Objective Structured ClinicalExamination (OSCE) Practice Cases

Information for Candidate

Further Information for Model Patient

Answer

Information for Candidate

Ms CB has presented with bleeding at 10 weeks of pregnancy. An ultrasound demonstrates: (1) an intrauterine gestation sac, (2) a fetal pole, (3) crown-rump length of 9 mm and (4) the absence of fetal heart activity. She has been told that, sadly, she has experienced a miscarriage. Please speak to her regarding her options at this point.

See Chapters 6 .

Further Information for Model Patient

Possible questions for you to ask:

• Why has this happened? Is this really unusual?

• What are the risks of management? Will there be any impact on my future fertility?

• Will I be able to get pregnant in the future? When can I try for another pregnancy?

• Are there any investigations I should have? Is there any treatment available?

Answer

It is important to be understanding and sympathetic. It is a good idea to start by recognising that this is a distressing situation.

The incidence of miscarriage is about 20%, increasing significantly with age.

A woman may ask why this has happened. It is helpful to be reassuring that the woman’s actions have not caused a miscarriage. In at least 50% of cases, no reason can be found. Some 50% of cases appear to be caused by chromosomal abnormalities within the fertilized egg. Rarer causes include autoimmune conditions, such as anti-phospholipid syndrome or poorly controlled diabetes. It is unclear whether structural abnormalities of the uterus play a part. Smoking cessation advice should always be given.

Options for management include:

• Expectant management (a ‘wait-and-see’ approach)

• Medical management of miscarriage, with synthetic prostaglandins (misoprostol)

• Surgical management of miscarriage, usually under general anaesthetic whereby a suction curette is used to aspirate the contents of the uterus. Cervical preparation with misoprostol is usually used beforehand.

Risks include:

• Retained products of conception

• Infection–women should be specifically told to report whether they have any symptoms, such as fever, heavy bleeding, pain, offensive discharge

• Haemorrhage and, in rare cases, blood transfusion

• In the case of surgical management, trauma to the genital tract, including perforation of the uterus and cervical trauma. In the case of perforation, further surgery, such as laparoscopy or laparotomy, may be required to diagnose and treat any complication, such as bowel or bladder injury.

In terms of impact on future fertility, there is no clear evidence that either method impacts on future fertility. Asherman syndrome is a rare condition which has been described after uterine evacuation whereby adhesions and scarring of the endometrium cause secondary amenorrhoea.

If asked when it is okay to become pregnant again, it is appropriate to say that it is usually when a woman feels emotionally and physically ready.

Investigations for rarer causes of miscarriage are usually performed only in cases of recurrent miscarriage, which is defined as 3 or more miscarriges. Only a small percentage have an identifiable and treatable cause. However, even in these cases, the chance of a successful future pregnancy is 60% to 75%. Counselling and reassurance are currently the mainstays of treatment, although this is an area of ongoing research. Unproven treatments should be avoided.

See Chapters 6 .

Information for Candidate

Ms EF has arrived in the emergency department with a 1-day history of vaginal spotting and severe abdominal pain. She had an episode of fainting while in the waiting room. You are the on-call emergency department doctor. Please discuss with the examiner how you will assess her.

See Chapters 6 and 44 .

Further Information for Examiner

Encourage a systematic approach. Provide information when specifically asked. The woman is lying still on a hospital trolley. She looks pale. She is conscious but not answering questions clearly and keeps saying she feels really unwell. No one is available to provide a collateral history.

• A

  Airway is patent.

• B

  Respiratory rate (RR) is 12, oxygen saturation 98%, chest is clear on auscultation.

• C

  Heart rate (HR) is 120 beats per minute, regular. Heart sounds pure. Cool peripheries, peripheral capillary refill 4 seconds, central capillary refill less than 2 seconds. Blood pressure (BP) 110/65 mmHg. Ask what actions would you take at this point. Expect intravenous (IV) access; bloods, including full blood count (FBC) and blood group; and fluid replacement with crystalloid.

• D

  Blood glucose 6.3, Glasgow Coma Scale (GCS) 15.

• E

  Abdomen tender and peritonitic. Pregnancy test is positive. Left shoulder pain.

Ask about differential diagnoses.

Ask initial management.

Ask whom they would like to contact for assistance. Ask them to make the phone call.

Ask about further management.

Answer

In an emergency situation, it is helpful to take a structured ABCDE approach.

An ectopic pregnancy should always be considered in collapse of a woman of childbearing age.

• A

  Airway

• B

  RR, oxygen saturations, auscultate chest

• C

  HR, BP and capillary refill. Actions: gain IV access (large bore, 2 cannulas), take bloods tests including FBC, renal function, and blood group. Start IV fluid circulating volume resuscitation with crystalloid fluid.

• D

  Blood sugar and GCS.

• E

  Expose, palpate abdomen, looking for evidence of bleeding (external and concealed), shoulder pain.

A urinary catheter should be inserted to obtain urine for a urinalysis, perform a urinary pregnancy test and guide fluid replacement.

A speculum should be inserted to look for vaginal bleeding or an open cervical os, which may suggest miscarriage.

Young healthy women typically compensate well in the early stages of ongoing bleeding. By the time their vital signs are abnormal, they are very unwell. Therefore, a normal BP in this case is not reassuring. This woman is showing signs of haemorrhagic shock, including tachycardia, dizziness and cool peripheries. A peritonitic abdomen and positive pregnancy test point towards an ectopic pregnancy test being the most likely cause. It is important to recognise the seriousness of the situation and escalate appropriately. An appropriate person to contact on this occasion would be the on-call gynaecology registrar or consultant.

Good communication is key and could take an SBAR approach. For example:

• Situation —I’m phoning with regard to a 23-year-old woman who I suspect has an ectopic pregnancy. She has signs of severe hypovolaemia and has collapsed once already.

• Background —She has a short history of abdominal pain, vaginal bleeding and dizziness.

• Assessment —On examination, she is tachycardic with cool peripheries. Her abdomen is peritonitic. Her pregnancy test is positive.

• Recommendation —I have gained IV access and taken bloods, including blood group, and started IV fluids. I would like you to come and review her with a view to urgent surgery.

A pelvic ultrasound would be useful in determining the diagnosis but should not delay management, which, in this case, will be transfer to theatre for surgery. A FAST (Focused Assessment with Sonography for Trauma) scan in the Emergency Department may be useful to look for the presence of free fluid in the abdomen, which in this context, is intraperitoneal blood.

See Chapters 6 and 44 .

Information for Candidate

Further Information for Model Patient

You have a 6-week history of constant bleeding. Your GP started a course of tranexamic acid and norethisterone 2 weeks ago, which helped while you took it, but as soon as you stopped this, the heavy bleeding came back.

Prior to this, your periods were regular, bleeding for 5 days in 28. They have been heavier over the last year and have become significantly more painful. You have had time off work because off this, which is very unusual for you. You are para 2+0 having had 2 vaginal births in the past. You have not had any postcoital bleeding and do not have any pain with sexual intercourse. Your smears have always been normal in the past, although it is 10 years since you had one. You do not use contraception, as your husband has had a vasectomy. You have had no new sexual partners.

You have been feeling very run down recently. Your past medical history includes hypothyroidism, for which you take thyroxine. You are allergic to penicillin. Your mother had a hysterectomy in her 50s, although you are not sure what this was for.

Answer

Information for Candidate

IH is a 28-year-old para 1 who has been experiencing heavy periods. She has had a normal examination, recently had negative vaginal swabs, a normal pelvic ultrasound and has a normal cervical smear history. She would like to discuss treatment options. She feels that her periods are ruining her life.

Please discuss this with her.

See Chapter 7 .

Further Information for Model Patient

If asked, you are not currently trying for another pregnancy but are not sure if your family is complete.

You would specifically like more information on intrauterine contraception, including side effects and risks.

Answer

Medical options for managing heavy periods include:

• The levonorgestrel-releasing intrauterine system (LNG-IUS)—also offers contraception for up to 5 years and 95% reduction in blood loss at 12 months, with many women experiencing amenorrhoea. Side effects include irregular bleeding, particularly in the first 3 to 6 months, and expulsion rate is about 5%. There is a small risk of perforating the uterus on insertion. There is an increased risk of pelvic infection. If pregnancy does occur, there is an increased risk of ectopic pregnancy. However, overall lower numbers of pregnancies also means fewer ectopic pregnancies.

• Tranexamic acid and mefenamic acid—tranexamic acid is an antifibrinolytic. It can reduce blood loss by about 50%. Side effects include gastric upset and tinnitus. It is not suitable in individuals at high risk of venous thromboembolism (VTE). Mefenamic acid is a non-steroidal anti-inflammatory drug. It reduces blood loss by 25% and acts as a painkiller. Side effects include headache, dizziness and gastric upset. This is the best option for women trying to conceive, as other medical options also act as contraceptives.

• Oral contraception—can be taken in a cyclical fashion to cause a withdrawal bleed, or ‘back to back’. There is an approximate 50% reduction in blood loss. Not always appropriate for those at high risk for venous thrombosis aged over 35 years and experiencing persistent migraine with aura. The progesterone-only pill may be suitable for some women who cannot take the combined contraception pill.

• Cyclical norethisterone—may be used to regulate an irregular cycle, although it does not appear to reduce blood loss.

• Injected long-acting progestogens—depot-injectable progestogen frequently results in amenorrhoea when taken for an extended period. Side effects include irregular bleeding initially, bloating, breast tenderness, headaches, increased appetite and skin changes. It can sometimes take 12 to 18 months for periods and fertility to resume once the injections are stopped.

• GnRH analogues which cause amenorrhoea by pituitary downregulation would not be an appropriate first-line treatment in a 28-year-old.

• Both endometrial ablation and hysterectomy are inappropriate in this case, as IH wishes to preserve her future fertility.

See Chapter 7 and 21 .

Information for Candidate

Further Information for Examiner/Model Patient

Answer

Information for Candidate

LM, a 25-year-old, returns to your clinic for a follow-up appointment. She has recently had a diagnostic laparoscopy due to chronic pelvic pain. This has demonstrated superficial endometriosis on the left pelvic side wall and in the pouch of Douglas, which has been excised. She has been told she has endometriosis but does not know what it is. Please discuss the operation findings with her.

See Chapter 8 .

Further Information for Model Patient

Questions you ask could include:

• What is endometriosis?

• What causes it?

• Can it be cured?

• I have heard that you cannot get pregnant if you have endometriosis. Is this true?

• How can endometriosis be treated? Will I have to have more surgery?

Answer

A question like this tests your communication skills. It is important to explore what the woman already understands and what she is concerned about. An explanation should be clear and should avoid using medical jargon when possible. It may be helpful to look at patient information leaflets or websites to get an idea for how to explain medical ideas simply.

Endometriosis is the presence of endometrial-like tissue outside of the uterus. This is usually in the pelvis, such as the uterosacral ligaments or pelvic peritoneum but more rarely can affect more distant sites. These tissues respond to hormones in the same way that endometrium does, causing inflammation and pain. The incidence is reported to be between 4% and 43%. It is unclear what causes it—theories include retrograde menstruation and metaplasia. It is difficult to know why it affects some women and not others, although there may be genetic or immunological factors. Typically, it causes pain just before or during a period, although some women also experience chronic pain unrelated to their cycle. Other symptoms include pain during sex, pain during ovulation, pain on defecation, cyclical or menstrual symptoms and subfertility. There is a poor correlation between the extent of disease found at laparoscopy or on imaging and the severity of the symptoms. There is an association with subfertility, but it is not the case that all women with endometriosis will have problems conceiving.

Management options can be split into analgesia, ovulation suppression or surgery. Ovulation suppression may be with combined or progesterone-only contraceptives, or with LNG-IUS. GnRH analogues are second line and usually limited to 4 to 6 months, with add-back hormone replacement. Surgery can include treatment of superficial disease, a pelvic clearance or treatment of deep infiltrating disease in a specialist centre.

There is an association with subfertility. Treatment of minimal to mild disease does appear to improve fertility, but the role in moderate to severe endometriosis is less clear. Removal of large endometriotic cysts may improve fertility. Assisted reproductive techniques may be required more often than in the non-endometriosis population.

See Chapter 8 .

Information for Candidate

Further Information for Model Patient

You have been experiencing incontinence for several years. You find that you need to go to the toilet up to 10 times daily, including many times overnight and sometimes will not make it to the toilet in time. You have not noticed any leakage of urine when coughing or sneezing.

You are a para 4, having had 4 vaginal births. Your favourite drink is tea and you do not tend to drink anything else. When out for the day, you will not drink anything at all to avoid needing the toilet. You are a smoker and do not drink alcohol. You have not been aware of a prolapse.

This is having a huge impact on your confidence and quality of life.

Answer