Specialist level practice OSCE questions

Chapter 5 Specialist level practice OSCE questions



MRANZCOG OSCE E



E1



Q1



Letter


Dear Doctor,


I am referring Mrs Harvey, a 26-year-old woman with a kidney transplant, to you for advice, as she wishes to start her family. Please advise and manage her.


Regards


Dr N Ephron



Q2


Mrs Harvey returns for the results of her tests.



Investigation results



• U+E+Cr normal, apart from mildly elevated creatinine (130 μmol/L)

• MSU neg

• 24-hour urine creatinine – normal

• 24-hour urine protein – 0.12 g

• Rubella immune

• Pap smear normal

• Antihypertensive changed to Aldomet (methyldopa) by renal physician

“Can I start trying for a pregnancy, doctor?”



Q3


How will your management of her pregnancy differ from a normal pregnancy?



Q4


Mrs Harvey is 23+3 weeks pregnant, and was admitted to the ward with pre-eclampsia 2 weeks ago. You are the resident on night duty and have been called by the midwives to see her as she is feeling unwell with abdominal pain. Please manage.



E2



Encounter 1


Mrs M presents with a 3-month history of post-menopausal bleeding.


Please take an appropriate history from Mrs M.



Encounter 2


Please ask for relevant examination findings. What investigations would you order?



Encounter 3


The patient presents a week later for the results of her investigations.



Investigation results



• FBE: Haemoglobin 110 g/dl, normal white cell count and platelets

• U+E+Cr: normal, creatinine 105

• LFTs: normal

• HbA1C: 10%

• Pelvic ultrasound: Anteverted uterus measuring 80 mm length × 45 mm A–P × 50 mm width. The cervix is normal in appearance. The uterus is mobile and non-tender. The endometrium is thickened, measuring 15 mm, with increased vascularity. The right ovary measures 17 × 16 × 19 mm, is mobile and non-tender. The left ovary could not be identified. No adnexal mass is seen. There is no pelvic free fluid. Conclusion: thickened endometrium.

“What do we do now, doctor?”



Encounter 4


You are now seeing Mrs M following her hysteroscopy/D+C.


• Histopathology of uterine curettings: Grade 2 endometrial adenocarcinoma

“Doctor, what are the results from my test? Do I have cancer? Am I going to die?”



E3



Encounter 1


You are the obstetric registrar on call for a tertiary level labour ward. A midwife calls you for a Mrs CK, who has been pushing for 2 hours in second stage, and now has an abnormal CTG. Please manage.



Encounter 2


With the third pull of the forceps the head of the baby is delivered, but the shoulders are stuck. How do you proceed?



Encounter 3


Following delivery of the baby, Mrs CK has had a post-partum haemorrhage, which is being managed with oxytocics, as well as IV resuscitation with whole blood. Half an hour later the bleeding has been controlled and the midwife calls you back to the labour ward: “Mrs CK is distressed with fever, chills, and chest discomfort with wheezing!” Please advise on your management.



Encounter 4


Mrs CK’s baby was successfully delivered, with a birthweight of 3.7 kg, but her baby appears to have a brachial plexus palsy. You are now seeing her on the postnatal ward. Please counsel both with regards to her baby and any implications for her next pregnancy.



E4



Encounter 1



Letter


Mr and Mrs F are unable to become pregnant after trying for 5 years. Could you please advise them regarding their options.



Encounter 2


Mr and Mrs F return 6 weeks later to discuss the results of their tests.



Test results



• Days 2–4 FSH 4IU/L
– LH 4IU/L

– Oestradiol 80 pmol/L

• TSH 1.45

• Mid luteal progesterone 40 nmol/L

• Rubella immune, varicella immune

• SA+IBT: 45 million/mL, 50% forward motility, 80% abnormal forms, negative IBT

“Is there anything else to be done, doctor?”



Encounter 3


A diagnostic laparoscopy is performed and the patient is discovered to have severe endometriosis with a 4 cm left endometrioma. The anatomy is distorted with both ovaries adherent in the POD with bowel overlying, the fimbrial ends of both tubes are not present within the adhesions. The tubes are patent, the hysteroscopy is normal.


“What do you advise, doctor?”



Encounter 4


The operation proceeded well, and you advised the couple to try for a pregnancy for 6 months before coming to see you again.


The couple re-present as pregnancy has not occurred after 6 months of regular sexual intercourse.


“Is there anything we can do to start our family, doctor?”



E5



Encounter 1


You have been asked to do the elective caesarean section list at a tertiary hospital for a colleague who is ill. The first case is a 32-year-old woman, Mrs M, gravida 4 para 3, with a suspected placenta percreta.


The patient, Mrs M, is in the theatre reception area. Please take a brief history from her.



Encounter 2


For which investigations would you like to see the results? What should have been done prior to delivery?



Encounter 3



Investigation results



• Haemoglobin 98 g/dl

• U+E+creatinine, coagulation profile normal

• Urinalysis: no blood

• Ultrasound: shows anterior placenta invading the full thickness of the myometrium with a suggestion of invasion into the bladder

• MRI: shows possible bladder invasion

What are the alternative options for management of the placenta in this case?



Encounter 4


You proceed to surgery. To attempt to decrease blood loss you decide to ligate the internal iliac arteries. Describe how you would go about this.



Encounter 5


What are the branches of the internal iliac artery, and what are the potential complications of dividing the posterior branch?



E6



Encounter 1


Mrs B, a fit and sprightly 80-year-old woman, is referred to you by her GP after he has tried unsuccessfully to treat her vulval itch.


Please take an appropriate history from Mrs B.



Encounter 2


Please ask for relevant examination findings.



Encounter 3


What investigations would you like to perform?



Encounter 4


The vulval biopsy shows squamous cell carcinoma of the vulva (SCC). The other investigations are normal. There is no evidence of groin node enlargement on the CT scan.


What is the most appropriate management?



Encounter 5


You have referred Mrs B to a gynaecological oncologist, but she wants to know why, what will they do next, and are there any risks involved?



E7



Encounter 1



Letter


Thank you for seeing Miss B, a 25-year-old woman who presents with a 2-year history of irregular periods. Please manage her problem.



Encounter 2


The patient returns 4 weeks later for the test results. She still has not had a period.



Test results



• FSH 4 IU/L

• LH 16 IU/L

• Prolactin 400 mIU/mL (0–600 mIU/L)

• Testosterone 3.5 nmol/L (0.2–2.8 nmol/L)

• DHEAS 13 μmol/L (2–11μmol/L)

• TSH 2.5 (0.4–5.0)

• FAI 12 (<5)

• SHBG 10 (20–200)


Ultrasound



• The uterus is not enlarged. The endometrium has a non-specific appearance and measures 8 mm

• Each ovary contains between 40–50 follicles. There are no cysts in either of the ovaries

“What do the results show, doctor?” Please discuss results and any further tests required.


“Are there any long-term health risks associated with my condition, doctor?”



Encounter 3



Further test results


GTT: Fasting 4 mmol/L



– 1 hour: 8 mmol/L

– 2 hour: 6 mmol/L

• Cholesterol 6.6 mmol/L (<5.5 mmol/L)

• Triglyceride 1.5 mmol/L (<2.5 mmol/L)

• HDL 1.2 mmol/L (>2.5 mmol/L)

• LDL 3.8 mmol/L (<3.5 mmol/L)

Discuss the results of the further tests with Miss B.


“Is there anything that can be done to reduce the hair growth, doctor?”


“Are there any other treatments necessary for my condition?”



E8



Q1


You are seeing Mrs Bertram in antenatal clinic for her first antenatal visit, with a twin pregnancy from IVF (in-vitro fertilisation).


Please take a history and advise on management.



Q2


Mrs Bertram is returning to the clinic for the results of her Down syndrome screening test.


• Blood group: A neg, no antibodies

• FBE: Hb 130 MCV 86 platelets 197

• HepBsAg: neg

• Rubella: immune

• TPHA: negative

• HIV: negative

• MSU: no growth on culture

• Down syndrome screening by nuchal translucency for twins:
– Normal nuchal translucency for twin 1

– Increased nuchal translucency for twin 2

• First trimester maternal serum screen: increased T21 risk

• Combined screening risk result: 1 in 80

“What do we do now, doctor?”



Q3


The result from the amniocentesis shows trisomy 21 in the second twin, and 46XY normal in the first twin.


Please counsel Mrs Bertram regarding her options.



MRANZCOG OSCE F



F1



Encounter 1


A 28-year-old woman, Mrs K, is referred to you with a history of right iliac fossa pain for 6 months. A pelvic ultrasound scan has shown a 14 cm solid mass arising from the right ovary.


Please take an appropriate history from Mrs K.



Encounter 2


Please ask for relevant examination findings.



Encounter 3


What investigations would you like to order?



Encounter 4


Mrs K cancelled her follow-up visit to discuss her results, as she had an important meeting to attend interstate. On her return, she was driving back from the airport when she developed acute abdominal pain. Her husband drove her to the Emergency Department and you have been asked to attend.


What would be your management on arrival?



Encounter 5


At laparotomy, a ruptured haemorrhagic right ovarian mass was removed. The mass appeared to be predominantly blood clot. The left tube, ovary and the uterus looked normal. The abdomen was irrigated with warm saline thoroughly to remove the blood. All peritoneal surfaces were inspected, as well as the bowel, liver, spleen and stomach. Lymph nodes were checked (none enlarged). The incision was closed.



Final histology: Granulosa cell tumour


Had the patient not had an emergency operation for an acute abdomen, and had you known that the initial blood results had shown a raised Inhibin B (2492 pg/mL), what would have been the appropriate surgical management for this woman, who wishes to preserve her fertility if possible?



Encounter 6


If the patient had atypical endometrial hyperplasia and Stage 1A germ-cell tumour, what would be your future management?



F2



Encounter 1



Letter


Thank you for seeing Miss A, a 16-year-old who presents with primary amenorrhoea. Please manage her problem.



Encounter 2


The patient returns 4 weeks later for the test results. She still has not had a period.



Test results



• FSH: 4 IU/L

• LH: 4 IU/L

• Estradiol 400 pmol/L

• Progesterone 50 nmol/L

• Prolactin 400 mIU/mL (0–600 mIU/L)


Ultrasound

A transabdominal scan was performed. The uterus is not present and there is no vaginal stripe. Both ovaries are seen and there are 10 follicles in each ovary.


She and her mother ask: “What is the diagnosis?”


“Is there any treatment necessary?”


“What are the options for future child-bearing?”



F3



Encounter 1

Related posts:

  1. Specialist level OSCE answers and discussion
  2. How to approach an OSCE: clinical stations
  3. How to approach an OSCE: counselling stations
  4. Practice OSCE questions for medical student exams

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Jun 15, 2016 | Posted by in GYNECOLOGY | Comments Off on Specialist level practice OSCE questions

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