You are on page 1of 95

End of 4th Year

Clinical OSCE
A/L 2001 Batch

Dinusha Liyanapatabendi

Q7
1. Identify A-G
2. Write the corresponding letters in
order of most effective method to
least effective method

A

B .

C .

D E .

F .

G .

Write the corresponding letters in order of most effective method to least effective method D E F G . Identify A-G 2.A B C 1.

• A – Female condom • B – Levonorgestrel releasing intra uterine contraceptive device (Mirena®) • C – Copper T-380 A intrauterine contraceptive device • D .Depot medroxy progesterone acetate injectable suspension • E – Norplant subdermal contraceptive implant system • F – Combined oral contraceptive pill • G.Male condoms E>B>F=D>C>G>A .

3 3 0.Male 5 15 2 8 0.% of women experiencing an unintended pregnancy within the first year of use Method Typical use1 Perfect use2 No method4 85 85 Withdrawal 27 4 Periodic abstinence Calendar Ovulation method Sympto-thermal6 Post-ovulation 25 9 3 2 1 Condom .5 0.1 LNG implants (Norplant) 1 0.3 4 0.10 Combined pill and minipill DMPA (Depo-Provera) IUD (copper T) Female sterilization Male sterilization 3 3 Emergency contraceptive pills: Treatment initiated within 72 hours after unprotected intercourse reduces the risk of pregnancy by at least 75%.15 0.1 0. .05 0.5 0.8 0.6 Mirena (LNG IUS) 2 0.05 0.Female 6 21 5 Condom .

B) A 35 yrs old healthy woman with two children aged 3 & 5 yrs requests an emergency contraceptive after unplanned coitus 4 days ago.A) 21 yrs old unmarried girl presents to your clinic after having unprotected sex last night. Name a method that you would offer to this woman. 1 3 2 4 . What method/s that you can use in this patient as post-coital contraceptive method/s.

Copper T 380-A intrauterine contraceptive device • A copper-releasing IUD (Cu-IUD) can be used within 5 days of unprotected intercourse as an emergency contraceptive. when the time of ovulation can be estimated. if necessary. the Cu-IUD can be inserted beyond 5 days after intercourse. 1 – Postinor2® take one tab immediately and the second tablet 12 hrs later 2 – Combined oral contraceptive pill Take 4 tablets immediately and repeat the same dose 12 hrs later B. as long as the insertion does not occur more than 5 days after ovulation. . However.A.

What should you do if a woman gets pregnant after placing it . List 2 advices you would give after inserting this to a patient 3. How long can it be used 2.Q11 1.

1.the threads are not felt .Severe abdominal pain Prolonged or excessive bleeding 3. 2.delayed menstrual period (Pregnancy?) . Remove the IUCD . Follow up – In one month and thereafter annually Prompt medical advice should be taken if . 10 years (6-8) Expect some bleeding PV for a few days Check for the presence of the threads (Specially during menstruation period) First 3-4 menstrual periods may be heavier than normal Take paracetamol tablets if she develops lower abdominal pain.

? PID .• Timing of insertion 1st seven days of the cycle (Ideal during menstruation) • Removal of IUD pregnancy Perforation Acute PID Menopause – one year after last period • Absolute contraindications Pregnancy Acute/Chronic PID Abnormal uterine bleeding Suspected/confirmed genital tract malignancy • What you should ask in the Hx: LRMP – to rule out possibility of pregnancy Mucopurulent vaginal discharge .

what advise would you give her? .A B Q7 C 1. Name above items and write one non-contraceptive benefit of each above given methods 2. 30 yrs old female who is on OCP has forgotten to take her last two pills.

1) A .Relief of menstrual problems Regularizes previously irregular cycles Decrease number of days of bleeding and amount Improves iron deficiency anaemia Relieves and reduces premenstrual tension Protection against ovarian and endometrial cancers Decreases incidence of benign breast cysts and fibroadenoma Prevent ectopic pregnancy .Protection against STD Protection from carcinoma of the Cx C.Levonorgestrel releasing intra uterine contraceptive device (Mirena®) B – Male condom C – Combined oral contraceptive pills 2) A- Improves menorrhagia Decrease dysmenorrhoea and pelvic pain in patients with endometriosis B.

From next day onwards take one pill daily. .Missed pills Sri Lanka Family Planning Association Guidelines • Missed one tablet Take the missed pill as soon as you remember & take the scheduled pill at the usual time • Missed consecutive two pills on two days Take two pills on the third day and two on the fourth day. Till you get your next menstrual period use condoms as a backup method OR abstain from sex.

Missed “Pill” WHO Guidelines .

What is the advice you would give to the patient when prescribing this 2. List 3 Common side effects .1.

2 nd tab should be taken 12hrs after the 1st dose • If vomiting occurs within 2hrs of intake take another tab. Vomiting • Consult a physician if you missed your next period • Advise her about proper use of suitable contraceptive method . Lower abd pain. Treatment necessitate to take 2 tabs • Reliable (75%) post coital contraceptive method if it takes <72 hrs after unprotected sex • 1st tab should be taken immediately. breast tenderness. • Can cause irregularity to your next menstrual period • Not a method of abortion • No adverse effects to an already existing pregnancy • Adverse effects – Nausia.Advice • Postinor contains two tabs.

Q9 Mother giving breast milk to child. looking far away 1. List 2 maternal complications due to incorrect technique of breast feeding . List 2 correct techniques when breast feeding 2.

e) Each feed to be around 20 minutes.Mother sitting comfortably. c) Good attachment.The areola covered by baby’s mouth with the lower lip everted and cheeks should be puffed out. b) Posture.neck and body in one line supported by the mother’s forearm. • Maternal complications: a) Cracked nipples b) Breast abcess . d) Eye contact to be maintained.• Correct technique: a) Good exposure of both mother and baby. The baby is held with his head .

Q 14 • How do you prepare a patient for LSCS • What are the complications of LSCS .

Consent

Co-ordinative part- inform aneasthetist, PHO and theatre.

Keep fasting

Investigations- Grp & DT( Reserve 1 unit)

Pre-medication- Metachlopromide 10mg oral, Famotidine 20mg oral

Emergency- O2, IV Ranitidine 50mg, IV Metachlopromide 10mg, Na
Citrate 0.3M 30ml. Mother in left lateral position.

Send Urinary cather, IV antibiotics ( Metronidazole 500 mg,
Cefuroxime 750 mg ( 1 vial each) to theatre.)

Complications of LSCS
• Anaesthetic – Aspiration ( Mendelson’s
synd)
• Immediate- PPH, shock, damage to bladder,
ureters or colon
• Early- Sepsis, Wound complications
(Haematoma, dehiscence)
• Late- risk of scar rupture in future
pregnancies, incisional hernia, intestinal
obstruction due to adhesions

Q6
Give 4 risk factors from this antenatal record (Two slides)
Mrs. A

PAGE 1

Orange +++ .

• • • • • • Short stature Previous death in-utero Previous miscarriages Blood pressure of 160/110 Proteinuria Grand multi para .

Q8 • Tick the items used in manual removal of placenta 1 Plasters 2 14G foley catheter 3 14G IV cannula 4 Vacuum cup 5 A pair of gloves 6 Cusco’s speculum 7 IV drip set 8 Vulsellum 9 IV metronidazole 10 Betadine .

1 Plasters 2 14G foley catheter 3 14G IV cannula 4 Vacuum cup 5 A pair of gloves 6 Cusco’s speculum 7 IV drip set 8 Vulsellum 9 IV metronidazole 10 Betadine .

Q4 94/95 batch 1. Identify/name the instrument 2. Write 2 uses .

1. • In obtaining a Pap smear • In obtaining a high vaginal swab • To visualize the cervix & vaginal wall in pelvic examination . Cusco’s bivalve self retaining vaginal speculum 2.

What do you see 2.Q18 1. Write 2 causes .

1. CPD OP position Inadequate uterine contractions Mx: CPD – Em LSCS OP position Inadequate uterine contractions Exclude obstruction Increase oxytocin infusion rate Observe and if no progression Em LSCS . Secondary arrest 2.

Q19 Write a clinical condition where each of these drugs are used Hydralazine A B .

C D .

A B C D .

Following evacuation of uterus. In atonic uterine bleeding foll. Miscarriage. Active Mx of 3rd stage labour & control PPH. Ergometrine Prophylaxis against excess heamorrhage foll. . Hydralazine In Pre-eclampsia and eclampsia. Mg sulphate As eclampsia prophylaxis.Oxytocin Augmentation of labour. mole. delivery Therapeutic. expulsion of H.In PPH: atonic uterine bleeding.

• Counsel this 30 yrs old patient who is diagnosed to have an incomplete miscarriage .

• Ask whether patient has any questions to ask . there is nothing that she could have done to prevent the miscarriage ) • The need to undergo surgery ( Evacuation of retained products under GA) • Preparation for the next pregnancy – wait at least 3 months. put the patient at ease • Explain what has happened ( Most miscarriages are due to fetal anomalies. during this period take folic acid • Early antenatal clinic booking and regular follow up.• Introduce yourself.

• Ask 5 leading questions to determine the severity of this patients condition who has a blood pressure of 160/100 mmHg .

• Visual disturbance.flashing lights and spots • Epigastric pain • Nausea/ Vomiting • Swelling • Malaise .unrelieved by simple analgesia.• Frontal Headache.

Mr. A

Write the

5-07-2006

names
of the 5
abnormalities
you see.

2.2 ml
10 million/ml
none
25%
30%

20%

+++

Normozoospermia

When all the spermatozoal parameters are normal
together with normal seminal plasma ,WBCs and
there is no agglutination.

Oligozoospermia

When sperm concentration is < 20 million/ml.

Asthenozoospermia

Fewer than 50% spermatozoa with forward
progression(categories (a) and (b) or fewer than 25%
spermatozoa with category (a) movement.

Teratozoospermia

Fewer than 30% spermatozoa with normal
morphology.

Oligoasthenoteratozoospermia

Signifies disturbance of all the three variables
(combination of only two prefixes may also be used).

Azoospermia

No spermatozoa in the ejaculate.

Aspermia

No ejaculate.

Leukocytospermia

more than 1 million white blood cells per ml of semen

Normal values
Volume

2.0 ml or more

pH

7.2-7.8

Sperm concentration

20x106 spermatozoa/ml or more

Total sperm count

40x106 spermatozoa or more

Motility

50% or more with forward progression or
25% or more with rapid progression
within 60 min after collection

Morphology

30% or more with normal morphologyb

Vitality

75% or more live

White blood cells

Fewer than 1x106/ml

preferably taken at least two or three weeks apart. . should be analyzed.• sensitivity of 89%. • At least two samples. poor specificity repeat semen samples provides greater specificity.

• What is the advise you would give regarding obtaining a semen sample for analysis .

• Wide mouthed sterile plastic container will be provided. • Coitus interruptus is not recommended as the first part of the ejaculate contains the highest concentration of sperm.• This test is conducted to check for male factor subfertility. • Sample should be delivered to the lab within 30 min. . • Abstinence from intercourse for 3 days. of collection. • Specimen should be produced by masturbation. • Condoms should not be used for collection as they contain spermicide.

2. Identify List 3 prerequisites in using these instruments 3.1. Give 3 indications for these instruments .

Wrigley’s Forceps .

Keilland’s Forceps Simpson’s Forceps .

Position of the foetal skull – Position of the saggital suture & posterior fontanelle . Confirm that the cervix is fully dilated 3. Empty the bladder 4.Always prior to applying forceps 1. Check station of the presenting part 5. Abd examination – Head engaged? 2.

vertex. aftercoming head of breech. • Abdominally head should not be palpable. • Ruptured membranes. If more than 1/5th palpable abandon vaginal delivery. • Rule out cephalopelvic dispropotion. .face. Position of the fetal head should be known. • Cervix should be fully dilated. • Engaged Presenting part.Prerequisites for applying forceps • Valid indication must be present • Suitable presentation. • Bladder emptied.preferably by catherisation.

Indications for forceps delivery • Delay in progression of second stage of labour • Maternal exhaustion • Medical problems which require avoidance of excessive maternal effort • Fetal distress in the second stage • Delivery of the after coming head of a breech presentation .

What is the fixative and the stain used B A D E C F G .1. Name the required instruments in order of use when obtaining a pap smear 2.

F . Fixative – 95% Alcohol Stain.Papanicolaou stain (The glass slide is fixed in 95% alcohol for 30 minutes and air dried before sending to the histology lab) .Cusco’s bivalve self retaining vaginal speculum G .Cytobrush/ Endocervical brush A .1.Ayre’s wooden spatula B .Glass slides 2.

Name 5 instruments in an episiotomy set. What are the advise given to mother after repairing an episiotomy . 2.1. List 3 complications of an episiotomy 3.

.

Sterile towels (Two) Sterile sanitary towel .

Dressing Scissors Artery Forceps Needle Holder Toothed Catch Forceps .

Round body needle Cutting needle .

Complications of episiotomy – Immediate- • Extension of the incision .Early • Vulval haematoma • Infection • Wound dehiscence – Remote • Dyspareunia .

Advise to mother following episiotomy • Keep the area dry and clean. . soap is sufficient. • Do not use antiseptics. • Can wear a sanitary pad to keep area dry.

Repair of a cervical tear . Dilatation & Curettage 2.What instruments are used in the following procedures in order of use 1.

1. D&C : • Performed under GA • Placed in lithotomy position • Local antiseptic cleaning & draping • Sims’ double bladed posterior vaginal speculum is introduced • Anterior lip of cervix held by vulsellum • Olive pointed malleable graduated metallic uterine sound to confirm position & length of cavity • Cervical canal dilated with Hegar’s graduated dilators • Uterine curette – sharp end for benign lesions and blunt end used for suspected malignant lesions • Curetted material preserved in 10% formal saline and sent to histology lab with a short clinical history. .

  • Oxytocin 10 U given foll. . .Post procedure care: •  Give paracetamol 500 mg by mouth as needed.severe or increased pain. . counselling or a family planning method. . .prolonged cramping (more than a few days). if possible. including tetanus prophylaxis. chills or malaise.bleeding more than normal menstrual bleeding.fainting. ERPC • Offer other health services.fever. • Advise the woman to watch for symptoms and signs requiring immediate attention:  . .prolonged bleeding (more than 2 weeks).

• Sims’ speculum is introduced • Gently grasp the cervix with Green armytage forceps. give pethidine IM • Good light source and patient is placed in lithotomy position.  • Close the cervical tears with continuous chromic catgut (or polyglycolic) suture starting at the apex (upper edge of tear). For tears that are high and extensive. There may be several tears. .Repair of a cervical tear • Anaesthesia is not required for most cervical tears. Apply the forceps on both sides of the tear and gently pull in various directions to see the entire cervix. which is often the source of bleeding.

.• What are the instruments found in a delivery set.

Sterile sanitary towels Gullipot .

Artery forceps Straight scissors Curved mayo’s scissors Kidney tray .

CTG • What are the parameters that should be observed in a CTG • Types of CTG’s • If foetus is distresed what features would you expect .

Parameters observed in a CTG • • • • • FHR Any decelerations in HR Basal heart rate variation Frequency of uterine contractions Strength of uterine contractions .

Types of CTGs .

Features when foetus is distressed • Decelerations in FHR • • • • .

What advise you give on using this 3. e. c. d. On which day according to the chart would you do the following a. b. What is the day of ovulation 2.Basal body temperature chart (BBTC) 1. Post Coital Test Progesterone levels to detect ovulation Endometrial biopsy HSG IUI .

5-1 0F (0.5 0C) Ovulation 2 days .2-0.0.

.

• Mark the date in the column and shade the area on the day of menses.day 1 on the chart. Day 14 of the cycle. . There is a biphasic pattern of variation in ovulatory cycle. on the first day of the period. • Measure the oral temp. ( do not wash mouth) • Days when intercourse takes place should be noted with an arrow. • Begin recording temp. 2. using a clinical thermometer. • Take the oral temp daily on waking before getting out of bed.1.

Progesterone levels to detect ovulation – Day 21 in a 28 day cycle.a. IUI. HSG.washed sperms are placed in the uterine cavity at the time of ovulation. d. .day 12-13 in a regular 28 day cycle. Post Coital Test. Ovulation detected by follicular growth monitoring by USS. e. Endometrial biopsy.Day 21-23 in a 28 day cycle. b. c.First 10 days of the cycle.

Identify Name which one you would use in the following procedures • To insert an IUCD • In vaginal hysterectomy • In D&C • In obtaining a pap smear • Repair of a cervical tear .1 2 1. 2.

Cusco’s bivalve self retaining vaginal speculum a) Inserting an IUCD b) Obtaining a pap smear • Sims’ double bladed posterior vaginal speculum a) Vaginal hysterectomy b) Dilatation and curettage c) Repair of a cervical tear • .

What are the instruments needed for the insertion of an IUCD Give 3 possible complications 2 3 1 5 4 6 7 . 2.1.

.

Complications • Inter-menstrual bleeding • Pelvic inflammatory disease • Expulsion (1st 3 months) • Perforation .

1. List an indication and a contraindication . Identify 2.

such as vaginitis b) Pelvic inflammatory disease c) Patients who are noncompliant or unlikely to follow up d) Allergy to silicone or latex .Name of instrument – Ring pessary Indications for use of vaginal pessary a) Prolapse of uterus b) urinary incontinence c) cystocele d) rectocele Contraindications a) Active infections of the pelvis or vagina.

Foetal movement chart 1. List 3 causes for reduced FM 4. When do you call it abnormal 3. How to advise mother to maintain a Foetal movement chart 2. List 3 non invasive tests to assess foetal well being .

Test sensitive for fetal well-being after 28 weeks Physiology of normal third trimester fetal movement • • – – – – Fetus spends 10% of its time making gross movements Active fetal periods last 40 minutes Inactive fetal periods last 20 minutes (<75 minutes) Fetal activity peaks with maternal Hypoglycaemia Usually occurs between 9 pm and 1 am Activity not increased after meals or glucose load Advise to mother: » » » » » Patient self monitors kick counts daily at home Count performed at same time every day Lie on left side in comfortable location Count fetal movements to a count of 10-12 in 12 hours If perceived movements are <10/12hrs seek medical advise .

• Umbilical artery Doppler .Causes of reduced foetal movements: • Normal sleep phase • Physiological • Reduced maternal perception • Sedative drugs given to mother • Polyhydramnion/oligo • Intrauterine asphyxia Non-invasive tests to assess foetal well being: • CTG • USS..foetal growth & Liquor. biophysical profile.

USS abd given (H.Mole or missed abortion) A) What is the condition B) What is the diagnosis C) Give 2 causes .

45 yrs 400 times higher – over 50 yrs Maternal DNA lost from ovum 23x Duplicati on of haploid 46xx sperm Proliferation of monospermic androgenetic complete HM Maternal DNA lost from ovum 23x 46xy Two paternal genetic contributions Proliferation of dispermic androgenetic complete HM 23x 69xxx Maternal and two paternal genetic contribution 69xxy Proliferation of triploid partial HM .Age 40.Lowest risk – Age 25 – 29 years 6 times higher – Age less than 15 yrs 4 times higher . History of previous GTD Age . 2.Risk factors 1.

F>D Investigations 1. Hyperemesis 4.•Absence of a foetus (In complete mole) Presentation •“Snow Storm” appearance 1. 2. Contraception . Passage of vesicular grape like structures per vaginum 3. Evacuation 2. CXR Management 1. Vaginal bleeding 2. S. Early onset PIH Examination findings 1. Anaemia 2. Follow up (2 yrs). hCG 3.hCG assays 3. USS abd.

Missed abortion .