SEPTEMBER 2018 RECALLS

STATION 1;MODULE ; GYNAE PROBLEMS

This was a simulated patient task;
 Applied clinical knowledge.
 Patient safety.
 Communication with colleagues.
 Communication with patient.
 Information gathering.
I forgot whether it was GP letter, or she attended in Gynae clinic directly.
You are a ST5 and going to attend Mrs. XYZ 35 years old, with c/o heavy menstrual cycles.
She has no medical problems. Has 2 children.
Hgb 10 gm/dl , UPT was negative
US showed normal uterus with a fibroid of 2x2 cms, not distorting the cavity.
Task was take relevant history and discuss management.

Role player
35 years, working lady. Cycles regular , heavy for last 1 year. Condition is worsening gradually,
bleeding lasts for 7-8 days, previously it used to last 3-4 days. Says was having flooding also.
Cycles were affecting QOL. No PCB or IMB. No c/o dysmenorrhea or dyspareunia. Has not taken
any t/m so far except iron tablets. C/o feeling tired and lethargic.
LMP was 2 weeks back. Cx smear were up to date and normal. May be was using condoms, but
cant recall accurately. No h/o STI. No multiple partners
No known medical problems. No previous surgeries. No allergies. No family h/o cancers.
2 NVDs, good support from family. No other problems.

So I started by Mrs. ......, I am Dr Swaleha, senior doctor in Gynae clinic today. Nice to meet you.
How would you like me to address you.
I understand that you are having some problems with your periods, is that right ?
So can you tell me in your own words about that?
She said; Cycles regular , heavy for last 1 year. Condition is worsening gradually, bleeding lasts for
7-8 days, previously it used to last 3-4 days. Says was having flooding also.
Then I told her that I will ask her few questions to know more about her situation, may need to
examine her also and then will discuss the treatments available and will also give her written
information to read in detail and also write back to her GP about today’s consultation.
Then I told her; I am sorry to hear that,you went through this.I asked how it effects her daily
life.Then she said really cycles are affecting her home and work routine.
On asking there was no h/o PCB or IMB. No c/o dysmenorrhea or dyspareunia. Has not taken
any t/m so far except iron tablets. C/o feeling tired and lethargic.
After asking about presenting complaints, I completed rest of Gynae history , like contraception,
smear, STI, LMP.
SEPTEMBER 2018 RECALLS

Then I asked about obst history, medical, surgical, allergies, Medications, social, family history.
But all was normal. I said thank you for sharing all this info, is there anything which you think is
important and I didn’t ask.
Then I told her that I will need to examine in presence of chaperone , so to exclude local causes
of bleeding and to assess size of womb and if any other problems by doing PV, PS.
I explained about blood tests, USg ; fibroid of this size is unlikely to affect pattern of bleeding.
Then I informed her Different types of treatment available; Medical/ Surgical
Medical ; Hormonal/ Non hormonal
Non-hormonal; Transaminic acid is effective in 60-70% , taken during the period of bleeding only
, dose is 500 mg, can be taken upto 2-4 times daily. If found effective, Can be used every month ,
initially use for upto 3-6 months. Keep menstrual calendar. I asked about personal and family h/o
DVT.
Mefenemic acid also effective, but usually advised if there is pain also.
Hormonal include 2 hormones estrogen and progesterone , different prep; COC, POP, Inj DMPA,
Implanon, Mirena. Mirena is most effective treatment for women with HMB, provides effective
contraception also. Very effective, control HMB in 90%in one year, but may experience irregular
bleeding PV up to 6 months.
GnRH analogues; cant be used for more than 6 months, induce menopausal like condition.
Symptoms return when t/m is stopped.
Surgical; Ablation; which destroy lining of womb and controls bleeding but not a choice for
women who have not completed their family. Reqire endometrial sampling before procedure.
UAE; more helpful if bleeding because of fibroid uterus.
Hysterectomy as last resort , when other methods fail and your family is complete.
After informing her about all options I told her as she has not tried anything so far, lets start with
transaminc acid for 3 months or COC / Mirena, If wants contracption also, then mirena is 1st
choice.. Keep menstrual calendar, mark degree of severity.
She said she does not hormonal treatment and will take transaminic acid.
She asked if it can be cancer, I answered unlikely as she is young, BMi is normal, cycles are
regular, No RF like DM, PCOs, nulliparity,family history of cancer. However if bleeding not
subside with simple measures, like non-hormonal and COc, may consider doing pipelle biopsy
Then i told her i will write prescription and arrange f/u in 3 months. Continue hematinics. If any
further complaints she can f/u with GP, will write to her Gp also about today appointment.
Leaflet given and buzzer went out.

STATION 2Module Maternal Medicine;

Simulated patient task;
 Applied clinical knowledge.
 Patient safety.
 Communication with colleagues.
SEPTEMBER 2018 RECALLS

 Communication with patient.

 Information gathering.

You are an ST5 going to see this young lady 19 years old with Marfans syndrome. She is attending
for booking visit. She is taking ARBs for BP control, her BP is 110/80 mm of hg.
She is otherwise healthy. Some investigations done; Blood gp A+ve, CBC normal.
Your task to take relevant history. And how you will manage her pregnancy.

 After introduction, I asked her whether this is planned preg, she said not planned but she is very
excited to carry on. I asked what her partner thinks, she said he is equally excited and they both
want to continue with pregnancy.I said very well.
 I asked if she has started taking folic acid , she said she is on folic acid now, 400 mcg daily.
 Then I asked her that as she is diagnosed with Marfans, so when and how it was diagnosed.
 I couldn’t recall clearly, but maybe she said it was diagnosed because she had some lens problem
when she was 12 yrs old. Then I asked since you are diagnosed, who is taking care of her medical
problem and how.
 She said she is under care of cardiologist and has f/u every year, last check up with cardio was 3
months back and it was fine.
 Then Is asked if she feels breathless on lightor moderate excertion, if she has to climb flight of
stairs. She said no. I asked her what she is doing for living and how are things at home. She is
everything is good and she didn’t find her work making her tired.
 Then I told her that will it be ok I ask you some questions, may need to run some more tests, and
then will discuss about genetic aspect of this diorder, then your care during your preg, delivery
and post delivery. Will give written info also and will update your GP also about plan of
management. She said okay.
 Then I completed other history medical, surgical, allergies, social, family. All was fine. I thanked
her for sharing info and asked if there is something which I didn’t ask
 Then i told her i will give you brief idea about marfan, how it affects pregnancy and how preg
affect Marfans.
 Then i draw some funny diagram to make her explain that Marfans involve aortic root , aorta is
main channel to deliver blood from heart to rest of body. If width of aoric root less than 4 cms,
outcome for mother and baby is like normal pregnancy provided condition remains unchanged.
But if aortic width is more than 4 cm , then there are risks for mother and baby both. Mother may
experience worsening of condition, hospital admissions, ICU admissions, may need to terminate
preg, heart failure and even death. For baby , may be SGA, risk of Preterm delivery and risks after
preterm, NICU admission and maybe affected by Marfans.
 Pregnancy it self cause changes in body and total blood volume gets almost doubled which puts
extra starin on heart and if heart is doing well then it can adjust to preg stress adequately.
 Marfans is inherited condition, involves heart, eyes, joints and skin. As it is genetic disease ,
transmission to baby can occur. Marfans is autosomal dominant (I will explain you ), chance to
affect baby is 50%, for each pregnancy. Transmission occurs in 2 ways, in some 2 genes are
required one from both parents for disease to affect baby, and in other one gene is enough from
either of parent. 1st condition is called autosomal recessive, other one is called autosomal
dominant.
 This can be detected by doing needle test. Do you have any idea about needle test? She said No.
Then I draw a diagram and explained her that it is done under USG and either small of fluid or bit
of after birth is removed through very fine needle passed thru tummy inside womb. Usually
patient feels it like pain when they put cannula in their hand. CVS can be done after 10 weeks,
SEPTEMBER 2018 RECALLS
while amnio done after 15 weeks. As she is still at 9 weeks, she has time to think and decide. Both
have small risk of miscarriage , like 1-2 out of 100.
 Then I said women with such condition are recommended to be followed under consultant care in
tertiary care centre. A multidisciplinary team of cardiologist, consultant obstetrician, genetist and
nurse specialist will follow up every 2-4 weeks depending upon your clinical condition. Right now I
will arrange urgent appt with cardiologist to alter your medications and to do ECHO to know that
everything is okay with your heart.
 ARBs are not advised to be taken during preg, may need to switch to beta blockers, but i have to
d/w cardiologist first. She asked so ARBs have affected my baby . I said unlikely but will need to
check with detailed USG at 18-20 weeks.
 Then i explained routine care, Downs screening b/w 11-14 weeks , anamoly scan at 18-20 weeks ,
serial growth scan for baby from 24-26 weeks.
 May need echo every 2 week to check if any complications occurring.
 Aim is for vaginal delivery, Cs for obs t indications or if there is worsening cardiac status.
 Peripartum and post partum period is time when most complications occur.
 Cause of death is; If your aorta is severely enlarged, there is risk of it tearing or splitting ,
which can occur upto 6 months to 1 year post partum. Therefore post partum f/u is equally
important.
 Then I told her i know i have given you lot of info, do you have any questions.She had no
questions.
 I gave leaflet and told her that will write to her GP also.
 I think this was all.

STATION 3 Module POST-Op

Structued Discussion
DISCHARE DOCUMENT (DD)
There patient’s notes from hospital admission till discharge and discharge summary.
Discharge summary was brief , prepared by FY2 ,mentioned patient name, she had laproscopic
salpingectomy done for ectopic pregnancy.
Operation uneventful. Discharge to home. No further f/u .

So examiner asked that what are your comments about DD.

I said this DD has brief information and some important information should be included.
So he said how you will do it.
Then I gave brief intro about DD
When patients are discharged from hospital back into the care of their general practitioner, essential
information about their stay in hospital is sent by the hospital to their general practitioner in the form of a
discharge document. Improving the quality of discharge documents may lead to improvements in patient
safety. It is sort of handover tool from secondry to primary care to provide smooth transition of care and
maintaing quality of care.
Then I started to put information from hospital notes and covered the format of discharge
document.
1) Hospital name with address ,
SEPTEMBER 2018 RECALLS

2) patient name , DOB , Address, Community heath number, Post Code

3) GP ID, adrees, post code
4) Consultant ID Speciality, Contact No
5) Ward Contact Number:
6) Date of admission:
7) Date Of discharge; Important to mention DOA and DOD as it will give an idea to GP how
long patient stayed in hosp, if its 2-3 days then unlikely that patient had any
complications
8) Presenting complaints; abdominal pain and bleeding PV
9) Mode of admission; thru ER
10) Primary diagnosis ; reason for admission ; suspected ectopic pregnancy
11) Significant operations/ procedures; Avoid abbreviations. Mention date of operation; relative
operative findings; laparoscopic Left salpingectomy done on date ---------
12) In hospital Clinical progress ; relevant investigations performed , description of any
complications (medical and/ or surgical), adverse reactions to medicines . She is negative blood
group, anti D was given.
13) Results awaited ; in this case some vaginal swabs were awaited, histopathology awaited
14) Investigations pending; No
15) Allergies ; No
16) medicines advised on discharge name of medicine (generic where possible) , formulation ,
strength of preparation , current dose , route of administration , frequency & duration of
treatment
17) Follow up arrangements ; Specify the type of follow up that is required, stating when and by
whom. In this case community midwife can check for wound care and post –op recovery, UPT
after 3 weeks in GP clinic. Patient was advised to report to A&E or GP if becomes unwell, feels
feverish, or has excessive abdominal pain, bleeding PV, Foul smelling discharge, or feels
dizzy.Follow up in hosp after 4-6 weeks for discussion regarding what happened, how it effects
her future fertility, recurrence of ectopic 7-10%, how she is recovering.
18) Copy to patient ; yes
19) Copy to GP ; yes UPT after 3 weeks in GP clinic.
20) Copy to CMW ; yes community midwife can check for wound care and post –op recovery
21) Extended discharge document(EDD) is required where patient needed surgery, where more
detailed information about the hospital stay or follow-up arrangements is required, or where the
results of tests and investigations are awaited. EDD can be given at the time patient leaving
hospital or can be given in upto 7 days of discharge.
22) Consultant sign-off and comment
23) Signature and name and position of person making discharge
24) Writen info given ; yes

I tried to mention these headings and filed info for them from hospital notes in front of me.
When I finished that, examiner asked me how you can improve quality of discharge summary.
I told him by arranging tutorials which will involve senior and juniors . In this we can bring
different discharge documents prepared in department and then compare then with standard
DD . It will be only for learning purpose , not to critisize others. We can make formatted sheets
in computer with all the headings already placed , so the person who is filling DD will know what
all info he has to complete.
Then buzzer went off.
SEPTEMBER 2018 RECALLS

STATION 4; Early Preg Complications

Simulated patient task; I Think 32 years , maybe nullipara or para1, presented to EPU for f/u.
Presented 48 hours earlier with 6 weeks amenorrhea , mild lower abdominal pain, bleeding PV.
BHCG done was 2900, USG was inconclusive. Today BHCG 3900, USg showed uterus with
thickened endometrium, small adnexal sac 2.7 cm, minimal free fluid.
 Task is to explain diagnosis and
 discuss management.
Role player.; anxious, mild abdominal pain only, spotting Pv only.
Previous normal delivery, no surgeries done. No allergies.

I started by Mrs. Sara smith, I am Dr Swaleha , the senior doctor in EPU.

How would you like me to address you?
In understand that today you came to repeat some tests to check on your pregnancy.
She said yes I have done some tests today and I want to know what is the result.
Then I told her if she allows me , before discussing her results I will explain her about how normal
pregnancy occurs.
I draw diagram with uterus and tubes and showed her that mostly pregnancy sac get attached to
lining of womb and star growing there , but in 1-2 % cases pregnancy sac gets attached with
lining of tubes and started growing there. This is called ectopic pregnancy. As you can see tubes
are very narrow channels, there is no room for preg to grow and continue,if pregnancy grows
there, it can cause tube to burst. I am sorry to inform you that in your case, pregnancy has got
attached in tube. I am sorry , this must have been hard for you. Is someone accompanying you or
you want someone to attend with you. Then I kept quiet for few moments.
She said its ok, now what next.
I told her that this is not normal pregnancy, it is rather life threatening condition, needs to taken
care of immediately. Mrs Sara there is nothing which you have done to cause this or something
which you have not done. I just happened on its own, some times some risk factors are there but
not always.
Before we discuss treatment is it okay if i will ask you few questions, she said ok. Then I asked
about LMP, if cycles regular, is preg planned, any issue of fertility, what contraception you were
using previously, any sexual health infections, obstetric history, mode of delivery, medical,
surgical history, any allergies. Do you smoke, take alcohol, things at home, if there enough
support. I think all was normal.
Ectopic preg can be managed in 3 ways; choice of treatment depends upon many factors.
Your condition presently, signs/symptoms, level of BHCG, preg sac size on USg, presence of free
fluid, choice of patient.
1st option ; to wait and see; depend on level of preg hormone, if leveare less than 1500-2000 ,
then may be an option. So not ideal in your situation
SEPTEMBER 2018 RECALLS

2nd option is Medical treatment involves giving an injection in muscles. Tube is not removed.
After injection preg hormone levels are checked after 4 and 7 days, if no fall seen in preg
hormone, then another injection is required. 15% of women may need another injection. Even
after this treatment, there is chance that tube can rupture in 7% of women, in which case
emergency operation will be required.
After taking this injection, pregnancy should be avoided for 3 months as it has harmful effects for
baby.
3rd option is surgery; either thru small cut in belly button and camera is inserted , called key hole
surgery or thru large cut on your lower tummy depending on your overall condition.
If other tube is normal then entire tube which is carrying preg is removed to reduce risk of
further ectopic.
If other tube not healthy, then small cut is made in tube carrying pregnancy and preg is removed
while saving the tube but this can result in incomplete removal of preg or even continuation of
preg and also puts you at high risk of further ectopic.
Right now it seems that medical treatment will be a good option for you, as sac size is less ,
minimal free fluid, you have mild pain only. What you think? Will you be able to attend for f/u ?
So if you agree , I will admit you, run some tests and after injection stay overnight and then if
everything ok, you can be discharged next morning.She said she want to wait for her partner and
then will decide.
I also want to inform you that women with one ectopic pregnancy are at risk of getting it again.It
happens in 7% of women, therefore early appointment in EPu in next pregnancy to confirm
location of preg.
I said take your time, i give you leaflets, just go thru them and then you can decide. Any
questions? I will inform my consultant also.
Thank you

STATION 5 Oncology
Simulated patient task; Cant remember , maybe Gp letter
35 years old lady in Gynae clinic. She has recently lost her friend , who has died of ovarian
cancer.
She has searched on internet about ovarian cancer and discovered that removing both ovaries
will reduce her risk of having ovarian cancer. She wants to discuss this option.
 Task is to answer her concerns.
 Management plan
After introduction I said I understand that you have lost your friend recently and you have some
concerns regarding that.
Is that right. I am really sorry for your friend. Then she started crying. I asked her if anyone
accompanying her. She said she is fine.
SEPTEMBER 2018 RECALLS

Then I asked can you tell me more what happened to your friend. She said that her friend was
same as her age and diagnosed with ovarian cancer. She died because of Ovarian CA. Then I
asked if there was family history, she said she doesn’t know about her family.
Then I asked her what her concerns are. She said I searched on internet that removing both
ovaries will remove risk of ovarian cancer. I want to have this operation. Can you tell me more
about this?
Then I asked her If she can allow me to ask few questions to know more about her and then will
discuss what options she has and also will give written info to know more in detail. She said Ok.
She was para3, all delivered by CS, no known medical problems. No surgeries except Cs. She
breast fed her all babies. There was no issue of fertility drugs. Cycles regular. Cx smear were up-
to-date and normal. No family or personal history of any cancers. No smoking, not drinking. Was
using some contraception. Working woman with well supported family. Generally fit and well.
Then I told her that from her history I didn’t find any risk factors for ovarian cancer.
Lifetime risk of having Ov CA is 1.2%. Difficult to diagnose at early stage as cause non-specific
signs/symptoms. No effective screening tool available like cervical screening. CA 125 and TVS
sometimes used but not supported by evidence.
Out of all ovarian cancers 15% are genetic cancers. Some women carry high risk genes called
BRCA 1 &2 and other genes. These genes put women at risk of developing ovarian and breast
cancer at very young age. These women are advised to undergo risk reducing surgery like
mastectomy and oophorectomy by age of 35-45 to prevent risk. Women having family or
personal history of cancers esp ovarian, breast are offered genetic testing, which is not the case
with you. Am I clear so far? Any questions?
Roleplayers insisted that she want genetic testing. I told her that I can understand her anxiety. I
will discuss with my consultant also and if appropriate then will arrange for her to be seen by
genetic specialist.
Then she asked. If I remove my ovaries what is the harm ? I told her that if you are fit and well
and has no risk factors of ov CA, removing ovaries might be more harmful rather than giving her
benefit. Ovarian hormones are responsible for her overall health. It is very important for heart
health. It keeps women at low risk of heart attack till menopause. It is important for bones and
keeps bone strong and healthy.Also important for function of sexual health and waterworks. Also
effective for mental health. So it is very important decision. I would suggest don’t take decision in
rush , read written info also and then decide what you want.Also it will cause state like
menopause, no further pregnancies will be possible.
Then I told her that will arrange for her her to talk to nurse counsellor also , she might find this
helpful.
I think this was all I told her.

STATION 6 Surgical module

Structured discussion; Placenta previa/Accreta
I cant remember what was written outside, but something to give you an idea that case is about
placenta previa.
SEPTEMBER 2018 RECALLS

Examiner asked how women with placenta previa present ?

I said all women present with vaginal bleeding after 20 weeks of pregnancy should be
considered for placenta previa or present with high head at term or with abnormal lie or
malposition. It maybe seen on detailed scan at 18-20 weeks.
How you diagnose placenta previa?
Usually by 3-D power doppler on TVS. If this is unclear then MRI can be helpful, it gives more
detail about depth of placenta attachment.
Whom you offer further testing for placenta previa?
In asymptomatic women where placenta is covering cervix or where there is previous scar , those
women should be offered further USG at 32 weeks. If placenta is minor or its not covering cx,
then at 36 weeks. Symtomatic women manged individually.
Then examiner give MRI report which showed preg at 32 weeks and it was placenta accreta. She
asked how you will manage?
I said, this patient is at risk of preterm delivery and massive PPH, blood transfusions,may need
emergency hystectomy also.
Such patient should be followed up in tertiary care hosp where there are facilities of blood bank,
cell salvage, Interventional radiology, ICU, NICU. Placenta previa care bundle to be followed,
which includes involving consultant obstetrician, consultant anesthesiologist, ICU bed, blood
bank facility, facility of ( cell salvage and inteventional radiology), appropriate consents from
patient.
Patient hgb should be optimised before delivery. Patient mayneed to be admitted from 34 weeks
onwards, but this needs discussion with patient. About social circumstances, e.g. distance
between home and hospital and availability of transportation, previous bleeding episod. Inj
corticosteroids between 34-35 weeks. Planned delivery b/w 36-37 weeks to balance risk of
preterm delivery and patient going in labor.
If hospital admission has been decided, an assessment of risk factors for VTE in pregnancy should
be performed.This will need to be balanced against the risk of bleeding from placenta.
Then what you will tell tell patient?
Patient needs to be informed about her diagnois, all frequent and serious risks. Discusiion about
type of skin and uterine incision, need of blood transfusion and even hysterectomy. Mapping of
placenta is done at time of delivery and incisions are planned to avoid cutting through placenta,
so as to offer conservative management and recourse to hysterectomy and to avoid massive
hemorhage. Placenta if separtaes on its own or expelled by simple expression, then it will be
removed and hemostatic sutures will taken if there is bleeding from placental bed. Compression
can be applied thru bakri ballon also to control bleeding from placental bed.No attempt will be
made to remove placenta partially as it can cause massive hge. If placenta found inseparable
then either hystectomy or conservative management . Conservative management not routinely
offered as can result in serious infection, DIC and need for hysterectomy later on.
Appropriate consents need to be taken for Blood transfusion, cell salvage, interventional
radiology, hysterectomy.
SEPTEMBER 2018 RECALLS

Then what you will do if patient decline blood transfuion?

I asked is she Jehovah’s witness, examiner said no.
Then I said I will
 optimize her HGB before delivery
 I will discuss with patient what blood products she will accept /decline, like packed
cells,whole blood, FFP, platelets, Cryoprecipitate, Inj Anti D , cell salvage and document in
her notes.
 Discuss about delivery in centre with cell salvage, interventional radiology. Hysterectomy
might be needed to avoid excessive bleeding. Risk of DIC, collapse, even death should be
discussed. Appropriate consent or advanced directive should be taken in advance.

STATION 7 UROGYNAE
Simulate patient; This station appeared in May 2017 also.
Outside Urodynamics study with graph was given, it showed stress in continence. Patient was 52
years, she has tried PRMT , supervised for 3-4 months. Her symtoms not resolved. Now she
came with result of UD study.
Task was to take targeted history and outline futher management.
Roleplayer;
Menopausal lady, working as cleaner. Menopause occurred 3-4 years back, not on any HRT. C/o
leaking urine with coughing, laughing or doing exercise for 3-4 years, which is getting worse with
time. No urgency, No voiding problems, No UV prolapse. This is happening for 1 st time. No other
urinary or bowel complaints.
Feels vaginal dryness and discomfort on intercourse.
Para3 all NVD.Had average size babies, no prolonged or difficult labor. Cycles were regular, Cx
smear all regular and normal. No known medical problems, like cough, constipation. No previous
surgeries done. No allergies. No smoking or alcohol intake.BMI 27-28 cant recall exactly.

Then I started with Mrs XX, I am Dr swaleha , senior doctor in gynae clinic.Nice to meet you.
I understood that you are having some problem in controlling your urine and you have tried
PFMT , which have not helped much and you have done tests to check the problem in detail ,
urodynamic study. Is that right?
Kindly if you can tell more about this?
Then she said that C/o leaking urine with coughing, laughing or doing exercise for 3-4 years,
which is getting worse with time. She has tried PFMT but no help and now this test done, so
what will be next step.
Then I said if you allow me , can I ask few questions and then will explain you the test result and
further managemnt. Will also written info in end. She said ok.
Then I asked about urgency, frequency, nocturia, lump down below, hesitancy or poor stream,
dysuria, hematuria, any similar episode previously , esp after deliveries, any improvement after
SEPTEMBER 2018 RECALLS

PFMT.Any h/o chronic cough, constipation, lifting heavy weights. She said as she is working as
cleaner sometime she has to push heavy furniture.
Then I asked her gynae history( LMP, what were cycles like, Cx smear), medical, sugical, social
and family history.
Then I explained her that the test has showed a condition called stress incontinence. Have you
hear this word before, she said no. Then I said, its actually has nothing to do with stress. It
happens muscles of pelvic floor are weakend from previous childbirth or after menopause and
cause changes in position of waterworks and its tube which bring urine out called urethra.
I draw diagram to show her that the angle b/w urethra and bladder is altered and also muscles
and tissue around urethra become weakened with menopause. Coughing, laughing , doing
excercises cause increase in pressure within abdomen and this pressure exert strain on muscles
of birth canal and water works. When this happens, urethra fail to close properly and result in
laekage of urine. This is why it is very important to strengthen pelvis floor muscles even if you
don’t see any improvemet now, but they will be helpful.
Now coming to options, different types of operations are done to lift urethra so to restore its
natural postion and thus avoid leakage of urine. Different procedure are done like TVt/
colposuspensio. In TVT a ribbon like tape made of mesh in inserted through small nick below
urethra and it make sling around urethra (again I draw diagram). Recently there are some issues
about mesh.
Medical treatment with tab duloxetine is not advised routinely , unless surgery cant be
performed either because of medical condition or patient choice. Some special medicines are
injected around urethra and they increase tissue mass around urethra and help acchieving
control over urinary leakage. They may need to be injected multiple times.
But before you consider any operation , I would suggest that lets work on those factors which
effect success of surgery like if you can think about changing your work , bringing your weight in
more optimal range and consider using HRT,(explained little bit , that they are same hormones as
produced by ovariesbefore menopause) especially local estrogen as it will improve tissue
atrophy.( I would like to examine you also with chaperone) Then I asked quickly if she has any
contra-indiactions for HRT. I explained to her that best results after operation is obtained with 1st
procedure. But if continue to lift or push heavy weights it may cause failure of procedure, if you
agree I will prescribe local estrogen, continue PFMT. I will give leaflets about different types of
surgeries offered. You don’t have to take decision now. Take your time. I will arrange further
appt with yr convinience and then we see what are your wishes about further treatment. I will
also discuss this with my consultant. Have consulation with dietician also.
You have any questions. Take all these PIl home, go through them and if you have queries, we
can meet again.
Before patient said anything buzzer went off and I was puzzled that I could not complete telling
her about different operations.

STATION 8Labor and delivery

this is repeat station from may 2017

SEPTEMBER 2018 RECALLS

Primi 41 years, 36 weeks, BMI 35, requesting home birth. Diagnosed with fundal fibroid of 2x3
cms.
Recent USG shown normal size baby, ceph, liq normal.
Task is to
 take targeted history and
 outline further management.

Role player; 41 years, school teacher, primigravida. 36 weeks. All booking, downs, anamoly scan
normal. Preg course uneventful. Following up with midwife. Planning to have home birth.
No Medical problems, no surgeries done, no allergies, well supported family..

After intro I said I understand that you are here to discuss plan of delivery, is that right ? What
this preg and delivery means for you. She said she is really excited and looking forward for home
birth. Why so keen for home birth. She said her friends had home birth and they liked it a lot.
I then asked her that will it be okay if I ask you few questions. Is it planned preg, when you 1 st
booking visit. Are booking test normal? Have you had down screening done and was result
normal. Was detailed USG done and it was normal. Your recent USG also showed that baby
grwoth is fine and its presenting with head first.
Then I confirmed her age, asked if any medical problems now or before, any surgeries done, any
allergies , family history of concern. Do you smoke, or take alcohol, or any drugs. You are working
as teacher , and how are things at home. With whom you are living. She said she is married and
staying with her partner..
I said thanks for sharing this info.
Now coming to plan of delivery.Home birth is very good option, you are close to your home
envoirment. but maynot be for every womwn. I want to talk to you about 3 things. 1st that this is
your first preg. It is usually advised for women who deliver for 1st time that they have their
delivery in either midwifery care unit or in hospital. Why is that so, because it is seen that as
compared to women are multi, poor baby outcomes for primi are 2 times more common. Also it
is seen that primi are more likely to need hospital transfer during home birth because of either
concerns for baby or progress of labor. No mother wants to take any risk regarding safety of their
baby, isnt it? She said off course. I would suggest that if you can plan delivery with midwife of
your choice in midwifery unit. But off course decision lies with you.

Then I said 2nd issue is that it is seen that women who are age more than 40, if their preg is
allowed to extend beyond 40 weeks, there is small risk of baby dying in womb. Therefore it is
advised that women who are more than 40 , their delivery planned b/w 39-40 weeks. Women
may start with sponatneous labor around this time, but if not then labor has to be stated
artificially by giving medicine , this is called induction of labor.
3rd concern is that women with BMI 35 although can deliver in midwifery unit , but they may be
at risk of having prolonged labor , or difficulty monitoring the bay during labor. So if delivery is
planned in alongside midwifery unit , any emergency arising during labor, can be dealt with
adequately.
I am not here to make any decisions for you. But I will give you all relevent info, so you can make
informed decision. You don’t have to take any decision now. I will give you PIL, go through them
if you have any queries , you can contact us. You have any questions.
She asked what about fibroid. I told her that this fibroid is on outside of womb and unlikely to
effect labor or delivery of baby. She said she is now confused. I asked her if I can be of any help.
SEPTEMBER 2018 RECALLS

She sais no , you explained it doctor, I need sometime to decide. I said I will discuss with my
consultant also and arrange another appointment to discuss her plan.

STATION 9; Post partum complications

This is also repeat staion frommay 2017
Patient in post natal ward, today her 3rd post natal day. She has sustained 3rd degree tear during
labor.
Today she is planned for discharge.
Your task to explain her 3rd degree tear and discuss further mangement.

Role player; Primi, preg course uneventful. Has spontanoeus labor, had normal vaginal delivery.
Sustained 3rd degree tear during delivery. Baby was average size. No instruments used for
delivery. No known medical problems. No allergies.
Worried about her tear, why and how it happened. Why episiotomy not given? How it will effect
her fertility . Does she need CS in next delivery.

After intro , I asked that today you are 3rd day after delivery, how are you doing. You had baby
boy or girl? Have you named him. How you feel your experience with new baby. Any issues with
breast feeding? Have your bleeding settled down.
How is your pain? How are your bowel habits, she said, she feel she cant control her stools and
its watery. Any issues with water works?

If you allow me can I ask few more questions. How was your delivery like? Any instruments used?
What is weight of baby? Any conerns during pregnancy like DM? There were no issues , all was
normal.

She asked why it happened? I told her that women can get tears during normal birth. I draw
diagram and showed her what are different types of tear. When tears extend to involve muscle
which control back passage is called 3rd degree tear or anal sphicter injuries. Muscle which
control back passage are in 2 layers. I nner layer is called inner muscle, outerlayer is called
external muscle. When tear extend to less than half of width of external muscle it is 3A , but if
involve more than half of external muscle , its 3B.
Sphincter tears can happen in 6 out of 100 women who deliver for 1 st time.
Episiotomy is not done routinely , only when its needed it is done.
I have checked medicines which are being given to you, you have been prescribed 2 medicines to
make stool soften, which may be a reason that you are having watery stools and you feel
difficulty in controlling them. I would suggest, that stay in hospital till you get control of your
bowel habits.

Once you are discharged , you will be advised to keep good hygiene, wash from front to back,
wash hands before and after using washroom, change sanitary pads frequently, take balanced
diet and good fluid intake to avoid constipation. Continue antibiotics for 5-7 days (amoxicillin+
metro), they are safe with breast feeding. Continue taking stool softners for 10 days to avoid
strain on stools. Continue analgesics , they will help in coping with pain in stitches.
You can expect some pain on sitting, you can use some horseshoe shape cushoin to remove
strain on stitches. You may feel that passing urine is stingy, but that will improve with time.
Stiches are absorable, they may come out, but thts normal. Starting sexual life is your own
SEPTEMBER 2018 RECALLS

decision, when you feel you are ready to do so, but better till bleeding settles down and sitches
have healed.

You should start doing excercises which strengthen your birth canal muscles and help in
recovering. Physical therapist will teach you how to do them. Continue PFMT for 4-6 months.You
will be seen in 6-12 weeks to see that you are recovering well, wound has healed and you have
no complaints like feeling urgency of wind or stools or having staining with stools on inner wear.
Most of women have straight forward preg and delivery after OASIS. 6-8 out of 10 completely
well with no complaints , after 1 year. Chances of having further tear in next delivery is 5-7 %. In
case of having symtoms , CS delivery is an option.

She asked how it could be prevented? Using warm compress in 2nd stage of labor, support during
labor and perineal protection when head is crowning may prevent this. Epi is not protective.
I will give you written info to understand it better. I write to your GP and community midwife
also , so they can follow , to check your recovery at home. In case you feel unwell, feverish ,
have lower abdominal pain, heavy bleeding PV, foul smell discharge, painful and heavy legs or
shortness of breath , contact A&E or GP immediately.

STATION 10 Sexual healthStructured discussion

A 9 year old girl brought by her mother to GP with lower abdominal pain and inability to pass
urine. GP noticed some blisters or ulcers on ano-enital areas, suspecting herpes. GP has urgently
referred the girl to hospital A&E.
Mother is insisting to just give some medicines to relieve pain so she can take her daughter
home.
GP also noticed that girl was not hesitant on private examination, which is not normal attitude of
young girls.

So examiner asked what is your diagnosis?

I said it look most probably a case of sexual abuse in very young girl.

He said what are going to do now?

I said this is very issue, could be a case of rape, need to involve police, social services, safe
guarding agencies, consultant on call.
I said that this girl need to be re-examined in presence of assistant to confirm GP findings, also
she needs admission so that appropriate investigations and treatment can be offered.

Examiner asked me what you call when many agencies are involved?
I couldn’t answer, he said multiagency referal

He asked where you will admit her? She needs admisiion in peadiatric ward.
What other specialities you will involve? Consultant peadiatrician and consultant adolescent
gynaecology ( this was mentioned by examiner)

How you manage further?

SEPTEMBER 2018 RECALLS

I said need to take blood samples to check for HIV, HBSAg, Syphlis, CBC, CRP, Antibodies to HSV.
Also need to take vaginal swabs for other STI. Need to put catheter to revlieve pain from full
bladder.
Needs to give her analgesics, antibiotics, systemic and local anti-virals after d/w peaditric to
adjust the doses. Need to ask if she started her periods, then she may be at risk of pregnancy.
After making girl comfortable, can ask her what happened to her, Does she know the person who
is culprit? Does he /she threaten her or give her any gifts. How long this has been happening.
Whether she has informed any family member and what was reaction. Does she has other
siblings who may also be at risk. Was she intoxicated with drugs or alcohol before such event. Is
she attending school regularly? Is she an adopted child?

He asked because of pain girl declines inserting catheter and taking vaginal swabs?
I said I will explain her that I will not hurt her , but first apply some medicines to ease her local
pain, but need to insert catheter to relieve abdominal pain. I will first apply lidocaine gel to make
that area numb and then insert small size catheter 12 Fr after lubrication. If she declines for
vaginal swabs, it can be taken after sometime when she is more comfortable.

This girl needs lots of psycological support as she has gone thru a lot at this young age. She is at
risk of further exploitation, risk of drug abuse, risk of STI and its implication on her fertility,
flashbacks of abuse, social withdrawal. She should be encouraged to attend school and return to
normal routine.
Need to involve child psychatrist as she may need extended follow up . Nurse counsellor should
also be involved who know how to deal with children and how to bring them their self esteem
and confidence.
I didn’t did so well in this station.

STATION 11Structured discussion

Bridging thromboprophylaxis This station appeared in may 2018

49 years old lady with BMI 52, planned for laproscopic TAH and BSO for stage 1 endometrial CA.
Previous h/o DVT, diagnosed with anti thrombin deficiency. Taking tab rivoroxiban daily.
Her eGFR and creatinine clerence was given, which was normal.
There were many tables showing which women should be offered bridging, how you bridge with
LMWH or UFH. Dose of heparin according to body weight, how to adjust dose of heparin
according to eGFR and creatinine clearence. How to switch back to NOAC after surgery.All the
info was given, only it has to be delivered to examiner.

Examiner asked what you find in this cae?

I said this lady is at very high risk of VTE while undergoing this surgery as her BMi is very high, she
is diagnosed with high risk thrombophilia and she is planned for surgery for malignancy. She has
h/o DVT in past also. As she is taking oral anti-coagulants to prevent VTE, which are long acting
agents. This lady needs to be switched from long acting agents to short acting agents around
time of surgery to prevent risk of VTE as well as to avoid risk of bleeding during surgery.

How you will bridge NOAC with heparin?

Ideally hemotologist should be involved from very beginning. Then I just read from table, that tab
rivoraxiban should be stopped 48 hours before surgery and LMWH started at the same time with
SEPTEMBER 2018 RECALLS

12 hourly dose regime. Patient will receive LMWH evening before surgery, but morning dose of
LMWH is omitted. LMWH can be started 4 hours after surgery. Dose was given in another table
according to weight and creatinine clearence.

How to reduce risk of VTE during and after surgery?

Patient needs to be explained that she is at very high risk of VTE, pulmonary embolism. She
should be explained about warning signs and symptoms of DVt, pulmonary embolism.Hoe she
can contribute to reduce these risks by keeping her mobile and taking enough fluids before and
after surgery to avoid dehydration.
All possible measures will taken to reduce the risk. Her medication to control blood clot will be
modified. Duration of admission before surgery should be kept minimum.Prolonged fasting and
dehydration to kept minimum. TED stocking should be worn all the time from before , during and
after surgery. Anesthetist should be informed about her her high risk of VTE. Surgery should be
done by experienced surgeon to reduce duration and complications in surgery. Adequate
hydration with warmed saline to avoid hypovolemia. Patient should be kep warm during surgery.
Meticulous surgical technique, keeping blood loss to minimum, complete hemostasis. May need
to put pelvic drains to avoid blood collection inside.
Compression devices to be worn during and after surgery.
After surgery patient to be kept adequately hydrated, adequate non –narcotic anlgesia to ensure
pain relief and early mobilization.Heparin should be started as early as safe to start, to avoid
bleeding as well as VTE. Catheters, drains should be kept for minimum duration so not to hamper
mobility.
NOAC can be started from 3rd day after surgery if no concerns for bleeding . Heparin should not
be stopped till INR in desirable range. Patient should report if has painful and heavy legs or feel
breathless.

How you would have managed her if she presented before surgery?
She should habe been supported to loose weight before surgery, needs input from dietician and
exercise specialists. Even weight reducing medications could also have been used. As her BMI 52,
she could have been planned for bariatic surgery. But as patient is now diagnosed with
malignancy , cant delay her TAH as it may cause progression of her disease.

Station 12 MODULE: MANAGEMENT OF DELIVERY.

This station I copy pasted from recalls of Dr Mohammad which he posted in Nov 2017 recalls.
I couldn’t do anything better than him, so just copied as it was. Thanks to him .
This is a simulated patient task assessing the following: tested per station]

 Applied clinical knowledge. [Not sure, as max 4 domains are

 Patient safety.
 Communication with colleagues.
 Communication with patient.
 Information gathering.

You are ST5 on duty and were called to see this lady who came to the A & E complaining of
regular tightinings. She came alone as she is a foreigner [some east European countery-but good
SEPTEMBER 2018 RECALLS

english] on vacation. She is currently 28wks and her hand held notes are available [attached on
board and desk]. Take relevant history, answer her concerns and formulate her management
plan.

Hand held notes: 28 yrs, 1st pregnancy, a lot of info including full personal and family history,
maternal HTN, her BG is Rh-D +ve, early pregnancy booking tests/down’s screening & anomaly
scans all normal. About 4 visits to MW with normal BP reading, clear UG & normal SFH.

Recent UG showed +++ nitrate, ++

USG; ceph, alive baby corresponding with gest age

SIMULATED PATIENT BRIEF:

You are Mrs……….., 28 yrs old from [some east European country], now on vacation alone on UK.
You are currently 28 wks on your first pregnancy which was planned.
Everything was fine with your pregnancy [scans, tests, checks] till today when you felt regular
tightening [about 1 every 10m, you think they are getting closer].
No losses from below. Your baby’s movements are fine. You don’t have any medical or surgical
history of note.
Mother has high blood pressure.
You used to smoke & drink occasionally before you got pregnant. Everything is fine at home.
You are not known allergic to any drug.
You should mock a contraction as soon as the buzzer alarms & the candidate enters.
Questions to ask:

 I am I having a labour?
 I am I going to deliver my baby this early?
 Will my baby survive if delivered now?
 Can’t you give me anything to stop contractions?
 So, what are you going to do now?

A moment of silence till contraction fades, then I introduced my self & offered to call the MW to
start pain relief. I acknowledged the fact that she is alone & reassured her that we will do our
best for her and her baby.
I put agenda: “I need to ask you few questions & to examine you, then may need to run some
tests so that we a better idea about what’s going on, then will discuss your options of
management. I may need to involve my senior and my colleagues in peadiatrics, is that ok with
you?”
Then details about her presenting complain (tightinings): duration, how frequent, regularity, any
losses from below, your baby’s movement, any fever, loin pain, urinary symptoms [I think no
sypmtoms].
SEPTEMBER 2018 RECALLS

Then asked about the course of her pregnancy so far. She pointed to her hand-held notes
attached on desk  labeled as low risk, followed by MW, maternal HTN. For me all visits’ records
were normal.
Then asked about remaining history template including allergy. Nothing significant.
Then offered to examine her “I need to measure your wt, your temperature, BP & PR, then will
examine your tummy to see if there is contractions and pain on examination& will listen to your
baby’s HR. Then with your permission and with the presence of a chaperon I need to do a private
exam to see if the neck of your womb is changing in preparation for labor &to make sure that
your waters didn’t break”. I expected the examiner to say something, but he didn’t.
She asked “what is going on?”. I answered “You may be experiencing a premature labour. Your
investigations also showed that you may have a UTI”.
“You think I am going to deliver my baby now? Will he survive?”. Since i don’t know her cervical
dialatation, and she didn’t mock any labour pain again, I said “I can’t give you a definite answer
till after I examine you. I will also arrange for an US scan which will help us to know which way
round your baby is and, if needed, a TVS-or a swab taken from vagina- can help to predict
whether or not you are going to deliver your baby. I will also inform the baby doctor to make
sure that a cot is available-just in case, and will ask the the neonatologist-a doctor who
specialized in caring for newborn babies-to talk with you about the outlook of babies delivered at
this age, but generally 80% of babies born after 28wks do survive” I think I got this figure from
PIL about PTL, but not sure honestly.
“So what are you going to do now?”. “I need to admit you for further workup. We will offer you
some medicines which we used to offer for mothers if we think they are going to deliver
prematurely. These medicines include steroid injections, which will help with your baby’s
breathing if born prematurely, an infusion of a drug called magnesium sulfate which can reduce
the chance of harm to your baby’s brain, and antibiotics against certain bacteria called GBS, risk
of which is higher in premature babies. All these medicines are safe for you and your baby. We
will also keep monitoring your baby’s heart beats and contractions, & may need to do frequent
vaginal exams if labour is progressing to see whether or not you need to be transferred to labour
ward
“Can’t you give me anything to stop contractions? ” She is clearly asking about.” tocolytics.
“There are some drugs that may slow down contractions, but we may only think of them if your
neck of the womb didn’t change so much in preparation of labour so as to give time for steroids
to work, or if we need to transfer you in case no available cot in nursery. In both cases your baby
monitorings should be fine & your waters didn’t break.”. I felt this answer is weird but she looked
understanding.
I forgot to mention the need for antibiotic for UTI or if we find PPROM, possibly same antibiotic
to cover for GBS.
I recapped the plan with her as there was some time before the buzzer.
Communication with patient: addressing that she is alone, delivering info & explaining possible
interventions in lay language.
Info gathering: Relevant history about current presentation and risk factors for PTL.
I didn’t talk about mode of delivery.
SEPTEMBER 2018 RECALLS

Communication with colleagues: involving senior, nursery & neonatologist.

Safety: Need for admission, safety of medicines [steroids, Mg, ? penicillin for GBS], toco needed?
Applied knowledge: Knowledge about mng of suspected PTL [NICE]

STATION 13 Fertility module

OHSS repeat station from may 2017

Simulated patient
I think 35 years, IVF cycle, has 25 eggs removed 3-4 days back. Embryo transfer was not done.
Now came with c/o nause, i cant remember if there was vomiting, there was mild lower
abdominal pain.
Some blood tests were given like HCT, electrlytes, but all were normal.
USG showed ovaries 8cm on both sides with multiple follicles.
Task was to explain diagnosis and further mangement.
Role player. I cant recall much as so many days have passed now. Maybe she came in A&E

So I started as Mrs. XX? I am Dr Swaleha in senior gynae on-call .

A&e nurse told me you feelabdominal pain and sickness , do you want me to give you some
medicines for that . She said she recieved some pain killer and she is better now. Then I said you
recently had egg removal , is that right? She said yes. Can you tell me more when you started feel
unwell.
Then she told after egg removal, this started.
Then I asked if its okay with her can i know why she is having IVF, is it 1 st cycle. She told
something but I forgot. Then I asked whether her fertility centre warned her of such problems
and have asked her to contact if it happens, she said she is not sure.
Then I asked her if i ask her few questions before I inform her about her condition.
I asked about vomiting, feeling unwell, diarhea, dizziness, any difficulty in breathing esp on lying
flat, did she notice any increase in size of abdomen, Any change in amount of urine she usually
pass. Severity of pain, ist continous, relieved by medications.
Then I said I will explain what probably is the reason for your pain.When ovaries are prepared for
IVF pregnancy, some injections are given to make more eggs, you remember if you have recieved
any? She said yes. This situation is called stimulation of ovaries. But when ovaries over react to
these injections, they make many large follicles and result in rather hyperstimulation of ovaries.
Am I clear so far..
It looks probably you are having ovarian hyperstimulation syndrome which is complication of IVF
preg.
Mild OHSS occur in 33 out 100 women, more common if there was h/o PCO. There is wide range
in seriosness of this condition.
Other possibilties are twisting of ovary or ovarian cyst.
SEPTEMBER 2018 RECALLS

When ovaries get hyperstimulated they relaese some chemicals which make blood channels in
our body leaky. This leakge of fluid cause thickening of blood and make blood to clot or make
lump and also cause fluid to build up in lungs, abdomen and even in brain.
Clotting of blood can be dangerous and clot can impact in lungs and make breathing very difficult
or impossible. This is very serious condition. This is why it is very important that you keep yr self
mobile, take plenty of fluids to avoid dehydration and avoid VTE. I will prescribe for you special
stocking called Ted stocking which also help to prevent this complication. You have to wear them
all the time.
Build up of fluid in lungs can cause of having difficulty in breathing esp on lying down , if fluid
build up in abdomen can cause distension or large abdomen.
There is wide range in seriosness of this condition. Ovaries are usually enlarged to 3-4 times
then normal size. Rightnow you have moderate degree of OHSS. I would suggest that admitting
in hospital would be better. I need to examine you with chaperone. I need to do some other tests
as it may effect liver and kidneys also.Will check BMI.
Patient said she could not be admitted as she is arranging wedding anniversary of her parents
next day. She agreed for doing tests.
I said , its okay if you can attend for f/u daily or on alternate days.She sais she can attend. I would
suggest that you should attend every day so that you can be assesed daily for s/s, Bp, pulse RR,
O2 sat, UOP , abdominal girth, relevent labs,so that complications can be picked up earlier. Keep
yr self mobile. Drink to thirst. Waer Ted stocking all the time. Keep an eye on how much urine is
passed, is it less than her average routine. You may need medicines to prevent blood from
clotting.
Repot immediately if has breathlessness, painful legs, unwell or sudden abd distension. I write to
your fertilty centre also, so they will know about your condition.
She asked why embryo was not transferred.
I said OHSS is self limiting like in 7-10 days but if pregnancy does occur this condition become
worse and may continue upto 3 months of pregnancy. For this reason probably embryo was not
transferred.
Embryo are freezed.Frozen embryo has similar conception rate as with fresh embryo, so don’t
get upset about this.
I will give you leaflet also so you will know more detail about this condition.
Any questions.

Station 14 was about signing AoP (assesment of performance) for summative OSATS on knot
tying.
I was not sure what was reqired in that staion.
Trainee showed me knot tying. His technique was srange but knot was correct. He was very
anxious and was asking or literally forcing me to sign OSATS. I asked why he is so anxious to
exclude bullying but he said everything is ok

I made many mistakes, kindly ignore them , its just to give you an idea. I passed my exam by
grace of Allah in sep 2018.
SEPTEMBER 2018 RECALLS

DR.SWALEHA SHAIKH