OBGYN Station 2

Setting:

You are a junior doctor working in an obstetric clinic. This patient has presented from her GP with a headache. She is 30 weeks pregnant.

Name: Caroline Gilbert

Tasks:

1. Take a history from the patient.

2. Interpret the initial investigations to the examiner.

3. Give your preferred diagnosis to the examiner.

4. Give your initial management plan to the examiner.

You are not required to examine the patient.

Briefing

Diagnosis: Pre-Eclampsia
You have presented to the obstetric clinic after seeing your GP about a headache. Your GP referred you to this clinic on the same day. You are 30 weeks pregnant with your second+third children on the way (twins!).

For this scenario, your details are:
Patient Name: Caroine Gilbert (36yo)

Opening statement

“Thank you for seeing me on such short notice Doctor, I went to my GP earlier today (about 6 hrs ago) because I’ve had a headache and it’s driving me crazy. She took my blood pressure and she said it was high, and then sent me in to see you. But she didn’t tell me what she was specifically worried about so now I’m really scared that my babies aren’t okay.”

Information to Give Freely

I’ve had this headache for about 18 hours, and paracetamol wasn’t helping at all. I couldn’t cope with it anymore so I went to the GP to see if other pain medications would be available, and she sent me here with none!

Presenting Complaint (bleeding)

Site – headache, frontal area of head
Onset – gradual onset about 18 hours ago, no trigger
Character – dull, throbbing but intense pain
Radiation – just in the head near the front
Associated symptoms – nausea (no vomiting), and visual changes (flashing). Only state about visual changes if they ask specifically.
Timing – just gradually getting more intense
Exacerbating/relieving factors - nothing makes it better or worse, it’s just always there. Paracetamol did not help.
Severity – it started around a 4/10 and it’s now 7/10

Gynae History

Last menstrual period - LMP was about 7 months ago before I was pregnant.
Age of menarche - Started period at age 14.
Relevant sexual history/current status- Living with husband. Monogamous relationship. No previous STIs. Last test was 10 years ago before we got married.
Smear status - up to date, no abnormal results.

Obs History

No problems so far in the pregnancy, your scans have been normal except that you are having twins. They are growing well so far. I have had one extra scan than usual to monitor them, but they are in good positions according to the scan.
1 previous baby boy was born vaginally at 39 weeks and was 8lb. This was 3 years ago and the birth was uncomplicated. You went home the same day with no problems.
No previous ectopic pregnancies or terminations.
You have felt fetal movements recently.

Past Medical and Drug History

Previous similar episodes - nil
Other medical conditions - Eczema, well managed with emollients.
Previous surgeries - nil
Prescribed medications - emollients for eczema. Nil else.
Over the counter - Has tried paracetamol for the headache.
Allergies - NKDA.
Contraceptive methods used: nil for the last year, was using the progesterone only pill until you started trying for your second baby.

Family History

Nil

Social History

Smoking history - nil
Alcohol - nil since pregnancy. Previously had about ½ bottle wine per week.
Home - fully independent living in a house with your husband and other child (3 years old).

Systems Review

Headache (as above)

Visual changes - flashing lights occasionally for the last 12 hours. Painless. No triggers. No blurring.

Nausea - since the onset of the headache you have felt nauseous. No vomiting. You are managing to eat despite it.

NO abdominal pain, seizures, or leg/face swelling.

NO urinary symptoms.

You CAN feel the babies moving as normal.

Ideas / Concerns / Expectation

Ideas - you are wondering if it’s a migraine
Concerns - you are worried that it’s something that going to hurt your babies
Expectations - you want to find out what is going on and that if your babies will be okay

Discussion and Questions

If the candidate does not acknowledge your fears about your babies’ well-being then you can get angry or upset about them not listening to you.

Please interpret these results

Blood pressure earlier today at the GP surgery (6 hours ago): 152/101

Observations in clinic now;

HR 79bpm

RR 16

Temp 37.1C

BP 156/104

Sats 99% on room air

URINE DIP
Hb -ve
Glucose -ve
Protein ++
Ketones -ve
Leucocytes -ve
Nitrites -ve