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OG35.4-6 | Focused Gynaecological Case Approach — SDL Guide (Part 3)

Supervised Practice: Presenting and Discussing a Gynaecological Case

Mastery of the focused gynaecological case approach is only achieved through supervised clinical practice — not through reading or classroom instruction alone. The NMC competencies OG35.4, OG35.5, and OG35.6 are assessed at the 'should help' (SH) level, meaning you are expected to perform the full case approach under faculty supervision in the OPD and ward setting during your clinical posting.

The structured practice framework for each of the three case types works as follows. For suprapubic lump, identify a patient in the gynaecology OPD who consents to a student examination. Before the examination, write out the history template you will use and the examination findings you are looking for. After taking the history and performing the examination (with faculty present), present your findings in the standard format: 'This is a 38-year-old woman, para 2, who presents with a 12-month history of a lower abdominal lump associated with menorrhagia. On examination...' Construct a differential of three diagnoses in order of likelihood, and state the single investigation that would most rapidly discriminate between them. Your resident will provide structured feedback on the history, the examination technique, and the differential — note specifically whether your bimanual examination technique was adequate to determine uterine versus adnexal origin.

For vaginal discharge, the practice exercise is to perform a bedside diagnostic assessment using pH paper and wet-mount microscopy on a consenting patient with discharge, under faculty supervision. This is a technical skill and requires practice — the ability to prepare a wet mount from a vaginal swab, identify clue cells under the microscope, and distinguish trichomonads from WBCs is not learned from a description; it requires handling the microscope in the clinical setting. Once you can perform and interpret these bedside tests, your clinical decision-making for vaginal discharge becomes immediate rather than dependent on laboratory turnaround.

For genital ulcers, the practice exercise focuses on ulcer characterisation and differential construction from case vignettes and, where available, direct examination of a consenting patient. The key supervised skill here is the sexual history — taking a full, non-judgmental sexual history in a culturally sensitive way, including asking about the number of sexual partners, partner symptoms, and condom use, requires a communication skill taught in AETCOM sessions and applied specifically here. In your debriefing, ask your faculty: How should I phrase questions about sexual history to make them non-threatening? In what order should I ask these questions? The OPD setting is the optimal context for practising this skill before postgraduate practice.

Self-Assessment

The three scenarios below test your ability to apply the focused gynaecological case approach across all three presentation types covered in this module. Each scenario represents a clinical situation you are likely to encounter in your first year of postgraduate practice or your internship. For each, work through the full four-phase framework — history priorities, examination findings to elicit, differential diagnosis with supporting and refuting clinical evidence, and investigation plan — before comparing your reasoning with a faculty member or resident. The objective is not merely to state a diagnosis but to articulate a clinical reasoning pathway: what features point toward each diagnosis, and what single investigation would be most immediately decisive. This kind of verbal reasoning is assessed in long case OSCE and viva examinations at the final MBBS level, and it is the skill that distinguishes a clinically safe practitioner from one who guesses.

1. A 50-year-old post-menopausal woman presents with a 3-month history of right iliac fossa pain and a right-sided pelvic mass on examination. On bimanual, the mass is separate from the uterus, irregular, approximately 8 cm, and non-tender. CA-125 is 180 U/mL. Ultrasound shows a mixed solid-cystic mass with internal papillary projections and a small amount of free fluid in the pouch of Douglas. What is your differential diagnosis? What is the most important next step?

1. A 22-year-old woman presents with a 5-day history of purulent, frothy, yellow-green discharge with marked vulval soreness and dysuria. On speculum the discharge is frothy and pools in the posterior fornix. Vaginal pH is 5.8. Construct a diagnosis and management plan, including partner treatment.

1. A 28-year-old woman presents with two painful genital ulcers noticed 5 days ago. She has tender right inguinal lymphadenopathy. The ulcers have undermined edges and a necrotic base. VDRL is negative. What is your most likely diagnosis, what additional test would confirm it, and what is the treatment?