• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a foundation doctor working in obstetrics

Patient: 31 years old, 34 weeks pregnant presents with bleeding

Task:
– Take a focused history from the patient
– After 6 minutes you will be asked a series of questions by the examiner
– Answer any questions that the patient may have

Note to actor: Try to restrain yourself from volunteering too much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested. The aim of the exercise is to take a focused history; short answers are required.

You are a 31 year old female patient who is 34 weeks pregnant. This morning you were at work, you went to the toilet and you noticed some blood in the toilet bowl. If asked state about a large cup full. You put on a pad and it soaked straight through almost immediately, you were really worried about this so you called an ambulance and came into hospital.

You did not notice any pain at the time but have had a bit of mild cramping since being in hospital.

You have noticed the baby has been moving less over the past hour which is surprising because they have been really active in the last couple of weeks.

You have not experienced any nausea or vomiting, you have no fevers or rigors. You have no LUTS (lower urinary tract symptoms), you opened your bowels this morning without issues. You have not experienced any chest pain or shortness of breath.

Before this episode occurred you have not experienced any bleeding. Your 20 week scan was ‘normal’ although you are told your placenta was low down, you’re supposed to have a scan in two days time to see if its moved.

You have previously had one child, born at 37 weeks, birth weight 3kg, vaginal delivery, no problems during pregnancy. Now is 5 years old, healthy.

Past medical history
– Frequent urinary tract infections as a child

Social history
– You do not smoke
– No alcohol or recreational drugs

When the candidate has finished answering your questions you should ask what they think is going on. If they decline – ask them to please tell you what they think is going on as you are really scared.

If the candidate appears to have finished early remind them how long is left at the station and enquire if there is anything else they would like to ask, or whether they have finished. If they have finished, please remain silent and allow the candidate that time for reflection.

Category Question
Done
Excellent
Introduction Candidate appropriately introduced themselves with:
Full name
Role
Clarifies who they are talking to
Asks patient for preferred name


PC PV blood
Volume
Colour
Use of pads


PC Pain 1
Time of onset of pain
Location of pain


PC Pain 2
Severity
Radiation


AF Associated features 1
Vaginal bleeding & volume present
Fetal movements
Fever / rigors
Seizures


AF Associated features 2
Lower urinary tract symptoms
Change in bowel habit
Shortness of breath / chest pain


Pre-eclampsia symptoms
Headache
Visual disturbance
Epigastric pain
Oedema


Current obstetric history 1
Anomaly scan done and result
Pregnancy complications to date
Admissions to hospital during pregnancy


Current obstetric history 2
Fetal movements
Contractions


Previous obstetric history 1
Previous bleeding during pregnancy (APH / PPH)
Previous obstetric issues (pre-eclampsia, gestational diabetes)


Previous obstetric history 2
Gravida (number of previous pregnancies)
Para (number of children born)


Previous obstetric history 3
Miscarriages (stage, complications)
Terminations (stage, method)


For each child born establishes:
Delivery at what week
Birth weight
Mode of delivery
Any abnormalities


PMH Past Medical History
Past medical history appropriately explored
Specifically asks about hypertension / pre-eclampsia


DH Drug History
Drug history appropriately explored
Drug allergies


SH Social History
Alcohol
Smoking
Job
Living situation


ICEF ICEF
Explores ideas, concerns, expectations, feelings
Asks patient if they have any questions


Question Given your history what are your differentials?
Placenta praevia
Placental abruption
‘Bloody show’ / Labour
Other appropriate answer


Question What is your management plan?
IV access
Bloods = FBC / U&Es / Coagulation screen / Cross match / Group and save
CTG (Cardiotocography)
Ultrasound
Senior review



Score