• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: Foundation doctor in general practice.

Patient: 17 year old female patient has come to discuss contraception

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 17 year old patient, currently living at home with your mum and dad, you are in your last year of A-levels and you are planning to go to university in September. You have come to the doctors today as “I would like to start taking the pill”, your friends have started taking the pill and this has worked really well for them.

You have been in a relationship with a male partner (also 17) for the past year.

Your last period was 3 weeks ago. Your periods are regular every 4 weeks, you menstruate for 4 days. You do not experience any breakthrough bleeding in-between your periods.

You do not experience any pain during sex. You do not have any abnormal discharge.

You always use “protection” when you have sexual intercourse and only use condoms.

PMH – you are usually fit and well, you were previously treated a couple of years ago for an ear infection. No previous operations.

DH – no regular medication / OTC / herbal

SH – you do not smoke, you drink less than a glass of wine a week.

FH – no family history of VTE (DVT / PE ect.), cardiovascular disease or breast cancer

ICE
– Ideas – you think the pill is more effective than condoms.
– Concerns – that you do not want to become pregnant if you don’t start taking the pill
– Expectation – Prescription for the combined pill

If asked you have read about the different types of contraception on the internet and you are interested in taking the pill. You do not like needles and you are not interested in patches / implants / coils

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


Sexual history
Regular / casual partner
Gender - M / F
Type of intercourse - oral / vaginal / anal
Contraception - condoms / pill / prep


Sexual history 1
Previous STIs
HPV status / vaccination


Gynaecology history
Vaginal bleeding - menorrhagia / inter-menstral bleeding / post-coital / post menopausal
Vaginal discharge
Pain - dysmenorrhoea / dyspareunia / lower abdominal pain
Pregnancy - LMP / sexually active


Menstrual history
LMP (last menstrual period)
Menarche (age of first period)
Regularity of cycles & length (e.g 21 days regular)
Duration of periods (e.g 3-7 days)
Heaviness - clots / flooding


Obstetric history
Previously been pregnant


Contraindications to COCP specifically asked about:
Hypertension
Smoking
Obesity
Hypertension
Previous VTE / thrombophilia
Migraine with aura
Family history of breast cancer


PMH Past Medical History
Past medical history appropriately explored


DH Drug History
Drug history appropriately explored
Drug allergies


SH Social History
Alcohol
Smoking
Occupation
Living situation


FH Family history
Family history appropriately explored


ICEF ICEF
Explores ideas, concerns, expectations, feelings


Interpersonal score
Empathic and non judgemental approach
Comprehensible explanations which maintain rapport
Involving the patient in decision making


Question What are the contraindications of the combined pill
Blood pressure
BMI
Migraine with aura
PMH of VTE
Breastfeeding
Women aged 35 years or more and smoking 15 or more cigarettes daily
Family history of breast cancer
Other acceptable answer


Question How should the combined oral contraceptive pill be started and taken?
If the COC is started within the first 5 days of the cycle then there is no need for additional contraception
If it is started at any other point in the cycle then alternative contraception should be used (e.g. condoms) for the first 7 days
Should be taken at the same time everyday
Taken for 21 days then stopped for 7 days - similar uterine bleeding to menstruation
Advice that intercourse during the pill-free period is only safe if the next pack is started on time



Score