Basic Clinical Skills / OSCE Flashcards
Steps for management of a patient with a broken implant
OSCE
Introduction, confirm patient name + DOB
Set agenda - confirm purpose
History - how long broken
How it became broken
Any symptoms - neuro etc
How long has it been in - ?expired / in date
Patient concerns
Patient ideas / wishes re what do to
Offer to examine
Reassure re efficacy
Options - leave if in date or remove and replace / alternative cont
If removed ensure all is out - 4cm by 2mm
Report to MSD / yellow card
Answer pt qs
Special considerations for contraception for <16yo
OSCE
Confidentiality and limitations
Fraser guidelines
Consent CSE / grooming / presents for sex Safeguarding and vulnerability factors Any concerns / fear / pressure Where they met, where they have sex, do family / friends like partner Age of partner Encourage to talk to parent etc
Any symptoms / pain
Menstrual history / preg risk / EC
Safe sex / STI screen
Management of a 45 yr old
BRCA2 +Ve
Bilateral mastectomy + Hysterectomy with BSO 4 yr ago
Coronary Artery disease confirmed on CT angio
Hypothyroidism
Currently on elleste solo 1mg OD for 4 years but GP is concerned and asks if she should be taken off this?
Not stop HRT due to young age at BSO therefore needs HRT until at least 51 for CVD reduction and bone protection.
Could switch to a transdermal preparation - 25mcg patch equivalent to 1mg PO
Transdermal carries less VTE and stroke risk
However VTE risk greatest in initial 12m of use therefore continuing PO likely more benefit than harm
Currently on quite low dose - confirm symptom control and if not adequate consider increasing dose
Managment of a 53 year old
Previously on continuous combined HRT 2mg dose
Had NSTEMI age 53 and HRT stopped by cardiologist
Menopause symptoms have returned and affecting QOL/ ADLs/ mood
Current smoker with IGTT and controlled hypertension
GP requesting oppinion re HRT
As she has stopped HRT there is a risk with re-starting it as this may de-stabilise the atherosclerotic plaque and could cause further cardiac events - risk also dependent on amount of time off HRT
Remaining off HRT will also increase CVD risk due to estrogen deficiency.
Needs referal to a specialist menopasue clinic to consider transdermal HRT
Would have been preferable to continue HRT and consider switching to transdermal and reducing dose
Management of a patient with a subtotal hysterectomy requesting HRT
Some endometrial tissue may remain in the cervical stump, Therefore needs continuous combined HRT.
If histology showed a lower resection margin which did not contain endometrium could use estrogen only.
Could do a progesterone withdrawal test and see if any bleeding occurs and if not consider estrogen only
Management of a 68 year old
Had menopause at age 40
Used HRT for a few years but then stopped due to SE mastalgia
Now aged 68 developed symptoms including hot flushes / night sweats and palpitations.
Hx of osteoporosis on raloxifene
POI ideally should have had HRT until age 51
Now off HRT for a long time and >60yo
NOT to re-start HRT as this would increase the CV risk.
Menopausal symptoms would not have been expected to develop at 68 when menopause was age 40
Consider raloxifene as cause of sweats and flushes as this is a known side effect.
Ask rheumatology to consider switch to bisphosphonate
Management of a patient on PO HRT who has a stroke but wishes to continue HRT for symptoms
Switch to transdermal HRT
Use lowest dose to control symptoms
Start with 25mcg patch for 6 weeks and increase to 50mcg if not controlling symptoms
If 50mcg patch not controlling symtoms by 6/52 request serum estradiol to see if adequate absorption - average F should get 250pmols/L from a 50 patch
Establish which symptoms are troublesome and consider vaginal estrogens if appropriate
Management of a peri-menopausal woman using sequential HRT who complains her migraines are worse with HRT but requires it for VM symptoms
If Migraine without aura and no other risk factors consider combined contraception until age 50 - used continuously
Switch to continuous combined as this avoids fluctuations in estrogen/progesterone and is less provocative of migraines
Consider alternative to HRT - tibolone
Management of a 54 year old perimenopausal woman with erratic bleeding and VM symptoms
Paternal history of breast cancer
Paternal and brother history of VTE
Genetics referral
Refer for increased breast surveillance
Genetic pre-disposition is not a complete CI to HRT
History of VTE in the family is not a CI to HRT
Consider transdermal HRT to avoid the increased risk fo VTE / Stroke
But combined HRT would increase the breast cancer risk - but does not appear to increase mortality risk
Managment of a 42 year old patient with a history of squamous cervical cancer treated with chemo-radiotherapy and brachytherapy
Since this treatment she has been amenorrhoeic and experiences flushes.
Wishes to start HRT
Limited evidence regarding HRT use with a history of cervical cancer
Squamous cervical cancer is not usually hormonally responsive
Due to her age she has increased long term risks of cardiovascular disease and ostroporosis and therefore this warrants HRT to age 50
Use of continuous combined would mean continuation of amenorrhoea and therefore may help to detect any recurrence if bleeding occurred with this (but it may not)
Management of a 37 year old lady with trisomy 21
LMP 5months ago
increased irritability reported by her carers
A single FSH level is 52
Advise re management
T21 patients often experience POI
Life expectancy is often much beyond the age they experience menopause and therefore long term health needs to be considered
POI should be diagnosed on 2 serum blood tests at least 4-6 weeks apart. - Could consider repeating this to confirm menopausal status.
HRT should be advised until at least age 51 to protect bones and prevent cardiovascular risk
Continuous combined would continue amenorrhoea and may be less distressing for the patient and easier to manage
Consider any other risks - mobility, weight, pre-existing CVD etc
Transdermal is likely less risky
history taking for new patient in menopause clinic
OSCE
PC, Hx PC - duration, serverity, worsening, associations
Associated symptoms
LMP, cycle duration and regularity, blood loss + duration
Obs hx - G and P, problems
Cervical smear, Mammogram
contraception
Gynae hx, problems, treatment, surgery
Urinary hx - UTIs, dysuria, frequency, urgency, leakage
Vaginal dryness, dysparunia, STI risk
PMhx, meds, allergies, OTC / supplements
Hx of HRT or alternatives
Family hx - early menopause, CVD/stroke, osteoporosis, cancer
Social hx - employment, stress, exercise, smoking, alcohol, relationship impact
Steps for management of a patient with irregular bleeding with an implant
(OSCE)
History - implant duration, prev bleeding pattern
STI risk + screening
exclude pregnancy
smear hx
Any other symptoms / concerns
Offer COCP for 3m (or if CI offer POP) - outside licence
Suggest NSAID - Mefenamic acid 500mg TDS or ibuprofen Max 800mg TDS
Review in 3m
if no improvement and SDI 2yrs+ consider changing SDI early / alternative method
If 45+ ref to exclude endometrial pathology
Steps for management of a patient with irregular bleeding with the contraceptive injection
(OSCE)
History - implant duration, prev bleeding pattern
STI risk + screening
exclude pregnancy
smear hx
Any other symptoms / concerns
Offer COCP for 3m (or if CI offer POP) - outside licence
Offer next injection early at 10wks - outside licence
If bleeding continues after 2-3 inj change method
If 45yrs+ exclude endometrial pathology
What should be done in an initial CHC consultation
OSCE
Prev contraception use ICE Assessment of medical eligibility ► Pmhx ► Medications ► Lifestyle factors - smoking, shift work, menstrual cycle preference ► BP ► BMI Contraceptive options - UKMEC Offer LARC Pt choice - COC / CTP / CVR Offer ≤30 μg EE COC with LNG or NET first line Discuss: MOA, how to take, effectiveness, non-contraceptive benefits, Health risks, Side effects Explain standard and tailored regimens Missed pill rules Offer EHC and explain re Em-IUD explain superior efficacy of LARC Written info
