Posted: Thu Nov 19, 2009 12:33 am Post subject: OSCE - Nov 2009, Tue am

# Prep station- Website on PCOS (info from a non-medical Dr promoting a questionnaire for
diagnosing PCOS on line and then taking on their nutrition/weight reduction treatment of
symptoms and prevention of implications.

# Structured viva Re:website.

# Structured viva Re: 12/40, history of RTA with "complex" pelvic fructure. What info you would
ask, advice for pregnancy and labour, presents on LW at term with mild lower pelvic pain -
management and last question: pushing for 90 min, epidural on board, CTg normal, clear liqour, no
caput/moulding, station at +1to +2, management.

# Strucutred viva on Chickenpox- questions - answers from the guideline.

# Role play-Breaking bad news- Primigravida: open spina bifida and ventriculomegaly at 21/40
scan. Decline NT and and wouldn't have invasive testing. Explain diagnosis, options. From taking
the history you get that she had no dating scan. When she heard the (option) word termination
went off upset and shouting why would she do that.

# Prep station- Risk management- Folder of "notes given".

# Structured viva: discuss immediate clinical management then risk management issues.

# Role play: Severe dyskariosis on HIV pt (taking HAART), husband knows and is negative- explain
dx, management and answer patient's questions.

# Structured viva on Uterine inversion: questions included: called in and saw mass in the vagina
and placenta in situ-what would you do, then becomes obs hypotensive and tachycardic, finally
results given: DIC and Hb 4.2. Management.

# Role play: 14 days post TAH-BSO for severe endometriosis-constant leaking of fluid and from
the Hx, Lt flank pain. Marks for history, investigations & management.

# Role play: 44yrs menorrhagia not responding to TXA and OCP. Hypothyroid on thyroxine and
normal TFTs. Hb 8.9. USS shows 20/40 size uterus, endometrium distorted by fibroids. Hx,
Investigations, management.

# Role play: 37 yrs old, 36/40 wanting c/s. From the history taking: had ELCS for breech followed
by vaginal delivery and MROP and bad labour experience ie no getting epidural on time, not
listened by the MW... Not demanding c/s, quite sensible pt who needs to listen the pros and cons
of each option.

Forgot to add that the uterine inversion patient was grandmultip - ?P8.

Risk management case: CPP patient with 5 previous laparotomies for different reasons including
TAH for severe endometriosis and c/s. The consultant sees her in the GOPD and advises lap
oophorectomy. He had seen Harmonic scalpel once and decided to use it for the first time. Patient
returns back ?48hrs with acute abdomen seen by the FY1 in A+E. Tasks: Immediate management
(Hx,Ex,Inv,2 differential diagnosis,Mx). Then risk management questions: poor documentation,
incomplete consent, no preop assessment, lack of appreciation of severity, next day FY1 reviews
and sends home after updating the consultant on the phone etc. One question was about
how/what Clinical Governance does for the use of new instrument: I said about teaching-training,
number of cases to do under supervision-auditing and risk management of cases with unexpected
outcome, but apparently the examiner wanted something more as well. ?any ideas

Sun Nov 21, 2010 9:56 am Post subject: Questions: OSCE Nov 2010
i was on the first day the first batch

had severe tachycardia at each station

1.the first was the domestic abuse it wasa blighted ovum and woman had bruises on thighs
counsel her and she was insisting on surgical management as partner was away so she wanted to
get it over as soon as possibe

2 it was a picture of lichen sclerosis the role play was referrred from gp and had no benefit from
his treatment she was 48 so i took a history explain the diagnosis and the treatment the steriod
and how to use when to follow and risk of cancer a bit of hrt and the dyspaurenia she added what
to do for that

3 it was an audit on ecv with a calculator to study it and the information was a b c d e f consultant
r doing it the no of delieveries the results pt missed the venue the containdications the success
rate and to discuss with the examiner who is at the next station

4 role play with cgin explain the diagnosis and what is to be done she was asking from where i got
and how to follow

5 a gp letter staing he counselled some body having severe endometriosis

and described about her sister whom he also treated in the letter
so find the unambigious information and comment on various things on the letter the examiner
was asking

6 structued viva on preeclampsia as the pt presented with a high bp and proteinuria and walked
slowly starting at 32 weeks initial assessment and then thru delivery and postnatal care

7 a single mother at 20 years had an anomaly scan showing gastroshisis with loops of bowel
floating
so explain the diagnosis the further management and postoperative care to her

8clinical governance i do not know what i said

a case of vaginal hys done by registerar that slowly deteriorated with the initial complain of nausea
on first post op day and on day 3 seen by consultant and then had xray and on day 4 seen by
surgical team and on day 5 had laprotomy and had a loop of bowel stiched with the vault and had
reanastomosis done later
so the risk management steps recommendations etc

9 a woman with previous 3 miscarriages on taking the history she told she has 1 child born via cs
at 34 weeks and then followed by 3 miscarriages
the investigations showed anticardiolipin antibodies positive so a case of antiphospholipid
syndrome so discussed further management

10 very difficult station felt like collpasing it was the examiner who gave a paper to read that a
woman had 2 previous cs and now complains of incontinence i think 6 months after cs so now the
examiner asked
what will u ask in the history to rule out the type of incontinence
then she showed a msu result that was showing no uti as written in the report then she showed a
flow chart and asked comment on the flow
and then she showed a cystometric graph and asked comment on the type of incontinence it
shows and describe further management the type u think it is

Posted: Fri Nov 19, 2010 11:27 pm Post subject:

I was feeling blue as it was a horrible exam with lots of clinical governance, however have made it
on to the past list so must have done something right!

There wasn't much obstetrics.

Someone else has asked me to email him the stations so have summarised them here:
1. Gynae clinic, just examined a woman with pelvic pain and noticed lots of bruising on inside of
legs, back in clinic room and need to investigate further, in other words domestic violence
(roleplayer)

2. 17 year old admitted as emergency with abdo pain and unable to PU afer vigourous sex 3 days
before. Photo given which looks like herpes, take history and discuss management (roleplayer)

3. prep station for 4.

4. audit of departmental treatment of stress incontinence, already started by another doctor, 4

slides with results on to comment on and then discuss conclusions and recommendations with
examiner

5. 32 year old lady seen in colposcopy clinic with glandular abnormalities on smear, discuss and
formulate management plan (roleplayer)

6. Viva station with examiner discussing management of a booking lady who previously had a
1.8kg baby by emergency LSCS at 35/40 for severe PET. Discuss management in this pregnancy
and then they take you through scenario of presenting with same at 37/40 and then having an
abruption and IUFD

7. Discuss a letter written by consultant to GP regarding inpatient treatment of a lady with a

ruptured ectopic. Many inappropriate things written in the letter about patient and surgeon.
Discussed with examiner with them asking questions. This I found really tough and wasn't sure
exactly what they were after. They wwere asking things like what are the irrelevent facts here and
what is potentially liable. Probably the worst station.

8. Counselling a poorly controlled diabetic at 19/40 whose detailed scan (just had) shows spina
bifida. Doesnt want TOP. (role player)

9. prep station for 10.

10. Case review and discussion of patient who underwent TAH, didnt have antibiotics as penicillin
allergic, post op had temp and ? ileus, developed intra abdo mass and eventually taken for
laparotomy 5/7 by surgeons ? obstruction. Discussion with examiner re events, anything done that
was suboptimal, recommendations to prevent same mistakes etc

11. Patient presents to gynae clinic with history of recurrent miscarriage. Take history, has had
investigations done already in Scotland for which she gives you results. Only abnormality is
balanced translocation in partner. Discuss results and options. (role player)

12. Postnatal lady seen at 6/52 postnatal with urinary incontinence after forceps delivery. VIVA
station where examiner asks what would you want to know antenatally/in labour/delivery and
postnatally. Then what investigations would you do. He then gave you Ix results and you discuss
diagnosis and management.

Mon Nov 22, 2010 6:21 pm Post subject: Nov osce

1. Role player with rec peg loss: pt insisted on knowing whether she will be able to have a baby
with her husband at all. As far as I remember the translocation did not involve chromosome 21 but
I may be wrong.

2. Structured viva on UG:

6 weeks postpartum pt. Had a difficult vaginal delivery in theatre. Now c/o urinary incontinence
a) What would you like to know about her delivery and what other history would you take from
het?
-forceps delivery
-had catheter in situ for 6 hrs
-1st void after removal of cat her was after 10 hrs
-h/o nocturia
-symp of UTI
b) these are her investigations
-urine microscopy showing raised total white cells
-culture: E Coli sensitive to cefexime
-filling cystourethrogram showing voiding dysfunction (voiding pressure about 25 and residual vol
376 ml)

c) what is your diagnosis

Postpartum urinary dysfunction with UTI

d) how will u treat her?

e) what is the prognosis?

3. Domestic violence role player was 45 yr old P2 who had come with chronic pelvic pain. On
examination: mild tenderness on pelvic examination; rest NAD. She insisted that the husband was
nice to the kids and they did not require any protection from him. After the counseling on doom
violence, she wanted further discussion regarding the pelvic pain.

4. The letter from GP for herpes girl said that she was 21 yr old, on OCPs, had "vigorous sex" with
new boyfriend and suddenly developed swelling of vulva and is unable to pass urine. He wrote that
he suspected trauma.
Ques was.. Ask relevant ques, make diagnosis and answer her queries.

5. I found the audit ques very difficult. There were 4 slides: first showing that it was a
retrospective audit over 6 mths. Total no of patients enrolled.
The next slide was a list of all the procedures offered in this particular unit for stress incontinence
and included ant repair, MMK procedure, abdominal sling apart from TVT, TVTO, open bursch. The
next slide showed how many patients each consultant was operating on and how many out of
these patients had UDS done prior to surgery. The last slide showed the no of patients offered
physiotherapy by each consultant. There was an asterix at the bottom of this slide saying that the
unit did not have a physiotherapist with special interest in pelvic floor.
The ques were:
a)comment on the audit design
(retrospective, duration, no of pts, no defined std, incomplete audit)
b)what conclusions can u draw?
c)what are the good points?
d)what are your recommendations?
Phew! I had no clue what they wanted.
. The role player with abnormal smear had borderline changes with glandular cells on 2
consecutive cervical smears. She was para 1 and had a coil in situ and had been referred to the
colpo clinic. She was happy when told that it was not cancer; wanted to know how the colpo would
be done, and was keen on discussing impact on future fertility and pregnancy in case any further
abnormality came up that may require treatment.
(ques was take relevant history and address pt concerrns)

7. Structured viva on preeclamsia

Part 1: G2P1 with h/o severe PE and IUGR in prev pregnancy which necessitated a preterm LSCS
at 35 wk comes at booking visit. BP at this visit is normal. How will you manage her?
Part 2: she had uneventful pregnancy till about 36 wk when she presented with high BP,
proteinuria, scan showing oligohyd but normal Doppler and ctg normal. Pt asymptomatic.
Part 3: she is planned for em LSCS but has sudden acute abdominal pain with fresh vaginal
bleeding. US confirms IUD. How will u manage her?

(there was no specific ques on postpartum care for this pt but there was enough time to talk about
bereavement counseling, lactation suppression, postmortem)

8. Structured viva on a very lousy letter written by consultant to GP regarding a pt who apparently
had a ruptured ectopic.

It went something like this:

"this pt had come to emergency with acute abdominal pain and had no clue that she was
pregnant. In fact she was due for IVF at my unit due to husband's azoospermia and I suspect that
she is having an extramarital affair. She had extensive facial surgery 7 hrs ago for a road traffic
accident which was performed by my dear friend.. (Some surgeon.s name).

She underwent laparoscopy for right sided ectopic by my registrar which was converted open
surgery which according to me was entirely uncalled for. However I was not there at the time of
surgery. The pictures of the operation show that the damage was extensive.

As it is not trust policy to see these patients further, I'm referring her to your care"

(the letter had no date on it)

Questions were:
- what statement breaches pt confidentiality?
- which 2 statement are irrelevant?
- which statement might be quoted against the surgeon in case of litigation?
- which statement would the pt object to?
- what does the code at the left hand top corner of the letter stand for?
( it was an alphabetical code with NHS number.. Pt identification no?)
- a copy of the letter is given to the pt also.. What is its importance?
- what is the importance of good written communication amongst health care staff?

9. A 19 yr poorly controlled iDDM came for FA scan at 19 wks and is found to have Arnold chiari
malformation, large meningomyelocele, bilateral CTEV. The sonographer noted that there was no
movement in both lower limbs. She has been very excited about this preg.
Explain findings, address patient concerns and discuss further management.
She did not want termination.

10. An ST3 assisted by SHO did a routine TAH with BSO in 48 yr old pt
for fibroids. The surgery was straightforward. Postoperative notes are as follows:

Day 1: review by ST3, intraop finding explained

Observations stable

Day 2: r/v by SHO

Obs stable, remove catheter, allow orally, off drip
Pt c/o nausea, has not passed flatus

R/v PM by ward nurse.. Iv line resited as pt unable to take orally

Day 3: r/v by consultant and ST

Pt febrile, vomiting, abdomen distended, has not passed flatus
Suspected ileus.. Abd X Ray ordered

Day 4: pt febrile still vomiting and abdominal distension

No bowel sounds X Ray not back as yet

Day 5: RV by SHO: abdo distended with rebound tenderness, VE: mild tenderness; calls GS who
take over pt, traces X Ray which is suggestive of int obstruction. Em laparotomy done.. No bowel
injury but right sided pelvic abscess. Drained, lavage done, drain left in situ. Pt recovered well over
next 2 wks.

Ques: u are meeting the CRM team head

- identify areas of deficient care and make recommendations
- who are the people who should make a statement in this case?
- how is this case relevant to other departments in the hospital?
- the pt.s family is threatening litigation.. What can be done to minimize the chances of litigation?

Hi some of the stations that appeared, cant remember the exact wordings
1. structured viva - 18 year old primary amenorrhoea has come to see you in the clinic
a) what do you look for in examination 6M
b) what specifically would you look for
c)what are the investigations
d) what treatment would you offer
The case was of androgen insensitivity

2.teach ST1 shoulder dystocia. You are tested on your teaching skills as well as knowledge of
procedure. You are provided with manequin

3. Structured Viva - pharmacology. He had magnisium trisilicate, magnisium sulphate, calcium

gluconate, mifeprestone, misoprostol, haemabate. and a few more drugs we dont normally seen in
obs and gynae.
a) name two drugs from this which are used for upper GI
b)what are the side effects of misoprostol, mifeprestone
c)which one of these two cause hypertension
d) showed a drug card, asked what was wrong ? guess this was clinical risk, it had no printed
name, no bleep no, units were not clear
e) gave a report which shows asyptomatic bacteriuria sensitive to augmentin, cephalexin and
notrofurantoin. Pt had anaphylaxis to penicillin. ASKED US TO PRISCRIBE THE DRUG ON A PROPER
OUT PATIENT PRESCRIPTION. Guess they were looking for legibility and documentation

4. Preparatory station - Talk to the husband who has returned after a long journey to find out his
wife has caesarean hysterectomy. YOu are given a case notes, which shows she had 2 previous
NVDs, this was major placenta praevia, admitted from 34 wks, now 35 +, had major haemorrahe
at night. Caesarean was straight forward. Started to bleed half an hour later, tried medical
management, failed, blood loss 3.5 lits.decision for hysterectomy.Consultant obstetrician was
present. No mention of bakri ballon, any other surgical procedure like internal iliac ligation,
UAembolisation , sustures. Husband kept asking was there nothing that could have been done. She
had elective section booked next week. He was not particularly angry, was upset, tired and wanted
the answers.

5. Preconception counselling for 32 year old who has a valve replacement at 9 yrs of age due to
aortic stenosis. She has been on warfarin, current INR 3.5. She is a smoker and had BMI of 36.

6.Counselling a 28 lady in her 3rd pegnancy, 1st - TOP,2nd miscarriage at 20 weeks. Now 14
weeks , booking.Scan normal. When yu take history she comes up with DVT 4 wks ago in this
pregnancy also sister had a DVT. She kept asking what will you do now in the next few weeks.
History sounded more like thrombophilia. though we had to mention BV and Cervical weakness.
she also mentioned her worry about baby having cleft as her sisters baby had cleft.

7.preparatory station - Labour ward prioritisation. bad weather staff are stuck after night duty. You
have taken handover at 8.30.You have these staff
2 night shift midwives
night registrar
2 fresh midwives
an F2 and consultant oncall on his way. other consultant in the clinic.
Dont remember exact case it goes some what like this

a) young russian approx 32 wks , with tender abdomen, tachycardia, hypotension. Cant speak any
english
b) 5cm primip, transferrd from home for lack of progress, having late decels, refusing CTG or
examination
c)Iv drug abuser, grand multip, 4cm membranes intact. previous pph
d)36 wks, swine flu patient, tachycardic, hypotensive with high temperature, cough.
e) 37 wks, iugr with absent edf.waiting iol on lw
f) primip, 3hrs secondstage.

8 ) describe abdominal hysterectomy. thgere were questions about what clamp and why

9)CIN3 pathology report of lletz- minimally invasive with complete excision.heavy smoker. talk to
her

10) cant remember what this is. will post it later if i rember

Prep station- Website on candida

# Structured viva Re:website
# Structured viva Re: SPD
# Strucutred viva on Malaria in pregnancy- Case scenario given: Discuss management,
maternal/fetal risks & prevention (This was the holy crap station which I am sure most would have
found difficult)
# Role play-Breaking bad news- holoprosencephaly, single ventricle-incompatible with life. Explain
diagnosis, options
# Prep station- Risk management- Folder of "notes given"
# Structured viva: discuss immediate clinical management then risk management issues
# Genital Warts in Pregnancy-role play
# Structured viva on PPH
# Role play: 14 days post TAH BSO-constant leaking of fluid. Marks for history, investigations &
management
# Role play: Chronic pelvic pain. Hx, Investigations, management
# Role play: VBAC requesting home birth.