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MiniOSCE Obs/Gyne C Group 6th year Hope Group All the answers are suggested answers and are by no means at all confirmed by any authority relating to the faculty or Obs/Gyne Department. Q1. • A 23 year old female G2P1. P1 she had severe pre-eclampsia. Now she is 20 weeks and there is no fetal heart for last 4 weeks 1. Name 2 serious complications because of the delay of her diagnosis 2. What is the best treatment option 3. What is the investigation you order to determine the cause of this miscarriage 1. A. Disseminated intravascular coagulation (DIC) B. Infection (Septic abortion) 2. Medical termination by misoprostol (cytotec) 3. Coagulation profile and antiphospholipid antibodies? (i.e Lupus anticoagulant, beta-2-glycoprotein and anticardiolipin antibody) Q2. • 23 year old female G3P2 with history of 2 LSCS patient 33 weeks GA with central placenta previa presented complaining of mild vaginal bleeding. She is now stable, fetus is well and is receiving fluids 1. Mention 3 steps in her initial management 2. Mention two risks that you should counsel her about Answer 1A. CBC and cross-match 2 units of blood B. Dexamethasone (or betamethasone) administration C. Plan for caesarean section 2A. Risks of prematurity B. Possible risk of hysterectomy if bleeding is uncontrollable Other suggested answers: -Risks of uterine rupture if she goes into labor Q3. • A 30 year old female P2+0 presented complaining of chronic pelvic pain. An initial ultrasound assessment and pelvic exam is normal 1. Mention two other problems you would like to ask about in the history relating to her condition 2. Mention the best diagnostic investigation for this patient 3. Mention one complication for this investigation Answers: 1. A. Secondary dysmenorrhea B. Dyspareunia, vaginal discharge Other possible answers: details of her menstrual cycles, type of any contraception method used, if her 2 previous pregnancies were spontaneous or assisted … 2. Laparoscopy 3. Injury of surrounding organs during the procedure such as the ureters Q4. • A 65 year old female presented complaining of vaginal bleeding. Her US findings are seen below (Image of US with 15 mm thickened endometrium that was written on the pic) 1. Name the most serious cause for her condition 2. Name 2 investigations related to her condition (other than ultrasound) 3. Name the most common cause for her condition Answers: 1. Endometrial cancer 2. A. Hysteroscopic guided endometrial biopsy (or just endometrial biopsy) B. Pap smear 3. Atrophic changes (vaginitis or endometritis) Q5. 1. Name the active ingredient in this device 2. Name the 2 most common side effects after initial use you should tell the patient about ? 3. If the patient comes complaining of amenorrhea for 2 weeks, name 2 initial tests that you would order 1. Copper 2. A. Breakthrough bleeding B. ?? Suggestions were: Increased risk of PID, increased risk of ectopic pregnancy if device fails, menorrhagia 3. A. Pregnancy test (beta-hCG level) B. Ultrasound Q6. 30 year old patient G2P1, 32 weeks pregnant, sure date, presented complaining of a gush of fluid. Patient isn’t in labor. She was diagnosed with premature preterm rupture of membranes (PPROM) and was admitted. 1. Mention 2 indications for immediate delivery in this patient 2. Mention 2 medications that you will administer to her 1. A. Chorioamnionitis B. Fetal distress Others: cord prolapse, placental abruption … 2. A. Betamethasone/dexamethasone B. Antibiotics I think tocolytic is a wrong answer Q7. A 27 year old pregnant female at 39 weeks presents where routine ultrasound shows a fetus with a fetal weight greater than the 90th percentile and AFI is 32. Her dates are sure. 1. Mention the most common cause of her current condition 2. Mention the best investigation to confirm the diagnosis 3. Mention 2 intrapartum fetal complications of her condition 1. Gestational Diabetes Mellitus 2. Oral glucose tolerance test (OGTT) 3. A. Cord prolapse B. Shoulder dystocia and obstructed labor Q8. A 20 year old female presented complaining of oligomenorrhea, hirsutism and acne and has the following appearance on her ultrasound 1. Name the condition causing her symptoms 2. Mention 2 investigations that will confirm this condition’s diagnosis 3. Mention one long term gyneacological complication of this condition 4. Mention one long term non-gyneacological complication of this condition 1. Polycystic ovarian syndrome (PCOS) 2. A. LH and FSH levels (LH:FSH ratio >3:1 expected) B. Serum androgen levels (e.g. serum testosterone levels) 3. Endometrial cancer 4. Type II diabetes mellitus Alternative answer: Metabolic syndrome Q9. 1. Name the maneuvers in the images 2. Name 2 fetal complications of shoulder dystocia 1. A. McRoberts maneuver B. Rubin I (suprapubic pressure) C. All fours/Gaskin maneuver 2. A. Asphyxia B. Birth trauma (e.g. Erb-duchenne’s palsy) Q10. A 20 year old primigravid presented at term to the hospital in labor and her partogram is shown below (This isn’t identical to the partogram in the exam but is very similar) 1. Is the fetus engaged at admission? 2. Comment on the progress of labor 3. What is the most common cause of her condition 4. Mention one finding seen on vaginal exam related to your diagnosis 5. What is your management for her condition 1. No (descent of head was 4) 2. Prolonged active phase first stage of labor? versus arrest of the active phase first stage of labor? (Arrest is probably the answer) 3. CPD (cephalopelvic disproportion) 4. Fetus station above 0 and non-fully dilated cervix 5. Delivery by emergency C/S OSCE Hope Group C Obs/Gyne Station 1 • This is a 27 year old female P1 has been trying to conceive for 3 years now and is unable to do so. Her husband is healthy. She is in good health and her pelvic ultrasound is normal. a. Mention two further initial investigations that you will do Answer: Semen Analysis and assessment of tubal patency (using HSG or laparoscopy) b. Mention two advantages of laparoscopy over HSG Answer: 1. Therapeutic interventions can be carried out 2. More sensitive investigation c. Mention two pathologies that can be treated with laparoscopy Answer: 1. Adhesions by adhesolysis 2. Hydrosalpinx by salpingectomy Station 1 (Continued) d. Her is the male’s semen analysis Count: 0.5 ml Morphology: 50% Motility: 35% Volume: 3 ml What is your interpretation? Answer: Low sperm count, other values are normal e. What is the finding in the semen analysis called? Answer: Oligospermia f. What is your management for this couple Answer: In Vitro Fertilization (IVF) g. What are complications of IVF? Answer: Multiple gestations, OHSS (ovarian hyperstimulation syndrome) Station 2 • This is a 25 year old who had 12 weeks of amenorrhea presents complaining of vaginal bleeding and abdominal pain for few hours. On examination her uterus is 16 weeks in size and she reports frequent nausea and vomiting a. Mention two causes for her current presentation Answer: Molar pregnancy or multiple gestations b. Mention an investigation to confirm your diagnosis. What do you expect the result to be if the patient has a molar pregnancy Answer: beta-hCG. It would be very highly elevated if the patient has a complete mole c. Mention 3 steps in the management of the patient Answer: Suction evacuation followed by gentle sharp curettage, serial beta-hCG testing and contraception d. Mention the karyotype of the molar pregnancy in this patient Answer: Possibly 46 XX if complete mole. 96 XXY if partial mole *Other variants exist but answering those in my station granted me the required marks Station 3 • This is a 40 year old patient with G3P2, P2 by lower segment cesarean section who presented for elective cesarean at 38 weeks of GA. Counsel her about the complications of her operation -Mentioned a few intra-operative complications (Intraoperative bleeding, risk of nearby organ injury and risk of fetal injury, hypotension in cases of spinal anesthesia) -Mentioned a few post-operative complications (can be found in the lectures) -What would you do to prevent DVT in this patient? Answer: Early mobilization after surgery, administer LMWH* *This is low risk according to the Caprini score where recommendation is to go with mechanical prophylaxis rather than anticoagulating with LMWH.Uptodate. I am not sure what the answer the department wanted was. Station 4 • This is a 24 year old female, 38 weeks pregnant presented complaining of sudden gush of watery vaginal discharge with no abdominal pain. 1. Do an obstetric examination (findings included a transverse lie fetus which was very easy to spot) 2. What would you do now? Vaginal speculum examination to confirm ROM. If not confirmed go for HVS (high vaginal swab) 3. The patient has confirmed ROM,what would you monitor in this patient? -CTG for fetal wellbeing, maternal well being assessed through vital signs 4. A couple of other questions I can’t remember Q1 • This CTG for Female pt. presented with abdominal pain, 2cm dilation and ruptured membrane. 1) Give two abnormality in the CTG: 2) What’s the underlying pathology: 3) If the condition become worse what is the next step: 1) Late deceleration, poor variability, tachycardia 2) Uteroplacental insufficiency , also umbilical cord compression accepted ! 3) Immediate delivery … fully we can use instrument … not fully go for C/S Q2 • Lady with twins pregnancy presented with Hb.9g/dl. 1)What the most common type this condition: 2)What is the possible causes: 3)Two line of management: 1) Iron deficiency anemia 2) a-Increase the demand, b-poor nutrition, c- heamodilution 3) a- Oral iron supplementation b- Diet Q3 • According to the picture. 1)what’s the type of twins: 2)Two late pregnancy complication: 3)What’s the cause of the primary PPH: 1) Dichorionic Diamniotic twins 2) a- preterm labor b- PROM 3) Uterine atony Q4 • P2 deliver vaginally and after 10 days she presented with excessive vaginal bleeding. 1)what’s the Dx: 2)What’s the underlying cause: 3)How you confirm the Dx: 4)Two specific line of management rather than stabilization: 1) Secondary PPH 2) Retain product of conception 3) US 4) a- D/C b- antibiotics Q5 • This picture in 40 yo lady after doing hysterectomy for sever menorrhagia . 1)what’s the cause: 2)Two other investigation before doing hysterectomy: 3)Do we remove the ovary routinely in such case: 1) Fibroid 2) a- Endometrial biopsy b- pap smear 3) No need. Q6 • 35 years old female medically free complaining from amenorrhea for 2 years. 1)what’s the cause: 2)What’s the most serious complication of this condition: 3)How you will treat her condition: 1) Premature ovarian failure 2) Osteoporosis 3) a- HRT b- Ca and vitamin D Q7 • This was found during the laparoscopy investigating infertile female. 1)what’s the most likely Dx.: 2)Other investigation that can be done during this: 3)One symptom the pt. may come complains of: 4)Two medical management: 1) Endometriosis 2) Methyline blue dye test for tubal patency 3) Secondary dysmenorrhea and any thing … 4) a- continuous combined OCP b- GnRH analoge Q8 • Female pt. complains of white thick vaginal discharge, itching and erethema with this result of the wet mount test. 1)what’s the cause: 2)How to confirm it: 3)How to treat: 4)Two risk factor: 1) Candida albican 2) Culture 3) Local antifungal 4) a- DM b steroid use …. Q9 • Young pt. presented with vaginal bleeding at 7 week amenorrhea with BhCG =1400 and by trans vaginal US the uterus is empty. 1) what’s your DDx.: After 3 days she still stable with BhCG of 2100 and empty uterus. 2) How to treat: 1) a- early pregnancy b- ectopic pregnancy 2) Methotrexat or surgery Q10 • Rh –ve lady married to Rh +ve male come at 14 weeks gestation with vagianal bleeding that has bees stopped. 1)Two specific thing in the management: 2)Fetal complication in the next pregnancy if not treated well now: 1) a- Anti D b- Indirect coombs test 2) a- fetal hydrobs b- fetal anemia c- IUFD مالحظه: مش هذا هو النص الحرفي بس هذا هو المضمون !!! OSCEبالنسبه السئلة ال station #3يعني االسئله ما كانت هالقد واضحه ومفهومه وخاصه Station #1 • 45 years old female, p5, completed her family doing pap-smear for her abnormal vaginal bleeding 3 weeks ago and comes now to the clinic with this report … Conventional pap-smear Adequate HSIL “high grade sequamous intraepithelial lesion” * Then the doctor start to ask the following questions … 1) What do we mean by adequacy? The smear contain two type of cell (sequamous and columnar). 2) Other type for pap-smear? Liquid based pap-smear 3) What’s the cause for this lesion? HPV (16-18) 4) What’s the next step in this patient? Immediate colposcopy+biopsy with or without ECC. 5) On colposcopy we see mosacim and punctuation what stage of disease this? CIN III and more. 6) How we prevent this condition? By HPV vaccine (bivalent and quadrevalent) given at age 12-29 years 3 doses IM injection. 7) How to manage? By excision or total abdominal hysterectomy since she complete her family. Station #2 • 35 primigravida come to the ANC at GA 12 weeks with BP of 151/95 with nothing remarkable. 1) what’s your Dx.? Chronic HTN 2) What to do other than the routine investigation? Order internal consultation (my doctor just want me to say this) 3) At 32 GA BP=150/90 and protein +1 what’s your Dx.? Chronic HTN superimposed with PET. 4) What to do? Stabilize the pt, give steroid, PET profile, 24 hrs urine collection. 5) How to treat this pt during pregnancy? Methyl dopa 6) At 36 weeks GA BP=150/95 ,with symptom what’s your Dx? Sever PET 7) What to do? Stabilization, anti HTN, MgSo4 prophylaxis, immediate delivery. Station #3 • P1 lactating come to your clinic asking for mini pillis … 1) Tell the pt how to use: given every 28 days without free period 2) Side effect: vaginal spotting, functional ovarian cyst, acne, hirsutism, breast tenderness. 3) Tell the pt about pregnancy after stopping the pillis: she can get pregnant immediately after stopping the pillis without having period of amenorrhea. 4) What do we afraid of if she get pregnant while she is using the pillis: ectopic pregnancy 5) Tell the pt about missing pillis: same as missing compined pillis BUT with 3 hrs instead of 12 hrs 6) Failure rate: 2-3% Station #4 • Examination station … as usual 1) what’s your comment after the examination? Singleton Breech Longitudinal Back to the left Not engaged 2) When we do ECV? At term >37 weeks 3) what’s the complication of ECV? Preterm labor, PROM, cord compression, failure. 4) If Fetal distress on CTG what to do? Emergent C/S