Tutorial 30 May 2011

Podcast.

Website.

Tonight we discussed three essays.

Question 1.

A woman complains of breakthrough bleeding on oral contraception.

a.         justify the history you will take.                                   6 marks.

b.         justify the examination you will perform.                       4 marks.

c.         justify the investigations you will arrange.                     4 marks.

d.         justify the advice and treatments you will give.              6 marks.

Question 2.

Critically evaluate screening for gynaecological cancer.

Question 3.

You have been asked to review your departmental policy for the use of anti-D.

1. Justify how you will go about the process.                          8 marks.

2. Outline the key issues to be included in the document.      12 marks.

I had planned to discuss a fourth but we did not have time.

Question 4.

You have been asked to write guidance for the unit in relation to labour and delivery in water.

Outline how you will go about the task.                                   8 marks.

Discuss the key issues to be included in the guidance.          12 marks.

I wrote an  EMQ this afternoon.  It will probably have flaws. Have a go at answering it. Send me what you think and I'll send my thoughts. If it needs to be changed, I'll sort that out.

Lead-in.

The following scenarios relate to vulval conditions.

Choose the most likely vulval condition from the option list.

Each option can be used once, more than once or not at all.

Scenario 1.

A 22 year-old woman attends the colposcopy clinic after 2 smears showing minor atypia. The cervical appearances are of aceto-white with punctation. 

Scenario 2.

A 60-year old woman has an erythematous rash of the vulva extending to the inner thighs. A similar rash is noted under the breasts. She is not known to have diabetes.

Scenario 3.

A woman attends the gynaecology clinic with a white vulval rash. The main additional feature is a “lacy” appearance.  

Scenario 4.

A 35-year old woman attends is noted to have a vulval fistula. She has a history of episodic diarrhoea. 

Scenario 5.

A 25-year old woman attends the gynaecology clinic with a history of intense vulval itching and soreness. The appearances are of diffuse erythema with excoriation. Diabetes, candidiasis and other local infections have been eliminated by the GP. 

Scenario 6.

A 35-year old woman attends the gynaecology clinic with vulvitis. She also has a scalp rash. Clinical examination shows scaly, pink patches with signs of excoriation. Skin samples grow Malassezia ovalis.

Scenario 7.

A 40-year old woman has evidence of chronic vulval ulceration. She has recently been seen by a dermatologist for mouth ulceration and has been started on thalidomide.

Scenario 8.

An African woman of 35 years attends the gynaecology clinic. She has a ten-year history of chronic vulval ulceration. Examination shows multiple, tender vulval and pubic subcutaneous nodules, some of which have ulcerated.

Scenario 9.

A Caucasian woman of 29 years attends the gynaecology clinic with a chronic vulval rash. Examination shows erythematous areas with clearly defined margins and white scaly patches. 

Scenario 10.

A 30-year old woman attends the gynaecology clinic with vulval itching. Examination shows erythema of the labia minora and perineum. Full-thickness biopsy shows abnormal cell maturation throughout the epithelium with increased mitotic activity.

Option list.

A.	Acne.
B.	Behçet’s syndrome.
C.	Candidiasis.
D.	CIN 3
E.	CIN1
F.	Crohn’s disease.
G.	Dermatitis.
H.	Eczema.
I.	Genital warts.
J.	Hidradenitis suppurativa.
K.	Leprosy.
L.	Lichen planus
M.	Lichen sclerosis
N.	Lymphogranuloma venereum
O.	Normal skin.
P.	Psoriasis.
Q.	Seborrhoeic dermatitis.
R.	Type 1 diabetes mellitus
S.	Type 2 diabetes mellitus
T.	Ulcerative colitis.
U.	VIN III.

Tutorial 26 May 2011

Podcast:
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Tonight we discussed three essays.

Question 1.

You have been asked to perform an audit.

Outline the key issues involved in preparing and performing an audit.

Question 2.

A woman books at 8 weeks’ gestation in her first pregnancy. She is concerned because she works in a nursery where there has been an outbreak of cytomegalovirus infection. Critically evaluate the management.

Question 3.

It is Saturday morning.  You are the on-call SpR for gynaecology and have been asked for help by the locum Registrar in A&E. A man has returned from Africa on a surprise visit home. On arrival he cut his finger on a kitchen knife and has attended A&E for treatment.  He is accompanied by his wife. His finger has been cleaned and two sutures have been inserted. Prior to treatment he mentioned that he was found to be HIV+ve as a result of extra-marital heterosexual activity in Africa and was started on anti-retroviral therapy there. He refuses to disclose his HIV status to his wife as she would “go mad” if she were to discover his infidelity. She has asked for contraceptive advice as he was not due to return for several months and she stopped contraception when he left 3 months before. The A&E Consultant has gone out to a major road traffic accident and is not expected to be available for about an hour. The husband is not prepared to await his return. The sexually-transmitted disease STD clinic is closed and will not open until Monday. You have spoken to your Consultant who has said he doesn’t want to know and that you have to “get on with it”. Outline and justify your management.

 

We then discussed an EMQ.
One or two of the questions were not very good, so I'll rewrite them and put the amended version here.

Tutorial 23rd. May 2011

Podcast.
Website.
Tonight we discussed plans for 3 essays.

Question 1.

A woman attends the antenatal clinic at 10 weeks. Her son developed chickenpox two days ago. Her sister is 38 weeks pregnant. Critically evaluate the management.

Question 2.

A woman books at 6 weeks in her first pregnancy. She smokes 20 cigarettes daily.

1.            Detail the key aspects of the history you will take.             6 marks.

2.            Outline the risks to the mother.                                        4 marks.

3.            Outline the risks to the fetus / baby.                                 6 marks.

4.            Justify the steps you will take to reduce the risks.             4 marks.

Question 3.
A 25-year-old primigravida attends the antenatal clinic at 36 weeks. She has read a magazine article about delayed cord clamping (DCC)
1. Outline the factors that make DCC unwise.                                     6 marks.
2. Justify the advice you will give about the benefits and risks of DCC.  8 marks.
3. Outline the arrangements necessary for DCC.                                 6 marks.            

We also managed an EMQ.

If you e-mail your answers, I'll send what I have written.

Early pregnancy complications.

Lead-in.

The following scenarios relate to early pregnancy. For each, select the most appropriate answer from the option list.

Each option can be used once, more than once or not at all.

Abbreviations.

AFC.         antral follicle count.

AMH.       anti-Mullerian hormone.

CRL.         crown-rump length.

EPU.         early pregnancy unit.

FSH.          follicle stimulating hormone.

GTD.         gestational trophoblastic disease.

GTG 17.    RCOG Green-top Guideline 17. ”Recurrent Miscarriage.”  2003.

GTG 25.    RCOG Green-top Guideline 25. ”The Management of Early Pregnancy Loss.“ 2006.

hCG.         human chorionic gonadotrophin

MEUC.     medical evacuation of uterine contents.

PUL.         pregnancy of unknown location.

PUV.         pregnancy of uncertain viability.

RM.          recurrent miscarriage.

SEUC.       surgical evacuation of uterine contents.

TVS.          trans-vaginal scan

USS.          ultrasound scan

Scenario 1.

A nulliparous woman attends the booking clinic at 8 weeks’ gestation. An ultrasound scan shows a missed miscarriage of a size commensurate with the gestation. What will be your management?

Scenario 2.

A nulliparous woman attends the booking clinic at 8 weeks’ gestation. An ultrasound scan shows a missed miscarriage of a size commensurate with the gestation. She has had two previous pregnancies; both resulted in 1^st. trimester miscarriage. What will be your management?

Scenario 3.

A primigravid woman attends the A&E department with abdominal pain and vaginal bleeding. A home pregnancy test was +ve 1 week ago; the date of the LMP is uncertain. What will be your management?

Scenario 4.

A 40-year old woman is pregnant for the first time. Her periods have been erratic for 12 months and she has occasional hot flushes. She attends the A&E department with abdominal pain and vaginal bleeding. The bleeding is slight and her condition is good. An hCG is +ve and a TVS shows an incomplete miscarriage. What will be your management?

Scenario 5.

A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows endometrial thickening but no evidence of intra-uterine pregnancy. No pelvic abnormality is seen. What will be your management?

Scenario 6.

A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows a 15 mm. intra-uterine sac, but no fetus or yolk sac. What will be your management?

Scenario 7.

A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows a 30 mm. intra-uterine sac, but no fetus. What will be your management?

Scenario 8.

A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows an intra-uterine fetus with crown rump length of 5 mm., but no evidence of fetal heart activity. What will be your management?

Scenario 9.

A 35-year-old woman has had two normal pregnancies. She attends the booking clinic after an unplanned conception. Her hCG is +ve. A TVS shows an intra-uterine fetus with crown rump length of 6 mm. Fetal heart activity is seen. What will be your management?

Scenario 10.

A 35-year-old woman attends the A&E department at 6 weeks’ gestation with pain and bleeding. She became pregnant after IVF. An ultrasound scan shows a viable intrauterine pregnancy of a size compatible with the gestation. What will be your management?

Option List.

A.    Admit as an emergency case.

B.    Counsel and arrange TVS in 1 week.

C.    Counsel and arrange TV colour Doppler scan.

D.    Counsel re expectant management.

E.    Explain diagnosis and counsel re MEUC and SEUC.

F.    Explain diagnosis and counsel re expectant management and MEUC and SEUC.

G.    Explain diagnosis and counsel re expectant management, MEUC and SEUC and refer to the EPU.

H.    Explain diagnosis and counsel re treatment options with accent on the relative merits of SEUC and refer to the EPU.

I.     Explain diagnosis and counsel re treatment options with accent on the relative merits of MEUC and refer to the EPU.

J.     Counsel re missed miscarriage and refer to the EPU.

K.    Explain diagnosis and refer to the EPU for PUL protocol.

L.    Explain diagnosis and refer to the EPU for PUV protocol.

M.   Manage as ectopic pregnancy until proven otherwise.

N.    Arrange progesterone assay.

O.   Arrange AFC.

P.    Arrange AMH assay.

Q.   Arrange serial hCG monitoring for 48 hours.

R.    Administer anti-D immunoglobulin.

S.    Administer ergometrine 0.5 mg i.m.

T.    Prescribe mifepristone.

U.    Prescribe misoprostol for vaginal use.

V.    Continue with routine booking.

Tutorial 19th. May 2011

Podcast.
Website.
Tonight we discussed plans for 3 essays.

Question 1.

A 40-year-old woman books at 6 weeks gestation with a singleton pregnancy.  The GP referral letter states that she wishes to discuss amniocentesis in relation to her risk of Down syndrome.

1.            Outline the important facts to be elicited from the history.          5 marks

2.            Justify the information you would provide.                               10 marks

3.            Outline the other important issues to discuss.                          5 marks

Question 2.

You are an SpR in O&G and in the gynaecology clinic.

You are about to see a patient. The GP referral letter reads: “This woman would like to conceive. She has scanty periods and is overweight. Please see  and advise”.

1.            Outline the key elements of the history you will take.                      8 marks

2.            Outline the main issues to discuss with her.                                 12 marks

Question 3.

A woman attends for pre-pregnancy counselling. Her father has severe haemophilia A.

1.            Outline the key elements of the history you will take.           8 marks

2.            Justify the investigations you will arrange.                           6 marks

3.            Outline the information you will give.                                   6 marks

I assembled these just before the tutorial. If you send me your plans or essays, I'll let you know my thoughts. I cannot offer to mark and comment on each essay. There are too many of them and it would become a full-time job.

This week I had a copy of an EMQ book delivered. It is "EMQs for the NRCOG part 2 in Obstetrics" by Sinha and Mishra and published by Ansham. So far we have found it OK, unlike most of the similar books I have looked at. But it is probably a bit too early to suggest that you buy it. We'll discuss a few more questions from it next week, by which time its usefulness should be a bit clearer.

Tutorial 16th. May 2011

Podcast.
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Tonight we started the preparation for the written. There is advice about this here.
We started by writing an essay plan for a woman of 55 who had been referred after an episode of PMB. The question was "Critically evaluate the management". If you write an essay or a plan for an essay and e-mail it to me, I'll send you my thoughts. I cannot offer to mark and criticise every essay I get - it would become a near-full-time job and I have not got the time. But writing essays is essential. Get started now and always do them under exam conditions. I.e. with no preparation and within the exam time limits.
Then we tried to remember the 10 top recommendations from the recent maternal mortality report. You will need to know the report well and the recommendations would make a perfect essay or OSCE. The report is discussed here.
Then we wrote a plan for an essay: "Critically evaluate the management of asthma in relation to pregnancy". Again, send me your thoughts and I'll try to produce something as well.
Finally we did an EMQ from the book by Sinha and Mishra. I only got it today, so I have not had a chance to read and evaluate it.

Tutorial 5th. May 2011

Podcast.
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We started with you being asked to write a report for the risk management committee about a patient who had a post-operative problem that was not very well managed. This is a very typical station and you can easily manufacture an example or two. The parallel obstetric station will usually be mangement prior to delivery with failure to deploy a protocol, late involvement of the consultant etc. Abeer, who joins the tutorials on-line sent her example to me wondering how best to answer it. I changed her version slightly. Send me an e-mail and I'll e-mail it to you so that you can print it off. My e-mail is on the webpage: http://www.drcog-mrcog.info/contact.htm.
You are going to be asked what information you don't have and who needs to be asked to write a summary of their involvement to provide it. You may be asked to point out areas in which care may have been deficient and how this can be assessed. You may be asked about implications for the O&G department or the whole Trust. Remember that the incident might indicate a need for an audit.
You are likely to be asked about complaints and litigation and how to lessen the chances of the patient going down this route - all stuff that we have discussed on a number of occasions. The strategy is to make sure that she is given all the facts by someone senior, total honesty being the policy. You tell her how to make a complaint and to pursue litigation. In real life, as in the exam, this tends to defuse the situation. You talk about the seriousness of the adverse clinical incident investigation procedure and the outcomes for those found negligent, including you! This ranges from re-training and restrictions on what you can do to getting the sack and being reported to the GMC.
You are usually going to have a number of issues that need you to display "senior doctor thinking" - how often have you now heard that?
Then it is about scrutinising the details of the case. The case we dealt with was a woman of 48 having hysterectomy for fibroids. Why 48? Because it raises issues about her being close to the menopause and the operation being unnecessary.The problems caused by the fibroids were not specified, nor did we know their size, number or location.
What was done by whom and were they qualified to do it? What was not done that should have been done? What was done but later than would have been good care? And so on.
These scenarios are all very similar. You will have a pre-op problem: obesity, medical disorder, penicillin allergy, bleeding disorder, history of VTE etc. You will have an operation that may be inappropriate. A failure to do a proper assessment pre-operatively e.g. the WHO check list (which we failed to work into the viva) and so on. Then the post-operative care will usually be deficient. Things like pyrexia or hypotension + tachycardia will be ignored, the consultant will be involved too late, investigations will not be asked for or the results will be misinterpreted. The records will be poor with dangerous phrases like "routine procedure" for an operation, "observations stable" or "observations normal" without saying what they observations were. I think the group covered it pretty well.
Then we discussed a patient with inoperable cancer coming to clinic for the results of the tests that showed pelvic recurrence of a cervical cancer and a lung metastasis. You had to discuss the results and her subsequent care. Unfortunately, I turned off the recording when they were writing their plans and was slow to turn it back on again, so the early part of the discussion is missing.
I'll write something tomorrow. Send me your plan and I'll send mine. My e-mail is on the webpage: http://www.drcog-mrcog.info/contact.htm.  But don't ask for mine until you have attempted to write an answer. Tackling these difficult stations is essential preparation for the exam.
My thoughts and best wishes go with all of you who are sitting the exam next week. Let me know how you get on.

Tutorial 2nd. May 2011.

Podcast.
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Tonight we did a station in which you had to instruct a junior doctor in the basics of suturing with a view to them closing the skin of an abdominal wound. Apart from the technical details of suturing, you need to demonstrate a bit of knowledge about how to teach and a capacity for "senior doctor thinking ". It would be much better if we could video sessions like this, but Skype is not yet capable enough and it would be too expensive as a podcast. Parallel stations could be teaching instrumental delivery, safe insertion of a laparoscope etc.
We also did a critique of the RCOG's patient information leaflet about herpes in pregnancy. You can find it here: http://www.rcog.org.uk/genital-herpes-pregnancy-information-for-you.