Structured Clinical Examinations (OSCEs) in gynaecology

Published on 09/03/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 22/04/2025

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Appendix Objective Structured Clinical Examinations (OSCEs) in gynaecology

Miriam Lee, Amy Mellor

Case 1

Information for candidate

Dear Doctor,

Thank you for seeing Liz, aged 36, in your gynaecology outpatient clinic. She has an 8-month history of hirsutism and irregular menses.

Yours sincerely,

Dr Jones

(General Practitioner)

Encounter 1

‘I will play the role of the patient and you the gynaecologist. Please commence.’

Encounter 2

‘So Doctor, what did my tests show?’ (Results requested from encounter 1 supplied.)

Encounter 3

You are seeing Liz at 6 weeks postlaparotomy, total abdominal hysterectomy–bilateral salpingo-oopherectomy (TAH—BSO) and staging. (Histology report now supplied.)

‘Doctor, what happens from here with respect to the cancer? I’m also having terrible hot flushes.’

Investigation results (if requested)

• beta-human chorionic gonadotropin (B-hCG): <2
• CA125: 12
• cortisol: normal
• 170H progesterone: normal
• dehydroepiandrosterone sulfate (DHEAS): normal
• testosterone: >200
• free androgen index: elevated
• prostaglandin E2/progesterone: normal
• luteinising hormone/follicle-stimulating hormone (LH/FSH): normal

Pelvic ultrasound

• 4 cm posterior wall fibroid
• endometrial thickness 6 mm
• normal left ovary
• 8 cm lesion in right adnexae, solid and cystic components
• increased vascularity
• no normal ovarian tissue seen

Histology

• right ovary: Sertoli-Leydig tumour
• normal left ovary, normal uterus
• washings negative, appendix and omental biopsies normal

Information for examiner

Case summary

The candidate plays the role of the gynaecologist in the outpatient clinic. Liz has been referred by her general practitioner with an 8-month history of hirsutism and irregular menses. She has a history of breast cancer, and on examination is found to have an 8 cm adnexal mass. An ultrasound reveals a complex lesion and androgen levels are raised. Gynae–oncology referral is called for, with an explanation of likely management. The patient returns following a TAH–BSO with a diagnosis of stage 1 Sertoli-Leydig tumour. The patient is suffering with hot flushes and a discussion of treatment options on a background of breast cancer is required.

Encounter 1

History

• increased hair growth on abdomen and face last 8/12
• previously regular cycles; now 2–3 days/2–3 months
• no weight gain
• normal Pap smear 1 year ago
• implanon in situ
• G2P2: both spontaneous vaginal delivery (SVD) at term (now aged 12 and 10)
• hypertension: on captopril 1 year
• modified radical mastectomy and chemotherapy 6 years ago for breast cancer
• nil allergies, non-smoker, social alcohol
• sister and aunt also with breast cancer

Examination

• body mass index: 25
• blood pressure: 150/90
• acne, facial and abdominal hirsutism
• palpable mass in right adnexae

Expectations of candidate

• history and examination
• order investigations
• hCG, CA125
• thyroid function tests, prolactin
• testosterone/free androgen index
• DHEAS, 17-OH progesterone, cortisol
• pelvic ultrasound
• organise follow-up

Encounter 2

Expectations of candidate

• explain possible suspicious nature of lesion
• arrange gynae–oncology referral
• staging investigations
• chest X-ray, computed tomography abdomen/pelvis, full blood count, enzyme liver function tests
• explain procedure
• laparoscopy, oophorectomy +/– laparotomy +/– staging +/– TAH–BSO if family complete

Encounter 3

History

• uneventful recovery
• hirsutism resolved
• several hot flushes/day, night sweats

Examination

• looks well
• laparotomy scar well healed
• no masses felt on bimanual

Expectations of candidate

• explain findings
• stage 1: prognosis good
• no adjunctive treatment required
• no hormone replacement therapy, as history of breast cancer; discuss alternatives (e.g. tibolone, venlafaxine)
• discuss referral for breast cancer gene (BRCA) testing
• organise follow-up

Scoring for case 1

Encounter Mark
Encounter 1  
• History and examination

____ out of 1

• Order investigations

____ out of 2
• Arrange follow-up
____ out of 1
Encounter 2  
• Explain possible diagnoses
____ out of 1
• Gynae–oncology referral
____ out of 1
• Staging investigation
____ out of 1
• Explain surgery
____ out of 1
Encounter 3  
• History and examination
____ out of 1
• Explain findings
____ out of 1
• Adjunctive treatment
____ out of 1
• Hormone replacement therapy
____ out of 2
• BRCA
____ out of 1
• Follow-up
____ out of 1
Global competence ____ out of 5 TOTAL SCORE ____ out of 20

Case 2

Information for candidate

Dear Doctor,

Thank you for seeing Mrs Smith who is a 60-year-old woman with urinary incontinence.

Yours sincerely,

Dr Brown

(General Practitioner)

Encounter 1

‘I will play the role of the patient and you the gynaecologist. Please commence.’

Encounter 2

‘So Doctor, what do you think the problem is and what are you going to do?’

Encounter 3

Mrs Smith returns for a review 3 months later. She has been to the physiotherapist and has commenced oxybutynin. Mrs Smith tells you that:

• urgency is much improved; triggers resolved
• no urge incontinence
• voids six times during the day and 0–1 times at night
• voided volumes (from urinary diary) increased from an average of 100 mL to 250 mL
• still complains of urinary stress incontinence

‘How can you help me doctor?’

Encounter 4

You are seeing Mrs Smith following her urodynamics. Here is the report:

First uroflowmetry

Voided 220 mL, normal flow rate

Residual volume 55 mL

Cystometrogram

Stable bladder, normal capacity

Maximal urethral closure pressure of 63 cm H20

Marked leakage in sitting position due to urodynamic stress incontinence

Second uroflowmetry

Good flow rate, voided to near completion

‘So what are you going to do to help me doctor?’

Information for examiner

Case summary

The candidate plays the role of the gynaecologist in the outpatient clinic. Mrs Smith has been referred by her general practitioner with a history of urinary incontinence. She has mixed incontinence. Initial management is conservative with mid-stream specimen of urine (MSU), pelvic floor rehabilitation, reduction of caffeine, and anticholinergics plus topical oestrogen.

Mrs Smith responds well to the treatment of her overactive bladder and returns with ongoing urinary stress incontinence. Urodynamics confirms a stable bladder, urodynamic stress incontinence and no voiding problems.

The candidate is to discuss management options and risks of surgical options.

Encounter 1

History

• worsening urinary incontinence with activity (stress incontinence) over the past 5 years
• urgency
• occasional urge incontinence
• triggers: key in the door, turning on the taps
• daytime frequency/voids = 10
• nocturia = 3
• denies coital incontinence
• no voiding difficulty
• wears incontinence pads regularly
• no known urinary tract infection
• drinks 4–5 cups tea/coffee a day; total fluid intake 1500 mL
• constipation: for many years

Past history

• three vaginal deliveries
• total abdominal hysterectomy (TAH) at aged 42 for menorrhagia
• no glaucoma
• no other medical history

Examination

• body mass index: 25
• blood pressure: 140/80
• mild atrophy, no significant prolapse, no pelvic masses
• small urinary leak on coughing

Encounter 2

• explain that there is a mixed picture; treatment of the overactive bladder is conservative
• MSU
• urinary diary
• pelvic floor rehabilitation with physiotherapist/continence nurse
• reduce tea/coffee and increase water intake
• medication

• anticholinergics: common side effect is constipation
• topical oestrogen

• review

Expectations of candidate

• history and examination
• discuss management
• order MSU
• refer to physiotherapist/continence nurse
• organise follow-up

Encounter 3

• for urodynamic assessment

Expectations of candidate

• to explain procedure

Encounter 4

• Urodynamics has confirmed pure urodynamic stress incontinence.
• Mrs Smith has had a trial of conservative management. Surgery is a viable option.
• Management options for urodynamic stress incontinence: vaginal devices or surgery.

Surgical options

• primary procedure: slings, colposuspension
• risks: 15% failure to treat the stress incontinence, voiding difficulty with prolonged catheterisation or clean intermittent self-catheterisation, overactive bladder symptoms, injury to lower urinary tract and pelvic structures
• anaesthetic risks: deep venous thrombosis (DVT), bleeding, infection

Scoring for case 2

Encounter Mark
Encounter 1  
• Elicit history of mixed incontinence

____out of 2

• Risk factors (e.g. caffeine, constipation)

____out of 1

Encounter 2  
• Explain possible diagnoses
____ out of 2
• Investigation
____ out of 1
• Initial management (e.g. physiotherapy, caffeine)
____ out of 2
• Medical therapy and side effects
____ out of 2
Encounter 3  
• Order urodyamics
____ out of 1
• Explain urodynamics
____ out of 1
Encounter 4  
• Management
____out of 1
• Risks of surgery
____out of 2
    Global competence ____ out of 5 TOTAL SCORE ____ out of 20

Case 3

Information for candidate

Dear Doctor,

Thank you for seeing Mrs Green who is a 67-year-old woman with symptoms of vaginal prolapse.

Yours sincerely,

Dr Lane

(General Practitioner)

Encounter 1

‘I will play the role of the patient and you the gynaecologist. Please commence.’

Encounter 2

‘So Doctor, how can you help me and what are you going to do? I do not want to have an operation.’

Encounter 3

Mrs Green returns 2 weeks later. The pessary fell out after a week. During the first week, she had good relief of the prolapse symptoms and was voiding much better.

‘How can you help me doctor? What are my options now and can you tell me the risks?’

Information for examiner

Case summary

The candidate plays the role of the gynaecologist in the outpatient clinic. Mrs Green has been referred by her general practitioner with symptoms of vaginal prolapse and voiding dysfunction. Initial management is a mid-stream specimen of urine (MSU), check residual urine (ultrasound, in–out catheter or urodynamics), exclusion of a pelvic mass, pelvic floor rehabilitation and discussion about management, including vaginal pessary.

Mrs Green’s voiding difficulty improves temporarily with a pessary, but the pessary fell out and the candidate needs to discuss surgical options, including vault suspension. The candidate is to discuss management options and risks of surgical options.

Encounter 1

History

• worsening vaginal lump over the past 9 months
• needs to reduce the prolapse frequently
• needs to reduce the prolapse to overcome voiding difficulty, no need to reduce to defecate
• urinary frequency, problems initiating voiding, especially as the day progresses
• daytime frequency/voids = 10
• nocturia = 3
• not sexually active at present, husband unwell
• urinary tract infection 6 weeks ago, no recent test
• no constipation
• no per vaginal bleeding

Past history

• four vaginal deliveries
• left inguinal hernia
• tubal ligation
• hypertension controlled

Examination

• body mass index: 28
• blood pressure: 130/85
• atrophy, thickening and cornification of cervix and anterior vaginal wall
• palpable bladder
• no urinary incontinence with prolapse reduced
• prolapse Aa+2, Ba+3, Ap+1, Bp+2, C+5
• significant anterior vaginal wall prolapse, posterior vagina wall prolapse and cervical descent

Encounter 2

• explain that there is a significant prolapse and probable voiding dysfunction
• MSU
• options: pessary, surgery
• patient does not want surgery
• assess voiding function: ultrasound, in–out catheter or urodynamics
• topical oestrogen
• review

Expectations of candidate

• history and examination
• discuss management
• order MSU
• check residual
• organise follow-up

Encounter 3

Pessary has fallen out. Mrs Green was voiding much better with the pessary in situ. There was also reduction in her frequency and no urinary stress incontinence.

Expectations of candidate

• try a bigger or different pessary (e.g. shelf)
• surgery: counselling

• repair of anterior/posterior and vault suspension; possible uterine conservation
• may be performed vaginally or abdominally or combination
• voiding difficult may persist
• risks of surgery

— general surgical: anaesthetic, deep venous thrombosis (DVT), infection, bleeding
— injury to pelvic structures (e.g. bladder/urethra, rectum, ureter)
— dypspareunia
— occult urodynamics stress incontinence
— if sacrospinous colpopexy: buttock pain
— recurrence of prolapse

Scoring for case 3

Encounter Mark
Encounter 1  
• History: elicit voiding difficulty

____ out of 2

• Examination

____ out of 1

Encounter 2  
• Options: pessary and explain follow-up, risk
____ out of 2
• MSU
____ out of 1
• Check residual volume
____ out of 1
• Follow-up
____ out of 1
Encounter 3  
• Option 1: try bigger pessary or shelf pessary
____ out of 1
• Option 2: surgery
____ out of 1
• Types of surgery available
____ out of 2
• Risks of surgery include occult stress incontinence
____ out of 2
• Risk of ongoing voiding difficulty
____ out of 1
Global competence ____ out of 5 TOTAL SCORE ____ out of 20

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