Late lower abdominal pain during pregnancy


  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a foundation doctor working in obstetrics

Patient: 28 years old, 36 weeks pregnant presents with lower abdominal pain

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 28 year old female patient who is 36 weeks pregnant.

You are worried because you have had sudden onset severe “tummy pain.” The pain is a 10/10 and is there all the time but has episodes when it is much more severe.

If asked the pain is in the lower part of the “tummy” and does spread to the back. When you went to the toilet you noticed a small amount of dark red blood and that’s when you decided to come to hospital as you were really worried about what could be going on. You have noticed the baby has been moving less and 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. If asked at the time you were told your placenta was lower down but were told that this can move as the weeks go on.

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
– ACL (anterior cruciate ligament) repair

Social history
– You have been smoking during pregnancy but have cut down a lot, you used to smoke 20 / day but now you only smoke one or two.
– 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 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
Gravida (number of previous pregnancies)
Para (number of children born)


Previous obstetric history 2
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?
‘Bloody show’ / Labour
Placental abruption
Placenta praevia
Sensible non-obstetric cause = appendicitis / AAA / ect.
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