OBGYN Station 4

Setting:

You are a junior doctor working in a walk in Gynae clinic. This patient has presented with vaginal discharge.

Name: Fiona Heart

Tasks:

1. Take a history from the patient.

2. Interpret the results provided.

4. Explain the results and management plan to the patient.

You are not required to examine the patient.

Briefing

Diagnosis: Chlamydia
You are Fiona Heart, a 29 year old female.
You have presented yourself to a walk in a Gynaecology clinic because you have been experiencing discharge from the vagina.

Opening statement

“Hello doctor, this is really embarrassing but some things have changed down below so I thought I should come in and see you." (do not state the fact you have had altered discharge - the candidate must specifically ask)

Appearance and behaviour

Act embarrassed at the start of the consultation but respond well to any reassurance from the doctor relating to privacy and confidentiality.

Presenting Complaint (bleeding)

Site / main symptom – main presenting complaint is discharge from the vagina.
Onset - It started 1 week ago
Character - You’re having to use pads to stop the discharge, it’s not soaking through but it’s definitely there all the time. It is yellow. It has no smell. There is no blood.
Radiation - No urinary symptoms and the discharge is definitely from the vagina and not the urethra. No anal symptoms, no throat symptoms.
Associated symptoms - you have pain during sex since the discharge started but none at rest. You have never had pain during sex before this discharge started.
Associated symptoms - itch is present, no rashes, no ulcers, no dysuria
Timing - it’s only been a week so you haven't noticed if it’s worse in different parts of your cycle but you wouldn’t usually have discharge like this at this point in your cycle.
Exacerbating factors - none
Severity - You have stopped going out because you are embarrassed that the discharge might start to smell.

Gynae History

Last menstrual period - 18 months ago, you’ve not had periods since starting the COCP.
Age of menarche - 16
Relevant sexual history/current status - you broke up with your ex-boyfriend 5 weeks ago as you had unresolvable differences around having children. You were together for 3 years. You have had unprotected sex with 1 casual male partner since the breakup. You do not know if your recent casual partner has had symptoms because you were too embarrassed to ask him.
Type of sex - vaginal sex only, no oral sex, all sex had been consensual.
STI status - you’ve never been tested
Contraception - you are on the COCP which you like very much because it stopped your periods. You are very good at taking the COCP despite your busy lifestyle - you have an app that reminds you. You do not like condoms and you think it is unlikely you will catch anything because “I only sleep with people I know”.
Smear status - the last was 6 months ago it was normal
BBV (blood bourne virus) screen - never paid for sex, never had tattoos/piercings overseas, never used IV drugs, never has sex abroad, you have had your Hepatitis A, B, and HPV jabs.

Obs History

Any previous pregnancies - no, you do not want kids and it’s why you and your partner split up
Any previous terminations of pregnancy - no
Pregnancy test - you have taken a test this week and it was negative

Past Medical and Drug History

Previous similar episodes - none
Other medical conditions - occasional migraines (with no aura)
Previous surgeries - none
Prescribed medications - none
Over the counter - you occasionally take paracetamol for headaches
Allergies - none

Family History

None relevant

Social History

Smoking history - none
Alcohol - 4-5 glasses of wine at the weekend with friends
Home - living alone, independent with daily living
Job - financial adviser
Relationships - feels happy and secure with recent sexual relationships

Systems Review

General/red flags - NO fevers and feels well in yourself
Period - NO change in periods (no periods since the pill was started)
Rectal symptoms - NO change in bowel habits, NO bleeding, NO pruritis
Throat - NO cough, NO sputum/discharge, NO pain, NO ulcers
Breast - NO breast tenderness or discharge
Skin - NO rashes

Ideas / Concerns / Expectation

Ideas - you’re not sure if the pill protects against STIs
Concerns - you’re worried it might be an STI
Expectations - you have no idea if STIs can be treated

Discussion and Questions

As the station ends the candidate will explain the diagnosis to you. Be receptive, but shocked. If they ask for any questions ask;

1. “Can it be treated?”

2. “Can I have sex again?”

3. “Does my pill not protect me?”