Thursday 31 October 2013

Tutorial 31 October 2013

Tutorial.
Website.
Contact us.

https://soundcloud.com/drtmcf/31-october-2013

Tonight we had 3 role-plays and a viva.

I was a few minutes late starting the recording.
We covered the obvious things like not operating if there was a suitable and safer non-surgical option.
Then the reduced risk of adhesions with laparoscopic compared with open surgery.
And the basics of good practice.
We discussed these later in the tutorial, so nothing was lost.
I have a document that details all of this which I will send when I see your notes about how you would tackle the station.



Role-play.  Teach junior about adhesion prevention.
Role-play. Teach junior about handling complaints.
Viva. You have to write a protocol for PPH management.
Roleplay. Pregnant & plans to travel to Africa.


We will have an extra tutorial on Sunday starting at 10.30.
Anyone is welcome - just send me an e-mail to let me know you are attending.

Monday 28 October 2013

Tutorial 28 October 2013

Tutorial.
Website.
Contact us.
https://soundcloud.com/drtmcf/28-october-2013

There was mention of a recent paper on the use of cffDNA in conjunction with the combined test and various biomarkers.
It can be found here: http://onlinelibrary.wiley.com/doi/10.1002/uog.12511/pdf.

"First-trimester contingent screening for trisomy 21 by biomarkers and maternal blood cell-free DNA testing." Nicolaides, Wright, Poon, Syngelaki & Gil. Ultrasound in O&G. Vol. 42, Issue 1, pages 41-50, July 2013.

We started with an adverse incident report. Unfortunately I was late turning on the recording device, so this was not recorded.
This is probably a blessing in disguise as it will make you write your version/
Send it to me and I'll send my ideas on the subject.


Adverse incident report.

Candidate’s instructions.
Mrs Penelope Jane Brown sustained a 4th. degree tear after the delivery of her second baby.
Dr. James Peter White conducted the delivery and was asked to write a statement for the Risk Management Team (RMT), to whom the incident has been reported as an adverse clinical incident.
You have been asked to look at Dr. White’s report, comment on it and identify issues  that the RMT need to explore further. You have 15 minutes to read Dr. White’s report, after which you will have a viva with the examiner. The examiner will not lead the discussion and will simply listen to what you have to say.

Dr. White’s Statement.
I am Dr. J. White. I have been SpR in obstetrics and gynaecology at the Royal Infirmary for over a year.
On the 27th. September I was bleeped by a midwife on the labour ward and asked to see a Mrs. Brown who needed to be delivered as there had been delay in the second stage and she was becoming exhausted.
On arrival on the labour ward I felt that Mrs. Brown was not trying very hard to deliver the baby naturally and that the midwives were not making much effort to encourage her. I advised that they should get her pushing properly and that I would go for a coffee and return in half an hour.
I returned in 50 minutes, having had a phone call from my wife about arrangements for our forthcoming holiday. The situation was unchanged and I was not impressed with either the woman’s endeavours or the midwives’ encouragement of her.
Examination showed the head to be midcavity. I felt that it could get it out using forceps. The midwives told me that her bladder was empty. I applied the forceps with ease. The baby delivered in good condition. I then noted that she had a 4th. degree tear. I repaired this in the usual way.
I went on holiday the next day for two weeks and did not see this woman again.

Then we had a roleplay about Down's screening with a woman who had read an article about a new test in the Daily Mail.


DS Screening. Daily Mail article.

Candidate’s instructions.
You are the SpR in the antenatal clinic. Mrs Smith, whom you are about to see, wishes to discuss her risk of having a baby with Down’s syndrome and appropriate screening. She has read a Daily Mail article about a new test which she would be happy to pay for.


Daily Mail. June 2013.
For expectant parents, whether or not to test their unborn child for Down’s syndrome can be an agonising decision.
Routine scans at ten and 13 weeks can flag up a heightened risk of the condition, which causes lifelong disability and a host of complex health problems.
But a definitive diagnosis can be given only after amniocentesis, an invasive procedure that draws amniotic fluid from around the baby with a needle and syringe – and brings with it a risk of miscarriage.
Now, Carolyn and Neil Blockley, who are expecting twins, have become one of the first couples in the UK to benefit from a controversial blood test that can accurately identify Down’s and eliminate the danger of the traditional method.
More than 98 per cent accurate for twins and 99 per cent accurate for a single baby, the new non-invasive Ariosa Harmony test – one of a number of similar tests – requires no more than a blood sample drawn from the pregnant woman’s arm.
However, disability campaigners believe that if such a test were to become widely available, it would increase terminations of Down’s babies – nine in ten women given the news choose to have an abortion.
At present, mothers to be are given a combined test for the syndrome at the end of the first trimester. It comprises an ultrasound known as a Nuchal Translucency (NT) scan, which measures the fluid behind the baby’s neck, a larger amount of which can indicate Down’s, and a blood test, which looks for hormones and proteins related to the syndrome.
 The two results are combined to give a risk rating. If the risk is high, then women are offered amniocentesis.
Because these hormones and proteins are already higher in a multiple pregnancy, women expecting twins have only the NT scan – which is 80 per cent accurate. The combined test is 90 per cent accurate at best.
It was after the NT scan that doctors first alerted the Blockleys to potential problems. Carolyn, 29, an accountant, from Pentre, Mid Glamorgan, explains: ‘They said there was more fluid than was usual around one baby’s neck. We were shocked when the doctor told us he thought it could be Down’s syndrome. It was very upsetting as these are our first babies and I hadn’t had any problems before.’
With amniocentesis, performed from 15 weeks, there is a one in 100 chance of miscarriage – and with twins this risk is doubled.
Carolyn says: ‘Had I not had the new test, I would have faced a terrible dilemma about whether or not to have an amniocentesis. Although we would have wanted to know our babies were healthy, the thought we could risk losing them was devastating.’
Thankfully for Carolyn, her consultant suggested having the Ariosa test, which has been available privately since May. She chose the screening at 12 weeks, and ten days later the results showed her babies were healthy.
Now 17 weeks pregnant, she says: ‘It was a huge relief to be given the all-clear. I’m looking forward to enjoying the rest of my pregnancy without worry.’
The couple’s doctor, Dr Bryan Beattie, a consultant in foetal medicine at the University Hospital of Wales, Cardiff, wants the NHS to provide the test as a routine screening.


Ariosa Harmony Test.
Flexible for Multiple Patient Populations
The Harmony Prenatal Test detects >99% of fetal trisomy 21 cases at a false positive rate of <0.1%
Optional X and Y chromosome analysis available for fetal sex and X,Y sex chromosome analysis.
This test does not assess risk for mosaicism, partial trisomies or translocations.
The Harmony test is available for all singleton and twin pregnancies, including those conceived by IVF
The Harmony Prenatal Test has been developed and is performed as a laboratory test service by Ariosa Diagnostics, a CLIA-certified clinical laboratory located in California, USA.
Ariosa™, Harmony™, and Harmony Prenatal Test™ are trademarks of Ariosa Diagnostics, Inc.
©2013 Ariosa Diagnostics, Inc. All rights reserved.
Customer service: 1-855-9-ARIOSA (855-927-4672)

 Then we had a viva on neonatal jaundice.


Thursday 24 October 2013

Tutorial 24 October 2013

Tutorial.
Website.
Contact us.
https://soundcloud.com/drtmcf/24-october-2013

Tonight we did a theatre admissions prioritisation station.
Then a viva on child sexual abuse.
Then a role-play about androgen insensitivity.

 

Waiting List Prioritisation.

Your consultant is away.
The waiting-list manager comes to see you.
The following patients have been listed by junior staff.
The waiting-list manager wants you to:
confirm the appropriateness of the proposed treatment,
decide the degree of urgency,
confirm the appropriateness of the proposed venue,
decide any special requirement(s) for each patient.

Name
Age
Clinical Problem
Proposed operation
Venue
Special Needs
Urgency
JK
5
chronic discharge.
? foreign body
EUA
Main theatre


JM
32
1ry. infertility
Laparoscopy + tubal patency tests
Main theatre


GN
77
Vulval cancer. Coronary thrombosis x 2. Unstable angina.
Radical vulvectomy agreed at MDT.
Main theatre


RU
55
PMB x1. Weight 20 stones. (127 kg.)
1 kg. = 2.2 lb.
1 stone = 14 lb.
D&C.

DCU.


LD
32
Menorrhagia. Fibroids. Anaemia.
Vaginal hysterectomy.

Main theatre.


DT
22
Does not want children.
Lap. Steril.
DCU


HB
14
Unwanted pregnancy at 10/52.
TOP
DCU. TOP list.
.

JY
44
GSI.
Anterior colporrhaphy.

Main theatre.


JS
23
Vaginal discharge. Cervical ectropion.
Diathermy to cervix.

DCU


DT
55
3 cm. ovarian mass.
Laparoscopy ? proceed to Hyst + BSO.

Main theatre.


EV
32
CIN3.
Cone biopsy.

DCU


UW
34
Endometriosis
Laparoscopic ablation
DCU


HT
88
Cystocoele/ rectocoele/ 2nd. degree uterine prolapse
Manchester Repair.

Main theatre.


KN
58
Haematuria
Cystoscopy
DCU


JW
18
Menorrhagia & copes badly with menstrual hygiene. Has Down’s syndrome. Sexually active.
Hysterectomy
Main theatre


TB
30
Menorrhagia. 2nd. degree uterine descent. Been sterilised. Jehovah’s witness.
Vaginal hysterectomy and repair.
Main theatre.


BM
55
Stage Ib cancer cervix. Been discussed at MDT. For Wertheim’s hysterectomy. Factor V Leiden. VTE on Pill. On warfarin.
Wertheim’s hysterectomy.
Main theatre.


NU
60
Recurrent rectocoele.
Posterior colporrhaphy.
Main theatre.



Viva.
 

Candidate's Instructions.
This is a viva station.
The examiner will ask you 7 questions.

Roleplay.


Candidate's Instructions.
This is a role-play station.
The patient is Euphemia Johnstone. She is 17 years old. She attended the gynaecology clinic 1 month ago with primary amenorrhoea.
Clinical examination showed an apparently normal young woman with normal breast development but absent pubic and axillary hair. The external genitalia appeared normal. Vaginal examination was not attempted.
She has come today for the results of the ultrasound scan and blood results.
The scan has shown absence of the uterus. There are no ovaries in the pelvis. There are bilateral groin masses that could be gonads.
The blood tests which were done are reported as:
Karyotype. 46XY.

Your tasks are to explain the results and answer her questions.