Tutorial.
With the exam results out, we start a new cycle of preparation.
It is important to be realistic. This is the toughest exam you are likely to sit. Unless you are an Einstein, you need six months minimum to prepare and this with devoting all your spare time.
We now have just over 3 months to the March exam. If you have not started your preparation, you should think seriously about the wisdom of attempting the exam in March as you are almost certainly going to fail.
Failure is very depressing and it seriously dents your self-confidence. This makes it hard to get going again, so your next bout of preparation is also inadequate and you end up in a downward spiral. You finish by concluding that it is impossible for anyone from your part of the world ever to pass the exam. This is untrue, but a common conclusion.
Far better to plan to sit the exam well-prepared. If you still fail, your results will show that you came very close and a bit more of an effort will see you through.
My advice about preparation is here:
http://www.drcog-mrcog.info/MRCOG%20how%20to%20pass_first_time.htm
Note the really important advice about having a good system for reading, note-taking and revision:
http://www.drcog-mrcog.info/MRCOG%20how%20to%20pass_first_time.htm#Effective reading
Tonight we started with a roleplay. This was to illustrate the point that you can start practising communication skills now so that they are slick by the time of the OSCE.
There is advice on the website: http://www.drcog-mrcog.info/Topics%20not%20in%20the%20textbooks.htm
The Roleplay was:
A 55 year old woman is referred by her General Practitioner.
Candidates Instructions.
You are an SpR in the gynaecology 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 Practioner.
Manor Lodge,
High Street,
Anytown.
PO5 S00
Re: Mrs. Betty Black,
5b High Street,
Anytown.
PO5 SO1
Dear Doctor,
Please see Mrs. Black who has had bleeding.
Yours sincerely,
James Thick,
General Practitioner.
Then we had an EMQ.
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 1st. 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.
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