Tutorial 15th. October 2015

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15 October 2015

36	Roleplay. Cystic fibrosis.
37	Viva. Waiting list prioritisation.
38	Roleplay. Teach a FY1 about shoulder dystocia.
39	Viva. HPV vaccination.
40	Viva. Whooping cough & pregnancy.

36.  Roleplay. Cystic fibrosis. Teenager. Early pregnancy.

Candidate’s instructions.

You are a year-5 SpR and are running the antenatal clinic as your consultant is on sick leave.

You are about to see Helen Smith. She has an early pregnancy and has attended for booking. The midwife started to take the history, found that she had cystic fibrosis and has asked you to see her.

The midwife has taken a general, family and social history. She has not found any major issues apart from her age, she is 17 years old, and her BMI, which is 20 kg/m². Your tasks are to take a history relevant to the CF and advise about management.

37.  Viva. Waiting list prioritisation.

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	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.

38.  Roleplay. Teach a FY1 about shoulder dystocia.

Candidate’s instructions

It is a quiet day on the labour ward. You are working alongside a new FY1. There was a case of shoulder dystocia on her last labour ward on-call and she had very little idea of what was going on. She asked the consultant about the management and she has asked you to teach the FY1 the basics.

39.  Viva. HPV vaccination.

Candidate’s instructions.

This is a viva station about the UK programme for routine HPV immunisation.

The examiner will ask you 18 questions.

When you have finished a question, you will not be allowed to return to it as later questions may indicate earlier answer. If you return, no marks will be awarded, even for correct answers.

40.  Viva. Whooping cough & pregnancy.

Candidate’s instructions.

The examiner will ask you 4 questions about pertussis and pregnancy.

Tutorial 8th. October 2015

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8 October 2015

31	Role-play. Fragile X syndrome
32	Viva. Adverse incident report. 4th. degree tear.
33	Roleplay. Abnormal cervical smear
34	Viva. Neonatal jaundice.
35	Viva. Apgar score.

31.   Roleplay. 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. There were no other significant issues in the history.

Your task is to discuss Fragile X syndrome and the implications for Mary.

32.   Viva. Adverse incident. 4^th. degree tear.

Adverse incident report.

Candidate’s instructions.

Mrs Penelope Jane Brown sustained a 4^th. degree tear during 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 which the RMT need 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 Statement.

I am Dr. J. White. I have been SpR in obstetrics and gynaecology at the Royal Infirmary for over a year.

On the 27^th. 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.

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 4^th. 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.

33.   Roleplay

Candidate's Instructions.

This is a role-play station.

You are the SpR in the colposcopy clinic.

The patient is attending after a smear showed severe dyskaryosis.

Your tasks are to take a history and explain the investigations you propose.

34.   Viva. Neonatal jaundice.

Candidate's Instructions.

This is a viva station.

The examiner will ask you 6 questions.

35.   Viva. Apgar score.

Candidate's Instructions.

This is a viva station.

The examiner will ask you 8 questions.

You are not allowed to return to earlier questions.

You will not be awarded any marks if you do, even for correct answers.

5th. October 2015

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5 October 2015

27	Viva. Parvovirus.
28	Roleplay. Audit. Teach the basics to a new FY1.
29	Viva. Obstetric surveillance systems.
30	Viva. Diathermy.

27.   Viva. Parvovirus.

Candidate's Instructions.

This is a structured viva station. The examiner will ask you 22 questions. Do not return to earlier questions – you will get no marks, even for correct answers.

This station tests good time management as well as knowledge.

28.   Roleplay. Audit. Teach the basics to a new FY1.

Candidate’s instructions.

You are the SpR on call for the labour ward.

It is a quiet afternoon: all the patients are healthy and in normal labour.

Dr. Jane Jones has started in the department as a new FY1.

She is keen to specialise in O&G and has already passed the Part 1 examination.

A measure of her enthusiasm is that she has asked her consultant if she can be involved in doing an audit, but she is aware that she knows little about it.

Her consultant happens to be the consultant on duty for the labour ward and has asked you to ensure that she has enough knowledge to be a useful member of a team conducting an audit.

29.   Viva. Obstetric surveillance systems.

This is a viva station.

The examiner will ask you 2 questions about surveillance systems used in obstetrics.

The examiner will suggest that you move to the next question when you appear to have completed the one you are answering to ensure that you have time for the remaining answers.

30.   Diathermy.

Candidate's Instructions.

This is a viva station about diathermy and its uses and complications.

The examiner will ask you 8 questions.

1st. October 2015

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1 October 2015

23	Role-play. Mechanisms   of normal labour & delivery.
24	Viva. Headache.
25	Roleplay. Phenylketonuria
26	Viva. Enhanced recovery

23.   Roleplay. Normal labour and delivery.

Candidate’s instructions.

Mechanisms of normal labour & delivery. Explain these to the role-player, who is a medical student and keen to learn how to do a normal delivery. Your consultant has said that she needs a clear understanding of the mechanisms before considering conducting a delivery.

24.   Viva. Headache.

Candidate's Instructions.

This is a viva station.

The examiner will ask 13 questions.

25.   Roleplay. Phenylketonuria

Candidate’s instructions.

You are the SpR in the pre-pregnancy clinic. Your consultant is off on sick leave and you are the most senior doctor in the clinic.

You are about to see Jane White who is planning her first pregnancy. Your task is to take a history and discuss the optimum management now and during pregnancy.

The GP letter reads:

Prime Health Practice,

Primetown,

Sussex.

0298766543.

Practice Manager:

Mrs Willhelmina Bland.

Dear Doctor,

Please see Jane White, 35 years of age and planning her first pregnancy. Her health is good – she seems only to attend the Practice for routine checks such as cervical smears – the most recent of which was taken last year and was normal. From talking to her and examining her records, it is clear that she is very healthy and has always had good physical and mental health. Her social circumstances are good. The one thing of concern is that she told me she was on a diet in childhood supervised by the local paediatric team. She can’t recall what it was about and she stopped the diet at about the age of 14. Both of her parents are dead – her mother fifteen years ago at the age of 40 and her father two years ago in a RTA, so cannot shed light on what the diet was for. Fortunately, when I checked through her notes I came across correspondence indicating that the problem was phenylketonuria. I have told her that I am no expert in phenylketonuria and the implications for pregnancy, so have eschewed the temptation to provide any advice.

I look forward to receiving your expert report.

Dr. John Worthy.

26.   Viva. Enhanced recovery

Candidate’s instructions.

       You are a newly-appointed consultant.

The Clinical Director has asked you to develop a programme for enhanced recovery for inpatient gynaecological surgery.

As a first step, she has asked you to deliver a talk to a unit meeting (all staff can attend) to outline the key features of enhanced recovery.

She suspects that little is known by most of the staff about the subject and hopes that your talk will encourage their enthusiastic participation.

Your task is to tell the examiner the key points you would wish to cover in the talk.

This is not a structured viva: the examiner will not ask questions or help you in any way.

28th. September 2015

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28 September 2015

19	Viva. Incomplete ECV audit.
20	Role-play. Pre-pregnancy counselling. Dad recently diagnosed with Huntington’s.
21	Viva. Breast-feeding.
22	Role-play. Neonatal screening.

19.   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, what conclusions you can already make and any recommendations. The examiner will not ask questions or assist you in any way.

20.   Role-play. Huntington’s disease.

Candidate's Instructions.

You are the SpR in the pre-pregnancy counselling clinic.

Mary Smith has been referred.

The GP referral letter is brief. “Please see this woman who is considering becoming pregnant. Her father has Huntington’s chorea, about which I know very little.”

Your task is to take a history and advise about appropriate investigations.

21.   Viva. Breastfeeding.

Candidate’s instructions.

This is a viva station.

The examiner will ask you 6 questions.

22.   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.