Structured Clinical Examinations (OSCEs) in gynaecology

Published on 09/03/2015 by admin

Filed under Obstetrics & Gynecology

Last modified 09/03/2015

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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
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