1

2
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Contraception
5-Mirena counselling

you are at your GP when a 30 year old jane come to you requesting mirena. She had 2
previous pregnancies. She was on OCP before but now she would like to be put on
mirena.
Tasks
further history
counsel the patient
History
1-can you tell me why you want to be put on mirena? (bothered about the pill)- nausea,
bloating, breakthrough bleeding
2-5Ps questions
periods
-when was your LMP? Are they regular?
-how many days of bleeding and how many days apart?
-any pain or heavy bleeding during menstruation?
-any bleeding or pain in between the periods? (Intermenstrual bleeding imp)
Partner or sexual
-are you in a stable relationship?
-have you or your partner ever been diagnosed with STI
- if no stable partner----history of multiple partners and safe sex?
Pregnancy
-how many pregnancies have you had?
-any previous miscarriages? Have you ever had an ectopic pregnancy?
Pill
-how long have you been using the pills?
-are you still taking them?
-what type do you use?
-Have you had any side effects?
Cervical screening
3-contraindications questions (LCP: liver, cancer, PID)
-have you had a history of active liver disease?
4

-any history of cancer breast or uterine?

-any abnormal vaginal bleeding,discharge, fever, tummy or back pain?
4-General questions
-Past medical and surgical history?
-medications and allergy?
Counselling
1-action and contents
-show the specimen
-mirena is a temporary method of contraception and I think you are a good candidate for
mirena as you do not have any contraindication like genital cancer or breast cancer,
genital infection, liver disease and also you are in a stable relationship.
-but because you are sexually active it is always better to do a urine pregnancy test before
we put Mirena in.(Critical error if done <4weeks of LMP)
-mirena contains female hormone called progesterone.
-This prevents pregnancy by:
*thickening the cervical mucosa so that the sperms find it difficult to get through.
*Also it changes the lining of the womb make it thin a unfavorable for implantation.
*And because it is within the uterus so act as a barrier and inhibits normal sperm moving
inside the uterus or the tubes
2-Adminstration.
-it is a small T shaped device made of soft plastic and has a cylinder containing hormones
and to its base is attached to fine threads.
-Usually fitted by trained doctors so after a gynecological examination, a speculum will
be put in the vagina to see the neck of the womb or cervix which is then cleaned with
antiseptic solution. -Mirena is then fitted into uterus using a thin flexible application
passed through cervix.
-once it is in its place the applicator is removed and the thread at its base will hang down
into the vagina, which is then cut short. Not interfere with intercourse.
-it can cause a bit discomfort during insertion but there is no excessive pain.
-it is better to be fitted during your period or within 7 days of getting period because it
provides immediate protection against pregnancy if fitted within the first 7 days.
-otherwise, you have to wait for intercourse up to 24 hours to minimize the risk of
conception.
-it provides contraception for up to 5 years.
3-Side effects
-it can affect your periods even though initially there could be an increase in the number
of days of bleeding but eventually you will have reduction in number of days and
sometimes will stop all together.
-could be spotting in between periods for about 3-6 months
-irregular periods sometimes
5

-cramping pain in lower part of the tummy or back usually settle in a few weeks.
-headache, genital discharge as hormonal effect
-can get extruded out of the body or go somewhere else and cause perforation but these
are very rare to happen.
4-advantages
-high efficacy (99%), also does not interact with oral medications
-forget about pregnancy for the next 5 years system.
-bring down heavy periods, certain ca
5-disadvantage
-does not protect against STI
- Can cause breakthrough bleed, amenorrhea, irregular periods
- Slight increase risk of EP

6-follow up
-I will teach you self-palpation of the strings and it is better to get checked once a month
after each period.
-follow up every 4-12 weeks then annual follow up
7.Explain Other options
- Implanon
- Depoprovera
6

Feedback (5/10/2017) Pass

Contraception request
37 yrs old lady comes to your GP to discuss about Mirena as she was told by her friend
that it is good. She is allergic to sulphur.
Task:
Relevant focused history
Explain her about Mirena
Answer her questions
Introduced myself and assure confidentiality.
Asked how was she doing and acknowledged her concern.
And ask permission to ask history before explaining about Mirena.
1- Asked about contraindications for Mirena ( DVT, undiagnosed vaginal bleeding,
breast CA, Stroke, migraine, PID, ectopic pregnancy ). she asked me what is ectopic and i
explained to her
2- 5 P ( Pregnancy, pill, period, partner, pap smear).
*She has 3 children and happy family and good support from partner.
*Used COC (can't remember the duration she used, but no complications of COC) but
stopped 6 months ago and only using condom sometimes.
*Normal period, LMP was 2 or 3 wks ago
* pap smear was normal last time..
3- She has no symptoms of UTI. No fever, bleeding per vagina, no abd pain at the
moment.
4-She heard Mirena from her friend and she wants to know about it.
- Explained her about what is Mirena, content, mode of action and how long it lasts.
7

- Then i told her i will arrange pregnancy test and then refer her to specialist.
- I explained her the procedure ( measure the depth of uterus with probe, about the string)

- ( reassured her that it wont interfere her sexual activity).

- And then the side effect of Mirena (breakthrough bleeding, dysmenorrhea and reassured
her that they can b manageable and mostly goes away within few weeks.
I kept on asking her what more she wants to know and she kept on asking me what more
she should know.
I told her about the red flags of Mirena and then told her i will review her after she is seen
by specialist.
Covered 3 key steps out of 5
Approach 4 History 4 Choice and technique of exam 3 Patient Counseling 5 Global
score 4

Dysmenorrhea

10-Endometriosis
Your next patient at your GP is 28-year-old Samantha, complaining of severe abdominal
pain during menstruation since the last 6 months.
TASKS
- Focused and relevant history
- Examination findings from examiner
- Diagnosis
- Relevant investigations and management

Differential Diagnosis of Secondary Dysmenorrhea: (PEF) older women with no history

of dysmenorrhea until proven otherwise. Symptoms include menorrhagia, intermenstrual
bleeding, dyspareunia, postcoital bleeding, and infertility.
8

1-Endometriosis
2-Fibroids
3-Pelvic Inflammatory Disease
4-Intrauterine Contraceptive Device
APPROACH
History
1-Pain questions
if in pain now
-Hi Samantha, I'm Dr. ---- your GP for today. I can see from the notes that you've been
having abdominal pains during your periods.
Do you have your period now? are you currently in pain?
-it must be very distressing for you. Let me assure that I’m her to help you. I just want to
ask you a few questions in order to reveal the nature of the problem.
Onset and Duration
- How long have you been experiencing this pain? (I've been having this pain during my
periods for the last 6 months)
-When does the pain start in relation to the periods? (It usually start 2 days before I get
my period, then it gets worse as my period starts)
-does the pain get relieved when the period flow started? (No)
-is there any pain in between the periods? (key issue)
Site and radiation
-Can you point exactly where you feel the pain? (It's around here in my lower tummy,
and it's a sort of a crampy pain )
-Does the pain go anywhere else? (Sometimes it goes right through my back.)
Character and severity (because she is not in pain now you can ask severity later)
-Can you describe it for me (sharp, throbbing pain)
-How severe was the pain from 1-10, 1 is the least 10 is the most? (It's around 8-9 on bad
days doctor)
Relieving and aggravating
- did you take anything to relieve the pain?

2-5P’s questions
Period history
-When was your last menstrual period? Around 3 weeks ago
-are they regular? Yes.
-How many days of bleeding and how many days apart?
- do you have heavy bleeding during menstruation? (fibroid)
-any pain in between the periods? (if you forget to ask this before)
Partner or Sexual history
-Are you currently sexually active?
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-are you in a stable relationship? Yes, I have a boyfriend of 4 years.

-Do you experience pain during coitus? (dyspareunia for endometriosis) Yes oh my god
doctor, it hurts so bad during coitus
-have you or your partner ever been diagnosed with STI? (PID)
Pregnancy
- Any previous pregnancies or miscarriages in the past? None (infertility)
Pill
Do you use any contraception? (to rule out IUCD) Yes, I'm currently on the pill.
Pap
is your pap or HPV up to date? (It was just last year, everything's normal.)
3-Differential diagnosis questions (PEF)
PID
Any fever?
Any abnormal or offensive vaginal discharge?
Endometriosis
-Any pain during opening of bowels? Yes
-any pain on passing urine? Yes
Fibroids
-Do you feel any mass in your tummy? (fibroids) No.
Okay, thank you for those information Samantha, I'd just would speak to my examiner
for a while, I'd get back to your shortly.
4-General
Past medical or surgical history
SAD

Physical Exam finding from examiner

1-General appearance
there pallor, lymph node enlargement? BMI?
2-Vital signs (especially BP and Temp)
3-quick CVS and respiratory examination
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4-focus on abdomen
inspection any visible distension, mass?
Palpation any mass (fibroid) any tenderness in the iliac fossae (PID)
5-Pelvic examination (consent and chaperone)
inspection
are there any abnormal/offensive discharge or bleeding from the vulva and vagina?
Vesicles or rash?
Speculum exam
any discharge or bleeding from the cervix?
Per vaginal exam,
is there cervical motion tenderness?
What is the position and mobility of the uterus? Any tenderness?
Any mass or tenderness in the adnexa?
Findings in those with secondary dysmenorrhea

Endometriosis- fixed uterus or reduced uterine mobility, adnexal masses, and uterosacral
nodularity.

Frequently symptomless, the main reasons for investigation being menstrual

irregularities, premenstrual ‘dysmenorrhoea’ pain, noncyclical pelvic pain, dyspareunia
and infertility

PID - mucopurulent cervical discharge. CMT + , uterine tenderness, adnexal tenderness

Adenomyosis - uterine enlargement or asymmetry.  menorrhagia

6- Per rectal exam

any nodularity or tenderness in the pouch of Douglas and in the uterosacral ligament?
7-Office tests
I would like to do urine dipstick test and blood sugar level
Okay thank you for the information examiner, I would like to speak to my patient.
Diagnosis and Management
-Okay Samantha, based on your history, physical exam and office tests, your most likely
diagnosis is endometriosis. Do you know anything about this?
11

-Endometrium is the normal inner lining of the womb. During each period and under
hormonal influences, this endometrium is shed and it comes out with the bleed through
the vagina. When this endometrium is present in sites or places outside the uterus like in
the pouches or the ligaments surrounding the uterus or the ovaries this is called
endometriosis.
-So during each period the endometrium at these sites also starts bleeding but there is no
outlet for the blood so the blood clots, form adhesions and scars causing pain during
periods and in between the periods.
-The exact cause is unclear, but one theory is the backward flow of blood through the
tubes or retrograde menstruation. Another theory is it can also spread through blood and
lymphatics.
-If untreated, it can lead to complications such as dysmenorrhea or severe pain during
pain , menorrhagia or heavy bleeding, and infertility.
Investigations (IMP)
- I would order blood exams for you such as a FBC, UEC, LFT, BSL, blood group.
- imaging tests such as pelvic Ultrasound and transvaginal ultrasound.
- Laparoscopy (key issue) refer you to specialist, where a flexible tube with a camera is
passed into your tummy to look for endometrium deposits. This is the investigation of
choice and the benefit is that it is therapeutic as well.

Management
-I would give you painkillers that you could use at the time of your periods, and refer
you to an OB-G specialist. (Key issue)
There are two types of treatment, medical and surgical treatment.
For medical treatment:
-you could take a combined oral contraceptive pill continuously for 6 months,
skipping sugar pills. You will not have your periods and the deposits will not bleed as
well and start shrinking.
-Another option will be progestogens like Depo-provera or minipill and Mirena. Can
cause endometrial regression and can act as a method of contraception as well
-GnRH analogues can also be given which would induce a medical menopause. However
it should not be used for more than 6 months because you might develop severe
menopausal symptoms like hot flushes, bone pain and osteoporosis.
-lastly Danazol can be given which would also induce a medical menopause, but should
not be used for more than 6 months because it could cause you to develop male
characteristics like voice changes, hair growth because it is an androgen.
12

If medical management fails or if you present with infertility or severe symptoms, our
next option would be surgical management via laparoscopic excision which is cutting
away or burning away of endometrial deposits using laser or electrocautery.
I will give you reading materials and arrange for a review with you once your blood test
results are in.
Do you have any questions at this point?

Feedback 28-11-2017 Menstrual Dysfunction - Pass

Lady having pain during periods.
Task:
-Take history.
-Ask PEFE .
-Explain diagnosis to patient and arrange investigations.
( s/s for 12 months. Pain started before the period and stays the whole time and goes
away after the period. Dyschezia, Dysperunia present. No Dysuria, no abdo pain or
mass)
Examination – Left adnexal tenderness./this finding was not given to some
candidate. )
Key steps: ¾
Approach to pt: 4
History: 4
Choice of examination, organization and sequence: 6
Dx and DDx: 5
Management plan: 4
Global score: 5
History:
Is it first time?
PAIN: SORTSARA:
d/d endometrosis: pain during passing stool, passing urine and during intercourse.,
previous pregnancies (infertility)
D/d Fibroid: Normal period question(increase bleeding)? lump in tummy?
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D/D: PID: Previous history of PID? Fever? Vaginal discharge? Rash? Lower tummy
pain.
D/d IUCD: Any methods of contraception (pill/iucd)
Previous surgery? (adhesions)
Pap smear?
HOW IS THE PAIN AFFECTINGYOUR LIFE? SADMA? FHx? Past mhx?
(If you ask 5Ps all the dds will be covered)
Exm:
GA: PICKLED (asked whichever relevant- Pallor, Dehydration)
Vitals: Pulse, BP with postural drop
Adbomen: Inspection/palpation: marks, distention, tenderness
Pelvic examination: Inspection, Speculum examination, bimannual examination: Left
adnexal tenderness./this finding was not given to some candidate.
Complete the exam with other system
Explain the diagnosis:
Most likely a condition called endometriosis which is a painful condition in which the
tissues that line the inner lining of the womb is deposited at sites other than the womb
(draw picture). Can also be because of other conditions like any inflammation of womb
or associated organs (PID), any device in the uterus (iucd), any mass/lump in womb
(fibroid), previous procedures or operations done.
(while mentioning the differential diagnosis explain why it can be and why it cannot be
for the particular patient)
Arrange investigations:
- Basic blood tests, USG(scanning), specialist will do futher investigations like looking
inside the womb through a camera which we call laparoscopy.
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Feedback 8-11-2018
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13-PPROM

25 year old Mary, who is 32 weeks pregnant, presents to you at your GP clinic with
complaints of passing fluid from vagina since the past 1 hour.
TASKS
-Relevant history
-Examination findings from examiner
-Management
Differential diagnosis
1-PROM
2-Urinary incontinence
3-abnormal vaginal discharge
APPROACH
History
1-Fluid questions (duration-action-trauma-amount or severity-colour-odour)
-how long have you been passing fluid?
-what were you doing the time you passed fluid?
-did you hurt yourself or have any trauma to your tummy?
-How many pads have you used? are they fully soaked?
-What is the color of the fluid? Is it like greenish or is it just like water? Is it blood
stained? (Key issue)
- Is it smelly?
2-Late pregnancy complications questions
-Any pain in your tummy (preterm labour) (Key issue)
- Any fever , nausea and vomiting or abnormal vaginal discharge before this happened?
(Infection) (Key issue)
- How’s your urine? Any leakage of urine, burning or stinging during urination (urine
problems)
-how’s your bowels habit? (Bowels problems)
- Any bleeding from your vagina? (Placenta Previa, abruption etc..)
-any headaches, bluring of vision or leg swelling? (Preeclampsia)
-do you feel your baby kicking well or not? (Baby problem)

3-Regular Antenatal visit questions

-Have you had regular antenatal visits? When was the last one?
-have you done Down syndrome screening in the first trimester?
-have you done ultrasound at 18-20 weeks ? Repeat US at 32 weeks?
-have you had sugar test at 28 weeks? Was it normal?
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-are you aware of your Blood group? (Key issue)

-did you take Folic acid in the first 3 months of pregnancy?

4-General questions (Imp but If I had no more time I would leave them)
-Smoking, alcohol, recreational drugs, medications, allergy
-Past medical and surgical history
-Support from partner

Physical Exam from Examiner:

1-General appearance (PODL)
Pallor, Oedema, dehydration, LAP
2-Vital signs (especially temperature and blood pressure).
3-quick chest and heart examination
4-focusing on abdominal examination: (key issue)
- Any Tenderness on plapation?
- Any uterine contractions per abdomen?
- Fundal height? (32 weeks)
- FHR?
- Fetal Lie? Presentation? (Longitudinal, cephalic)
5-Pelvic exam:
Consent
Inspection of the vulva and vagina:
-Any fluid leaking out of the vagina? (yes)
-Trickling of the fluid or gush of fluid that I can see?
-Color of the fluid? Smelly or not?
-Any other abnormal bleed or discharge that you can see?
-Any rash or vesicles?
Sterile speculum exam
-any fluid leakage from the cervix? (if there is discharge from cervix, it invariably tells
you that it is coming from the uterus)
-Is the OS open or closed? (Key issue) closed
-Can you see fluid collecting in the posterior fornix? (If yes, it is amniotic fluid) (Key
issue) Yes, you can see fluid in the posterior fornix
**I'd like to take
1-a sample of this fluid and send it for nitrazine test (to confirm if amniotic fluid)
2- vaginal swab and a cervical swab and give it for microscopic culture and sensitivity.
3- Low vaginal swab and an anorectal swab for GBS.
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Do not do a pervaginal exam.

6-Office tests:
I'd like to do a UDT and BSL.

Explanation
-From history and examination you most likely have a condition called premature rupture
of membrane.
Normally when labor sets in, around 40 weeks, it is labour pain that happens first and it is
then followed by the rupture of the membrane or bag of water. But if the membrane
rupture, before the onset of labour pain, it is called premature rupture of membranes or
PROM, and if PROM happens before 37 weeks, it is called PPROM or preterm
premature rupture of membranes.
-There could be several causes of PROM. But anything that overdistends the uterus
can lead to PROM like: (you don’t have to list all the causes) and sometime the cause is
unknown.
1-polyhydramnios (excessive fluid in the bag of water).
2-multiple pregnancy (twins).
3-cervical incompetence.
4-maternal infections.
5-gestational diabetes causing big baby
-preeclampsia (sudden sever rise of BP during pregnancy)
-One of the complications that happens in PROM is infection. WE need to be careful
about this.
Management
1-GP role
-You need to be referred to a tertiary hospital with a neonatal intensive care unit.
(Critical error) I'll arrange for an ambulance and call the hospital and liaise with the ED.
-I need to start you on an IV line with slow IV drip, and take blood for certain
investigations like FBE, ESR, CRP, UEC, Blood group, blood sugar level, coagulation
profile. I will also send urine for microscopic culture and sensitivity.
-I will give you your 1st dose of steroid, to bring about the lung maturity of the baby
just in case you progress into labor. (Key)
-I will also give you your first dose of antibiotic, erythromycin, and you need to be
continued on it for 10 days. (Key)
2-Hospital role
-Once you reach the hospital, you will be:
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Admitted, seen by the specialist, who will do an ultrasound and CTG.

If Severe leakage (Do not say mild or severe just talk in general)
-need frequent monitoring, further steroid dose and continued antibiotic use.
-Just in case the labour doesn’t start the labour might need to be induced at 34 weeks
gestation
-If she has any signs of infection like fever, blood counts going high, or baby becomes
unwell, delivery will be planned immediately either by induction or C-section.
-Do you have support? Anybody to phone in to be with you?
-I'll arrange a review with you once you are out of the hospital.
Notes (NOT THAT IMPORTANT)
**If mild
-advise bed rest till leakage stop and once stop and if CTG and US normal then she can
be discharged home and also if swab showed no infection.
-Rest of pregnancy should be managed in high risk pregnancy clinic
-warning signs (running a fever, tummy pain, further leakage, baby not kicking well she
should inform immediately the ED.
-more frequent ANC and scan
**Cervical suture
36 weeks pregnant, cervical suture in place, presenting with PROM.
*usually remove cervical suture at 37-38 weeks
But in this case, in the GP do all bloods and swabs, don't give antibiotics. In the hospital
consider removal of cervical suture (risk for uterine rupture if cervix remains tight), and
sent for microscopic culture and sensitivity. If labor does not set in, induce labor by 34
week if no infection. Once the suture is taken out and sent for microscopic C&S, give her
antibiotics.

Feedback 21-7-2018
Preterm PROM - PASS (G.S – 5)
Stem: 30yr old lady, 30wk primi, in rural hospital 200km from tertiary centre. Presenting
with vaginal fluid loss
Tasks: -History
-PEFE
-DDx
-Mx
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-Primi with spontaneous vaginal fluid loss since the past hour or so, had a significant
loss, ongoing, appreciating fetal movement, no fever, not in labour. ANCs all ok,
singleton pregnancy, no fibroids etc.
- Asked all PE findings in a proper sequence, including vulval inspection, speculum exam
(os closed, clear fluid noted to be coming from cervix) Specifically said I don’t want to
do bimanual exam. Should have asked for fetal fibronectin, vaginal swab at that point (I
mentioned vaginal swab in investigations later)- maybe the reason for score of 4in choice
of investigation
-Preterm PROM….could be coz of various reasons…many times no reason can be found.
But what we’ll do now is right now do a CTG, USG. Will send you to tertiary hosp by
ambulance. Specialist will see you. Will do blood tests, vaginal swab, give Abx, Steroid,
monitor you continuously. Sometimes ppl go into preterm labour, tocolytics will be given
if that happens. Asked for Blood gp, family support (as for ALL Obs cases)

Antenatal check

Transverse Lie
35 year old Jenny is your next patient at your GP clinic. She is at 37 weeks pregnant and
has come to you for antenatal checks. This is her fourth pregnancy.
TASKS
Take a further history
PE from examiner,
explain diagnosis, Discuss further management with the patient
History
outside the room you might suspect that this case is anemia due to spacing but you should
suspect any late pregnancy complications and all the history will be normal
1-Late pregnancy complications questions
-How’s your pregnancy so far?
-any tummy pain, vaginal bleeding or discharge? (Preterm labour. Placenta Previa or
abruption, PROM)
-any headache, blurring of vision or leg swelling? (Preeclampsia)
20

-any fever, nausea or vomiting? (Infection)

-any burning or stinging on passing urine? (Urine problem)
-Nay problem with your bowels? (bowels problem)
-any dizziness, tiredness or funny racing of the heart? (Anaemia)
-is the baby kicking well? (Baby problem)
2-recurrent visits questions
-Have you had regular antenatal checks?
-How were the blood tests? Are you aware of your blood group?
-have you done down syndrome screening?
-US at 18-20 weeks gestation? Is it single baby? Any birth defects? What is the position
of the placenta?
-Sweet drink test at 28 weeks?
-Repeat ultrasound at 32/34 weeks?
-Bug test at 36 weeks?
-did you take your folic acid?
- Have you done your pap smear? What were the results?
3-past obstetric history questions
-How were your previous pregnancies and deliveries? Any complications in during
pregnancy, delivery or after delivery?
-When was your last pregnancy? (can predispose to anemia if no proper spacing)
4-General questions:
-Are you eating a healthy balanced diet? Do you drink a lot of fluids?
-Do you have a regular exercise routine?
-Are your influenza and pertussis vaccinations up to date?
-do you smoke? Do you drink alcohol? Do you take any medications or any recreational
drugs?
-Do you have good support?
- have you had any medical illnesses? (clotting, DM, thyroid, hypertension)
Physical Exam from examiner
1-General appearance (PODL)
pallor, oedema, dehydration, LAP
2-Vital signs (all)
3-quick CVS and chest
4- Abdomen:
-any tenderness
-any uterine contractions
-what is the fundal height (36 cm)
- FHR,
- lie and presentation (hard ballotable mass on one iliac fossa and soft mass towards the
21

other)
-is the lower pole of the uterus empty or not?
5-Pelvic:
-Inspection of the vulva and vagina: any bleed, discharge, rash, vesicles
-Speculum: cervical os open or closed, discharge or bleed from the os
6-Office test:
urine dipstick, blood sugar level
Explanation (4C)
Condition
-Most likely your baby is in a transverse lie. Normally, the baby lies in a longitudinal
position which means that the baby is parallel to your spine. But in transverse lie, the
baby lies perpendicular to your spine.
*Draw a picture of a longitudinal and transverse lie.
Clinical features
I can say this because on tummy examination I can feel the head on one side and the butt
on the other side
Cause
-The cause of this that I suspect in you is multiparity. As this is your fourth pregnancy,
the uterus could be lax and this allows the baby to adopt abnormal position and lies.
-The other causes can be polyhydramnios, or excessive fluid in the sac surrounding the
baby, but that is not a probability here as the uterine size is less.
-Another causes are:
placenta Previa; when the placenta attaches itself to the lower pole of the uterus,
Fibroids or benign overgrowth in the uterus
birth defects in the baby,
but these could have been detected in the ultrasound that have been done earlier.

Complication
The problem with a transverse lie position of the baby is, when you go into labor, the
labor might now progress, and you will end up having an obstructed labor, and there is a
chance of cord prolapse as well.
The cord usually comes out after the delivery of the baby, but in cord prolapse, the cord
comes out first and the cord can get compressed between the baby's head and the birth
canal leading to decreased oxygen and nutrient delivery to the baby. The baby then
becomes distressed and unwell.
22

Management
-I need to refer you to a tertiary hospital, where you will be admitted and seen by the
specialist. -An ultrasound will be done to rule out the other causes of transverse lie,
and a CTG will also be done to look for the baby's wellbeing.
-There are two options for you as far as delivery goes: the first option is an elective C-
section by 37/38 weeks, and second option is to do an external cephalic version.
ECV will be done by the specialist after ruling out contraindications like fetal distress or
unwell baby, placenta previa, a cephalopelvic disproportion, or a short cord or
oligohydramnios. In ECV, the baby will be manipulated over the tummy by using the
hands and finally the head of the baby will be brought down so that the baby will have a
longitudinal lie and a cephalic presentation or head down.
Labor will then be induced by artificial rupture of the membranes.
There are complications associated with ECV such as fetal distress, abruptio placentae or
placenta separates from the wall of the uterus, rupture of membranes, and the most
important complication is the cord can get twisted around the neck of the baby. It is
usually done around 37/38 weeks. After 38 weeks, it is not done anymore.
Do you have somebody to take you to the hospital now?
I will give you reading materials regarding transverse lie.

Feedback 10-5-2018
please tell us in case one what was the presenting complaint? how did you suspect it was
a transverse lie? in pe did examiner ask you how will u tell it is a transverse lie?
So the question for transverse lie case was she was coming for regular antenatal check for
her fourth pregnancy. She has been regular with her ANC and her blood test were
normal. 18wks scan showed single foetus with normal liquor and placenta in the
posterior.
Task: take history
23

PE from examiner
Explain ur finding to the patient and the reasons for it.

She had no complains at all. All history was normal. When I asked PE from examiner, on
asking Lie and Presentation the examiner asked me how would you check for lie and
presentation so i explained it to the examiner and he replied there is no presenting part.
Then once again i asked and he smiled and said the same.
Then I went on to explain it to the patient. But i did not mention transverse lie coz it just
dint come to my mind. I went abt explaining things abt mobile head at term, so i
explained all the possible causes for it and i told her not to worry as everything in history
taking and PE was otherwise normal. So all the causes for mobile head and transverse lie
are same so i guess i passed this case
I showed him practically how I would check for it by doing the grips ( in air). Fixing one
side and checking the other side and then vice versa. Looking for spine on one side and
looking for baby limbs on the other...
And I kept giving assurance to patient that everything seems fine on history and PE so I
don’t want u to worry. Let us just get a scan and we will know if there is any cause
present.
there was no management.

Feedback 5-12-2018
GP, Lady, 36 weeks, 4 th pregnancy long stem all antenatal test USG, Sugar test 18
normal, all previous checkup normal, BP normal, all details given.
Task:
1. Ask History for 4 min(was thinking what else to ask as everything in the stem)
24

2. Ask PEFE from examiner and he will give you specific findings you want
3. Tell mom possible causes of your findings

Greetings, Introduction. Appreciated that she was regular with her ANC and most of her
tests were normal. Just to be confirmed I would ask few more q , is that Ok X?Do you
have any specific concern before I start?
Started HX : ( kept in mind risk factors of transverse lie: poly hydrammions, structural
defect,
Routine Q:
PETQ? Bleeding, discharge baby kick. Any infection or fever?
ANC HX: (most of them given in stem, just asked as gross)
I know all the Blood tests and sugar tests were normal, how about Down screening?, 18
wk USG – single / multiple, position of placenta? Repeat usg at 34-(can’t remember
whether she said—not done or not sure about the result), Bug test- I didn’t ask (probably
it’s the 3rd key point that I missed).
OBS HX: Any complications, mode of delivery (all were NVD)
MED/SX HX: I asked specifically about any tumor / fibroid or any previous sx in the
womb
Asked about folic acid?
(Did not ask about all SADMA)
PEFE:
General appearance; ( I did not ask
Head to toe General PE: Pallor, icterus, oedema
Vitals: started asking BP.. Examiner said vitals normal
Focused abdominal examination: FH : 34, when I ask about lie and presentation: how
will you examine: I said rt and left lateral grip. Examiner asked what you looking for. I
said: babys back abd limbs.
Presentation: I will do pelvic grip placing my both hand in lower pole and I will look for
head or breech.
Then examiner gave me finding: you are feeling: hard ballot able structure in left. Lower
pole is empty.
FHR: normal
Pelvic examination: Examiner said all normal.
Pt counselling:
Hi X, I have examined you good thing is you baby is doing fine but what I found is your
baby is lying transversely in your womb which is not normal. But don’t worry it quite
manageable condition. Let me draw and explain it to you.
Then I explained it and all the possible causes..
Poly hyd: where there is excess fluid in your womb.
Placenta prev: where structure attaching you baby to your womb lying in lowrer part.
Structural abnormality or tumor like fibroid in your womb, or any structural defect in
your baby. But all these are less likely as all the usg and investigations are normal
in your case most likely its lax uterus due to multiparity. Baby gets enough rooms to
freely move and take abnormal position.
I am gonna refer you to Specialist and MDT in TLH. Sp will decide on further mx . There
is 2 options they may try to reposition which we call ECV or they may suggest for C/s.
25

Key step 1234: yes, yes no yes

Approach to pt : 6
History: 5
Accuracy of exam: 5
Pt counselling: 6

29-Thalassemia in pregnancy
You are in Gp when Jane an 8 weeks pregnant comes to you to get the results of her
blood tests that you had ordered for her during the last visit.
FBC shows low Hg and low MCV Anaemia Q (Susan 184)
iron studies are normal
Intake – Diet – what kind of a diet? vegan? red meat?
rest blood tests normal
blood group id AB +ve Loss – Resp S*/N/V/ Bowels-Bleeding? LOW? Period
tasks (excessive bleed)
take further history Origin- Mediterranean, Middle East, Asian and African
tell diagnosis to patient people.
management chronic disease- PMH
Differential diagnosis FHx blood disorders/ anyone in family having blood
1-Iron deficiency anemia transfusions
2-thallassemia
SADMA – If relevant
3-chronic disease
NSAIDS,OTC, recreational drugs,
History alcohol,smoking
it nice to see you again I’ve got your blood tests results to discuss with you but before
that can I just ask you a few questions in order to get a better view for the diagnosis.
1-anaemia questions
-do you feel dizzy, tired?
-do you have shortness of breath, funny racing of the heart or chest pain?
-have you ever had any of these symptoms before?
2-current pregnancy questions
-how is your pregnancy so far
-do you have tummy pain, vaginal bleeding or discharge?
3-General questions
-can you tell me briefly about your diet?
-do you exercise regularly?
-do you smoke? Drink alcohol? Take any medications?
-do you have enough support from your partner?
-any past medical or surgical illnesses?
4-thallassemia questions (all key issues)
-have you had history of miscarriage?
-can I know please which country are you from? (Italy)
26

-and where your partner is originally from? (Italy)

-does your partner have any symptom?
-any family history of anaemia? (father looks pale but no reason)
-do you take folic acid?
-blood group? (if not with the results)

Interpreting the results and explain the diagnosis and ddx

-look Jane I’ve got the results of your blood tests with me let’s see it together.
The blood picture showing a low hemoglobin level and the size of the red blood cells is
also small. Normally your blood has 3 types of cells the RBC which contain an iron rich
protein called hemoglobin which enables these cells to carry and deliver oxygen to
different parts of the your body. Low hg means that you are anemic.
You also have White blood cells which helps fighting infections and also platelets that
helps blood clotting. Your WCC and platelets are normal.

-Usually this sort of blood picture is seen when someone is deficient in iron but we have
already ordered iron studies, which revealed to be normal. So it is unlikely that low hg id
caused by Iron deficiency.
Another reason could be due to any chronic illnesses but they are unlikely because your
general health is good.
-So what I am suspecting is a condition called thalassemia have heard about it?
Condition and cause
-This is a group of inherited blood disorder where there is a defect in production of
hemoglobin so it happens when your gene becomes mutated or permanently altered
affecting the body’s ability to make health hemoglobin.
-This is a lifelong condition and most common in Mediterranean, Middle East, Asian and
African people.
Clinical feature and complication
-Let me assure that you have a minor form of the disease in which you have no symptoms
except sometime mild anemia that could become more prominent during the latter half of
the 2nd trimester and early 3rd trimester, this is because pregnancy demands higher rate of
RBC production.
-Normally baby won’t have any birth defects because of this but depends on the genetic
constitution the baby might get thalassemia.

Management
-first I would like to confirm thalassemia by another test we call hg electrophoresis for
which I would like to refer you to the specialist hematologist.
-Once it is confirmed, your partner also needs to be tested for thalassemia and DNA
gene testing also needs to be done.
27

-if you alone has got thalassemia the baby has a 50% chance of having the minor form
and 50% not having thalassemia.
if both you and your partner have thalassemia then there is 25% chance that you baby
doesn’t have thalassemia, 50% a minor form and 25% got the disease or major form.

- I will refer you for genetic counselling as well (CVS, amniocentesis, fetal blood
sampling)
-the rest of your pregnancy will be monitored in high risk pregnancy clinic.
- I’m gonna start you on folic acid 5mg/day and it will be given throughout the
pregnancy.
-you will be followed up with frequent blood check, US etc…
-I will give you reading materials regarding Thalassemia, and I will arrange a review
with you when the results of the hemoglobin electrophoresis come in.

Feedback 19-7-2018
STATION 15 PASS(all Key steps Yes score 6,6,6,7)
Thalassemia minor in pregnancy
24 years old primary gravida found to have Hb 9 on first antenatal visit and u ordered
iron profile which came out to be normal ,now she is here for her reports,
Task , further focused Hx , Most likely Dx, Further Investigation, council
Young girl sitting I asked about planned pregnancy and congratulated her, then asked abt
how pregnancy going, all anemia questions ( intake/loss/origin/ch disease) Fhx and
sadma.
Then I explained Hb , Anemia , Iron ,thalassemia minor and major .
Advised Hb electrophoresis , partner testing and if positive chances in baby and diagnosis
and all.
28

Case (5/10/2017)
First trimester complication
Fail
9 weeks pregnant lady who is 24 yrs old comes back to be reviewed by you after the
antenatal blood tests. All the tests are normal except Hb 90, MCV 65. You ordered Iron
studies which came back normal.
Task:
Brief history
Explain what investigations you want to do to patient
Explain Dx and DDx to patient and Management
Introduced myself and reassured confidentiality. Asked if it is a planned pregnancy and
she said yes and congratulated her. She said this is her first pregnancy. Coping well
with the pregnancy and good support from her partner. No dizziness, SOB, Chest pain.
Normal period before pregnant and no history of heavy period, as well as no bleeding
disorder. Diet is balanced and she is not on any special diet and no family history of
coeliac disease and no family history of low blood count either. Italy descent and her
partner is from same country too. Then, i explained her about blood test. ( In our blood,
there's 3 main blood cells, RBC , WBC and platelet. For now, i will focus on RBC to
explain to u. It helps carrying oxygen to various parts of the body and it has protein called
Haemoglobin which helps carrying oxygen. In you, there is low Hb count and it also
shows cells are small. We call it Microcytic Anaemia and usually most likely due to iron
deficiency but in ur case, iron studies is normal. So, I am suspecting u have the condition
called Thalassemia, which is a genetic condition in which u have small cells with low
blood count. I will arrange a blood test called Hb electrophoresis to confirm the
diagnosis, and Patient asked me what is that and i explained to her. Then, i asked her that
i would like to see her partner as well and would like to arrange some blood tests on him
as well to rule out this condition. I explained to her possible other differential dx with
reasons ( iron def, coeliac, bleeding disorder and multiple very close pregnancies). I
told her that i will refer her to high risk clinic where she will b followed up very closely
by specialists. I offered her reading materials and told her red flags. I told her i will start
her on folic acid and she said she is already on folic acid.
29

I totally forgot to mention about detail antenatal care ( 8 week dating scan, Sweet drink
test at 26 wks, USG at 28 and 32 wks, Bug test at 36 wks ).
Covered 3 key steps out of 5
History 3
Dx and DDx 4
Choice of InVx 4
Global score 3
I didnt ask details about 5 P as the task mentions brief history. I forgot to ask about LMP
and blood group.

Feedback 25-10-2018
Scenario: 1st trimester complication
Stem.
Young primi, returned for the blood reports. U ordered iron profile as her hb was low.
Iron profile comes out to be normal.
Tasks
Further relevant hx
explain results
further inx after greeting took a short hx that’s why got (3 in hx) thought relevant hx
should be short. Well then explained her the results. Explained her whats hb whats mcv n
what is the significance of them being low -> anemia i.e hypo micro anemia there are 2
most common causes of this type of anemia, 1 is iron but we did ur iron profile and its
normal which means theres some thing else going wrong, as u r of Greek ethnicity also ur
dad had some form of anemia(she told me this when i asked anyone in family having
anemia or blood transfusions) it shows most likely this is something we call thalaseemia.
Have you ever heard of it before ( NO)
explained thalaseemia . and that she could be minor type need to do hb electrophoresis.
And later if it comes out to be positive will test parter as well. Explained risk of having a
baby with thalassemia, n that we can do some tests to check baby n if major dx its
incompatible with life and she can decide to abort but don’t need to worry at this point as
u don’t have any symptoms I will see u again after hb electrophoresis and then will go
from there, if needed willl refer u to specialist, bell rang.

Grade: pass
GS:4
30

3/5 key steps covered

Hx: 3
Dx/ddx:6
Choice of inx: 6

37-Mitral stenosis in pregnancy

You are a Gp when a 25 year old woman who is 10 weeks pregnant comes to see you.
She has done all the first antenatal visits tests with another GP, which are all normal. So
she has just moved to a place nearby your practice from another town the previous GP
had picked up a murmur during her first antenatal check and told her that she needs to be
assessed further.
TASKS
Take a further history (5 minutes)
PE from examiner (card)
Discuss your diagnosis and management with the patient
Differential Diagnosis:
Physiological murmur
Anemia
structural heart defects
Infections (infective endocarditis)
History
1-current early pregnancy questions
-How is your pregnancy so far
-any tummy pain, vaginal bleeding or discharge
2-Murmur Differential diagnosis questions
Anaemia
-any dizziness, tiredness or funny racing of the heart?
-how’s your diet? Does it contain meat and green leafy vegetables?
-have you had a history of heavy periods?
-any bleeding?
-is this your first pregnancy? How many pregnancies have you had? (to rule out spacing)
Infections
-any fever?
-any surgical procedure recently? Especially tooth extraction?
Cardiac causes
-any chest pain,
-any Fainting episodes?
-any shortness of breath? (Mild SOB since pregnancy started)
are you SOB now?
31

Are you Short of breath on exertion or rest or both? (Walks or work)

anything make it better or worse? (Rest)

3-risk factors questions

-any previous heart disease?
-any previous medical or surgical illnesses? (Yes I had joint pain , sore throat , and fever
when 8 years old admitted to hospital and given medication)
-what treatment have you had at that time? (antibiotics)
-was it a long-term treatment or not? (Took for 3 years then stopped)
4-regular visit questions
-early symptoms of pregnancy?
-how was your blood tests? Blood group?
-have you been advised of down syndrome screening? (no)
-any previous ultrasound?
-do you take folic acid?
-SAD?
-support?

Physical Exam from examiner

1-General appearance:
pallor, Dyspnea, cyanosis, clubbing, lymphadenopathy, rash
2-Vital signs: HR, RR with O2 saturations, BP with postural drop
3-Focus CVS system examination
-JVP
-visible pulsation
-apex beat/ thrill and heave
-S1 and S2 (loud S1)
- added sound S3 , S4
-murmurs (low pitched rumbling diastolic murmur best at apex with little radiation
in left lateral position)
4-Respiratory:
- Excess work of breathing like nasal flaring, tracheal tug, overuse of SCM or pectoralis.
Intercostal or subcostal recession)
-Air entry, breathing sounds and adventitious sounds
-basal crepitation
32

5-Abdomen:
-hepatosplenomegaly, soft or tender, mass
6-pelvic examination
-inspection (vulva and vagina) bleed, discharge, vesicles, rash
-speculum (cervix) healthy or not
-bimanual examination: cervical motion tenderness, uterine size and tenderness, adnexal
mass and tenderness
7- Office test: UDT, BSL, ECG (ECG not available)
Explanation
-From history and examination I think you have a structural defect in your heart called
mitral stenosis
-Draw a diagram
The heart has 4 chambers, two upper and two lower chambers. Blood normally flow from
upper to lower chambers and this is controlled by valves. The valve on the left side called
mitral valve and in mitral stenosis the opening of this valve become narrow so blood does
not flow freely from the upper to lower chamber of the left side and this causes a back
pressure on your lungs causing shortness of breath.
-the infection that you had during childhood could be a rheumatic fever and this can
affect the valves of your heart if you do not take a long-term treatment with antibiotics.
-And why you are SOB now is due to pregnancy which is a hyper dynamic state with
increased volume of blood so the heart need to pump more blood.

-This is considered a high-risk pregnancy as you can develop complications like heart
failure and the baby can also go for growth restriction. But you do not need to worry
about complications at this stage because you will be working by a MDT trying to make
your pregnancy and baby as safe as possible.
Management
-I will refer you to a cardiologist, and he will arrange further tests like echocardiography
which is a scan of the heart and its blood flow, for the confirmation of the diagnosis and
assessing the severity, and the functioning of the heart.
Further blood tests also would be arranged if necessary.
just in case you need any medications the cardiologist will put you through.
-I will also refer you to the high-risk pregnancy clinic where you will be looked after by
MDT consisting of obstetrician, cardiologist, pediatrician and anesthetist.
you need to go for more frequent antenatal visits. Like US at 18 weeks , sugar test 28
weeks, repeated US at 32 weeks, bug test at 36 weeks.
I will give you referral for down syndrome screening now.
-as far as delivery goes unless severe mitral stenosis or heart failure happens, you can
have a normal vaginal delivery, but it should be in a tertiary hospital under the guidance
33

of the specialist. certain precautions will be taken like:

1-continuous monitoring of your vitals and continuous CTG for the baby as well.
2-You will be given oxygen during labor and after delivery.
3-You will be offered a stress free labour with adequate pain relief in consultation with
the anesthetist.
4-Usually the second stage of labor is cut short by using instruments such as forceps or
vacuum.
-Try not to stress at the moment take some rest, limit your activity and have a healthy
diet.
-reading materials
-review after she sees the heart specialist

21-C-section request
You are at your GP when jenny, 25 year old, at her 20th week of her first gestation
presents to you with a request of C-section to be conducted as she does not want a
vaginal delivery.
TASKS
Take a further history
Counsel the patient
34

History
1-WHY
-hi jenny I can see from the notes that you are pregnant at 20th week, is it a planned
pregnancy?
Congratulation!
-So I can see that you come to ask for CS instead of vaginal delivery, can you tell me
why?
(Because of pain one of my friend had CS and had lots of pain)
2-recurrent visit questions
-How is your pregnancy going so far?
-have you had regular antenatal checkup?
-have you done down syndrome screening at 11-13 weeks?
-US at 18 weeks (no) ok I’ll give you a referral because it is important to have one
-have you done blood tests, blood group? Did you take folic acid?
3-late pregnancy complications questions
-any headache, blurring of vision, leg swelling?
-tummy pain?
-any vaginal bleeding or discharge?
-any fever, nausea and vomiting?
-burning or stinging on passing urine? How’s your bowel habits?
- Have you started to feel the baby kicks?
4-General questions
-SAD
- exercise
-support
-past medical and surgical history
Counselling
1-explain the mode of delivery (draw a diagram)
-Vaginal birth is a natural way of giving birth to your baby. Whereas C-section is a
surgery where we a cut is made in the lower part of your tummy along the bikini line and
another similar cut along the lower part of your womb through which the baby and
placenta will be delivered under anesthesia.

2-Indications
-We usually go for a C-sections if there are definite indications.
-C section can be done in a planned or an elective way or as an emergency procedure.
*So Indications for elective CS are:
35

- placenta previa (low lying placenta covering the birth canal)

- cephalopelvic disproportion (due to narrow birth canal or big baby)
-abnormal presentation or lie (transverse rather than longutidinal)
- previous2 CS or a vertical CS.
*An emergency CS can be done in the following situations:
- prolonged labour
-labour obstructed at any stage
-some cases of abruptio placenta
-uncontrolled preeclampsia
-cord prolapse (cord presents earlier than the baby)
- Fetal distress (if the baby becomes unwell at any point in time)
So far you have no indication for CS
3-Complications of CS
C-sections carries certain complications to you and to your baby.
Immediate complications can be:
-risk of anesthesia
-bleeding problems
-infections
-injury to the surrounding structures like the bowel or the bladder.
-breathing difficulty in baby
Let me assure that all of these can be minimized because it is usually done by a trained
specialist.
Long term complications include:
-clots formation in the vessels of your legs
-when you will be pregnant next time and as you will have a scar in your womb so there
can be a high risk of rupture if you choose normal vaginal delivery.
-pain in case of normal vaginal birth will be gone by the time the delivery is complete but
for CS even though you do not have pain at time of delivery but the pain continues till
the wounds heal.
4-advantages of the vaginal birth over a C section:
-recovery is quick
-less hospital stay (in a day or two then you can go home while in CS you need to stay for
3-5 days)
-you can walk around soon after birth but in CS you require rest and more support to look
after yourself and the baby.
-there are no complications like bleeding or risk of anesthesia, or infection from the
womb because it is not a surgery.
- You can have any number of future vaginal deliveries. Whereas in CS it is always
limited to 3
36

5-Risks of vaginal delivery

However, there are some risks with vaginal birth as well. These include
-a failure which can lead to a C-section.
- there could also be some damage to the pelvic floor muscles that can lead to future
complications like incontinence. But it can very well be managed if you start doing pelvic
floor muscle strengthening exercises after delivery.
-tears and lacerations which will be repaired at time of birth.
6-pain relief options
As I see that you are concerned with the pain associated with the vaginal birth, there are
excellent pain relief options that are available for you at the time of labor. It could be
pharmacological or non-pharmacological.
*Pharmacological options:
-epidural, where anesthetic drugs will be introduced into the outer covering of your spine
and it can be topped up anytime.
- By giving nitrous oxide and oxygen inhalation via mask
*Non-pharmacological methods
- Certain positions during labor can also reduce the pain
- Deep breathing techniques can also be used as well.
- Hydrotherapy can also be done, which is giving birth while on water
- Using TENS (transcutaneous electrical nerve stimulation) where 2 electrodes are placed
on either side of the spine and a small electric current will be passed which can inhibit the
pain fibers.
Ending
-by the end of the day, it is your choice.
-But if you go through CS without indications you need to cover the expense by yourself.
-You are only at 20 weeks, and there is still a long way to go. If any complications will
occur, we may go ahead with the C-section if indicated.
-When the specialist meet you next time make sure to discuss this with them (no need to
refer her)
-reading materials regarding vaginal birth and c section, and also pain relief options that
are available during your labor and delivery.
37

OTHER CASE:
when you ask why the reason they give you: incontinence following vaginal birth
(all the same but you can say these instead of pain relief options)
Incontinence sometimes happen after vaginal birth, which is due to weakness of pelvic
floor muscles that support the womb, birth canal and vagina.
Vaginal birth is not always the cause of incontinence. There are other causes like:
- weight gain after delivery
- chronic constipation,
- chronic cough
- injury or tears of the birth canal
To deal with these
1-make sure that your weight is in the normal range after delivery
2-healthy diets with fibers and fluids to prevent constipation
3-just in case you developed a chronic cough report immediately
4-tears also will be repaired at the time of delivery
Key things you need to do is pelvic floor exercises, you can go to prepartum and
postpartum classes where you will be taught correct way of doing such exercises which
you can continue lifelong.
38

Feedback 26-10-2018 Obstetric counselling Passed (GS – 4)

28 year old women with 20 week GA comes to your clinic with request of C-section to be
conducted as she doesn’t want Vg delivery.
Task: take Hx, counsel her regarding her delivery plan
Hx:
 Any symptoms now? (BPV, discharge, pain)
 ANC Hx ( blood group and blood tests, STI screening, USG at 18 week)
 SADMA, Past medical and surgical history, Obstetric Hx (G1 P0)
 Her concern & reason why you want to do C-section – she is worried about labour
pain)
Counsel
 Explain procedure of NVD and CS
C-section
 Indication of CS (CPD, big baby, abnormal lie and presentation, if mom is unwell
due to PE, other medical comorbidities such as epilepsy, or if baby is unwell)
 Risk of CS over NVD
i. risk of anaesthesia
ii. risk of surgery (bleeding, injury to surrounding structure, infection such as
pneumonia, UTI, wound infection
iii. Although there is no pain during operation due to LA, pain will continue
after CS until your wound is healed. However, in NVD, pain will go away
shortly after delivery. Therefore, compared with NVD, CS will need
longer hospital stay.
iv. Other post-partum risk (risk of DVT in C-section are higher than women
with NVG)
 Limitation of CS: can do maximum 3 times.
NVG
 As you are concerned about labour pain during NVD, we can give effective
medication which will be injected into spine. There are also some non-
pharmacological methods such as hydrotherapy.
I will give reading materials regarding delivery options. You can read at home and
discuss with your partner. Also you are now in 20 weeks GA. There is long way to go.
We will follow you up throughout the pregnancy. If there is no complication, decision ic
39

up to you. Obstetrician will be the best person to discuss delivery plan in late pregnancy.
Are you with me so far?

36- Subfertility
27 year old Janet is your next patient at your GP. She tells you that she had been trying to
fall pregnant since more than 1 year now but she could not and she is quite worried about
this.
TASKS
1.Appropriate history
2.Examination findings from examiner
3.Relevant investigations
4.Management
Subfertile - if less than 35 y/o, unprotected sexual intercourse x 12 months; if >35 y/o
unprotected sexual intercourse x 6 months or more
Differential diagnosis:
-Unknown
-Infrequent sexual intercourse and ignorance about fertile period
-PCOS
-PID
-Endometriosis
-Fibroids
40

-Thyroid disorders - hyper/hypothyroid

-Hyperprolactinemia
-Eating disorders
-Stress, exercise
-Medical- DM, SLE, renal disorders
-Surgical- Asherman’s syndrome
-Medications- antipsychotics, spironolactone, chemotherapeutic agents
-SAD – marijuana
-Family history of subfertility
APPROACH
History
1-approaching+ confidentiality
-Hi Janet, I'm Dr. ___ your GP today. I can see from the notes that you have been trying
to become pregnant for 1 year now but you couldn’t. I just need to ask a few questions
and some of them would be sensitive and personal but let me assure you that everything
we gonna talk about will be private and confidential. Would that be alright with you?
2-5 P’s questions
Period
-when was your last menstrual period?
-Are they regular?
-How many days of bleeding and how many days apart?
-Have you had any heavy bleeding or pain during menstruation?
(Yes, regular. No problems with periods)
Partner (sexual)
-How long have you been in the stable relationship? (We've been together for 2 years
now)
- Has your partner done evaluation for subfertility so far? (No he hasn't)
-Does your partner have any medical or surgical conditions?
-Any medications that he is taking? (None)
-Sorry to ask you this, but does your partner have any children from previous
relationships? (No, he has none)
-have you or your partner ever been diagnosed with sexually transmitted illnesses? (No)
Pregnancy
-have you ever been pregnant before?
-any previous miscarriages? (None)
Pill
-what type of contraception you were on before planning for pregnancy?
Pap or HPV screen
-when was your last pap or hpv screening?
41

3-Differential diagnosis questions:

infrequent sexual intercourse
-how frequent do you undergo intercourse? Do you live with your partner always?
(About once or twice a month or so cause we're not living together always cause he's
working in something and comedown once a month)
Unawareness about fertile period
-Do you know about your fertile period? (What is that doctor?)
-Fertile period is the time during which you undergo intercourse, there's a high chance of
PEF (PID, Endometriosis, fibroids)
-do you have any abnormal, offensive vaginal discharge? Any fever, back pain? (PID)
(None)
-Any pain in between periods or during intercourse? (Endometriosis) (None)
-Any mass, lumps or heaviness that you can feel in your tummy? (Fibroids) (None)
PCOS
-Any recent weight gain, acne, excessive hair growth? (None)
Thyroid disorders
-Do you have any weather preference? How are your bowel habits? (None)
Hyperprolactinemia
-Any headache, blurring of vision, milky discharge from nipples? (None)
Eating disorders/ stress/ Excessive exercise:
-Do you think that you are excessively overweight? Do you try to reduce your weight
through crash dieting or excessive exercise? (Eating disorders) (no)
-What is your occupation? Do you have any stress at home or at work? (Stress) (I do
office work. None.)
-How much exercise do you do? (Excessive exercise)
4-General questions
past surgical and medical history
-Have you had any surgical procedures especially those done down below? (Asherman's)
(No)
-Any medical illnesses like diabetes or renal disorders? (No)
Smoking/ alcohol/ Drugs or Medications
-Do you smoke, drink alcohol, or take any recreational drugs?
-Do you take any Medications or over the counter medications?
Family History
Do you have a family history of subfertility?
Thank you for those information, Janet. I'd just talk to my examiner and will get back to
you shortly.
42

Physical Exam findings from the examiner

1-General appearance
-what is the BMI? 23
-Any Acne, excessive hair growth?
-Any Pallor, lymph node enlargements, edema? None
2-Vital signs
-What is the BP and temperature? 110/70, 36.8
3-Quick respiratory and CVS examination
4-Thyroid examination
5- Abdominal examination:
Inspection
-Any visible distention? Any mass?
Palpation
- Palpable mass or tenderness? (No visible distention, no mass or tenderness)

6-Pelvic examination:
-Consent
with her consent and in the presence of a chaperon I need to do pelvic examination.
-Inspection of vulva and vagina
any bleed, discharge, vesicle, rash? (No bleeding or discharge)
-Speculum exam
is cervix healthy? Discharge and bleed? (No discharge or bleed from the cervix)
-Per vaginal exam (CMT+ Bimanual)
is there CMT? (None )
What is the size, position and mobility of uterus? Any Tenderness? (Uterus size is
normal, anteverted, mobile, no tenderness)
-Any Adnexal mass or tenderness? (No adnexal mass or tenderness)
7-Office tests
Urine dipstick
blood sugar level
Thank you for those information, examiner, I would like to go back to my patient.

Investigation
- I would also like to arrange for some investigations such as FBE, U&E, LFT , TFTs,
serum prolactin
-urine MCS (microscopy culture and sensitivity)
- Mid luteal hormone assessment (21st day serum progesterone; if >3nanograms/mL it
means lady is ovulating) (Key issue)
- FSH, LH, estrogen, progesterone
43

- transvaginal ultrasound (Key issue).

- If everything turns out to be normal, we need to arrange for a hysterosalphingogram. It
is done to check the patency of the tubes. A dye will be injected through the cervix, and
we will look if the dye is passing through the tubes or not. (Note say this only if
everything normal)

Diagnosis and Management

-As far as the details you have given me and after examining you, I could not find any
organic reasons, the most likely cause is infrequent sexual intercourse and your
ignorance regarding the fertile period. So I'll advise you further on this.
-If you are planning for a pregnancy, it would be better to undergo intercourse 2-3
times/week.
-To find out about your fertile period or whether you're ovulating or not:
1-you can get ovulation kits from the pharmacy which are urine kits and just like a
pregnancy kit. You can start testing from the eleventh day of your periods.
2-Other methods by which you can detect your ovulation is by basal body temperature
method. For this you need to get a basal body thermometer from the pharmacy, you will
also get a chart along with this, and you need to record the temperature from your armpit,
every morning before you get out of bed, and record it on the chart. A rise of 0.2C for 3
days over the previous 6 days temperature will tell you that you're ovulating.
3-Next is cervical mucus method, You need to observe the cervical mucus everyday so
at time of ovulation the secretion will become thin, more in amount and lubricative. After
ovulation it changes to thick mucus .

-It is always better to treat both partners so when you come for your next appointment I
would like to see your partner as well.
-I will also give you reading materials about subfertility.
-if none of these methods work then I can refer you to infertility clinic.
-review when results of Ix also come.
Only Notes
If it is due to PCOS, you need to do lifestyle modifications. I will refer you to a dietician
and you need a structured exercise program. You need to continue this for 6 months. If it
is not working, I will refer you to specialist who will start you on ovulation-inducing
agents like clomiphene citrate, and give you metformin along with that. If that still
doesn't work, you can undergo a surgery we call laparoscopic ovarian drilling. We put
multiple holes in the ovary through a keyhole surgery and that itself can induce ovulation
as it drastically brings down the testosterone or the male sex hormone production.
If it is due to fibroids,
we need to do surgical management such as myomectomy or uterine artery embolization.
44

If it is due to endometriosis,
we need to do a laparoscopic excision of endometrial deposits or we can burn away the
deposits with electrocautery or laser.
If it is due to thyroid disorders, treat the disorder with medications.
If it is due to hyperprolactinemia,
-look for cause, either a micro or macroadenoma (<1cm micro, >1cm macro), use of
dopamine antagonists like antipsychotics, or hypothyroidism.
-Refer to specialist,
-Do a serum prolactin, TFTs, high resolution MRI.
-Pituitary microadenoma - treat by giving cabergoline or bromocriptine and review by
measuring serum prolactin and MRI imaging.
-Pituitary macroadenoma - do a transsphenoidal approach to remove the macroadenoma
-If due to Asherman's (unexplained uterine adhesions usually following a surgical
procedure within the uterus)
treatment is 3 steps
1-hysteroscopic removal of adhesions under antibotic cover,
2-then prevent adhesions by inserting a IUCD or Foley's catheter to keep the uterine
cavity apart until healing takes place.
3-To regrow the endometrium, we need to give you estrogen.
-If both tubes completely blocked, your option is to do an in-vitro fertilization. IVF
is when fertilization occurs outside the female body. It is done by a specialist. You will
be put in ovulation-inducing drugs such as clomiphene, and once the eggs are mature, it
is taken out and combined with the sperm from your partner in the lab. Once embryo
happens, a healthy embryo is chosen, and is implanted into the uterus. If only 1 tube is
completely blocked, 1 tube patent, we could do a GIFT procedure. It is a gamete
intrafallopian tube transfer. Fertilization takes place inside the female body. Introduce a
healthy egg and a sperm into the patent tube and allow fertilization take place in the tube.
Once embryo is formed, it will be implanted in the uterus. We could also do a ZIFT
procedure. IT is a zygote intrafallopian transfer. Here fertilization happens outside the
female body. And once the embryo is formed, it is introduced into the patent tube. Then it
will travel down the tube and get implanted in the uterus

Feedback 23-6-2018 FAIL

Feedback: Conception Difficulty: female pt, been trying to get pregnant for 1 year. Take
Hx,
Investigations, Counselling.
Taking Hx:
- How are you doing? Could you tell your concern? To find out the possible cause which
45

may cause your infertility I need to ask you several questions which may be private, is
that OK?
- I started ruling out possible causes of female infertility: eating disorder, excessive
exercise, DM, thyroid issue, POF, PCOS, Pituitary adenoma, PID, Endometriosis,
- Male issue: is your husband alright? Does he has any diseases related to this issue that
you know of? Do you or your husband any family or children before you guys?
- Sexual activity: how often? (ONCE a MONTH)? Why? (COAL MINER)? Any
problems happened during sexual performance? (NO)
- 6Ps., especially any miscarriages? (NO)
- SADMA.
- Medical, surgical Hx Family Hx.
I said: the most likely cause your infertility so far is decreased frequency of sexual
intercourse.
Normally, we need 3 times per week to have good chance of getting pregnant. However, I
need to carry out many investigations to rule out other causes: USD to check if any
uterine abnormalities, hormone tests, GSL, TFT, maybe Ctscan abdo/pel to find out any
hidden causes. And I may do some test on your husband’s sperms, USD,..
Counselling:
- While waiting the test results to come back, I recommend you to increase the frequency
of sexual activities.
- If any tests turn out positively abnormal, I refer you to the specialist to treat you
accordingly.
- Otherwise, I would like to refer you to infertility clinic where MDT will help you.
Don’t worry
There are a lot of hope.
The examiner and the pt were very happy and gave me a big smile.
Grade: FAIL GS: 2
All key steps: no,no,no,no
Hx: 2, Investigations:2, Counselling:2
SHOCKED, I thought I definitely passed this case. What did I do wrong?
46

Feedback 27-10-2018 FAIL

25 year old female patient came to your GP. She has been trying to fall pregnant for more
than a year. height and weight was given in the stem.
Task
- further relevant history
- investigation that you would arrange
- management history
- never been pregnant before
- period history (normal)
- sexual history
sexual intercourse → 1-2 times / month STI symptoms (-), past history of STI (-)
- doesn’t remember what type of contraception she was on.
- having unprotected sex for 1 year as they are trying to get pregnant
- however, unaware of her fertile period
- she is generally healthy
- not taking any medications
- no symptoms of PCOS, thyroid, prolactinoma, no procedure done down below
- sticking to normal healthy lifestyles
- up to date with HPV screening.
- husband is also healthy and doesn’t have any children from previous marriage.
Investigation
- told her that I will run some test to check some hormone level in your blood.
- then, i changed my mind and told her that i will arrange those test in the next visit
Management
- told her to increase her frequency of intercourse (3-4 times/week)
- told her about ovulation kits and basal body temperature methods
- told her to try this for 6 months and will review her again
- if she still couldn’t get pregnant in 6 months time, i will arrange some tests (does
not mention name of the tests in details)
Grade - fail
Global score - 3
Key steps
1,2,3, 4 - Yes, No, No, No
History - 3
Choice of investigation - 2
patient counseling - 4
47

38-Recurrent Candidiasis
You are at your GP when 32 year old Lisa presents to you with complaints of severe
itching and burning sensation in her vagina, with discharge. She tells you that this is
the 4th time that this has been happening for her during the past 3 months. The last time,
her GP had done a culture and it came out to be severe Moniliasis, and she was treated
with Nystatin cream 100 mg intravaginally for 5 days during each episodes.
TASKS
Further history
PE from examiner
Discuss further Investigations and Management with the patient
Note/ Recurrent candidiasis: 4 episodes or more in 1 year
History
1- discharge questions
-how long have you had this discharge form vagina? (Past 3 days)
-how many pads have you used?
-what is the colour? (White)
-is it smelly? (No)
-what is the consistency? (curdy, cheesy)
-any blood stained?
2- Associated symptoms.
-any burning or stinging on passing urine?
-how is your bowel habits?
-any ulcers, rash?
3-Causes questions
Medication non compliance
-I can see that you have given nystatin cream. Have you applied it at the correct dose and
number of days? (yes)
diabetes
-do you feel thirst? are you passing large amount of urine? Do you need to go to toilet
more frequently? Any history of diabetes? (ask them together use any..)
Immunosuppressive disease
-any loss of weight? Loss of appetite? Lumps or bumps around the body?
Antibiotics or steroids
-do you take any antibiotics or steroids medications
vaginal douches/ pessaries/ shower gels change
- Any vaginal pessaries or douches that you have used?
-have you changed your shower gels?
Tight clothes
48

Do you use tight clothing or tight jeans, panty hose

any recent weight gain? Any evidence of infections elsewhere?

4-5Ps questions
periods
-when was your LMP? are they regular?
Partner or sexual
-are you sexually active? Are you in a stable relationship?
-have you or your partner ever been diagnosed with STI?
-any pain during intercourse?
-any similar symptoms in the partner?
Pill
-what type of contraception do you use? (OCP micrpgynon 30)
-for how long? (5 years)
pregnancy
-any previous pregnancies? Any miscarriages?
Pap or HPV
5-general questions
-past medical and surgical history
-SAD

Physical Exam from examiner

1-General appearance:
BMI, pallor, lymph nodes, rash, evidence of infection anywhere in the body
2-Vital signs: temperature, BP
3-CVS/Respi
4-Abdomen:
inspection: visible distention, mass,
palpation: palpable mass and tenderness
5-focus Pelvic examination
Inspection of the vulva and vagina:
-discharge, color of the discharge, is it smelly.
-any swelling or erythema of the vulva or vagina (brick red vagina)
Speculum:
cervix healthy or not, discharge or bleeding, erythema of the cervix
Per vaginal: DON'T to avoid spreading the infection
6-take a high vaginal swab for MCS just to confirm tht this time she is having candidiasis
and to look for any resistant form
49

7-Office test: urine dipstick and blood sugar level (both imp), UPT

Investigations
Basic bloods: FBE, UEC, LFT (you will give an antifungal, you want to know if the liver
is okay),

Explanation
-What you are most likely having is again Candidiasis. It is a common yeast infection that
affects many women and could be irritating and painful.
-It is caused by an overgrowth of a fungus called Candida albicans, which is normally
present in your vagina. The other healthy bacteria in the vagina, usually prevents the
overgrowth of Candida. However, changes in your lifestyle and other health conditions
causes the yeast to multiply rapidly leading to recurrent candidiasis.
-what I think the trigger factor in you is the combined pill. The estrogen and to lesser
extent the progesterone in the pill can favor the growth of the candida.
-so it is better to stop the OCP taking at the moment and during this time it would be
advisable to wear condom.
Treatment
-I will prescribe you oral antifungal to induce remission (fluconazole or itraconazole
daily for 2 weeks or till the symptoms go off)
-next is to maintain remission using the same medication once weekly for next 6 months.
-have a good genital hygiene
-try not to wear tight jeans or pantyhose
-whatever you go for swimming remove wet clothes ASAP.
-better to avoid sexual intercourse till symptoms go off.
-reading materials
-review 2 weeks
50

Feedback (23/2/2017)
Gp, young lady with vaginal discharge.
Tasks:
1. Hx,
2. PEFE,
3. Probable diagnosis and DDx.
2 minutes: Ddx: Candidiasis, Trichomonas, Cervicitis, Bacterial vaginosis, other STI
Entered room. Greeted by examiner.
Greeted and introduced myself, patient was a bit embarrassed as this was not her first
time having such discharge.
Reassured her she was doing the right thing by coming to see me.
Gave confidentiality statement during my hx taking as well.
Discharge questions: duration, type, color, smell, pain/sore at private part, itchiness,
ulcers/rash at private part.
Any lower part tummy pain/dysuria/lumps and bumps/fever.
5Ps, PMHx, SADMA.
PEFE:
GA, V/S
P/A: mass, tenderness,
pelvic examination:
-inspection – rash, scratch marks, ulcers,
speculum exam – vagina and cervix (white chessy discharge),
bimanual exam – uterus position and size, adnexal and CMT.
Office tests: urine dipstick, BSL
Dx: Dear Cindy, based on the information you have told me and the physical
examination, most likely you are having a condition called candidiasis albicans. Have
you heard about it?
Don’t worry I will explain to you, it is basically a kind of fungal infection, and it is
common in women.
I would like to reassure you that this is not a sexually transmitted infection and it can be
curable. (tried to limit myself from telling too much as Mx was not my task). Do you
understand me so far?
51

It could be other types of condition as well by other bugs, or overgrowth of the usual bug
in the private part. I will give you reading materials about the condition.
Thanked examiner and patient

Feedback (27/4/2017)
a 25 y/o lady comes on combined OCP,with 4 times vaginal candidiasis in the last 3
months . The last time has been proved by culture as severe monoliasis infection and has
treated by nystatin cream 100 mg for 5 days but immediately aftef stopping the
medication it has recurred.
Task:
1- take detailed history from the patient
2- ask the requested physical findings and investigations from the examiner
3- talk about the measures that you want to do with the patient
woman around 30 c/o vaginal d/c, itchines, no urnariy symptoms, she is taking ocp for
contraception. This is 4 th time. 4 wks ago, u did test and showing nisillina (not sure), so
u give her nastytin 10,000 ng sth to her. She got the symptoms again soon after the
treatment.
H/o, ask pe, explain the condtion, mx.
After reading the question, I was thinking about recurrent candida infection and need to
stop OCP and ask other risk factors.
I entered the room and start introduction and as usual, greeting. How are you feeling
today .
She said that she still got the problem and a little bit upset.
I reassure her and said that it will be very distressing for you. So, I would like to ask you
a few more questions to clarify the condition.
I asked routine discharge questions and previous time, and the treatment she had
received.
Ask 5ps. No other risk factors like medications, steroid, tampon use, DM, wearing of
tight jeans.
*pf (she is married and use ocp , no multiple partners, no use of steriod , itchiness ++, no
fever or nausea or vomiting..
O/E; systemic are normal.
valva-redness + , no rash,
SSE- vaginal wall -healthy but whitish d/c +, BME -nl)
52

No BST available.

I explained her that it could be recurrent infection called candida infection. Reassure her
it has been four times. I also explained her that in case of recurrent infection, sometimes,
it can be associated with prolonged use of medications like OCP, steroid, and medical
condition like DM and certain risk factors like wearing of tight jeans. So, I want you to
stop using OCP right now and use other form of contraception like condom. I will
prescribe you oral medication again for your condition. I will also give you medication to
relieve your itchiness like antihistamine cream. I also explained about general vulva
hygiene and avoid wearing of tight jeans. Give advices about red flags and reading tips. I
told her that I will follow you up regularly to check your condition. You need to be
patient, alright. If we work out together, we can overcome the problem. Reassure…
FB-PASSED, OVERALL-4, HISTOR-3, ASK PE-5, MX-4
 
39-HIV in pregnancy
You are GP when 30 year-old woman presents to you. She is 12 weeks pregnant and has
come for blood tests results. She has done her blood tests with another GP and as her
usual GP is not available today, she has come to see you.
Tasks
-short history
-explain results to patient
-immediate and long term
Blood tests
FBC, UCE, BSL (all normal) blood group (O+ve)
rubella and varicella antibodies (+ve) hepatitis A and B (-ve)
VDRL (-ve) HIV (+ve)
History
1-current pregnancy and visits questions
-how is your pregnancy so far?
-is it planned (DO NOT CONGRATULATE HER)
-any tummy pain, vaginal bleeding or discharge?
-have you done a dating scan?
-have you been offered down screen?
-do you take folic acid?
-blood group (no need to ask as it is already in the result but ask if it is not In the stem)
-is your Pap or HPV up to date?
2-Sexual history
-are you in a stable relationship?
-how long have you been in this relationship? (3 months)
-how many partners have you had in the last 6 months? (multiple)
53

-do you practise safe sex?

-what type of contraceptive do you use? (condom) do you use it regularly? (yes)
-have you or your partners ever been diagnosed with STI?
3-SAD
-do you smoke or drink alcohol?
-have you used any recreational drugs? (yes)
-any chance you taken it through your veins? (yes)
-any needle sharing? (yes)
-are you still taking recreational drugs? (stopped 3 months ago)
4-past history
-Past medical
-past surgical
-past obstetrics (previous pregnancies or miscarriages)
-other medications
5-support

Explain results (good news then bad news)

Good news
-I got the results of your blood tests.
-It showed normal blood count, normal kidney function.
-Normal blood sugar so no DM at the moment.
-You have O+ve blood group and that’s good because –ve one can carry risk to the baby.
-your body has got the power to fight against infections like german measles and chicken
pox.
-no hepatitis or syphilis infections.
Bad news
-the next news is a bit concerning so have you been told why HIV screening has been
done for you and what will happen if it was positive. (Yes)
-unfortunately, HIV screening test has turned to be positive.
-Start crying so offer tissue box and glass of water.
-do you need to call anybody to be with you?
-are you happy to continue the consultation today.
Explain what is HIV
-HIV is a virus that can get transmitted through methods like unprotected sexual
intercourse or IV drug use especially if there is needle sharing.
-this is a transmissible disease but at this point you don’t have AIDS, you are just
HIV+ve and AIDS may not develop for 10 years or longer. (use may not rather than may)
-what I’m concerning is about risk of transmission to the baby which can happen during
pregnancy, time of delivery or breastfeeding.

GP role management
54

1-Confirm HIV
-the first thing I need to do is to confirm the diagnosis by doing another test called
western blot test. However once the screening test turned to be +ve there is a high chance
that the diagnostic one can be +ve.
2-Report
-Hiv is a reportable disease so my obligation as a Gp legally is to report this to the health
services. But your confidentiality will be maintained throughout.
3-Contact tracing + STI screen
-partner need to be tested for HIV and other STI so contact tracing need to be done.
you also require screening for other STI. And monitor also for hepatitis C.
4-Advice safe sex
-follow safe sex practise (condom during intercourse)
5-Refer to high-risk pregnancy clinic
-I would like to refer you to a high risk pregnancy clinic when you will be looking after
by MDT (HIV specialist, obstetrician, pediatrician, psychologist, social worker)
6-review and reading materials (tell this at the end of the consultation)
-I will arrange a review after specialist counselling and I’ll give you reading materials.
MDT management role
-HIV specialist will order further test looking for CD4 cell count, viral load, HIV
resistance test.
-will start you on antiretroviral agent which you need to take at the correct dose all
throughout the pregnancy, delivery and after delivery.
-the risk of transmission to baby is reduced by 2-5% if you take medication. If not the
risk can be 25-30%.
-you need to go through more frequent ANC, blood check, sugar test and ultrasound.
-the specialist might opt for CS to minimise the transmission of HIV to the baby at time
of labour.
-after delivery, the baby will be monitored by pediatrician and HIV specialist and put
on antiretroviral agent at least 1st 6 weeks.
-you will be advised not to breastfeed your baby as breast milk might contain the virus.
-both you and your partner will be offered counselling services
55

Case (4/10/2017)
Antenatal care
Scenario:
You are a GP. Seeing this patient for the first time. 30year old female 12 weeks POA,
your colleague had done antenatal bloods. Patient had come back for results. Usual GP
not available today. You will be given a card inside the room with investigation findings.
Tasks:
• Explain results to mum.
• Explain management. Immediate and long term.
I was expecting something like rubella or varicella positive. So, it was shocking to see
HIV positive (Antigen and antibody). Even before you finish reading Ix card patient talks
to you asking how are the tests. I decided to handle it as a breaking bad news case (I
myself was still in shock!) and asked if she knew what tests were done. (no)
I summarised that they’ve done blood group (…+ve) and some checks for certain
infections that are important in pregnancy. Rubella and varicella is negative but there is
one concerning result…… waited for a while... Did you know HIV test was done? I don’t
remember the specific words I used but said that she is HIV positive, and waited for that
to sink in … She acted very worried but did not cry (there was a tissue box, but I did not
give it to her.)
…. Then I said something to show empathy… and gave hope saying that HIV is not what
it used to be, as nowadays there are very effective antiretroviral drugs…
Then I asked her I can explain things in more detail regarding her further care now or
56

does she wish to wait or want someone else to be present. She said its ok to continue.
Then I assessed her knowledge on this stated this does not mean she has AIDS… Asked a
bit of history- gathered that she has had casual partners before current long-term partner
but always used condoms in those encounters. Baby was unplanned but now they are
happy to have the baby.
IV drug abuse – when she was a teenager shared needles!
Current smoker and drinks alcohol (not much) – Addressed then and there but postponed
more discussion 😊 Felt overwhelmed as so many issues kept coming up. ☹ I think she
was already on folic acid…
Management:
Will refer her to high risk pregnancy clinic where infectious disease specialist and
obstetrician will look after her with frequent clinic visits. They will do further testing to
confirm HIV and see the viral load as well. More Ix to check for other STI and blood
borne viruses. Possibility of vertical transmission explained but it’s not a must and means
of minimising the risk will be discussed with her and starting of antiretroviral drugs will
be considered by ID specialist.
I totally forgot her partner or contact tracing…so I thought I lost the case, but with a
worried patient being led by her reactions is more important than covering all the points I
think. I had to talk slowly and show my empathy on and off, so this takes time…😉
All 4 key steps covered

40-SLE Pre pregnancy counselling

Case
You are a GP and your next patient is 25 year old Mary, who was diagnosed with SLE 5
years back. She wants to start a family and is now seeking your advice regarding her
future pregnancies.
TASKS
-Take history
-Counsel the patient
AMC exam Case
27 years old Lady who has SLE for 5 years. Now wants to get pregnant. Letter to GP
from Rhematologist 6 months ago said ANA, anticardiolipin, antiphospholipid are
negative and disease is well controlled on low dose of Prednisolone.
Tasks:
-Take history
-Physical findings from examiner
-Arrange investigations
-Management or Counsel the patient
57

History
1-I can see from the note that you have SLE and you would like to become pregnant. Is
that right? I appreciate your coming to see me. I’d just like to ask you a few questions
would that be all right?
2-SLE questions
-you have SLE for 5 years. Can you tell me what symptoms did you have when you had
your SLE? Like skin rash, joint pain? (yes, skin rash and joint pain)
(As it has already mentioned 5 years in the stem but if not ask for how long have you
been diagnosed with SLE?)
-do you have any of these symptoms now? (No)
-How long have you been symptom-free?
-when was the last episode of flare up? (2-3 years ago)
-Do you experience any symptoms of kidney problem? (No)
3-Medication questions
-I can see that your SLE is well controlled with prednisolone. So how long have you been
taking it?
-Any other medications you take? (No)
-have you ever had any Side effects from medication?
(as it has already mentioned she is on prednisolone. If not you can ask What medications
were you put on? How long have you been off the medication?
4-Well control questions
-do you have regular checkups with the specialist? (Yes)
-any hospitalisation due to SLE? (No)
5-5Ps questions
Periods
- when was your LMP? Is it regular? Any problems with your periods? (Normal periods)
Partner/sexual
-do you have good support? (good support)
-Any history of STIs?
Pregnancy
-When are you planning for your pregnancy?
-is this your first pregnancy?
-any previous miscarriages? (Never become pregnant)
Pill
-what type of contraception do you use?
Pap and HPV (up to date)
6-General
-Do you smoke, drink alcohol or take recreational drugs?
58

-How is your diet? Exercise?

-Any other medical illness?

Physical findings from examiner

1-General appearance
pallor, jaundice, rash, LAP, joint swelling.
2-Vital signs
3-Chest (air entry, dullness, abnormal breathing sounds, adventitious sounds)
4-CVS (JVP, heart sounds and murmurs, apex beat site, pericardial rub)
5-abdomen (distention, tenderness or mass)
6-Pelvic exam (examiner will tell you not available)
7-joint
-tenderness, joint effusion, warmth
-restriction of movements
8-office tests
BSl and UDP

Arrange investigation and counselling

?? Explain SLE
-Do you know what SLE is? (yes)
As you are already aware, SLE is an autoimmune disorder in which certain factors called
antibodies develop against your own cells leading to inflammation of the body tissues
especially the skin, the joints, and others.
Reassure
-I got a letter from your specialist with all the investigations normal so let me assure
about it and as you haven’t had any flare ups for the last 6 months so you can get
pregnant.
SLE on pregnancy and pregnancy on SLE
-In majority of cases there will be no flare-ups of SLE during pregnancy especially if you
59

have no symptoms for the last 6 months so flare up in your case is unlikely. However, if
flare up happened it would be just mild to moderate.
- let me assure you that many women with SLE can go for a normal pregnancy and
delivery. But sometimes, SLE can affect the mom and the baby:
To mom:
*20% miscarriages
*20% hypertension in pregnancy.
*can go for preterm labour.
To baby:
*Intrauterine growth retardation: this happens because blood clots can form in the
placenta and that can interfere with the nutrition of the baby
*Birth defects: especially if the mom is on medications other than prednisolone.
*Prematurity: if the mom goes in for premature labor
*Neonatal Lupus syndrome: after birth; it is not SLE in the baby. The baby can present
with skin rash and some unusual blood counts and it usually settles in 3-6 months time.
Arrange investigations
-I need to do blood tests like FBC, blood grouping and RH, UCE, LFT, RFT including
GFR, vitamin D, German measles and chicken pox antibodies, STI check with consent.
- along with that I need to arrange for thrombophilia screening like protein C and S,
antithrombin 3, factor V Leiden, antiphospholipid and anticardiolipin antibodies , SLE
antibodies like anti Ro and Anti La, lupus anticoagulant.
-We can also do a urine microscopy culture and sensitivity, urine protein/ creatinine ratio.

Management
-Start you on folic acid 5 mg 3 months before you consider pregnancy, and for 3 months
after you become pregnant.
-refer you to the specialist rheumatologist to check if your condition is under control
-Once your pregnancy is confirmed, you will be referred to a high-risk pregnancy clinic.
MDT which includes the obstetrician and rheumatologist will be looking after you.
*-You need to go for More frequent antenatal checkups , regular ultrasound to monitor
baby growth, blood sugar at 28, bug test at 36 weeks, heart scan to detect fetal heart
block!, more screening if needed, and you will be carefully monitored for any
complications.
*-During the first and second trimester they will do monthly FBC especially platelets.
60

*-At the end of each trimester will repeat renal function test including GFR. Antibodies
like anticardiolipin and complements, urine protein/ creatinine ratio.
(regarding * *I’m not sure if we need to repeat these Ix now and again in this counselling
we can give a summary like the red star above them. However if you see you have time
mention them)
-just in case flare up occurred in pregnancy. The specialist will decide to increase the
dose of prednisolone and you will be monitored for high BP and sugar levels.
-You need to follow life style modification, sow salt diet, Ca and Vit D supplementation,
regular exercise
-If everything is normal you can go for normal vaginal delivery.
-After delivery, there is a chance of flare up but you will be monitored for that. You can
breastfeed your baby.
-Don’t worry I gave you a lot of information, I gonna give you reading material regarding
all of these.
-I want to see you again when the results appear.
-Are you a member of the SLE association of Australia? If not, refer you to that.

Recall of 10-5-2018 and 6-7-2018

Case (5/10/2017)
Station 2 Pre-pregnancy counselling Pass
27 yrs old lady with SLE on prednisone wants to discuss with about future pregnancy.
Her recent blood tests are normal including Cardiolipin antibodies, C3 C4 level, dsDNA,
ESR CRP, renal function test.
Task: History, PEFE
Counsel the patients
Explain her what investigations you want to do
61

Introduced myself , acknowledged her concern and appreciated her effort to come to
discuss, then reassure confidentiality. Told her before i explained to her about pregnancy,
would like to ask few questions to get to know more about her. Then History of SLE -
when diagnosed, follow up, last appointment, how well controlled, last episode of flare
up was 2 or 3 yrs ago, now she is doing ok, no fever, rash, jt pain. Then 5 P ( never
pregnant before, normal period, dont remember what contraception she is using, partner
is supportive, pap smear is normal). PEFE from examiner was everything normal ( i
asked for pelvic examination as i just wanted to do inspection but examiner said not
available, oops ).Then tell her about the blood tests which was done and reassured her
that they were normal. Told her that since her last flare up was more than 6 months ago,
she can get pregnant now.
Then explained to her about SLE on pregnancy and pregnancy on SLE effect ( that she
could get flare up during pregnancy, but it is very less likely and it could be mild flare up
cus she hasnt had flare up for over 6 months, she could develop complications like
miscarriage, preterm labour, Gestational HTN, preeclampsia, and baby could develop
complications like IUGR, preterm delivery).
I reassured her that most of SLE patents can go through normal pregnancy and normal
delivery and you wont be going thru this alone and we r here to support and help u. Then
told her about baby could develop Lupus like syndrome ( rash, heart beat abnormality)
but it will go away within few weeks but if it develped, there is high chance that baby
could develop SLE in later life. I am gonna start u on folic acid right now and will
arrange to do blood test like ur basic blood count FBE, inflammatory markers like ESR
CRP, renal function test, LFT and all the infection tests and SLE tests that mention on the
stem. And once u r pregnant, i will refer u to High risk clinic where they have
Multidisciplinary team and u will be followed up very closely with blood tests ( RFT and
SLE tests). Dont worry, i am giving you too much information right now, i will give u
reading materials about all of this. I dont remember if i mentioned i would refer her back
to her Rheumatologist or not.

Covered 3 key steps out of 4

History 5
Choice and technique of exam 4
Choice of investigations 4
Patient counselling 6
Global score 5

Case (28/11/2017)
Station 5 : Pre-pregnancy counselling - pass
Lady has SLE for 5 years. Now wants to get pregnant. Letter to GP from Rhematologist 6
months ago said ANA, anticardiolipin, antiphospholipid are negative and disease well
controlled on low dose of Prednisolone.
62

-Tasks:
-Take history
-Arrange investigations
-Management
Key steps: 3 /4
History: 5
Choice of exm, organization and sequence : 5
Choice of investigation : 5
Pt counselling: 5
Global score: 5 – Pass
History:
rapport
When was dx?
How many flair ups
Tretment you are on
Last time you had relapse
Regular with specialist? Last time saw specialist?
atm any rash/joint pain?
Present drug ? what is the dose?
5ps in short (hx of any miscarriage )
fhx of sle
Arrange investigations:
-FBE, Blood grouping typing, Rubella antibody screening (I mentioned that I will be
doing all the inv that we normally do in the first visit of pregnancy earlier for this patient
before conceiving)
-Apart from inv mentioned in the stem I arranged other ones. (thrombophilia screening:
protein c, protein s, antithrombin 3, factor v leiden, anticardiolopin antibody,
antiphospholipid )
-Refer to rheumatologist and obstretritian before getting pregnant
-Complications:
Sle on pregnancy
Pregnancy on sle
-Reassuring the pt that she will be managed by a multideciplinary team (gp, obs,
rheumatologist), under high risk clinic)
-More frequent visits, more scanning if needed , carefully monitoring for complications
that may occur
-Delivery will be in a controlled manner under the obstetrin preferably in a tertiary
center.
-4Rs: SLe association aus.
63

Feedback 27-10-2018 PRE-PREGANCY COUNSELLING FAIL

Patient with known case of SLE is planning to get pregnant. Certain investigation has
been done.
Task
- history
- PEFE
- investigation
- management

History
Details of SLE
- diagnosed a few years back.
- taking steroids
- last attack was 6 - 7 months ago
- no complications such as kidney Period (normal)
no past history of miscarriage
PEFE
- totally unorganized in this case.
office test
- urine dipsticks (protein) was arranged, but the result was not available
Investigation
- FBE
- blood group
- kidney function test
- Urea, electrolyte and creatinine
Management
- told her that I will refer you to your specialist to assess your condition again.
- they will review your medication and adjust the dose.
- patient with SLE should be symptoms free for 6 months to avoid complications
during pregnancy.
- if the symptoms are not well controlled during the pregnancy, it can lead to pre-
eclampsia.
- after consultation with the specialist and your condition is well controlled, I will
refer you to the high risk pregnancy clinic to prepare for the pregnancy.
- for the time being, you can start taking folic acid.
- reassure her that there are support group available.
64

• In this station, I was totally unorganized.

• didn’t explain how SLE would affect her and her baby in details if the condition
was not controlled.
• didn’t arrange albumin: creatinine ratio and GFR which are key steps in the
investigation. Grade - fail
Global score - 2
Key steps
1,2,3,4 - Yes, No, Yes, No
History - 3
choice and technique of examination - 2
organization and sequence
choice of investigation - 3
Patient counseling - 2

43-Pubertal Menorrhagia (Anovulatory DUB)

Your next patient at you GP is 14 year old Maria, brought in by her mom Jenny. Jenny
tells you that Maria had just had her first period and she is having a heavy bleed .
TASKS
-Take a further history from the mom
-PE from the examiner
-Diagnosis and differential diagnoses
 
Differential Diagnosis:
 Pubertal menorrhagia
 Pregnancy complications
 Infection
 Thyroid disorders
 Bleeding disorders
 Blood-thinning medications

History
1-rapport+ immediate action
65

-Introduce yourself and say I can see from the notes that you are complaining of heavy
menstrual bleeding is that right?
-Are you still bleeding?
-I just need to ask you further questions to know about the problem but before that I first
need to check your vitals; your pulse and blood pressure I’ll ask the examiner about it.
-Examiner Is my patient hemodynamically stable? I would like to take her vitals and
measure the pulse and blood pressure
- Note/ in the exam the examiner will say she is hemodynamically stable

Note/Just in case she was not hemodynamically stable say this:

-for example, the examiner said: She is pale, anxious and sweating. BP is 80/60, PR 90
bpm regular, RR 24/min, Temp 36.7, O2 93%
-I would like to shift the patient to the treatment room and proceed with the DRABC
protocol:
Call for help. Put in 2 large bore IV cannulas, take blood for investigations such as
FBE, ESR/CRP, UEC, B-Hcg, thyroid function test, blood group crossmatching and
hold, coagulation profile
Start IV bolus, then as IV infusion
Start O2 by mask
-Once the patient is stabilized, I would like to proceed with the rest of the history from
the mom

2-reassurance
-I have checked your vitals and they are all ok so let me assure you that you are stable
now. I would just like to ask you some questions in order to unravel the nature of the
problem.

Note/ if she was in shock and you stabilized her

-Since you were a little unstable a while ago, we have done measures to stabilize you.
you are stable now. I would like to ask further questions about your condition.

3-bleeding questions
66

-Is this your first period? (Yes)

-when was your menarche or first menstrual period? (10 days ago)
-How many days have you been bleeding? (10 days)
-What is the severity of the bleed? How many pads has she used per day? Is it fully
soaked? (More than 4 pads a day)
-What is the color of the bleed?
-is it smelly? (No)
-Any clots? (one feedback say +ve!!!)

4-associated symptoms (pain+ anaemia)

-are you complaining of any pain in your tummy? (No)
-do you feel tired and dizzy? Are you short of breath? Any chest pain or funny racing of
the heart? (No)

5-Differential questions:
-Any weather preferences? Any changes in weight recently? How about your bowel
habits? (Thyroid disorder)
-Any history of bleeding disorders? Do you bruise easily? (Bleeding disorders)
-Any medications that you are taking? (Blood thinner medications)
-any fever? (Infection)
-Any trauma? (Trauma)
- Any elder sisters that you have? Any history of heavy bleeds in your sister? (Pubertal
menorrhagia) (Her sister had her first menstrual period at 14 years old)

6-5Ps
-period (already asked)
-partner: are you sexually active? (no)
-Pills
-pregnancy (no need)
-have you had your Gardasil vaccine (no answer from feedback)

Physical Exam (in the exam all normal, may be mild anaemia!!)
-General appearance: dehydration, rash, bruising or petechial, pallor, LAP, acne,
hirsutism
-I hope that the vitals of the patient is now stable, so I would like to re-assess all the
systems
67

-Respiratory - equal air entry, abnormal breath sounds

-CVS - normal S1 and S2, abnormal heart sounds
-CNS
-Abdomen - visible mass, distention, palpate for mass and tenderness
-Thyroid
-Pelvic: inspection of the vulva and the vagina any bleed? What is the color? Any clots?
Rash and vesicles? DON’T GO FOR SPECULUM AND PER VAGINAL EXAM
-Office test:
UDT, BSL
Urine pregnancy test (-ve)
 

Explain the diagnosis+ DDX

1-Pubertal menorrhagia
condition
-What you are having is most likely a condition called pubertal menorrhagia. It is a
condition where you get heavy bleeding during the first periods.
Cause.
-Usually there are many hormones that regulate the menstrual cycle, and a disruption in
the hormonal balance can lead to a heavy bleed.
Course.
-It will take quite some time for the hormones to come back to normal.
2-DDX
other possibilities could be thyroid problem, Bleeding disorder, blood thinner
medications, Infection, trauma, miscarriage. Say all unlikely and give reasons from
history and examination.

Management (not a task)

Investigations: (from RCH)
FBE & Ferritin
Coagulation screen
serum ßhCG
Measurement of serum TSH to exclude thyroid abnormalities
Consider pelvic ultrasonography if accompanied by pain or palpable mass (to exclude
structural causes, such as fibroids, polyps, and/or ovarian tumors)

Active bleeding management

68

-because you are bleeding heavily and you have gone into shock, you require a referral to
the hospital and need to be admitted and be seen by the specialist.
Bleeding has to be stopped immediately by giving you IV Premarin 25mg (high dose of
conjugated estrogen). Even with a single dose, the bleeding can be stopped. But if not,
you can be given up to 4 doses. This will inhibit the access in the brain that controls the
menstrual cycle. But you have to be consequently given oral Progestogen for the next
14 days to compensate for the high levels of estrogen (otherwise she will go in for a
withdrawal bleed).

if no active bleeding or when active bleeding stops

-Once the active bleeding stops, we need to consider medications or treatment for the
next 2 -3 cycles, as it will take around 2-3 months or even up to 6 months for the
hormone levels to stabilize. For this, we can put you on non-hormonal conservative
management with Tranexamic acid or Mefenamic acid, or hormonal management
with combined oral contraceptives, which regularizes her periods and makes it
lighter and shorter as well.
These are the options that I can put her on for the next 3 months.

-provide her with adequate psychological support during this time and give her
adequate nutrition especially iron rich foods. (if you are talking to mom)
If iron is low, start her on iron pills.

Feedback 20-2-2018
GP, 17 years old lady came complaining of heavy menstrual bleeding.
Tasks:
-Take history
-Physical examination from the examiner
-Explain the probable diagnosis and differential diagnosis to the patient
2 min thinking: assess haemodynamic stability, 5Ps, menorrhagia ?cause (hormonal,
bleeding diastasis, medication), rule out ectopic pregnancy
History:
Introduce myself, ask the patient how does she feel? How long has she been bleeding and
how many pads? (this is the 10th day of period and ? pads for today). Then explain to
her I need to make sure she is stable by measuring her blood pressure and other vital
signs and turn to the examiner. (Examiner said she is hemodynamically stable).
More questions about her period: clots, foul smelling, pain in lower part of belly,
associated symptoms eg: light-headedness, tiredness, fever. BO/PU unremarkable.
Then asked about when did she had menarche? (10 days ago) I asked again – when did
you had your first period? (10 days ago). I was confused at that time, but decided to let it
go and asked other Ps – partner? (no), sexual intercourse (never), so I did not ask about
pills, pregnancy and PAP smear.
69

PMHx: hypothyroidism, bleeding disorder, medication usage – all unremarkable

I decided to ask her when she attained her menarche again. (10 days ago). Suddenly I
realised this is her FIRST menstrual period! I explain now I understood what she said and
apologised to her for causing her feeling stressed by asking the same questions
repeatedly.
SADMA unremarkable, family history: mother and elder sister attain menarche at 14
years old.
Physical examinations:
All unremarkable
Asked about Tanner staging for breast and pubic hair growth – (Examiner said there are
breast and pubic hair growth)
Only did inspection on pelvic examination as patient is a virgin
Explanation:
Dear Judy, you are having heavy bleeding in your first menstrual period. It is quite
normal for some people to experience that. (I forgot the term puberty menorrhagia). It
could be other possibility like hormone imbalance i.e hypothyroidism, bleeding disorder
however you do not have any family history of this condition. Infection but it is less
likely. Don’t worry too much, it is manageable and first I will give you some medication
to reduce the bleeding . (I did not proceed to much in management as it was not my
task). Assess understanding, reading materials, review.
(Most likely this is the non-scored station)
70

Feedback 20-4-2018
71

RCH reading
https://www.rch.org.au/clinicalguide/guideline_index/Adolescent_Gynaecology_Menorr
hagia/
72

Definition

1. excessive menstrual flow in its duration (>7 days) or its volume (equates to
needing to change a super pad/tampon more frequently than every two hours)
2. Bleeding causing symptomatic anaemia or lifestyle disturbance

Background
Menstrual cycles are often irregular in the first years after menarche. 
Most cases of cases of heavy menstrual bleeding in adolescents can be caused by
anovulatory cycles, which is related to immaturity of the hypothalamic-pituitary-ovarian
axis. Other causes include pregnancy, infection, the use of hormonal contraceptives,
stress (psychogenic or exercise induced), under- and over-weight or weight changes, and
bleeding disorders.
Less common causes of heavy menstrual bleeding in adolescents include systemic illness
and endocrine disorders. Structural lesions that cause heavy menstrual bleeding in
adolescents are incredibely rare (cervical polyps and uterine leiomyomas such as
fibroids).

Assessment
History:

1. Menstrual history (menarche, last menstrual period, frequency, duration, flow,

pain)
2. Bruising
3. Galactorrhea
4. Lethargy, headache

Examination:

1. Pallor
2. Evaluation for signs of androgen excess: hirsutism; acne;
3. Examination of the skin for acanthosis nigricans or signs of abnormal bleeding
(eg, petechiae and/or bruising)
4. Palpation of the abdomen for uterine or ovarian mass

Investigations:

1. FBE & Ferritin

2. Coagulation screen
3. ßhCG
4. Measurement of serum TSH to exclude thyroid abnormalities
5. Consider pelvic ultrasonography if accompanied by pain or palpable mass (to
exclude structural causes, such as fibroids, polyps, and/or ovarian tumors) 
73

Management

 Single or combination of non-hormonal and hormonal treatment (for example

NSAIDS & Tranexamic acid & Progesterone) can be used depending on severity

Non-hormonal forms of treatment

 If anaemic or recurrent/severe bleeding: Iron supplements

 First line to decrease flow:

o NSAIDS (Naproxen, Mefenamin acid, Ibuprofen) - unless contraindicated.

Can decrease flow up to 30% if taken regularly during the first 48 hours of
menstruation
o Tranexamic acid (1 gram, every 6 hours) can decrease flow 50%, does
not reduce the duration of menses or regulate the menstrual cycle, needs to
be taken for 3-5 days following cessation of bleeding

Hormonal forms of treatment

 Progesterone (e.g. Norethisterone 5mg, Medroxy-progesterone acetate 10mg).

Good with anovulation (infrequent periods) due to the lack of progesterone

o Acute treatment: 5-10 mg x 21 days (N.B. Will bleed when ceased!)

o Prophylactic treatment: 7-10 days/month
 Combined oral contraceptive pill : can decrease flow by 50%. Good with
anovulation/irregular menses: often commence with Ethinylestradiol
30mcg/Levonorgestrel 150mcg, and transition to continuous use after the first
month’s withdrawal bleed.

Discharge criteria & follow up

Organize follow up with GP within a month. If concerned or persistent symptoms refer to
Paediatrician or local Gynaecologist.

When to admit/consult local paediatric team

Admission for hemodynamically unstable adolescents with a low hemoglobin
concentration, or who have symptomatic anemia.
74

When to consider transfer to tertiary centre

If unable to control bleeding

46-Recurrent miscarriage
Case 1
30 or 37 year old Lisa presents to your GP clinic. She thinks that she's pregnant now as
her home pregnancy test has turned out to be positive. She gives a history of having 3
miscarriages before.
TASKS
-take relevant history
-Counsel the patient
Case 2 (AMC exam 2018)
37 year old lady wanting to get pregnant for the past 6 years but has no health related
issues. General, abdominal and gynecological examinations are unremarkable.
Tasks
-take history for 6 mins.
-Investigations with reasoning.

Note/Recurrent miscarriage: greater than or equal to 3 miscarriages which is consecutive.

Causes of recurrent miscarriage: (CII SEE U)
1-Chromosomal abnormalities
in the mother/father or baby (parental or embryonic) - most common cause of first-
trimester miscarriages
2-Immune-mediated
-APAS
-SLE
-thrombophilia
3-Infections
-TORCH
-STIs
75

-Hepatitis B and C.
4-SAD
5-Endocrine causes
-DM
-Thyroid disorders.
6-Epidemiological factors
-advanced maternal age,
-number of previous miscarriages - after 3 consecutive miscarriages, the chance of a
miscarriage is 40%
7-Uterine abnormalities
-cervical incompetence
-gynecological surgeries
-septate or bicornuate uterus.
7-Unknown
Case 2 (AMC exam 2018)
History (6 minutes)
1-5 Ps Questions
Period
-When was your last menstrual period?
-Are they regular?
-do you have any pain or heavy bleeding during menstruation?
-any pain or bleeding between menstruation?
Partner or sexual
-are you in a stable relationship?
-do you have any pain during intercourse?
-do you have good support?
-have you or your partner ever been diagnosed with STI?
Pregnancy
-have you ever become pregnant?
-any previous miscarriages? (3 previous miscarriages)
Sorry to hear that.
When do you have these miscarriages at what age and which weeks of pregnancy? (all
first trimester)
When was the last miscarriage?
Any successful pregnancy for you so far?
Any surgical intervention done at the time of miscarriages? (None)
Any analysis been done on the fetal parts at that time?
Have you received counselling after the miscarriages?
-are you planning to become pregnant? Do you think you are pregnant?
-Early pregnancy questions:
any tummy pain, vaginal bleeding or discharge?
Any nausea or vomiting, breast tenderness or mood changes?
Pill (OCP)
76

Pap or HPV -is your pap or hpv up to date

2-General questions (to rule out other DDx)

-Past medical history
*any immune related or blood diseases like SLE or blood clotting problems?
*Any history of thyroid problems? any weather preference ? how is your bowels habit?
*Any history of diabetes? Do you feel thirsty? Are you passing large amounts of urine?
*Have you ever been tested for immunity against Rubella? Any pets at home?
(Toxoplasma - mainly the cat litter that contains the Toxoplasma) Any raw meat in your
diet? (Toxoplasma)
-Past surgical history
-do you take any medications?
-SAD: Do you smoke, take alcohol or take recreational drugs?
-Family history of miscarriages? Are you aware of your blood group? (RH –ve can
cause miscarriage)
Case 2 (Task 2 investigation with reasoning)
I finish history and all examinations are unremarkable. I need to order some
investigations to know more about the possible causes of these recurrent miscarriages.
1-Urine pregnancy test to rule out current pregnancy.
2-Baseline and routine (FBE/ ESR&CRP/ UCE/ LFT) + blood group and RH
3-CII SEE U
-Chromosomal abnormalities (as all miscarriages happened during the first trimester so it
is likely that it could be due to a chromosomal abnormality in the baby so I need to refer
you and your partner for karyotyping)- Karyotyping.
-Immune and blood clotting problems SLE antibodies, thrombophilia screen for
clotting problem, antiphospholipid antibody
-Infections-- chicken pox and German measles antibodies, hepatitis serology and STI
screen with consent.
-SAD- no need just history
-Endocrine-- thyroid function test to look for thyroid problems and BSL to look for
diabetes
-environmental-- no need just form history
-Uterine abnormalities-- pelvic ultrasound scan

Recall of 6-7-2018 and 21-4-2018

Feedback 21-4-2018
37 year old lady wanting to get pregnant for the past 6 years but has no health related
issues. General, abdominal and gynecological examinations are unremarkable.
Take history for 6 mins – 3 previous episodes of first trimester miscarriages , no
investigations done, all other negative in the hx ( frequency of intercourse normal )
Investigations with reasoning – Rule out Pregnancy now ( urine test ) , Karyotyping ,
FBC , EUC , LFT , TFT , FSH /LH and Prolactin , USS pelvis , Partners SFA
77

Global score - 5 ( Approach 4, Hx 5 , Choice of Ix – 4)

My Comment - Out side thought subfertility but when it comes to hx its Recurrent
miscarriages( go inside in an open mind)

Case 1
History
Period
-LMP and regularity (6 weeks ago)
-any concern about periods
-tummy pain, vaginal bleeding or discharge
Partner or sexual
-stable relationship?
-good support?
-STI?
Pregnancy
-Early signs of pregnancy?
-when did you do your pregnancy test?
-have you seen a doctor?
-did you start taking folic acid? For how long?
-blood group? (RH –ve can cause miscarriage)
Others
Any immune disease or blood disorder like SLE or clotting problems
Any history of thyroid problems? any weather preference ? how is your bowels habit?
Any history of diabetes? Do you feel thirsty? Are you passing large amounts of urine?
Any history of multiple cysts in the ovaries?
have you done pelvic scan before?
Life style modification (diet, exercise, SAD)
78

specific miscarriage questions

-sorry to hear you have had 3 miscarriages
-when did you have them? (all between 8-10 weeks)
-when was the last one?
Any successful pregnancy for you so far?
Any surgical intervention done at the time of miscarriages?
Any analysis being done on the fetal parts at that time?
Have you received counselling after the miscarriages?

Case 1 Counselling
-Confirm the pregnancy by doing the UPT
-Explain the causes one by on
-as all miscarriages happened during the first trimester so it is likely it could be a
chromosomal abnormality in the baby.
-Although we have to look at other causes as well, that is why we need to arrange some
investigations such as:
1-Routine: FBE, UEC, LFT, BSL, vitamin D level
2-Antenatal: blood group and Rh, antibodies to rubella, varicella.
3-Causes: TORCH screen, TFT, thrombophilia screen, antiphospholipid antibody screen,
STI screen including hepatitis B and C.
4-I will refer you and your partner for karyotyping, and we will also do a pelvic
ultrasound.
Case 1 Management
-from now on your pregnancy will be managed at a high risk pregnancy clinic.
-if not start her on folic acid for the 1st 3 weeks of pregnancy.
-depends on Ix you will be managed further
chromosomal abnormalities: you will be referred to a clinical geneticist
any blood disorders: she will be followed up by a hematologist
-You need to go for regular antenatal checks, and it is always advisable to do a Down
syndrome screening as well (important if 37 years old) Ultrasound scans and frequent
monitoring.
79

-Lifestyle modifications - healthy diet with no unpasteurized diary products and no raw
meat, if you have a pet at home do not handle the litter, regular exercise, no SAD
-Reading materials regarding recurrent miscarriages. Arrange a review once the blood
test results are out.

Another feedback FAIL

7. 37 year old lady wanting to get pregnant for the past 6 years but has no health related
issues. General, abdominal and gynecological examinations remarkable.
Task take history for 6 mins. Investigations with reasoning.
Thought it was infertility outside but was a case of recurrent miscarriage when asked the
history. Had 3 miscarriages.
Station 10 First trimester complications
I am upset by this case.
When I read the stem, it appeared to be an infertility case, then DDx in my mind:
Female factor: PCOS, Pills, POF, Prolactinaemia, PID, STI, Fibroid; male factor: STI,
sperm quality issue, mumps in childhood etc.
When I sat down in front of pt, I said I understood it is frustrating, let me help, could you
please tell me more about your condition, AND pt replied what do you want to know,
doctor. (after exam, other candidates told me when they asked, pt just told them
everything about her multiple times of miscarriage).
80

Anyway, I carried on then, I mentioned confidentiality (I am not sure if I mentioned this

earlier) then started to ask relevant questions all about infertility but not in an well
organized way.
Mx: blood tests to check hormone, check partner bala bala, pt seemed to be surprised
when I mentioned some tests, anyway, it was not important at all
Another mistake that made me miss this case is that in 5 Ps questions, I did not ask
miscarriage!
I failed this case which was not unexpected.
Approach to pt: 4
Hx: 2
Choice of Ix: 2
Global Score: 2 fail
I feel it was just a bit unfair. But this is AMC. If one did not ask the specific question or
make the specific statement (confidentiality), he/she would not get the answer. One of my
tutor and friend told me in our class that he always made confidentiality before he started
to take hx.

Feedback 5-7-2018
Young lady married for 6 years unable to have a baby.
Task: 1- Hx 2- Dx and DDX with investigation
My first Qs was any pregnancy before (to differentiate between infertility and recurrent
abortion) .. multiple miscarriages between 8-10 weeks of pregnancy. I asked details of
miscarriage. Any Ix done (none). Asked 5ps, her LMP was 2 weeks ago .. then I start to
ask about my DDx
1- SLE and antiphospholipids (rash, blood clot)
81

2- endocrine: PCOS qs, thyroid (bowel motion, wt gain, neck lump), DM

3- PID and previous surgeries
4- Uterine abnormalities
5- TORCH (contact with pets, fever)
6- asked about diet, exercise, headache, blurred vision, fertility period.
In explanation, I draw a diagram mention my DDx and what Ix to exclude each like
thrombophilia scree, hormonal study, TFT, FBS, screening for TORCH antibodies and I
even mention US and HSG and explained it. Reassure the pt she still has hope.
Passed: global score 6

Feedback 5-7-2018
37 yr old female , married for 6 years, unable to have children
Tasks
Take relevant history
Explain d/d to the patient and relevant investigations
Asked all 5 P’s… no contraception, stopped 1 year ago, period regular, sexual history and
if she knows her fertile (ovulation) she said all good.
She had 3 miscarriages all between (8-10 weeks gestation), no investigation done, nil
other positive findings (no hirsutism, acne, regular periods, stable partner, no STI),. No
known medical condition
I forgot to ask about thrombophilia screening.
I explained the most likely its due to her age as chromosomal abnormalities are higher in
this age group. Or could be antiphospholipid syndrome.
Investigation: I FORGOT PREGNANCY TEST! Her LMP was 2 weeks ago
Thrombophilia screening
Hormonal investigations (prolactin, estrogen, progesterone, testosterone)
Antiphospholipid antibodies, SLE antibodies

75-Threatened Miscarriage
You are at your GP, when 27 year old Susan presents with bleeding from the vagina since
the past 1 hour. She has done a home pregnancy test which has turned out to be positive
(2 days ago)
TASKS
1.Take a further history
82

2.Get the examination findings from the examiner

3.Discuss your diagnosis and further management with the patient
Differential Diagnosis:
1-Miscarriage (Threatened, incomplete)
2-Ectopic pregnancy
3-H-mole
4-Trauma
5-Infections
6-Bleeding disorders/ Blood thinning agents
7-Cervical polyps
APPROACH
History:
1-Is the patient hemodynamically stable?
2-Bleeding questions (Duration-Action-Trauma-Amount or severity-colour-odour-
content-dizziness- bleeding disorder or blood thinner)
- for How long have you been bleeding? Is this the first time?
- What were you doing the time you passed blood?
- have you had any trauma to your tummy? (Trauma)
- How many pads have you used so far? Is it (are they) fully soaked?
- What is the colour of the bleed?
- is it smelly? (infection)
- Are there any clots or tissues? Any vesicles or grapes? (Molar, Incomplete miscarriage)
- do you feel dizzy or tired? (Effect of bleeding)
-have you had any bleeding disorders or take any blood thinner medications?
2-Associated symptoms (tummy pain, fever, N&V, discharge)
- do you have any pain in your tummy? (Mild pain)
ask only severity + pain killer, site and radiation.
- Any fever? Nausea or vomiting? Abnormal vaginal discharge?
3-5 P’s questions
Period questions: (only ask LMP and regularity)
-When was your last menstrual period?
-were they regular?

Partner or sexual (only support and STI)

-do you have good support?
-have you or your partner ever diagnosed with STI?

Pregnancy (very important)

- are you trying to become pregnant?
83

- have you had any previous pregnancies or miscarriages?

- do you have any vomiting, breast tenderness?
Pill
how long have you been off the contraception?
Pap or Hpv
is your pap or Hpv up to date?
4-Early Pregnancy questions
-Any antenatal checks you'd done so far?
- Have you taken your folic acid?
-are you aware of your blood group?
5-General questions (Diet-SAD, OTC- pets, PMH-PSH-Family hx)
- Diet: any intake of raw meat? (predisposed to toxoplasma), how many coffee do you
take in a day?
- Do you smoke, drink alcohol or take recreational drugs?
-Any prescription or over the counter medications?
- Any pets at home? (toxoplasma in cat litter)
- Any other medical or surgical illness?
-Family history of miscarriages?

Physical Exam from examiner

1-General appearance:
pallor, dehydration, LAP (PDL) , Bruises or bleeding
2-Vital signs
Blood pressure (+ postural hypotension) , Tachycardia, Temperature
3-quick Systemic exam
4-focus on Abdomen
Inspection (distension, Mass)
palpation (tenderness, mass)
Bowels sound
5-Pelvic exam
consent of patient and presence of chaperone:
Inspection: colour of the bleed? Tissues, clots?
Speculum: look if bleeding is coming from cervix , cervix closed or open? (Key)
Per vaginal: CMT, uterine size, position, tenderness adnexal mass and tenderness (key)
6-Office test: urine pregnancy test, UDT, BSL
Explanation
-Most likely what you're having is a threatened miscarriage. It is a bleeding from the
vagina before 20 weeks of pregnancy. More than half of the women stop bleeding and
they continue to have a normal and healthy pregnancy.
84

-Exact cause is unknown but there are certain risk factors associated with this like
smoking, alcohol and recreational drugs, excessive coffee intake, infections, trauma,
could be due to problems in the placenta feeding the growing baby, or could be due to
genetic abnormalities in the baby.
-From the details that you have given me, I have not found any risk factors in you, so
there is nothing that you have done that has caused this miscarriage, and there is no way
by which we can predict a miscarriage.
Management
You need to be referred to the hospital now and seen by the specialist.
Blood investigations needs to be done such as:
-FBE, UEC, ESR/CRP, blood group and Rh typing, coagulation profile, vitamin D,
antibodies against rubella and varicella, STI screen, and also a TORCH screen.
-Urine needs to be given for microscopy and sensitivity.
-Ultrasound will also be done to check if the pregnancy is viable or not and also to rule
out other causes of bleed.
As you are not bleeding heavily, and the opening of your birth canal is closed, if the
ultrasound shows a normal viable pregnancy, then the specialist might advise you to
return home.
Once you are at home, you need to:
-avoid overexerting yourself. No activities like no sports, lifting heavy weights.
-Rest is not usually advisable, because rest will not prevent the miscarriage from
progressing.
-Do not insert tampons into the vagina for the bleed, but you should use pads for the
bleed.
-No sexual intercourse until the symptoms have gone completely for 1 week.
Red flag: Seek urgent medical advice in the emergency department if the bleeding
becomes heavy, any passage of tissues to the bleed, and if the cramping worsens, or if
you develop fever.
Follow up: A repeat ultrasound needs to be done after 1 week. As the pregnancy
progresses, you need to come for regular antenatal checks and do a Down syndrome
screening.
I will start you on folic acid which you need to take for the first 3 months of pregnancy.
(Key)
Refer to high-risk pregnancy clinic, Another ultrasound will be done at 18 weeks, sweet
drink test at 28 weeks, a repeat ultrasound at 32 weeks if needs, and a bug test at 36
weeks.
Maintain a healthy diet, do not eat any raw meat, no smoking, alcohol or recreational
drugs and limit coffee to 2 cups per day.
85

I will arrange a review with you once you are out of the hospital.
***if woman is Rh negative, a threatened miscarriage up to 12 weeks, there is no need
to give anti-D, unless patient goes in for a complete miscarriage.
But if it is any other kind of miscarriage, you need to give the anti-D.
Feedback Case (29/11/2017)
Young lady (24-27years) with vaginal bleeding.
Tasks
-Take history
-Ask for Physical examination findings.
-Explain reasons and arrange investigations.
Positive findings on history
-Bleeding is bright red,
- 2-3 pads per day. - First time happening.
- LMP was 6 weeks back. - Periods are regular.
- Had been trying to get pregnant. - Contraception history was negative.
- Not bleeding from anywhere else. - Pregnancy s/s – nausea, breast tenderness was
positive.
Positive findings On examination
- no pallor, Retroverted uterus, os closed, no s/s of bleeding).
Key steps: 5/5
History: 6
Choice, organization, sequence of examination: 6
Choice of investigations: 4
Global score : 4/5- pass
Went inside, Greeted examiner and patient
haemodynamic stability?
Any chance Pg?
Bleeding ques
Bleeding from anywhere else (bleeding disorder)
Passage of grape (molar)
Passage of tissue, still feel n, v, breast tenderness (incomplete/complete)
Anything started it? (trauma, sex..)
Anemia ques
5ps
Blood group
Folic acid
SADMA
PE- General appearance, vitals, Anaemia, postural drop
Abdominal examination, pelvic examination,other systems
Office test- UPT, blood sugar, urine dipstick
Investigations -USG- to see fetal condition , FBE, Blood group, U&E
86

Explained dds to the patient

1. delayed period 2. Trauma 3. Threatened 4. Incomplete 5. Complete 6. Ectopic 7. Molar
8. bleeding disorder
Feedback 16-8-2018
Station 7. Threaten abortion
GP, 24 years old lady came to see you for bleeding per vagina.  
Task: Take history 
          Ask PEFE 
         Give diagnosis 
         Differential diagnosis 
  
Pt has no eye contact.  
Reassure. Check stability: stable.  
Bleeding per vagina: start morning. 3 pads soaked with blood, no vesicle, tissue and clot.
No dizziness, SOB. No abd pain. 
LMP: 8 wks ago. Regular. 
Stable partner. No history of STI. 
Contraception: Use condom & OCP. OCP stop 12 weeks ago. No pills problem. I asked
trying to be pregnant (she didn't answer exactly) 
Pregnancy: breast tenderness (+), no history of pregnancy & miscarriage. Her bld gp is
O+.  
Pap smear: forget when & result. I offered I will do after this section. 
General health: no history of bld disease. Not taking bld thinning medication. No
symptoms of hypothyroid, SLE, Cancer and injury. 
PEFE: All normal except VE: I: dark bleeding, Os close, No adnexae and cervical motion
tenderness, ut size is 6-8 wks size & no tenderness. No lymph node. Normal BMI. 
Office urine dipstick: normal 
Urine pregnancy test: positive 
  
I said she has pregnancy. Draw a picture. Now bleeding fr downbelow: Threatening
miscarriage. I said other differential diagnosis.  

Grade: Pass
  Global score: 4
Key Steps: 1- Yes
2- Yes
3- No
   4- Yes
Approach to patient: 4
History: 3
Choice & Technique of examination, organization and sequence: 5
Diagnosis/ Differential diagnosis: 4
87

Feedback 7-12-2018
30 yrs old with complain of vaginal bleeding since morning.
task :history, pefe from examiner, investigation, diagnosis with reasons.
entered greeted both of them, asked vitals-stable.
history - bleeding started- yesterday, slight, red in color , no other discharge. no
vesicles, no pain, no trauma, no itching, no ulcers , not dizzy, no SOB, 5 Ps - LMP-8
weeks back ,pregnancy test positive, primi, did not use any contraceptive before.
no STD, PArtner- supportive,
family history-no history of special babies, twins, molar .
past history- no HTN, DM, bleeding disorders, abortions
SADMA-nil
pefe - all normal
pelvic examination- inspection-slight bleeding, no signs of trauma,
per speculum- os closed, vagina healthy
bimanual- uterus normal in size (was confused as not enlarged)
no adnexal tendenness, no CMT.
BSL,UDT-normal.
UPT+ve
i asked ultrasound -examiner said fetal sac present along with heart beat.
explained it could be threatened miscar, (reassured it is harmless, fetal heart beat seen ,
which is good sign )there could be many reasons like trauma, intercourse, problem with
baby, problem with placenta - asked her can you relate to any of these - then she noded
could be intercourse related. i explained other dd names but less unlikely as ultrasound
confirmed diagnosis.
scenario-vaginal bleeding,
GLOBAL-4( approach-4, history -5, examination -5,investiagation-4, d/dd-4)
88

Feedback 7-12-2018
Vaginal bleeding - 4
26 year old female with painless vaginal bleeding after 8 week of amenorrhoea. The stem
is a bit long.
Task: History
PEFE
Ask investigation
Dx
2 min thinking: incomplete/complete/threatened miscarriage; h.mole; ectopic; bleeding
disorders; if tissues were found  to skip UCG test and USG
History
Patient looked impatient. Greeted the patient. Checked stability.
(+)ve findings – LMP 8 weeks ago; regular period; no nausea and vomiting. Using
contraception ocasionally but no plans to get pregnant. No vesicles in the blood; no pain.
GH – good; no bleeding disorders; no thyroid problems; blood grp – O(+)
PEFE
GA – as you can see
Vitals – normal
Abdominal examination – nth significant
Vaginal examination – on inspection, no active bleeding; SSE shows os is closed; no
tissues or clots around the os; on BME, uterus is 6 week pregnancy size, no tenderness;
no adnexa swelling or pain
Investigation
FBE (you need to be more specific in what you are searching cuz the examiner remained
silent until I specifically said what I wanted to know) – Hb – 11%; platelet count –
normal. When I asked grouping and matching, he didn’t seem to understand me. So I
89

repeated and he still didn’t get me. After saying grouping and matching for 3 times, I
finally told I would like to check blood group of my patient – O(+) ve. Then I asked UCG
– the examiner said “do you mean serum beta hCG?” Yes. It was around 80,000 while the
serum beta hCG at 6 week of pregnancy should be around 60,000. (I had no idea what it
means, maybe H.mole?) USG – baby of 6 week size; intrauterine gestation; FHR –
80/min

Dx
I explained my patient what threatened miscarriage is. Things got awkward when I tried
to reassure my patient that this is not dangerous because suddenly, I remembered that it is
not intended pregnancy. The conversation came to abrupt halt, with plenty of time left.
After a while, I asked my patient if she wanted me to inform about this to her partner.
“NO. So, doc am I having a miscarriage?” No, about 90-95% of woman with threatened
miscarriage go on to have a successful pregnancy and a healthy baby. This is a fairly
common condition in pregnant ladies in their early time of pregnancy. To my rescue, the
bell rang.
GS – 4
Key steps 1 and 4 – No; 2 and 3 – Yes
Approach – 4
History – 4
Choice and technique of examination, organisation and sequence – 5
Choice of investigation – 6
Diagnosis and DDx – 4
90

50-Preterm Labor
A 28-year-old primigravida presents to you at 30wks of gestation with sudden onset of
abdominal pain. You are a GP in a rural practice about 300km away from a hospital with
O&G facility.
TASKS
Relevant and focused history
91

Examination findings from examiner

Discuss management with patient
Differential diagnosis
1-preterm labour
2-placenta abruption
3-preeclampsia
4-acute abdomen (appendicitis, pyelonephritis, cholecystitis)
5-UTI
6-ovarian cyst rupture
History
1-Check for hemodynamic stability.
- Is my patient hemodynamically stable? What is the BP, pulse, RR, temp and sats of my
patient?
2-Abdominal pain questions
severity
- Hi --- I'm Dr----your GP today. I understand that you suddenly experienced abdominal
pain. How severe is your pain from 1 to 10 1 is the least 10 is the most? (8-9)
-I would like to give a painkiller if you don't have allergies.
painkiller can take some time to work in the meantime can I ask you a few questions?
Duration and onset
-for How long have you had the pain?
-what were you doing when the pain start? Did you hurt your tummy by any chance?
-has it started suddenly?
-is it constant or does it come and go? (It is an on/off pain) (Abruption is continuous pain
while preterm labour come and go)
-Is the pain coming at regular intervals? Have you noticed that the intervals are coming
shorter and Pain duration coming longer? How frequent and how longer does it last?
(Coming regularly, shorter intervals, pain coming longer)
Site and radiation
-Where is the site of pain? (All over the tummy)
-Does it go anywhere else? (It goes to my legs, thighs, back)
Character
-can you describe it for me?
Aggravating or relieving
-does anything making it better or worse? Nothing.
3-Late Pregnancy complications question
- do you have any bleeding from your vagina. (placenta Previa, abruption)
- Any vaginal discharge? (PROM/ infection)
- Any fever, nausea or vomiting? (Acute abdomen/ Infection)
-any headache, blurred of vision or leg swelling? (Preeclampsia)
-Any burning or stinging while passing urine? (Urine problem)
92

-have you opened your bowels? (Bowels problems)

-Is the baby kicking well? (Baby problem)
4-regular visit questions?
- How’s your pregnancy so far? have you had Regular antenatal checks?
-have you had down syndrome screening at 11-13 weeks?
-US at 18 weeks? Is it a single baby? What was the Position of the placenta?
- Sweet drink test at 28 weeks?
- Folic acid in the 1st trimester?
- blood group?
5-General questions
-When was your last pap smear?
-Do you smoke, drink alcohol, or take recreational drugs?
-Do you have good support?

Physical Examination from examiner

1-general appearance (PODL)
- Is there pallor, edema, dehydration, lymph node enlargements?
2-Vital signs
especially BP, temperature.
3-abdomen examination
-Is there uterine tenderness? None (tenderness in abruption)
-is there any uterine contractions per abdomen? How frequent are the contractions
coming? How long do the contractions last? (Contractions happening 3-5minutes, lasting
30seconds to 1 minute.)
-What is the fundal height? 30cm (increase in abruption while decreased in preterm
labour)
-FHR? 150bpm
-Lie, presentation? Longitudinal, cephalic
-Is the baby's head engaged? Not yet
4-pelvic examination
-Inspection of the vulva and vagina, any discharge or bleed, rash or vesicles?
-Sterile speculum exam, any bleed or discharge from the cervix? Cervical os open or
closed? Dilated 3cm
**Don't do a per vaginal exam.
-I would like to take a vaginal swab and give it for fibronectin test. (Fibronectin is the test
to look for preterm labor. If it is positive, she might deliver in the next 7-10 days. If it is
negative, she will not deliver in the next 7-10 days)
-low vaginal and anorectal swab for GBS
93

5-office tests
urine dipstick and BSL
Explanation
-From history and examination, you most likely have a preterm labor. Normally labor
happens in and around 40 weeks, but if it happens before 37 weeks, that is called preterm
labor.
-there are several cause, but anything that over distends the uterus such as:
*excessive fluid in the bag of water we call polyhydramnios.
*big baby
*Multiple pregnancy.
*Cervical incompetence (could become earlier)
*Maternal infections (no fever or discharge)
*other maternal conditions such as diabetes and preeclampsia, which is a sharp rise in
blood pressure with leakage of proteins to urine.
*trauma
however we could not identify any of these so sometimes it can happen without a cause.
Management
-you need a referral to a tertiary hospital with a neonatal intensive care unit.
- I'll arrange an ambulance for you, I'll ring up the hospital and make them aware of your
condition so that all arrangements will be made once you reach the hospital.
- I will start you on an IV line, take blood for investigations like FBE, ESR, CRP, UCE,
blood group and Rh factor.
- I will give you your 1st dose of steroid (betamethasone), to bring about lung
maturity in the baby, (if less than 34 weeks) (2 doses at 12-24 hours interval), and 1st
dose of tocolytic. Tocolytic is the medication given to prevent further uterine
contractions. (Nifedipine, salbutamol)
-Once you reach the hospital, you will be admitted, seen by the specialist, ultrasound
and a CTG will be done to look for the wellbeing of you and the baby.
- Let me assure you that you will be in safe hand and they will do everything possible to
continue your pregnancy.
-They will give you further doses of tocolytics, and further dose of steroid.
-Just in case if your labor progresses and you deliver, the baby will be taken cared of by
the team at the neonatal intensive care unit.
Do you need me to call your partner to be with you during this time?

Feedback 20-7-2018
New case ( unscored)
94

27 years old Generalized abdominal pain

History , PEFE , diagnosis with reason
I was thinking surgery or medicine or OG ( like PID , ectopic)
But on entering pt is sitting on the chair , look tummy distension I thought that may
be she is fat or intestinal obstrution or bowel distension :D , I just took most of
history time to ask about surgery and medicine cause , when I asked about LMP is 6
months ago , immediately turned to obstetric question quickly… regular follow up ,
blood test normal , blood gp o pos , Folic acid + , USG normal , feeling baby kicking
, no headache , no vision disturbance , no bleeding , no water leakage, no leg
swelling
PEFE need to ask all before giving me card ( long findings card)
vital sign is normal , BP 120/70
SFH is 26 cm
no uterine tenderness ( sure)
as I remember there is no abdominal sign ( I don’t remember contraction is
given in the card )
cervix is 3 cm dilated ….. ( as I remember ,not sure , no discharge or
bleeding )
Tell about preterm labour , so that i need to transfer you immediately to hospital
Pt started to cry , no time for D/Dx ( was not asked though ) , I am also shocked cos
nothing about pregnant was given in stem

52-Pre-eclamptic/ Eclampsia
32 year old Maria, who is 32 weeks pregnant, presents to your GP, with headache since
the last 2 days. She had regularly done her antenatal checks with you and a week before,
when you saw her, she had mild swelling of her legs. At that time all relevant
investigations were done and they were all normal.
TASKS
Relevant history.
Examination findings from examiner.
Explain diagnosis to patient.
Management.

Differential diagnosis
1-preeclampsia
2-Migraine
3-Tension headache
95

4-URTI
5-ear or tooth infections
6-meningitis/ encephalitis
7-head trauma

APPROACH
History:
Hi Maria, it is nice to see you again, I can see that you are complaining of headache is
that right? Just let me ask you few questions to unravel the nature of the problem
1-Headache questions (rule out tension and migraine)
-Can you tell me more about it?
-Severity
-First of all how severe is your headache from 1 to 10 1 is the least 10 is the most?
-I can offer painkillers for you so do you have allergy to any medications?
Onset and duration
-How long have you been having the headache?
-Sudden or gradual? Constant or come and go? Is it getting worse
Site and Radiation
can you show me exactly where you have the pain?
Does it go anywhere else?
Character
can you describe it for me?
Aggravating and relieving
does anything make it better or worse
Timing
any specific time when the pain is worse?

2-Differential diagnosis questions

-any recent infection? (URTI)
-any pain in your ear or teeth? (ear or teeth infections)
-Any fever, rash or neck stiffness. (Meningitis/ encephalitis)
-have you had any trauma or injury to your head? (head trauma)

3-Preeclampsia questions (Headache, BOV, leg swelling, tummy pain, vomiting,

bladder and bowels, complications: confusion, bleeding, discharge, baby kicking)
-do you have any blurring of vision? (no)
-has the swelling extended? (extended to the knee)
-have you had any vomiting? (vomited twice)
-any pain in your tummy?
-how’s your urine output? How often do you go to toilet? (not quite often)
-how’s your bowels motion?
-any confusion or dizziness? (Imminent eclampsia)
-Any discharge or bleeding from down below? (PROM, abruption)
-do you feel your baby is kicking? (Key) (fetal distress)
96

4-General questions
-Any past history of migraine?
-Any high blood pressure before your pregnancy?
-Any family history of migraine or high blood pressure?

Physical Exam from examiner

1-General appearance: PODL + J
-pallor
-oedema (oedema up to the level of the knees with facial puffiness)
-Any dehydration?
-LAP
-jaundice (HELLP)

2-Vital signs + O2 sat

- BP 180/100
- PR 100/min
-RR 20/min
-Temp 38.7
-O2 saturation 99% in room air

As her blood pressure is quite high I'd like to shift her to the resuscitation room, put in a
large bore IV cannula just in case to gain IV access, take blood for investigations ( FBE,
LFT, UCE, BSL and coagulation profile)

I would like to give her the first dose of antihypertensive medication IV labetalol,
methyldopa or Nifedipine whichever available

Then proceed to the rest of my examination.

3-CVS: S1, S2, murmurs

4-Respiratory system: air entry, adventitious sounds

5-CNS:
tone, reflexes there is hyperreflexia and clonus
Fundoscopy to look for papilledema mild papilledema

6-Abdomen:
-Uterine tenderness (abruptio placentae)
-Hepatic tenderness?
-Fundal height 34cm
-FHR? 150bpm
-Lie, presentation? Longitudinal, cephalic

7-Pelvic exam (consent and chaperone)

Inspection of vulva and vagina, any discharge or bleed, rash or vesicles
97

Speculum exam: any bleed or discharge? Is the OS closed or open?

No pervaginal or Bimanual ex

8-Office tests:
-UDT look for urinary proteins proteins 3+
- BSL (already taken)
-ECG

Explanation
-Most likely you are having a severe preeclampsia. It is a condition where there is a sharp
rise in your blood pressure and leakage of proteins in the urine.
-it is common in first pregnancy and The exact cause is unknown but anything that
decreases the blood supply to the placenta, can cause the placenta to secrete certain
chemicals which could damage the lining of the blood vessels of all major organs.
because of this, the pressure within your brain goes high causing headache and vomiting.-
Pre-eclampsia is an emergent condition and if it is not controlled, can result to fits and if
runs for a long time it can lead to growth restriction of the baby.

Management
-You need an immediate referral to the tertiary hospital with neonatal intensive care unit.
I would arrange an ambulance for you, and I will ring up the hospital and make them
aware of your condition so they can setup everything for when your arrive.

Once you reach the hospital:

- you will be admitted and seen by the specialist.
-Ultrasound and CTG will be done to monitor you and the baby. (key point)
- Antihypertensive medications: IV hydralazine will be given
- IV magnesium sulfate to prevent fits from happening
- If everything is well controlled with you and the baby is also doing well, they will try to
prolong your pregnancy till completed 36 weeks but you need to be in hospital during
this time.
- Labour will be induced by 37 weeks.
- Just in case the baby becomes unwell or your condition become uncontrolled, an
immediate delivery will be planned either by C-section or induction.
- You have to take an absolute bed rest. Continuous monitoring of the vitals, BP
recording every 2 hour, urine protein twice daily, fluid input output.

Notes/ 37 weeks pregnant: same management; but plan her delivery immediately.
Because delivery is the treatment of choice for pre-eclampsia and eclampsia

Another scenario (all steps very important)

While taking examination findings, the patient will start fitting. Patient has started fitting.
1-I would like to shift to the DR ABCDE protocol now.
2-Call for help.
98

3-Put her in a left lateral position.

4-Start her on oxygen by mask, 6-8 liters per minute.
5-to stop fit
If in GP Give her IV diazepam.
If in hospital ED give her IV MgSo4 (4g initially over 10-15 minutes, and then 1g/hour
as continuous infusion).
6- Anti hypertension medication
-If in GP give IV labetalol
-if in a hospital IV hydralazine
7-If in GP:
-What you have is fit or seizure during pregnancy due to preeclampsia or sudden sharp
rise of BP. Now I need to re-assess all the systems, and I need to refer you immediately
to a tertiary hospital, seen by the specialist, Ultrasound and CTG done, all the blood
investigations, IV MgSO4 and IV hydralazine to control your condition.
And once eclampsia has happened, baby has to be delivered no matter the gestational age
is.
So once your condition settles then the specialist will decide to deliver you immediately
either induction or CS.

  MILD MODERATE SEVERE

Diastolic BP 90-99 100-109 >= 110
Systolic BP 140-149 150-159 >=160
Proteinuria 1+ 2+ 3+/more
99

Edema minimal up to the level of the calf Massive( up to knee

and above)
Management Can be managed -Requires admission to DRSABCDE.
at home the hospital. Secure airway,
Bed rest -She needs to be seen by Oxygen by mask, I/V
Salt and protein the specialist. line and blood for
restricted diet. -Bed rest with toilet investigations.
Review by GP privileges MgSO4- 4 gm bolus,
every 2nd day. -Blood pressure recorded then 1-2gm
Red flags. 4th hourly, urine protein infusion/hour at least
If not controlled, twice daily, fluid input for 24 hours after last
referral to and output chart seizure. If seizure
hospital. -UTZ, CTG recurs, give 2 gm
  -Oral antihypertensives: bolus.
first line is labetalol: If MgSo4 not
Methyldopa, nifedipine available, I/V
 -Once her condition is diazepam 2mg/mL,
under control, and the max 10mg.
baby is doing well, you Hydralazine I/V.
can discharge her but Catheterize, Fluid
refer her to a high risk intake and output
pregnancy clinic chart.
 -If already at 37 weeks, Immediate referral to
plan delivery by tertiary hospital.
induction. CTG, U/S.
 
 

Feedback (23/2/2017)
ED, Primigravida, 36 wks, severe headache. All AN check up N.
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Tasks:
1.History (2min),
2. PEFE,
3. DX & Mx
2min thinking:
DDx: preeclampsia, tension headache, migraine, other causes of headache.
Patient might fit, be prepared with initial management.
-Entered room. Greeted by examiner.
-Patient was holding her head, in pain.
-Introduced and greeted the patient,
-offered pain killer after assessing severity of pain.
-Asked pain Q (SORTSARA), any BOV/nausea/vomiting/epigastric pain/ankle oedema.
-Ruled out migraine, stress from home/work, recent URTI.
-How is baby’s movement/any contraction/ bleeding/discharge from private part.
-PMHx of HPT and DM.
-SADMA.
-Did not asked about previous antenatal check up and USG as was normal given in the
stem.
PEFE:
GA, V/S – BP 180/110, HR, RR, T, O2,
P/A: symphysial fundal ht, presentation and lie of fetus, FHS.
Hypereflexia and clonus present. Ankle oedema.
Office test: urine protein +++
Dx: Dear Cindy, as you are having headache and nausea, and the urine test shown
presence of protein, you are having a condition called preeclampsia. Have you heard
about it? Don’t worry I will explain to you…
(Examiner interrupted me and said the patient suddenly has a fit)
I stood up, faced my patient who was “sitting comfortably” on the chair, and mentioned I
would manage my patient according to DRSABCD protocol, try to access IVL for
administration of IV diazepam, if unsuccessful will give PR diazepam, arrange
ambulance immediately, liase with ED doctor. In the hospital the doctors will do
necessary Ix and she will be seen by obstetrician as well. Aim is to prevent fit, control BP
and aim to deliver baby but all will be dicided by obstetrician.
Bell rang, thanked the examiner and patient.
Passed. Global score 5

Feedback (13/10/2017)
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You are in GP, a Lady with 35 weeks old pregnancy presented to you with headache.
Task:Hx, PEFE, Dx to the patient with reasons.
I entered room after introducing myself I asked haemodynamic stability? Examiner said
what you are looking for? Bp: 180/100, PR: 80 regular, RR:NL, Temp:37 I said I want to
secure two IV line and start dose of labetalol IV line and transfer the patient to the
treatment room while I am taking history from my patient.
Hello Jilly? I am… one of the doctor in this GP. Where is your HA exactly (all around
the head) When did it start? It was there for couple of days but today it is more severe.
How sever it is?(7-8) Do you want pain killer?(yes) no allergies?(no) I will arrange a
painkiller for you.
Just quick questions: BOV?tummy pain? trauma?discharge? BLD? (no) swelling on legs?
Baby kicking?(yes) no hx of HTN DM… this is first pregnancy and no miscarriage
before. All the antenatal tests were positive( sweet drink test, U/S 18 wks was NL).

If you are OK I want to ask some questions from my colleague?

Dear examiner, Is there any pallor, jaundice, dehydration in my pt's general appearance?
(no)
Any change in V.S? Bp is now 150/90 all others the same.
I want to systemically do examination mainly focusing on abdomen. Neurological
examination of upper and lower limb? Tone(inc) reflex(brisk) power(nl) sensation(nl)
ophtalmoscopy? (Blurring of disc margins) Cardiovascular and respiratory (NL). As for
the abdominal examination, in inspection any scars?bruises? Dilated veins?(no) In
palpation, tenderness?(no) Lie(longitudinal) Presentation(cephalic) FH(34cm) FHR(150).

I want to do per-vaginal examination with the consent of the pt and presence of the
chaperon. Just inspection and speculum (OS closed) thanks I won't go further.
Urine dipstick? ++Protein, Nitrate
-,BSL AND ECG?No ECG no CTG no BSL available(he got cranky I think:D) OK thank
you examiner I go back to my patient.
Jilly during hx and px most likely you have condition called pre-eclampsia have you
heard of it before? This condition more common in first pregnancies and runs in family
can be due to smoking recreation drugs(not sure that was only my performance).
So some particles produced in placenta attaching the baby to the womb( drew picture) are
going to other places in body causing vessel damage and kidney damage as well
specifically brain vessel that is why you have high blood pressure that is serious
condition please do not worry you are in safe hand that is why I want to send you to
hospital to be checked as you may develop seizure and…Bell rang
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Feedback: Third trimester Complication, PASS(G.S:5)

Key steps:2,3,4 &5: Yes, 1 :No
Hx:4

Feedback 14-3-2018
37 weeks lady with headache.
Task.. History
Physical examination from examiner
Diagnosis to the patient.
2 min thinking.. my key points for this case.. ( In History; vision problem, epigastric pain,
cloudy urine, oedema, past history of HTN., kidney disease or FH of HTN)
In PE; BP, pulse, reflexes and tone,, fundoscopy, oedema, urine dipstick.
Mg; usg, ctg, delivery and ensuring mother’s and baby’s well being!!
After entering the room and introduction I started by asking if she was okay for me to ask
few questions or needed any painkillers. She said she was fine. I started with typical
headache questions, SORTSARA. It was for the first time she had such a headache. She
had it since last night, constant and everywhere in the head. Almost 5 in intensity.
No aggravating or relieving factors. There was no vomiting or visual aura.
She had no visual problem, no epigastric pain, no change in colour of urine but had
oedema since a week. Baby was still kicking, no reduction in kicks. She hadn’t noticed
any swelling on tummy. There was no bleeding or discharge from her private area.
Antenatal history was uneventful. It was her first pregnancy (so no need to ask
complications in previous pregnancies), no previous miscarriages. No history of HTN or
DM kidney disease. or any Family history of HTN.
On PE examiner gave me specific findings that I asked for. BP was 170/120mmHg (at
this point I told the examiner I’ll shift patient to the resuscitation cubicle and start with
hypotensive agents)
Pulse 90
Temp 36.5
Reflexes and tone brisk and exaggerated
Oedema +ve
Fundoscopy showed hypertensive changes.
Urine dipstick +ve for proteins
FHR 140 bpm
Fundal height was consistent with age of gestation
Fetal lie was cephalic
I got back to the role player and explained that I’m a little concerned because the cause of
your headache is one of the complication near the end of pregnancy. We call it Pre-
eclampsia. In this the after birth or what we call placenta in medical term( I started
103

drawing here). It starts sending certain particles in blood that cause changes in blood
vessels in brain, eyes, kidney, tummy and legs etc so you have all that clinical picture. It
is an emergency so I’ll refer you to ED to be seen by specialist. They’ll do CTG, USG
and certain blood tests to see the affect of your condition. Our main concern is your and
your child’s well being so you are in safe hands. Do you have any questions to ask? She
said no. The Bell rang
Feedback Scenario Third trimester complication. Grade Pass Global score 4
Key steps 1,3,4 yes 2, No History 4 Examination… 4 Diag/ D/D.. 4 Patient
counselling 4

Feedback 19-7-2018
STATION 10 PASS (all key steps yes, score 6,4,6,5,6)
Its Pre eclampsia turning to Eclampsia)
Again long scenario of36 weeks primary gravida came with headache since morning, all
previous finding and test normal.
Task ,Hx ,PEFE , Dx and Mx.
I offered the patient painkiller, asked examiner abt vitals he said 180/90 I asked for
nefedipine spray and rectal diazepam on bedside, than asked very focused history( which
he didn’t like that’s y got 4) than asked focused PEFE and while explaining diagnosis she
seized, I asked for help and DRABCD protocol, I said I will consult my registrar and Obs
specialist and start her on IV anti HTN acc to them, MgSO4 to prevent further seizures,
wanna go Blood test ,US and CTG. Although she is at 36 weeks but obs will decide abt
steroid for fetal lung if in case required.

Feedback9-5-2018
19 Case: Headache
Preeclampsia and Eclampsia.
ED department. Your next patient 36 weeks gestations is coming because severe
headache. She has done antenatal care and she has been well. She notices some days ago
swelling of her feet.
Task
Take history
PE from examiner
Diagnosis to the patient.
Not sure if they asked about management but examiner asked me at the end.
Patient was lying on the bed. I forgot to ask vital signs before starting consultation. She
had severe headache for the last 3 hours, seeing lights and pain on epigastrium, she
noticed swelling on her legs for the last few days, baby was moving well no any bleeding
or fluid per vagina, no other symptoms. No any relevant personal or family medical
history. Patient has done all the antenatal care and everything has been well until now
104

that she came with severe headache. PE vital signs 180/110 positive findings: fundoscopy
was normal no papilledema, no abdominal tenderness, increased reflexes, and pitting
oedema in lower limbs present. Fetal heart was present, no uterine activity. Urine
dipstick: +++ protein. And patient started to convulse. I moved patient to resuscitation
area gave diazepam and called the registrar and then the examiner stop me and asked me:
which is your management now doctor? I explained all the management for eclampsia.
Passed. Global score 4

Feedback 19-7-2018
Station 10 : Headache (pre eclampsia turned into eclampsia) Pass
Total 5 key steps 4 yes 1 no Score : 5 5 6 5 overall 5
Case : 35/36 wks pregnant lady having headache since morning. All antenatals were
normal so
far .B.P was given outside which was 180 / something (quite high )
Tasks : hx ( for not more then 2 min )
Pefe, dx to pt , mx
When i entered lady was lying on a couch. I asked abt is she is stable enough to continue
with the tasks (yes) Started with calling for help , i/v cannula, basic
blds, nasal nefidpine spray and all emergency equipments in my hands .
Then i asked her abt if she is having this kind of headache fir the first time (migrain ?)
Right now she is having high bld pressure so is it for the first time (already a k/c of
Hypertension? ) asked abt trauma , any previous pregnancy.. any problems during this
pregnancy so far.is the baby kicking? Etc Then asked pefe ... all the abdominal then
pelvic examination n then hyper reflexia n clonus ,
opthalmoscopy. I forgot urine dipstix while asking pefe n remembered it while
Explaining dx to pt ... so asked later n then explained dx . While Explaining the lady had
a fit and became unconscious. So then told all the mx to examiner . Call for help , left
lateral recovery position etc . Admit her and will call seniors, do U/S + CTG , blds, start
her on i/v mgso4 or hydralazine.then
seniors will decide whether to observe her or proceed with the delivery.

Feedback 9-5-2018
2. Ed setting, 35 wks preg c/o headache. Lying on bed.
Task hx, pefe, explain pt, then mx > pre eclampsia turning to eclampsia , on pefe once BP
was 180/100 advised will send nurse to call obs register n another to put iv lines n
bloods... Then continued with rest of the pefe. While explaining the pt collapsed then
moved to DRSABC.. then the examiner asked what about seizure and what anti htn
midazolam n hydralzine
105

2 minutes outside- this maybe pre eclampsia, eclampsia, pregnancy induce hypertension,
trauma on the head. The matter of this question is the task. There is 2 minutes for history
only, PE ask from examiner, tell diagnosis and dd and management. This is really long
cases so i need to be care full. Reflex, urine for protein, 12 cranio nerve, Investigations
are needed even they did not ask.
Inside the room: the patient laid on the bed, she is pregnacy lady. I came in, ask Vital
signs, her BP is high, i try to stable her by medications and call the senior.( It took me 30
s for this) then i asked about pain questions, some questions about baby kicking and
complications of HELLP. Then I jumbed into PE. I checked her from head to toe
including all important point. Then i thanks to examiner and turn to patient to explain my
diagnosis. In the middle of this, patient had some abnormal movement, I did DRABCD,
give her diazepam and call for obstetric for Magiesium sulphate. I said about all
investigations including- blood goup, liver FT, plaplate, KFT, US, CTG, crossmatching..
Even i thown all of that out, the patient still have abnormal movement, i said i will
observer her and wait for my senior as the medication need time to acting. i will follow
her VS closely .I will call her family and explain the situation as well in case we need to
do CS for patient as this is the ultimte way to solve the eclampsia. Bell reng.

Feedback 25-10-2018 3rd trimester complication

Stem : 32?34 week pregnant lady , primi with headache. Previous all labs normal.
Regular with ante natal visits no complication till now.
Tasks:
Hx
Pefe
Explain probable dx
I entered the room after greetings asked pain scale (5 she said)offered p.k, she refused to
take ir. I told her no worries but if during this consultation u feel its becoming unbearable
let me know please. I excused her and asked my examiner for vitals (he said I will let you
know once you complete hx) I moved to my pt. asked her all SOCRATES of pain then
ruled out all other headache ddx like trauma, stroke, temporal arteritis, flu, sinusitis,
meningitis, migraine.
Asked associated symptoms of tummy pain (she said yes for last few days n pointed on
epigastrium) no dizzy no blurry vision leg swelling for 1 week. No other issues. Asked
fam hx it was negative.
Pefe. Asked everything as per KARENs.
Positive findings BP was high, papilloedma was there, tone inc, clonus positive, udr 3+
proteins.
Explained pre eclampsia, she made a bad face while I was explaining so I stopped and
asked her if she couldn’t understand anything , she said yeah I do understand its affecting
my kidneys and eyes now but what is it. I was confused what to say more but bell rang n
106

I came out of room.

Grade: pass
Global score: 6
2/4 key steps covered
Hx: 6
Choice and technique of ex: 6
Dx/ddx : 6

Feedback 25-10-2018
35 weeks of preg came with headache- pass( got 2 in history)
Task: history
Pefe
Diag/dd
I asked hd stability then took history- very short: like sortsara for headache, baby
movement, vision problems, migraine history.
Pefe as in handbook, got 5 for that
Dd said: protein in urine so preeclampsia, could b migraine. Cant remember other dd that
I may have said.

Feedback 5-12-2018
You are working as intern, 36 weeks old lady with right upper tummy pain, Leg swelling
when you saw her last week, All previous Checkup were normal and Investigation also.
Task
1 Take Hx
2 ask PEFE, exam will give u specific findings u want
3 Give Diagnosis and management
+ve- Headache, BOV, ankle edema, BP-180/110, Clonus and hyper-reflexia and UDS-4+
protein, Right upper quadrant pain, no bleeding/ discharge paravaginal.
Pt was sitting with her Rt hand on tummy. I introduced myself, nice to meet you. I
understand you have got some pain in tummy can you pls show exactly where it is?( she
indicated rt hypo chon. And epi. Gastrium) asked to rate pain. It was 6 or 7 out of 10. (I
did not offer pain medication as was confused about it). I took permission to ask q to
examiner. Asked examiner the vitals: BP 180/110,Resp normal, no fever. Told would like
to move to / rx room, give oral nifidipine, and per rectal Diaz, open iv line.
Then proceeded to hx taking: I have arranged initial mx for you. Will you be able to
answer if I ask few q?
HOPI Q: pain Q (SORTSARA- continuous dull aching for ½ an hr or 1 hr can’t
remember).
107

Ass symp q: Fever , rash , nausea , vomiting, BOV+ headache+, Leg swelling up to knee,
No discharge or bleeding down below, can feel baby kick, No other medical or sx
condition. (did not ask about ANC hx as in stem it was mentioned normal)
PEFE: general appearance: as you can see
Vitals: as before ( not changed)
GPE: Pickled (only edema upto knee, no jaundice or rash)
Then I said want to do focused abdominal exam: FH, Lie, presentation: normal. FHS:
normal, Rt hypc tenderness+, No tenderness or rigidity in other site, no Ut construction.
I want to do Full neurological exam: Examiner asked what you looking for? I asked about
tone, reflex clonus (hypertonia and clonus present), Fundoscopy- not available
Asked office test urine dipstick for protein +++
(did not ask about resp and cvs)
Turned to pt: Now X from hx and physical examination I think you are having a
condition called Preeclampsia where there is rise of BP with associated leakage of protein
in urine. let me explain to you (I draw the pic. ). Its womb and baby is attached to womb
with placenta. Now what happen is some chemicals are released from here ( I indicated
placenta) which may damage the lining of our blood channels in different parts of our
body. That’s why you are having pain in your tummy, headache and BOV. R you with
me? Now what I am concerned is it may turn to a complication called eclamsia means fits
while pregnancy which if occurs can be harmful to you and baby inside. Don’t worry, its
good that you came early. I am gonna immediately send you to tertiary hospital where
you will be managed my Sp obs. And MDT. They will They will give BP lowering meds
through your vein called hydralazine and fit preventing med called MG SO4.They will
frequently monitor your BP and urine and baby . if you or baby become unwell Sp may
do C/S. Bell rang. Don’t worry they will take good care of you. Thanked her and
examiner
Key step 12345: yes yes yes yes no,
HX 4
Choice and tech of exam: 5
DX/DDX: 4
MX: 3
108

52-Pre-eclamptic/ Eclampsia
32 year old Maria, who is 32 weeks pregnant, presents to your GP, with headache since
the last 2 days. She had regularly done her antenatal checks with you and a week before,
when you saw her, she had mild swelling of her legs. At that time all relevant
investigations were done and they were all normal.
TASKS
Relevant history.
Examination findings from examiner.
Explain diagnosis to patient.
Management.

Differential diagnosis
1-preeclampsia
2-Migraine
3-Tension headache
4-URTI
5-ear or tooth infections
6-meningitis/ encephalitis
7-head trauma

APPROACH
History:
Hi Maria, it is nice to see you again, I can see that you are complaining of headache is
that right? Just let me ask you few questions to unravel the nature of the problem
1-Headache questions (rule out tension and migraine)
-Can you tell me more about it?
-Severity
-First of all how severe is your headache from 1 to 10 1 is the least 10 is the most?
-I can offer painkillers for you so do you have allergy to any medications?
Onset and duration
-How long have you been having the headache?
-Sudden or gradual? Constant or come and go? Is it getting worse
Site and Radiation
can you show me exactly where you have the pain?
Does it go anywhere else?
Character
can you describe it for me?
Aggravating and relieving
does anything make it better or worse
Timing
any specific time when the pain is worse?

2-Differential diagnosis questions

-any recent infection? (URTI)
-any pain in your ear or teeth? (ear or teeth infections)
109

-Any fever, rash or neck stiffness. (Meningitis/ encephalitis)

-have you had any trauma or injury to your head? (head trauma)

3-Preeclampsia questions (Headache, BOV, leg swelling, tummy pain, vomiting,

bladder and bowels, complications: confusion, bleeding, discharge, baby kicking)
-do you have any blurring of vision? (no)
-has the swelling extended? (extended to the knee)
-have you had any vomiting? (vomited twice)
-any pain in your tummy?
-how’s your urine output? How often do you go to toilet? (not quite often)
-how’s your bowels motion?
-any confusion or dizziness? (Imminent eclampsia)
-Any discharge or bleeding from down below? (PROM, abruption)
-do you feel your baby is kicking? (Key) (fetal distress)

4-General questions
-Any past history of migraine?
-Any high blood pressure before your pregnancy?
-Any family history of migraine or high blood pressure?

Physical Exam from examiner

1-General appearance: PODL + J
-pallor
-oedema (oedema up to the level of the knees with facial puffiness)
-Any dehydration?
-LAP
-jaundice (HELLP)

2-Vital signs + O2 sat

- BP 180/100
- PR 100/min
-RR 20/min
-Temp 38.7
-O2 saturation 99% in room air

As her blood pressure is quite high I'd like to shift her to the resuscitation room, put in a
large bore IV cannula just in case to gain IV access, take blood for investigations ( FBE,
LFT, UCE, BSL and coagulation profile)

I would like to give her the first dose of antihypertensive medication IV labetalol,
methyldopa or Nifedipine whichever available

Then proceed to the rest of my examination.

3-CVS: S1, S2, murmurs

4-Respiratory system: air entry, adventitious sounds
110

5-CNS:
tone, reflexes there is hyperreflexia and clonus
Fundoscopy to look for papilledema mild papilledema

6-Abdomen:
-Uterine tenderness (abruptio placentae)
-Hepatic tenderness?
-Fundal height 34cm
-FHR? 150bpm
-Lie, presentation? Longitudinal, cephalic

7-Pelvic exam (consent and chaperone)

Inspection of vulva and vagina, any discharge or bleed, rash or vesicles
Speculum exam: any bleed or discharge? Is the OS closed or open?
No pervaginal or Bimanual ex

8-Office tests:
-UDT look for urinary proteins proteins 3+
- BSL (already taken)
-ECG

Explanation
-Most likely you are having a severe preeclampsia. It is a condition where there is a sharp
rise in your blood pressure and leakage of proteins in the urine.
-it is common in first pregnancy and The exact cause is unknown but anything that
decreases the blood supply to the placenta, can cause the placenta to secrete certain
chemicals which could damage the lining of the blood vessels of all major organs.
because of this, the pressure within your brain goes high causing headache and vomiting.-
Pre-eclampsia is an emergent condition and if it is not controlled, can result to fits and if
runs for a long time it can lead to growth restriction of the baby.

Management
-You need an immediate referral to the tertiary hospital with neonatal intensive care unit.
I would arrange an ambulance for you, and I will ring up the hospital and make them
aware of your condition so they can setup everything for when your arrive.

Once you reach the hospital:

- you will be admitted and seen by the specialist.
-Ultrasound and CTG will be done to monitor you and the baby. (key point)
- Antihypertensive medications: IV hydralazine will be given
- IV magnesium sulfate to prevent fits from happening
- If everything is well controlled with you and the baby is also doing well, they will try to
prolong your pregnancy till completed 36 weeks but you need to be in hospital during
this time.
- Labour will be induced by 37 weeks.
- Just in case the baby becomes unwell or your condition become uncontrolled, an
111

immediate delivery will be planned either by C-section or induction.

- You have to take an absolute bed rest. Continuous monitoring of the vitals, BP
recording every 2 hour, urine protein twice daily, fluid input output.

Notes/ 37 weeks pregnant: same management; but plan her delivery immediately.
Because delivery is the treatment of choice for pre-eclampsia and eclampsia

Another scenario (all steps very important)

While taking examination findings, the patient will start fitting. Patient has started fitting.
1-I would like to shift to the DR ABCDE protocol now.
2-Call for help.
3-Put her in a left lateral position.
4-Start her on oxygen by mask, 6-8 liters per minute.
5-to stop fit
If in GP Give her IV diazepam.
If in hospital ED give her IV MgSo4 (4g initially over 10-15 minutes, and then 1g/hour
as continuous infusion).
6- Anti hypertension medication
-If in GP give IV labetalol
-if in a hospital IV hydralazine
7-If in GP:
-What you have is fit or seizure during pregnancy due to preeclampsia or sudden sharp
rise of BP. Now I need to re-assess all the systems, and I need to refer you immediately
to a tertiary hospital, seen by the specialist, Ultrasound and CTG done, all the blood
investigations, IV MgSO4 and IV hydralazine to control your condition.
And once eclampsia has happened, baby has to be delivered no matter the gestational age
is.
So once your condition settles then the specialist will decide to deliver you immediately
either induction or CS.
112

  MILD MODERATE SEVERE

Diastolic BP 90-99 100-109 >= 110
Systolic BP 140-149 150-159 >=160
Proteinuria 1+ 2+ 3+/more
Edema minimal up to the level of the calf Massive( up to knee
and above)
Management Can be managed -Requires admission to DRSABCDE.
at home the hospital. Secure airway,
Bed rest -She needs to be seen by Oxygen by mask, I/V
Salt and protein the specialist. line and blood for
restricted diet. -Bed rest with toilet investigations.
Review by GP privileges MgSO4- 4 gm bolus,
every 2nd day. -Blood pressure recorded then 1-2gm
Red flags. 4th hourly, urine protein infusion/hour at least
If not controlled, twice daily, fluid input for 24 hours after last
referral to and output chart seizure. If seizure
hospital. -UTZ, CTG recurs, give 2 gm
  -Oral antihypertensives: bolus.
first line is labetalol: If MgSo4 not
Methyldopa, nifedipine available, I/V
 -Once her condition is diazepam 2mg/mL,
under control, and the max 10mg.
baby is doing well, you Hydralazine I/V.
can discharge her but Catheterize, Fluid
refer her to a high risk intake and output
pregnancy clinic chart.
 -If already at 37 weeks, Immediate referral to
plan delivery by tertiary hospital.
induction. CTG, U/S.
 
 
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Feedback (23/2/2017)
ED, Primigravida, 36 wks, severe headache. All AN check up N.
Tasks:
1.History (2min),
2. PEFE,
3. DX & Mx
2min thinking:
DDx: preeclampsia, tension headache, migraine, other causes of headache.
Patient might fit, be prepared with initial management.
-Entered room. Greeted by examiner.
-Patient was holding her head, in pain.
-Introduced and greeted the patient,
-offered pain killer after assessing severity of pain.
-Asked pain Q (SORTSARA), any BOV/nausea/vomiting/epigastric pain/ankle oedema.
-Ruled out migraine, stress from home/work, recent URTI.
-How is baby’s movement/any contraction/ bleeding/discharge from private part.
-PMHx of HPT and DM.
-SADMA.
-Did not asked about previous antenatal check up and USG as was normal given in the
stem.
PEFE:
GA, V/S – BP 180/110, HR, RR, T, O2,
P/A: symphysial fundal ht, presentation and lie of fetus, FHS.
Hypereflexia and clonus present. Ankle oedema.
Office test: urine protein +++
Dx: Dear Cindy, as you are having headache and nausea, and the urine test shown
presence of protein, you are having a condition called preeclampsia. Have you heard
about it? Don’t worry I will explain to you…
(Examiner interrupted me and said the patient suddenly has a fit)
I stood up, faced my patient who was “sitting comfortably” on the chair, and mentioned I
would manage my patient according to DRSABCD protocol, try to access IVL for
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administration of IV diazepam, if unsuccessful will give PR diazepam, arrange

ambulance immediately, liase with ED doctor. In the hospital the doctors will do
necessary Ix and she will be seen by obstetrician as well. Aim is to prevent fit, control BP
and aim to deliver baby but all will be dicided by obstetrician.
Bell rang, thanked the examiner and patient.
Passed. Global score 5

Feedback (13/10/2017)
You are in GP, a Lady with 35 weeks old pregnancy presented to you with headache.
Task:Hx, PEFE, Dx to the patient with reasons.
I entered room after introducing myself I asked haemodynamic stability? Examiner said
what you are looking for? Bp: 180/100, PR: 80 regular, RR:NL, Temp:37 I said I want to
secure two IV line and start dose of labetalol IV line and transfer the patient to the
treatment room while I am taking history from my patient.
Hello Jilly? I am… one of the doctor in this GP. Where is your HA exactly (all around
the head) When did it start? It was there for couple of days but today it is more severe.
How sever it is?(7-8) Do you want pain killer?(yes) no allergies?(no) I will arrange a
painkiller for you.
Just quick questions: BOV?tummy pain? trauma?discharge? BLD? (no) swelling on legs?
Baby kicking?(yes) no hx of HTN DM… this is first pregnancy and no miscarriage
before. All the antenatal tests were positive( sweet drink test, U/S 18 wks was NL).

If you are OK I want to ask some questions from my colleague?

Dear examiner, Is there any pallor, jaundice, dehydration in my pt's general appearance?
(no)
Any change in V.S? Bp is now 150/90 all others the same.
I want to systemically do examination mainly focusing on abdomen. Neurological
examination of upper and lower limb? Tone(inc) reflex(brisk) power(nl) sensation(nl)
ophtalmoscopy? (Blurring of disc margins) Cardiovascular and respiratory (NL). As for
the abdominal examination, in inspection any scars?bruises? Dilated veins?(no) In
palpation, tenderness?(no) Lie(longitudinal) Presentation(cephalic) FH(34cm) FHR(150).

I want to do per-vaginal examination with the consent of the pt and presence of the
chaperon. Just inspection and speculum (OS closed) thanks I won't go further.
Urine dipstick? ++Protein, Nitrate
-,BSL AND ECG?No ECG no CTG no BSL available(he got cranky I think:D) OK thank
you examiner I go back to my patient.
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Jilly during hx and px most likely you have condition called pre-eclampsia have you
heard of it before? This condition more common in first pregnancies and runs in family
can be due to smoking recreation drugs(not sure that was only my performance).
So some particles produced in placenta attaching the baby to the womb( drew picture) are
going to other places in body causing vessel damage and kidney damage as well
specifically brain vessel that is why you have high blood pressure that is serious
condition please do not worry you are in safe hand that is why I want to send you to
hospital to be checked as you may develop seizure and…Bell rang
Feedback: Third trimester Complication, PASS(G.S:5)
Key steps:2,3,4 &5: Yes, 1 :No
Hx:4

Feedback 14-3-2018
37 weeks lady with headache.
Task.. History
Physical examination from examiner
Diagnosis to the patient.
2 min thinking.. my key points for this case.. ( In History; vision problem, epigastric pain,
cloudy urine, oedema, past history of HTN., kidney disease or FH of HTN)
In PE; BP, pulse, reflexes and tone,, fundoscopy, oedema, urine dipstick.
Mg; usg, ctg, delivery and ensuring mother’s and baby’s well being!!
After entering the room and introduction I started by asking if she was okay for me to ask
few questions or needed any painkillers. She said she was fine. I started with typical
headache questions, SORTSARA. It was for the first time she had such a headache. She
had it since last night, constant and everywhere in the head. Almost 5 in intensity.
No aggravating or relieving factors. There was no vomiting or visual aura.
She had no visual problem, no epigastric pain, no change in colour of urine but had
oedema since a week. Baby was still kicking, no reduction in kicks. She hadn’t noticed
any swelling on tummy. There was no bleeding or discharge from her private area.
Antenatal history was uneventful. It was her first pregnancy (so no need to ask
complications in previous pregnancies), no previous miscarriages. No history of HTN or
DM kidney disease. or any Family history of HTN.
On PE examiner gave me specific findings that I asked for. BP was 170/120mmHg (at
this point I told the examiner I’ll shift patient to the resuscitation cubicle and start with
hypotensive agents)
Pulse 90
Temp 36.5
Reflexes and tone brisk and exaggerated
Oedema +ve
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Fundoscopy showed hypertensive changes.

Urine dipstick +ve for proteins
FHR 140 bpm
Fundal height was consistent with age of gestation
Fetal lie was cephalic
I got back to the role player and explained that I’m a little concerned because the cause of
your headache is one of the complication near the end of pregnancy. We call it Pre-
eclampsia. In this the after birth or what we call placenta in medical term( I started
drawing here). It starts sending certain particles in blood that cause changes in blood
vessels in brain, eyes, kidney, tummy and legs etc so you have all that clinical picture. It
is an emergency so I’ll refer you to ED to be seen by specialist. They’ll do CTG, USG
and certain blood tests to see the affect of your condition. Our main concern is your and
your child’s well being so you are in safe hands. Do you have any questions to ask? She
said no. The Bell rang
Feedback Scenario Third trimester complication. Grade Pass Global score 4
Key steps 1,3,4 yes 2, No History 4 Examination… 4 Diag/ D/D.. 4 Patient
counselling 4

Feedback 19-7-2018
STATION 10 PASS (all key steps yes, score 6,4,6,5,6)
Its Pre eclampsia turning to Eclampsia)
Again long scenario of36 weeks primary gravida came with headache since morning, all
previous finding and test normal.
Task ,Hx ,PEFE , Dx and Mx.
I offered the patient painkiller, asked examiner abt vitals he said 180/90 I asked for
nefedipine spray and rectal diazepam on bedside, than asked very focused history( which
he didn’t like that’s y got 4) than asked focused PEFE and while explaining diagnosis she
seized, I asked for help and DRABCD protocol, I said I will consult my registrar and Obs
specialist and start her on IV anti HTN acc to them, MgSO4 to prevent further seizures,
wanna go Blood test ,US and CTG. Although she is at 36 weeks but obs will decide abt
steroid for fetal lung if in case required.

Feedback9-5-2018
19 Case: Headache
Preeclampsia and Eclampsia.
ED department. Your next patient 36 weeks gestations is coming because severe
headache. She has done antenatal care and she has been well. She notices some days ago
swelling of her feet.
Task
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Take history
PE from examiner
Diagnosis to the patient.
Not sure if they asked about management but examiner asked me at the end.
Patient was lying on the bed. I forgot to ask vital signs before starting consultation. She
had severe headache for the last 3 hours, seeing lights and pain on epigastrium, she
noticed swelling on her legs for the last few days, baby was moving well no any bleeding
or fluid per vagina, no other symptoms. No any relevant personal or family medical
history. Patient has done all the antenatal care and everything has been well until now
that she came with severe headache. PE vital signs 180/110 positive findings: fundoscopy
was normal no papilledema, no abdominal tenderness, increased reflexes, and pitting
oedema in lower limbs present. Fetal heart was present, no uterine activity. Urine
dipstick: +++ protein. And patient started to convulse. I moved patient to resuscitation
area gave diazepam and called the registrar and then the examiner stop me and asked me:
which is your management now doctor? I explained all the management for eclampsia.
Passed. Global score 4

Feedback 19-7-2018
Station 10 : Headache (pre eclampsia turned into eclampsia) Pass
Total 5 key steps 4 yes 1 no Score : 5 5 6 5 overall 5
Case : 35/36 wks pregnant lady having headache since morning. All antenatals were
normal so
far .B.P was given outside which was 180 / something (quite high )
Tasks : hx ( for not more then 2 min )
Pefe, dx to pt , mx
When i entered lady was lying on a couch. I asked abt is she is stable enough to continue
with the tasks (yes) Started with calling for help , i/v cannula, basic
blds, nasal nefidpine spray and all emergency equipments in my hands .
Then i asked her abt if she is having this kind of headache fir the first time (migrain ?)
Right now she is having high bld pressure so is it for the first time (already a k/c of
Hypertension? ) asked abt trauma , any previous pregnancy.. any problems during this
pregnancy so far.is the baby kicking? Etc Then asked pefe ... all the abdominal then
pelvic examination n then hyper reflexia n clonus ,
opthalmoscopy. I forgot urine dipstix while asking pefe n remembered it while
Explaining dx to pt ... so asked later n then explained dx . While Explaining the lady had
a fit and became unconscious. So then told all the mx to examiner . Call for help , left
lateral recovery position etc . Admit her and will call seniors, do U/S + CTG , blds, start
her on i/v mgso4 or hydralazine.then
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seniors will decide whether to observe her or proceed with the delivery.

Feedback 9-5-2018
2. Ed setting, 35 wks preg c/o headache. Lying on bed.
Task hx, pefe, explain pt, then mx > pre eclampsia turning to eclampsia , on pefe once BP
was 180/100 advised will send nurse to call obs register n another to put iv lines n
bloods... Then continued with rest of the pefe. While explaining the pt collapsed then
moved to DRSABC.. then the examiner asked what about seizure and what anti htn
midazolam n hydralzine
2 minutes outside- this maybe pre eclampsia, eclampsia, pregnancy induce hypertension,
trauma on the head. The matter of this question is the task. There is 2 minutes for history
only, PE ask from examiner, tell diagnosis and dd and management. This is really long
cases so i need to be care full. Reflex, urine for protein, 12 cranio nerve, Investigations
are needed even they did not ask.
Inside the room: the patient laid on the bed, she is pregnacy lady. I came in, ask Vital
signs, her BP is high, i try to stable her by medications and call the senior.( It took me 30
s for this) then i asked about pain questions, some questions about baby kicking and
complications of HELLP. Then I jumbed into PE. I checked her from head to toe
including all important point. Then i thanks to examiner and turn to patient to explain my
diagnosis. In the middle of this, patient had some abnormal movement, I did DRABCD,
give her diazepam and call for obstetric for Magiesium sulphate. I said about all
investigations including- blood goup, liver FT, plaplate, KFT, US, CTG, crossmatching..
Even i thown all of that out, the patient still have abnormal movement, i said i will
observer her and wait for my senior as the medication need time to acting. i will follow
her VS closely .I will call her family and explain the situation as well in case we need to
do CS for patient as this is the ultimte way to solve the eclampsia. Bell reng.

Feedback 25-10-2018 3rd trimester complication

Stem : 32?34 week pregnant lady , primi with headache. Previous all labs normal.
Regular with ante natal visits no complication till now.
Tasks:
Hx
Pefe
Explain probable dx
I entered the room after greetings asked pain scale (5 she said)offered p.k, she refused to
take ir. I told her no worries but if during this consultation u feel its becoming unbearable
let me know please. I excused her and asked my examiner for vitals (he said I will let you
know once you complete hx) I moved to my pt. asked her all SOCRATES of pain then
ruled out all other headache ddx like trauma, stroke, temporal arteritis, flu, sinusitis,
meningitis, migraine.
Asked associated symptoms of tummy pain (she said yes for last few days n pointed on
119

epigastrium) no dizzy no blurry vision leg swelling for 1 week. No other issues. Asked
fam hx it was negative.
Pefe. Asked everything as per KARENs.
Positive findings BP was high, papilloedma was there, tone inc, clonus positive, udr 3+
proteins.
Explained pre eclampsia, she made a bad face while I was explaining so I stopped and
asked her if she couldn’t understand anything , she said yeah I do understand its affecting
my kidneys and eyes now but what is it. I was confused what to say more but bell rang n
I came out of room.
Grade: pass
Global score: 6
2/4 key steps covered
Hx: 6
Choice and technique of ex: 6
Dx/ddx : 6

Feedback 25-10-2018
35 weeks of preg came with headache- pass( got 2 in history)
Task: history
Pefe
Diag/dd
I asked hd stability then took history- very short: like sortsara for headache, baby
movement, vision problems, migraine history.
Pefe as in handbook, got 5 for that
Dd said: protein in urine so preeclampsia, could b migraine. Cant remember other dd that
I may have said.

Feedback 5-12-2018
You are working as intern, 36 weeks old lady with right upper tummy pain, Leg swelling
when you saw her last week, All previous Checkup were normal and Investigation also.
Task
1 Take Hx
2 ask PEFE, exam will give u specific findings u want
3 Give Diagnosis and management
+ve- Headache, BOV, ankle edema, BP-180/110, Clonus and hyper-reflexia and UDS-4+
protein, Right upper quadrant pain, no bleeding/ discharge paravaginal.
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Pt was sitting with her Rt hand on tummy. I introduced myself, nice to meet you. I
understand you have got some pain in tummy can you pls show exactly where it is?( she
indicated rt hypo chon. And epi. Gastrium) asked to rate pain. It was 6 or 7 out of 10. (I
did not offer pain medication as was confused about it). I took permission to ask q to
examiner. Asked examiner the vitals: BP 180/110,Resp normal, no fever. Told would like
to move to / rx room, give oral nifidipine, and per rectal Diaz, open iv line.
Then proceeded to hx taking: I have arranged initial mx for you. Will you be able to
answer if I ask few q?
HOPI Q: pain Q (SORTSARA- continuous dull aching for ½ an hr or 1 hr can’t
remember).
Ass symp q: Fever , rash , nausea , vomiting, BOV+ headache+, Leg swelling up to knee,
No discharge or bleeding down below, can feel baby kick, No other medical or sx
condition. (did not ask about ANC hx as in stem it was mentioned normal)
PEFE: general appearance: as you can see
Vitals: as before ( not changed)
GPE: Pickled (only edema upto knee, no jaundice or rash)
Then I said want to do focused abdominal exam: FH, Lie, presentation: normal. FHS:
normal, Rt hypc tenderness+, No tenderness or rigidity in other site, no Ut construction.
I want to do Full neurological exam: Examiner asked what you looking for? I asked about
tone, reflex clonus (hypertonia and clonus present), Fundoscopy- not available
Asked office test urine dipstick for protein +++
(did not ask about resp and cvs)
Turned to pt: Now X from hx and physical examination I think you are having a
condition called Preeclampsia where there is rise of BP with associated leakage of protein
in urine. let me explain to you (I draw the pic. ). Its womb and baby is attached to womb
with placenta. Now what happen is some chemicals are released from here ( I indicated
placenta) which may damage the lining of our blood channels in different parts of our
body. That’s why you are having pain in your tummy, headache and BOV. R you with
me? Now what I am concerned is it may turn to a complication called eclamsia means fits
while pregnancy which if occurs can be harmful to you and baby inside. Don’t worry, its
good that you came early. I am gonna immediately send you to tertiary hospital where
you will be managed my Sp obs. And MDT. They will They will give BP lowering meds
through your vein called hydralazine and fit preventing med called MG SO4.They will
frequently monitor your BP and urine and baby . if you or baby become unwell Sp may
do C/S. Bell rang. Don’t worry they will take good care of you. Thanked her and
examiner
Key step 12345: yes yes yes yes no,
HX 4
Choice and tech of exam: 5
DX/DDX: 4
MX: 3
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58-Antinatal Checkup counselling

Sample case you are GP when 20 years old laura comes to you for advice regarding
planning for pregnancy. She also wants to know the care she is provided with once she
becomes pregnant.
Tasks
-further history
-counsel accordingly
History
1-current condition
-when are you planning for pregnancy?
-Any specific concerns
2-5Ps questions
Period
-when was you LMP?
-are they regular?
-how many days of bleeding and how many days apart?
-any pain or heavy bleeding during menstruation?
-any bleeding in between menstruation?
Sexual history
-are you in a stable relationship?
-do you have good support?
-are you or your partner ever been diagnosed with STI?
Pregnancy
-Is this your first pregnancy?
-any previous miscarriages?
Pill
-what contraceptive methods do you use?
-do you still use pill?
Pap
-is your HPV or pap up to date?
3-Lifestyle
-can you tell me briefly about your diet?
-do you do regular exercise?
-SAD ( if alcohol say it is better to quit alcohol once planning for pregnancy as it can
cause birth defects)
-any PETS
4-Occupation
5-vaccination status
-are you immunized against chicken pox and German measles?
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6-General
-PMH (DM, hypertension, thyroid, epilepsy, chicken pox, German measles)
-PSH
-family history of miscarriages or birth defects
-are you aware of your blood group?
Prepregnancy
1-SNAP
-make sure you stick on healthy diet with no raw meat or unpasteurized dairy products,
no soft cheese.
-limit tea or coffee intake up to 2 cups a day. Avoid smoking and alcohol.
-Do regular exercise (30 minute/ day for 5 days/ week)
-maintain BMI within the normal range.
-all these life style measure need to continue even during pregnancy.
2-Examination
-need to do complete physical examination.
3-Investigations
I would like to do some tests like:
-FBC, UCE, LFT, BSL, blood group and RH, Vitamin D level
-chicken pox and German measles antibodies to look if your body has the power to fight
against these infections.
-Urine sample
-if HPV not up to date do one now.
*if you are not immunised against rubella and varicella then you need to be given
vaccination but make sure not to become pregnant within 4 weeks of these vaccination.
4-Folic acid
-I will start you on folic acid 0.5 mg to be take 3 months before and the 1st 3 months od
pregnancy

Pregnancy
1-Confirm the pregnancy
-stop the contraceptive when you are ready for pregnancy and inform me once you miss
your period.
-we will confirm your pregnancy by doing office test called urine pregnancy test amd
also blood tests.
-we will establish the date expected for delivery.
-if you were unsure about LMP we can arrange dating scan at 8 weeks.
2-Further Investigations
-FBC (Hg)/ BSL
123

-STI screen with consent

-urine MCS

3-ANC visits
-book you onto hospital which is a shared care that we usually give with GP, obstetrician
and Midwife.
-need to come for regular antenatal visits (once during 1st trimester, every 4 weeks till 28
weeks then every 2 weeks till 36 weeks then weekly till delivery.
-during each AN visit your weight and BP will be recorded and the baby will also be
looked for with Fundal height, fetal heart rate, lie and presentation.
-we will offer you Down syndrome screen in the first trimester, which is combined
Ultrasounds and blood tests.
-Routine Ultrasound at 18-20 weeks to give an idea regarding any birth defects, position
of placenta and fluid surrounding the baby. This Ultrasound will be repeated at 32-34
weeks.
-you start feeling baby kicks around 20 weeks when you can monitor your baby’s kick.
-sugar test will be done at 28 weeks to test for DM or high blood sugar during pregnancy.
Along with this FBC also will be done.
-Bug test at 36 weeks by taking a vaginal swab.
-just in case if your bay develop any complications you will be referred to high risk
pregnancy clinic with MDT
4-Advice
-it is advisable to take flu shot anytime during pregnancy and also whooping cough
vaccine for you and other family member after 28 weeks.
-it is normal to get a bit of leg swelling. Back pain and also as the pregnancy goes you
can feel a bit breathless.
-you can continue going to work even up to 1 week bedore date of delivery.
5-Rs
-review once blood tests results appear.
-reading materials (normal pregnancy and what to do once becoming pregnant)
-folic acid prescription
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AMC exam case 5-4-2018

GP, 27 year old lady comes to see you coz home pregnancy test shows positive & the
first appointment in hospital will be in next 2 months. Her period is irregular
4 to 8 weeks cycle. ( it was quite a long stem )
Task:
-Explain the inv u’re going to do b4 the appointment.
-Management between now & hospital appointment.
Feedback 10-11-2017
ANC 
-Long stem , all were normal and confirmed she is pregnant by UPTyour task explain
what you should do for your px before she get her 1st ANC in hospital that has been
arranged .
-Again I don’t know what to do, as task was confusing for me but anyway I have to do
something. -Arrange blood test , STI,vit d B 12 level , varicella/rubella , FBC , LFT ,
UEC , BSL ,urine microscopy and USG to make sure the embrio grow in right place and
is viable , check hormone pregnancy in blood and explained bit more about those Ix
Script folic acid, Iodine, do SNAP. 
-As I don’t know what to say again I said about next ANC routine in trimester 2 and 3 but
examiner cut me off again stick to your task make me more nervous 
-Then I talk about SNAP , 4R
-Again messy and disorganised.
Feedback passed approcach /ix/mx 4/3/4
Notes/ no more feedback is there for this case
1-the difference between exam case and the sample case is that the woman is confirmed
to be pregnant and (her cycle is irregular may be or may be not)
2-regarding history will be
current condition
-is it a planning pregnancy? Congratulation!
-then ask 5Ps then lifestyle, occupation, vaccination then general.
3-now as she is pregnant now start from
-doing office pregnancy test to confirm and all blood tests mentioned in Prepregnancy
and pregnancy.
125

-do not talk about vaccination now as she is pregnant already.

-talk about all lifestyle advice same.
-folic acid is important here.
-then talk about examination and HPV if not up to date.
-talk briefly about ANC if the examiner did not tell stick to task
-talk about advice similar to previous approach
-then Rs add her the red flags very important (vaginal bleeding, tummy pain, fluid
leakage, baby not kicking well)

Feedback 4-7-2018
22 yr lady with irregular periods 4-8wk interval
LMP 9wks ago, home preg+ve
PAP-10/12 ago-normal
Clinic visit in 2/12
Task Ix you order
How do you manage her until clinic visit
No hx/Ex
Ix-
Confirm POA-bhcg
Blood-FBC/Fe studies/bld gp & Ab/TFT/vitD/B12
Serology-Rubella/VZ/hepatits/HIV/syphilis
Urine-m/c/s, Chlamydia/gonorrhoea PCR
u/sscan-dating scan at 7/52 dp on bhcg & confirm intrauterine pregnancy
screening T1 combined screening( blood & scan), non invasive prenatal screening, T2
screening-explained in brief
Mx-diet-what to eat & what not to eat-eg soft cheese/ exercise/smoking/alcohol- just
asked 1-2 Q
Avoid pets/litter
Supplement-folic acid/multivitamin
Dps on Ix-act accordingly
Managing Morning sickness-
126

In case bleeding/abd pain- seek medical advise

Recall 12-7-2018
Long stem for 27 y old, period every 7 -8 weeks LMP 9 weeks ago, no significant finding
in the stem, recently +ve home pregnancy test, the next anenatal in the antenatal clinic 2
months from now counsel the pt. about Invx Management until the coming antenatal
visit! 

64-HRT Counselling
Case 1
You are at your GP when 53 year old Mary presents to you. She has come to you to
discuss about HRT.
TASKS
-Focused history
-Counsel regarding HRT
History
1-Approach
-I can see from the notes that you are here requesting for HRT. Can you tell me why?
2-Indications Questions
Vasomotor symptoms:
-Are you experiencing hot flushes, heavy sweating?
Psychological:
-Are you having mood changes, sleep disturbances, depression?
Somatic symptoms:
-any muscle aches and pains? Any bone pain? Any history of fractures?
Reproductive symptoms
-Any vaginal dryness, itchiness, discharge?
Urinary symptoms
-Any burning or stinging while passing urine? Do you have to go to toilet more
frequently? Do you fell any lump downbelow?
-bowel motions along with it
history of osteoporosis
3-5Ps questions for old women
menopause (as period)
-At what age did you have your menopause?
127

-Any bleeding after menopause?

Partner: do you have good support
HRT (as pill): no need here as she is requesting)
pregnancy : How many pregnancies have you had?
Pap or HPV and mammogram: if up to date
4-Contraindications for HRT questions
- Any undiagnosed vaginal bleed?
-Any history of clotting in your leg veins?
-any history of cancers (breast, womb or ovaries? Lumps or bumps?
-Any history of stroke
-Any recent heart problems like angina or heart attacks?
-Any history of active liver disease?
-Diabetes, uncontrolled blood pressure, high cholesterol
-Any medical or surgical conditions in the past?
5-Lifestyle
-healthy balanced diet
-regular exercise
-SAD
-How does these symptoms affect your life?

Counselling
-Look Mary why you have menopausal symptoms is due to lack of hormone estrogen. As
after menopause, the ovaries shut down producing very low levels of estrogen and no
progesterone at all.
-HRT has both estrogen and progesterone in it and this will replace the lost estrogen and
progesterone added to estrogen to prevent the thickening of the endometrium or the inner
lining of your womb.
-HRT is usually a combination of both estrogen and progesterone so it can carry some
risks: can lead to DVT or increased clotting tendency in your veins, stroke, breast cancer
(especially if you use it for more than 3 years), womb and ovarian cancer, and gallbladder
disease.
-The benefits of HRT is that it can relieve all menopausal symptoms, and can make your
bone strong and protects against fractures. Also, give some protection against bowel
cancer it is found that there is a possible decrease in the incidence of Alzheimer's and
other forms of dementia.
-Before starting HRT, I need to do full examination looking for your general health and
reproductive health. Need to record you BMI and BP. Examine your lungs and heart and
do pelvic examination as well.
-I need to do certain blood tests like FBE, UEC, LFT, BSL, TFT, lipid profile.
-Mammogram and HPV should be up to date
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-you need to take a continuous combined HRT, which is estrogen and progesterone to be
taken in continuous way. You can take it orally preferably the same time every day or
patches.
- Side effects of HRT:
-Nausea, headache, breast tenderness, blotting
-breakthrough bleeding: Usually settles in 3-6 months' time
-Review every 6 months
-will try to stop it in 2 years and no more than 5 years
-lifestyle modifications: exposure to sunlight avoiding peaking hours, diet rich in
calcium, regular exercise
Note/There are different methods for giving HRT. HRT can be given in 3 separate ways:
-Estrogen only HRT: this is given if the patient had hysterectomy already
-Cyclic/Sequential HRT: if the patient is menopausal for up to 1 year, or perimenopausal
Give estrogen continuously for 28 days, add progestogen from 14th day to 28th day of
cycle.
Once you stop this, the patient will have withdrawal bleeding
-Continuous combined HRT: if the patient is menopausal for more than 1 year
Estrogen and progesterone for 28 days
She will not get a bleed at all
Case 2 (AMC Case)
You are GP, 52 year old lady come for requesting HRT. Her LMP was 18 mths ago.
Task
-Take relevant HO
-The examiner will give u PE findings on card
-Explain patient initial management and investigations that u want to do
History
1-Approach
-I can see from the notes that you are here requesting for HRT. Can you tell me why?
(My friends recommended it to me)
2-Indications Questions
Vasomotor symptoms:
-Are you experiencing hot flushes, heavy sweating? (No)
Psychological:
-Are you having mood changes, sleep disturbances, depression? (No)
Somatic symptoms:
-any muscle aches and pains? Any bone pain? Any history of fractures? (No)
Reproductive symptoms
-Any vaginal dryness, itchiness, discharge? (Yes dryness and itchiness)
Urinary symptoms
-Any burning or stinging while passing urine? Do you have to go to toilet more
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frequently? Do you fell any lump downbelow? (No)

-bowel motions along with it
history of osteoporosis (No)
3-5Ps questions for old women
menopause (as period)
-At what age did you have your menopause? (18 months ago)
-Any bleeding after menopause? (No)
Partner:
-Gonna ask you sensitive questions
-Are you sexually active? (Yes)
-Any problems or pain during intercourse? (Yep Dr. I need to use a lot of lubricants for
sex)
-do you have good support
HRT (as pill):
-no need here as she is requesting)
pregnancy :
-How many pregnancies have you had? (I have two children with normal delivery)
Pap or HPV and mammogram:
- if Pap or HPV up to date (pap smear it was done 4 years ago and normal)
- What about ur mammogram? (I haven’t done it before)

4-Contraindications for HRT questions (all normal)

- Any undiagnosed vaginal bleed?
-Any history of clotting in your leg veins?
-any history of cancers (breast, womb or ovaries? Lumps or bumps?
-Any history of stroke
-Any recent heart problems like angina or heart attacks?
-Any history of active liver disease?
-Diabetes, uncontrolled blood pressure, high cholesterol
-Any medical or surgical conditions in the past?
5-Lifestyle (all normal)
-healthy balanced diet
-regular exercise
-SAD
Physical examination from examiner
Thank you for ur information. I like to go to examiner for some findings and I ll get back
to u soon. (Findings will be given on card)
PE findings (a long list full of one page)
GA - well. BMI - 30, Vital signs - All stable.
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CVS, Resp, Abdomen, Breast - all normal

VE - Dry atrophic vagina, all clear on BME.

Counselling
-I finished examination and I could not find anything serious. Your BP is OK; breast
exam is fine, Heart and lungs normal
-look Mary, HRT is a hormone replacement therapy, which contains two hormones
estrogen and progesterone. This is usually given if you have clear indications of some of
menopausal symptoms like hot flushes, sweating, and mood changes.
-HRT never prescribed without clear indications as it can carry many risks like increased
clotting tendency in your veins, stroke, breast cancer, womb and ovarian cancer, and
gallbladder disease.
-at this time, it is better not to start you on HRT because of its risks.
-Just in case you develop any indications, we will be happy to start you on HRT if you do
not have any contraindications for it. And after complete examination and investigation.

-from the history you most likely have atrophic vagina means the lining of you vagina is
dry and thin most likely due to lack of hormone estrogen. As after menopause, the
ovaries shut down producing very low levels of hormones, which are essential to
maintain the lining of the vagina healthy. That is most likely why u have dry vagina and
pain during sex and need to use lubricants.
For that, I can give u Oestrogen creams.
I need to run some Investigation as well to check your general health
-I need to do certain blood tests like FBE, UEC, LFT, BSL, TFT, lipid profile.
-Mammogram and HPV should be up to date
-From examination, it looks that your body weight, is higher than it should be. I would
like you to follow some life style measures
S - Smoking avoided
N - Nutrition : take balance diet. I can get involve dietician who can give u proper diet
plan to help u lose wt.
A - Avoid alcohol if possible
P - Physical exercise: do regular exercise at least 30 min per day, 5 days per week.
I can refer you to dietician.
Reading materials and review after Ix.
Feedback (22/2/2017)
You are GP, 52 year old lady come for requesting HRT. Her LMP was 18 mths ago.
Tasks
Take relevant HO
The examiner will give u PE findings on card
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Explain patient initial management and investigations that u want to do

2 mins thinking
This is typical recall of HRT
Have to ask symptoms of menopause, contraindications for HRT, 5P including
mammogram, general health in HO
Breast exam, BMI, BP in PE
Mx depends on case
History taking
When I stepped into the room, examiner checked my ID and introduced the name of role
player.
Greeting - Good morning, I am Dr Khine. I am one of the Drs in this GP. Nice to meet u.
How can I help you today? (RP : Dr, I want to know if I can take HRT)
Ok, what is ur concern to take HRT? (My friends recommended it to me)
All right, let me ask u a couple of questions in order to know if u are suitable candidate
for HRT. (Sure Dr)
Menopausal symptoms
Physical : At the moment, do u have any night sweats, tiredness and hot flushes?
(No)
Psycho : Do u think ur mood is irritable and easily get angry? (No)
Urinary : Any burning pain when u pass urine? Do u need to pass it more
frequently? (No)
Genital : Any itchiness and dryness in ur down below? (Yes), I wanna ask u
sensitive and private Q, is that ok for u? (Yep). Are u sexually active (yep). Are u in
stable relationship (Yep). Do u have pain during sex intercourse (yep Dr. I need to use a
lot of lubricants for sex)
Alright, I see. We ll fix that problem surely.
Musculoskeletal : Any aches and pain? (No)
CI for HRT
- Have u ever been Dx with CA breast? (No)
- I understand that ur LMP was 18 mths ago. Do u have any bleeding from down
below after that? (No). Did u notice any mass in ur tummy? (RP : what’s that Dr? seems
like she doesn’t know the term mass) Ok, any lumps or bumps in ur tummy? (No)
- Any liver problem before like yellow coloration of skin and urine? (No)
- Any previous heart ds or heart attack? (No)
- Any migraine HA? (No)
- Any blood clotting problems before? (No)
5P - Any previous preg and miscarriages? (Yes, Dr I have two children with normal
delivery). What about pap smear (it was done 4 years ago and normal) Didn’t u go for it 2
years back? (No) Why? (Coz I am healthy and I didn’t see any Dr) Ok
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What about ur mammogram? (I haven’t done it before) Any bulging from u down below?
(No)
General health, SADMA - all clear
Thank you Samantha for ur information. I like to go to examiner for some findings and I
ll get back to u soon. Then, the role player flipped over the paper which is already on the
table. It includes all PE findings.
PE findings (a long list full of one page, I cant remember all)
GA - well. BMI - 30, Vital signs - All stable.
CVS, Resp, Abdomen, Breast - all normal
VE - Dry atrophic vagina, all clear on BME.
Management with pt
Well, Samantha, according to HO and PE findings, I didn’t find anything that is serious.
Your BP is OK, breast exam is fine. Heart and lungs normal. And I didn’t see any
conditions we need to start u on HRT. U dun have any menopausal symptoms like hot
flushes, night sweats, irritable mood, right? (RP nodded her head). So, at this moment, u
dun need any HRT. But what I am a bit concerned is ur body wt which is higher than it
should be. So, I like u to stick to life style measures which can be memorized by
beautiful short form : SNAP (I wrote down SNAP on paper)
S - Smoking avoided
N - Nutrition : take balance diet. I can get involve dietician who can give u proper diet
plan to help u lose wt.
A - Avoid alcohol if possible
P - Physical exercise : do regular exercise at least 30 min per day, 5 days per week.
So far, do u understand my explantion. (Yes, Dr)
Ok, another thing is lining of ur down below is dry and thin coz of menopause. In
menopause, female hormones are no longer produced from ovaries which are essential to
maintain ur lining of down below to be healthy. That’s why u have pain during sex and
need to use lubricants. For that, I ll give u oestrogen creams to apply ur down below.
Are u with me so far? (Yep) What else do u want to know? (What else should I know?)
Ok. Let me check ur profile again (I read the PE findings again and read the tasks.
OMG!!!, I am about to miss one task which is investigations)
At the same time the bell rang. I told quickly that I will check female hormone levels in
ur blood and imaging of ur tummy called USG (I couldn’t tell about pap smear, other
blood tests, mammogram)
Then examiner told me “Thank you, Dr. U can go out now”
AMC Feedback - Menstrual complaint : Pass (Global Score - 4)
Approach to patient - 4
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History - 5
Counseling/Education - 4

Feedback (29/11/2017)
( Feedback – Menstrual complaint!!)
You are GP, 52 year old lady come for requesting HRT. Her LMP was 18 mths ago.
Tasks - Take relevant HO
- The examiner will give u PE findings on card
- Explain patient initial management and investigations that u want to do
History taking
Greeting
Dr, I want to know if I can take HRT
Ok, what is ur concern to take HRT? (My friends recommended it to me)
Alright, let me ask u a couple of questions in order to know if u are suitable candidate for
HRT. (Sure Dr)
Menopausal symptoms
Physical : At the moment, do u have any night sweats, tiredness and hot flushes?
(No)
Psycho : Do u think ur mood is irritable and easily get angry? (No)
Urinary : Any burning pain when u pass urine? Do u need to pass it more frequently?
(No)
Genital : Any itchiness and dryness in ur down below? (Yes), I wanna ask u sensitive
and private Q, is that ok for u? (Yep). Are u sexually active (yep). Are u in stable
relationship (Yep). Do u have pain during sex intercourse (yep Dr. I need to use a
lot of lubricants for sex)
Alright, I see. We ll fix that problem surely.
Musculoskeletal : Any aches and pain? (No)
(4B- Bone, Breast, Bowel, Bladder, 2p- Prolapse, Post menopausal s/s)
CI for HRT
- Have u ever been Dx with CA, uterus breast? (No)
- I understand that ur LMP was 18 mths ago. Do u have any bleeding from down
below after that? (No). Did u notice any mass in ur tummy? (RP : what’s that Dr?
seems like she doesn’t know the term mass) Ok, any lumps or bumps in ur
tummy? (No)
- Any liver problem before like yellow coloration of skin and urine? (No)
- Any previous heart ds or heart attack? (No)
- Any Stroke?
- Any HTN?
- Any SLE?
- Any migraine HA? (No)
- Any blood clotting problems before? (No)
- ‐ Contraindications of HRT:
- o Estrogen-dependent tumor (endometrial,
- breast cancer)
- o Recurrent thromboembolism
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- o Acute IHD (absolute)/history of CHD

- (relative)
- o Uncontrolled hypertension
- o Active liver disease
- o Pregnancy
- o Undiagnosed vaginal bleeding
- o Otosclerosis? Intermittent porphyria
5P - Any previous preg and miscarriages? (Yes, Dr I have two children with normal
delivery). What about pap smear (uptodate)
What about ur mammogram? (I haven’t done it before) Any bulging from u down below?
(No)
General health, SADMA - all clear
PE findings (card)
GA - well. BMI - 32, Vital signs - All stable.
CVS, Resp, Abdomen, Breast - all normal
VE - Dry atrophic vagina, all clear on BME.
Management with pt
Well, Samantha, according to HO and PE findings, I didn’t find anything that is serious.
Your BP is OK, breast exam is fine. Heart and lungs normal. And I didn’t see any
conditions we need to start u on HRT. U dun have any menopausal symptoms like hot
flushes, night sweats, irritable mood, right? (RP nodded her head). So, at this moment, u
dun need any HRT. HRT are hormones, so they have their own side effects.
Investigations
(only mentioned a few hormone and blood tests.)
but what I am a bit concerned is ur body wt which is higher than it should be. So, I like u
to stick to life style measures.SNAP
S - Smoking avoided
N - Nutrition : take balance diet. I can get involve dietician who can give u proper diet
plan to help u lose wt.
A - Avoid alcohol if possible
P - Physical exercise : do regular exercise at least 30 min per day, 5 days per week.
Refer to dietacian.
Ok, another thing is lining of ur down below is dry and thin coz of menopause. In
menopause, female hormones are no longer produced from ovaries which are essential to
maintain ur lining of down below to be healthy. That’s why u have pain during sex and
need to use lubricants.
For that, I ll give u oestrogen creams to apply ur down below.
Review- after seen by dietacian
Redflag – pv bleeding, lump in breast, something coming down PV

Case 3
Another case: patient has clear indications for HRT, but patient had breast cancer 10
years back, fully treated
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HRT should not be started here

Advise the patient lifestyle modifications:
-healthy balanced diet
-decrease spicy foods
-limit coffee should to 2 cups/day
-alcohol safe limit, no smoking
-Advice to wear light cotton clothing.
- Exercise like swimming (because the water can keep the body cool).
-Ask her to sleep in cool rooms.
Put her on medications (alternatives to HRT):
-First choice: Pregabalin (Lyrica)- derivative of Gabapentin, can bring down all the
vasomotor and psychological symptoms
or
Gabapentin itself
or
SNRIs/SSRIs - venlafaxine/paroxetine

 
Case 4
47 year old Jane is your next patient at your GP. She has come to you to discuss the
136

options of starting HRT. She is on combined oral contraceptives for the past 5 years.
TASKS
-Further relevant history
-Counsel accordingly
History
1-approach and why (menopausal symptoms)
2-HRT indications questions (+ve)
3-5Ps questions
-LMP and regularity
-Stable relationship/ STI
-Pregnancy
-type of pill, since how long, any SE
-HPV and mammogram
4-HRT contraindications questions
5- PMH and PSH and lifestyle

Note/ As long as the patient is on combined OCPs, usually they do not get menopausal
symptoms, and if they do, it is during the dummy pill period. But if the patient on
combined OCPs get menopausal symptoms, it tells you that the estrogen content in the
pill is not sufficient to replace the loss of estrogen that she is having.
Note/ Normally, the option here is to increase to high dose COC. BUT never increase the
dose if the patient is perimenopausal. If she is and she presents with perimenopausal
symptoms on combined pills, stop her on combined pills, estimate her hormones
(FSH, LH, estrogen --usually FSH is the main predictor of menopause; FSH and LH
high, estrogen is low), then start her on HRT and advice on alternative method of
contraception like condoms.
Counselling
-describe what HRT is
-what OCP is
-tell her that the estrogen of the OCP is not enough to cover the loss that is why you have
these symptoms.
-we need to stop OCP and start you on HRT
-explain risks of HRT
-need to do complete physical examination, basic Ix and hormonal essay especially FSH
-prescribe cyclical or sequential HRT and tell all side effects
-IMPORTANT: tell that HRT is not a contraception so you need to use alternative
methods of contraception.
-lifestyle modifications
-reading materials
137

-HRT is hormone replacement therapy where we replace the hormones that become
deficient as you go towards menopause, and also after menopause. The symptoms that
you are having is due to a decrease in the secretion of estrogen from the ovaries, as the
ovaries start to become less functional as you go towards menopause, and this estrogen is
replaced by HRT.
-Even though the combined pills contain estrogen, the estrogen in the pill does not
replace the estrogen that is deficient from your body.
-At this age, we do not recommend you to be shifted to a high dose combined OCPs.
What we can do however is to stop the combined OCPs that you are currently taking, and
start you on HRT instead as you have clear indications, and no contraindications.
-But I must also advise you that HRT carries multiple risks. It can lead to
thromboembolic disease or increased clotting in your veins, stroke, womb cancer or
endometrial cancer, ovarian cancer, breast cancer, and also gallbladder disease.
-The benefits of HRT are: you can get rid of perimenopausal symptoms, decreases the
incidence of bowel cancer, and there is a possible decrease in the incidence of
Alzheimer's disease and other forms of dementia.
- Blood tests including hormones need to be done like FBE, UEC, LFT, BSL, lipid
profile, FSH, LH, and estrogen levels.
-After a complete physical examination and a pelvic examination, I will start you on HRT
on a cyclical or sequential manner. Taking the menstrual cycle for 28 days, we will put
you on continuous estrogen, and progestogens during the last 14 days, and after finishing
the progestogens, you will expect to have withdrawal bleeding.
-You may experience a bit of nausea, abdominal bloating, headaches, and breast
tenderness, and sometimes a breakthrough bleed.
-We may stop you on HRT once you become cleared of the symptoms, and it is usually
advisable to take HRT for only 2 years, and by any chance not more than 5 years.
-HRT cannot act as a method of contraception, so you need to use alternate methods of
contraception like condoms.
-I will give you reading materials regarding HRT for further insight and I will arrange a
review with you regularly.
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Case 5
Another case: She is on combined pill, no symptoms of menopause, she is coming to you
for HRT because her friends tell her that you feel more feminine if you start on HRT.
Counselling
-describe what HRT is, indications and risks
-at present you have no indications so we cannot start you on HRT.
-Ask her to go on with the COC and stop the combined COC at 50 years old. If she has
no periods after that, she is menopausal. If she is getting irregular periods, estimate her
hormones (FSH, LH, estrogen) and then at that time, if she has clear indications with no
contraindications, you start her on HRT.
-If she is menopausal after 50 years, always ask her to use alternative methods of
contraception like condoms for 1 year after menopause.
-If she attains menopause before 50 years, she needs to use condoms for 2 years.

-As from the information that you have given me, there are no indications in you to be
started on HRT. The indications for HRT are when you experience perimenopausal
symptoms like mood changes, irritability, sleep disturbances, muscle aches and pains,
history of bone fractures, vaginal dryness, burning or itching, and problems with your
water works.
-HRT should always be started with caution, as there are lots of risks associated with
HRT. The risks are…
-Because of these risks, HRT is never started if there are no clear indications for it. HRT
will never act as a contraceptive.
-What is advisable this time is that you continue on your combined pills if you are
comfortable with that, until 50 years of age. After then, you can stop your pills, because
as long as you're on the pills, you will go on getting your periods, and we will not know
whether you've hit menopause or not. Once you stop the pills by 50 years old and if you
do not get your periods anymore, that could mean that you are already menopausal.
However, if you get irregular bleeds after stopping the pill, and there are indications in
you for HRT, we will estimate your hormones like FSH, LH, and estrogen. If FSH, LH
are high and estrogen is low, that means that you are menopausal, and at that time if you
have no contraindications for HRT like…, we can consider starting you on HRT with
your informed consent. We will do a full physical examination and pelvic examination on
you before we start you on HRT. Make sure that your pap smear and mammogram is up
to date as well by doing it every 2 years. It is advisable to use alternate methods of
contraception like condoms for 1 year after menopause, if the menopause happens after
50 years of age.
-I will give you reading materials regarding HRT for further insight and I will arrange a
review with you regularly.
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Feedback 22-6-2018
10. 52 yo patient with no periods for the last 18months coming in to consult for HRT.
Task:
hx,
PEFE ( PE card given),
Explain to pt what you found,
ask for any necessary investigations and mx.
Approach
Greeted patient
Open ended question
She said her friends are tsking HRT so she came in for advice
I told her that It is therapy that is not required for every post menopausal women as there
are certain side effects of these medications.
I will asses her situation first and then will advice on that
Confidentiality
Asked about Hot flush, night sweats, sleeping problem, mood changes, dryness or
discharge from down below ( all neg) asked about sexually active or not, post coital
bleed, dyspareunia
Past hx or family hx of breast, womb or ovary cancer
Past or family hx of fractures
Any co-morbidities
Any lumps, bumps or unintentional weightloss.
Asked about screening tests like Pap’s done or not ( 5 years ago) so mentioned will
arrange a HPV screen for her
Asked about mammogram (not done) said will arrange
Asked SADMA
Past hx of any known medical illness
PEFE—showed card
Very detailed
Positive was for atrophic vaginitis and cystocele
So I mentioned I will arrange for all the screening tests to be done. (Mentioned HPV
screen, Mammogram, Asked about any heaviness or bulging down below or any
involuntary dribbling of urine she said no
Then explained as she has no indications she is not a candidate for HRT. Explained
atrophic vaginitis and said will give local estrogen cream and jelly to use during
intercourse.
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Mentioned will refer to gynaecologist for cystocele.

66-Lichen sclerosis
Michelle, a 54 year old lady is you next patient at your GP. She complaint of severe
itching in her vulva for the past 2 months.
TASKS
Further relevant history
Examination findings from examiner
Investigations
Management
Differential Diagnoses
1-Atrophic vaginitis / menopause
2-Infections/ candidiasis/ UTI
3-Lichen sclerosis
4-Skin conditions (Dermatitis, Eczema, Psoriasis) / Skin allergies due to cosmetics or
undergarments
5-Diabetes/ Steroids
History
1-Itchiness questions
open ended question
-I can see that you are complaining of itching in your vulva can you tell me more about
it?
Onset & duration
-for how long have you had itching in your vulva? (past 2 months)
-has it started suddenly? Is it constant or does it come and go? Is it getting worse?
(continuous, worsening)
-has this happened before?
Site
-is there itching anywhere else?
Severity
- do you think it is interfering with your daily activities?
- does the itching affect your sleep?
Aggravating and relieving.
-Does anything make it better or worse?
2-Differential diagnosis
- Do you have any bleeding or discharge from you vagina? (Atrophic vaginitis/
candidiasis)
- Any colour changes over your private area? (lichen sclerosis)
141

- Any fever? (Infection)

- How’s your waterworks? Any burning or stinging on passing urine? (UTI/ Lichen
sclerosis/ menopause)
- Any rash, ulcers, or vesicles around the area? do you have any skin condition like
eczema, psoriasis? (Skin conditions)
-Have you changed your cosmetics like shower gel or soups? do you use any vaginal
douches? Any allergies? (Skin allergies)
-any medical illnesses like diabetes? (Diabetes)
-do you use any medications? (Steroids)
3-5 P’s Questions
Menopause (= period in young age)
-When was your menopause age or last period?
- do you feel your vagina is dry or thin?
-any symptoms like Hot flashes, excessive sweating or mood changes?(menopause
symptoms)
Partner (sexual)
-Are you sexually active?
-any pain during intercourse? Any bleeding post coital?
-any history of STI
Pregnancy (not relevant here)
HRT (= pill in young age)
-do you use any HRT?
Pap and Mammogram
is your pap or hpv and mammogram up to date?
4-General (if enough time)
-diet rich in calcium
-SAD
-exercise
-good support
Physical exam from examiner
1- General appearance
- BMI
- pallor, lymph node enlargements, generalized rash, eczematic or psoriatic patch?
2- Vital signs:
Especially temperature (infection)
BP HR with rhythm, RR with saturation
3-Quick CVS, R/S
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4- Abdomen
-Visible distention, any mass?
-Palpate for any mass, tenderness (soft and non-tender)
5- Pelvic exam (with the consent of the patient and presence of a chaperone)
Inspection of the vulva and vagina:
-visible discharge, any bleed?
-Any other skin lesions? (White, shiny, wrinkled plaques in the vulva and perivaginal
areas in a laced-like pattern) ask specifically if not given by examiner
Inspection of the anal area:
is there any lesions, excoriation marks, plaques?
Speculum exam:
- is the cervix healthy or not? Any discharge or bleed?
-Does the vagina appear thin or atrophic?
Per vaginal exam:
-uterus size and tenderness (normal, no tenderness),
-adnexal mass and tenderness
6-Office tests:
UDT, BSL (rule out diabetes)

Investigations
- FBE, UEC
- TFT (autoimmune thyroiditis)
- refer to specialist for multiple punch biopsy (critical error)

Explanation (4C)
Condition
From the history and examination, most likely you have a condition called lichen
sclerosis. It is a chronic inflammatory skin condition. It is not infection or contagious.
Clinical feature
this usually presents with severe itching and causes white, wrinkled plaques in your
genital area.
Cause
Exact cause is unknown but thought to be an autoimmune disease. The immune system of
your body usually protects the body against infections, but in autoimmune conditions, the
system can get confused, and it starts attacking your own body cells rather than
protecting it.
Complication
It can result to scar formation and it can join up with the surrounding genital skin leading
143

to adhesions. Occasionally or 4% of the lichen sclerosis can turn nasty or be pre-

cancerous. (I prefer not to give percentages)
Outcome
because this is an autoimmune condition, there is no permanent cure for lichen sclerosis.
But we can keep the condition under control.

Management
-You needs to be seen by the specialist because the multiple punch biopsy needs to
be done.
-the treatment is with local steroid creams which you need to apply twice daily for the
first one month then once daily for the second month and then depending upon your
response the strength and number of applications can be reduced.
You need to be put on a maintenance therapy of a lifelong 1-2 applications per
week.
-If not responding to steroids, we can use retinoids or ultraviolet therapy.
- When do you go for surgery?
If there is scar formation or adhesions, and also if there is any malignant change or
cancer.
-maintain a good genital hygiene
-keep your HPV and mammogram up to date
-you needs to be on a lifelong surveillance because of the malignant change to begin
with 6 monthly intervals, and then annually.
- Red flags: in case you experience any bleeding, abnormal discharge, or if the itching is
becoming worse, please report back.
- I will arrange a review with you in around 1 monthtime and see how you are doing.
- I will give you reading materials for lichen sclerosis.

Is it due to menopause?
Lichen sclerosis has nothing to do with menopause. It is an autoimmune condition, not
associated with any hormones. It can happen at any age, not only in menopause.
144

….For the exam, the roleplayer may tell you that she's been having this for one year. She
has seen some doctors who have prescribed her with vaginal estrogen creams which is
not helping. (estrogen cream is for atrophic vaginitis)

Feedback 5-7-2018
77 years old lady present with itching.
Task: 1- hx
2- PE from the examiner
3- management plan
Outside the station I thought it’s the recall of lichen sclerosis, however I thought about
ddx (allergy, DM, STD, atrophic vaginitis and vulvar CA). when I entered a nice old lady
is sitting on the chair.
I introduced myself and start taking hx: for how long? Continuous or intermittent (was
continuous)? Anything makes it worse or better (nothing)? Any discharge (none)?
Any problem with water work (none) Any Hx of recurrent UTI or vaginal infection
(none)?
Any Hx of DM (no)? any discharge(no)? Any lump from below?
Any change in wt or appetite(no)?
Last LMP (I think she says 20 years ago and no bleeding since that time)?
Any HRT ( I think she said yes for 2 years I’m not sure)? Not sexually active?
I asked for 4 B (bone, breast, bladder, bowel) and 2 p (post-menopausal symptoms and
prolapse)? Pap smear (not done)?
Any Hx of STD? SADMA
The examiner gave me a picture of lichen sclerosis and asked me to describe, I said the
pic showed the valvular, perineal and anal area of a lady, there is redness and
scratch marks on both sides of labia with some white patches.
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I turned to my pt, told her there is a lot of possibilities, the most likely one is lichen
sclerosis, I drew a diagram and tell her its autoimmune disease where the immune system
in our body which originally fight infection, start to attack certain parts of the body in ur
condition, the skin of vulva. Reassure the pt its not infection and not a cancer.
Start her on steroid cream with follow up if unresponsive refer to gynecologist.
Need to be treated sometimes nasty growth (cancer) develop in scaring tissue. Other less
likely causes infection, allergy and atrophic vaginitis (she asked about that and I explain)
Passes: global score 5

Feedback 5-7-2018
a 77 year old female c/o itchy vulva for long duration
Task
Relevant historyf
Examination finding from the examiner
Explain condition to the patient
The rash has been there for many years, when asked she said she tried estrogen cream
and fungal cream but did not help her. No other positive finding I could elicit.
Asked for vaginal discharge – no
Urine problems –no
LOW, LOA, lumps or bumps? – NO
Itching anywhere else? - no
Any soaps or anything you put down below? – she said she washes with non-soaps.
5 P’s > menapaused, no partner, no HRT or pill, no children.
SADMA > no medication, occasional alcohol. .. no medical or surgical condition done.

On examination , the examiner gave a pic of the vulva and asked me to describe it. I said
so this is urethra, this is vagina, labia majora and minora, this is anus .. I can see
scratching mark, redness, some white and purple discoloration along with purple
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papules… the skin looks thin. This is lichen planus or sclerosus ( I don’t know if
there is difference!!)
(explanation: define / cause / risk / complication / prognosis)
I explained to the patient that this is lichen sclerosis. Its likely an autoimmune condition,
common in older people. Loss of hormones could be a cause.
Risks of becoming a nasty growth (she asked what is nasty growth?) – I told her:
cancer. She said (OH). I told yes that could happen that’s why I want to make sure that
you’re ok so I’ll refer you to a gynaecologist to take a biopsy and check if everything is
okay. How about that? – tes doctor.
I can give you some steroids and calamine lotion for the time being to lessen the
scratching and try not to scratch because that irritates the skin further.
Wear loose cottor undies and make sure the area is clean.
I will give you some reading material and hope to see you soon in 2 weeks to see if
everything is ok.

Feedback 5-12-2018
77 years old lady with itchy vulva,
Task
1 History taking
2 examiner will give picture
3 Describe the photo to examiner and give him ur provisional dx on the picture
4 Tell Dx to patient and manage her accordingly.
D/D atrophic vaginitis, Lichen sclerosis, Infections (candidiasis, Bact vaginosis, Eczema
Psoriasis, Allergies
Approach: greetings, How are you feeling right now? Would be asking some personal q
Is that Ok? Positives in HX: Pt is having itching for 2 yrs. previously managed my local
estrogen, lubricants. She does not know any specific dx for that.(Can’t remember now rx
worked for he or not).She mentioned of some bleeding probably from scratching). No
constitutional s/s of Cancer. No discharge down below. Mammogram was normal PAP
was normal. No sex activity. Examiner gave a big photo of vulva and asked to describe
that.
HX :
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HOPI Q: Pt is having itching for 2 yrs. previously managed my local estrogen, lubricants.
She does not know any specific dx for that.
Associated symp Q: No pain, no fever, no ulcer or discharge, No itchiness in anywhere
else, No rash she thinks (she mentioned she can’t see there properly). She mentioned of
some bleeding probably from scratching)
DD Q: No allergy,. Have not applied any creams or perfume No dryness down below, no
incontinence, Any other skin cond. in her or family like eczema or psoriasis, No lumps or
bumps or wt. loss.
5P and menopausal Q: Menopause 20 yrs ago. Have not been sexually active for long. No
menopausal syndrome or use of HRT, Up-to-date with mammogram and PAP.
Went to second task: Told examiner want to do focused pelvic examination. Examiner
gave me photograph and asked to describe what I can see._ there was shiny wrinkled skin
and some whitish plaque in vulvar area with no ulcers or discharge, most probable dx is
lichen sclerosis of vulva. Asked for speculum exam. Examiner said rest are normal or
said unavailable – can’t remember. Then asked me to talk to Pt.
3rd task: Described Lichen sclerosis, in 5C manner (condition, clinical features,
Commonality, cause, coarse, complication)
Will refer to gynecologist for confirmation with punch biopsy. Reassured her its quite
manageable, also told unfortunately it’s a chronic condition need lifelong surveillance.
Rx: initially gym will start steroid 2 times daily for 1 month and then 1nce daily for 2nd
month. Then depending on response dose will be reduced. Even after control she need to
continue application for 1 or twice a week for life long. We call it maintenance therapy.
(Did not mentioned about SX, or UV therapy or retinoid)
Advised about good genital hygiene, regular HPV and mammogram. And lifelong
surveillance 6 monthly for 1 year and then yearly.
Key steps 1234: No yes, yes, yes
Approach to pt : 5
HX: 4
Accuracy of the examination: 5
Dx/ DD:5
Management:5
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71-OCP request
Sample case/ Your next patient at your GP is a 19 year old, university student Jessica,
asking you for a prescription of oral pills, as she is now planning to become sexually
active.
TASKS
Focused relevant history.
Examination findings from examiner.
Counsel the patient accordingly.
History
-Hi Jessica, I'm Dr----- one of the GPs of the clinic, how can I help you with today? (Well
doctor, I'm going to Uni soon, and I'm considering starting on oral contraceptive pills.)
Only 5 P’s Questions
period
-When was your last menstrual period? (3 weeks ago.)
-Are they regular? (yes)
-how many days of bleeding and how many days apart? (28 days cycle)
-any pain or heavy bleeding during menstruation? any pain in between the periods? (Just
moderate, and no problems with periods or bleeding in between periods.)
Sexual history
-Have you been sexually active before? Do you have a stable partner? (No, I haven't.
But my boyfriend and I are going to Uni together)
(If yes, do a urine PT to confirm if patient is not pregnant at the moment)
Pregnancy (not relevant)
Gardasil vaccine
Have you received the Gardasil vaccine? (Yes, I received 3 shots of that already)
Pill (Contraindications to OCPs)
BC (bleeding, clot)
MSHL (migraine, stroke, heart, liver)
BOW (breast, ovary, womb)
DDH (diabetes, depression, hypertension)
SAD (smoking, alcohol, drugs)
- any abnormal vaginal bleeding? (Bleeding), any history of clotting in the veins of legs?
(Clot)
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- Any previous history of migraine, stroke, heart diseases, liver disorders?

- Any history of breast, ovarian or womb cancer?
-any history of diabetes, depression, high blood pressure?
-smoking, alcohol and recreational drugs?
-Do you take any prescription or over the counter medications? Any allergies?
Thank you for those information, Jessica. I will just talk to my examiner and I will get
back to you shortly.
Physical Exam from examiner
1- general appearance
-What is the BMI of my patient?
-Any pallor, icterus, cyanosis, lymph node enlargement, edema, poor skin turgor, dry
mucous membranes, delayed capillary refill time?
- Any edema or tenderness of the lower leg?
2-Vital signs
What is the BP, PR, RR, Temp and Sats of my patient?
3-quick chest and heart
how are the heart sounds? Is the rhythm regular? Any murmurs?
Is air entry equal? Any abnormal breath sounds?
4-breast
Any palpable breast lumps, tenderness or visible distortion or dimpling?
4-CNS
How is the motor and sensory exam of the upper and lower limbs? (stroke symptoms)
5-Abdominal examination
Is there any visible distention or mass of the abdomen? Is there any hepatosplenomegaly,
any mass or tenderness?
6-Pelvic examination (just inspection)
Are there any visible lesions in the vulva and vagina? Any discharge or bleeding?
7-office tests
I'd like to do a urine dipstick test and a blood sugar level.
Thank you for those information. I'd speak with my patient again.

Diagnosis and Management

1-OCP mechanism of action
-Okay, it seems like it would be possible for you to start on combined OCPs, so I would
like to give you information about it.
-Combined OCPs contain 2 hormones, estrogen and progesterone which is normally
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present in your body which regulates your periods.

-it inhibits ovulation, the release of egg from the ovary. To a lesser extent, it increases
the thickness of your cervical secretions so the sperm will find it difficult to get through.
And just in case fertilization happens, it changes the lining of your womb so that
implantation does not happen.

2-Dose
(TAKE PILL PACK)
In a pill pack, there are 28 pills, 21 are hormonal pills, 7 are sugar-coats or dummy pills.
Starting taking the hormonal pill from the 1st day of your next period, 1 pill a day, at
the same time everyday.
-Continue the hormonal pills for 21 days and then on starting the sugar pills, you get your
periods.
-However if you want to start taking the pill right away without waiting for your next
period, you may, but use alternate methods like condoms for 7 days.
3-Side effects (minor and major)
While taking the pill, you may experience side effects such as:
-Minor SE like nausea and vomiting, abdominal bloating and breast tenderness.
-Breakthrough bleeding or bleeding in between periods will usually settle in 3-4
months.
-Major side effects such as DVT, stroke and MI could happen but are rare with low dose
pills, such as what you will be taking.
4-Advantages
Advantages of the pill include:
- periods become more regular, lighter and shorter.
- There is less dysmenorrhea.
- There is decreased incidence of benign breast lumps and pelvic inflammatory diseases,
- decreased incidence of endometrial and ovarian cancer, and thyroid disorders.
5-Disadvantages
However, you must remember that OCPs do not protect against sexually
transmitted infections, so you must use condoms along with it just in case you're
concerned about STIs.
6-Missed pill (imp)
-there will be a leaflet that come with the pills
-if you missed a pill of less than 24 hours just take the recently missed pill As soon as
you remember and keep going with the rest even if it means taking 2 pills on the same
day.
-if you miss a pill for more than 24 hours, take the recently missed pill and just keep
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going with the rest even if it means taking 2 pills on the same day.
-If you keep going with the rest, and the dummy pill period falls within 7 days of missing
the pill, skip taking the dummy pills and start the hormonal pills from the next pack. This
will mean that you will miss having your periods. Alternate methods of contraception like
condoms should be used for 7 days after missing the pill.

-I will give you reading materials for your further information, and if you experience
any problems with the pill, report back to me.
-Remember to do a pap smear every 2 years.
-I will review you in 3 months time, and then yearly after that. Do you have any
questions at this point?

Feedback 7-9-2018
Station 20 – OCP request – PASS
OCP counseling
- 15 –year-old girl , wants to get OCPills , as gonna have sexual relationsh with her
boyfriend aged 16-year-old , at the same school ,
Not getting along with her parents, but living with her grandmom. LMP – 10 days ago .
Task:
1. ask history ( 4 minutes )
- explain about the patient’s age and explain about the definition of Minor for
contraceptive pills
Ask about absolute and relative CI to COC pills
- all normal
- understanding of attitude to the pregnancy , understanding about the pills MOA after
explanation
2. Focus PEFE ( Specifically ) – ask about breast lumps, BP , hepatomegaly , Jaundice ,
UDS - all normal this task 2 , ask about secondary sexual characteristic – examiner
slowly mention that tanner stage 2 , pubarche – normal , adrenarche for axillary hair -
normal for age
- I don’tknow what I need to ask for this PEFE for OCP,
2. Provide counseling to the patient
- explain the eligibility to the pills , but encourage to involve with family members esp:
with nana .
( Patient said that , in next visit, she would try to visit me with nana – okay doctor ? )
explain MOA and before explanation about miss pills, diarrhea – bell rang
- so quickly explain about need to know miss pills and vomiting – examiner said that –
relax – time’s up 
Feedback – Contraception request – Pass
Global score – 4
Key step 1 to 3 – YES
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Key step 4 – NO
Approach – 4
History – 5
Examination , sequence – 5
Patient counseling/education – 4

Feedback 7-9-2018( Contraception request- PASS)

15 year old girl comes to you know about OCP. She is going to start sexual
relationship soon. She lives with her granny.
- HX
- PEFE
- Counsel accordingly.

FEEDBACK-PASS
Global score: 5
Key steps: 4/4
Approach to pt: 5
HX: 5
Choice of technique of examination, organisation and sequence: 5
Patient counselling: 5

2mint thinking-
5P, Partner's age, contraindication for OCP, missed pill, follow up after 3 months. Red-
flags. side effects of ocp.

There was an smiling young girl sitting on the chair. after introducing myself, I said
confidentiality. I said I am very glad that you are here to ask for OCP. I'll give you all the
information that you need, but I need to ask few personal questions as well. Would it be
alright with you? (YES) Have you talked about this to your parents? to your granny?
(No) How older is your boyfriend?(16) Is he your family relative or teacher by any
chance? (no, my senior in school) Have you started sexual relationship yet?(no) How
much do you know about OCP? ( Pills, need to take every day, got info from internet)
Well, I'm going to ask you a bit embarrassing question now, tell me what could happen if
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you haven't used any contraception? ( She smiled and said pregnancy) I smiled and said
good. Now tell me what else is associated with unprotected sex? She became confused
and looked at examiner I guess. Then, I said, have you ever heard about Sexual
Transmitted Infections? Then, She smiled at me and said no. I said , no problem, I'll
make sure that at the end of this conversation you will know all info.
Now, I ask about her periods(2 weeks back), any bleeding, pain, discharge, gardsil
vaccine, any pregnancy symptoms? any medical problem?
Contraindication of OCP- migraine, spotting, liver problem, clotting problem, fx of
cancers.
Then I said her that I'm going to talk to my examiner and will come back to you soon.
I asked examiner-
VITALS- all, especially BP
BMI
PICKLED
Any abnormality in breast
Hepatomegaly
Pelvic exam with presence of a chaperon - any discharge? Hymen intact? (IF NO- then
PT )
thanked him.

I said to her, Okay Jenny, everything seems normal to me and I'll prescribe you OCP.
There's a starter pack available to make it more convenient for you . I draw a rectangle
box and said there is a red line in the starter pack. You will start from this line and 7
tablets are included in this red block. This medication will be effective after 7 tablets.

There are 21 hormonal pills and 7 sugar or iron pills. They usually change your female
hormone level in your body to prevent pregnancies. You have to take this medicine every
day, preferably at the same time. Make a specific time, such as 9 o'clock in the morning
or at night. Make sense? (yes).

Now, you must be thinking what if I missed a pill? Right? (She smiled at me). I started to
explain if one pill within 12 hours- no problem, take it as soon as you remember. More
than 48 hours, any vomiting, diarrhoea- Use condom. Any unprotected sex - go to
pharmacy for emergency contraception.
Always use condom to protect yourself from any STI.
154

Then, I ask her to repeat all the info I just said. She did.

I said, any time you feel headache, unwell, yellowish discolouration, spotting- come back
to me.
I will give you all reading materials, give it a read. Come back to me after 3 months for
some blood tests.(LFT) I would like to talk with your boyfriend as well if you are okay
with it. She said alright.

I did finish every points in time in this case. I was worried for my time mx about this case
but I did it.

Feedback 18-9-2018 OCP request 15 years old

15 yr girl ask for OCP, boy friend 16 yrs old. Task: Hx, PEFE, counsel the patients
same as Karen
HX: Said confidentiality.
Ask contraindications for OCP– none of them
HEADSSS: She said her parents know about the bf but not sexual activity. She argues
with parents and moved out after that. I encouraged her talk to parents and she agreed.
A bit stress from the exams in school but manageable.
PEFE: everything normal
Counsel: explained the need to assessed ability of mature minor.
The stem said the patients are aware of how to take the OCP so I didn’t say that part. Said
complications, risk, failure rate, not prevent from STD.
Score: 4 Key step; yes/yes/yes/no
Approach: 4, Hx: 5, PEFE: 4, counselling: 4

Feedback 18-9-2018 OCP request

You are a GP and your next pt is a 15 year old Uni student who came to you with
request for a script of OCP. She knows how to use the OCP. She has been living
Independently with her BF for the last 6 months and recently they decided to
start sexual relationship. Her BF is 16 years old and studies in the same uni. She
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doesn't have good relationship with her parents, she used to live with her grand
mother but recently move out to live with her BF. She doesn't have any known healt
issue and her last check up with regular GP was 6 months ago and everything was
normal. Her immunisation is up to date. You are seeing this pt for the first time.
Your task is to
1. Take further history from the pt to assess the competency of the pt regarding
OCP use. ( you should spend no more than 4 mins in this task)
2. PEFE from the examiner ( examiner will only give findngs of what you have asked
for)
3. Consel the pt accordingly.
The pt was a teenager and she was not helpful. She didn't wanna talk much , she
just
wanted the script and go. So I explained her that yes I will give you the script but we
need to
follow some protocol as you are 15 years old. So I will ask you some questions and then I
will
explain everything and then give you the script. She agreed with that.
So I asked all past Hx, surgical history, O&G history, recent infection, breast ca history,
Migrain,
SADMA, 5PS all were normal.
On PEFE I asked GA, BMI, Vital signs, Breast , abdomen, Pelvic examination, Urine
deepstick,
ecg and BSL
Explained her that you can qualify for OCP as you are living independently and your BF
is just 1
year older than you. Then I was running out of time. So i rushed and quickly told her
what to do
if she misses the pill in different days of her cycle. I didn't talk about how to take the pill
as it was given in the stem that she knows how to use it. I told that it will prevent
conception but not STI so you still have to use condom for that. But I forgot to check her
understanding as I was rushing. Then talked about break through bleeding and some side
effects. Gave her 4Rs and bell rang. AMC feedback: Station 04: Contraceotion
Request Grade: Pass Global score: 4
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76-Bacterial vaginosis
AMC case 21-6-2018
A young lady come to GP with grey, foul smelling vaginal discharge for 3 months or so.
Had doxycycline and antifungal but didn't work.
Tasks
- history
- PEFE
- diagnosis
- management
History
1- discharge questions
-how long have you had this discharge form vagina?
-how many pads have you used? (Profuse)
-what is the colour? (Grey)
-is it smelly? (Yes, fishy)
-what is the consistency? (Thin) is it bubbly? (Yes)
-any blood stained?
2- Associated symptoms.
-any itchiness or soreness? (yes a bit)
-any fever, tummy pain, vaginal bleeding? (No)
-any burning or stinging on passing urine?
-how is your bowel habits?
-any ulcers, rash?
4-5Ps questions
periods
-when was your LMP? are they regular?
Partner or sexual
-are you sexually active? Are you in a stable relationship? (stable relationship)
-have you or your partner ever been diagnosed with STI?
157

-any pain during intercourse?

-any similar symptoms in the partner?
-do you practise safe sex? (Yes)
Pill
-what type of contraception do you use? for how long?
Pregnancy
-any previous pregnancies? Any miscarriages?
Pap or HPV

5-general questions
-past medical and surgical history
-SAD
-diabetes
-do you feel thirst? are you passing large amount of urine? Do you need to go to toilet
more frequently? Any history of diabetes?
Immunosuppressive disease
-any loss of weight? Loss of appetite? Lumps or bumps around the body?
Antibiotics or steroids
-do you take any antibiotics or steroids medications
vaginal douches/ pessaries/ shower gels change
- Any vaginal pessaries or douches that you have used?
-have you changed your shower gels?
Tight clothes
Do you use tight clothing or tight jeans, panty hose

Physical Exam from examiner

1-General appearance:
BMI, pallor, lymph nodes, rash, evidence of infection anywhere in the body
2-Vital signs: temperature, BP
3-CVS/Respi
4-Abdomen:
inspection: visible distention, mass,
palpation: palpable mass and tenderness
5-focus Pelvic examination
Inspection of the vulva and vagina:
-discharge, color of the discharge, is it smelly. (no discharge visible)
-any swelling or erythema of the vulva or vagina (mild erythema)
Speculum:
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cervix healthy or not, discharge or bleeding, erythema of the cervix (mild to moderate
greyish smelly discharge)
Per vaginal: DON'T to avoid spreading the infection
6-Office test: urine dipstick and blood sugar level (both imp), UPT

Explanation
-you most likely have a condition called bacterial vaginosis. It is caused by imbalance of
the bacteria normally present in your vagina and this happens when the normal healthy
bacteria is suppressed or replaced by an overgrowth of other unhealthy mixed bacteria.
-the exact cause is unclear but could be sexually transmitted and this is one of the most
common causes of abnormal vaginal discharge in women.
-It usually produces a watery, white or gray discharge, and has a strong unusual fishy
smell.
Investigations
-In order to confirm this, I need to take a high vaginal swab which is given for
microscopy and gram stain, and it will show clue cells, which is a normal vaginal
epithelial cell with bacteria attached all around.
-Another test is an amine whiff test where 10% potassium hydroxide is added, and it will
give a pungent fishy smell.
-Another one is to estimate the pH of the vaginal fluid and usually the pH will be greater
than 4.5 if it is bacterial vaginosis.
-I would also like to take some blood tests (FBC, UCE, LFT) and urine for MCS
-STI screen with your consent (key)
Treatment
-Even after treatment, in about half of the women, it can sometimes recur in the next 6-12
months.
-Management of this is by prescription of antibiotics, metronidazole wither orally for 7
days or as a gel intravaginally for 5 days. * if pregnant clindamycin
-Avoid vaginal douching because that can also alter the bacteria in your vagina. Follow
good genital hygiene.
-You partner does not require any treatment as of the moment, but always practice safe
sex.
-I will give you reading materials regarding bacterial vaginosis.
Feedback 21-6-2018
Young to middle-aged woman with profuse greyish smelly discharge unresponsive to
antifungal and doxycycline for 3months. Take history. Ask for examination findings from
examiner. also explain your management. [ stable relationship and safe sex—bacterial
vaginosis including asking for management] Vaginal Discharge: Pass: Global Score: 4
-I asked about characteristics of discharge and possible burning sensation or itching down
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below. Also asked about previous medications. Asked about previous medical conditions
such as diabetes. Also asked about hormonal contraception and her relationship (whether
she practiced safe sex. And history of possible previous STIs. She did not have any risk
factor for any sexually transmitted infection and no risk factor for developing candida
infection.
-In examination findings from the examiner, I asked for General appearance, (she looked
concerned) vital signs especially temperature Normal. Lung and hearts equal air entry
and normal heart sounds, abdominal examination no distension and no tenderness in
palpation. In genital examination in the presence of a chaperone and with the consent
of the patient, no obvious discharge from outside, in speculum examination, mild to
moderate greyish smelly discharge. I do not remember the presence of the
inflammation in vagina, but I guess cervix was healthy. I took a high vaginal swab
sample for gram staining and microscopy and did not proceed to bimanual examination.
So I put to her that her symptoms looked like a bacterial vaginosis. So I explained that as
she has not had any improvement with previous medications, I suggested waiting for the
results of swab sample and in the meanwhile, I suggested improvement in the
genital hygiene, wearing cotton underwear, changing underwear often, not using
any pessaries or vaginal douches, and after the results were available we discuss
further management which would be a suitable antibiotic or antifungal medication

91-Lithium in pregnancy
Sample case/ You are at your GP, when 30 year old Lisa comes to you for Prepregnancy
counselling, she has a history of bipolar disorder and is on lithium for the past 2 years.
TASKS
Take a further relevant history
Counsel the patient accordingly

History (she is well controlled on lithium)

1-Ensure confidentiality
2- disease questions (Bipolar Disorder)
-for how long have you had Bipolar disorder?
-how many episodes have you had during that time?
-When was the last episode of your bipolar disorder? She is symptoms free (if she has not
160

had an episode in 1 year, you can stop Lithium)

- are you able to identify early warning signs of bipolar disorder?
3-Medication questions (Lithium) DISCO (duration, indication, side effects,
compliance, and other medications)
-how long have you been on lithium? (Duration)
-indication (already given bipolar disorder)
-have you ever had any SE like dizziness, tremor, weather preference, diarrhoea? (SE)
-do you regularly take lithium? (Compliance)
-do you tale any other medications? (Others)
4-well control questions
-have you had regular check up with your psychiatrist? When was the last visit?
- How often are your Lithium levels monitored? When was the last check?
- have you ever hospitalized due to bipolar disorder?
5-Brief Psychosocial history (as this case is combination psych and obs)
-How is your mood?
-Do you have passing thoughts of harming yourself or others?
-How is your sleep? (sleep deprivation can lead to bipolar disorder)
-do you hear, see or feel things that others do not? Do you feel someone is following you
or trying to harm you?
6-5Ps questions
Period history
-When is your LMP? Is it regular?
Partner or Sexual history
-Are you into a stable relationship?
-Do you have a very good support from your partner?
-Any history of STIs?
Pregnancy
-Have you ever been pregnant before?
-Any previous miscarriages?
Pill
what type of contraception do you use?
Pap or HPV
When was your last pap smear or HPV, and what was the result?
7-general questions
-Any previous history of any medical or surgical illness, mental illness?
-SAD
Counselling
1-reassurance
161

many women who have bipolar disorder and on medications for bipolar disorder go for a
normal and healthy pregnancy and deliver healthy babies.
2-effect of pregnancy on bipolar and lithium on pregnancy
-Bipolar disorder can sometimes worsen during pregnancy.
- The medication of lithium that you are taking can have some effects on the baby
especially if you take it during the 1st 3 months of pregnancy. It can cause
neural tube defects sometime
heart defect
liver problem
respiratory difficulties once the baby is born
hypothyroidism
developmental delay
3-prepregnancy plan (psychiatrist role and GP role)
Now, I need to reconsider the lithium in you. For this I need to Refer you back to the
psychiatrist for review of your medications. There are three strategies that the psychiatrist
can do, depending on the severity of the bipolar episodes.
First strategy is a medication-free pregnancy. The specialist might decide on a safe and
supervised withdrawal of Lithium.
**It is usually done if a patient has a few episodes of the disorder, long periods of mood
stability (at least 1 year), low risk of self-harm, good support, and if the patient is able to
identify early warning signs. (No need to mention this point **I think)
Second strategy is to go for a medication-free first trimester after discontinuation of
lithium now and monitoring you further. Lithium will be reintroduced after the 1st
trimester.
Third strategy is to give a mood stabilizer throughout the pregnancy . The specialist will
consider the option of changing Lithium to another mood stabilizer carrying less risk like
Olanzapine and if necessary (If the bipolar episodes are not controlled with these
medications) Lithium will be reintroduced after in the 2nd trimester.
-I will do all the baseline antenatal blood tests like FBE, UEC, Blood group and Rh,
coagulation profile, rubella and varicella serology, hepatitis serology, and TFTs.
-I will prescribe you folic acid for 3 months before and for the first 3 months of your
pregnancy
4-during pregnancy plan
-Once you become pregnant, you will be monitored in the high-risk pregnancy clinic, and
will be seen by a multidisciplinary team composed of the obstetrician and the
psychiatrist.
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-if on lithium at any stage you requires regular check of your kidney and thyroid function
and also lithium level (lithium levels monthly in the first half then weekly in the second
half).
-daily dose of lithium will be broken down into small frequent doses to avoid lithium
level peaking.
-During your pregnancy you need to go for more frequent antenatal checks, a Down
syndrome screening, ultrasound at 18 to 20 weeks, fetal echo or heart scan need to be
done by 22-24 weeks, sugar test at 28 weeks, repeat ultrasound at 32 weeks will be done,
and a bug test at 36 weeks will be done.
5-labour, delivery and postpartum plan
-usually, the dose of Lithium has to be decreased by 38 weeks to reduce high levels of
Lithium in the baby.
-you may go for normal vaginal delivery but Delivery should be in tertiary hospital under
specialist guidance with continuous monitoring of your lithium level and also the baby
with CTG.
-once labour is finished and when you go to postpartum period, you might get a relapse
of your bipolar disorder so lithium level need to be increases to the dose was before
introduced.
- You cannot breast feed your baby while you are on lithium.
6- Ending
- Our goal during your pregnancy is to maintain maternal wellbeing, ensure your baby's
safety, and also prepare you for the post-partum period.
-I will give you reading materials regarding bipolar disorder during pregnancy for
further insight, and will review you regularly.
-give you referral to the psychiatrist

Feedback9-5-2018
Case: Medication in Pregnancy
Possible pregnancy + Bipolar on Lithium
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Young female in her twenties with history of bipolar in management with Lithium a year
ago she has multiple recurrence of psychosis but she has been well for the last 10 months
I think. She comes because she believes she is pregnant. A bit long stem talking about
her bipolar.
Task
Take history no more than 2 minutes.
Counsel her about her pregnancy
I managed this case as many other doctors have posted before.
Passed. Global score 4.
Bipolar well controlled, on lithium n THINKS she is pregnant and what's to find out
what's the effect of lithium in general pregnancies. Task counselling /mx

Outside- my goodness, i did not remember what i should say, may be ask some questions
and mentions about risk for mother and baby, how to manage during pregancy.However,
she may not pregant so i have to do pregnacy test first as on the question, patient has
irregular period only , she did not do any PT test.However, they did the thyroid test, KFT
and CBC test for her on questions given.

Inside: talk with patient, ask her about her health, when she was diagnosis with bipolar,
what medication. Ask her about 5 P, intention to have baby or not and what did she
prepare like folic acid. I asked about complication of lithium.I told her i will do
pregnancy test for her now. There are 2 ways. If she is not pregnant, it may due to side
effect of lithium on her thyroid. If she pregnant, there are some risk factor for
mother( relapse) and baby( heart disease, thyroid disease, death inside the womb). I told
her about MDT and all investigations for antenatal check up, folic acid need to be
use...Then i ask examiner any test result back, he said no. i talk again and again just all of
this information including 5R.

 
164

Feedback 13-12-2018 Medication in pregnancy: Pass

2 mins outside: Pt is on lithium for bipolar since last ? 1-2yrs. She has no symptoms
currently and no problem with lithium. She missed her period thinks she is pregnant. She
come to see you regarding that.
Tasks: history
Management

Outside thinking: Thought about what need to ask in history as I knew management.
Inside: Me: I come to know from the notes that u come to see me regarding your possible
pregnancy and wether you should be on lithium or not.
Pt: yes
Me: start with history od presenting complaint.
Pt: none
Me: asked full psy history for bipolar such as symptoms of bipolar and side effects of
lithium. Also asked about full psy history such as delusion, hallucination and depression.
Also asked about psy visits. She did not see psy since missing period.
Pt: none.
Me: special history of periods and pregnancy tests. He did not have pregnancy test done
at home. Then I asked about remaining 4 Ps. Quickly ased about current medical
problems, which were none.
In all cases, I kept my history short and sweet as I knew u don’t need perfect history. It is
better than missing tasks.

Me: First of all we will do pregnancy test. If it comes negative then we will do some
hormonal tests to see why u r having irregular periods. ( to do pregnancy test is very
important even if pt has done pregnancy test at home, according to HB, in threaten
abortion case it is a critical error if u don’t do pregnancy test even pt has done this test at
home.)

If it comes positive then we need multi-disciplinary approach as this would be a high-risk

pregnancy (scared her here, I should have said as this is a specialist area). As you know
that some medications have side effects on person and on foetus if person is pregnant.
There are certain side effects of lithium on fetus such as heart problem in fetus and blah
blah blah ( I mentioned all the side effects, 8-10, which I read form internet, my
biggest mistake, scared the pt here too. did not need to mention them. Just needed to
say such as heart problem). Because of this issue I will need to refer u to obstetrician
and psychiatrist. The current approach is for mild case of bipolar: May be psychiatrist
will withdraw the lithium and monitor u regularly. For moderate case: lithium may be
withdrawn for 1st trimester and resume after that. For sever case: keep pt on lithium
throughout the pregnancy. In either case we will keep monitoring you and your baby by
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regular visits, regular ultrasound and any necessity investigations. Again, it is a specialist
area and we need to adopt an balanced approach according to your psychiatry condition.
Don’t worry, many pts with this condition have successful pregnancy and we will try our
best to get good results.

Me: do u have any que?

Pt: no, is there anything else I need to know?
Me: OMG, what have I forgotten? I checked my tasks again. Bell rang.
Key Steps: all yes. Global score: 4
Approach to pt: 2 ( I think I scared her, that why)
History: 3 ( I kept my history short)
Pt Counselling/education: 4 Management Plan: 4

94-primary amenorrhea
Sample case/ you are at your GP when 17 years old Maya presents to you with complaint
of not starting her periods yet.
Tasks
-take further history
-Physical examination from examiner
-DDX with the patient
-further Ix with the patient
Differential diagnosis
1-hypothalmus
-eating disorders
-exercise induced amenorrhea
-stress induced amenorrhea
-chronic illnesses like liver disease or diabetes
-severe depression
-kalman syndrome
2-Pituitary
-hyperprolactinemia
-thyroid
3-ovarian
-turner syndrome
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-Premature ovarian failure

-PCOS
-chemotherapy
4-uterine
-pregnancy
-mullerian agenesis
-androgen insensitivity syndrome
5-Vaginal
-imperforated hymen
-transverse vaginal septum
6-adrenal (Cushing’s)
7-delayed puberty

History
1-ask her regarding her concerns?
2-Differential diagnosis questions
-do you have monthly basis pain or cyclical pain? (Imperforated hymen, TVS)
-have you developed secondary sexual characteristic like having your breasts developed,
having pubic and axillary hair? (Turner syndrome)
-any hot flushes, heavy sweating, mood changes? (Premature ovary failure)
-any weight gain, hirsutism, acne? (PCOS)
-any weather preference? How’s your bowels habit? (Thyroid)
-any headache, blurring of vision, milky discharge from nipples? (Hyperprolactinemia)
-do you think you are excessively overweight? Do you try to lose weight through crash
dieting or exercising? (Eating disorder)
-how much exercise do you do? How many hours? (Exercise induced amenorrhea)
-any stress at home? Are you working or studying, any stress at work or UNI? (Stress
induced amenorrhea)
-are passing large amounts of urine? Do you feel thirsty? (Diabetes)
-any past history of liver or kidney disease? (Liver/ kidney problems)
-are you on any medications? (Chemotherapy)
-any change in the sense of smell? (Kalman syndrome)
-are you sexually active? Have you ever been sexually active? Any acne problem for
which you take OCP? Have you had Gardasil vaccine? (Pregnancy)
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-SAD
-when your mother or sister first had their periods? (Delayed puberty)
Physical examination from the examiner
1-general appearance
-BMI
-Dysmorphic features (short stature, web neck, wide carrying angle, wide spread nipples)
-verilisation
-acne/ hirsuitism
-Tanner staging (pubic and axillary hair, breast)
2-Vital signs
3-all systems
-abdomen for mass
-thyroid
-pelvic examination (just inspection) looking for imperforated hymen. Atrophic vagina)
4-Office tests
-urine dipstick
-urine pregnancy test
-blood sugar level

Explain the diagnosis

-there are several reasons why you have not started your periods yet.
-let me explain to you using a diagram (Draw hypothalamic pituitary ovarian axis). There
is an axis in our body we call HPOA that control your normal menstrual cycle. Your
periods usually regulated by hormones secreted from the brain (hypothalamic-pituitary)
then act on the ovaries, which in turn produces more hormones, which act on the womb
causing the bleeding of the periods.
Hypothalamus:
-sometimes lifestyle factors can cause absence of periods like eating disorder because of
excessively low body weight, extensive exercise or any stress at home or work all these
can alter the functioning of an area in your brain called hypothalamus causing n periods.
Certain medical conditions like liver, kidney problems or diabetes can also cause this.
Pituitary
-it could be due to overactive or underactive thyroid glands.
-may be due to a small benign overgrowth from pituitary causing over secretion of a
hormone called prolactin causing no periods.
Ovary
-can also happen in a condition called PCOS when multiple cysts developed in the
ovaries due to relatively high and sustained level of hormones rather than the fluctuating
level needed for normal periods.
-it could be due to genetic conditions like turner, premature ovary failure, or medications.
168

Uterus
-could be a structural problem like absence of uterus, cervix or vagina in a condition
called mullerian agenesis or due to outflow tract obstruction like imperforated hymen or
septum.
Delayed periods
Look from history and examination I couldn’t find anything to suggest one of the above
conditions so it could be just due to a constitutional delay of the periods. But need to do
Ix to make sure it is just normal delay in your periods and rule out others.
-Basic blood tests (FBC, UCE, TFT, BSL, prolactin)
-pelvic US
-LH and FSH
-may need karyotyping according to the results
Note/
in pelvic ultrasound:
-if uterus is present it could be either t outflow tract obstruction like imperforated hymen.
If no outflow tract obstruction it could be because the uterine lining is not responding to
hormones so we need to do another test called pregnancy challenge test.
-if uterus is absent need a chromosomal analysis or karyotyping to rule out mullerian
agenesis or androgen insensitivity syndrome
In LH and FSH
-if low could be due to eating disorder or exercise or stress induced and sometime in
constitutional delay.
-if high need karyotyping for turner syndrome
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95-Permanent Sterilisation
1-sample case
47 years old lady presented to GP clinic asking for tubal ligation.
Tasks
-History.
-Counselling
History
1-why
-why you want tubal ligation to be done? (I have heavy periods and my friend told me
that it helps stopping the bleeding)
2-Menorrhagia questions
-How long have your periods become heavy? (6 months)
-when was you last menstrual period? Are they regular?
-how many days of bleeding and how many days apart?
-how severe is the bleeding? how many pads a day do you use? (15 pads)
3-Differential diagnosis questions
Fibroids
-do you feel any lumps or swelling in your tummy or heaviness?
Cancer
-any LOW, LOA, lumps or bumps?
-is your mamo or HPV up to date?
-any bleeding in between the menstruation? Any bleeding after intercourse?
PID
-any fever, vaginal discharge? Any tummy or back pain?
-have you or your partner ever been diagnosed with STI?
Endometriosis
-any pain during intercourse
thyroid
any weather preference? How is your bowels habit?
Bleeding disorder/ blood thinner medications
4-pregnancy
-how many pregnancies have you had?
-any previous miscarriages?
-are you quite sure you do not want any children in the future? Have you discussed this
with your partner?
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5-Pill
-what type of contraception do you use? Any difficulty with OCP or SE?
6-General
-PMH, PSH, medications and allergies

Counselling
heavy bleeding.
-from the details, I see you are having heavy bleeding. there are several possibilities:
could be fibroid or benign growth of the womb, endometriosis or when the lining of the
womb present at some other parts, pelvic inflammatory disease or pelvic infection. Could
be due to nasty growth of womb or cervix. Could be due to other medical conditions like
thyroid or bleeding disorders or even medications.
-I could not find any cause from the history so I need to do full examination and also do
further Ix like blood tests, hemoglobin, RFT, TFT, clotting factors and blood group.
Arrange for transvaginal ultrasound.
-if no pathology could be seen in examination or Investigations then this could be a
dysfunctional uterine bleeding which is a quite common condition that happens towards
the menopause due to hormonal imbalance.
Tubal ligation.
-coming to your concern about tubal ligation.
-First tubal ligation is not going to help with the heavy bleeding. It is just a permanent
method of contraception and should be considered irreversible, as the success rate is very
low with reversion. So you need to be sure that you do not want any child in the future.
-Tubal ligation is usually done as a key hole procedure under General anesthesia where 2
or 3 cuts will be made around your belly button. A camera will be passed with tube
through one cut and through the other cut the surgical instrument. The tubes are then
identified and will be blocked using either clips or rings as this will prevent the sperm
from reaching the egg.
-there is risk of anesthesia, bleeding, infection, injury to surrounding structures but rare as
it is usually done by expert specialist and staff.
-the advantage is that it is permanent method and also does not interfere with menopause
or sexual desire.
-look as tubal ligation is not helped with heavy bleeds, you have another option like
mirena which is an IUCD having hormone progesterone and once inserted inside the
womb it controls heavy bleeding and also provide long term contraception for 5 years.
And by this time you will go into menopause. Do not worry about contraception as it is
almost similar to tubal ligation but its course is reversible.
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-ask if your partner is willing to do a vasectomy as this will carry less complications than
tubal ligation.

2-AMC exam Case

GP, 47 years old woman came to request for sterilisation. She has 3 children and the
youngest is 17 years old. She has been taking OCP since the 3rd child.
Tasks:
-History
-Physical examination findings from examiner
-Explain about the sterilisation method
-Explain further management
History
1-sterilisation questions
-I can see that you are here requesting for Sterilisation. Which type are you thinking
about? (tubal ligation).
-why you want tubal ligation to be done? (I do not want to take OCP anymore and my
friends had tubal ligation and it was good)
-all right can I appreciate you come her to discuss about tubal ligation but before that can
I ask you a few questions?
2-5Ps questions
Pill
-for how long have you been taking the pills? (30 years)
-what type of pills do you take? (Microgynon 30)
-any difficulty with OCP? Any side effects? (No)
Periods (normal)
-LMP? Regularity?
-heavy bleeding or pain during menstruation?
-bleeding in between menstruation?
-any hot flushes, night sweating or mood changes? (No)
Pregnancy (normal)
-how many pregnancies have you had? (She has 3 children and the youngest is 17 years
old).
-any previous miscarriages?
-are you quite sure you do not want any children in the future? Have you discussed this
with your partner?
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Sexual (normal)
-support from partner?
-STI?
Pap and HPV
-when was your last pap or HPV vaccine (4 years ago) it is important for your cervical
screen to be up to date I can arrange another consultation to discuss about it.
3- General
-PMH (hypertension, diabetes, high cholesterol, stroke, heart, liver, clotting problems)
-PSH (laparoscopic appenicectomy)
-Medication and allergies
-SAD
-Family history
Physical examination findings from examiner (I doubt it would be a task really but one
feedback said and other if it was just do like any gynecological exam case )

Tubal ligation Counselling

- First I want to mention that tubal ligation is a permanent method of contraception and
should be considered irreversible, as the success rate is very low with reversion. So you
need to be sure that you do not want any child in the future.
-Tubal ligation is usually done as a key hole procedure under General anesthesia where 2
or 3 cuts will be made around your belly button. A camera will be passed with tube
through one cut and through the other cut the surgical instrument. The tubes are then
identified and will be blocked using either clips or rings as this will prevent the sperm
from reaching the egg.
-like any surgical operation it carries some risks so with tubal ligation there is a risk of
anesthesia, bleeding, infection, injury to surrounding structures but to happen is rare as
tubal ligation is usually done by expert specialist and staff.
-the advantage is that it is permanent method and also does not interfere with menopause
or sexual desire.
Further management
-As you are 47 now, so in a 3-4 years you could go for menopause, If menopause happen
there will be no risk of pregnancy.
-In the meantime I can give another option for contraception that you can consider, which
is a copper IUCD; a small plastic device with copper wrapped around its stem. Once
inserted inside the womb it can provide long-term contraception for 5 years. And by this
time you will go into menopause. And it is almost similar to tubal ligation but its course
is reversible.
-ask if your partner is willing to do a vasectomy as this will carry less complications than
tubal ligation.
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Ending
-Assess patient’s understanding.
-Dear ---, you do not have a make a decision today. I will give you reading materials for
tubal ligations and other forms of contraception so you can read at home. When you
decided which is best for you we can make another appointment and we will proceed
from there. I
- will refer you to the specialist if you would like to have tubal ligation. I will also assist
you if you think about other form of contraception.
-it is important to have regular cervical screening if you want

Feedback 20-2-2018
GP, 47 years old woman came to request for sterilisation. She has 3 children and the
youngest is 17 years old. She has been taking OCP since the 3rd child.
Tasks:
-History
-Physical examination findings from examiner
-Explain about the sterilisation method
-Explain further management
2 min thinking: need to clarify what kind of sterilisation? Ask reasons. Take a normal
gynae history. Remember to give very brief explanations and other form of contraception
in management.
History:
Introduce myself. Patient stated that she is thinking about tubal ligation as she does not
want to take OCP anymore and her friends had tubal ligation and it was good. I expressed
to her it is very good for her to come here today and we can talk about tubal ligation in a
short while. Get consent to ask a few more questions about her general health.
PMHx: unremarkable
5Ps: pills – Migrogynon 30, missed some pills recently, pregnancy – unremarkable, PAP
smear – 4 years ago, I explained there is a new cervical screening program and we can
talk about it during next consultation, Partner – unremarkable, periods – regular, no signs
of premenopausal symptoms
FHx: unsure about when did her sisters/mother attain menopause
Past surgical history – laparoscopic appendectomy.
SADMA – unremarkable
Physical examination: – Unremarkable (forgot whether it was given in a card or have to
174

ask verbally)
Explanation:
Drew a diagram and explain very briefly about tubal ligation (key-hole surgery as what
you had for your appendectomy, clip/suture/ensure coil on both the fallopian tubes). It
prevents the ovum and sperm from meeting each other, however does not disrupt
hormonal production by ovaries. A form of permanent sterilisation, very good success
rate. Done by gynaecologist, risks includes surgical and anaesthetic. Assess patient’s
understanding.
Further explanation:
As you are 47 now, which you might become menopause in a few years’ time, there are
other forms of contraception which you could consider. I explained Implanon (lasts 3
years) and Mirena (5 years). Assess patient’s understanding.
Dear Jane, you do not have a make a decision today. I will give you reading materials for
tubal ligations and other forms of contraception so you can read at home. When you
decided which is best for you we can make another appointment and we will proceed
from there. I will refer you to the specialist if you would like to have tubal ligation. I will
also assist you if you think about other form of contraception.
AMC Feedback – Contraception request: PASS
175

Feedback 20-4-2018
176

7-9-2018
47yo woman come for sterilization she is on ocp ask hx pap smear was before 5 years
ago , pefe all normal , counsel about sterilization, mx plan
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96-Advanced age pregnancy

42 years old woman comes to your GP clinic after her Home pregnancy test appears
positive
tasks
-history
-PEFE card
-counsel the patient
History
1-approah
-I can see that you are here for checkup as your HPT is positive. Is it a planned
pregnancy? (yes)
-congratulation!
2-5Ps questions
periods
-when was your LMP? (6 weeks ago)
-were they regular? (yes)
-any pain or heavy bleeding during periods? (No)
Partner
-are you in a stable relationship? (yes)
-is your partner supportive? (yes)
-have you or your partner ever been diagnosed with STI? (No)
Pregnancy
-is this your first pregnancy? (yes)
-have you had any previous miscarriages? (No)
-do you have Nausea, vomiting or breast tenderness?
-any tummy pain, vaginal bleeding or discharge? (No)
Pills
-what contraceptive method were you in? (OCP)
-how long have you been off the pill? (since 1 years)
pap or HPV
-is your pap or HPV up to date? (yes)
3-General questions
-do you take any medications?
-do you start taking folic acid?
-Past medical history (HPT, DM, SLE, Epilepsy, heart) (No)
-SAD (does not smoke or drink)
-family history of birth defects?
178

-diet and vaccination?

-blood group?

PEFE card (everything normal except BMI 32)

Counselling
-I finish examining you let me assure you that everything looks fine. I could not find any
serious problems.
-your vitals are normal. Your heart is fine and tummy as well. There is one thing, which
is your BMI which is thing we use to assess your weight which appears to be higher than
it should be. Normally it should be less than 25 but yours is 32.

-it is good that you are here so that I can discuss about your pregnancy.
-firstly, I need to confirm your pregnancy by doing an office pregnancy test.
-I would also like to arrange some routine blood tests for you: FBE, Blood group and RH,
BSL, UCE, urine MCS, LFT, vitamin D, serology for chicken pox and German measles,
and STI screen with your consent.
-you need to follow some life style measures:
* take a healthy balanced diet rich in fruits and vegetables, cereal and bread,, avoid soft
cheese, raw meat,
*increase your fluid intake
*limit coffee to 2 cups a day. I appreciate that you stop smoking and drinking alcohol as
it is good for your pregnancy.
* do regular non-contact exercise
*I can also refer you to a dietician Will help you attain the ideal weight.
- I would you to continue with your folic acid but I will prescribe a higher dose, to be
taken in the 1st 3 months of the pregnancy.

-Because of your advanced age, I need to refer you to high-risk pregnancy clinic where
you will be seen by a specialist and will have frequent regular ANC checkup with regular
visits up to your delivery.
-during each visit, your body weight and BP will be recorded along with baby wellbeing.
-let me assure you that many woman at your age can go through normal pregnancy and
have safe delivery. But for further precautions we offer close monitoring as there is a risk
of having complications during pregnancy with increasing age for example: DM, high
BP, PROM, Preterm,. Any of these if detected can be managed properly by specialist at
high-risk clinic.
-for the baby there can be a risk of birth defects and the most important one is Down
syndrome. So that we offer screening tests at 11-13 weeks of pregnancy which is a
combined test; blood tests and us in addition to confirmatory test in the 1st or 2nd
trimester; CVS in 1st trimester when a needle inserted through the tummy to take a
179

sample of cells from placenta. And amniocentesis in 2nd trimester; when needle passed
into your tummy to take portion of fluid in the bag of water surrounding the baby. Risk
of miscarriage with CVS is 1% while 2% for amniocentesis.
-you will have Ultrasound imaging at 18 weeks and repeated ultrasound at 32 weeks,
sugar test at 28 weeks and bug test at 36 weeks.
-lots of things but Do not worry I will give you reading materials about all of these.

-red flag. (Tummy pain, bleeding, discharge)

-review.

98-Pre pregnancy DM counselling

AMC Case (9-2-2018/ 1-6-2018/ 6-6-2018)
Woman Type 1 DM on insulin. Plan to become pregnant. Her husband is a farmer and
they are living in a rural area 2.30 hr from tertiary hospital. Would like to conceive but
wants to have care and delivery in local rural hospital.
Tasks:
-take history
-PEFE
-convince to have ANC is tertiary hospital.
History
1-Approach
-Hi my name is --- I’m one of the doctors here I understand from the notes that you have
DM and you’ve come to discuss about pregnancy planning. Is that right?
-when are you planning for the pregnancy? (in 6 months)
-it is a great start from you to come here and discuss about it. So we can address it
together.
-First, can I just ask you a few questions to assess your current health condition?
2-Diabetis Mellitus questions
-since when have you been diagnoses with DM? (Since 9 years old)
-do you feel thirsty? Are you passing large amounts of urine? Any trouble seeing? Any
skin or vaginal infections? (No)
3-Medications questions
-what medications do you take to control you DM? (Insulin)
-do you take it regularly? (yes)
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4-Well control questions

-have you had regular check-up with your physician? When was the last one? What was
the result? (7 months ago and HBAIC is 11%)
-do you regularly measure you BSL at home? What was the most recent result?
-is there any time when your BSL was too low or too high that you had fainting episodes
or need hospitalisation?
5-5Ps questions
-Periods: LMP, regularity (2 weeks ago and regular)
-partner: support, STI? (Normal)
-pregnancy: 1st or not, previous miscarriage (1st)
-pill (No)
-pap or HPV (up to date)
6-investigations
-have you had any blood tests like (blood group, rubella or varicella serology)
7-May I know the reason why you want to deliver in rural hospital?
(I wants my husband and family members to stay around me)
Physical findings from examiner
1-GA (PODL)
2-VS
3-BMI
4-chest and heart:
air entry, breathing sound, dullness, adventitious sounds, apex beat, heart sounds and
murmurs.
5- focus abdomen
inspection: distension, mass
palpation: mass, tenderness
auscultation: bowels sounds
6-pelcvic
inspection of vulva and vagina: discharge, bleeding, rash, vesicles
speculum: healthy cervix, discharge
Bimannual: uterine size and tenderness, adnexal mass and tenderness.
7-office tests
-urine dipstick (glucose 2+)
-BSL

Counselling
Effect of DM on pregnancy (mother and baby)
-all right, first let me assure you that many woman with diabetes can have normal
pregnancy and can get through safe deliveries with healthy babies. However, you need to
181

be closely monitored during pregnancy as there are some issues that might arise during
pregnancy.
-because of DM, you could have increase in BP or increase amount of fluid in the womb
called polyhydramnios. Having DM can increase the risk of birth defects or having a big
baby, it can cause breathing problems to the baby. However, these risks can be minimised
by keeping your BSL during pregnancy under control in addition to monitoring you
closely with the help of MDT. So if any complications happened it can be dealt with
appropriately.
Prepregnancy
-from history and examination it seems like your blood sugar is not well controlled so I
would like to perform some blood tests like BSL, HBAIC to assess DM control.
-I would also like to refer you to diabetic physician for complete assessment of nerves
and kidneys and your DM.
-refer you to eye specialist to check your eyes.
-once all investigations are normal then it will be safe to attempt pregnancy.
-I will start you on folic acid now, (2.5 mg high dose)to be taken prior to pregnanct and
continued for the 1st 3 months of pregnancy. And will also arrange all routine blood tests
usually performed at 1st antenatal visit.

During pregnancy
-you will be managed at high-risk pregnancy clinic by MDT
-you might need increase In insulin requirement to keep BSL under control.
-need to go through more frequent antenatal checkups
Delivery
-will be in tertiary hospital under specialist guidance. Usually planned at 38-40 weeks
After delivery
-insulin dose will be return back to Prepregnancy level.
-you can breastfeed your baby.

Address rural concern

-I understand that the presence of your husband or family members is very important and
comfortable to you.
-the reason why you need to be managed in the tertiary hospital is that rural hospitals
have limited facilities as well as specialists, and due to all possible complications that can
happen during pregnancy like big baby, high BP, PROM it would be best for you and
your baby to be managed in tertiary hospital where facilities are available there.
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Feedback 1-6-2018

Pre preg counselling. T2 DM. Task: Hx, Counseling

6 months ago last HbA1c 11%. Presently RBS 8. Under insulin. Asked DM questions,
pre preg questions. Explained need to repeat HbA1c, complications in preg (to mother
and to baby) and what to expect, increased insulin demand etc….

Feedback 1-6-2018
Pre preg counselling. T2 DM. Task: Hx, Counseling
6 months ago last HbA1c 11%. Presently RBS 8. Under insulin.
Asked DM questions, pre preg questions. Explained need to repeat HbA1c, complications
in preg and what to expect, increased insulin demand etc….

Feedback 1-6-2018
Type 1 DM on insulin. Plan to become pregnant in 6 months.husband is a farmer and
they are living in a rural area 2.30 hr from tertiary hospital.Prepragnancy counsling. C
wants to deliver at rural hospital.
Hx, PEFE,advise.(DM since her 9 years. Couldnt remember her blood sugar. Last HbA1c
8.last specialist visit 7 months ago. On Ex all normal except urine sugar2+.)
It was a confusing station as she didn’t have good control ps wanted to deliver in rural set
up
Any ways in hx asked her about her DM control(not controlled, HB1AC deranged, last
visit to specialist 6-7 months back, regular with her meds i.e insuln don’t remember how
much she was taking , no compli on hx like BOV, numbness tingling, sob, excessive
weight, frothy urine, urine frequency, no discharge, recurrent infection over all she didn’t
give any complication of dm from hx).
Then I asked about 5 Ps: last period 2 weeks back, previous preg: no, pap: recently
normal, pills: no , partner: healthy no std no health issues and is supportive, Blood gp B
+ve, no other chronic ailments.
I asked her reson to deliver in rural set up and she said that she wants her family members
to stay around her and no financial and other issues
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PEFE: quckly asked examiner for stigmata of dm complications and examiner said al
normal

MX:
I told her after seeking hx I don’t think it’s the right time to conceive as well controlled
DM it self make a pregnancy high risk for mum and the baby and in your situation ur
blood sugar is not controlled . first we need to run fresh set of investigation, seek
specialist review for DM management and adjustment of insulin accordingly, maintain
DM diary and started her on folic acid then told her compli of dm on pregnancy , risks to
her and baby . and told her that I know its comforting to see all the loved one around you
once u r deliverling the baby but because of high risk issues and complications I would
suggest you to review your decision and arrange family meeting with ur consent as she
needs frequent monitoring during pregn and at the delivery even after delivery there are
risks for baby like RDS. I said how do u feel about mx plan she said I will do what ever
you will suggest I said good lets work as MDT (referral to DM physician, high risk preg
clinic ince she is pregn, but ran antenatal tests, and dietitian referral)
It was a long station could cover rest
Feed back: pass Global score: 4
Key step 1&2 : no, 3 & 4 : yes Approach to pt: 3
Hx: 5 Choice and technique of exam :5 Pt education: 5

Feedback 10-11-2018
pregnancy advice DM type 1
She was dx since 9 yo so far no hx hospitalised due to her illness, routine checking up
her BSL , last time to see sp 3 weeks ago all were normal , blood test normal eye normal,
no bowel/urinary problem , no weight loss no vaginal problem no hx of STI in stable
relationship .Partner supoortive , living in rural want to be deliver in local hospital ,
periode , papsmear were normal never pregnant before didn’t take any contraceptive
SADMA only, diabetes + finding .
PEFE : I was confused what to ask in here I asked from head to toe BMI normal VS
normal
Ix : bsl 11 , glucosuria + 2 , UPT not provide
184

Counselling : reassurance that she can have normal pregnancy like other women but need
close monitor as there’s some issues that may arise during pregnancy : such from from
baby like …
From your pregnancy it self such as …..those could be happen as well in normal
pregnancy .
From delivery as well …that’s why delivery will be planned and the facility that has all
supports you need.
Looking at those issues thast why we need to control your BSL before you start falling
pregnant that why it a great start from you to come here so we can address all those and
put everything in place .I will refer you to diabetes specialist for that as well as dietitan
that could help control your BSL once reach 5 to 7 its good environment for baby to grow
and yourself. I will give you script for high dose folic acid to minimise the complication
to baby as well that u need to take before pregnant and I will see you again after you
coming back from specialist
Address about her wish deliver to rural hospital that is quite understanding that she need
to her support , unfortunately due to all those possibilities that may happen and we need
to prepare and rural hospital has limited facilites as well as specialist that would be the
best for her in bigger hospital as you and your baby well being is our most priorities .
My head thinking should I do ANC now or not but time tickling as her BSL just too high
so I decided I didn’t say it and address that 1st
Give some reading material
Feedback passed
Approach /hx/pefe/counselling/ 6/54/6

Feedback 6-6-2018
type 1 DM prepregnancy advice- pass
28 years old , type 1 DM since childhood, controlled well. Now she wants to get
pregnant.
Task: history
Explain possible cx to patient if she gets pregnant
Explain possible cx to baby if she gets pregnant
185

History: appreciate the patient coming for advice prior to pregnant. Any specific
concern?
Type 1 DM, seen by specialist regularly, on insulin, compliant with meds, kidney check,
eye check done 6 mths back, was normal. No tingling and numbness. HB A1c within
normal limit, no admission to hospital for DM emergency, diet , exercise, 5Ps, social hx,
family hx of complicated pregnancy no
Cx to mother: uncontrolled DM, DM can cause complications in pregnancy as well as
pregnancy can complicate ur DM, need tight control of sugar to prevent cx, might need
more insulin than usual, kidney, eye pblm, PIH, polyhydramios, pprom,
Cx to child: miscarriage, birth defect, prem, IUFD, big baby, difficult labour,
hypoglycaemia, neonatal jaundice
Don’t worry, I am not meaning all those cx will happen to you. Just explained you of all
the possible cx. We can prevent those by tight control of your DM and close monitoring
during the pregnancy, you will be manage by MDT team. (Please try to reassure the
patients after explaining cx in all case, they looked so worry after explaining about a list
of complications)
I had time, so talked to patient about mx briefly ..like taking folic acid from now on , AN
blood tests from now, to see specialist before she gets pregnant, continue diet and
exercise .

102-HSIL
32 years old woman comes to your GP for the result of cervical screening.
HPV is positive and pap showed HSIL
-take history
-Explain result and treatment
History
1-approach
-I can see that you are here for the results of your cervical screening is that right?
186

-Before that, can O just ask you a few questions in order to assess your current health and
correlate the history with the results?
2-5Ps questions
periods
-when was your LMP? are they regular?
-how many days of bleeding and how many days apart?
-any pain or heavy bleeding during menstruation?
-any bleeding in between menstruation?
Partner/ sexual
-are you sexually active? (Yes)
-are you in a stable relationship? (Yes)
-have you had multiple partners before? (Yes)
-what type of sexual activity do you prefer?
-do you practise safe sex? Do you use condoms?
-have you or any of your partner ever been tested for STI?
-any pain during intercourse or bleeding after intercourse?
Pregnancy
-have you ever been pregnant before?
-are you planning for pregnancy?
-any previous miscarriage?
Pill
have you had Gardasil vaccine
3-Symptoms questions
-any tummy pain, vaginal bleeding or discharge?
-any Loss of weight, loss of appetite, lumps or bumps?
4-General
-medications and allergies
-PMH, PSH
-SAD
-occupation
-family history of any cancer?
Why you ask me this question? We need to ask such questions as a routine to assess the
general and reproductive health.
Explain results
-here is the results with me, let me explain it and I am gonna draw a diagram to be more
clear. If you have any question or confusion feel free to interrupt me.
-First, these tests are part of cervical screening program. The aim for this screening is to
identify any early changes in the cervical cells before becoming nasty or cancer. So it is
not a test to diagnose cancer.
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-this is the womb and this is the neck of the womb or the cervix. In cervical screening we
scrape a sample of tissue to detect the presence of HPV which is a type of virus that can
cause abnormal growth and changes in the cervix. The result shown to be HPV+ve which
mean that you have this virus.
this virus usually transmitted by direct skin to skin contact usually from sex and any
sexually active woman can contract the virus.
-this sample of tissue also been examined for the presence of abnormal cells as there are
levels of cervical cells abnormality. The test showed that you have a high grade
squamous intra epithelia lesion which is a moderate to sever abnormal cells of the cervix.
Is it cancer doctor?
-the presence of HSIL does not mean that you have cancer; some cells are growing and
dividing abnormally, and it is good that we picked it up because, if not treated these can
turn into cancer. So we can prevent this with early treatment.

Management
-as you have abnormal cells so further tests need to be done for you:
UPT to rule out pregnancy
FBE, BSL, UCE, LFT
-would like to refer you to a specialist for colposcopy which is a procedure when the
doctor use light and magnification to see the vaginal and cervical tissues more clearly.
(Critical error)
and in some cases they might take a sample of your cervical tissues in a procedure called
biopsy.
-treatment will be decided by the specialist. Options could be
local destructive therapy by cryotherapy or electrotherapy
local excision od suspected segment
cone biopsy if the upper segment cannot be seen which is taking a cone shaped segment.
-what if I become pregnant?
it can cause miscarriage in the 2nd trimester or having labour prior to the exact date called
preterm labour. But all of these will be managed and prevented accordingly by frequent
checkups.

Feedback
32 yr old female with hpv +, hsil
188

-take hx
-explain result and tt
Regarding the case of HSIL
During the two minutes outside I asked myself is this breaking bad news but how come
pap smear is only screening test . So don't forget asking about gardasil vaccine ,pregnant
or not ,
Good morning my name is ahmed am your GP today can I get your name ... I understand
you are here to get the results for your pap smear ..
Yes doctor what do you have for me ?
I would like to ask you few questions before we talk about the results .. Why do wanna
ask me is there anything wrong ? I just need to ask you few questions ..ok
Are you sexually active ? Yes when did you start your sexual life ? She said around 16 I
think
Are you in stable relationship? Yes
Practise safe sex ? Yes using condom
Multiple partners before ? Yes long time ago
Ever been diagnosed with STD? No
Pain during sex .. No
Bleeding after sex.. No
Have you had gardasil vaccine ? What ? Gardasil vaccine .. No what is that ? Then I
explained quickly about it
Asked about her periods :
Regular .. Yes
Pain ? No
Bleeding in between ? No
LMP: 2weeks
Could be pregnant ? I don't know
Then I asked about signs of pregnancy.. All no
Any pregnancy or even miscarriage? Never
General health ? Ok
Smoke ..no
Drink .. Occasionally
Family hx of cervical cancer ?? Why doctor what is wrong and she started to cry
I offered her water and tissues she didn't take and just tell me what is wrong
I said as you know pap smear is just screening test for cervical cancer .. What screening
means ? Means not confirmatory means of it shows any abnormality we need to do
further investigations ..
What this has to do with me doctor (crying )
your pap smear shows you have some abnormal cells .. What abnormal cells mean ?
So i realised am going to have hard time so i draw diagram of the cervix quickly with
some cells and said this is the cervix and this is the lining during the pap smear we took
189

some cells and we tested it under microscope and it shows some abnormal which means
different in shape than expected for the lining of the cervix we call it HSIL of course she
said whaaaat ! I said don't worry about the name .
Then she said oh my god am I having cervical cancer ? I said no we need to do more
further investigation to confirm the presence if these cells .
Firstly we need to make sure you are mot pregnant so i will run blood test to
confirm or exclude pregnancy .
Then I said i will refer you to gynaecologist he will do colposcopy.. What that ? it is
small tube with camera he will go and look at the cervix looking for the abnormal cells
and take a biopsy .. What is the biopsy ? (👀)
take the abnormal cells out and test it and the treatment will depend on the results ..
What could be the ttt? If is confirmed they may do cone biopsy and i talked briefly about
the complications .
If it is LSIL I talked about ablation .
If he has to do the cone will i be able to be pregnant ? Yes but as i mentioned there is
increase risk of premature labor and PPROM .
The bell rang before I mentioned future follow up or mentioned gardasil vaccine because
she kept asking about everything . I was so upset and I said I will not make it for this
station ..
But fortunately passed it.

Feedback 1-3-2018
HPV PASS
32 year old female with pap showing HSIL and HPV
hx explain result tx
frankly i hadnt done pap smear as i tought its obsolete now so they wont give it but its
AMC you should expect anything !!
as soon as i read the task i knew im screwed and was cursing myself for leaving it
anyway i went in
i took 5p and sexual hx and gardasil vacc hx ,previous pap,fam hx of gynaecological
cancers
explained the result by drawing the epithelium and explaining that some cells are
growing and dividing abnormally however is not cancer but can convert into it so
needs to be treated
tx i said il refer her for colposcopy (explained what it is) and then i said they might
excise the area if needed or treat by cautery...vell rang i thanked the roleplayr and
examiner
190

103-Recurrent genital ulcer

Woman with recurrent vulvar ulcer this is the fourth attack in the last 12 months
Tasks
1-take history
2-dx and ddx
3-management

History
1-chief complaint, Ulcer questions
-I can see that you are complaining of recurrent ulcer on the vulva. So for how long have
you been suffering from this? (It is the fourth attack within the last 12 months)
-All right do you have an ulcer at the moment? (Yes)
-Anywhere else (no)
-Has it appeared suddenly? Increasing in size? for how long does each attack last?
2-associated symptoms questions
-do you have any pain? Is it painful? (Yes there is pain but no discharge)
how severe is the pain from 1-10 (severe enough) ask allergy and arrange painkiller
does the pain go anywhere else (no)
anything alleviate or aggravate the pain? (Panadol gives bit relief)
-Any itching, redness, vaginal bleeding or discharge? (no)
-any burning or pain during urination? (No)
-Any fever (No)
-any LOW, LOA, lumps or bumps around your body? (No)
2-5Ps questions.
Period
-LMP and regularity (2 weeks ago and regular)
-how many days of bleeding and how many days apart?
-heavy bleeding or pain during menstruation (no).
Partner/ sexual (critical)
-are you sexually active (yes)
-are you in a stable relationship? (Yes)
-how long have you been in this relationship?
-have you had any previous multiple partners? (Yes)
-do you practise safe sex? Do you use condoms? (No)
191

-have you or your partners ever been diagnosed with STI? (Not sure the answer what!
mostly No).
-does your partner have similar symptoms?
Pregnancy
-are you planning to become pregnant? (no)
-Pills (no)
-Pap test or hpv vaccine (up to date)
3-general questions
-Medications or OTC (no)
-PMH or PSH (no)
-smoking or alcohol and recreational drugs
-family history
-Travel history, occupation.
Explain
-from history and examination there could be few possibilities why you have recurrent
painful vulvar ulcers
-the most likely cause is due to a viral infection called herpes simplex virus 2. Firstly, it
enters the body and stays in the nerves in your body then it is activated might be due to
exhaustion, infection or pregnancy, sometimes even the pill and high weigh can
precipitate it.
-it presented usually as a painful genital ulcer sometimes associated with itching, rash or
discharge, and it can recur again and again.
-this is a sexually transmitted disease; transmitted through unprotected sexual activity,
and from the history it seems like you have history of multiple partners with no use of
condoms which makes transmission most likely.
-Others could be syphilis but unlikely as it is painless or could be other STI like
gonorrhea or chlamydia but unlikely as there is no discharge or tummy pain.
Treatment
-I would like to examine you and arrange some Ix like FBE, BSL, UCE, and urine
dipstick, urine pregnancy test.
-I would like to take swab from the ulcer for M&C.
-I also after your consent would like to test for other STI like Syphilis, HBV, HCV, HIV ,
take 1st pass urine for chlamydia, endo cervical swab for gonorrhea.).
-I will prescribe you oral acyclovir to treat viral herpes infection and painkiller.
-try to rest in warm sitz bath, wear loose cotton clothes and underwear.
-try to avoid sex until active lesions clear and symptoms go away, and It is important to
practise safe sex using condom in order to protect against STI.
192

-I need also to see your partner and organise STI screening with his consent.
-If you develop bleeding, tummy pain, fever report
-review once result appear and follow you up regularly to ensure everything is all right
gave reading material.

Feedback (13/10/2017)
Young woman came with 4 episodes of recurrent ulcers on vulva over 12 months
Tasks: Hx, Tell the pt the Most likely diagnosis,Csl (Very kind Asian examiner!)
In hx, the pt was having unsafe sex with several men,
No symptoms at the moment no rash, ulcer, pain, discharge or bld.
Pap smear 18 month before (NL) (period was regular and no bld between no pregnancy
before no PID she is on pill (COC).
So I said the most likely condition you are having is called Genital Herpes ulcer have you
heard of it before?
- It is kind of viral infection. Firstly, it enters the body and stays in the nerves in our body
thence it is activated due to the exhaustion or infection or pregnancy or even with pill and
obesity and
- it gives the symptoms of rash ulcer itchiness and discharge.
- This can be happened in your partners as well as this is sexual transmitted disease so I
need to visit your partners to examine and treat them as well.
- Meanwhile, I want to run some investigation to rule out other STI like HIV,
Syphilis, HBV, HCV and take swab for bugs like chlamidia and gonorrhea and
obviously confirm the Herpes with T-zanc test if there is any.
- At the moment I will not start medication for you I wait for the result and review you
once result back if any was positive we treat you with 3 days of Acyclovir and then once
weekly for 6 month-period.
- It is important to over this period have safe protected sex with condom.
- be cautious about the hygiene and wipe yourself from front backward.
- Have warm bath sitz.
- if symptoms occurred, apart from medication I prescribe lignocaine gel which can help
to decrease the amount of your pain.
- I don't notify DHS now but I need to notify if any of STI screening came back
positive.
- We can later talk about other options of contraceptive methods like Implanon or
devices and - so forth about which I can give reading materials if you want…
Feedback: Vulval complaint,

PASS(G.S:5)
Key steps:1,2,3 and 4: Yes
Approach to patient:6
193

History:5
Choice and technique of examination and organization and sequence:5.
Dx/DDx:6
Patient counseling and education:5.

Feedback 25-10-2018 pass

Scenario : vulval complaint
Stem: young female had 3rd episode of ulcers on genitalia.
Task:
Hx
Ddx
Counselling
Inside the room when I asked her if shes in pain or anthing, she said right now she
doesn’t have anything at all. But she had previous episodes of ulcers on genitalia . noe
she wanted to get herself checked that why did she have those ulcers and any other
serious problem going on because she has started a new relationship recently. So I took
hx of the ulcers (1st episode was v painful later episodes were not that bad) Had 3 4
sexual partners previously. Was on the pill so didn’t use condoms all the time. No sexual
relation for last 6 months. All other things negative
Explained her the ulcers are related to HSV and its an STI she said none of her partners
had such a condition. Told her sometimes men are carrying it without any symptoms.
Then told other sexually transmitted infections and that need to do complete STI screen,
including some blood tests, urine tests. Cervical swabs and if any active ulcer swab of
that she said no I don’t have any at the moment. Explained in blood will be doing hiv as
well and that I need your written consent.
Safe sex education and told her I can arrange another appointment to discuss about
contraception. Reading material.
GS: 5 5/5 key steps covered Approach to pt :6 Hx:5 Dx/ddx:5 Pt counselling:5

Feedback 25-10-2018 pass

22 year old woman came with recurrent ulcers in genitals, at the moment not there.
Task”
History
Diag/dd
Counselling
194

I had herpes in mind., told confidentiality, Asked about nature of ulcer- pain discharge,
fever, itchy,anywhere else similar ulcer. Partner? Safe sex? Wt loss, lumps bumps,
periods, pregnancy
dd- said herpes, chancre, chancroid. Forgot dermatitis.
Counselling: advised antiviral for next time, all STI check up, warm bath for soothing,
safe sexual practices,
Got 3 for dd

107-Secondary Post-partum hemorrhage

You are at your GP clinic, 30 year old Jane presents to you with bleeding per vagina
since today morning. She had a normal vaginal delivery, 10 days back.
TASKS
Relevant history
Get the examination findings from the examiner
Discuss your diagnosis and reason for diagnosis with the patient
Management
Differential diagnosis of secondary post-partum hemorrhage
1-Retained product of conception: placenta or membranes
2-Endometritis
3-Laceration, tears, episiotomy wounds
4-Bleeding disorder
5-blood thinner medications
History
1-Bleeding questions (from here you can rule out retained product of conception)
-Is the patient hemodynamically stable?
-do you feel tired, dizzy or have funny racing of the heart?
-how long have you had bleeding form vagina?
-how many pads have you used so far? Are they fully soaked?
-what is the colour of the blood?
-is it smelly?
-have you noticed any clots or tissues?
-are you aware of your blood group?
195

2-Endometritis (fever, tummy pain, discharge)

-do you have any fever? (slightly flushed since yesterday)
how high is it? have you had the chance to measure your temperature?
Is it constant or does it come and go?
Any chills, shivers?
Have you taken any medication for your fever?
-any rash?
-do you have any pain or discomfort in your tummy? (yes)
ask severity and give painkillers after allergy
site and radiation
-any abnormal offensive vaginal discharge?
3-pregnancy questions (you can rule out breast problem and laceration/ episiotomy
here)
-any condition you had during the pregnancy?
-congratulate her and ask:
how is the baby doing? Are you enjoying your motherhood?
Do you cope well with the baby? Do you have enough support?
Do you breastfeed the baby? Any problems with breastfeeding
-any cuts made at time of delivery? Is it healing well or not? Any tears or lacerations
4-general questions (you can rule out other sources of fever)
-any coughs or cold recently? (respiratory infections)
-how is your waterworks? Bowehabits? (UTI)
-SAD
-any history of bleeding disorder? (bleeding disorder)
-do you take blood thinner medication or any medications? (blood thinner meds)
Physical exam from examiner
1-General appearance:
pallor, dehydration, Oedema, lymph node enlargements, rash, bruises, skin petechia
2-Vital signs: temperature, blood pressure and postural drop
3-quick CVS and respiratory
4-Abdomen:
inspection:
-visible distention,
-visible mass,
palpation:
-palpable mass (yes you can feel a mass)
-can I get below the lower border?
-is it the uterus that I can feel in the abdomen?
what is the size?
Is the uterus tender? (yes)
196

is it contracted or laxed? (slightly laxed)

Auscultate for bowel sounds
5-Pelvic exam
Inspection:
-bleeding, color of the bleed, tissues or clots in the bleed
-episiotomy wound is well healed or not
-any other lacerations or hematomas,
Speculum:
-is the os open or closed? (slightly open)
-any other offensive discharge that you can see
-Is there bleeding from the cervix?
-any cervical laceration?
-I want to take swab from vagina for MCS
Per vaginal exam:
-CMT
- uterine size, tenderness (tender, enlarged to 14 weeks)
-palpate adnexa for mass, tenderness
6-Office test: BSL, UDT

Explanation
-from history examination you have a condition called secondary post partum
hemorrhage which is heavy bleeding that occur after 24 hours up to 6 weeks after
delivery.
-there are several causes:
*1st if you have products of pregnancy retained inside like bits of placenta or membranes
but in this situation you might noticed tissues coming with the blood and will not have
fever or tummy pain unless get infected.
*another could be episiotomy wound that also bleeds but the pain is usually coming down
when the wounds heal completely.
*could be due to laceration or tears but examination shows nothing.
*tears in the birth canal could also be a cause but I am not suspecting this in you.
*bleeding disorder and blood thinner medications are also possibilities but history does
not suggest them.
*what I am suspecting is endometritis: the normal lining of the womb called
endometrium and infection of the endometrium called endometritis. This can lead to
heavy bleeding with fever and tummy pain and when I examined you, I could see the
uterus size larger than it should be. It was tender to touch and the neck of the womb was
open.
this is common after delivery because at time of delivery the normal organism inside
vagina can get disturbed and climb higher into the uterus causing infection of the uterus
especially at the site of placental attachment which is a bit raw.
197

Management
-You need to be immediately referred to the hospital. I will arrange an ambulance for you
and I will liaise with the ED of the hospital and I will make them aware of your
condition.
-Meanwhile, I will start you on an IV line, and start you on IV fluids, take blood for all
investigations such as FBE, UEC, ESR/CRP, blood group, cross-matching and hold and
Rh typing, coagulation profile, and blood culture. A urine sample needs to be sent for
microscopic culture and sensitivity.
Once you are in the hospital:
-you will be admitted, seen by the specialist.
-An ultrasound will be done to look for any retained product of conception.
-If there is no retained product of conception, you will be started on IV antibiotics
(triple regimen: co-amoxiclav + gentamicin + metronidazole) and usually responding win
2 days then will be shifted to oral antibiotics to be continued for 10 days. Panadol for
fever.
-You will also be given IV oxytocin to stop bleeding +/- IV or IM ergometrine (if she is
not responding to oxytocin, give ergometrine).
-ask if there is somebody with her to look after the baby.
-Review once out of the hospital

Just Note/ If there is a retained product of conception,

-an exploration under anesthesia will be done
-gentle blunt curettage to remove the products of conception under antibiotic cover.
-after cervix dilated give IV oxytocin
Feedback 20-2-2018
GP, young woman 10 days puerperium came because of bleeding from down below.
Tasks:
- Take history
- Physical examination from the examiner
- Explain the probable diagnosis and differential diagnosis to the patient

2 min thinking: assess patient haemodynamic stability, ask mode of delivery in history,
and ask temperature in examination findings
History:
Introduce myself, ask the patient how does she feel? How long has she been bleeding and
how many pads? Then explain to her I need to make sure she is stable by measuring her
blood pressure and other vital signs and turn to the examiner. (Examiner said she is
haemodynamically stable).
More questions about the bleeding – colour, any clot, foul smelling, any pain at lower
part of belly, fever (she felt flushed), any problem with BO/PU (no pain/burning
198

sensation).
Ask mode of delivery (normal vaginal delivery), no instrumental, there was
episiotomy done, is she aware of the placenta delivery (the midwife said it is
complete), duration of hospital stay (2 days). Pregnancy course (unremarkable), any
previous pregnancy (1st one?), bleeding problem in the past (no)
Quick question about support for her and baby (yes), any concerns about baby?(no)
Physical examinations:
Temperature around 38/39, other vital signs within normal range,
P/A: soft, non-distended, uterus? 10cm, forgot whether there is any tenderness
Pelvic examination: inspection unremarkable, episiotomy wound well healed
Speculum examination: vaginal wall normal, cervical os closed
Bimanual examination: uterus? 10cm, no adnexal tenderness, positive cervical motion
tenderness
Urine dipstick: blood stained (contaminated), the rest (nitrate, leucocyte) negative
Explanation:
Most likely you are having some infection in the womb due to retaining of fraction of
placenta/after birth. Other possibility would be bleeding from the episiotomy wound but
the wound is well healed on examination, urinary tract infection but it is less likely. Don’t
worry too much it is very good that you are here, I will arrange you to go to the
emergency department because you need further investigation and treatment. (Did not
elaborate further as it is not my task). Assess understanding, ?reading material (I forgot
whether I said so)

AMC Feedback – Postpartum bleeding: PASS

Feedback 31-5-2018
secondary PPH,GP ,a lady who delivered the baby 10 days ago ,now presenting with
vaginal bleeding.placenta was complete.baby is well and takes breastfeeding well.
Tasks -H/O,PEFE,Dx and Ddx
when I went into the room a lady was lying on the bed.i asked vitals BP 110/70 P around
100 T 38 or 39.bleeding 2-3 days after delivery,no clots ,no tissues,2-3 pads per day,
heavy, tired ,no dizziness no SOB.Feeling hot.
No problem at the time of delivery,no prolong assisted,no episiotomy. Pain at the lower
abdomen the same day with bleeding ,(ask pain scale and offer pain killer, also ask a
few questions about pain).5Ps normal with good support,blood group O+,no family
history of bleeding.no trauma.
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PEFE-other systems normal.abdomen tenderness at SPA, uterus still enlarge . Mid way
between umbilicus and symphasis pubis.Pelvis examination Bleeding present,no clots ,no
tissue.no cut or tear. Sterile speculum no vaginal and cervical tear.
Bimanual uterine tenderness present no cervical and ednexa tenderness
Explained- endometritis by drawing,don’t worry treatable with antibiotics,other possible
causes RPOC ,even though placenta was complete we still need to do USG to make
sure.trauma,tear,bleeding disorder all unlikely.arrange ambulance and refer to hospital do
some blood test and take swab for culture.
Key 5/5 approach 4,history 4,choice and technique of examination,organisation and
sequence 2,accuracy of examination 4,dx and ddx 5 .global 4

Feedback 27-10-2018
30+ year old patient came to your GP with bleeding per vagina. She has given birth to her
baby 10 days ago. She had a normal delivery and placenta was complete. Task
-take relevant history
-perform physical examination on the patient
-explain the Dx and DDx to the patient History
a young lady is sitting in the chair looking anxious.
introduced.
checked the vitals with examiner (examiner told me to stick to the task)
asked the role player
are you feeling dizzy?

details about bleeding?

- Duration (does not remember)
- color (bright red)
- amount (soaked 2-3 pads)
- smelly (no)
associating symptoms
- pain in the lower tummy (present)
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- fever (present)

- asked her blood group.

- ruled out other causes of bleeding
- blood thinning medications? (-)
- bleeding disorders? (bleeding elsewhere in the body) (-)
- cut made down below (episiotomy) (present, but pain becoming less and less)
- ruled out other causes of fever
- breast pain? (no)
- waterworks and bowel habits? (no)
- calf pain? (no)
- cough? (no)
- asked her about the baby whether baby is doing fine? (normal)
Examination
- asked the patient to lie on the couch and started the examination Abdomen
Inspection - normal
Palpation - tenderness in the SPA
Percussion - normal
Auscultation - normal Pelvic
inspection - bleeding (+), smelly (-), episiotomy wound healing well
sterile speculum - os (open), no tear on the cervix bimanual
- I told the examiner that i will skip the bimanual examination ( hence only 3 in
accuracy of examination )
- but examiner gave me the findings
- CMT (+)
- size of uterus is 14 weeks
- tenderness over the uterus
- adnexa normal office test
urine dipstick - RBC (4+++)
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Dx/DDx
- most likely due to endometritis (drew and explained) other possibilities
- tear in the birth canal and cervix
- bleeding disorder
- placenta retained in the womb, but these are less likely. Grade - pass
Global score - 4
Key steps
1,2,3,4,5 - Yes, No, Yes, Yes, Yes
Approach to patient/relative - 4
History - 4
Choice and technique of examination, - 4
organization and sequence
Accuracy of examination - 3
Dx/DDx

Feedback 13-12-2018
Postpartum Bleeding: Pass
2 mins outside. I don’t remember the stem but it was the case of postpartum bleeding. I m
not sure fever was mentioned outside or not.
Tasks: history, Dx and DDs to patient
Thinking outside: in History, need to ask about presenting complaints, associated
symptoms. Then full last preg with full delivery history. Then past pregnancy. Then other
present, past and f/h.
Inside: asked about bleeding, such as since when, how much, colour (bright red), any
blood clot (for DIC), any tissue (for retained placenta).
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Any bruising anywhere (for DIC, any blood disease). Then asked for associated
symptoms specially fever (present, this gives our diagnosis). Then I asked about
abdominal pain and all que to rule out dds of bleeding and postpartum fever. Then I
asked about full history as I mentioned above including blood thinners but did not ask
much about irrelevant past and present history. Please read history from Karen’s as it is
good to know all questions but need to know when to apply relevant questions.
I think it is good idea to ask many questions in history but because of time problem I kept
my history to relevant questions.
PEFE: same as karen. Positive findings were temp 37.8, lower abdominal tenderness,
mild bleeding seen on speculum, no clot or tissue. Episiotomy scar well healed.
Dx and DDs: from the history u have provided to me, I think you have a condition called
endometritis because of fever and bleeding plus pain in lower abdomen. There are many
conditions that can be possible such as retained product of placenta but less likely as it
is generally does not cause fever unless infected. Could be medicine but u r not on any
blood thinners, could be DIC where person have bleeding at the same time blood get
clotted, this is less likely as u don’t have any symptoms of it. I think she had episiotomy
but it was healing okay. I think I have mentioned 4-5 DDs. When it comes to explain to
pt, it takes too much time so please hurry up.
Key steps: all yes. Global score: 5, History, Choice& technique of examination,
organisation and sequence (which was not in task I think) and dx/dds: all 5.
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108-Post CS fever
You are an HMO in the maternity ward. You are asked to see Mary 32 years old Jane who had
underwent an elective lower segment C-section 3 days ago for breech at 38 weeks. This is her first baby.
The birthweight of the baby is 3.5kg and the baby is doing well.
She wants to get discharged today. She's taking paracetamol for pain. She was given 1 dose of
ceftriaxone intraoperatively and enoxaparin 2 doses given post-surgery. The patient's vitals chart is
given outside the door:
BP range 120/70 - 130/80
PR normal
RR normal
O2 sat normal,
temperature on day 1 is normal, but on day 2 it is 38.0C and day 3 it is 37.7C.
TASKS
Take a further history
PE from examiner
Talk to patient about her findings
If you think she can be discharged discharge her otherwise give reasons
Causes: (genitourinary, chest and breast, limbs)
1-wound infection
2-Endometritis
3-UTI
4-mstitis/ breast abscess
5-URTI
6-DVT/thrombophlebitis
History
1 Approaching
-Congratulate her on her delivery.
-are you coping with your baby well?
-are you enjoying the motherhood?
-do you have good support?
-Look Jane, I can understand that you keen to be discharged today. Before that can I just ask a few
questions?
2-chief complaint and Differential diagnosis questions
fever
-I have seen in the chart that your temperature has been high for the past few days. Are you feeling
feverish? (slightly flushed at times)
-Any rash (no)
wound infection
- have you noticed any discharge form the wound?
-is your wound’s pain coming down?
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Endometritis
-do you have tummy pain in the upper part away from the site of the wound? (Generalised pain)
-How about your bleeding? is it coming down or becomes heavy? How many pads have you used? Are
they the same number you were using? (Minimal bleeding)
-any smelly bleeding?
-Any other offensive vaginal discharge? (no)
Urinary tract infection and bowels
-how is your waterworks?
-any burning or stinging on passing urine>
-is it smelly?
-any change in the colour of the urine?
-have you opened your bowels after the surgery?
Mastitis/breast abscess
-do you breastfeed your baby? Any problems with breastfeeding? (day 1 she cannot breastfeed properly
but day 2 latching very well)
-any sores or cracks in the nipples?
-any painful lumps in the breasts?
Upper respiratory tract infections/ atelectasis
-any coughs or cold that you having? Ant sore throat?
-are you short of breath? Any chest pain?
DVT/ thrombophlebitis
-any calf welling or pain?
-any pain or redness at the site of Cannulae?
-any excessive pain at the site of anaesthesis?
3-general questions
-Any other medical or surgical illness?
Physical Exam from examiner
1-General appearance: PODL
pallor/ oedema/ dehydration/ LAP
2-Vital signs (as you seen in the chart)
3-ENT (rule out URTI)
4-CVS and respiratory
-air entry/ added sounds
-S1, S2 and murmurs
5-Calf:
tenderness, swelling.
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6-Abdomen:
Wound:
-wound covered with bandage that is minimally soaked with blood.
-I would like to remove the pad with the consent of the patient and have a look at the wound, looking for
any erythema (+ve), discharge (+ve) , wound dehiscence
Uterus:
-what is the size of the uterus? (Enlarged)
-is the uterus contracted or lax? (Contracted)
-any uterine tenderness towards the upper pole? (Tender)
-bowel sounds
7-Pelvic exam:
Inspection:
-bleed, abnormal vaginal discharge.
Speculum:
cervical os open or closed, bleeding from the os? (Cervix still open)
bimanual examination:
size and tenderness of uterus
adnexal mass or tenderness
8-breasts
mastitis/ abscess
9-Office test:
Urine dipstick, BSL

Explanation
-I am a bit concerned as you have a rise in temperature yesterday and also today.
there could be several causes of having fever after CS:
*could be due to wound infection but the wound site is healing well and the pain is coming less.
*could be UTI but you have no burning or stinging on passing urine and the urine dipstick come out
normal.
*another cause is URTI but you do not have coughs or cold
*another is atelectasis where your lung expansion becomes affected after surgery but you do not have
chest pain or SOB and your lungs are clear on examination.
*other possibility is DVT or clots in your legs vessels that lead to blockage of the blood supply but this
usually cause pain and swelling in the calf muscles that you are not having. Also you were given 2 doses
of blood thinner at time of delivery so it is unlikely.
*could be infection at the site of the cannulae but no evidence of this.
*could be mastitis or abscess…
*the most likely one is a condition we call endometritis where the inner lining of the womb becomes
infected. It is common in post CS patients. That is why you have fever, uterine tenderness or pain in
your tummy and also discharge later.
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Management
-As I could not confirm the cause I would still like to keep you in hospital (critical error) for further
monitoring, assessment and management. further investigations need to be done such as FBE, blood
culture, urine microscopy culture and sensitivity, ultrasound to see if there is anything happening in the
uterus or not.
-I need to have a talk with the specialist and if it is Endometritis, it can be managed by giving IV
antibiotics. Once you start responding to IV antibiotics, you will be shifted to oral antibiotics.

-So it would be better for you to stay in the hospital till at least 24 hours when you have no fever.

Feedback 4-7-2018
post partum D3-has fever-planning to go home
Observation chart given-T-mild fever/ I guess PR/RR
Task hx, PEFE, Mx
Hx-all infective foci-mastitis/endometritis/wound infection/UTI/DVT/thrombophelebitis
Asked about coping with baby/family a support/feeding/ bld gp/bleeding
Antenatal complication
PEFE- asked what not given in the chart-can’t remember exactly
But apart from mild fever-nothing very significant
Mx-explained as having mild fever need to do some Ix –blood/urine to exclude infection
Fluid/PCM
Will r/v with obs reg

109-Endometritis Fever
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110-Post-partum mastitis
Material Case/
28-year-old Emily, mom of a 5-week-old baby, comes to your GP with complaints of tiredness and fever
since the past 2 days.
TASKS
1. Focused history
2. PE from examiner
3. Diagnosis and Management
 
Differential Diagnosis:
 Breast: Mastitis/Breast abscess
 Birth canal: endometritis, episiotomy wounds, laceration that has become infected
 Bladder: UTI
 URTI
 DVT 

History
Congratulations on the pregnancy. How is your baby doing?
1-fever questions
-Since how long are you having the fever?
-Is it a continuous fever or an on and off fever?
-Have you recorded the temperature?
-Any rash? Any chills or rigor?

2-DDX questions
URTI
-Any runny nose, cough or colds?
Mastitis/ abscess
-Are you breastfeeding your baby? Any problems with breastfeeding?
-Any lumps that you have in your breast? How long have you been feeling the lump?
-Is the lump increasing in size?
-Is it warm and painful to touch?
-Any other lumps that you can feel in the same breast or in the opposite breast?
-Do you have a sore or cracked nipple on that side?
-Any blood-stained or purulent discharge from the nipple?
-Is the baby being positioned to the breast correctly? Has somebody taught you the correct
positioning of the baby during breastfeeding? (key issue)
Endometritis/ lacerations
-Did you have any conditions during your pregnancy or was your pregnancy uneventful?
-What type of pregnancy did you have?
-Any cuts made down below? Any tears that you had at the time of delivery?
-Any abnormal foul smelling discharge from down below? Have you stopped bleeding? Are you having
any tummy pain?
UTI
-Any burning or stinging while passing urine?
-Any constipation that you are having? Do you open your bowels regularly?
DVT
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-Any calf pain or swelling?

3-Lifestyle and support

-Rule out depression: Do you have a good support from your partner to look after the baby? Are you
enjoying your motherhood?
-Do you eat a healthy diet?
-Do you smoke, drink alcohol or take recreational drugs?
-Have you done your pap smear? What was the result?
-Any medical or surgical conditions in the past?
 
Physical Exam
1-General appearance: pallor, edema, lymphadenopathy, is it tender? dehydration
2-Vital signs: temperature
3-CVS, Respi, CNS
4-Breast: key issue
-compare right with the left breast.
-look for any visible lumps in the right breast, size, shape of the lump, color of the skin over the lump.
-inspect the nipples for any cracked nipple.
-palpate for local rise in temperature, confirm the site, palpate the borders if well-defined or not, palpate
the consistency, mobility of the lump, any fluctuations, examine the same breast for any other lumps,
and the opposite breast as well
5-Abdomen:
any abnormal distention, any mass, on palpation, do you still feel the uterus in the tummy or has it
involuted already? Any other mass or tenderness in the tummy? Auscultate for the bowel sounds
6-Pelvic exam
-Inspection of the vulva and vagina: abnormal discharge, bleed, episiotomy wounds or lacerations
-Speculum: cervix healthy or not, OS open or closed, discharge or bleed from the cervix
-Per vaginal exam: uterine size, CMT, tenderness, adnexal mass and tenderness
7-Office test: UDT, BSL
 
Diagnosis and Management
-Most likely you've got a condition called Mastitis of the right breast. This is the cause of your fever and
tiredness. Mastitis is an infection of the connective tissue of the breast caused by bacteria, and the
bacteria that usually causes this is staph and e. coli.
Where did these bugs come from? It usually enters into the breast if there are any cracks in the nipple,
from the baby's mouth or from the surrounding area of your skin and this condition will worsen if there
is poor milk drainage from the affected breast. The usual cause of the cracked nipple is due to poor
positioning of the baby to the breast.

-You need to continue breastfeeding from the affected side, the milk is not affected by the bugs. Put
the baby on the affected side first so the breast will be drained completely. Before breastfeeding, you
can put some hot washers on the breast, so that the milk ducts will dilate, and during breastfeeding, you
can massage the lumps towards the nipple. And after breastfeeding, you can put some cold washers on
the breast.
Take plenty of fluids, and take adequate rest.
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-I need to put you on antibiotics such as cephalexin, or flucloxacillin 500mg QID, for 7-10 days, and
analgesics such as Panadol. I will give you reading materials regarding proper breastfeeding
techniques.

-Just in case that there is no improvement in your symptoms, the lump is increasing in size, becomes
more painful, you have high spikes of temperature, report to ED immediately.

-I will arrange review with you in 1 weeks time.

 

**Breast abscess management:

Do an ultrasound if you have doubts whether it is mastitis or breast abscess. If it is breast abscess, she
required referral to the hospital.
If it is a small breast abscess: do an aspiration of the abscess
If it is reasonably big: do surgical drainage under anesthesia
Curve-like incision over the breast to drain the abscess. Discharge will be sent for microscopic culture
and sensitivity. Put in a drain for 2 days.
Antibiotics and painkillers. Go in for a temporary weaning from breastfeeding. Make sure the breast is
empty by using a breast pump.

Note/ in mastitis case, I am not sure If you need to add ultrasound as Ix or not.

Recall of 11-4-2018

121-post-partum Check up
Sample Case
23-year-old Amy has come to your GP clinic for a 6-week post-partum check-up. She had a normal
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vaginal delivery and she delivered a 3.3 kg healthy baby boy.

TASKS
-Relevant history
-PE from examiner
-Counsel Amy accordingly
AMC Exam Case 20-7-2018
Women come for 6 week post-partum checkup, child was examined by your colleagues yesterday,
normal, didn’t bring the child today, on the stem , pregnancy and delivery was uneventful nor
episiotomy or laceration at delivery , normal vaginal delivery
tasks
-History
-PEFE
-counsel
History
-Congratulate her on her delivery. ? How are you coping? Are you enjoying your motherhood?
(Motherhood totally fine, mood is great)
- Thank you for coming today, do you have concerns that I can help you with?
- I’m happy you and baby doing good, I can help with you that (contraception and lack of libido)before
some Qs
1. Baby (normal)
- Is the baby doing well? Any concern that you have regarding your baby?
- Was he given the first dose of vaccine? Gaining weight?
2. Breast (normal)
- Are you currently breastfeeding your baby? (give the exclusive breast feeding 4 hrly)
- Any sore or cracked nipples? Any lumps or pain in your breast?
- Do you know the proper breastfeeding technique? Laching well- (if the baby is not latching well, it can
lead to sore and cracked nipples, leading to mastitis and breast abscess)
3. Bladder/ bowels (normal)
- Any problems with your waterworks?
- Any burning or stinging while urinating? Any incontinence?
- Are you opening your bowels regularly?
4. Birth canal/ delivery/ systemic (normal)
- Any conditions that you had during pregnancy or was it uneventful? (Mentioned in the stem)
- Any complications during your delivery? Any cuts made down below or any tears that you had at that
time? (Mentioned in the stem)
- Have you had excessive bleeding right after delivery? (Primary postpartum haemorrhage)
- have you stopped bleeding now? (Secondary postpartum haemorrhage)
- Do you have any tummy pain? Any fever? Any abnormal, offensive vaginal discharge?
- Have you felt any dryness, itching and burning down below?
- Any calf swelling or pain, SOB, chest pain?
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5. 5Ps (Critical)
- Have you resumed your sexual intercourse? Any problems that you are having e.g dyspareunia? Do
you have good support in looking after your baby? (Yes doctor, it is embarrassing, I restarted 4 days
ago, I have pain with intercourse)- Are you on any contraception?
- What contraception were you on before you planned for you pregnancy? (Microgynon 30)
will you be interested in talking about contraception again? (Yes, i am interested doctor, but i do not like
minipills)
- When was you last Pap smear done? What was the result? (I did it 5 yrs. back ... haven’t done one
since then)
6. SADMA, PMH, PSH
7. Social History; Support, mood, Partner any issues, any violence( I routinely ask this question is there
kind of problem between you two?

Physical Exam from examiner

1-General appearance: BMI, pallor, calf for swelling/tenderness
2-Vital signs: temperature
3-Abdomen: visible mass, tenderness, Palpable mass (usually the uterus goes back to the pelvis in 2
weeks time) has the uterus involuted or not? Tenderness
4-Pelvic examination
-Inspection of the vulva and vagina: any bleed or discharge, thin, dry atrophic vagina
-Speculum: arrange for a pap
-Bimanual examination: size of uterus, tenderness, Adnexal mass and tenderness
5-Office tests: UDT, BSL
Counselling
-When I examined you, you are generally healthy but I could see that your vagina is dry and thin we call
this; atrophic changes. Most likely, you have a condition called lactational atrophic vaginitis.
-It is quite common after the delivery because as you are breast-feeding, sometimes it can cause reduced
female hormone in the body leading to dryness. As the prolactin or the milk secreting hormone acts
against the estrogen.
-Normally, it resolves spontaneously in 2 weeks once the hormones come back into place, but you can
use vaginal moisturizers during this time. If it becomes severe, then we can use vaginal estrogen creams
or tablets.
-It is not advisable to take a combined pill if you are breastfeeding as the estrogen content in the pill can
suppress the breastmilk production. But there are other methods that you can use, such as progestogen
only pills but you don’t like it, others are: Depo-provera, Implanon, or intrauterine contraceptive device.
Depo is by injection to your buttock every 12 wks , its effective , but there are some side effect , risk of
delayed returning to fertility after stopping it , risk of wt gain , acne.
Another one is IUCD , it last long 5 years , very effective , no delay in returning to fertility when you
stop it, but the side effects are increase risk of infection , ectopic pregnancy.
Another option is implant , that can last 3 yrs , which is very effective as well , but it needs minor
procedure done by specialist to put under the skin of your arms.
-As your pap smear is already due, I will arrange one for you now
-I will give you reading materials regarding contraceptive options so you can think about these options.
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Feedback 20-7-2018
6 wks post partum
Health review Pass , global score 5
key step 1,2,3,4 all yes
history 6 ,
chocie and technique of examination , organisation and sequence 6
patient counselling/education 4
Women come for 6 wk post partum check up , child was examined by your colleagues yesterday ,
normal , didn’t bring the child today , on the stem , pregnancy and delivery was uneventful nor
episiotomy or laceration at delivery , normal vaginal delivery
History , PEFE , counsel
hello , Karen , i do utd you have come for 6 wks post partum check up , how are you doing these
days ... i am fine , how is your motherhood .... totally fine , do you get enough support ... yes ...
how your mood ... great ...
she said she didnt bring the child today who has been already checked out and normal.....
any specific concern ... no
i asked systemic question ... no fever , no cough , no sOB , no chest pain , no abdominal pain ,
appetite good, no pee and poo problem , no discharge or bleeding from down below
breast feeding the baby ... fine , no soreness , baby suck well , give the exclusive breast feeding 4
hrly
so i said i would like to ask private and sensitive quesiton
5 P .... have you restarted sexaul activity ... said yes doctor , its embarassing , i restarted 4 days
ago, any problem ... pain on sexual interourse , but no contact bleeding , no discharge have not
returned any period
pill ... have you ever use contraception pill before .. yes i use microgynon 30 , will you be interested
in talking about contraception again...... ... yes i am interested doctor , but i dont like minipills .......
pap smear ... i did it 5 yrs back ... havent done one since then
do you have any plan to get pregnany in near future .... i dont have plan yet but if i get it , i dont
mind
SADMA NAD, no PMH or PSH
PEFE
GA , VS , CVS , RESP , BREAST .. all normal
abdomen normal
pelvic examiantion .... atrophic changes , no dischagre
Explanation
Karen , i did examination on you , you are generally healthy , only finding is there is some
dryness and thining of your down below . what we called atrophic changes . it is quite common
after the delivery because as you are breast feeding , sometimes it cause reduced female hormone
in the body leading to dryness. but its not serious , it will resolve with time . i will prescribe
soothing cream and if oestrogen cream to apply, if not relieved , will refer you to specialist .
as your pap smear is already due , i will arrange one for you
now in terms of contraception , microgynon is not suitable for your breast feeding , as it can
suppess breast feeding
there are other options like depo injection to your buttock every 12 wks , its effective , but there
are some side effect , risk of delayed returning to fertility after stopping it , risk of wt gain , acne
another one is IUCD , it last long 5 years , very effective , no delay in returning to fertility when
you stop it, but the side effects are increase risk of infection , ectopic pregnancy
215

another option is implant , that can last 3 yrs , which is very effective as well , but it needs minor
procedure done by specialist to put under the skin of your arms
i am going to give you reading materials so you can think about each options
bell rang
i didnt have time to talk about non hormonal method

Feedback 30-5-2018
‘Health review’: Pass
6/52 post-partum atrophic vaginitis.
Mum & bub well, pregnancy and L&D benign, completely w/o concern.
Task: Brief Hx, PEFE & counsel
 HOPC
o Basic rapport/Mum & Bub Qs
o Lactation consultant/BF issues/support/pelvic floor regime etc
o Any concerns
216

o Has anyone had a chat to you about contraception

 We’ll touch on that
o Have you resumed sexual activity
 Any trouble in the bedroom
 Pain
o Further Sx evaluation
o Talked about ANC/L&D hx/Cx [all NAD]
o Basic screener for other Sx: Br Wind Wound Water etc
o PMHx FHx SHx HPV IUTD SADMA

 O/E
o Usual spiel
o GA BMI VS>Br>CNS>RS>CVS>Abdo>chaperone>pelv>spec>biman>Wards: uDip BG
 Typical atrophic vag
 Asked specifically re: other injury/perineal tear/wound/Ut changes
 Ax & P
o Atrophic vag (quick description of why it happens 2/2 lo female hormone etc)
 Moisturise
 No good  local oest cream
o LSM SNAP *Pelvic floor ex resources etc
o Bub  arrange immunization + *Offer paeds check [already done]
*ran out of time in this case & so couldn’t go further into POP etc; honestly thought I bombed this case

Feedback11-12-2018 Station 11 Pilot Case (Assessed, not scored)

A woman comes for her 6-week postpartum check. She has no complaints.
Tasks: Hx, PEFE, Dx and Mx.
I came in the room and greeted the examiner and the patient.
I introduced myself and congratulated the mom for the baby. I asked how he was, if he was thriving,
how she was coping with it, if she had enough support.
Than I went to more specific questions:
How was the delivery? Vaginal
Was it at home or at the hospital? At home
217

Was it necessary to have a cut down below? Yes. Is it healing well? Yes
Did the baby have any complication? No. Did he need CPR or go to ICU? No.
Did you have any bleeding? No.
Were you both discharged together from hospital? Yes
Do you have any fever? No.
Did you have gestational diabetes? No
Are you breast feeding? Yes Any breast tenderness? No Any bleeding? No Any nipple fissure? No
Any vaginal discharge? No, only on the first week after delivery.
Are you back to your sexual life? Yes. Are you on any kind of contraception? Condom
Any pain during sexual intercourse? Yes, doctor. And it is very dry. But it is ok if I use lubricants. Any
bleeding? No.
Any edema of the legs? No
SADMA
Last HPV screening? (I don’t remember the answer exactly but I think she was due for a screening.)
( I skipped family history)

I excused and asked PEFE:

Everything was normal except for vaginal atrophy on speculum exam.
Urine dipstick and BSL were normal.
I thanked the examiner and returned to the patient:
“ Mary, according to your Hx and PE, you have a condition called atrophic vaginitis. It is a common
condition and it is not serious. It happens because the hormone that is responsible for the milk
production acts lowering the production of estrogen by the ovary. This comes to normal in a few weeks.
Meanwhile you can continue with the lubricants. If it doesn’t get any better we can start you on estrogen
vaginal cream.
As you are back to your sexual life, we should discuss the contraceptive options because you can only
have pills or other devices with progesterone…”
The bell rang.
I thanked both as I left.

122-Cyclical mastalgia
GP, 22 years old female with bilateral breast pain for 2 weeks or 2 months. Her mother was diagnosed
with breast cancer and currently under treatment.
Tasks:
218

-Relevant history
-Physical examination from the examiner
-Explain to the patient probable diagnosis and differential diagnoses
History
1-pain questions
I can see that you have pain on both breasts for about 2 weeks
-do you have pain now? How severe is it from 1-10? (Yes so ask allergy and offer painkillers)
-can you tell me more?
-Is it constant or does it come and go? Is it getting worse?
-can you point out exactly where you feel the pain?
-does the pain go anywhere else?
-does anything make it better or worse? (Worse in periods and relieve by wearing bra)
-how the pain related to periods? Does the pain come down when the period starts? (Pain worse before
periods and relieved after the periods)
-does it interfere with activities of daily life?
2-associated symptoms
-have you noticed any lumps in your breasts? (Yes)
-One or both breasts? (Both breasts)
-have you noticed any increase in the size?(Not sure)
-Any skin changes of the breasts?
-Any nipple discharge?
-Any lumps or bumps in your armpits or the neck?
-Have you noticed any weight loss?
-any trauma to the breasts?
3-5Ps and general
-period: when was your first menstrual period? Any problems with periods? (No)
-pill: do you use any contraceptive methods? What is the type? (Use OCP for 5 years)
-sexual history: are you sexually active? (Not sexually active)
-SAD and coffee
-PMH/ PSH/ medications and allergies
-Family history of breast or ovarian cancers (mother has breast cancer, had surgery, radio and chemo,
and she is worried that she has cancer)
when was your mother diagnosed with cancer? (at/before 50)
have you had any imaging before ?

Physical examination from the examiner (may be card but just in case)
Inspection (normal)
-any asymmetry, Scars, any skin changes (erythema), Puckering or dimpling of the skin
-nipples (retraction, distortion, ulceration, discharge)
Palpation
219

if I can feel any lump or lumps?

-Site and size
-Surface and border: smooth surface or not/ regular or irregular border
-Consistency and tenderness: if soft, firm or hard/ tender or not
-Mobility and fluctuation: are they fixed or mobile/ fluctuant or not
note/ in the exam there will be multiple small lumps with one dominant lump. Not tender and all other
normal.
Lymph nodes on neck or armpit + quick systemic examination
Explain
-from history and examination most likely you have a condition called cyclical mastalgia, which is a
pain in your breasts that is related to periods, usually due to hormonal changes during menstruation.
-on examination, I can feel small lumps as well. Most likely, are due to fibrocystic disease or
fibroadenosis, which is a common and benign breast condition that can cause cyclical breast pain and
lumpy breasts.
-lump may also be a benign growth of breast tissues called fibroadenoma.
-Infection, pus collection or injury can also cause lumps in the breast but less likely in your case.
-Lumps may also be the result of fatty tissues accumulation called a lipoma.
-could be nasty growth but unlikely from history and examination.
Management
1-Triple tests as lumps always need to be evaluated
-send her for ultrasound
-refer to specialist may need FNAC to confirm diagnosis
-reassure cancer is unlikely
-self breast examination monthly + review yearly by GP doing breast examination
-later discuss about mammogram
2-painrelief
-Panadol or NSAIDS
-supportive bra
-evening primrose oil
3-review medications
-if on OCP (advise stop and change it in another consultation)
4-lifestyle modifications
-low fat, high fibre diet, exercise, weight reduction
-decrease coffee and alcohol intake
-avoid smoking
Case (1/3/2017)
Bilateral breast pain
( In this case there was another lump consistent with fibroadenoma so I send for us+fnac )
Cyclic mastalgia ok this case again young girl,27.
Pain on bilateral breast.
worse around period, relieve by wearing bra.
220

Mum has hx of breast cancer. I said sorry about that. is she feeling alright now? she said yes.
she is taking OCP for 5 years but she is not sexually active? I said why who prescribe it for you? do you
have any problem with period? she said no in case if start any relation.
okay the examiner handed paper of examination typical for cyclic mastalgia ( multiple fibrocystic I think
bilaterally ).
I said I know you are concerned about breast cancer lump in the breast could be cancer the patient face
sad or fibroadenoma but from the hx and examination most likely cyclic mastalgia.
But again it could be related to pill I want you to stope the pill, wear supporative bra, NSAIDs and hot
pad and see you again.
As I remember the patient on ocp but not sexually active so I advised her to stope the pill, wearing
supportive bra and take NSAD for pain and reassure her is it a normal condition. ( EPO, Vit E,
Bromocriptine ).
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222
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Feedback 20-2-2018
GP, 22 years old female with bilateral breast pain. Her mother was diagnosed with breast cancer and
currently under treatment.
Tasks:
-Relevant history
-Physical examination from the examiner
-Explain to the patient probable diagnosis and differential diagnoses
2 min thinking: worried patient needs reassurance. Usual gyne history taking (5Ps, PMHx, FHx,
SADMA)
History:
Introduce myself. Empathy with patient having pain on both breast, offered stronger pain killer after
asking allergic history.
Asked more about chief complaint (pain question: severity, type, aggravating/relieving factors,
worse/better, associated symptoms) – as far as I could remember, had breast pain since 2 months ago,
pain is constant, more severe during menstruation, feels lumpy on both breasts. No recent injury or signs
of infection on the breasts.
5Ps: regular period, on Microgynon 30, forgot the answers for partner, pregnancy, PAP smear.
PMHx: unremarkable
FHx: mother, 50 years old, had breast cancer diagnosed recently, had mastectomy, ? LN excision, on
chemotherapy/tamoxifen?? She is unsure about BRCA status.
SADMA – unremarkable
Physical examinations:
Positive findings: multiple lumps on both breast, no skin changes, no nipple discharge, forgot whether
there is any tenderness on palpation
Explanation:
Dear Mandy, there are various reasons for a person to have breast pain. It could be due to infection to
the breasts, injury but they are unlikely in your case. Sometimes it is related to female hormones which
could be normal. As you are having breast pain for two months now and it is quite disturbing for you,
we can help you by giving stronger pain medication, some heat pack to reduce the pain. I would like to
reassure you that it is not cancer, but as you are having family history of breast cancer and it increases
the risks of you having breast cancer. We could do some basic test, I would liaise with your mother’s
physician, if she is having the BRCA test, a genetic test then we might suggest for you have the test as
well. Otherwise I would recommend you to start breast screening at the age of 40. Assess patient’s
understanding. Reading material.
(I do not think I do well in this case and my management might be wrong, please counter check with
John Murtagh and RACGP)
AMC Feedback – Breast pain: PASS
(Approach to patient/relative 4, History 5, Diagnosis/Differential diagnoses 3, Management plan 4)
225

Feedback 11-12-2018
...27 year old lady comes complaining of pain in both her breasts.
TASKS-a.History (Not more than 3 mins)
b. PEFE( from examiner in form of card)]
c Dx, DDx
d. Mx
-Hx-introduce yourself(should be done in a good way as patient lookS very concerned)
Reassure her in the beginning(as from stem I know… it is cyclical mastalgia)
Ask pain question(SOCRATES)--patient says pain increases before her periods and is relieved after.
Then ask questions about local (breast )- skin shanges, lump, nipple discharge
Ddx- always start from benign to malignant cause( fever,weight loss, night sweats, Loss of appetite,) 5
P(TAKING OCP)
Review of systems- genitourinary system, GIT
Past medical hx- not significant
Family history-I asked any history of similar condition, she said none
SADMA.
Then I rephrase my question- any family history of breast cancer or any other cancer(need to rule
ovarian cancer , colon cancer as it can predispose someone to breast cancer)- at this time she said mother
got cancer and underwent treatment—then always show your concern for mother..like I am sorry and
how she is now? Then if she is doing good…then say that’s great.
Thanks to patient for history then turn to examiner(he gave me a card of physical findings)-PEFE –
multiple lumps in both breasts and one dominant one. All lumps are rubbery, mobile, not fixated, not
hard.(findings were inconsistent with cancer but consistant with fibrocystic disease(cyclical mastalgia)
dx- always start like based on history and examination, first of alI, i would like to reassure you that it is
not cancer so please don’t worry..then explain cyclical mastalgia as diagnosis
ddx- abscess, fibroadenosis, mastitis , cancer(all less likely )
mgt- TRIPLE ASSESSMENT AS YOUR ARE CONCERNED AND POSTIVE FAMILY HX.
A- ANALGESICS
B- -GOOD SUPPORTIVE BRA
C- I STOPPED OCP
D- DANOZOL(D
E- -EVENING PRIMROSE OIL, VITAMIN E.
Passed- global score- 6, KEY STEPS- ALL

123-Perimenopause
226

AMC Case 7-7-2018, 14-3-2018 and 7-9-2018

47 year old woman with hot flushes, irregular periods, pap smear 3 months ago was normal
TASKS
-history
-most likely diagnosis and differentials to patient
-Send Investigations and Counsel

History
1-Open ended question
-I can see from the notes that you are complaining of hot flushes and irregular periods can you tell me
about it?
2-HRT indications Questions
Vasomotor symptoms:
--For how long have you had hot flushes? Is it constant or does it come and go? Is it getting worse? (Her
main problem was hot flushes, especially at night which. It started almost a year back and was getting
worst.)
-any heavy sweating at night?
Psychological:
-Are you having mood changes?
-Do you feel irritable, anxious or depressed?
-any sleep disturbances?
-have you lost weight recently? Any loss of appetite?
-do you have difficulty concentrating on things?
(She had become moody these days with some poor concentration, was interrupting her sleep so she
couldn’t sleep)
Somatic symptoms:
-any muscle aches and pains? Any bone or joint pain? (No)
Reproductive symptoms
-Any vaginal dryness, itchiness, discharge? (No)
Urinary symptoms
-Any burning or stinging while passing urine? Do you have to go to toilet more frequently? Do you fell
any lump down below? (No burning in pee and no prolapse)
history of osteoporosis
-any self or family history of fractures? (No)
-How does these symptoms interfere with your life and daily activities? (Her sleep was badly
affected so she felt tired through the day.)

3-5Ps questions
Periods
-when was your last menstrual period?
227

-How often do you get irregular periods?

-have you had any pain or heavy bleeding during menstruation?
-Any bleeding in between the periods?
(Her periods became shorter and lighter but no intermenstrual bleeding or pain during periods)
Partner/ sexual
-Are you sexually active?
-Have you ever been sexually active or not?
-any pain during intercourse?
(She was married, had no dyspareunia or bleeding after intercourse.)
Pregnancy
-Have you been pregnant before?
-how many pregnancies have you had?
-are you planning to become pregnant?
(Had children all deliveries were uneventful. not planning and her husband had a vasectomy.)
Pill
-do you use any contraceptive methods? (No)
Pap/ HPV
-is your pap/ HPV up to date?
-is your breast mammogram or ultrasound up to date?
4-Differential diagnosis questions
Thyroid
-any weather preference?
-any change in bowels habit?
-do you have shaky hands?
Infections
-any fever?
Malignancy/ Phaeochromocytoma
-any lumps or bumps around your body
anxiety disorders
-about any nightmares or bad memories from the past, but there was none.
-any stresses. at home or work?
5-Contraindications for HRT questions (None)
- Any undiagnosed vaginal bleed?
-Any history of clotting in your leg veins?
-any history of cancers (breast, womb or ovaries? Lumps or bumps?
-Any history of stroke
-Any recent heart problems like angina or heart attacks?
-Any history of active liver disease?
-Diabetes, uncontrolled blood pressure, high cholesterol?
-Any other medical or surgical conditions in the past?
6-Lifestyle
-healthy balanced diet (Her diet had enough Ca)
-regular exercise
228

-SAD (Not smoker)

Diagnosis and differentials

-There are several possibilities why you are experiencing these symptoms, most likely you have what we
call perimenopausal symptoms, means that you are most likely going through a natural phenomenon or a
perimenopausal phase of your life which is the periods before menopause when
your estrogen and hormone levels begin to drop. So because of these hormonal changes in your body
you are having hot flushes, mood changes, irregular periods.
-Other possibilities could be a thyroid problem, which is a butterfly shaped gland in neck but you do not
have weather preference or change in bowel habits, could be due to any infections but no fever, could be
due to anxiety or medications.

Investigations
So I would like to order few tests to know more about the diagnosis and rule out other conditions
-Basic blood tests like FBC, ESR, CRP, BSL, lipid profile, UCE, LFT, TFT.
-I would like do a hormonal test to look for FSH and LH levels.
-ECG to make sure your heart is fine because the decline in female hormones can affect it to.

Treatment
-I would like to refer you to the specialist for further evaluation.
-we might also consider giving you a combined sequential hormone replacement therapy to replace the
hormones that become deficient.
-advise life style modifications.

Feedback 14-3-2018
47 yrs old lady with irregular menstrual cycle and hot flush.
Tasks
229

HX , send investigations and counsel

2 min thinking..
Menopause/ perimenopause,
so menopausal h/o including 4Bs especially osteoprosis, 2 Ps, mood, cardiovascular risk and Ca
Indications and Contraindications for HRT
R/O medical cause like thyroid, infection, pheochromocytoma
R/O psychiatric cause
History
1-Menopause questions
-After introduction, I asked her to tell me what exactly was happening.
-vasomotor sx: Her main problem was hot flushes, especially at night which. It started almost a year
back and was getting worst.
-psych symptoms: She had become moody these days with some poor concentration, was interrupting
her sleep so she couldn’t sleep
-somatic: No breast tenderness or bone pains, She had no joint pain.
-reproductive: No discharge or itching, or dry feeling in private area.
-urinary symptoms: No burning with pee. No prolapse.
-bowel habit
- I asked how it was affecting her life and she said her sleep was badly affected so she felt tired through
the day.
2-5Ps
-Her periods became shorter and lighter but no intermenstrual bleeding or pain during periods.
-She was married, had no dyspareunia or bleeding after intercourse.
-Had children (forgot the number) all deliveries were uneventful.
On my asking if they had any plans for any other children, she replied no and that’s why her husband
had a vasectomy.
-Wasn’t using any contraception.
3-HRT CI
-She was never diagnosed with heart problem or any Cancer nor was there any family history suggestive
of it.
- Not troubled with headaches, clot in veins, non smoker, no liver disease. (CI for HRT)
4-Lifestyle
-Her diet had enough Ca and had no FH of fractures.
-She had never used any medication, I asked about Tamoxifen and she denied.
-Never diagnosed with PCOS.
-She had no weight-loss or any change in her appetite.
5-DDX
Asked about any tremors or weather preference or any change in bowel motion?
There was none. R/O pheochromocytoma and infections. Regarding her sleep problem I asked about any
nightmares or bad memories from the past, but there was none.
No stresses. SADMA nothing positive.
Counselling
-I told her that she was going through a natural phenomenon where there were some hormonal changes
230

in her body and that her periods might stop sometime soon. She was, what we called as Perimenopausal
phase of her life and her body was responding to the changing hormonal levels. -It could also be a
problem due to a butterfly shaped gland in neck called thyroid.
-infections and anxiety
Investigations
So I would do few tests to confirm and rule out any complications because of it.
-I would do a hormonal test too look for FSH and LH levels.
-Also included FBE, ESR, CRP to r/o any infection and anemia.
-ECG to make sure your heart is fine because the decline in female hormones can affect it to.
-We could do a bone scan but a specialist would organise that so I would write a referral.
-And to R/O thyroid disease, I would do some TFTs.
I referred her to specialist who would consider her for HRT use.
And because her sleep was disturbed, I told her about ways and lifestyle changes to improve her sleep.
Bell rang!
Scenario.. Health Review
Grade… Pass
Global score… 4
Key steps 1,2,3,4… yes
History… 4
Diag/ D/D… 3
Management plan…. 4
Feedback 7-7-2017 FAIL
47 year ild woman with hot flushes, irregular periods, pap smear 3 months ago was normal
TASKS
1. History
2. most likely diagnosis and differentials to patient
3. management to patient
WHAT I DID
asked about durATION of hot flushes...since 4 months
mood changes...no
on ocp...no
sexually active...yes
dyspareunia...no
were periods regular before...yes....any problems with periods...no
when did your mother had her menopause....i dont know
any aches and pains...no
any weather preference....no
smoking...yes
no alcohol
no medications
Mary you might be experiencing early menopausal symptoms and these could also be caused by changes
in thyroid gland functioning or due to some problems with ovary or womb so we need to do some
investigations...but probably its fue to menopausal symptoms
231

So will arrange for some baselines like fbe, crp.

Some hormones like thyroid functions and femake hormones estrogen, lh, fsh
ONCE RESULTS ARE BACK,specialist will decide whether any treatment is required or not
IN THE MEANTIME ADOPT SOME LIFESTYLE MODIFICATIONS LIKE HEALTHY
BALANCED DIET, EXCERCISE, STOP SMOKING, LIMIT ALCOHOL INTAKE
THANK YOU MARY AND EXAMINER.
FAIL
keystep 1 2 3 4 NO
history 3
diagnosis 2
management plan 1

Note/ Why he fail because his diagnosis is wrong he said early menopause not perimenopause.
his management is poor and did not mention she is a candidate for HRT.

Feedback 14-3-2018
Amenorhoea in 47 years lady – with flushing – counsel and send investigations.
Started with history – 5 Ps – mood changes – regularity – medications..etc – it was an obvious
premenopausal symptoms – explained that to her and offered her HRT to minimize her symptoms
and told her that I would give her reading material ( was an easy straight forward case ) . told her that
we might need to send for FSH/LH/Prolactin/U/S.

Feedback 14-3-2018
47 yrs old lady with irregular menstrual cycle and hot flush HX only irregular period ,hot flushes,no
mood swings on no pills now but she was on OCP for 5 years and then stopped,no weather preference
no lumps and bumps no contraindications of HRT.
counsel the pt (anovulatory cycle,we have to exclude other causes ,referral to gyn,might consider
giving combined sequential hrt)
send investigation(hormonal study fsh lh estrogen progesterone thyroid function test )

Another modification of this case came in 10-5-2018

-the same but the presenting complaint is sleep disturbance and tiredness. So start with all sleep
questions like duration, difficulty getting to sleep, wake up early in morning and difficulty getting back
232

to sleep.
then continue the same with indications and contraindications and lifestyle.
in DDX you can ask tiredness ddx questions HEMIFAD will be good
Feedback 10-5-2018
Can you plz share your approach for primenopausal wome along with sleep problems
Her presenting complaint was sleep problem and tired during day so I asked detailed sleep problem
questions, then few causes for tiredness like diabetes thyroid any infections, then asked period History
sexual history and detailed history of menopausal symptoms.
I forgot the exact task... but I remember taking history and talking abt diagnosis and ddx and abt
management part also... sorry but I don’t remember the exact task
So in summary 2 cases of perimenopause the same age
*first chief complaint is hot flushes and irregular periods
*second chief complaint is sleeping problems and tiredness
Feedback 7-9-2018
Station 15- peri-menopausal symptoms – PASS
. Peri-menopausal Symptoms
In STEM: Hot flushes and difficult to sleep
47-year-old lady , comes in . have 2 children ,
Not complaint about abdominal pain ,
TASK
1. history ( very disturbing night time , can’t sleep , please help me to get rid of it , - patient request )
patient herself - -nil known migraine headache, breast cancer , active liver disease , abnormal bleeding
apart from dyspareunia with her partner , blood clot or calf muscle pain .
5Ps- LMP was few months ago , few and few over time.
Family history – not all with those conditions as well .
Nil family history of bowel cancer , osteoporosis ( protective factors )
2. Explain INVEStigations to the patient ( routine , hormonal studies ( explain in details slowly
FSH/LH , estrogen , prolactin , ) 2 times apart to confirm menopausal stage.
3. Explain possible causes to the patient
( DDx – peri-menopausal symptoms – draw with a diagram of vagina , uterus , fallopian tubes and ovary
) – told quickly about ovary function – estrogen – which is deficient in the patient )
- other metabolic – thyroid dysfunction , sugar problem like DM ,
Need to rule out – least likely – infections
3. explain mgmt plan to the patient
- for sexual performance – lubricant gel or estrogen cream
- will refer to the specialist and they might start HRT – as no contraindication to the patient
Before explanation about mammogram , the bell rang.
Feedback – Health review – PASS
Global score – 4 Key step 1 to 4 – all YES
History - 5 Invx and DDx – 4 Mgmt plan – 2
233

Feedback 7-9-2018 (perimenopause) PRE-MENOPAUSAL SYMPTOMS- FAIL

47 year age old lady having hot flushes and mood changes, difficulty to sleep(I'm not sure about this
complaint??) Her BP -120/80, all other vitals normal. She has two kids. You have done pap smear ,
result - normal. few other invx were also mentioned normal.
tasks are-
Hx
Ddx
Invx
MX
FEEDBACK: Fail. HX 4, Dx/ddx: 2 , Mx: 2
This was my second station. I can't remember now but definitely I missed ddx or couldn't explain
properly. Please check the mx as well as I can see from another feedback that one candidate from same
date got 2 in mx in this case. I'm going to explain my thought process during the exam. To be honest, I
think I couldn't deliver in that 8 mints what I thought in 2 mints. Maybe, I was anxious, that's why I
missed points!!! However, for your convenience, I put all the ddx of this case.
2mints thinking-
5P- pregnancy, pap smear given. Have to ask details about period, contraception, dyspareunia ,
4B(Bladder, bowel, bone, breast) 2P( prolapse, incontinence, other peri-menopausal symptoms).
SADMA important. Plus need to ask HRT contraindications. Finally some general measurements.
DDX:
1. peri-menopausal symptoms or already reached menopause??
2. Hyperthyroidism
3. Pheochromocytoma
4. Generalised anxiety disorder
5. life-style stress
6. high caffeine intake
There was an thin old lady sitting on the chair. Confidentiality (could be a psychiatry case). Ask her
about hot flushes in details, mood problem, sleep problem, 4B, 2P , ddx questions, SADMA(nothing
positive). Everything was normal except period was scanty , dyspareunia and she is not using any
contraception. No stress as well. I forgot to ask HRT contraindication questions in HX time.
I started to explain her ; most probably due to peri-menopausal symptoms because of low female
hormones in your body and you are close to menopausal age. I'll do few invx to rule out other causes as
well.
- blood tests- TFT, hormone levels, LFT, RFT
-urine tests
- pap smear already done
- trans-vaginal usg to look for width of uterus
(I guess I explained ddx while I was talking about invx. As far as I remember, Invx was part of the task
but it's not mentioned in the feedback)
Then suddenly it came to my mind that I forgot to ask about HRT contraindications. I asked those
questions.(no hypertension, BP was given normal, no migraine, heart problem, liver problem, clots, no
fx of cancers) everything was normal. I said I would do few tests for HRT before referring her to
specialist. Then, I explained general measurement, physical exercise, yoga, meditation, sleep hygiene.
Reading materials regarding post menopausal symptoms. Plus oestrogen crème for dyspareunia.
I had enough time in this case. I asked her to repeat what I said. I was also thinking in my mind I guess I
had missed something!!
234

143-Polycystic Ovarian Syndrome

Sample Case
You are at your GP clinic when 20 year old Amanda presents to you with history of irregular periods
over the past 1 year after no periods at all for the past 3 months.
TASKS
-Take a further history
-PE from examiner
-Investigations with examiner
-Advise the patient regarding further management
Exam Case (4-4-2018) Was Unscored
23 yrs with mentrual abnormalities
Task
-hx
-Pefe
-Most likely diagnosis and and investigations.

Differential Diagnosis:
Hypothalamus
-Eating disorder
-exercise induced
-stress induced
-liver/ renal disease
Pituitary
-hyperprolactinemia
-Thyroid
-antipsychotic medications
Ovary
-PCOS
-premature ovarian failure
-post pill amenorrhea
-chemotherapy and radiotherapy
235

Uterus
-pregnancy
-asherman syndrome

Note/Amenorrhea: no periods for 6 months if she is having regular periods, and no periods for 3 months
if she is having irregular periods

History
1-Can you tell me more (if chief complaint was just menstrual abnormality)
2-5Ps questions
Periods
-when was your last menstrual period?
-When did you have your first period?
-Were your periods regular until the past 1 year? How often do you get irregular periods?
-have you had any pain or heavy bleeding during menstruation?
Note/ in the exam she has 2 cycles for the past 1 year, before normal with no heavy bleed.
Partner/ sexual
-Are you sexually active?
-Have you ever been sexually active or not?
Pregnancy
-if sexually active ask if by any chance she is pregnant? (Pregnancy)
Pill
-do you use any contraceptive methods? What is the type? (Post pill amenorrhea)
Pap/ HPV
-Have you taken the Gardasil vaccine?
-pap/ HPV up to date
3-Differential questions:
PCOS
-have you put on weight recently?
-any excessive hair growth? any acne?
-do you feel thirsty? Pass large amount of urine? (DM complication of PCOS)
POF
-do you have any hot flushes, heavy sweating, mood changes
Thyroid
-any weather preference? Any changes in bowel habits?
Hyperprolactinemia:
-any headache, blurring of vision? Any milky discharge from the nipple?
Eating disorders,
do you think that you are overweight? Do you try to lose weight through crash dieting or excessive
exercise?
Exercise-induced amenorrhea:
236

-do you exercise regularly and how many hours do you exercise?
Stress-induced amenorrhea:
Any stress at home? Any stress with your family?
4-General questions
-Do you smoke? (Smoking predisposes to PCOS)
-Any family history of a similar condition especially in your mom or sister?
-Any previous medical or surgical conditions? Any medications that you are on?
-any medications that you are on?
Note/ in the exam Acne positive, overweight positive. Remaining hx normal
Physical Exam from examiner
1-General appearance: hirsutism, acne, BMI, pallor, LN
2-Vital signs: BP
3-CVS, Respiratory
4-Thyroid exam
5-Abdomen:
any visible mass, distention
6-Pelvic: consent and chaperone
-Inspection of the vulva and vagina
-Speculum and Per vaginal exam CAN be done in PCOS, but NOT in this case because she is virginal.
7-Office test:
BSL, UDT, urine pregnancy test
Note/ in the exam bmi 31, acne and hirsutism positive.

Explanation of the Diagnosis:

-there are several possibilities leading to abnormality of the periods but from history and examination,
you most likely have PCOS have you heard about it?
Condition
-Normally during each menstrual cycle, even though several follicles develop in each ovary, one of the
follicles becomes mature, and then will break open to release the egg. PCOS is complex condition in
which, the ovaries are larger in size, and they develop many small immature follicles or cysts, none of
which grows to maturity and breaks open to release the egg. In other words, ovulation does not happen.
That is why your periods have become scanty and finally stopped.
Cause
The exact cause of PCOS is unknown but it has been found to run in families.
Complications
-There are also other hormonal disturbances in PCOS, like the body becomes resistant towards insulin,
which is a hormone that keeps your blood sugar level in check. This causes a rise in the blood sugar
level, leading to Diabetes.
The ovaries also secrete a small amount of male sex hormones called testosterone which gets out of
balance leading to weight gain, hirsutism and acne.
-This can also lead to high blood pressure, high cholesterol levels, infertility and even depression.
237

Investigations
I need to run some Ix to confirm the diagnosis and to rule out others
-FBE, UEC, ESR, CRP, LFT, serum lipid profile
-TFT
-FSH/LH ratio (Normal 2:1)
-Testosterone levels
-Pelvic ultrasound - greater than 10 follicles less than 10mm in size, this is PCOS

Management (according to the feedback it is not a task)

-I will refer you to the specialist.
-You need to folow lifestyle modifications. I will refer you to a dietician for proper diet chart. You need
to follow the advice of the dietician as even a 10 percent reduction in the body weight can normalize
your cycles. Along with exercise 30 minutes 5 days a week. So once the cycles are normalized, all the
other hormones can also be put back to place.
-We will also start you on low dose combined OCPs to bring back your menstrual regularity, decrease
excessive hair and acne.
-We will also start you on Metformin. It can increase insulin sensitivity so you will start losing weight
and once weight loss started it restores the menstrual regularity.
-If medical management does not work, we think about surgical management.
**What we do is laparoscopic ovarian drilling. Under general anesthesia, using a keyhole surgery, laser
or electrocautery is used to break through the thick outer layer of the ovary, and then destroys small
portions of the ovary. When the small portions of the ovary are destroyed, the testosterone production
comes down drastically. If you break any part of the circle, all the rest will fall back into place. (I do not
think it is necessary to talk about all of these)
-Meanwhile, because these medications take some time to act, you can go in for cosmetic therapies, like
laser or electrolysis. She can be put on combined oral contraceptive which contains the 3rd-generation
progesterone (has anti-androgenic property) cyproterone acetate (Dyne 35)
-review and reading materials

Note/ PCOS + infertility

1-lifestyle modification for 6 months
2-if doesn’t work- ovulation induction medications like clomiphen and add metformin with that
3-if not work laprascopic ovarian drilling
238

146-Secondary amenorrhea - Exercise-induced

AMC case
A young female who is not having her periods since 12 mnths .she had her pregnancy test done which
was negative. Pulse was 47 beat/min her husband is concerned so he asked her to seek consultation.
Tasks:
-History
-dx, ddx
-mx (no pefe)

sample case
Maria presents to your GP with complaints of absence of periods since the last 6 months.  
TASKS
-Further history
-PE from examiner
-Discuss management with the patient
 

Causes:
 Pregnancy
 PCOS
 Premature Ovarian failure
 Post-pill amenorrhea
 Asherman's syndrome
 Thyroid disorders
 Hyperprolactinemia
 Eating disorders
 Exercise-induced amenorrhea
 Stress-related amenorrhea
 

History
1-5Ps (pregnancy/ post pill amenorrhea)
Periods
-What are your concerns?
-Do you get spotting at the time of your normal periods?
-How were your periods before it stopped?
-How do you quantify your bleed before it stopped?
-Any pain at the time of periods?
Sexual history
-Are you sexually active? Are you in a stable relationship?
Pregnancy
239

-Were you planning for a pregnancy?

-Have you ever been pregnant?
Pill
-What contraception were you using?
2-DDX questions (PCOS/POF/ THYROID/ HYPERPROLACTIN/ EATING D/
EXERCISE/STRESS)
-Have you noticed any weight gain? Any excessive hair growth or acne?
-Any menopausal symptoms like hot flushes, heavy sweating, mood changes?
-Any weather preferences. How are your bowel habits?
-Any headache, blurring of vision, milky discharge from the nipples?
-Are you much bothered by your weight and appearance?
Have you ever thought that you are overweight?
Do you try to lose weight by crash dieting or self-starvation, vomiting or water pills?
-What is your occupation? (key)
How many hours of ballet dancing do you do per day?
Any other exercise that you do?
-How is your home situation? Any stress at home? Any stress at work?

3-lifestyle questions
-How is your diet?
-SADMA history
-Past history
-Family history
 
Physical Exam
1-General appearance:
BMI, pallor, dehydration
PCOS: any excessive hair growth, acne
Elasticity of skin - low estrogen can decrease elasticity
2-Vital signs
3-Thyroid
4-CVS/Respi/CNS
5-Abdomen: visible distention, mass, palpate for mass and tenderness
6-Pelvic examination
Inspection of the vulva and vagina: any discharge or bleeding, look for atrophic vagina
Speculum exam: cervix healthy or not, any discharge/bleed
Bimanual exam: CMT, uterine size, tenderness, adnexal mass and tenderness
7-Office tests: UPT, UDT, BSL

Diagnosis and Management

-Most likely you have a condition called exercise-induced amenorrhea.
Amenorrhea is when you have a loss of periods for around 6 months after established periods.

-Draw the HPO axis.

The estrogen and the progesterone that is released by the ovary, under the influence of the hormones
secreted by the hypothalamus and the pituitary is responsible for a normal menstrual cycle.
These sex hormones could be affected by a range of factors like excessive exercise when certain
exercise-related hormones like beta endorphin and catecholamines are released. The high levels of these
240

hormones suppress the areas in your brain which alters the secretion of estrogen and progesterone.

The other contributing factors could be eating disorders and low levels of body fat and also the
emotional stress that is associated. So an imbalance between the exercise and increased nutritional
demands along with stress can bring about amenorrhea, as it starts interfering with the normal hormonal
pathways.

-If this is not treated, this can lead to long-term complications, like the decrease in the fertility or
decrease in the bone density and the bones become brittle and break easily, increased cholesterol levels
and also premature aging.

- But first, we need to rule out all other possible causes of amenorrhea.
We have already done a pregnancy test, and it has come out to be negative.
All the basic bloods need to be done like a FBE, UEC, LFT, RFT, TFT, vitamin D (25-OH vitamin D),
serum prolactin, serum lipid profile, estimate all the hormones like GnRH, FSH, LH, estrogen,
progesterone, and also a pelvic ultrasound.

-You will be referred to the specialist.

Adopt lifestyle modifications:
Try to put on around 2-3 kilos of weight. I will refer you to the dietician who will give you proper
dietary advice.
I will put you on calcium and vitamin D supplementation.
Limit exercise to a maximum of 8 hours per week.

If these measures are not working in 6 month's time, then we can put you on combined oral
contraceptives.

I will give you reading materials regarding exercise-induced amenorrhea and I will arrange a review
with you in 1 month.
 
 
241

Feedback 19-7-2018
Menstrual complaint (exercise induced amenorrhea) Pass 4 key steps : yes
Case: a young female who is not having her periods since 12 mnths .she had ger pregnancy test done
which was negative. Pulse was quite low (i dnt remember exact value) her husband is concerned so he
asked her to seek consultation.
Tasks : hx,dx ,ddx, mx no pefe
when i entered the room there was a young female smiling n quite unconcerned abt her not having
periods . Consent for private qs and then I asked her 5ps in detail and then dds... pcos, thyroid,
hyperprolactinimia,pof,all were negative. Had a D&E some yrs ago (2 or 3) Then i asked her any
change in her diet ir routine or anything around that time since she has this complaint. She said she has
a marathon coming up in few mnths for which she was preparing since 15 /16 mnths . Exercise for
5 hrs n swimming for 2 n half hr . There i got my dx . Dx : exercise induced amenorrhea.
Ddx: pcos, Asherman's, thyroid, pof,
Mx: i explained her why she is not having periods.then said with her consent i need to include her trainer
in my team so we can midify her time and pattern of exercise bcz it is affecting her normal body
functions. Will also add a dietitian to modify and plan a good diet bcz she lacks the essential nutrients
which are important for normal body functions due to this heavy exercise.
I also said that i will do some basic investigations (blds and u/s) and will refer her to a gynecologist. i
didn't ask ger to quit the exercise because i thought i can't stop a person who is just few mnths away
from her goal and was preparing so much for so many mnths so i just said we need to modify things .and
if that doesn't work i will refer her .
Feedback 19-7-2018 PASS( KEY STEPS 1,2,3,4 YES,Score 5,5,3)
Menstrual complaint (Secondary Amenorrhea 2 to excessive exercise)
Task : Hx , provisional Dx and DDS and Mx, NO PEFE.
Long scenario outside .25 year old female came to u because of not having period for last 1 year ,did
preg test which was negative, vitals showed pulse -47/min rest all normal.
When I entered the room young lady was sitting ,seems quite unconcerned, told me that she is here
because her husband is worried. I told her confidentiality and asked consent about private questions,
then started with periods, covered 5Ps then PCO,POF ,Pituitary, thyroid , diet and exercise. She had a hx
of D&E 3 years back, no kids as don’t want to, doing exercise 5-6 hours day because preparing for
marathon, diet was good.
Most likely Dx was sec. amenorrhea due to excessive exercise, DDs Asherman, POF ,PCO, Thyroid.
MX multidisciplinary team as not ready to quit or dec exercise, need councilling as its affecting her
body badly, exercise instructor and me. I told her that I want to do hormonal assays(blood test and
US to make sure every thing is fine) After dec exercise ur period will return in couple of months, if not
then referral ,reading material and fu.

Feedback 13-12-2018 Menstrual Complaint: Pass

242

Young lady around 28 yrs with history of amenorrhoea since last 3-4 months. ( this is the case of
secondary amenorrhoea)
Tasks: History, Dx and DDX
Thinking outside: I remembered the causes of secondary amenorrhoea from karen’s.
Inside: Me: I am so sorry to hear about your problem.
Pt: Oh Don’t worry, I am not worried about not having periods. Its my husband who is worried that’s
why I am hear.
Me: Is it okay If I ask you few questions so we can find the cause of it.
Pt: Okay
Me: 1st please tell me more about your periods.
Pt: they were regular until 4 months ago, every 28 days, moderate not heavy last for 4 days. She gave all
the history including menarche as well.
Me: Is there any chance you could be pregnant? Pt: No
Me: Did you do pregnancy test at home? Pt: No
I asked about remaining 3 Ps. All negative.
Me: Then I asked questions regarding all the causes as per karen’s. (All negative except heavy exercise).
Me: Do you do lots of exercise? Pt: yes
Me: pl tell me more about it. Pt: I am preparing for triathlon. So I do lots of exercise. Me: okay.
Then I asked about anorexia nervosa such as what is your perception regarding your body? Pt: means?
Me: do u consider yourself fat? Pt: no way
Me: do u use laxatives of water pills by any chance? Pt: No
Then I ask about SADMA, present, past and family history.

Dx: Me: there could be many reasons why your periods are stopped.

I think it is your heavy exercise that is causing it. It is called exercise induced amenorrhoea. When
you do heavy exercise body thinks that you r losing lots of energy and not having enough energy
and body produce some changes that causes stopping of periods.

Others reasons such as thyroid problem ( but u done have thyroid symptoms), high hormone
production such as prolactin ( but u don’t have milky discharge from nipple and no visual
blurring), early menopause ( but u don’t have mood swing and hot flushes), pregnancy ( but u
don’t have symptoms), psychogenic causes (less likely bcas u don’t have symptoms), certain
medications ( but u don’t take them), certain problem with ovaries or womb.

Global Score: 4
Key Steps: 1&2 No, 3 yes
Approach to pt: 4 History: 5 Dx/ DD: 5
243

147-Bulimia nervosa irregular periods

Recall 14-3-2018
Young woman with menstrual irregularities. (There were clues that told it was eating disorder which I
can’t recall now)
Tasks
-History
-Diagnosis and D/Ds
Recall 5-5-2018
17 year old girl concerns about irregular periods. In her past medical history, she was admitted to
hospital because of hypotension and overuse laxatives. She still use laxatives and makes her sick as she
feels she is fat.
Tasks
-Take history
-explain diagnosis and cause for her irregular periods.
History
1-Can you tell me more
2-5Ps questions
Periods
-since when have your periods been irregular?
-when was your last menstrual period? (3 weeks ago)
-How often do you get irregular periods?
-have you had any pain or heavy bleeding during menstruation?
-any bleeding in between menstruation?
Partner/ sexual
-Are you sexually active? (No)
-Have you ever been sexually active or not?
Pregnancy
-if sexually active ask if by any chance she is pregnant?
Pill
-do you use any contraceptive methods? What is the type? (No pill)
Pap/ HPV
-Have you taken the Gardasil vaccine?
-pap/ HPV up to date
3-Differential questions:
PCOS
-any excessive hair growth? any acne?
-do you feel thirsty? Pass large amount of urine? (DM complication of PCOS)
POF
-do you have any hot flushes, heavy sweating, mood changes
Thyroid
-any weather preference? Any changes in bowel habits?
244

Hyperprolactinemia:
-any headache, blurring of vision? Any milky discharge from the nipple?
4-Confidentiality+ eating disorders.
-do you think that you are overweight? (Yes, I am fat)
-anybody told you that you are overweight? (Yes)
-can you tell me briefly about your diet? (I think I am eating healthy diet)
-have you ever lost control over how much you eat? (Yes, I take a lot of food at times and lose control)
-Do you feel guilty after that (yes)
-do you try to vomit or use any medications in order to lose weight (yes vomiting)
-do you exercise regularly and how many hours do you exercise? (30 minutes/ day)
-do you know your BMI? (21)
-dizziness, palpitations, dental problems?
5-Psychosocial history and HEADS
mood questions:
-how is your mood
-have you ever thought of harming yourself or others
-how’s your sleep
-do you find it hard to concentrate on things.
Delusion and hallucination
-I am gonna ask you certain questions that could be a bit sensitive but theses are just routine questions I
ask to some of my patients.
-do you feel, hear or see things that others don’t?
-do you think someone is spying on you or trying to harm you?
Insight and judgment
-do you think you need any professional help?
-if there is fire in this room what would you do?
HEADS
-any support at home, any stress?
- What do you do for living, any stress at work?
- have you lost interest in things you used to enjoy?
- SAD
- how is your social life? Do you catch up with friends quite often?
6-General questions
-Any family history of a similar condition especially in your mom or sister?
-Any previous medical or surgical conditions?
-any medications that you are on?
245

Explaining diagnosis and differentials

-From history and examination, there are several possibilities why you have irregular period.
-what I am suspecting it could be related to a condition we call bulimia nervosa; It is one of the eating
disorders when you think that you are overweight but in reality it is not as your BMI is falling within the
normal range. because you think you are overweight even though you go for a control diet, at times you
lose control and eat a lot of food then feel guilty about this, so try compensatory behaviors like vomiting
or others It can cause irregularity of your periods.
-other could be anorexia nervosa; another type of eating disorder.
-could be thyroid, pituitary, PCOS etc….. but less likely.
246

Feedback 14-3-2018
Young woman with menstrual irregularities. (There were clues that told it was eating disorder which I
can’t recall now)
Tasks
-History
-Diagnosis and D/Ds
2 min thinking.. Bulimia and Anorexia Nervosa but always rule about medical reasons. Causes of Eating
disorders, predisposing factors, complications of these condition, depression symptoms and drug abuse.
After introduction I started by building some rapport and asked how was she feeling and what was
she concerned about. She told about her menstrual irregularity.
I asked about how it all started? Since how long and how have her periods changed through this time?
She said they had become more irregular only. Last one was three weeks back. She wasn’t sexually
active, on no contraceptives. No chances of being pregnant (I still asked about morning sickness and
breast tenderness). Asked about any headache or visual problem (pituitary cause) any tremors or weather
preferences (thyroid cause) or any gynaecological procedure, but all was negative.
I gave the confidentiality statement and asked about her perception of her weight. She said she thought
she was fat. Here I asked if anybody told her about this and she started wrapping her cardigan around
her body saying yes some guys commented on my belly. I further asked if she was worried about any
of her body parts.. she said yes I’m fat and guys commented on that.
During further questioning she accepted that she was fearful of getting fat and tried to vomit after
food especially chocolates and that helped her feel better. She also had episodes of uncontrollable
eating that end up making her feel guilty . Her diet was normal and gave me a long description. She
ran 30 mins per day. There was laxative abuse previously but no diuretic use. Her BMI was 21 (she
told it to me herself without a question)
Further asked about complications like if she had any abnormal sense of rapid heart beat or dizziness or
dental problem but there was none.
Asked about Predisposing factors like anybody in the family had similar condition or she had any bad
experiences from her childhood or wether she had a perfectionist personality but none was positive. She
had no signs of depression and wasn’t using any drugs or smoking.
I started by explaining and writing the diagnosis and D/Ds. I told her that after talking to her there were
a couple of conditions that are in my mind that present like that. It could be Bulimia Nervosa.. because
her BMI was normal and she was vomiting and had uncontrollable episodes of eating.
It could be Anorexia nervosa as that causes menstrual irregularity.
It could be Body Dysmorphic Disorder as she was concerned about her body and thinks guys comment
on that.
Other causes can be pituitary, thyroid etc but were unlikely in her case.
She didn’t look happy so I asked if there was anything bothering her and why she looked unhappy? She
smiled ‘no everything’s fine.’ End of it!
Bell rang. Scenario… Menstrual Problem Grade.. Pass
Global score… 6 Key steps 1,2,3,4… yes Approach to patient… 5 History…. 7 Diag/ D/D…. 6
247

154-Anorexia induced amenorrhea

Amenorrhea for 12 months. BMI 17. Swimming 1.5 hour daily. On strict diet control.
Tasks
-History
-diagnosis and Ddx to pt.
History
1-5Ps (pregnancy/ post pill amenorrhea)
Periods
-can you tell me more about your concerns?
-when was you last menstrual period? (1 year ago)
-How were your periods before it stopped? (Before that, it gradually became irregular)
-Do you get spotting at the time of your normal periods?
-Any pain at the time of periods? (No)
Sexual history
-Are you sexually active? Are you in a stable relationship?
Pregnancy
-Were you planning for a pregnancy?
-Have you ever been pregnant? (Never been pregnant before)
Pill
-What contraception were you using? (Used OCP for long time but periods were normal while popping
the pills, currently using condoms, Taken pills until 2 years back)
pap/ HPV screening

2-DDX questions
PCOS
-Any excessive hair growth or acne?
POF
-Any hot flushes, heavy sweating, mood changes?
THYROID
-Any weather preferences. How are your bowel habits?
HYPERPROLACTIN
-Any headache, blurring of vision, milky discharge from the nipples?
Confidentiality+ eating disorder questions
248

-How is your diet? (Just veggies, no meat)

-do you think that you are overweight? How do you think about your appearance? (No)
-Do you try to lose weight by crash dieting or self-starvation, vomiting or laxatives? (No)
-any reason of strict diet control? (I want to stay healthy and no other perceptional issues at all)
Exercise induced
-do you exercise regularly and how many hours do you exercise? (No excessive exercise)
-What is your occupation?
Stress induced
-How is your home situation? Any stress at home? Any stress at work?

3-Psychosocial history and HEADS

mood questions:
-how is your mood
-have you ever thought of harming yourself or others
-how’s your sleep
-do you find it hard to concentrate on things.
Delusion and hallucination
-I am gonna ask you certain questions that could be a bit sensitive but theses are just routine questions I
ask to some of my patients.
-do you feel, hear or see things that others don’t?
-do you think someone is spying on you or trying to harm you?
HEADS
- have you lost interest in things you used to enjoy?
- SAD
- how is your social life? Do you catch up with friends quite often?
4-lifestyle questions
-medication
-Past history (medical and surgical)
-Family history
-childhood history (While exploring her child hood hx she said she used to be a fat and chubby kid I
asked her how does her feel about it and she said it didn’t upset me)

Explaining diagnosis and differentials

-from history and examination, there are several reasons why not having periods which we call
secondary amenorrhea.

-Draw the HPO axis.

The estrogen and the progesterone that is released by the ovary, under the influence of the hormones
secreted by the hypothalamus and the pituitary is responsible for a normal menstrual cycle.

-Our hypothalamus is usually very sensitive to change in body environment and I’m concerned about
your body mass index which is quite low 17 so it could be diet induced amennorhea, stress induced but u
don’t have any stress.
249

-Although you are not fitting in the eating disorder criteria, but it could be eating disorder; anorexia
nervosa or beginning of this condition.

-Although you do not have concerning symptoms but you are not having periods and your child hood
obesity history and that is making me feel if we take the help from psychiatrist. Who is going to conduct
a formal interview and help form dietitian and nutritionist who will design your work out schedule and
diet plan in such a well-balanced way that it will not affect your body.

-It also could be

Pregnancy (not PT –ve)
Prolactinoma(tumor of pituitary, but no head ache BOV , and milky discharge although we will run
basic investigations).
PCOS(not obese, no facial hairs, no acne)
Hypothyroid(no lump In front of neck, no hot or cold intolerance, wt is quite low)
Stress: (no stressors, except for child hood obesity which also didn’t bother her)
Exercise induced(she didn’t give me anything red flags).
Ocp induced (but periods were normal while she was on ocps)
POF: (no hot flushes, no dysperonia, no dryness of vagina)

Feedback 1-6-2018
amenorrhea for 12 months. BMI 17. Swimming 1.5 hour daily. On strict diet control.
-History
-diagnosis.
-DD to pt.
( never been pregnant before. Taken pills until 2 years back. After than had period only once. Pt
doesnt like to limit swimming and she told she want to be healthy. She know she is slim but want to
maintain health by diet and exercise)
This was the most controversial case but thankfully I passed it , I was very fixed headed on eating
disorder from the very beginning so tried to concentrate on psychosocial rather then amenorrhea
She told me that her last period was 1 year back and before that it gradually became irregular no
abd pain, she don’t think she is pregnant, used ocps: for long time but periods were normal while
popping the pills, currently using condoms, cervical screen / pap : normal, partner, stable healthy no
health issues no family stressors.
no stressors, no BOV, head ache, no thyroid related complaint, no acne hirusitism, no gynecological sx,
no previous or current pregnancy, no pid, no hot flushes or dryness of vagina.
then I moved on to psych hx stressors: no , eating habit: just veggies, no meat , no excessive exercise, no
purging, no laxatives, no body image issues, no frequent mirror check, no mood issues, no see, hear or
feel thingy, no family hx of eating disorder.
While exploring her child hood hx she said she used to be a fat and chubby kid I asked her how does her
feel about it and she said it didn’t upset me I explored any particular reason for strict diet plan she
said I want to stay healthy and no other perceptional issues at all. No hx of child hood abuse or
molestations.Explored HEADSSSS: all satisfactory
250

As it was DD station I told her there could be loads of reason for her not having periods wuch we call
secondary amenorrhea in our language, then drew pituitary ovarian axis on paper and started
enumerating the reasons.
Told her our hypothalamus secretes some hormaones which act on pituitary and inturn pituitary secreats
the hormones which act on the ovaries and that’s how the female experience regular periods on
monthyly basis.

Our hypothalamus is usually very sensitive to change in body environment and I m concerned about
your body mass index which is quite low:17 so it could be diet induced amennorhea, stress induced
(but u don’t have any). I m not a psychiatrist and although u r not fitting in the eating disorder criteria.
but it could be eating disorder; (anorexia nervosa or beginning of this condition.

although u don’t have concerning symptoms but ur not having periods and ur child hood obesity hx is
making me feel if we take the help from psychiatrist who is going to conduct a formal interview and
help form dieatetion and nutritionist who will design your work out schedual and dieat plan in such a
well balanced way that it wont affect your body.
Then went on to tell other DD’d
Told her I was thinking of
Pregnancy (not PT –ve)
Prolactinoma(tumor of pituitary, but no head ache bov , and milky discharge although we will run basic
investigations).
PCOS(not obese, no facial hairs, no acne)
Hypothyroid(no lump In front of neck, no hot or cold intolerance, wt is quite low)
Stress: (no stressors, except for child hood obesity which also didn’t bother her)
Exercise induced(she didn’t give me any thing red flaggish)
Diet (most likely).
Anorexia nervosa (querry , not sure but 1st DD)
Ocp induced( but periods were normal while she was on ocps)
POF: (no hot flushes, no dysperonia, no dryness of vagina)
No gyneacologic sx on ovaries or uterus
PID (no hx)
Feed back : passed Global score : 6 All key steps cpvered
Approach to pt: 5 Hx: 6 Dx, DDX: 6

Feedback 1-6-2018
251

Amenorrhea for 1 year. Task: Hx, explain cause of amenorrhea Anorexia nervosa.
DDx Mnemonics 5PTEAS (Pregnancy, Pills, POF, Prolactinoma, PCOS, Thyroid, Exercise and diet,
Asherman, Stress) which I gave as DDx and told why others are unlikely.
BMI 16 I think. Excessive exercise. Diet restrictions. Both started 1 year ago, no specific stressor in hx.
Patient wasn’t concerned about the condition. So I explained briefly what it is and how it can adversely
affect her health. Explained HPO axis. Other possible causes and they are unlikely. Mentioned possible
adverse effects of anorexia

157-Anemia in pregnancy
Case (21-6-2018)
Pt 30ws pregnant, comes to review the results you ordered the day before. Hb:9.0 microcytic
hypochromic anaemia. glucose: normal.
Task:
-hx (4min).
-Explain investigation
-Dx
-Management
Feedback 22-6-2018
Pt 30ws pregnant, comes to review the results you ordered the day before. Hb:9.0 microcytic
hypochromic anaemia. glucose: normal.
Task:
hx (4min). Explain investigation Dx Management
Approach Greeted patient
Asked if she is feeling light headed, dizzy would like to lie down. She said she is alright she wants to
know what the results mean So I explained the result first. Then told her number of causes and risk
factor and cause these so I would like to take a through hx.( I did not do well in this case) So I asked
252

about the any tummy pain, baby kick, discharge from below.
Asked headache or leg swelling, racing in the heart
Then antenatal checkup done or not, Folic acid taken or not, Asked diet—vegetarian
Bleeding diseases in her or family, Colour of urine, Stickiness of stool to pan, On any blood thinning
medication Known kidney or liver condition Ethnicity.
Previous pregnancies—she said 4 ( I completely forgot to ask about the gaps in the pregnancies
Periods—any heavy bleeding Blood group
The I said as I mentioned earlier you are having Anaemia. Then I said most likely it is Iron Deficiency.
Thought about chronic diseases, thalassemia seemed unlikely To confirm the diagnosis I would like to
take blood to do Iron profile
Mx
Refer to High risk preg clinic
Start on iron tablets
Will give stool softners
Check iron profile again in 2 weeks
Continue treatment for at least 2-3 months.
Asked her any questions—will this anaemia harm my baby
I said complication in mother is heart failure and in baby is IUGR
But don’t worry in the High risk pregnancy clinic you and your baby will be frequently monitored for
any complications.
Bell rang Said thank you to pt and roleplayer ( Most likely the cause was reduced gap in pregnancies
which I forgot to ask.)

Case (15-3-2018)
30 weeks pregnant, GP, 4th pregnancy. Tests show hypochromic microcytic anaemia.
Tasks:
-take further focused history
-ask pefe
-give dx
-mx
(vegetarian, children 5, 3, 1 respectively)
Feedback 25-10-2018
22 yr old woman, 8 wks of preg came with blood test results: Values were for microcytic hypochromic
anemia with normal iron levels.
Task:
History
d/d
further inv
I took history for possile causes of anemia. Asked ethnicity and finally explained possibility of
thalaseemia n said ALL antenatal inv plus hb electrophoresis.
253

Approach
Explaining results
-Some blood tests have been performed and the results are now with me to explain to you so let us see
the results together.
-We have three types of blood cells the red blood cells, which contain an iron rich protein called
Haemoglobin, which is responsible for carrying oxygen to the tissues. White blood cell to help fighting
against infection and platelets to help with blood clotting.
-Platelets and WCC are normal.
-But there is a decreased level of hemoglobin we call this anemia.
-Also this MCV is less than the normal range this mean that the size of the red blood cells are small.
-There are few possibilities but first I need to ask you a few questions in order to reach the diagnosis.

History
1-Late pregnancy complications questions
-How’s your pregnancy so far?
-Any tiredness, dizziness?
-any chest pain, palpitations, shortness of breath?
-any tummy pain, vaginal bleeding or discharge?
-any headache, blurring of vision or leg swelling?
-any fever, nausea or vomiting?
-is the baby kicking well? (Baby problem)
2-recurrent visits questions
-Have you had regular antenatal checks?
-How were the blood tests? Are you aware of your blood group?
-have you done down syndrome screening?
-US at 18-20 weeks gestation? Is it single baby? Any birth defects? What is the position of the placenta?
-Sweet drink test at 28 weeks?
-Repeat ultrasound at 32/34 weeks?
-Bug test at 36 weeks?
-did you take your folic acid?

3-Past medical history

-Any bleeding disorders, are you bleeding from anywhere in the body like gums, black stools?
-celiac disease or any chronic diseases?
4-past surgical history
5-past obstetric history
-is this your first pregnancy? How many pregnancies have you had?
-when was your last pregnancy?
- What are the ages of your children?
-How were your previous pregnancies and deliveries? Any complications during those?
-Did you have anemia before you got pregnant or anytime during your previous pregnancies?
6-Past gynaecological history
How were your periods before you became pregnant? Any excessive bleeding?
254

7-Social
-What is your usual diet? Does it include meat and green leafy vegetables? Are you on any special diet?
-SAD -Medications 
-family history and origin
PEFE
1-General appearance: pallor, skin for petechial or bruising
2-Vital signs
3-CVS/Respi/CNS
4-Abdomen: fundal height, FHR, lie, presentation
5-Pelvic examination
Inspection of the vulva and vagina: bleed, discharge
Speculum: cervix for any bleed or discharge
6-Office test: UDT, BSL

 
Diagnosis and Management
-What I am suspecting in you is an iron deficiency anaemia. It is a common condition that happens in
pregnancy because there is an increased demand during pregnancy because you need to supply iron for
yourself and your baby.
-The causes for this condition are multiple. It could be due to the diet, or the pregnancies that are close
together, and as you had a history of anaemia.
-other possibilities are thalassemia, chronic disease, infection, bleeding disorder but unlikely.

- Iron level is correlated with the oxygen supply, which is important for the baby's growth and
development. It is good if it diagnosed and treated early, to prevent any problems during pregnancy.

-If it is untreated, it can cause lethargy, tiredness, exhaustion and dizziness, it can lead to heart failure
and also postpartum haemorrhage or bleeding after delivery. In the baby, it can result in a low birth
weight and a growth retardation.
Management
-I would like to arrange blood test; iron studies including ferritin. (Critical error)
-Refer to High-risk pregnancy clinic.
-Start on iron tablets.
-The iron tablets should not be taken along with dairy products, but you can take orange juice along with
it as vitamin C increases the absorption of iron.
-After you start on iron, your haemoglobin levels will go up in two weeks' time, but you need to
continue taking the iron tablets still for at least 3 months after your iron comes back to normal to
replenish the iron stores. Will Check iron profile again in 2 weeks.
-Once you start taking the iron tablets, you may experience a bit of abdominal discomfort, and
constipation, your stools may turn black. You should take a lot of water to avoid constipation.
-Include green leafy vegetables, red meat, beans and lentils in your diet, and cut down on coffee,
tea, soy products as all these can decrease your iron absorption (key point).
-If no improvement is seen after taking the supplements, then I will refer you to the haematologist for
further assessment and management.
255

Read handbook condition 71

163-Atrophic vaginitis/ Endometrial hyperplasia

Sample case/ 62 year old Mary, presents to your GP, with complaints of vaginal bleeding since the last
2 days. She does not have any other medical or surgical illness and is not on any medication.
 TASKS
-Focused, relevant history
-Examination findings from examiner
-Order relevant investigations
-Further management of this patient.
   
Differential Diagnosis
1-Atrophic vaginitis 2-Endometrial hyperplasia
3-Endometrial or cervical polyps 4-Endometrial or cervical cancer
 
History
1-bleeding questions
-Is the patient hemodynamically stable?
-How long has your bleeding been going on? (2 days)
-How many pads have you used so far? Are they fully soaked (2 pads)
-What is the colour of the bleed? Are there any clots?
-Is it smelly?
-has this happened before?
2-Associated symptoms/ DDX
-Do you have any abdominal pain, fever, nausea and vomiting?
-do you feel dizzy or tired at the moment? (Anaemia)
-any dryness from down below? Any burning or itching sensation down below? Any abnormal
discharge? (Atrophic vaginitis)
-any bulging from down below? (Polyps)
-any weight loss? Any lumps or bumps around the body? (Cancer)
-any bleeding disorder? Do you take any blood thinner medications?
-are you aware of your blood group?
3-5Ps
Menopause (instead of period)
-When did you have your menopause?
-do you experience any hot flashes, mood swings, heavy sweating? Do you experience burning or
256

tingling when you pass urine? Have you experienced any incontinence? Do you open your bowels
regularly?
Sexual (partner)
-are you sexually active?
-Do you experience painful intercourse? (Atrophic vaginitis)
-Any bleed after intercourse? (Cervical cancer)
Pregnancy
-how many pregnancies have you had?
HRT (instead of pill)
-Are you on any hormone replacement therapy? (Can predispose to endometrial hyperplasia)
PAP and Mammogram
- Have you done your pap smear? What was the result? Mamogram?
Physical Examination
1-General appearance: BMI + PODL
-BMI, pallor, lymph node enlargements, dehydration, oedema
2-Vitals: BP with postural drop, temperature
3-CVS, R/S, CNS
4-Abdomen: Visible distention, mass, tenderness (abdomen is soft and non-tender)
5-Pelvic exam
Inspection of the vulva and vagina:
-bleeding, discharge, rash, vesicles
Speculum:
-does the cervix appear healthy?
-Any bleeding from the cervix?
-vaginal wall (vagina is thin, dry and atrophic with diffuse erythema)
Bimannual examination
-uterine size and tenderness of the uterus, adnexal mass and tenderness (uterine size is normal, no
tenderness)
6-Office tests:
UDT, BSL
 
Investigation
1-FBE, UEC
2-Transvaginal ultrasound and diagnostic pap
-Thickness of endometrium (in postmenopausal women, thickness should be less than 5mm)
-Polyps in the endometrium or cervix
-Any other abnormal growths
 
Management
Atrophic vaginitis
-From the history and examination, most likely you are having atrophic vaginitis. It is a condition where
the lining of the vagina becomes thin and dry, and breaks down at times, leading to a bleed. Normally,
the lining of the vagina is dependent on estrogen for strength and integrity. At time of menopause, the
ovaries shut down completely so that only very low levels of estrogen are formed, so when the estrogen
levels go low, the vagina becomes thin and atrophic.

-You can use local estrogen therapy in the form of vaginal estrogen cream, vaginal estrogen tablets
(Vagifen), or pessaries. You can also use vaginal lubricants, which is also effective to control dryness
257

especially during intercourse.

Should I be put on hormones doctor?

For atrophic vaginitis alone, HRT is not indicated. This condition can be well treated by local therapy
but it might take some time to act. However if you have other symptoms of menopause like hot flushes
or sweating then you need to be started on it.as HRT can carry some risk to you.

Reading material of atrophic vaginitis

review in 2 weeks’ time
red flags
Endometrial hyperplasia
-From the history and examination, most likely you are having endometrial hyperplasia.
-The endometrium is the normal inner lining of your womb. After menopause, the endometrial thickness
should be less than 5mm. But in your case, the thickness has gone up to 7mm. When there is an increase
in the endometrial thickness, it is called endometrial hyperplasia.
-It is due to an unopposed stimulation of the endometrium by estrogen in the absence of progesterone.
After menopause, the ovaries shut down completely, so that only very low levels of estrogen are formed,
with no progesterone at all. However, estrogen is still being produced in the body through peripheral
conversion of fat tissue and this estrogen causes the stimulation of the endometrium.
-In endometrial hyperplasia, the endometrium becomes quite unstable and breaks down at times leading
to bleeding. The other complication of endometrial hyperplasia is endometrial cancer which could
happen in around 7% of the patients.

-I will refer you to the specialist who will do a hysteroscopy and endometrium tissue sample
-once sampling is done treatment will be given depending on the type of endometrial hyperplasia so if it
is typical, you will be given progestogens either orally or an intrauterine contraceptive device like
Mirena will be placed. If the tissue sample shows atypical changes, the specialist may decide to do a
hysterectomy or removal of the uterus.

-I will give you reading materials regarding endometrial hyperplasia for further insight.
-I will arrange a review with you after the specialist consult.
-Life style modification and dietician if BMI is high

notes/
I think. There are 2 presentations for atrophic vaginitis case the first one is postmenopausal bleeding for
2 days.
The other would be a persistent vaginal discharge for 3 weeks
History
-You will do the same history like bleeding or discharge no difference then same differential and 5Ps or
general.
-in post menopausal bleeding the patient will say it is brownish discharge in lay term I think. And her
husband will be dead, if so no need to ask pain or bleeding after intercourse. Also she might not done
pap or mamo so arrange one if so.
-in the case of discharge 3 weeks as k importantly about the colour.
Examination
-for both there should be atrophic vagina, vaginal discharge or bleeding according to the case.
258

-there might be high blood pressure as incidental findings so again do LSM and arrange consultation if
so. But be careful they might be wrong with this feedback.
Management
-for both cases talk about atrophic vaginitis.
-in sample case they put Ix before discussion because the tasks are different. In the exam after talking
arrange Ix especially to rule out endometrial cancer.

Case (4/10/2017)
62 year old F with vaginal bleeding
- atrophic vaginitis
Vaginal bleeding – Pass
Scenario
Post-menopausal bleeding 2 days.
•History
•Focused examination from examiner
•Explain most probable diagnosis to patient.
C/O brownish discharge 2 days.
Menopause 15 years before no bleeding till 2days back. Used 2 pads so far. No abdominal pain. Last
pap smear 2 years back. (Told her we’ll have to do it today.)
Not sexually active for years. No previous vaginal discharge. No fever/ LOA/LOW
Waterworks and bowel habits normal.
Never been on HRT. No menopausal symptoms. Never had breast lumps/surgery.
Assessed for risk factors of endometrial ca. 3 children. No family history of endometrial (womb) or
colon cancer. Not taking any meds. (esp. tamoxifen), no evidence of PCOS in the past history. Not
used OCP…
SAD-no
PEFE:
All normal except blood in vagina/ not coming from OS. Atrophic vagina. Said I will do a PAP
smear during speculum exam. When asked for BMI, examiner said she is as you see her -role player was
quite lean.
Diagnosis:
Atrophic vaginitis is most probable diagnosis. Explained the effect of estrogen on integrity of
epithelium………. And explained her examination findings…
At her age, endometrial carcinoma is the most important diagnosis we want to rule out with this
presentation. (she got anxious- so added as she does not have any of the risk factors apart from being
post-menopausal and age, so atrophic vaginitis is the most probable), but cancer should be excluded
with a transvaginal USS, and PAP smear test before giving her above diagnosis.
• 4/4 key steps covered.
259

Feedback comment
I had this case in June. I passed it too. In the history, you have to rule out Endometrial/Cervical
cancer as the presenting complaint is brownish discharge in a post menopausal woman.
Ask detailed menopausal history about last menstrual period, any sexual problems (sexual history, my
patient's husband has passed away 10 years ago and she said she wasn't sexually active then),
vaginal dryness, emotional problems.
Then ask Cancer questions, like weight loss, appetite, night sweats, lumps or bumps.
(My task was history, ask examiner for phys exam findings and most likely diagnosis and DD)
Ask about her general health. When was her last Pap smear and mammogram? (This is very
important, my patient was due for a Pap smear, so I told her that I will perform one now and also
refer her for a mammogram).
Then asked the Phys Exam findings, it was consistent with atrophic vaginitis. I told her it is likely to be
atrophic vaginitis, but just to be sure I'd like to run a few more tests like an ultrasound to see how
thick her uterus lining is. (It wasn't necessary for the task)
My patient had an incidental high BP reading.
So I asked her if she is taking BP meds? She said no, she wasn't aware, so I told her that I will kee
an eye on her BP readings and if it was consistently high I will consider giving her medications in
the future.

Feedback 20-7-2018 (important)

Post menopausal vaginal discharge
Pass , Global score 4
key step 1, 3, 4 Yes
key step 2 No
approach to pt 4
history 4
choice and technique of examiantion , organisation and sequence 5
Dx/Dx 5
Mx plan 4

62 yr old femal , persistent vaginal discharge ,

History , PEFE , DX , Mx plan
history
discharge .. yellowish or brownish vaginal discharge for 3 wks , no foul smelling , no blood , no
need to use pap, not itchy , just irritation , especially when she passed urine , no rash in her down
below , no swelling from her down below, no urinary symptoms , no abdominal pain , no fever , no
LOW , no LOA , no lumps and bumps in the body ,
260

period last time at age of 52 , no menopausal symp , not on HRT , has 3 children , normal vaginal
delivery , pap smear 18 mths ago , ( result were good) , mamogram done , good , husband died? ,
not sexually active , no PMH or PSH , no family history of gynaecology cancer , SADMA not
relevant
PEFE
BMI as you see , normal
vital sign BP 140/90, PR 80 min , RR 20 min , temp normal
no pallor , no jaundice
CVS normal
REsp normal
abdomen normal
pelvic inspection - no discharge , no mass , coughing ... no urine leakage , no prolapse
SS atrophic changes + , os normal
BME normal
urine dipstick , BSL not available

Explanation
Julia , based on the examination finding and history taking , most likely the cause of vaginal
discharge is due to a condition called atrophic vaginitis , ,which is very common in women after
menopause , causing thining and dryness of vagina due to lack of female hormone after
menopause .that can lead to irritation easily and discharge as well. this is not serious condition .
however , whenever a women in her post menopause has discharge we should also consider and
rule out other condition , like nasty conditon of neck of womb ( CA cervix ) nasty condition of
womb ( CA endometrium ) , even tho it is less likely , infection of womb is unlikely as you are not
sexually active ,
so i would like to refer you to specialist , who will do further assessment , take swab for discharge ,
doing usg to your belly to check thickness of the womb and pap smear , if anything suspicious ,
biopsy ,
i will prescribe lubricant and oestrogen cream to apply in your down below to relieve the
condition , and will review you regularly .
as your blood pressure is a bit high side , i will make another appointment to recheck your BP as
well

Recall 12-4-2018
a 67- year old lady comes with vaginal discharge from 2 m ago. 
Tasks:
* further Hx
* ask p/e from examiner especificly
* mx
during hx these were found:
husband died 6 years ago , her LMP was 15 years ago , no any bleeding befor, was on pills and HRT for
2 years , no any other symptom, no itchiness, no wt loss.
not sexualy active, last pap was 2 years ago and was nl. not smoker. 
in p/e: 
just vagna was thin and cervix was pale and dry. no any other symptoms.
261

Feedback 31-5-2018
8)atrophic vaginitis,GP,57 yr old woman with one day blood stained vaginal discharge.vitals r Normal
Tasks- H/O,PEFE,dx and ddx
History-one day bleeding ,just pink spotting on the pad.no discharge,no itchiness,no smell,no urinary
symptoms no trauma,no abdominal pain.
No menopausal symptoms,no HRT,husband died 6 yr ago.no sexual activity since there.Cervical
screening test normal,mammogram normal.no LoW,LOA, No family history of cancer
PEFE-typical atrophic vaginitis feature was given by examiner.
Explained-by drawing ,other ddx endometrial hyperplasia,gynecological cancers,infection all less likely.
Keys 3/4 approach 3,examination 4,dx and ddx 4 ,global 4

Feedback 26-10-2018
Station 5: Vaginal bleeding Fail (GS - 3)
Post-menopausal woman with Hx of vaginal discharge.
Hx, PEFE, Dx & DDx
Hx:
 discharge (2-3 days, colour is period-like blood), other symptoms (fever, abd pain, no features of
UTI, no features of Cancer)
 menopause 15 yrs ago. no bleeding since then. No other menopausal symptoms, no HRT
 Sexual Hx – not active, (skip dyspareunia), STI screening (not done)
 Screening (did Pap smear 2 years ago), mammogram
 SADMA
PEFE:
GA, VS, abdomen exam (Normal),
Pelvic exam: normal on inspection (bleeding ??)
Speculum exam: atrophic changes in vagina, bleeding on areas where speculum is touched
Bimanual exam: uterus and adnexa – normal size and no TDN
Dx & DDX:
Explained Atropic vaginitis as my main Dx.
DDx: infection (candidiasis, Bacterial vaginitis, Trichomoniasis), Ca cervix and Ca endometrium
(patient looked worried as I mentioned cancer. But I reassured her that those are less likely as she was
healthy and she had no features of cancer. we just want to rule out cancer by doing some basic
screening.)
262

Feedback 8-11-2018
263

Endometrial hyperplasia feedback

Feedback 21-6-2018
A postmenopausal lady, (maybe 57-year-old) has come to see you for vaginal bleeding. Her Ultrasound
examination report is provided.
Tasks
-take history
-Explain the results to her.
(endometrial hyperplasia Ultrasonography 7-mms) I guess there was also talking about management as
well. Vaginal Bleeding:
Pass: Global score 5

I entered the room, introduce and greeted the role player. Took a history regarding her bleeding. Asked
about characteristics of bleeding. Any concurrent pain, or vaginal discharge. Also about the time of
menopause, contraception, HRT, osteoporosis, or any bone pain or fracture, also sweating, sleep
disturbance or mood change. And also asked about her BMI, recent weight gain, balanced diet and
routine exercise.
Then explained about menopause, hormonal change, and unopposed oestrogen secretion in menopause
especially among the overweight women, and also about endometrial hyperplasia and risk of cancer.
Explained that this sort of bleeding is not a definitive sign of endometrial cancer, however, as there is a
risk of malignancy, it is wise to do more investigation on her by endometrial sampling. So she needs to
be referred to specialist for further investigation. And the rest of the management depends on the results
of the investigations.
Feedback 11-12-2018
58year old presents back to your GP clinic for her vaginal ultrasound report. It shows endometrial size
of 7mm.
Take hx,
Examiner will give you result and you have to Explain the results to patient
DD
Ask hemodynamically stability, ask bleeding history- CCVO, Bleeding anywhere else. Onset, duration,
progression, 5 Ps, RULE OUT DDX- ATROPHIC VAGINITIS,CERVICAL POLYP ,CERVICAL
CANCER,(ASK ABOUT ANY ABNORMAL PAP SMEAR), ENDOMETRIAL CANCER, OVARIAN
TUMOR,ANY OTHER CANCER IN PATIENT AND FAMILY, BLEEDING DISORDER ,LIVER
DISEASES., trauma
RISK FACTORS- obesity, smoking, nulliparity(you will cover in obstetric history)sadma-negative
positive findings--patient has had a proper period for the first time since LMP 5 years ago. Bled for 5
days, used a couple of pads, no clots, not fully soaked. AT the moment, she is not bleeding but she is
worried..so have a guarded reassurance.
RESULT—USG FINDINGS—Endometrial thickness was 7mm, ovary and cervix- healthy, so explain
each part of results and also give above ddx with the result. So said will do further investigations. Try
not to scare the patient..
Global score- 5, all key steps covered
264

Feedback 11-12-2018
Station 5 (Vaginal bleeding) Global Score 4 Pass
58-year-old woman comes to GP Clinic for the results of her ultrasound. It shows a 7mm endometrium.
Tasks: History, explain the results and DDx. (Relevant PE will be given on a chart)
I came in the room and greeted both the examiner and the patient.
I introduced myself and noticed patient was distressed. She said she wanted to know the results.
I told her I would be pleased to explain her the results but I would need to make some questions first.
She agreed.
I asked her to tell me more about her bleeding. When it started? Last month. How long did it last? 5
days. How many pads? A couple. Fully soaked? No. Any clot? No. Any abdominal pain? No. Any
fever? No. When was your last period? 5 years ago. Did you have hot flushes back than? Yes. Were you
on HRT? No. Any symptoms now? No.
I told her I would have to ask some sensitive questions. She nodded. I asked if she was sexually active?
Yes. Any bleeding during or after intercourse? No. Any pain during intercourse? No. Any STD? No.
Any weight loss? On the contrary, doctor, I have been putting on weight. (that caught my attention).
Any lumps or bumps anywhere in the body? No.
I asked about her HPV screen she said she had done last year and was normal.
I asked about mammogram and she said the last one was three years ago. I told her I would arrange one
for her.
Smoke? No. Any medication? No. Any Blood thinners? No. Any drug? No. Diet? Normal and rich in
calcium.
Home situation was unremarkable. Family history: unremarkable Previous conditions: none.
I asked for the PE chart. Everything was normal but BMI was 30.
I showed her the ultrasound result and explained it to her. I draw the uterus and showed her what the
endometrium was. I told her that normally it is 5mm but hers was 7mm and that was the cause of
bleeding. I named the condition: endometrial hyperplasia.
I explained that when menopause occurs, the ovaries stop producing hormones like estrogen and
progesterone. But her body was producing estrogen because she was overweight.
She looked at me and said with half a smile: “ you don’t need to be this direct, doctor!”
I said: “ I am sorry, let me rephrase it. As you told me earlier, you have been putting weight and your
BMI is 30. That’s the main reason why your body is producing estrogen. It acts on the endometrium
making it thicker as you don’t have progesterone to oppose its action.”
“Other causes of postmenopausal bleeding could be: atrophic vaginitis but it is unlikely because there
was no atrophy on the specular exam and you have no bleeding and no pain during sexual intercourse;
coagulation problems but you have no family history and you are not using any blood thinner; polyps
but it did not show on your ultrasound; cancer but you have no weight loss, no family history and no
lumps or bumps in your body.”
Key step 1:yes. Approach to patient/relative: 5 Key step 2:yes. History: 5

Key step 3:yes. Interpretation of investigation. 4

Key step 4:yes.
265

184-Incomplete miscarriage
You are an intern at ED. Your next patient is a young woman came with vaginal bleeding after 8 weeks
of amenorrhoea. She looked pale.
Tasks:
-Take a history from the patient.
-Ask PE findings from the examiner.
-Tell the possible causes to the patient
Differential Diagnosis:
1-Miscarriage (incomplete, Threatened )
2-Ectopic pregnancy
3-H-mole
4-Trauma
History:
*ask patient if she has any pain, she said yes ask for severity and offer pain killer she said no thanks she
is ok now.
1-ask the examiner “Is the patient hemodynamically stable?”
*The patient unstable so need to stablise her by putting IV lines and start on fluid take blood for
FBE,UCE,LFT
2-Bleeding questions (Duration-Action-Trauma-Amount or severity-colour-odour-content-
dizziness- bleeding disorder or blood thinner)
- for How long have you been bleeding? Is this the first time?
- What were you doing the time you passed blood?
- have you had any trauma to your tummy?
- How many pads have you used so far? Is it (are they) fully soaked?
- What is the colour of the bleed?
- is it smelly?
- Are there any clots or tissues? Any vesicles or grapes? passed tissues +ve
- do you feel dizzy or tired? (yes)
-have you had any bleeding disorders or take any blood thinner medications? (no)
2-Associated symptoms (tummy pain, fever, N&V, discharge)
- do you have any pain in your tummy? (Mild pain)
ask only severity + pain killer, site and radiation.
266

- Any fever? Nausea or vomiting? Abnormal vaginal discharge?

3-5 P’s questions
Period questions: (only ask LMP and regularity)
-When was your last menstrual period? (Already given in the stem 8 weeks ago)
-were they regular?
Partner or sexual (only support and STI)
-do you have good support?
-have you or your partner ever diagnosed with STI?

Pregnancy
- are you trying to become pregnant? Said yes and UPT at home was +ve yesterday
- have you had any previous pregnancies or miscarriages? (no)
- do you have any vomiting, breast tenderness? (no)
Pill
how long have you been off the contraception?
Pap or Hpv
is your pap or Hpv up to date?
4-Early Pregnancy questions
-Any antenatal checks you'd done so far? (no yesterday I noticed myself pregnancy)
- Have you taken your folic acid? (no yesterday I noticed myself pregnancy)
-are you aware of your blood group?
5-General questions (Diet-SAD, OTC- pets, PMH-PSH-Family hx)
- Diet: any intake of raw meat? (predisposed to toxoplasma), how many coffee do you take in a day?
- Do you smoke, drink alcohol or take recreational drugs?
-Any prescription or over the counter medications?
- Any pets at home? (toxoplasma in cat litter)
- Any other medical or surgical illness?
-Family history of miscarriages?

Physical Exam from examiner

1-General appearance:
pallor, dehydration, LAP (PDL) , Bruises or bleeding
2-Vital signs
Blood pressure (+ postural hypotension) , Tachycardia, Temperature ( low BP, high PR +ve)
(she is still unstable, so tell the examiner to continue giving the patient fluid and arrange for blood group
and cross matching)
3-quick Systemic exam.
4-focus on Abdomen
Inspection (distension, Mass)
palpation (tenderness, mass)
Bowels sound
267

5-Pelvic exam
consent of patient and presence of chaperone:
Inspection: colour of the bleed? Tissues, clots? (Tissues positive) so here tell the examiner that you
need to remove these tissues.
Speculum: look if bleeding is coming from cervix , cervix closed or open? ( OS open with tissues)
Per vaginal: CMT, uterine size, position, tenderness adnexal mass and tenderness ( size 6 weeks)
6-Office test:, UDT, BSL ( Avoid asking for UPT, coagulation profile, US)
Explanation
-Show empathy to the patient like I’m sorry to tell you that you most likely having miscarriage…. Do
you want me to call anyone for you?
-Most likely what you're having is incomplete miscarriage. It is pregnancy loss presenting with bleeding
before 20 weeks of pregnancy, passing tissues and the neck of womb is open, the womb size is less than
age O/E.
-Exact cause is unknown could be due to genetic abnormalities in the baby.
-This usually managed by curettage(define it) by specialist….. you are in safe hands….
Other possibilities but unlikely are threatened miscarriage unlikely as in threatened misc the neck of
womb closed and no tissue passed. Molar pregnancy unlikely as no vesicles, and size of womb usually
larger than it should be. Ectopic unlikely as well

Feedback 15-8-2018
Vaginal Bleeding
Stem: Young lady with abdominal pain and vaginal bleeding after few weeks of amenorrhea (bp 80/40)
Tasks
~History
~PEFE
~Dx and ddx to patient
Inside the room there was a young girl in early 20s lying on the couch with sheet on. She was acting as
if she is in pain and looked anxious worried and breathing heavily.
Greeted her and address the pain first. Asked pain scale, allergy and arranged pain killers. Show
empathy.
Excused her to ask the examiner about vitals, he said already given. I asked if there is any change since.
He said no. So I told him to take patient to cubicle and give fluids before starting history. He said
sure.
Then took history ( You all know pain questions, bleeding questions.. keeping in mindtrauma,
intercourse, ectopic, molar, threatedned, imcomplete, complete abortion, appendicitis, pyelo etc( she told
she hasn’t seen any doctor and found out 1 or 2 days back with home pregnany test that she is
expecting). Asked about 5ps. And winded up.
PEFE
GA….Anxious breathing heavy
Vitals… Bp( still 80/40) even after fluids, PR Inc, RR Inc, Temp normal
Focused on Pelvic so asked for chaperone and patients consent ( examiner said offcourse you do)
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Inspection: blood +
Speculum: blood +, clots +, POC +, OS opened ( I told examiner that I would remove poc as bp isn’t
coming up with fluids).
Gave dx of imcompplete abortion( in breaking bad news manner)and explained it.. ddx of
complete, threatened, molar, ectopic etc same as mentioned above.
Grade:Pass
Feedback5-10-2018
Station 5 (Incomplete miscarriage)
Question: You are an intern at ED. Your next patient is a young woman came with vaginal bleeding
after 8 weeks of amenorrhoea. She looked pale.
Tasks: Take a history from the patient. Ask PE findings from the examiner. Tell the possible causes to
the patient.
Score: I passed this case with global score 5
Key steps 1, 2 Yes 3 No
Approach to patient: 6
History: 5
Choice and technique of examination, organization and sequence: 6
Dx/DDx: 4
My performance
Patient is lying on the bed with some concerned and tired look.
Hello, Mary. I’m Dr. MM, one of the interns in this department. I knew that you might be very
concerned as you have bleeding from your down below. How are you feeling right now? (Yes, doctor, I
feel rather weak) I have to ask you some questions first. Would that be ok for you? (Yes, doctor) Is it the
first time to have bleeding from your down below after losing your period for 8 weeks? (Yes) Is the
bleeding too much? (Yes) Any blood clots? (Yes) So I have to measure your vital signs first from my
examiner. Can you please wait for a minute? (Yes)
Dear examiner, as my patient has severe vaginal bleeding, I would like to measure blood pressure
and pulse rate first. (PR is 110/min and BP is 80/50 mmHg) My patient is having hypovolemic
shock and so I want to insert wide bore cannula on both hands and collect blood for grouping and
matching and basic blood tests. And I’ll run normal saline right now, examiner. (Done) Let me get
back to my patient.
Ok, Mary. I have done all the necessary urgent treatment right now. Can we continue for history?
(Yes) Previously, do you have regular periods? (Yes) Have you checked any pregnancy when you lost
your peroids? (Yes, doctor, pregnancy test was positive) Is this the first pregnancy? (Yes) Do you have
any recent injury history to your tummy or down below? (No) Have you seen any tissue passed or grape
like vesicles in your bleeding from down below? (No) Any tummy pain? (Yes, doctor and it’s right here.
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The patient is pointing around lower part of tummy) Ok, Mary, thank you for the information. I have to
examine you right now. OK?
Dear examiner, I want to measure vital signs again. (It’s still the same)
Then I’ll look for pallor. (Present)
I’ll do focused abdominal examination. Is there any tenderness? (Yes, in lower parts) Is there any
abdominal distension? (No) Any palpable mass? (No)
Then I’ll move on to pelvic examination with my patient’s consent and in the presence of chaperone.
On inspection, is there any bleeding at the moment? (Yes) Any blood clots? (Yes) Any foul smelling?
(No)
Any signs of injury or infection like redness and swelling? (No) Then, I’ll do speculum examination. Is
cervical os opened or closed? (open) Any tissue piece at the os? (Yes) Then I’ll remove it now. I’ll do
bimanual examination. I want to know uterine size, position and tenderness. (uterus is 6 week size, RV
position and slight tenderness present) Thank you , examiner. That’s the end of my examination.
Ok, Mary. I’m really really sorry to tell you that you’re having miscarriage now. Let me draw a
picture. This is your womb and here is neck of womb and here is birth canal. When I examined
you I saw some tissue piece at the opening of neck of womb and your womb size is reduced now.
This is a condition we called incomplete miscarriage. It’s very important for you to have a
procedure which will take out all the tissue pieces left in your womb. The other possible cause
might be a condition we called threatened miscarriage but it should present with only mild
bleeding and no tissue passed from your down below. There’s another condition we called molar
pregnancy but it’s unlikely as it usually presents with grape like vesicles passed. There’s another
unlikely cause we called ectopic pregnancy. Then the bell rang.
Comment: Examiner was a Chinese and looked very patient and good-natured. Role player was very
good at acting.

Feedback 5-10-2018 FAIL

You are in ED an young lady has come who has developed vaginal bleeding and she has 8 weeks
amenorrhoea. Your task is:
 Take further relevant hx
 PEFE , she will give you exactly what you want to know
 Talk with the pt abt ur diagnosis and dd
 No management is needed
This is the exactly the book case of Condition Number 79.
Nothing to add here. The roleplayer was an excellent actress. You need to show loads of sympathy and
empathy here as she she was losing her baby. Blood group was O+ve so no need to talk about anti D.
Feedback: Failed (which I was v sure I’ll pass)
Key step1,2: Yes 3: No
Approach to pt: 5
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History: 4 Choice & technique of examination: 5 DD: 3

Global score: 3

185-Large for date Uterus

Case 1 (Polyhydramnios)
Recall (2017)
You are in GP and 34 weeks pregnant lady come for antenatal checkup. Ur colleague saw her at last
appointment when she was 28 weeks and her FH at that time was 30 weeks. Now she is 34 weeks and
SFH is 38 weeks. All the blood tests and USG have been done which are all normal. Tasks
- Take further history
-Ask PE findings from examiner and investigations, where examiner will give u what u are asking for
-Explain possible causes of this condition to patient
Recall 17-8-2018
a patient has presented to you at 32 or 30 weeks of gestation not sure about that, with increased weight
gain during last 4 weeks.
Tasks
-take history
-Ask the pefe and you can ask investigations what you want from examiner. And you will be told only
those which you will ask
-Explain the most probable cause to patient with reasons
-And mention investigations you want to repeat
History
1-Late pregnancy complications questions
-How’s your pregnancy so far? (everyone is saying my tummy is bigger than normal, its uncomfortable)
-any tummy pain, vaginal bleeding or discharge?
-any headache, blurring of vision or leg swelling?
-any fever, nausea or vomiting?
-any burning or stinging on passing urine?
-any problem with your bowels?
-any dizziness, tiredness or funny racing of the heart?
-any shortness of breath?
-is the baby kicking well?
2-recurrent visits questions
-Have you had regular antenatal checks?
-How were the blood tests? Are you aware of your blood group?
-have you done down syndrome screening?
-US at 18-20 weeks gestation? Is it single baby? Any birth defects? What is the position of the placenta?
-Sweet drink test at 28 weeks?
-Repeat ultrasound at 32/34 weeks?
-did you take your folic acid?
- Have you done your pap smear? What were the results?
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3-General questions
-PMH (DM, fibroid)
-Family history (twins, big baby)
-SAD
-Pets, travel, raw meat

Physical Exam from examiner

1-General appearance (PODL)
pallor, oedema, dehydration, LAP
2-Vital signs (all)
3-quick CVS and chest
4- Abdomen:
-any tenderness
-any uterine contractions
-Fluid thrill
-what is the fundal height (fundal height is 6 or 7 cm large than dates)
-FHR
-lie and presentation
-is the lower pole of the uterus empty or not?
5-Pelvic:
-Inspection of the vulva and vagina: any bleed, discharge, rash, vesicles
-Speculum: cervical os open or closed, discharge or bleed from the os

Investigation you want from examiner

1-Office test: urine dipstick, blood sugar level (normal)
2-dating scan exam said normal, correct dates
3- torch screen ( normal)
4-18 week scan for *twin baby , *amount of amniotic fluid, *fibroids, *abnormal baby (all normal)
5- Oral glucose tolerance test (normal)
6- repeated scan recently (no)
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Explain diagnosis and Investigation

-From the history and examination, most likely you have a large than date uterus. As you are---weeks
but when measured the fundal height it is larger than it should be.
- There are several reasons why your uterus is larger than it should be:
*I am suspecting it could be due to polyhydramnios or an excessive amount of amniotic fluid around the
baby.
Infection, birth defects or DM can cause excessive amounts of fluid.
But still need to confirm it by referring you for USD.
Others are:
* Multiple pregnancy
* macrocosmic or big baby
* uterine fibroids.
*wrong dating,
however, these are less likely because your ultrasound at 18 weeks have confirmed your dates, a
singleton pregnancy, there is no evidence of diabetes, and there were no fibroids detected on your
ultrasound.
Management
-I need to refer you to the specialist
-arrange several Investigations
*FBC
*repeat OGTT
*viral serology (TORCHES)
*ultrasound to check amount of fluid around your baby.
*CTG to check the wellbeing of your baby.
-your pregnancy will be managed in high-risk pregnancy clinic for which you need to attend frequent
visit and follow-ups.
-Large than date uterus can cause problems in late pregnancy and labour including malpresentation,
premature rupture of the membranes, premature labour, and placental abruption following membrane
rupture.
-if at any time you have any water leakage from down below or bleeding or severe tummy pain , go to
ED as soon as possible.
-I will give you reading materials about Large than date and polyhydramnios for further insight.
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Case 1 Feedback
Feedback 17-8-2018 pass
Antenatal care (polyhydromnios handbook case),
Task-hx,pefe(ask any inv u want to review),d/d,inv
Hx-everyone is saying my tummy is bigger than normal, its discomfortable.
no hx/fhx of diabetes, no other medical condition, no fhx of congenital fetal abnormality, no exposure to
pets, vaccination uptodate, no s/s of dm or htn in pg,all antenatal test fine.
Pefe-uterus 6cm larger thn date, apart from that all r normal.
I asked for any inv available like bsl, usg(what pt told u that’s it) I asked again as task was any inv u
want to review, thn he said as I told u(bit angry I guess) office test-he asked me what u r looking for
specifically? i said bsl,urine dipstick-normal
dd-all 8 causes of hb
inv-same like hb USG,GTT etc.I said I need to send u to specialist,he might do some other invasive test
like amniocentesis(said how they will do this-taking some fluid from womb and check whether any
TORCH infection in baby)(score-5 here so enough inv).
I felt pt wasn’t happy as I had sob due to my physical illness, I had to take deep breath in between and
said sorry for that again and again bt still I had time-pt asked anything u want to tell me? i said yes ur
delivery is expected prior to due date, so red flag, stay near hospital, need to seen by specialist within
few days(all hb sentences)

Feedback 6-6-2018
large for gestational age- pass
? 29 wk pregnancy, regular patient at your clinic all AN screening tests were normal. Complaining of
abdominal discomfort and think her tummy is getting larger in size.
task: hx, PEFE, dx, ddx, arrange investigation for the patient
History: abdominal discomfort, no pain, no contraction, no nausea, no vomiting, pv
discharge/bleeding nil, no headache, visual disturbance nil, leg swelling nil, feel fetal movement ,no
urinary symptoms, no bowel symptoms, diabetes symptoms nil, pets nil, raw meat nil. Sweet drink test
done and normal, ultrasound done and normal, blood gp. LMP sure, regular period before, DM hx nil,
fibroid hx nil, family history of big baby present, no family history of twin.
PEFE: fundal height ? 32 weeks size( 3wks larger than the gestational age given in the scenario), single
fetus, FHS normal.
Ddx :likely polyhydramios, explain causes of it, ddx: DM, big baby, wrong date , twins, fibroids,
placenta abnormalities.
Inv: baseline blood tests, TORCH screening, would like to repeat sweet drink test, USG, CTG.
(Explained all ,with layman term)
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Feedback 17-8-2018 ANTENATAL CARE

A patient has presented to you at 32 or 30 weeks of gestation not sure about that, with increased wt gain
during last 4 weeks.
Your task is to take history
Ask the pefe and you can ask investigations what you want from examiner. And you will be told only
those which you will ask
Explain the most probable cause to pat with reasons And mention investigations you want to repeat.
INSIDE
I started by asking about wt gain and little bit about diet and well preg questions, like any tummy pain
,vaginal discharge, bleeding from down below, there was nothing concerning uptill now , all was
normal. Use of folic acid any supplements .she said her tummy is bigger than dates. I asked about
investigations like dating scan , first trimester infection screen (TORCH) baseline blood and blood
grouping, then 18 weeks scan that was normal single baby no mass in utrus or abnormal location of
placenta, or abnormality in baby, then I enquired about sweet drink test that was completely normal ,no
personal or family history of diabetes, no family history of big babies was there. Nothing was positive
in whole hist except wt gain and big tummy ( note that uptill now we don’t know about fundal
height) .
PEFE
Started from general appearance, vitals then moved to obs examination, fundal height was 6 or 7 cm
large than dates . rest of exam was normal. Fluid thrill was negative. I specifically asked for single
baby or twin on physical exam as well. There was single baby with cephalic presentation. I didn’t do pv
in this case Then in investigatins I asked for dating scan exam said normal, correct dates I asked torch
screen that was normal
18 week scan , *twin baby , *amount of amniotic fluid, *fibroids, *abnormal baby, nothing was present
all normal. Oral glucose tolerance test, normal
Any repeated scan recently , exam said no. ( I was so panic at this stage to find some cause for large for
dates that’s why kept asking lol.)
Now moved to the pat and explained all the causes for large for dates first of all polyhydroamnios
told in layman and said its unlikely because no fluid thrill on examination but I will refer you for USG
so that we can see if its present . could be due to infection in pregnancy they can also cause inc amount
of fluid around baby , or any abnormality in baby. There could be big baby due to diabetes in mum but
also less likely in your case. Could be twins but less likely , or wrong dates , less likely. Then I said
from the history and examination and the investigations I could not find anything abnormal except big
tummy I have tried to rule out all the possibilities which can cause this but could not find. So at this time
I am referring you to the specialist o that he can also have a look at you and I am giving you a
referral for usg so that we can check amount of water around your baby and we can also repeat
sweet drink test and infection screen. I am referring you to high risk preg clinic and you will be taken
care by them from now onwards. Gave her red flags any water leakage from down below or
bleeding or severe tummy pain , go to ED as soon as possible.
3 key steps out of 5 covered History 4 Choice and technique of exam organization and sequence5 Dds4
Choice of invest 4 Global 4

Feedback 14-3-2018
32 weeks pregnant lady with rapid weight gain over 4 weeks. (Don’t remember exact weight changes
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and gestation).
Take Hx, PE from examiner and explain diagnosis to the patient.
2 min thinking time; look for causes.. Polyhydromnios, multiple pregnancies, fibroid, wrong dates,
placenta previa, fetal abnormalities, low Hb, choriocarcinoma, gestational diabetes, preeclampsia,
infections, family history of large babies etc.
After introduction, I told her that I saw in her notes that she had rapid increase in her weight in these
last few weeks. So I need to ask her few questions if she was okay with that. She agreed. I asked her if
she felt any difference recently? Or any rapid increase in the size of her belly? Any difficulty breathing
or swelling in legs? All negative.
The baby was kicking well and there was no discharge or bleeding from her private area. I said let’s talk
about her antenatal tests. I asked if there was any abnormality in her blood levels and what her BG was.
It was fine and she was O+ve. Wether her pregnancy was spontaneous or assisted to R/O (multiple preg)
Then I moved on to her 18 week growth scan to ask further about multiple pregnancies, if the doctor
commented to where her placenta was, or if there was any abnormal growth in her womb, or if the baby
was fine and growing normally? She hadn’t eaten any raw or undercooked meat or didn’t come in
contact with cats. Her OGTT was normal and no previous or family history of DM or complicated
pregnancies.
Her husband and herself were of normal built and height and nobody in the family was very tall
etc. She didn’t travel anywhere recently.
I took a moment from her to talk to the examiner. Vitals were all stable. No edema. Abdominal exam
was more important so I focused on that. Fundal height was 34/35cm above pubic symphysis. FHR
was normal. No fluid thrill present. Fetal head wasn’t engaged and fetal presentation was cephalic. No
proteins on urine dipstick and BSL was not available.
I got back to her and told along with drawing that after talking to her and the examiner it looked like the
rapid weight gain was due to a Larger for date gestation. There could be a lot of reasons like
polyhydraminos, placenta obstructing the mouth of womb, preeclampsia with increased BP and release
of proteins in urine but I couldn’t elicit any in history.
So I would refer her to the specialist to do furthur testing to find the cause. He may do an USG to have
a look in the womb and the baby. A CTG will be done to make sure the baby is doing well. He may
repeat OGTT if he suspected DM. And a couple of other blood tests. Asked she understood?
Then told about complications of LDG mainly being preterm labour and malpresentation. So the
specialist may decide for an early delivery if any complications occurred. But from now on there will be
more frequent visits with doctor to keep her and her baby safe. Asked if she wanted to ask any questions
and the bell rang. Scenario … Antenatal Care
Grade… Pass
Global score… 5 Key steps 1,2,3,4…. Yes 5.. No
History…. 4 Choice of examination.…. 5
Diag/ D/D …. 5 Choice of investigations…. 5

Case (22/2/2017) (22/6/2017) (6/9/2017)

-polyhydramnios Karen case
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- You are in GP and 34 weeks pregnant lady come for antetnatal checkup. U colleague saw her at last
appointment when she was 28 weeks and her FH at that time was 30 weeks. Now she is 34 weeks and
SFH is 38 weeks. All the blood tests and USG have been done which are all normal. Tasks
- Take further history
- Ask PE findings from examiner and investigations, where examiner will give u
what u are asking for
- Explain possible causes of this condition to pt
(You are not supposed to discuss about treatment)
2 mins thinking
- Oh, Is it new case? I didn’t see this in last year recall. Can it be transverse lie? No, it should be
reduced fundal height in T lie.
- It can be large for date uterus, my DDx are wrong date, polyhydramnios, big baby, multiple
pregnancy, fibroids, etc.
- In HO - I ll ask general Q and ask routine in PE. See, how it goes inside the room and I ll play it
accordingly.
History
When I stepped into the room, there was a re known AMC examiner whom I have seen in official AMC
videos. I greeted examiner and he checked my name card.
Greeting - Good morning. I am Dr Khine. I am one of the Drs in this general practice. Nice to meet you
Samantha. (Yep, Dr). I understand from ur notes that u are here for antenatal check up, right? (Yep)
Antenatal Q -
-How’s ur preg going so far? (It’s going well).
-Did u do all antenatal check ups that u are supposed to do? (Yep), Are they normal? (yep)
-What about USG at 18 weeks? Do u have any concern for that? (No, Dr)
(I didn’t ask in detail like how many babies, placenta location, liquor coz the stem mentions that
it was normal)
-Sweet drink test at 28 weeks? (No problem). Ok that’s great.
Late preg Q -
-Any tummy pain, Any HA, blurring of vision, leg swelling (No)
-bleeding and water broke from down below? (No)
-Do u feel that ur tummy is larger than it should be? (I dun know)
5P - Is it first pregnancy (Yep), Any previous miscarriages (No), Stable relationship (Yes), Pap smear (1
year back and it was normal)
SADMA, PMH (fibroid) , PSH - all clear
blood group and coombs test

PE Findings from examiner

-GA - Pallor, jaundice, oedema, lymphadenopathy (No)
-Vital signs - All normal
-Focus Abdominal exam
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FH - 38 cm
Lie – Longitudinal
Presentation – Cephalic
-FHR - 140/min
-CVS, Resp – Normal
When I ask about PVE, examiner said no PVE has been done.
Bedside tests - not available
Then I asked USG report, examiner said “Ur patient has already told you”
(I was freaking out as the task mentions that ask invx results from examiner). I said “Sorry examiner,
my pt didn’t tell me anything.” Examiner said no USG report is available.
Any CTG report? (Examiner - what??) I said “Cardiotocogram”. (Examiner - for what?) (It widens my
eyes again) I said to check well being of baby. (Examiner - It s not available) Then examiner told me
talk to my patient. I thanked examiner
Explain to patient
Jenny, According to history and physical exam findings, I found out that ur tummy was larger than it
should be, we call it “large for date uterus”
It can be caused by a couple of reasons like wrong date, which means u wrongly memorise ur LMP.
Then I draw a diagram of uterus with baby inside.
Other possible causes are big baby, increased amount of fluid inside bag around ur baby we call it
“polyhydramnios”, and if there are more than one babies inside ur womb.
Let me ask ur USG finding of 18 weeks, Did Dr tell u how many babies are there? (RP : it is singleton
pregnancy)
OK, that’s fine. So far, are u with me? (Yep, Dr)
Alright, the last cause is fibroid (I draw a fibroid in diagram) which is non cancerous growth of muscle
layer of ur womb.
Before pregnancy, did u notice any lumps in ur tummy? (No). (I should have asked any issue with ur
period like increased amount of bleeding)
So, we ll do a couple of investigations like repeat USG to find out the causes, and CTG which is a
special test to check wellbeing of ur baby. And we ll treat u accordingly.
(Mx is not task. So I didn’t talk about it)
Then the bell rang. (I should have told causes of polyhydramnios in this case but I didn’t)
AMC Feedback - Antenatal care : Fail (Global Score - 3)
History 4 Examination 4
Dx/ DDx 3 Invx 3

Feedback11-12-2018 ( Antenatal care) Global Score: 4 PASS

27-year-old female, 34w pregnant. She missed her last antenatal check. All her blood tests and US were
normal. Fundal height is 37cm.
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Task: History, PEFE, Dx, DDx and Mx.

I came in the room and greeted the examiner and the patient.
I introduced myself and started by congratulating the patient for her pregnancy.
Than I started to slowly get into the questions:
How are you feeling right now? Any concerns?
Are you feeling any pain? Any vaginal discharge?
Is it your first pregnancy? Yes.
Was it planned? Yes.
When was your last period? Was it regular before? Yes. Any heavy bleeding? When and how did you
confirm your pregnancy?
Did you have early symptoms of pregnancy like morning nausea and breast tenderness? Yes. What
about now? No.
Were you on folic acid? Yes.
Did you make morphologic scan at around 20 weeks? Yes. Any concerns? No, it was normal. Was it
only one baby? Yes
Did you do the sugar test at 28 weeks? Yes. It was normal
Are you feeling the baby kicking? Yes
Any blurry vision? No. Headache? No. Tummy pain? No.
SADMA- unremarkable
When was your last HPV screen? (I don’t remember the answer!)
Do you have good support at home? Yes.
Is your partner the father of the baby? Yes. Is he a big man? Yes, doctor, he is a very big and bulky man.
Did anyone else in your family have big babies? Yes. My sister had three kids and they were all very
big. Was she diabetic? No.
Did you have any infection? No.
Are you coping well with the pregnancy? Yes
I excused her and asked the examiner for the PE:
I started with GA: “as you see”
Vital signs: normal
PICCLED
ENT: normal
RS: normal
CVS: normal
Abdomen: Soft, not tender. Fundal height: 37. Presentation and lying? Longitudinal and cephalic. Fetal
HR? 150. (I was a little confused at this part and the examiner did not seem happy)
‘With the consent of the patient and the presence of a chaperon I would like to perform the pelvic
examination. “ Examiner asked: “what do you want to know?”
On inspection: Any discharge? No. Any bleeding? No. Any rash or vesicles? No.
Sterile speculum examination: Any discharge? No. Any bleeding? No. Is os open or closed? Closed
Than I said that I was not going to perform the bimanual examination.
Asked for office test: Urine dipstick and BSL. (I don’t remember if it was normal or unavailable)
I thanked the examiner and went back to the patient: “ According to your history and PE, most likely the
cause of fundal height not compatible with the gestational date is because you have a big baby. That’s
what we call macrosomia. The reason is probably genetic because your husband is a big man and you
have family history of big babies. This is a very common cause.
Other causes could be wrong date, but you confirmed the pregnancy early right after missing your
period; big baby due to diabetes but your glucose levels are normal so far; multiple pregnancy but the
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US shows only one baby, fibroids but you had no problems with your periods before pregnancy and it is
not shown on US; and polihydramnios.
You are due to a new US at 34 weeks, which I will arrange now.
On 36 weeks we will do the bug test and I will see you weekly.
When you go into labor, the obstetrician will follow you up. If they think baby is too big for vaginal
delivery, a C-section might be performed”
Bell rang and I had no time for red flags and reading material.
Key step 1:yes. Choice of investigation: 4
Key step 2:no. History: 5
Key step 3:yes. Choice & Technique of exam, organization and sequence: 3
Key step 4:yes. Diagnosis/Differential diagnoses: 5
Key step 5:yes.

Read Handbook 110 

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Case 2 (Large for date + measure SFH only yourself during PEFE + give only DDX without likely)
Large for date
GP, 27 years old lady 34 week pregnancy came to see you for routine ANC. It is the first baby for her.
She lives with her husband and he is supportive to her. She came regular ANC and test results are
normal. She underwent sweat drink test and her blood group is B positive. 
Task:
Take history 
PEFE and you do yourself SFH 
Tell the patient possible causes 

Appreciate. I asked ANC: bld test normal. USG normal & no fibroid. Pregnancy complications: normal
apart she feels tense in tummy and discomfort. Baby kicking (+). 
No fever, no skin rash, jt pain, no exposure to animal poo & pee, no poo & pee p/b 
No chronic medical p/b. No taking medication except folic acid. 

Ask PEFE: No anaemia, no jaundice. Vitals: stable (normal BP). Ht and lungs: normal. Abd: soft, no
tender, no guarding & rigidity, no scar.
Examiner asked me to check pt abdomen. I forgot to wash hand & he remind me. Please make sure the
bed is completely flat (they intentionally elevate the bed upto 20'). I inspect abdomen and palpate it but
he said I want only SFH. I measured it (36 cm). Then I asked single fetus, longitudinal lie, vertex
presentation, not engaged yet. FHS (+) ?150/min. I defer VE.  
Office test: urine dipstick: he said no UTI, no Sugar, no protein (I am sure he told one by one) 
Blood sugar: NORMAL (I am sure I asked) 
I asked patient LMP: she said she forgot. 

I explained her Large for date: she asked what it is. Large the womb size compared with her pregnancy
age.  
Possible causes: wrong date, polyhydramnios, big baby, Twin baby, baby problem, fibroid, placenta
problem.  
Grade: Not scored
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Case 3 (Wrong date)

CASE 2 Feedback
Feedback 18-9-2018
wrong date
A girl with 2 months pregnant, during PE found fundus height 30cm. Others normal
Task: Hx, explain the causes of her abdominal finding, order Ix
Hx: irregular periods, didn’t confirm the pregnancy, did take folic acid, never do antenatal check
ups. Not aware of blood group. It is not a planned pregnancy, but she decided to keep the baby and
so far happy with it. Started to feel baby kicking 10 weeks ago.
No other worrying symptoms during pregnancy. No trauma, infection, bleeding etc.
Explain: most likely, wrong date
Other possibilities: fibroids, polyhydramnios (all causes for this), chorioangioma
Ix: ultrasound
All test needed for first antenatal check ups.
Score: 5 Key steps: yes/yes/yes/yes Hx: 5, Dx/D/D: 5, Ix: 5
Feedback 18-9-2018 (????????? )
You are working in a GP clinic and your next patient has come to you with 20 weeks of amenorrhoea.
She did pregnacy test at home 1 month ago and it was positive. This is her first antenatal check up so
far. For the last 6 months She has been travelling overseas with her boy friend and was out of Austrlia
this whole time. She has no other abnormality or complain about this pregnancy. On examination of this
patient the following has been revild:
BP: 130/85 mmHg
Pulse: 88/min
Temp: normal
Per abdomen: SFH: 30 cm
Fetal parts felt and FHR : detected 142
Per vaginal: there was list but everything was normal.
Your task is to
-Take history from this pt regarding the cause of her syptom ( You should take no more than 5 mins in
this task)
-Discuss the Dx and DDx with this pt with reason.
-Arrange necessary investigations.
My Approach:
I went in and there was a young lady sitting on a chair , she was so friendly and smiling all the time. I
greeted introduced myself then asked is it a planned pg? She said no. so I didn't congratulate her. Then I
asked ok but what is your view towards this pg? She smiled and said , ya I am possitive and I wanna
have this baby now. Then I smiled and appreciated her decision. Then I asked all pg related questions in
details, SADMA, 5P. All normal. asked about twins in family, big babies and infection specifically. She
wasn't immunised as well so I pointed it out. Her pap smear was 3 years ago so I talked about cervical
screening test and told that from now on you have to repeat it in every 5 years if comes back normal.
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Her period was irregular , she wasn't sure about her LMP.
Then I told it could be wrong dating as she wasn't sure abiut LMP.
As DDx I said twin pg, multiple pg, familial big baby, Polyhydramnios, Infections and explained
everything with a picture of the tummy.
As Ix I ordered all routine pg tests as it was her first visit.
FBE, Urine MCS, BSL, Urine deepstick, serology TORCH, Vericella, HIV, Hep B, A, and an
USG to find out the date and number of fetus.
AMC Feedback: Station 20: Antenatal care
Grade: Pass Global score: 4 Key steps: 1,2,3,4 yes,no,yes,yes
Assessment Domain: History: 4
Dx/DDx: 4 Choice of Investigations: 6

Case (7/3/2017)
20 weeks pregnant lady was overseas with her husband hasn’t seen anyone regarding her pregnancy so
when examined fundal height was 30 cm .. history and diagnosis and further management
I took the history asked for any symptoms she denied then asked about first pregnancy or not assisted or
not any previous heavy bleed or fibroid.
any symptom of DM any family history of big baby or birth defect and also any contact with raw meet
any SLE she denied everything so I gave her all options and said high risk pregnancy US viral serology
and sle screen the bell rang but I think I should tell about the OGTT and the other antenatal check as she
has nor seen dr before

Case (7/3/2017)
GP, 30 yr old lady, she moved to another country with her husband 2yr ago and now came back with 5
month pregnancy. She has never taken ANC before. On examination, u found that temperature- 37.2C,
fundal height-30cm, others are normal.
Task
-take history
-explain about your finding, possible diagnosis
-explain Investigation that you need to do to patient.
After reading the stem, I feel nervous a s it says possible diagnosis by taking only history. In history, she
has not taken ANC, don’t know blood group, no twin history, no USG and blood test done, no fever, no
rash, no BPV, LMP-5 months ago, Baby kick well, no known DM, also past medical and surgical
history-not relevant.
Pap smear not done and I said I will do it for you after our discussion then she said right now? I said yes.
Idon’tknow) Then, I explained that your temperature Is a little bit high( which I think) and your
pregnancy size is larger than it should be. (Until now, I don’t know what to tell about diagnosis.) Then, I
said may be due to polyhydraminion so I want to do ultrasound and check baby, liquor index & placenta,
also may be due to infection ( because I think she has low grade fever) so Blood test for infection
screening, blood sugar test to exclude DM. I also want to check your blood group. Also, may be wrong
date or twin ( which I forgot to tell her in exam). [I failed this case.
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Case 4 (Large for date early pregnancy) Feedback is good

Feedback 21-6-2018
11-weeks-old pregnant lady in her first pregnancy. She has done her first antenatal check-up, she was
supposed to do her first ultrasound tomorrow, but today had bleeding. So has come to see you. From 2
or 3 days ago she has developed sever nausea and vomiting. Take history, ask for examination findings,
and explain to her differentials.(Large for date 14 weeks, mild bleeding, no pain, no grape like
structures, DDx)
First trimester complication: Pass/ Global score: 5
I asked the role player about the severity of her bleeding, and the number of pads she had used. Also
about the presence of any pain in the lower abdomen or down below. Then asked about the regularity of
her menstruation and concerns regarding her menstruations before getting pregnant. Asked about her
relationship, (in a stable relationship and having enough support from the partner) also asked about her
contraception before pregnancy, and the history of possible previous STIs. Also checked her symptoms
of pregnancy. She had nausea and mild vomiting, but she was capable of eating small portions of meals.
And she did not mention breast soreness. In examination, I checked general appearance, and anaemia,
her vital signs BP and PR, air entry in the lungs and heart examination, then in abdominal examination,
asked for tenderness, and any mass. In vaginal examination, checked for obvious bleeding from vagina,
presence of bubbles or grape-like structures in the blood. In speculum examination checked the cervix,
cervical Os, and presence of bleeding from cervix. (cervix was closed, no bubbles, but the origin of
bleeding was from the cervical os. In bimanual examination, there was no tenderness in uterus or
adnexa, but the size of the uterus was enlarged, (more than the age of the gestation). In office test, beta
test was positive. I explained to the role player that there could be several reasons for her bleeding. One
reasons id that it is a threatened abortion or just a minor bleeding due to implantation, but the reason for
increased size of the uterus could be firstly a twin pregnancy, and secondly molar pregnancy. And also
talked about benign lesions in her uterus called fibroids. So I explained that she needed to have an
ultrasound examination to confirm the reason for the increased uterine size and bleeding. [ I think in the
stem her blood group was something like O+, so I neither thought nor talked about Anti-D injection.
Station: 15 ( Non Scored)
You are an HMO and the next pt is a 10 wks pregnant lady came with a complaint of vaginal bleeding
for 2 days. The bleeding started suddenly yesterday morning and she used 2 pads yesterday and 1 pad
today. Her all antenatal check up till now is normal. She doesn't have any tummy pain with it.
Your task is to
1. Take focused history form this pt in regard to find the cause of bleeding
2. PEFE
3. Arrange necessary investigation
4. Discuss Dx and DDx with the pt.
My Approach:
I went in and pt started crying, I told her that we are here to help, offered her tissue and water then went
back to examiner to ask about vital which were normal. Then I asked about PV examination, inspection
and speculum to make sure if there is any product of conception ( Incomplete abortion). OS was closed
and no product but bleeding present, no sign of trauma.
Then I asked about abdominal pain: Negative. Then asked Urin deepstivk, BSL .... Examiner said ketone
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present. Then I told my pt about Threatened abortion and explained the DDx as incomplete abortion,
molar pg, twin pg, UTI. Arrange an USG, FBE, UEC, urine MCS. There wasn't any Mx task so I didn't
talk about it.
AMC Feedback: Assessed but not scored

188-pregnancy induced hypertension

Sample case/ You are a GP when 31 years old mary who is 34 weeks pregnant comes for regular
antenatal check-up. During her last ANC 2 weeks ago with another GP her BP was 110/80 mm/hg but
today the BP is 150/110 rest otherwise normal.
Tasks
-History
-PEFE
-Dx and further Mx with patient
Differential diagnosis
1-preeclampsia
2-Pregnancy induced hypertension
3-chronic hypertension
4-secondary hypertension
History
1-regular visit questions questions
-How’s your pregnancy so far?
-is this your first pregnancy?
-have you had regular antenatal checkups?
-regular blood tests? Are you aware of your blood group?
-how about down screening 11-13?
-Ultrasound 18 weeks? And repeated US at 32 weeks?
-sugar test at 28 weeks?
2- Preeclampsia questions
-is there any high BP recording during any previous visits?
-any time you have leaked protein into urine?
-do you have high blood pressure before pregnancy
-any headache, blurring of vision, leg swelling?
-confusion, drowsiness, vomiting?
-tummy pain, vaginal bleeding or discharge?
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-dizziness, palpitation, chest pain?

-is your baby kicking?
3-Secondary causes
-how is your diet?
-do you exercise regularly?
-SAD
-stress at work or home
4-Support
5-Past medical history (heart or kidney diseases)

Physical examination from examiner

1-general appearance PODL
pallor, oedema, dehydration, LAP
2-Vital signs (monitor once again)
3-CVS (all)
4-quick respiratory system
5-CNS (-ve)
-hypertonia, hyperreflexia
-fundoscopy (for papilledema)
6-Abdomen examination
-uterine tenderness, contractions
-fundal height (34)
-fetal lie and presentation
-fetal heart rate (normal)
7-pelvic examination
-inspection for bleeding, discharge, vesicles, rash
-speculum for cervical OS
8-office tests
-urine dipstick for proteinuria (-ve)
-BSL
-ECG
Explain the diagnosis
-today the blood pressure that was recorded showed a bit rise so most likely you have PIH or gestational
hypertension. Which is the onset of high blood pressure after 20 weeks of pregnancy but not associated
with protein leakage into the urine and also no end organ damage.
-exact cause is unclear but could be due to hormonal changes in pregnancy.
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-if it is not well controlled it can lead to a condition called preeclampsia where there will be a sharp rise
of BP and protein leakage into urine. So a far as possible this need to be prevented.
Management
-we need to record your blood pressure in 4 hours time and if it is elevated then you have gestational
hypertension
-if you have pregnancy induced hypertension further blood tests need to be done like FBC, UCE, LFT
which will sometimes be repeated later.
-urine also need to be checked for protein creatinine ratio and urine protein need to be looked for
weekly.

-refer to high-risk pregnancy clinic to be seen by a specialist obstetrician.

-need to be out on oral anti-hypertensive (oral labetalol for example) (this is done at high risk clinic not
you)
-Ultrasound will be done now then at 2-4 weeks intervals
-CTG also for wellbeing of the baby
Warning signs
just in case any headache, blurring of vision, tummy pain, excessive swelling, baby not kicking please
report to ED ASAP.
Further management
-rest in lateral position if possible
-no added salt in your diet
-life style modification (healthy diet, regular exercise)
-our goal is to control BP and prevent preeclampsia and fit from happening and make pregnancy and
delivery safe for you and the baby.
Reading materials

Feedback (22/2/2017) FAIL

You are in GP, 34 weeks pregnant lady come to you for regular antenatal checkup, 1st antenatal visit BP
was 110/80 but now BP is 150/100 and other vitals are given which are stable. Other antenatal blood
checks and USG were normal.
Tasks - Take relevant history
- Ask PE findings from examiner
- Discuss with patient how u will manage this case
2 min thinking time
- This might be typical recall of PE or Eclampsia
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- The patient may throw fits when I ask PE from examiner

- Not to miss PE symptoms, late preg Q, BP before preg, family history and 5P in HO,
fundoscopy, CNS and urine dipstick on examination, and first aid measures if pt has fits
History
When I stepped into the room, the examiner checked my ID and introduced me the name of roleplayer.
Greeting - Hi Good morning, I am Dr Khine. I am one of the Drs in this GP. Nice to meet u Lindsay.
(RP : Yes, Dr. nice to meet you. What happened to my BP?)
Yep, let me ask you a few questions in order to know what’s going on with your BP but before we start I
d like to talk to my examiner first and I ll get back to u soon. (RP : Sure)
(I didn’t congratulate pt about her pregnancy coz it s now 34 weeks, a lot of ppl has congratulated
her and u have seen this pt before, so I think it’s a bit weird to say it. But I will surely congratulate
her if it is early trimester preg)
Examiner, considering the high BP of my patient, I d like to move her to the treatment room, put IV line
just to maintain the lumen of vessel open and attach her to BP monitor.
(Examiner nodded his head)
Then I turned to roleplayer.
Antenatal Q –
-How’s ur pregnancy going so far? (RP : It’s going fine)
-Did u do all the antenatal blood checks? (Yes) Are they normal (Yes)
-What about USG at 18 weeks? (normal)
-Sweet drink test at 28 weeks? (no problem)
-Alright, I understand that ur BP is a bit high today. How’s ur BP in previous visits? (normal)
-Did the Dr tell u that ur urine contains protein? (No)
Pre eclampsia -
At the moment, do u have any headache, vision problem, tummy pain, N, V (No) Do u have any oedema
of legs? (RP : what do u mean?) Oh, sorry, do u have any legs swelling? (No)
(This was my first station and it was a bit hard to control my nerves but things become settled and calm
starting from second station)
Late preg Q -
Do u have any bleeding from down below? Any water broke? (No) Do u feel ur baby is kicking well?
(Yes) Ok. That’s good. Urine and bowel work? (Fine)
Past HO -
Do u have high BP before u get pregnant? (No), any other significant health problems like DM, heart ds
(No)
Family HO – Any family HO of high BP during preg? (No)
5P -
Is it ur first pregnancy? (Yes), previous miscarriages (No), stable relationship (yes), pap smear (normal)
Thank you Lindsay for ur information. I ll ask my examiner for some findings and I ll get back to u
soon.
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Physical Exam
GA - Any pallor, jaundice, leg oedema (No).
VS - T - normal, BP - 150/100, PR - 100, others – normal
Fundoscopy – normal
CNS examination esp reflexes – normal
Then, I d like to focus on abdominal exam, FH - 34 weeks, Lie - longitudinal, Presentation - Cephalic,
FHS - 140/min
I d like to complete my exam by doing resp and CVS exam (Normal).
I d like to check UDS for protein, nitrates, and leucocytes (All negative)
(Actually, I was expecting at least positive urine protein or pt throwed fits while asking PE, but
there was nothing. So this is just preg induced HT)
Management
Well, Ms Lindsay, according to HO and PE findings, most likely condition u are having now is called
pregnancy induced hypertension. It means high BP during pregnancy which is caused by hormones
secreted from placenta during pregnancy.
(RP : Is it due to hormones? Yes, it is caused by hormones that raise ur BP during pregnancy)
This is not very uncommon condition. Let me reassure u that it is well manageable and u can have
normal delivery and healthy baby if we treat it properly. (RP : Yep)
So, what we have to do for now is I will refer u to the high risk pregnancy clinic and manage u with
MDT including pregnancy specialist, specially trained nurses and me as a GP.
U need to go for frequent antenatal check up as it is high risk pregnancy. We ll check ur BP in every
visit and check protein in ur urine. Specialist will do USG of ur tummy and CTG to check well being of
ur baby. Depending on ur severity, specialist will decide how frequent we need to do these tests.
In terms of delivery, it depends on ur condition, baby’s condition and the severity of ur high BP.
Specialist will decide it. It can be normal delivery or CS.
I will review you regularly. I ll give u reading materials to make u understand better ur condition. I am
gonna write down the referral letter for u to see specialist. And in the mean time, I want u to be aware of
some red flags features. (RP : what do u mean?) (seems like she doesn’t understand the word red
flags)
Ok, I ll let u know about some important symptoms that u need to be aware of. If u have any severe
headache, blurring of vision, leg swelling, bleeding from down below, u feel that baby is not kicking
well, just come back to see me or u can go straight forward to ED asap.
The bell rang. I thanked to roleplayer and examiner and came out of the room.
(What I should have done - Specialist will start u on medication to lower down ur BP)
AMC Feedback - Antenatal Care : Fail (Global Score - 3)
History - 6
Examination - 5
Diagnosis - 6
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Choice of Invx - 3
Management - 1

Feedback 8-11-2018 (IMPORTANT)

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291

189-Gestational hypertension headache

Check lecture 52 and 188 for similar approach

Feedback 23-6-2018
Feedback: Antenatal care: pregnant 30 weeks, with headache. Take Hx, PEFE, DDX, management.
Approach: vital signs? BP: 150/90. Any pains? Pain killers?
Hx:
Headache nature? 􀈋nature, score, where, radiation, increasing and decreasing factors,…􀈌?
Pre-eclampsia possiblity: visual disturbance, shaking, vomitting, tummy pain, urine change, seizure, legs
edema.
Pregnancy history: tests, ultrasounds, GSL.
6Ps and medicine 􀈋previous HT: NO􀈌, surgery,…
PEFE:
Vital signs?
Fundoscopy?: normal
CVS and chest: normal
Obstetric examination: fundal height (30cm), cephalic, vertical, no pain, fetal heart positive.
Relfexes: normal
Urine test: normal
Dx: Gestational HTN
Management: refer to high risk clinic, MDT to control your HT and OB specilaist will make a delivery
plan for you in controlled manner, do swab at 36 weeks.
Red flags: seizure, visual disturbance, tummy pain, water break, bleeding  Hospital.
Grade: PASS, GS: 5
Key steps 1,2,3,4: Y (all covered)
Hx:5, PEFE: 5, Dx: 5, Management: 5.

190-Concealed placental abruption

You are an HMO at the ED of a major hospital, when 25 year old Maria who is 32 weeks pregnant,
presents to you with severe abdominal pain since the last 2 hours.
292

TASKS
-Relevant history
-PE from examiner
-Diagnosis and management
AMC Case 21-2-2018
A young pregnant lady in her 32 weeks gestation presented to the ED with abdominal pain
tasks
-history
-PEFE
-diagnosis and management
 Differential Diagnosis
1-Preterm labour.
2-Abruptio placentae.
3-preeclampsia
4-Trauma
5-Torsion of ovarian cyst
6-Medical causes: UTI, appendicitis, cholecystitis, pancreatitis 
History
1-pain questions
when you will enter the room the patient will be crying and rolling because of pain
-is my patient hemodynamically stable?
-I read from the notes that you are having tummy pain. Can you score the pain from 1 to 10, 10 being the
worst pain? (7/10) I will give you some painkillers, do you have any allergies?
-when did it start? Is it sudden or gradual? (for few hours )
-Where is the site of pain? (All over the tummy)
-Is the pain going somewhere else?
-Does anything make it better or worse?
-has this happened before?
2-late pregnancy complications/ DDX questions
Preterm labour/ PROM
-do you think that the pain is coming intermittently or is it a continuous pain? (Constant)
-Has the pain been coming at regular intervals or not? (if not constant ask)
-any Fluid leakage?
Placenta abruption
-Any bleeding from down below? (no)
Pre-eclampsia:
any headache, blurring of vision, dizziness, oedema? (no)
Trauma:
-any hit or falls prior to the abdominal pain? (No)
Acute abdomen (UTI/appendicitis/cholecystitis/pancreatitis): (normal)
-how are your waterworks? Any burning or stinging during urination? Any smelly urine?
293

-How are your bowels? Do you open your bowels regularly?

-Any fever or vomiting?
Baby kick
-Do you feel your baby kicking? How long have you noticed that your baby is not kicking? (Not able to
feel baby movements)
Recurrent visits questions
-Did you do your antenatal checks, blood tests and blood group?
-Have you done your down syndrome screening?
-Ultrasound at 18 weeks? What is the position of the placenta?
-Sweet drink test at 28 weeks?
-Did you take your folic acid?
4-General
-Any bleeding disorders?
-Any medications taken?
-Any past history of medical or surgical illness?
-Any smoking, alcohol or recreational drugs?
-Do you have a good support?
 
Physical Exam
1-GA
2-Vitals (postural drop present)
-Put in 2 large bore IV cannula, and take blood for examinations (FBE, UEC, Blood group,
crossmatching, coagulation profile, BSL)
-Give IV fluid.
4-Abdomen
-Look for uterine tenderness, rigidity and guarding, Feel for uterine contractions (generalised tenderness,
uterus -/ contracted or rigid on palpation)
-Fundal height: 36 cm (blood is collecting inside)
-FHR: not heard
-Lie and presentation: hard to feel the lie and presentation
5-Pelvic examination (normal).
-Inspection of the vulva and vagina: bleeding, discharge, rash, vesicles
-Speculum: bleeding from the cervix, if the cervix is closed or not
-DON'T DO PER VAGINAL EXAM, because the patient is in shock
6-Office tests:
UDT, BSL

 Management
-From the history and examination, most likely you are having a condition called a severe, concealed
abruptio placentae.
-The placenta is the part that connects you to your baby, and which carries oxygen and food from you to
294

your baby. This placenta usually separates from the uterus after the delivery of the baby. But if the
placenta separates from the womb, during pregnancy, it is called abruptio placentae, which could be
revealed or concealed depending on whether the bleeding is coming out or not. In your case, it is the
concealed kind, the blood is collecting inside.
Breaking bad news:
-Unfortunately, the next news that I have for you is not very good.
-Do you want somebody to be with you while I discuss this with you? I can call your partner so that he
can be with you during this time.
-As you said, you have not been feeling the baby kick since this morning. And during my examination
as well, I could not hear the baby's heartbeat.
There is a probability that something nasty might have happened to the baby. But we need to confirm
this by doing an ultrasound to look at the condition.
-You will be admitted and seen by the specialist and the specialist might decide to do a C-section, as the
blood that has clotted inside needs to be evacuated or removed. Along with the placenta and the baby,
the leaking blood vessels needs to be seen.
-Once the emergency management is over, we can offer you and your partner counselling services as
well.
-I know this is a difficult time for you as you are hoping for this baby, but we are here to help you.

Feedback 21-2-2018
CASE 5: OG- IUD WITH CONCEALED ABRUPTION –PASS
young pregnant lady with tummy pain .tasks history, PEFE, management
while entering the room ,patient was lying in bed and crying and rolling with pain.asked pain scale,
offered painkiller, all pain questions, throughout the station she was crying with pain.
Pain all over the tummy, acute, no bleeding or discharge from vagina; not able to feel baby movements,
no bladder or bowel problem, no trauma immediately I arranged for doppler to check fetal heart rate,all
antenatal history normal so far.
Pefe; vitals postural drop present , told examiner that I secure cannula and start fluids.
Abd exn- generalised tenderness, uterus -/ contracted or rigid on palpation, absent fetal heart rate, pelvic
exn normal
Explained patient IUD due to ? Bleed – Placenta separated before labour. Offered support , asked for
partner, etc
arrange blood investigations, blood group and hold, specialist might arrange immediate surgery with
stable vitals.

Feedback placenta abruption

Abdominal Pain (FAIL)
You’re HMO in ED, 27 years old lady with 32 weeks pregnany comes with severe abdominal pain
which started this morning. This is her 3rd pregnancy.
Tasks :
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History
Ask PEFE
Dx with reasons.
Approach :
I greeted the patient. Offered her pain killer as patient seems very painful. Then I checked vital signs and
examiner said BP 90/50 mmHg, PR 100/min. When I told that I would like to do resuscitation, examiner
said no management needed.
History :
Asked about pain questions. This is the 1st time, the pain is very severe and she felt it all over the
tummy. No radiation. Nothing makes it better or worse.
Then asked DDx - Does not look like contraction. No bleeding or watery discharge from down below.
No history of injury. No fever, nausea, vomiting. No problem with poo and pee. No history of fibroid.
Then I asked about ANC which is unremarkable. I forgot to ask about fetal kicking. Past Obstetric H/o -
she delivered both babies normally and they’re fine. Everything was unremarkable. PMH and PSH –
PMH is unremarkable but she had laproscopic appendicectomy when she was young. Social h/o –
unremarkable.
PE :
GA – patient is in pain
VS – the same
EYES – slight pallor +, no jaundice
CVS, RESP – normal
ABDOMEN - Inspection - laproscopic scars in RIF.
OBSTETRIC exam - FH is 36 cm. The abdomen is tense & tender. Cannot feel the fetal parts well. FHS
cannot be heard.
VE – no bleeding or discharge. Bishop score – unfavourable.
BST – UDS shows protein 3 or 4 +
Reflexes – intact.
Dx : Abruptio placenta with IUFD ( i was explaining the condition to patient by drawing a pic that her
womb size was larger and which is tense and tender….then the bell rang. I need to rush & tell her that
it’s due to abruptio placenta and your baby might be probably dead. Then I came out. )

191-Preeclampsia Tummy pain

For more information about similar approach check lectures 50, 52, 190

Feedback 22-6-2018
8. In the GP 36w pregnant, came for check up as she was having cramp like upper tummy pain. Stem
296

refers that in previous control BP:125/80, and slight swelling of ankles, rest of control normal.
Task
Hx
PEFE
Dx
Initial management
Approach
Greeted the patient
Asked the score of the pain she said 5
I asked if she needs any pain killer she said no
I said before I proceed I would like to asses your vitals
Examnier said BP-180/100 and rest were normal.. I also asked hydration status he said normal so I said I
would like to shift pt to treatment room and start on labetalol and put on cardiac monitors
Then went back to pt.. asked open ended question.
Then said will ask sensitive question and asked about bleeding from down below, can she feel the baby
kick, headache (positive), leg swelling that is not going away (positive)
DD qs
Eclampsia
Cholecystitis
UTI
Gastroenteritis
Asked about antenatal checkups
Period
Obstetric hx
Pap’s
Any hx of STI
Blood group.
Past medical hx of high blood pressure, any kidney or heart disease
PEFE
GA
Edema
Icterus
Hydration
BMI
Vitals
Nervous system
Fundoscopy
Reflex
Abdomen
Inspection
Palpation
SFH
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Lie
Presentation
FHS
Pelvic-I think examiner said not done ( can’t seem to remember)
Office test—Urine dipstick positive for proteinuria
Dx- Pre-eclampsia—drew picture said some chemicals released from placenta (part connects you to the
baby) sometimes causes a sharp rise in blood pressure with protein in urine.
Initial Management
Shift to hospital
Call ambulance ask any help needed she said to inform partner
Talk to obstetric registrar
In the hospital they will admit you, OBG registrar will see you, start you on IV Hydralazine for blood
pressure control, Start Mgso4 to prevent complication like eclampsia and will do USG and CTG to
monitor baby’s condition.
Asked any question whether she understands
She said she understands
So I said the main management is delivery of the baby as she is 36 weeks the obstetrician might proceed
with it. But it depends on how she is responding to treatment, how baby condition is ( bell rang)
I thanked the patient and examiner and left

209-Uterovaginal prolapse (Materials)

56 year old Maya comes to your GP complaining of a feeling of something bulging from down below.
She appears really concerned about this.
 TASKS
1. Focused relevant history
2. Examination findings from examiner
3. Management
 
History
1-Prolapse questions + incontinence
-How long have you been having this? (Last 1 year)
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-Is it there always, or just at times? (Assess degree of prolapse. If it is always there, it is 3rd degree) (it is
just there at times)
-When do you have the feeling of the bulge? (When she stands for a long time)
-What relieves you of the feeling? (When she lies down, she can feel the bulge going inside) (Probable
2nd degree prolapse)
-Associated symptoms: bleeding, discharge, itching, rash? (Prolapse can get infected)
-any involuntary leakage of urine? (Incontinence)
2-past medical history
Chronic cough:
-any chronic cough?
Constipation
-how is your bowel motions?
-Any history of constipation? Do you open your bowels regularly?
UTI
ask about waterworks as well (can be associated with a cystocele or urethrocele, can have urinary
retention)
-any problems with passing urine?
-Is there any burning or stinging during urination?
3-Past surgical history (hysterectomy)
4-past obstetrical history:
-have you been pregnant before? how many pregnancies have you had? (3 pregnancies and 3 deliveries),

-any complications during the pregnancy?

-Were all your deliveries vaginal? Any C-sections?
-Any history of big babies? Any obstructed labor? Any prolonged labor?
-Any tears or lacerations that you had at the time of delivery?
-Any instrumental deliveries?
5-Past gynaecological history (Menopause)
-period history: have you had your menopause?
-Any menopausal symptoms like hot flashes, heavy sweating, mood changes?
-are you on any hormones or HRT?
-Any bleed after menopause?
-When was your last pap smear and mammogram? What was the result?

6-Social
-Sexual history: are you sexually active? Are you in a stable relationship? Any problems with
intercourse? Any bleed after intercourse?
-Do you smoke? How long have you been smoking? How many sticks per day?
-Alcohol drinking?
-medications and allergies

Physical Examination
1-General appearance: BMI (35, obese - can lead to weakness of the muscles), pallor
2-Vital signs
3-Systemic exam
Respiratory system (chronic cough is a cause) : air entry, adventitious sounds
CVS: normal S1 and S2, murmurs
Abdomen
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Visible mass, distention?

Palpate for mass and tenderness (abdomen is soft and non-tender)
4-Pelvic exam
Inspection of the vulva and vagina:
-any discharge/bleed? Any prolapse? Any thin, dry atrophic vagina?
Speculum exam:
-is it healthy? Any discharge or bleed?
-Key point: ask the patient to cough or bear down
-Ask if there is a prolapse (cervix is coming up to the level of the introitus)
-Identify the degree of prolapse
+First degree: remains inside the vagina
+Second degree: cervix comes at or near the introitus
+Third degree: most of the uterus and cervix lie outside the vagina
-Ask for any incontinence that you can see (pelvic floor muscle weakness can result into a prolapse or
incontinence)
*always rule out incontinence in prolapse, always rule out prolapse in incontinence
Bimanual exam
-Uterine size (size is normal), tenderness
-Adnexal mass or tenderness
5-Office test: UDT, BSL

Management
-The condition you are having is a uterovaginal prolapse. It is a common condition where the cervix or
the uterus or both bulge into the vagina. For you it is a second degree prolapse as it is not coming
outside the vagina.
-The cause of a uterovaginal prolapse, is due to the weakness of the pelvic floor muscles and
ligaments, that support the pelvic structures like the uterus and the cervix.
There could be a lot of reasons for pelvic muscle floor weakness, like chronic cough, constipation, but as
far as your case goes, I can see that you are having a bad obstetric history. So at the time of pregnancies,
due to the extra weight gain, and the hormonal changes, these muscles can become weak, and at the time
of labor, when you push or strain, these muscles become more weak. One of the deliveries that you had
is a big baby, that is why you had a prolonged labor due to that, and that might have contributed to your
prolapse.
 
-Why didn't I had it then? Why am I presenting with the prolapse now? The contributing factors for
prolapse, is menopause and the extra weight gain. At the time of menopause, as the ovaries shut down,
estrogen is formed in very low levels. And this estrogen is necessary, to maintain the strength, and
the stability of the pelvic floor muscles.
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-You need to be referred to a specialist.

-Start with lifestyle modifications. Your BMI is a bit concerning, so I would like to refer you to a
dietician who could give proper advice regarding your diet.
You need to have regular exercise, and maintain the BMI within the ideal range.

-You need to also do pelvic muscle exercises. I can refer you to a physiotherapist who could advise
you about this.
How do you do the exercise? You can do the exercise in a sitting, standing or lying down position.
Contract your bottom muscles, for a count of 8, relax it for the same amount of time that you have
contracted the muscles, or count of 8 also, and do it 8 times at a go, three times a day.
How long does the pelvic exercise take to work? Usually it takes around 3-6 months.
 
-Another option is a vaginal pessary, a device inserted into vagina. It will help to keep the prolapse in
place and prevent it from getting worse. But it is not a definitive treatment of prolapse. You need to
change it every 3-4 months.

-Surgical management/option is considered if the conservative management fails and if the symptoms
becomes worse. One is repair procedure and it is of two types. One is called colporrhaphy where you
reinforce the pelvic floor muscles by using stitches. Another type is you put in a synthetic graft thereby
strengthening the pelvic floor muscles.
The next procedure is a sacrocolpopexy. This is where you re-suspend the vagina, cervix and other
pelvic organs and secure it to the back bone or the sacrum.
The last option is a total hysterectomy.
 

***Another case is the patient has undergone hysterectomy and has prolapse: vaginal vault prolapse.
AMC EXAM CASE
Causes of vaginal vault prolapse:
Weakening of the suspension: due to extra weight gain, chronic cough, constipation
Management:
Referral to the specialist, lifestyle modifications (usually BMI will be high), Pelvic floor exercises,
vaginal pessary (but not a definitive treatment),
Surgery: sacrocolpopexy - resuspend the vagina and secure that to the sacrum

Management in summary
1-refer to gynaecologist for pessaries or surgery
2-lifestyle modifications (dietician, SNAP, physical exercise)

Karin case Uterine Prolapse

Case: An a 80-year-old lady comes to your GP clinic complaining of mass protruding down below and
rash around the private area for several months.
Task
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a. Relevant history
b. Physical examination (BMI 29, maculopapular rash around introitus and inside of thigh, urine dipstick
+ sugar, BSL 11.3mmol/L
c. Diagnosis and management
History
- I read from your notes that you have something bulging from your private area. Since when? Can you
tell how it happened? Is it increasing?
- Do you feel any abdominal discomfort?
- What is the effect of this bulging on your life?
- Is this swelling affecting your waterworks? Do you leak urine while you strain, cough, etc? Do you
have a strong urge to void on the way to the toilet or do you leak a large amount of urine on the way to
the toilet?
- Any discharge down below?
- Constipation? Waterworks?
- - Rash? Since when? Is it itchy? Can you describe the rash for me?
- Period: When was your last period? Any irregular bleeding after that? Hot flushes? Mood swings?
Breast pain? Irritable?
- Pregnancy: how many pregnancies? Were they big babies? Did you have any difficult labor or
prolonged labor?
- Partner: are you sexually active? Do you have a stable partner? Do you have painful intercourse? Have
you or your partner ever been diagnosed with STDs?
- Pap smear: When was your last pap smear? Result?
- Mammography?
- Past medical history: chronic cough, diabetes, asthma
- FHx: Osteoporosis, MI
- SADMA
Physical Examination
- General appearance
- Vital signs
- Abdomen
- Pelvic examination:
o Inspection for morphology of the rash (maculopapular rash around the introitus and groin area),
scratch marks, discharge, obvious bulge
o Speculum: wall of vagina, rash, discharge, blood, ask patient to cough (cervix comes up to the
introitus), leakage of urine, cervix
o PV: adnexal masses, CMT.
- PR: differentiate between cystocele and rectocele
- BSL and Urine dipstick
Diagnosis and Management
- You have a condition called uterovaginal prolapse with stress incontinence and candidiasis,
- Menopause resulting to lack of estrogen, difficult labor, big babies and constipation leads to the laxity
of the pelvic floor ligaments. It is a common condition among females in your age group.
- At this stage, I would like to refer you to the gynecologist. I would advise you to start with pelvic floor
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exercises (contract pelvic floor muscles as if trying to hold urine).

- The specialist might insert a pessary which is a device inserted into the vagina to support the uterus.
They need to be changed every 3-6 months. They also advise topical estrogen to improve the discomfort.
- Will it affect intercourse? Pessaries will not interfere with your sexual performance.
- If conservative measures do not work, the specialist might consider doing surgery to fix the ligaments.
- How long will I be in the hospital? Usually 3-5 days. You can go home once you’re feeling well and
once you have started urinating without problems.
- Postop advice: For the first two weeks, restrict your activities. Rest. Avoid heavy lifting. Avoid sports
and swimming. For 1st 6 weeks abstain from sexual intercourse.
- Driving: It is not advisable to drive for the first 2 weeks.
- Complications: Pain, bleeding, injury to nearby structures, anesthesia complications
- For the candida, I will prescribe you antifungals. It might be related to high blood sugar. I will give
you referral to physician to investigate further
- Lifestyle modification: normal BMI, stop smoking, high-fiber diet
- Referral to specialist obstetrician. Reading material. Review.
- Advise OGTT.
Prolapse:
- I: cervix remains within vagina
- II: cervix comes up to introitus
- III: most of uterus lie outside vagina
Karin case Post-hysterectomy Prolapse
Case: You are a GP and a 52-year-old female comes to your clinic complaining of something coming
out from her vagina especially after straining
Task
a. History
b. Physical examination
c. Management
History
- Please tell me more about your problem? Since when have you noticed this lump? Is it present all the
time or does it come and go? Any changes with change in position like prolonged standing or lying
down?
- Do you have associated tummy pain or heavy/dragging kind of sensation in the lower tummy?

- Any urinary complaints like frequency, burning or leaking of urine? Any loin pain?
- Any history of prolonged cough, constipation, asthma or respiratory problems?
- Do you have any problems emptying the bowels?
- Any complaints of discharge or bleeding from down below?
- Any fever? Itching?
- When was your LMP? Any problems during or after menopause?
- When did you have the hysterectomy? Why did you have it? Any complications afterwards?
- Was it done at a tertiary care center? After the surgery, did you do pelvic floor exercises? Any other
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surgeries that I should be aware of? Did you take any HRT afterwards?
- May I know are you sexually active at the moment? Any complaints of pain or discomfort during sex?
How many kids have you had? Any history of big babies? Difficult or instrumental deliveries?
- SADMA?
- Have you recently noticed weight loss? Change in appetite? Night sweats? Lumps and bumps in the
body? Pap smear? Mammogram?
Physical examination
- General appearance
- Vital signs
- Chest and Lungs
- Abdomen: for tenderness
- Pelvic exam
o inspection: Obvious lump, discharge, ulcer, redness, discharge
o Sterile speculum examination asking the patient to strain looking for any visible lump while straining;
sims left lateral position (knee-chest position)  gradually withdraw while asking a patient to strain 
lump/bulge in the vagina (best way to detect cystocele and rectocele)
- Urine dipstick and BSL
Diagnosis and Management
- Most likely what you have is prolapse of the vaginal wall after hysterectomy. Once the uterus is
removed, the upper part of the vagina loses its anatomical support. Usually, during hysterectomy, the
surgeon will secure the upper part of vagina with the help of ligaments attached to the backbone and
pelvic wall. Some of these ligaments become loose because of: a. loss of estrogen b. prolonged
straining/coughing c. putting on weight.
- This phenomenon is quite common after hysterectomy. Up to 30% of patients might develop this. It
can affect the urinary system leading to frequent recurrent UTIs. It can also affect the wall of the bowel
causing constipation. Sexual functioning may be affected and might cause pain and discomfort during
intercourse.
- The treatment will be tailored according to your wishes, but you will need to see a specialist
gynecologist. The first option is conservative management which includes pessaries along with pelvic
floor exercises. Usually, this suitable for old, females who are not fit for surgeries.
- The second option is the surgical approach. It is called vaginal wall suspension surgery
(sacrocolpopexy). The surgeon will attach the upper part of the vagina to the strong tissues within the
pelvis usually to the lower backbone or sacrum. There are 2 options regarding the approach:
laparoscopic or keyhole surgery OR abdominal approach best decided by the surgeon.
- The recurrence rate after the surgery is very low therefore the surgery is mostly curative.
- Review. Reading material.
- Pelvic floor exercise (kegel): done to strengthen the muscles of the pelvic floor. The exercise can be
done either sitting or lying down. The patient needs to empty the bladder before exercise. Contract the
pelvic muscles, hold contraction for at least 5 seconds, release it slowly and repeat 3-4x and gradually
build up duration for up to 10 seconds. She must not contract the abdominal, thigh or buttock muscles.
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Exercises must be repeated 3x a day as many times as possible. Results are usually apparent within 8-10
weeks. Safe to be done during pregnancy.
Case (28/4/2017)
Lump
Post menopausal with lump.examination n tell pt diagnosis.
on history
- lump in private part.
- no other menopausal symptoms.
- no hrt.no incontinence or constipation cough etc.
- on asking tells about hysterectomy few months ago.
- obs history not significant.
Examiner was standing beside me while doing per speculum on dummy.
On cough impulse patient pretends to cough.
After asking examiner tells no cervix.asked vault healthy? Lump is vault prolapse.
Finished examination with per vaginal biannual.explained patient diagnosis.advised ammo,pay.examiner
told management is not the task
Passed
Case (28/4/2017)
52 yr old woman with lump( didnt say where) .
task history, PEFE, DDx. On history she got vaginal lump and did hysterectomy 10 yrs ago. On
examination Vault prolapse.
Case (30/5/2017)
Uterovaginal prolapse with candida plus cyctocele and rectocele and having hight bsl obese (but she was
very thin RP)
hx ,pefe, tell possible dx , i think there was inx as well from the examiner.
- So she had mass down bellow which go up when she lay down and more when she cough or sneeze.,
- she had no drippling or constipation.
- no hx of chronic cough,
- meanopasue lady.
- not on HrT
- she had 2 pregnancies i asked size of baby was big 4.5 with NVD no instrumenal
- i ask about wtt loss or lumps or bumps non.
- no VB no discharge
not DM and she dont know if she had when i asked her specifically so i said i will adress this later.
- Having no medical condition
About the rash only itchy for long time didnt take anything and she didnt use any new things have no
allergy as well i asked if u have rash else where as well she said no she describe it as redness itchy only,
i think she wsnt smoker or alcoholic
Pe:
well looking normal
Vs
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BMI 37.
i asked abdominal wss normal.
then pelvic i asked i would like to do sims speculum in lt lateral so he gave me ut and vaginal wall come
all way out and normal looking cervix so i said it is grade 3 then ask about ant and post wall and was
postive for both.
- then i did urin dipstic was normal , she had high blood sugar level i asked mcu which wss normal as
well dont remember if i asked more than this.
I explain by saying u have all these things and we have to address each thing and u r in safe hand
*57 yo woman with vaginal lump feeling. Hx, PE, DDx, management.

Recall of 9-5-2018
Lump in vagina. Hx, pefe, explain ( hyresctomy 10 yrs ago, 3 vaginal births). ??Vaginal vault prolapse
Recall of 6-6-2018
Prolapse with Rash in groin, Blood test result given- DM, stem lump coming out of vagina. Rash in
groin area. On PEFE, ant and post wall Vaginal Prolapse.
Recall of 12-7-2018
Vaginal vault prolapse, no signs of incontinence Hx, PEFE, Causes DDx 
Recall of 15-8-2018
vaginal prolapse case
Feedback (vaginal vault prolapse) Important
A woman in her 50s (I cannot remember the exact age), comes to ur GP complaining of a lump going
down on and off mainly with sneezing and straining.
Task:
Hx,
ask examiner for examination findings
management.
History
-I do understand that u have been complaining of a lump from the down below? Could u please tell me
more about it? I have this lump on and off for months now but it is getting worse now.
-Is it there only when straining? Yes
-does it disappear by itself? Yes
Here the role player said “I had my womb removed 13 years ago”. Actually she surprised me when
she said that coz I was almost sure it is uterine prolapse. So I continued my history taking...
-Can I ask why u had ur womb removed? Coz of heavy bleeding.
-Any complication after the operation? No, everything was normal until months ago when I had this
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lump.
-Any problem with passing water? No, completely fine.
-Any bleeding? Discharge? No
-Can I ask some personal questions?Yes,please
-r u sexually active? Yes, I am married
-does this lump affecting ur sexual activity? Yes, it makes me feel uncomfortable.
-Any bleeding after sex? No
-Have u had any HRT before? No
-What about ur pap and mammogram? Done regularly and normal
-How is ur health in general? Fineany wt loss or loss of appetite? No
-do u have any cough? Constipation? No
- Do u have children? Yes 2(or three)
-What about the deliveries? All NVD and without any difficulties.
-Do u smoke? No
-Alcohol? Socially
-Some people used recreational drugs, have u ever used them? No
-Any chronic illnesses? No
-Any medication? Allergies? No
Examination
-General appearance? Normal
-BMI? 28
-Vitals? Normal
-Chest and heart? Normal
-Abdomen? Starting by inspection? Normal......Palpation, any masses, tenderness? No
-Vaginal examination after patient’s permission, starting by inspection, any lump? No...
-then by speculum examination, any discharge? No
-Then I would like to ask the pt to strain, any lump? Yes, the vagina comes down...
-Then I would like to use Sim’s speculum in left lateral position and ask the patient to strain again to
look for cystocele or rectocele? Normal
-Urine dipstick and BSL? Normal
Management
-Mrs x, from what u have told me and after examining u, it seems that u have vaginal wall prolapse
(Actually the right thing to say is “Vaginal vaultprolapse” and I knew that but it just did not come out so
I just said wall prolapse.
Also I drew to the patient and explain the condition but please read more about it as I have no enough
information and I am not sure if what I said is correct or not Coz u had ur womb removed, this can
leave the vagina unsupported and with age the ligaments become weak.
This is not serious but with time it can get worse and might lead to ulceration. We have conservative
treatment and surgical....so what treatment do u prefer?(The pt. says she wants to find a final solution to
the problem so I said:)so we need to refer u to a gynaecologist who will do further assessment and
most likely will decide an operation. but life style modification is also important and u need to lose wt,
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walking for 30 mins every day, healthy diet( I am not sure if we need to talk about pelvic floor
exercise ,actually I did not have time as the bell rang!!)
AMC feedback –Vault prolapse after hysterectomy (O&G) -- PASSED

Feedback 15-8-2018
Scenario :Lump
Stem: Old aged female came with a “ lump”. It was not mentioned where. ( I thought could be breast or
vaginal)
Tasks:
~History
~pefe
~dx and ddx
Inside the room was an old aged female sitting on chair.
Greeted her and asked her to tell me more.She told about the lump down there.
Lump history:
since when, how started? Getting better worse etc .She said its been few months and it comes and
goes but getting worse with time and feels on strain cough sneeze.
Detailed 5ps 1. Pregnancies: how many kids, last pregnancy, baby sizes, prolonged labour , any
instrument? 2. Pills 3. Partner.:She was not sexually active as far as I remember 4. Periods: She had her
periods stopped few years ago. 5. Pap: don’t remember what she said.
Detailed 4bs 1. Bladder: any leakage? (no)uti (no) 2. Bowel (normal) 3. Breast ( normal) 4. Bone pain
(no)
Then asked about any menopausal symptoms.
Any hx of cough, constipation?
Any surgery.she said yes its been few years my womb has been removed.just a quick history why was
it removed? Any complication? How have u been since apart from this lump any other complain related
to that?
SADMA.
PEFE
Asked in the usual form starting from GA, I remember all was normal then came on pelvic
exam( consent and chaperone)
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Inspection: blood, discharge, rash, vesicle , lump (no)

Speculum: cervical health ( normal) vaginal wall thinning, atrophy( no) . on bearing down, do I see
any lump. Examiner said yes. Any urine leakage (no)
Bimanual: dnt remember what examiner said.
Pr: any lump( wanted to ask abt rectocele) but he said no.
Ud and bsl : he told normal .
Gave dx of vaginal vault prolapse after hysterectomy and explained the condition. gave ddx of rectocele,
cystocele, any growth like cancer ( didn’t know much of ddx here)

No management was asked.

Grade: Pass

Feedback 9-5-2018
Lump in vagina. Hx, pefe, explain ( hyresctomy 10 yrs ago, 3 vaginal births). ??Vaginal vault
prolapse-
OUT side- this is the crazy case, when i out side the room, i understand the word" lumb" only then i
assum it is the breast lumb cases as they did not mention where is the lumb. All my dd turn in to
breast cancer, fibroadenoma....I think i got crazy in this case as the word:' lumb'( this is language barrier)
Inside: the lady sat on the chair then i ask her about the symptoms, after asking a few questions, i figure
out that she got some thing protrude down below.
then i delete all my dd outside the room in my mind and try to find out what is this things.
She is the women so i after asking about presenting complain, I ask about 5P. Then i asked about nasty
growth question, risk factor, combination like menopause, surgery, delivery baby, how big of baby,
consipatient..I though she is really old so I ask about 4B- bone, breast as well. Then i ask examinor
about the PE for prolapse organ.
i told her dd- most likely it is vaginal prolapse , other can be cystocele, rectalcele, nasty growth... i
told her why she got this- menopause, delivery a lot of baby and surgery . i told her about the refer
specialist the exminer stop me and say that there is no management. i draw the picture and tell her all
the thing a gain. Bell rang.

Feedback 6-6-2018
Station 20 UVP, newly dx DM with candidiasis- unscored
? 57 /67 yrs old lady, new patient to your GP, presented with lump and rash( did not mention the site in
the scenario, so I was thinking about infection and haemato differentials)
task:
history,
PEFE card,
explain causes of each of her complaints.
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history: site of lump , from her vagina ( so I realize at that time it is UVP or vaginal prolapse case)
coming out on walking or standing, no pain, no rash and ulceration on it, dragging sensation present, no
urinary and bowel symptoms. Causes…3 children, vaginal deliveries, first child need forceps, no
pelvic floor ex, no chronic cough, no constipation, BMI, (forget to ask abt other postmenopausal
symptoms) 5Ps not all.
rash… groin and down below, itchiness, ulcer, bleeding? Not on other area of body
no fever, no lump and bump, LOA,LOW nil. (I have no idea at that time why she has the rash)
No known chronic illness. No previous gyane sx. Smoking , alcohol?
Pefe card: UVP , rash in groin and vulva, RBG 18
Explain: 2 pblms, explain about UVP with diagram and causes of it.
Another thing, you might have DM because RBG is high, (not sure I asked her about DM symptoms at
that time) also the rash could be candidiasis which is strongly associated with DM . will do further tests
to confirm DM. don’t worry they are manageable conditions.
Feedback 9-5-2018 Fail
Vaginal prolapse.
47 year old or older woman comes to see you because a mass (didn’t say where) so during my 2 minutes
outside I was thinking about an enlargement of a lymph node.
Task
Take history
PE from examiner
Diagnosis and differentials with reasons to the patient.
Nice lady. When asked why she was coming, she said she has a mass coming from her vagina so took
me for surprise because didn´t say that on the stem outside, any way I think I managed this case well.
History of 3 normal pregnancies, no pain, no fever, no any urinary symptoms I think she said a bit of dry
vagina. Medical history of hysterectomy I don’t remember if I asked why? Last pap was normal. No any
other relevant medical history. PE normal vital signs, didn´t ask BMI, abdomen normal, genital
examination: a mass from anterior wall coming through vagina.
I explained about vaginal prolapse and my differentials where all about prolapses, could be your bladder
or just the wall of the vagina, no your womb because you don’t have it. Didn´t have time for more.
Failed
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218-Primary PPH telephone case

sample case
HMO in obstetric department of major hospital. On call. Asked to see a 29 years old Lisa who had just
delivered a baby boy (3.5 kg) 15 minutes back. Baby is alive and healthy. This is her 3rd delivery.
Informed by nurse over the phone that after delivery the cord has already snapped and patient having
sever bleeding.
Tasks
-talk to nurse over the phone
-advice about immediate management
AMC exam case
you are HMO in a rural hospital in duty for O&G ward. Nurse us calling you .A lady has delivered
recently and now is bleeding. From your room to ward take 5 min. before going there you want to order
what is needed.
your tasks:
* listen to her explanation and take history not more than 4 min.
* give advice and What she need do before you go
Approach
pick up the phone
-I am doctor---- the doctor on call today please May I know whom I talking to?
-which patient I will be dealing with?
-I can see that she is bleeding now so can you tell me the general appearance of the patient? (Pale,
anxious, sweaty)
-and what is the vital signs of the patient? (BP: 85/50, PR=120)
-I would like you to go ahead with DRABC protocol
*1st call for help
*put her on O2 mask 6-8 L/ min
*secure 2 IV large bore IV cannula
*take blood for all Ix  FBC, UCE, BSL, blood group and cross matching and coagulation profile.
*start infusing her Normal saline 20 ml/kg bolus till the BP becomes normal then put her on continuous
infusion.
*reassess her VS again after doing this.
 History: (all findings suggest uterine atony) (just exam case)
-just want to ask you few questions about her condition?
-can you tell me more about the bleeding? how much? Colour? Any tissues or clots? Is it smelly? (1250
cc bleed)
-what was the mode of delivery? (Normal vaginal)
-any problem during delivery? was it prolonged? (had difficult delivery last 14 hours)
-what was the baby’s weight? Single or multiple? (4.2 kg, single)
-has the placenta delivered completely? (yes)
-any episiotomy done? Is it healthy?
-any complications during pregnancy?
-is she nulli or multiparous?
-PMH, PSH?
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Advice and what she needs to do

-if you could perform abdominal examination for me?
*look if uterus is contracted or not (laxed in atony)
*if any uterine tenderness (No)
*if you could palpate the bladder
-ask the nurse to massage the uterine fundus
-start her on IV oxytocin 5-10 International unit IV as a bolus and then continuous infusion 40 IU/ hr.
-place urinary catheter
-proceed with pelvic examination
inspection
*bleeding
*if see cord outside the vagina (in sample case 2 cm cord outside vagina) if cord has been clamped
closed to introitus?
*episiotomy site
speculum
*laceration or tears in cervix
-is there bleeding anywhere else?
management
in sample case (please place one hand over the uterus and look for uterine contractions, once it starts
contracting give a gentle controlled cord traction and look weather you can deliver placenta or not and if
not possible shift her immediately to theater and specialist will do manual removal of placenta under
anesthesia.
In exam case
-Differential diagnosis
*uterine atony (most likely) causes could be prolonged labour, big baby, twin, multiparous
*retain product of conception
*laceration
*uterine inversion
-call specialist for manual examination under anesthesia

Feedback 12-4-2018
You are HMO in a rural hospital in duty for O&G ward.
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nurse us calling you .A lady has delivered recently and now is bleeding. from your room to ward take 5
min.before going there you want to order what is needed.
your tasks:
* listen to her explanation and take hx not more than 4 min.
* give advice and What she need do before you go
During the conversation via phone, pt has delivered a 4.2 kg baby, has had around 1250 cc bleed and has
had a difficult delivery 14 hours. a small episiotomy has been made and VS:
BP: 85/50, PR=120, others nl.
delivered placenta completely,no any bleeding from epi.

232-Hyperemesis gravidarum
Condition 144 Nausea and vomiting in the first trimester (Handbook materials)
 Your next patient is a 38 year old woman who has come to the general practice because of severe
nausea and vomiting for the last two weeks in this, her first pregnancy. She claims that she has been
unable to keep foods or fluids down. Her last menstrual period was eight weeks previously, and pelvic
examination by your colleague in the general practice two weeks ago showed the uterine size was
appropriate for gestation and a pregnancy test was positive. She has had no previous operations or
illnesses
 TASKS
1. Take any further relevant history you require
2. Ask the examiner about relevant findings evident on general and obstetric examination which
would assist you in making a diagnosis
3. Advise the patient of the likely diagnosis
4. Advise the patient of the care you would advise for her, including any investigations you would
arrange

APPROACH
o HEMODYNAMIC STABILITY--VITAL SIGNS: What is her current BP and is there a postural
drop, pulse and rhythm, respiratory rate, oxygen saturation, and temperature?
o If UNSTABLE: please transfer the patient to the treatment room, secure IV lines, and
take blood for FBE, UEC, ESR, CRP, blood grouping and cross-matching. I would also like
to do urine dipstick to check for ketones. Please start IV fluids: normal saline, hartmann
solution or Haemaccel whichever is available.
o Please give her an oxygen mask and start high flow oxygen at 10/L (if rr / o2 sat
unstable)
o HISTORY
o Congratulations on your pregnancy. I have read from your notes that you are currently at
8 weeks of pregnancy, and you have been suffering from vomiting for about two weeks now.
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I know this can be very distressing for you, but we'll do our best to manage you. Could you
tell me more about your vomiting?
 Is it getting worse? Does it usually come in the morning or a particular time
during the day? Could you describe to me the manner in how you vomit--is it projectile,
do you retch, etc? What does your vomit usually consist of? What's its color? Does it
have any blood? Did you eat anything out of the usual before you had these symptoms?
 Any changes in your bowel motion? Do you still pass gas? (r/o bowel obstruction
or gastroenteritis)
 Assess dehydration
 How is your appetite? Are you still eating or drinking? Did you have any
fever, diarrhea, or dizziness? How is your waterworks? Any burning or stinging
sensation? Do you go to the toilet more/less than the usual? Any change in the
color of the urine? Any loin pain?
o QUESTIONS ABOUT CURRENT PREGNANCY
 Is this a planned pregnancy? How were you able to confirm your pregnancy?
 Are you in a stable relationship? Do you have support for this?
 R/O causes of vomiting
 Do you have any family history of twins?
 Is this a natural or an assisted pregnancy?
 Any bleeding or tummy cramps?
 Did you have your initial blood tests requested during your previous visits to your
GP? Were you advised regarding screening and confirmatory tests for diseases in the
baby?
o Any history of STIs?
o When was your last pap smear?
o Do you know your blood group?
o Do you smoke, drink alcohol, engage in recreational drugs?
o Do you take other medications? Any allergies?
o Do you have any history of any medical or surgical conditions?
o PHYSICAL EXAMINATION
o GA: dehydration--skin turgor, CRT, tongue & oral mucosa moist? Lymphadenopathies,
pallor?
o VS: BP with postural drop? Temperature? HR?
o CVS, CNS, Respi
o Abdomen: distended or any masses? Tenderness? Rigidity/guarding? Any bowel sounds?
o Pelvic exam not needed
o Office tests: Urine dipstick and BSL
o Check for ketones
o PE findings from the case:
o She looks unwell and drawn. Her tongue dry and firm. Tissue turgor of the skin is
diminished.
o Pulse: 110/min
o BP: 120/80
o Temperatue 36.8C
o Abdominal examination, uterus not palpable
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o No loin tenderness
o Pelvic examination not repeated
o DIAGNOSIS AND MANAGEMENT
o From history and examination, it seems that most likely you have a condition we call as
Hyperemesis gravidarum. Have you heard about it? It is a condition common in early
pregnancy manifested by excessive nausea and vomiting. Its cause is multifactorial, however
it is usually implicated that the excessive vomiting and nausea is due to increasing hormone
levels especially the b-hcg hormone which supports your pregnancy.
o This condition usually goes away on its own, especially by 14 weeks of gestation as your
body becomes used to these new hormones, and the level of b-hcg goes down.
o However, it was seen from your examination that you are severely dehydrated, supported
by findings of ketones in your urine. Because of this, I will have to refer you to a hospital so
that you can be admitted for intravenous rehydration and monitoring. I will call an
ambulance to transfer you to the hospital.
o I will also refer you to a specialist who will see you and might do further investigations.
Although hyperemesis gravidarum can be a complication of a normal pregnancy, it also
occurs with increased frequency in association with other conditions such as a multiple
pregnancy, a urinary tract infection, or even a condition we call as a hydatidiform mole--
where there is an abnormal growth of placenta mimicking pregnancy. To rule out these
conditions, you will undergo blood tests such as an FBE, UEC, serum b hcg, liver function
tests, and also urine microscopy and culture, and a transvaginal ultrasound. You will be given
fluids through IV, and anti-vomiting/nausea meds (metoclopramide - maloxon/stemetil),
vitamin B supplementation (pyridoxine) to address your symptoms. You and your baby will
continually be monitored throughout your admission.
o Another thing that I would like to address is that you are currently 38 years old now, and
this puts you at a very high risk of having a baby with Down syndrome or other genetic
abnormalities.
 SHORTCUT: Because of this, I will arrange genetic counselling for you to
undergo screening tests for down syndrome which consists of a blood test done as early
as 9-13 weeks looking for factors in blood which denote possible presence of a baby
with down syndrome, combined with an ultrasound examination done at 11-13 weeks.
We can also do a screening test in your second trimester which will also involve a
blood test looking for 4 factors in the blood (AFP, BHCG, ESTRIOL, INHIBIN) which
will screen for the condition. We can also do confirmatory tests: the chorionic villous
sampling test done during 11-14 weeks, which involves getting samples from your
placenta and to send it for genetic testing. We can also do amniocentesis, which can be
done at 15-18 weeks, which involves getting a sample of your bag of water and we send
it for genetic analysis for down syndrome. All of these confirmatory tests have certain
risks for miscarriage with 1:100 for CVS, and 1:200 for Amniocentesis.
 FULL EXPLANATION: We have two screening tests, we usually do blood tests
looking for factors namely the bhcg and pappa as early as 9-13 weeks, together with an
ultrasound of the baby's back of the neck at about 11--13 weeks of your pregnancy. The
bhcg is inc, and pappa is decreased in a baby suspected of having downs. The detection
rate of this combined test is 87%
Another test that we do is the Noninvasive Prenatal Test (NIPT) which is done at 10
weeks. We get a blood sample from you and we send it for genetic testing. The
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detection rate is 99% but it is not covered by medicare and usually costs around 600-
700aud.
For the second trimester, 15-17wks. we can also do what we call a quadruple and a
triple screen. We test factors in your blood, namely the bhcg, inhibin, esriol and afp.
Both bhcg and inhibin are increased while the other two are decreased in a quad
screen.we test the bchg, estriol, and afp in the triple screen. Detection rates are 81%
and 71% respectively.
Once we get positive for downs in the screening tests, we do confirmatory testing for
downs
Chorionic Villous sampling that we do during 11-14 wks of pregnancy where we
insert a needle guided by ultrasound from down there and get a sample from the
placenta which we send for genetic testing. However miscarriage rates are 1:100.
We can also do an amniocentesis, which is done at around 15-18 weeks. We pass
a needle guided by an ultrasound to your womb, to get a sample of your bag of
water and we send it for genetic analysis. Risk of miscarriage for this is 1:200.
 
 
KEY ISSUES
 Ability to investigate and treat a woman with hyperemesis gravidarum
 Recognition of the need for genetic counselling in the view of advanced maternal age
 
CRITICAL ERRORS
 Failure to recognise the need for hospitalization
 Failure to do ultrasound and urine examination to check pregnancy, diagnose twins, molar
pregnancy, urinary infection, and the presence of urinary ketones
 
IMPORTANT POINTS FROM THE COMMENTARY
 Management depends upon the degree of vomiting and therefore the potential diagnosis.
 Common problems
o Failure to advise that the vomiting will usually cease or be markedly reduced by around
14 weeks of gestation

Handbook 144
Condition 144 (R4)
Nausea and vomiting in the first trimester in a 38-year-old primigravida
CANDIDATE INFORMATION AND TASKS
Your next patient is a 38-year-old woman who has come to the general practice because of severe
nausea and vomiting for the last two weeks in this, her first pregnancy. She claims that she has been
unable to keep foods or fluids down. Her last menstrual period was eight weeks previously, and pelvic
examination by your colleague in the general practice two weeks ago showed the uterine size was
appropriate for gestation and a pregnancy test was positive. She has had no previous operations or
illnesses.
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YOUR TASKS ARE TO:

• Take any further relevant history you require.
• Ask the examiner about relevant findings evident on general and obstetric examination
which would assist you in making a diagnosis.
• Advise the patient of the likely diagnosis.
• Advise the patient of the care you would advise for her, including any investigations you would
arrange.
AIMS OF STATION
To assess the candidate's knowledge about the diagnosis and management of hyperemesis gravidarum.
EXAMINER INSTRUCTIONS
You are 38 years old and have had severe nausea and vomiting for the last two weeks. You are now
eight weeks pregnant in this, your first pregnancy.
The examiner will have instructed the patient as follows: Appropriate answers to likely questions are:
Task 1
• No symptoms of urinary frequency, or pain with voiding. You need to get up once a night to empty
your bladder. (UTI- FREQUENCY, DYSURIA, NOCTURIA)
• No vaginal bleeding.(BLEEDING)
• Urine output satisfactory and apparently normal.(DEHYDRATION- URINE OUTPUT, FLUID
INTAKE)
• You have kept some fluids down today but have had difficulty keeping any fluids or food down
for the last week or two.
• No family history of multiple pregnancy.(FAMILY HISTORY- TWINS)
• This is a spontaneous pregnancy and fertility drugs have never been used. You have been
trying to conceive for the last 12 months.
• You are aware of the increased risk of Down syndrome due to your age, and will want tests
done to ensure this baby does not have Down syndrome. If it did, you would wish the pregnancy
terminated.

Questions to ask unless already covered:

• 'Why am I sick?'
• 'How long is the sickness going to last?'
• 'Will my baby be OK?'
Task 2
Examination findings to be given to candidate by the examiner on request
She looks unwell and drawn. Her tongue is dry and firm. Tissue turgor of the skin is diminished.
Pulse 110/min.
Blood pressure 120/80 mmHg.
Temperature 36.8 °C
Abdominal examination, uterus not palpable No loin tenderness.
Pelvic examination not repeated.
EXPECTATIONS OF CANDIDATE PERFORMANCE
The candidate should convey the substance of what follows to the patient:
Task 3
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• Hyperemesis gravidarum is a common condition in pregnancy, with significant nausea and vomiting
in up to 10% of patients, a small number of these requiring admission to hospital for
intravenous fluids and antiemetics.
Task 4
• In order to assess the severity of the process, a urine specimen needs to be tested for
ketones. If ketones are present, admission for intravenous rehydration is usually required. If the
candidate indicates the need for such ketone testing, advise that this was strongly positive. As the ketone
test was strongly positive, admission is required.
• Although hyperemesis gravidarum can be a complication of a normal pregnancy, it occurs with
increased frequency in association with multiple pregnancies, hydatidiform mole, and in association
with urinary tract infections. Ultrasound examination is therefore required to rule out the former
diagnoses, and a midstream urine specimen should be collected and subjected to culture to rule out a
urinary infection.
• Treatment in hospital consists of rehydration with saline solutions and additional dextrose,
usually with vitamin B supplementation. Pyridoxine, or antiemetic therapy with Maxolon® or
Stemetil® can also be used in an attempt to resolve the vomiting.
• Investigations such as assessment of the serum electrolytes and urea, and liver function tests should
be performed to assess the degree of effect of the vomiting on the maternal bodily function.
• Usually the hyperemesis settles spontaneously, often having reached a maximum at about 70 days
(ten weeks) of pregnancy, and by the time of 100 days (14 weeks) most of the symptoms will have
resolved.
• If nausea and vomiting do not settle satisfactorily, or following initial therapy, other causes such as
small bowel obstruction, cerebral tumour or Addison disease need to be excluded.
• As she is 38 years old, and is therefore at increased risk of a chromosomal abnormality of the
baby, genetic counselling should be arranged with advice given concerning the usefulness of the
quadruple maternal serum screening and nuchal fold thickness assessed by ultrasound examination
(screening procedures only) or the use of chorion villus biopsy (CVB) or amniocentesis to assess the
fetal karyotype and actually rule out Down Syndrome. As she has indicated this diagnosis needs to be
ruled out, the definitive tests of CVB or amniocentesis should be advised following advice to her
concerning the potential complication rates of each of these procedures (risk of abortion due to the
procedure is 0.5% for amniocentesis at 15-16 weeks, and about 1.5% for CVB at 11-12 weeks).

KEY ISSUES
• Ability to investigate and treat a woman with hyperemesis gravidarum.
• Recognition of the need for genetic counselling in view of advanced maternal age.

CRITICAL ERRORS
• Failure to recognise the need for hospitalisation.
• Failure to do ultrasound and urine examination to check pregnancy, diagnose twins, molar
pregnancy, urinary infection, and the presence of urinary ketones.
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Karin case
Case: 38 year-old woman who came in with a 2-week history of nausea and vomiting. She is 8 weeks
pregnant and her pregnancy is consistent with GA. She has no previous illness.
Task
a. History
b. Investigations (1 only) – MSU
c. Diagnosis and management
Differential diagnosis:
- Multifetal pregnancy - Hydatidiform mole (complete/incomplete) – UTI
- Infectious Gastroenteritis - Brain tumor/Addison disease/bowel obstruction
History:
- IS MY PATIENT HEMODYNAMICALLY STABLE?
- Congratulations on your pregnancy.
- How many episodes of vomiting did you have per day? - Is it getting worse? Is it in the morning or
throughout the day? What is the content?
- Do you have fever? Diarrhea?
- How is your appetite? Are you still drinking eating or drinking? - Did you eat outside?
- How is your waterworks? Any pain or burning sensation? Any increased frequency? Any change
in color of urine? Any loin pain?
- Pregnancy: is this a planned pregnancy? How did you confirm your pregnancy? Any family history
of twins? Is the pregnancy natural or assisted? Any abdominal cramps or vaginal bleeding?
- Periods? Pills? Partner? Pap smear? Blood group?
- SADMA?
Examination:
- General appearance: tired, signs of dehydration (tongue, skin turgor, CRT?
- VS: BP (check for orthostatic hypotension); PR (tachy), RR, T – normal
- Chest, heart, abdomen – normal
- No pelvic exam needed.
- Urine dipstick – nitrites, ketones (+), leukocytes
o MSU: (+) for ketones! – admit!!!
Investigations:
- MCU - Ultrasound examination - Test for electrolytes, urea, LFTs
Diagnosis and management:
- You have a condition called hyperemesis gravidarum. It means excessive nausea and vomiting in
pregnancy. These are common symptoms during initial pregnancy. However, 1 in 1000 women will
have excessive vomiting and require hospitalization.
- On examination, you are dehydrated and this was confirmed in urine analysis, so we need to admit
you. I will organize an ambulance.
In the hospital they will secure 2 IV cannulas, take the blood for FBE, U/E/, RFTs and LFTs because
dehydration can affect the liver and kidney. We need to do MCS to rule out UTI and USD to confirm
intrauterine pregnancy, rule out multiple pregnancy and molar pregnancy.
- They will also give medications to stop the vomiting (metoclopramide – mexalon, stemetil) and start
IV fluids and vitamin B6 (pyridoxine).
- We don’t know the exact mechanism behind it. However, it is usually due increased level of b-hCG
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which is one of the pregnancy hormones. Once the body has become used to the new environment, the
nausea and vomiting settles and this usually happens by 14 weeks.
- You are a 38-year-old mother and that puts you at a very high risk of having a baby with Down
syndrome. So I would like to offer you screening for Down syndrome (during your 10th week – blood
plus USD).
Case (29/11/2017)
Feedback (1st trimester complication)
You are a GP, a young female comes to you with 10 weeks of gestation with severe vomiting, not able
to keep anything down. Her antenatal course has been uneventful till now. ANC tests done.You are
seeing her for the 1st time. Further investigation, Tell her the diagnosis, management and explain the
reason for this.
Greet, introduce
Took a bit of history- anc checkup done or not
Planned pg?
Folate intake, FH of chromosomal prob, multiple pregnancy, pv bleeding or
discharge, any ovulation inducing drug
With vomiting fever, tummy pain and other prob
All negative
Mx- common condition, hyperemesis
Vomiting can u due to urinary infection, multi pg, molar pg, chromosomal prob even along with other
health conditions but also a normal variant. Vomiting due to body’s adjustment to pg and pg
hormones .Usually goes away once the 1st trimester is over, but as u are not able to keep anything down.
Will admit u. try out some IV fluids and meds. Run some ix- urine test (ketone, protein, leukocyte didn’t
mention details), liver test, kidney test, few blood tests(b hcg, electrolyte) and usg. Is that ok with u?
Want me to call someone?
Support at home?

Feedback 7-9-2018
Station 9 – hyperemesis gravidarum – fail
STEM : ( stem is very long )
middle age lady – UPT – positive
LMP 8/52 ago
nil bleeding , nil abdominal pain
Nil family history
Other doctor did
nil FBE ( sure )
blood group – B positive
Antibody – negative
HIV , Syphilis , Hepatitis screen – NEG.
On examination :
- nil fever, pelvic examination – os – closed, others – NAD , uterine size 8/52 ,
- vomiting several times since 2 days ago ( forget exact dates )
TASK
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1. Explain most likely cause and other possible causes to the patient
2. further investigations to the patient ( routine , other MMR serologies , serum Beta-hcg , U/S of
abdomen ) , refer to the specialist and explain about referral ( though mgmt is not necessary in the
TASKS)

Feedback 30-5-2018
‘First trimester complication’:
8/40 c nausea & vomiting (hyperemesis gravidarum). Benign 1st ANC bloods given in stem.
Task: Hx, counsel what Ix to do
Feedback: Pass
 HOPC
o Basic rapport (you’re blds are reassuring, I’ll be going through your concerns step by
step, just need to ask some focussed Qs 1st)
o PregQs (basic ANC summary)
 LNMP (any issues)
 Planned/partner/support
 Blood group
 HPV
o When/how many episodes/keep anything down
o Eat anything funky/BOV/swelling/Pain/CCVO
o Any PV d/c /ccvo/grape-like tissue loss
o DdxQs
 Bowel/bladder func
 Fever
 FHx twins
 Ax & P
o Explained that it fits with n/v of early preg but needs confirmation
o 2/2 pregnancy hormone (bHcg)
o I’d like to examine you now and arrange…(as not given as task: I felt the need to mention
for sake of maintaining practical sequence of events the way they would occur in real
life)
o Basic ANC bloods (preg test)
o Send you to HRPC where you go to the same ANC but more frequent monitoring of you
& bub under MDT
o We need to assess the extent to which you’re producing the preg hormone & US to
characterize the pregnancy (as it depends on the bHcg to be at a certain level)
o Drew an arrow from 1 – 40/40 and explained 18/40(USS), 28/40(OGTT), 36/40(GBS)
 And more freq US & CTG & bHcg monitoring
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o Other possibilities we need to r/o, not to scare you are

 Molar (GTD –with brief outline that it’s a growth not preg)
 Multiple pregnancy
 Gastroenteritis
o Summarized

Feedback 7-9-2018 hyperemesis gravidarum (important)

First trimester complication- PASS)
GP, A 22 year age old, young lady , c/o repeated vomiting for last 2 days. She has checked with her gp
last week- UPT-positive. 8 weeks. First pregnancy. Full blood invx- normal. HIV, Syphillis, Hepatitis
A,B- Normal. Blood group was given. No known medical condition. Her BP- 120/80, pulse 76/min-
basically all vitals are stable. A liitle bit hx and PE was given to indicate hyperemesis gravidarum.
- Explain dx, ddx
- Further invx you want to send
- Mx.
FEEDBACK-PASS Global Score: 5
Key Steps: 4/4 Approach to pt: 4 Choice of invx: 5 DDX: 5 MX: 4
2 mint thinking- PE details were not given, urine ketone bodies- present or not?( Dehydration??) vitals
stable- shall I refer to hospital?? I was confused to be honest about mx. Medication- metocloromide+ vit
B6.
I failed this case in my trial exam because I didn't admit the pt in hospital.
DDX:
1. Hyperemesis gravidarum 2. Multiple pregnancies 3. Molar pregnancy
4.UTI 5. Acute gastroenteritis
( I mentioned all of them, twice. I had 3/4 mints extra in this case!! No hx, just ddx, invx, mx- I sat down
quietly inside the room for few minutes!! :D)
As vitals were given outside, I didn't ask anything to examiner.
I directly started with the role player, an young lady, sitting comfortably.
I started like: Are you comfortable to talk right now? would it be alright if I start to explain why you are
having this? (yes)
I mentioned all the ddx with explanation and asked few questions in between as well.
Multiple pregnancy- have you taken help of assisted pregnancy clinic? Any family hx of twins?(no) .
Okay, sometimes, this symptoms are more common when multiple foetus insides. That's why I'm just
asking you this. Do you have family hx of twins? (No)
Molar pregnanacy- Have you noticed any bubbles like structure coming down below? (no) Okay.
alright. This condition we called molar pregnancy, where foetal parts do not grow well and forms
bubbles like structure inside. This actually resulted in higher level of pregnancy hormone into your
body, that leads to excessive vomiting. Seems like it's not in your case.
UTI- Any burning sensation while urinating? - no- Okay, good. It's also associated with urine infection.
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Acute gastro- Any eating out recently? how's your bowel movements? - normal
Then, I mentioned, most probably, you are having a condition we called "hyperemesis graviderum' , It's
very common in first trimester and in first pregnancy. Our body reacts differently with this very new
change in your body because of hormonal disruption and pregnancy hormones start to rise. Don't worry,
this condition will settle down by 14 weeks. Make sense? (okay).
I will do further invx to rule out the other causes as well:
Blood tests: electrolytes. B-hcg level rising or not? high or normal?( I might forget to talk about LFT,
RFT, or it was mentioned in the stem)
Urine tests: Microscopy n culture, ketone bodies.
USG
I also mentioned, look we have already done these tests, so I'll not repeat those. I mentioned ddx again
while explaining invx to her to justify why I'll do it.
Mx: I asked; how are you feeling? As I can see, your vitals are stable now, can you manage yourself at
home? ( She said, yes) Then, I thought, might be it's a trap. I said then n there; good, but I would like to
refer you to hospital right now. It would be better for you as well, as they will do all the tests
immediately and specialist can come and check you up. They will give you medications, called
metocloromide + vit B6, to stop your vomiting and nausea feelings. Okay? (Yes). Shall I call an
ambulance for you? (no) Is there anyone with you atm?(yes, my husband)

233-Placenta Previa
Sample case/ You are an HMO at the ED of a tertiary hospital when 28 year old Jenny, who is in her 34
weeks of gestation presents to you with vaginal bleeding.
TASKS
Further history
Examination findings from examiner
Diagnosis and management
Differential Diagnosis
1-Placenta Previa 2-Abruption placenta 3-Trauma 4-Bleeding disorders 5-Blood thinner meds
History
1-Is the patient hemodynamically stable?
2-Bleeding questions (duration, action, trauma, amount or severity, colour, odour, content, dizziness,
bleeding disorder and blood thinner)
- for how long have had vaginal bleeding? (Past 2 hours) is this the first episode of a bleed during your
pregnancy?
- What were you doing when you got the bleed?
- Any chance you had a hit to your tummy?
- How many pads have you used so far? Is it (are they) fully soaked or not?
- What is the color of the bleed?
- Is it smelly?
- Any clots?
-any tiredness, dizziness or funny racing of the heart?
-have you had a history of bleeding disorders? Do you take blood thinner medication?
3-Late pregnancy complications questions
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- Any tummy pain? ( abruptio placenta, preterm labour)

- any fever, nausea and vomiting, abnormal offensive vaginal discharge?
- any headache, blurring of vision, leg swelling?
- Is the baby kicking well?
4-regular antenatal visits questions
-have you had regular antenatal checks,
- Have you done your pap smear? What was the result?
- Have you done your down syndrome screening?
- Ultrasound at 18 weeks? What is the position of the placenta? Any birth defects? Repeat ultrasound at
32 weeks? What was the result? (not sure of the findings)
- sweet drink test at 28 weeks?
- are you aware of your blood group?
- Did you take your folic acid?
5-general questions
-Any past history of medical or surgical illness?
-smoking, alcohol or recreational drugs? (smoking cause placenta Previa)
-Do you have a good support?
Physical Examination findings from examiner
1-General appearance: (PODL) pallor, edema, dehydration, LAP
2-Vital signs: especially BP with postural drop.
3-quick chest and CVS examination
4-Abdomen:
-any uterine tenderness
- feel for any contractions
- fundal height (34 weeks)
- fetal heart rate (150 beat/min)
-fetal lie, fetal presentation (longitudinal and cephalic)
-Is the head of the baby higher than the lower uterine pole? (higher in previa)
5-Pelvic examination
Inspection of vulva and vagina:
-can I see any bleed? (+ve) Any clots?
-Any rash or vesicles?
Speculum exam:
-any bleeding from the cervix? (+ve)
-is the cervical OS open or closed? (closed)
**NEVER EVER DO A PER VAGINAL EXAM IN PREVIA (critical error)
6-Office tests:
UDT, BSL

Explanation (4C) if you do not know how to explain always remember 4C

Condition
-From the history and examination, most likely you have a condition called placenta Previa.
324

The placenta is the part that connects you to your baby, and which carries oxygen and food from you to
your baby. This placenta is usually situated on the upper part of your womb. But if it attaches to the
lower pole of your womb, it is called placenta previa. (draw)
Clinical feature
The bleed is mainly because of the head of the baby pressing against the placenta leading to bleed from
the placenta.
Cause
- the cause is unclear but it could be due to multiparty, advanced maternal age, chronic hypertension,
smoking, alcohol and drugs, previous C-section.
Complication
One of the major complications of this is bleeding, and you can go to a shock or coagulation or you can
go into preterm labor. The baby can have hypoxia or decreased oxygen supply, and intrauterine growth
retardation.

Management
- You need to be admitted and seen by the specialist.
- I am gonna put an IV line, take blood for investigation which include FBE, UEC, blood grouping,
cross-matching and hold. I will start you on IV fluid.
- Ultrasound will also be done to confirm diagnosis of placenta previa.
Ultrasound tell you what is happening (showed placenta Previa grade four)
Grade 1: low lying placenta previa, placental edge is not near the OS
Grade 2: marginal placenta previa, placental edge comes up to the level of the OS (Marginal PP)
Grade 3: partial placenta previa, partially covers the internal OS
Grade 4: total placental previa, completely covers the external OS]
- CTG will also be done to monitor the baby.
- bed rest at the moment.
-options
first: once you stop bleeding, wait in the hospital until 37 weeks when the specialist will do a planned
C-section. However, If the bleeding continues, and you become unstable, or if the baby becomes unwell,
an immediate C-section will be done.
Second: once you stop bleeding you can go home but if 3 criteria
*home near the hospital
*require constant companion
*need informed consent from the patient.
And the rest of your pregnancy should be in high risk pregnancy clinic
warning signs: bleeding, tummy pain, fluid discharge, baby not kicking well
I will give you reading materials about placenta previa for further insight.
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Notes
***In minor grades (grade 1 and 2) of placenta previa, usually C-section is done in 38 weeks. If major
grades (grade 3 and 4), C-section is done at 37 weeks.
***any grade of placenta previa, any gestational age, if the patient has heavy bleeding, becomes
hemodynamically unstable, or if there is fetal distress, stabilize the patient and go in for an immediate C-
section.
***if the patient insists on vaginal delivery, tell that it is always a C-section that is preferred in placenta
previa (any grade). But a trial of vaginal delivery can be considered if the placental edge is greater than
2cm from the OS and if the baby's head is below the placental edge.

Feedback
Case (11/2/2017)
you are a GP in a clinic 250km away from tertiary hosp. Ptn 34 weeks gestation comes for antenatal
visit. USG done recently and report says there is 4th degree placenta praevia, with the position of
placenta being mainly on posterior wall of uterus but covering the cervix.
Task:
Hx from ptn,
explain USG to ptn
management
Introduced myself, ask how is she doing.
A few questions on the pregnancy, if all is okay, baby kicking well etc. No positive hx there, no
bleeding or discharge from down below.
Then explained to her that the ultrasound shows something called placenta praevia. Drew the uterus, and
location of placenta. apologised that my drawing is horrible, i’m far away from being an artist. As i was
drawing, I told her the function of the placenta is for exchange of oxygen and nutrients between mum
and baby. Usually the placenta is located higher, here (i indicated on the picture i was drawing) but for
some reasons, its lower than it should be.
She asked me if it was dangerous, i said , yes it is a risky situation but not to worry we can handle this.
(I actually winged this case because I somehow did not read placenta previa during my revision so if I’m
wrong anywhere, ignore it).
I said that because of the location of the placenta, its too risky to have normal delivery so your safest bet
is a Caesarian section. What we need to do now is to do CTG. She didnt know what it was so i
explained that two (i cant remember what word i used, electrodes?) will be put on ur belly and that will
take the reading of the baby’s heart rate, movement and the uterine contractions.
I would like to discuss with the specialist, and upon his discretion maybe you may need to be sent to the
tertiary hospital soon, but I will arrange all that accordingly. If not, you will need regular monitoring wit
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possibly weekly USG and CTGs, also mentioned Blood grouping and cross matching somewhere in my
discussion.
Guys, I didn’t read this case and I really just talked on what I thought were the possibilities based on my
internship back at home 5 years ago.
Feedback: Late pregnancy complications, Pass, Global score: 4
Note/ according to the feedback, the patient presented to GP without bleeding or any symptoms. She
came for the results of ultrasound. So first we need to take history for 3 minutes, no PE task then we
need to discuss the result (Grade 4 placenta previa) I think the examiner will give a card with the result
or a picture and report. Just in case see images of grad 4. So explain the results calmly, listen to the
patient , draw a diagram. Then mx is to refer to specialist as her home is far and you are in GP so refer to
tertiary hospital to be seen by specialist, tell like option 1 in the lecture. Then the specialist will decide
etc.. most likely CS planned 37 for such grade.

234-Bleeding in pregnancy
Feedback 4-7-2018
Feedback: Bleeding. Young female pt, with period was 6 week late, bleeding.
Task
-Hx,
-PEFE
-Investigations.
Hx:
How severe was the bleeding? Dizzy? Pain? (no)
6Ps? (Pt has nausea, breast and pelvic discomfort), but Pregnancy test 2 wks ago: Negative.
SADMA, …
PEFE: everything normal, pelvic examination: cervix closed, no pain, uterus height consistent with 6
weeks pregnancy.
Investigations: Redo Pregnancy test right now and refer to USD, admit to hospital if pregnancy test is
positive.
Grade: PASS, Gs: 5
Key steps 1,2,3,4,5: Y (all covered)
Hx: 5, Choice of Examination:5, choice of investigations: 5

Note/ No dx in this case so just approach it like any previous lectures of vaginal bleeding with general
approach.
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243-Trauma during pregnancy (Materials)

38 year old Jane is brought to the ED of the hospital, where you are an HMO, with history of motor
vehicle accident. She's 32 weeks pregnant, and is complaining of abdominal pain.
 
TASKS
1. Focused history
2. PE from examiner
3. Diagnosis and Management
 
Positive points in the history: pain in upper part of tummy (rule out abruptio and preterm labor), it is a
dull pain, pain remains the same, bruise along the line of the seatbelt, baby is kicking well
Positive points in the PE: bruise along the line of the seatbelt in the abdomen, undal height: 32cm,
FHR: within normal limits, longitudinal lie with cephalic presentation
 
 
APPROACH
 History
o How are you feeling at the moment?
o Ask for consent. If it is okay with you, could you please tell me how that accident
happened?
o Were you driving the vehicle?
o Were you driving within speed limits?
o Were you wearing a seatbelt?
o When did this happen?
o Were you able to walk out the vehicle alone? (will tell you that she doesn't have any
major injuries)
o Did you hit your head or tummy anywhere?
o At any time, did you lose consciousness?
o Are you having any headache now? Any blurred vision? Any nausea or vomiting?
o Any neck pain? Any limitations in moving your neck?
o Any shortness of breath? Any chest pain? Any pain or limitation of movements of your
extremities?
o I have read from the case notes that you are having some pain. Where is the site of pain?
How severe is your pain? It it a continuous pain or an on and off pain? Is the pain coming at
regular intervals? What is the type of pain that you are having? Is the pain going somewhere
else or not? Is the pain worsening?
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o Any vaginal bleed or watery discharge?

o Have you got any bruises over your tummy?
o Is the baby kicking well or not? (most important question)
o Did you have your regular antenatal checks? What is your blood group? Down syndrome
screening? Have you taken your folic acid? Ultrasound at 18 weeks? Sweet drink test at 26
weeks?
o Other medical or surgical conditions? Any medications that you are taking? Any known
allergies?
o Do you smoke, drink alcohol or take recreational drugs?
o Do you have a stable partner? Do you have a good support?

 
 Physical Exam
o General appearance: pallor, dehydration, edema, bruises
o Vital signs
o Head: hematoma, swelling, depressed fracture
o ENT: bleed, discharge
o Neck: midline tenderness, limitation of movements of the neck,
o Chest: accessory muscle breathing, position of the trachea, air entry, abnormal sounds; S1
S2 normally heard, added sounds, murmurs
o Extremities: range of motion
o CNS: cranial nerves, neurological exam of the upper limb and lower limb
o Abdomen: fundal height: 32cm, FHR: within normal limits, longitudinal lie with cephalic
presentation
 Uterine tenderness, uterine contractions: none
o Pelvic examination:
 inspection of the vulva and vagina: bleed or discharge
 Speculum: bleed or discharge from the cervix, OS open or closed?
o Office test: UDT, BSL

 Diagnosis and Management

From the history and examination, there is no major issue that I can find, except for the pain that
you are having over your tummy. This pain may be due to the bruise over your abdomen. The baby
is doing well, as you can feel the baby kicking and I can also appreciate the fetal heart rate very
well. However, ss this is an accident during pregnancy, you need to be admitted, seen by the
specialist, to do an ultrasound to look for complications inside the uterus, and a CTG every 4 hours
for the first 24 hours to check on the condition of the baby. Your vitals also needs to be monitored,
and you need to be observed in the ED for 24 hours as complications like premature labor, and
abruptio placentae can sometimes happen, within the first 24 hours. Once you are discharged, if
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your pain becomes more severe or regular, if you break your waters, or if you have any bleeding
from down below, or if the baby is not kicking well, report immediately to the ED.
Do you have someone to be with you now?

254-Ovarian Cyst Torsion

Case (13/10/2017)
A young woman has come to ED due to sever abd pain. PT was weakly positive and LMP was 8
wk ago.
Task:
Px,
Most likely dx with ddx to the pt with reasons.
Inside, there were a clock and a sphygmomanometer on the table. Washed my hand introduced myself. I
started assessing V.S. Pulses as soon as I was checking examiner said it is NL. (Asian examiner, he was
checking the technique from close distance and was telling the result like he was whispering!:)) Bp was
NL as well I said no sunken eyes no dry mucosa no pallor.
Then I started abdominal exam by inspection( no dilated veins no scar no bruises no mass obviously) I
said first I check auscultation to prevent inadvertent changes(NL bowl sound). In palpation, started from
left side and went to right side just tenderness on RLQ no rebound no guarding. I said because you have
pain I won't do percussion and deep palpation to check organ enlargement.
Then I did Morphie sign(-) Obturator and psoas and Rovsing sign(all NL)Renal angel tenderness(-) I
said dipstick and bsl(not available)
Then I asked for DRE and PV with consent of the patient and presence of the chaperon.
Examiner gave me the card which was saying right adnexal mass which was tender to touch but no CMT
and size of uterine was enlarged.
To patient, I mentioned: Regarding the hx and px most likely you have condition called ovarian cyst
have you heard of it? (drew pic) it is fluid –filled sac formation in ovaries but it can be EP which fetus
and product of pregnancy can be formed in tube( fallopian tubes) instead of womb which is serious
condition.
It can be also a kidney stone or appendicitis which is a swelling at the end of your small bowl. Also it
can be mittelschmerz which is an inflammation in small bowel however it is unlikely due to your age of
pregnancy as it is happening in young girl in the middle of menstrual cycle.
We need to do U/S to confirm but most likely it is due to the ovarian cyst. Bell rang.
Feedback: Substance abuse, PASS(G.S:6)
Key steps:1,2,3 &4: Yes
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Approach to patient:6
Choice and technique of examination and organization and sequence:6,
Accuracy of examination:5
Dx/DDx:5

comment
Task was Do physical examination 
Diagnosis and management 
UPT weak positive on stem mentioned 
Severe pain at presentation 
So pain killer offer
Then do general examination: 
BP and Pulse to be measured on your own .. 
complete abdominal examination 
She had tender right iliac fossa
No rebound tenderness / no Mc burny point 
No ascites 
On pelvic examination : got a card ( adenexal tenderness)

Task : explain to patient about ectopic pregnancy .. patient crying as it was a planned pregnancy 
Explained her urgent USG / about urgency of surgery and management with specialist 
Time over 
In afternoon group : patient had no pain .. she was okay .. rest similar case 
Waiting for feedback to be sure
did u pass that pass? A detailed recall for 7 july with same scenario. Candidate diagnosed as ectopic
most probable diagnosis and gave other dds. Got only 2 score in diagnosis and failed that case
I failed that case too.. reason I didn't have time to mention DD and their invx and mx plan for Dd
So nutshell .. always mention DD to discuss along with the most likely situation
Show that you r safe and ready to take help from seniors

Case (9/3/2017)
female patient with pain in right iliac fossa for one week ,now got worse ,, her pregnancy test is vaguely
positive and 7 weeks amenorrhea.
Task
1)physical examination
2)tel most likely diagnosis
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positive findings tenderness right iliac fossa uterus enlarged and retroverted , adnexa tender ..
(CERVICAL EXCITATION /CMT IS NEGATIVE)

Feedback 5-7-2018
Young lady with missed period, lower abdominal pain. PT weakly positive.no bleeding
Task:
1- do PE
2- tell DDx
I did general, vitals examiner stopped me at blood pressure, abdominal exam (inspection, palpation,
bowel sound) rovsing sign negative. Asked pelvic exam.
DDX.. ectopic pregnancy, ovarian cyst or rupture or tortion, appendicitis, ureteric colic.
Passed: global score 4
Feedback 5-7-2018
25 year old girl, has been having RIF pain for 6 days, UPT was weakly positive 1 week ago, no PV
bleeding
Tasks
Relevant history
Focused abdominal examination
Explain the d/d to the patient
offered pain killer to the patient and asked for allergy.
Pain for 6 days, no shifting, no PV bleeding. no urinary sx, bowel normal. No vomiting but felt
nauseous. Bowels, urine all normal .
Examination (if you wear hijab, then be prepared to use you stethoscope)
general (as you see) .. vitals (I have to check them) so I did pulse and then blood pressure (examiner
stopped me when I starting inflating the cuff). on abdominal examination , there was RIF tenderness,
no guarding, Rovsing or psoas sign negative. Bowel sounds normal
Asked Pelvic examination and DRE, she gave me paper. > os closed, pain on right adnexa. Uterine
size is slightly enlarged.
d.d like pregnancy with ovarian cyst, ovarian/cyst torsion .. twin pregnancy (one in womb and other
ectopic). Ectopic pregnancy. also pregnancy with appendicitis / muscle spasm / kidney problem.
Feedback 5-4-2018
abdominal examination
GP, 27 years old lady c/o pain in RIF, n & v present these days, home pregnancy test weakly positive.
Perform PE, Dx, Ddx
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It took too much time for me to measure BP, only positive findings are tenderness in RIF, no RT, all
special tests negative, when it comes to VE, uterus slightly enlarged, no 
Cervial excitation pain, but right adnexal tenderness +, no bulging
I told complicated ovarian cyst but didn’t have a chance to say Ddx again 
It was my case: Acute abd Amenorrhe 6 weeks
Ut size was 6 weeks CMT -ve
Adenixial mass in rt side with pain Preg +ve 
D.D $Preg with ovarian cyst  $Ectpoic $Ap

Feedback 7-7-2017
20 year old presented with acute abdominal pain. bhcg was done and is weakly positive.
TASK
1. perform focused abdominal examination explaing to the patient what you are doing
2. Tell the patient your differential diagnosis
Hello examiner, hello Jane
I have been asked to examine your tummy that would involve looking at it, touching it..if you have pain
at anytime, let me know and i will stop...can you please lift up your shirt while I wash my hands
Im going to look at your tummy now
On inspection no distension, abdomen moving with respiartion, no scar marks
Im going to touch your tummy..tell me where does it hurt the most....she pointed to rif...im sorry for my
cold hands
did superficial palpation...

PATIENT KEPT ON SAYING YOUR HANDS ARE VERY COLD AND I KEPT ON
APOLOGIZING
THE STEM SAID ACUTE ABDOMEN...PATIENT SEEMED AS IF NOTHING WAS WRONG
WITH HER, WHICH WAS A BIT CONFUSING
on deep tenderness in rif...no rebound, rovsings negative
checked renal angle tenderness...negative
checked liver and spleen.
wasnt sure if i should do percussion....because it was acute abdomen and the patient kept on saying your
hands are very cold
checked bowel spunds...present
Covered her up and TOLD THE PATIENT NOW I WANT TO EXAMINE YOUR PELVIC AREA.
examiner came and said no need to do that we have already done for you and gave me a card
cmt negative
right adnexa tender
Jane there are some reasons for your pain
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Firstly ectopic pregnancy...pregnancy outside the womb in your tube

Secondly, twisting of your ovary
Thirdly, rupture of a cyst inside your ovary.
I have also ruled out appendicitis and any infection of your kidney
But to be sure we need to do an usg
Do you have any questions...no
Thank you examiner, thank you Jane
FAIL
keystep 1no 2yes 3yes 4yes
approach 4
choice of examination 4
accuracy of examination 4
diagnosis 2

272-Vaginal Birth after Caesarean Section

your next patient at your GP is Jenny, a 28 year old lady, who had previous delivery by CS 2 years back.
She's 8 weeks pregnant now, and wants to discuss about possibilities of having a vaginal birth this time.
TASKS
-Take relevant history
-Ask examiner for previous medical and surgical notes of the C-section
-Discuss possibility of a vaginal birth this time with the patient
History
1-I read from my notes that you are 8 weeks pregnant, is this a planned pregnancy for you?
Congratulation!
2-5Ps questions
periods
-When did you have your LMP? 8 weeks ago
-Are your periods regular?
Partner
do you have enough support for this pregnancy
Pregnancy
334

-How did you confirm your pregnancy? (Home pregnancy test) ok, I will do a confirmatory office PT as
well
-Do you have any breast tenderness? Morning sickness? Yes
-Do you have any tummy pain, or bleeding, or discharge from down below?
Pill
-How long have you been off your contraception?
Pap or HPV
3-previous pregnancies questions
-I have read that you had a previous C section done. When was it done? 2 years ago
-Was it an elective or emergency C section? Emergency C-section was done
-Why was it done? Sort of obstruction during the labor
-Do you know the weight of your baby at birth? 4.2kg
-What type of C-section was done on you? [draw a photo if necessary]
-Did you have any complications during your previous pregnancy? Like high blood pressure or diabetes
that you had?
-Did you have any complications after the surgery like any excessive bleeding? Infections? Or any
complications? Clotting in your veins?
4-Past surgical history
-Did you have any other surgeries done on your womb apart from the c section? None
5-Past medical history + Family history+ SADMA+ diet and exercise
How's your diet? Do you regularly exercise?

To Examiner
1-What is the reason for the c section (obstructed second stage of labor)
2-What is the cause of the obstructed labor? Was there any cephalopelvic disproportion (the baby was
big, but the pelvis was adequate)
3-What is the type of C-section done? (low uterine segment)
4-Any complications during or after surgery? None
5-How long until the patient was discharged from the hospital (normally should be 3 days)
6-Any previous uterine/pelvic surgeries done to her? None
7-How was the condition of the baby after birth?

Counselling
-Vaginal birth after a c section is an option for all women who had a previous c section provided that the
indication of the previous c section does not recur and in many women, successful vaginal birth could be
achieved safely for both mom and the baby. The success rate of vaginal birth after c section is 55-85%.
-In your case the previous c section was done as the baby was a little big and your labor was not
progressing smoothly. But this is not a recurring condition and your baby might not be that big this time.
And from the notes, your pelvis is not narrowed but quite roomy as well. At present, you do not have
335

any contraindications for the vaginal birth, and other points in favor for it is the type of C-section, which
is a lower segment C section, and also you don't have any previous uterine surgeries.
-You are in the early weeks of pregnancy now, and as the pregnancy progresses, if any complications
develop in you like uncontrollable high blood pressure, diabetes, or bleeding during pregnancy, placenta
previa, then a C-section needs to be considered again. Also certain complications in the baby like the big
weight of the baby, or any abnormal presentation or lie of the baby in the womb can also lead to a C-
section.
-There are certain advantages of the vaginal birth over the C-section. It avoids the risk of C-section like
complications of anesthesia, excessive bleeding, infection of the womb, and also injury to other organs.
The pain during the delivery will be short, and also you will have a shorter duration of stay in the
hospital.
-If you have one successful vaginal birth after a C-section, you can go in for any number of vaginal
births afterwards.
-VBAC carries risks as well. These include failure of the vaginal birth which will necessitate an
emergency C-section, and there is a risk of scar rupture (1:200), and a chance to develop endometritis or
infection of the womb. Repeated C-sections can lead to placenta accreta, a condition where the placenta
grows deep into the C-section scar of your womb. If you have one more C-section, the next deliveries
should always be by C-section and it is advisable not to have more than 3 C-sections.

Further Management
-Do all antenatal blood checks
-Start on folic acid
-Advice regarding down syndrome screening
-Needs to go for a shared antenatal care with ultrasound done at 18 and 32 weeks, sweet drink test at 26-
28 weeks. During each visit you will be monitored for any complications. And if any complications
happen, you will be managed at the high risk pregnancy clinic.
-I need to arrange for a specialist consultation at 26 weeks for discussion about the possible mode of
delivery, and another at 36 weeks for a definite decision.
-During delivery, you and the baby will be continuously monitored and the delivery should be done in a
tertiary hospital, under specialist guidance. You can also have excellent pain relief options.
-Here are reading materials regarding VBAC to give you more insight about this.
-Please observe to eat a healthy diet, and engage in regular exercise. Please avoid smoking, alcohol, or
recreational drug use.
-I will arrange a review with you once your blood tests are out
336

281-OCP-induced Hypertension 
You are a GP and 26 year old Susan comes to see you. She was started on combined pills 3 months ago
by a colleague of yours. She's having headache for the past 2 weeks.
 
TASKS
1. Further history
2. PE from examiner
3. Discuss management plan with patient
 
Differentials:
 COC-induced hypertension
 PCOS
 Hyperthyroid
 
Positive points in the history: COC for the past 3 months, character of the headache is undefined
Positive points in the PE/Investigations: BMI is 26, BP 155/95
 
APPROACH
 History
o Ask the pain scale. Offer painkiller.
o Headache questions
 Where exactly is the pain?
 How long have you been having the headache? On/off or continuous?
 Does it go anywhere else?
 What sort of pain are you having? Throbbing (migraine), band-like constricting
(tension)
 Anything making it better or worse? When exposed to light (migraine)
 Any food that you take that may trigger your headache -- chocolates, cheese, red
wine?
 Associated symptoms (Differentials)
 URTI/sinusitis: any fever, colds, facial pain?
 Referred pain: Any pain in your ears or around your teeth?
 Meningitis: Any nausea, vomiting, blurring of vision? Any rash?
 Trauma: Did you hit your head somewhere?
 CVS symptoms (side effect of pills): Any dizziness that you're having, any
chest pain, funny racing of the heart?
o COC history
 What type of pill are you having?
 What contraception were you on before this?
 Any particular reason why did you opt for these pills?
 Any other side effects of these pills?
337

 Breakthrough bleeding, weight gain, bloating, pain or swelling in your

calf?
o Period history
 LMP, regularity, pain, any bleeding in between your menses
o Sexual history
 Sexually active? Stable relationship? Pregnancies or miscarriages for you? STI?
o When did you have your pap smear? What was the result?
o Lifestyle
 What sort of diet do you usually take?
 Any regular exercise that you do?
 Do you smoke, drink alcohol, take recreational drugs?
 Any stress at home or at work?
o Any other medical or surgical illness? Any history of high blood pressure? Any heart
disorders? Any migraine?
o Any other medications that you are taking other than the combined pills? Any allergies?
 
 Physical Exam
o General appearance: BMI, PICCCLED, any hirsutism, acne (PCOS)
o Vital signs: BP
o Neck: any thyroid swelling
o CVS: S1 S2 normally heard, any murmurs
o CNS: fundoscopy to look for papilledema
o Abdomen: renal or suprarenal mass, bruit
o Pelvic examination
o Office test: UDT, BSL
 
 Diagnosis and Management
Most likely you are having a combined oral contraceptive pill-induced hypertension. This is also
the reason why you are having the headaches. However, with only one reading, we cannot say for
sure that it is already hypertension. We need to check your blood pressure two more times to say
that it is hypertension. Do you have a BP monitoring apparatus at home? If you do, please record
your blood pressure for the next two days. If not, please visit the GP for blood pressure monitoring
for 2 days. Meanwhile, you can take Panadol for the headache.
If it is confirmed that you have hypertension on the 3 readings, you need to stop the combined
OCPs. Then we will recheck your blood pressure after 2 days of stopping the combined OCPs. If
your blood pressure is already low after stopping, we can confirm that it is just the OCPs that is
causing the high blood pressure. I would like to discuss with you other options for contraception. If
your blood pressure remains high despite stopping the OCPs, then we need to look for other causes
of high blood pressure. We need to organize investigations such as FBE, UEC, LFTs, TFTs, serum
lipid profile, BSL, and also ECG.
I would advise you to adopt lifestyle modifications as your BMI is quite high. Do relaxation
exercises as well to decrease stress that might also contribute to an elevated blood pressure.
I will give you reading materials about hypertension. I will review you on the third day of
monitoring your blood pressure. If you experience worsening of your symptoms, please report
back.
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