs B
Para 1+2
31 yrs
28 weeks. Just admitted. "Show" + contractions
Mrs C
Para 5+3
40 yrs
In labour 8 hours. Cx 6 cm. dilated
Mrs D
Para 1+3
27 yrs
37 weeks. Diabetes. Admitted ½ hour previously. Previous Caesarean section.
Mrs E
Para 1+2
32 yrs
40 weeks. Previous 9 lb. baby. In the second stage for 1 ½ hours.
Miss F
Para 0+0
15 yrs
34 weeks. Concealed pregnancy. In labour. Just admitted. Breech presentation
Mrs G
Para 1+2

26 weeks. Admitted with severe abdominal pain
Mrs H
Para 2+1

39 weeks. In early labour.
Mrs I
Para 1+0

Delivered two hours previously by Caesarean section for severe pre-eclampsia. Diastolic BP / 110. Urine output 50 ml. since delivery
Mrs J
Para 1+0

Normal delivery + PPH >1,500 ml. one hour ago

Medical staff:

Consultant:              in his Rooms.
You:                        Registrar.
Foundation Year 2   six months’ experience.
Registrar in anaesthetics.

Midwifery staff:

Senior Sister.
Two staff midwives.
One community midwife.
Two student midwives.