Thursday, 23 October 2014

Tutorial 23 October 2014

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40
Viva.          Uterine inversion.
41
Role-play. Stillbirth. 6/52 follow-up.
42
Role-play. Sterilisation request.
43
Role-play. Cochrane.
44
Role-play. Neonatal screening.

40.   Uterine inversion.
Candidate's Instructions.
This is a viva station.
The examiner will ask you 7 questions.
1.     What are the risk factors for uterine inversion?
2.     What are the clinical features?
3.     What is the differential diagnosis?
4.     What are the diagnostic features?
5.     What would be your immediate management?
6.     What would be your subsequent management?
7.     What would be your management after the uterus has been replaced and the woman has been resuscitated?

41.   Role-play. Stillbirth. 6/52 follow-up.
Candidate's Instructions.
This is a role-play station.
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.

42.   Role-play. Sterilisation request.
Candidate's Instructions.
You are a 5th. year SpR. You are about to see Mrs. Mary Fecund in the gynaecology clinic. There is a referral letter from the GP.
Read the letter and then conduct the consultation with Mrs. Fecund as you would do in the clinic in your hospital.

Perfect Health Centre,
Paradise Lane,
Slagheap.
SLH 678.
Your ref: BRI 07/54843.

Re. Mary Fecund,
The Shoe, High Street, Slagheap.
Dear Doctor,
Please see Mrs Fecund who has too many children. She wishes to be sure she has no more and has asked to be sterilised – one of her friends was sterilised recently which has put her in the mood to have it done.
Yours sincerely,
Dr. John Williams.

43. Role-play. Cochrane.            
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. The trainee will ask 7 questions suggested by the Consultant.
2.     Explain the main elements and findings of the Forest plot below.



44.   Role-play. Neonatal screening.
Candidate’s instructions.
You are a SpR in year 5.
You are in the antenatal booking clinic and about to see Mary Eccles. She has been booked in by a midwife at 10 weeks’ gestation and all is well. She has recently arrived in the UK from the USA and asked about the routine neonatal screening that is done in the UK. She will be having the baby in the UK.



Monday, 20 October 2014

Tutorial 20 October 2014

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35.
Viva. MBRRACE.
36.
Viva. Obstetric surveillance systems.
37.
Role-play.  Request for labial reduction.
38.
Viva. Waiting list prioritisation.
49.
Role-play. Teach trainee fetal blood sampling.

35.   MBBRACE.

Candidate's Instructions.
This is a viva station.
The examiner will ask you 3 questions.
1. What is MBRRACE?                                                  2 marks
2. What is the role of MBRRACE?                              4 marks
3. How will MBRRACE differ from its precursor?   14 marks

36.   Obstetric surveillance systems.

Candidate's Instructions.
This is a viva station.
The examiner will ask you 2 questions.
1. What general data collection systems exist in the UK?                                    4 marks
2. What obstetric surveillance systems exist in the UK and what do they do?   16 marks                 

37.   Role-play. Request for labial reduction.

Candidate's Instructions.
You are the SpR in the gynaecology clinic. Your consultant is on holiday.
You are about to see Mary Adams. The GP letter reads: “Please see Mary who is convinced that her labia are too large and is adamant that she wishes to have them reduced. I have not examined her. Please see and advise”.
Your task is to take a relevant history and advise about investigation and management.

38.   Viva. Operation 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:
a. confirm the appropriateness of the proposed treatment,
b. decide the degree of urgency,
c. confirm the appropriateness of the proposed venue,
d. decide any special requirement(s) for each patient.

Name
Age
Clinical Problem
Proposed operation
Venue
Special Needs
Urgency
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.




39.   Role-play. Teach trainee fetal blood sampling.

Candidate’s instructions.
You are the SpR for the labour ward. Things are temporarily quiet. A new FY2 has joined the department and the Consultant has asked you to teach her the basics of fetal blood sampling.




Thursday, 16 October 2014

Tutorial 16 October 2014

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Tonight's topics

31.
Viva. Adverse incident report. 4th. degree tear.
32.
Viva. Neonatal jaundice.
33.
Viva. Write a model for taking an obstetric history for tutorial.
34.
Viva. Headache
35.
Role-play. Pre-menstrual syndrome. Use prepared papers.

31. 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.

32. Viva. Neonatal jaundice.
Candidate's Instructions.
This is a viva station.
The examiner will ask you 5 questions.

33. Viva. Write a model for taking an obstetric history for tutorial.
Candidate’s instructions.
You are to conduct a tutorial with hospital’s junior obstetricians and midwives about how to take an obstetric history.
You have 15 minutes to prepare the headlines you would put in a model for taking an obstetric history and to consider how you would conduct the tutorial.
Then you will have a viva with the examiner.
The examiner will ask 4 questions.
1. What are your headings?
2. Which clinical situations do you envisage covering?
3. Which teaching methods would you consider for use in the tutorial?
4. Which teaching methods would be most suitable and why.

34. Viva. Headache.
Candidate's Instructions.
This is a viva station.
The examiner will ask you 13 questions!

35. Role-play. Pre-menstrual syndrome.
Candidate’s Instructions.
You are a 5th. year SpR and about to see Jane Williams in the gynaecology clinic.
You are to take a relevant history and advise her about management of her problem.

Referral Letter.
The Surgery,
Main Road,
Blacktown,
Herts.
Phone 0845 689 432.

Re. Mrs Jane Williams,
35 High Street,
Blacktown.
BK88 4EU
d.o.b. 1 January 1990.

Dear Doctor,
Please see Mrs Williams who has pre-menstrual syndrome. She has tried vitamin B6 with no benefit.
Yours sincerely,
John P. Evans MRCGP, DRCOG.


Monday, 13 October 2014

Tutorial 13 October 2014




25
Viva. Risk management: Pelvic abscess post hysterectomy.
26
Roleplay. Teach a FY1 about shoulder dystocia.
27
Viva. Incomplete ECV audit.
28
Viva. Breast feeding.
29
Viva. Parvovirus.

25.  Viva. Risk management: Pelvic abscess post hysterectomy.
This is a fairly typical risk management question about a surgical case. You can put in whatever you like by way of the surgery and the postoperative problems: haematoma, bladder injury, bowel injury, pulmonary embolism etc.

Mrs. S. J, 48 years of age, was admitted for abdominal hysterectomy + bilateral salpingo-oophorectomy for fibroids. On admission she was noted to be healthy, but allergic to penicillin.
The surgery was performed by an ST3 assisted by a Foundation Year 2 doctor.
The theatre notes read:
“TAH + BSO. Pfannenstiel incision. Uterus enlarged by fibroids. Routine procedure. Vicryl to sheath. Clips to skin. Routine post-op care. Nurse discharge”.
The postoperative medical notes read: “
Day 1 review at 09.00 hours by the ST3 who performed the surgery:
“Op findings explained. Looks ok. Obs. satisfactory”.
Day 2 review at 09.00 hours by FdY2 doctor:
“Obs stable, remove catheter, allow oral fluids and take down i.v. line.
Pt c/o nausea, has not passed flatus”.
Day 2 review at 14.00 by Ward Nurse:
“I.v. line re-sited as pt unable to take orally and vomited x 1”.
Day 3 review at 09.00 by Consultant and ST3 who had not performed the surgery.
Pt febrile, vomiting, abdomen distended, has not passed flatus
Suspected ileus. Abdominal x-ray ordered”.
Day 4 review at 09.00 by ST3 who had performed the surgery:
 “Pt febrile, still vomiting and abdominal distension.
No bowel sounds. X-Ray not back as yet”.
Day 5 review at 09.00 by FdY2 who had assisted at the operation:
“Abdo distended with rebound tenderness, VE: mild
tenderness. For review by GS”.
Day 5 management and subsequent progress:
Patient seen by the general surgeons who take over her care. The x-ray report is tracked and is
suggestive of intestinal obstruction. Emergency laparotomy done by Consultant in general surgery that afternoon. Right-sided pelvic abscess, 8 cm. x 6 cm. with evidence of old haematoma. No bowel injury or damage to other organ. No evidence of active bleeding. Abscess drained, lavage done, i.v. antibiotics prescribed and pelvic drain left in-situ. Patient recovered well over next 10 days.
Your task.
You are an ST5. The case is being investigated by a Nursing Sister on behalf of the clinical risk management team for gynaecology. Your Consultant has been asked to produce a report, but has delegated the task to you, saying it will be useful experience for when you are a Consultant.
The Nursing Sister has produced a list of things she would like included in the report.
1.       is all the information needed for the report included in the above summary? If not, what additional information do you require and how should it best be obtained?
2.       do you need further statements and, if so, from whom should they be obtained?
3.       can you identify from the above any indicators of possible deficient care?
4.       are there any recommendations you can make relevant to the department of gynaecology and the other specialties in the hospital?
5.       the woman has lodged a complaint about her care and has indicated that she is likely to go on to sue the hospital. Is there anything that can be done to lessen the chance of litigation?

26    Roleplay. Teach a FY1 about shoulder dystocia.
         You are a year 5 SpR and have been asked to teach a new FY1 about shoulder dystocia.

27    Viva. Incomplete ECV audit.
Candidate’s instructions.
A colleague who has left the hospital was conducting an audit of ECV.
The audit is incomplete.
The data are:
    Consultant A offered ECV to one group of women and had an 70% success rate,
    Consultant B offered ECV to a different group and had a 30% success rate,
    Consultant C did not offer ECV at all.
Instructions.
Tell the examiner how you would go about completing this audit.`

28.   Viva. Breastfeeding.
Candidate’s instructions.
This is a viva station.
The examiner will ask you 6 questions.

29.   Parvovirus.
         Candidate’s instructions.
         This is a viva station.
         The examiner will ask you 22 questions!