Where you are:
You are an FY2 two doctor in obstetrics and gynecology.Who your patient is?:
Chloe Jerkins as 18 year old lady who has presented with right sided lower abdominal pain.Other Information you have about this patient:
A urine pregnant test is positive. An ultrasound scan has been requested but not yet done.
The hospital protocol states that patient cannot be allowed to leave without an USS.
But an ultrasound cannot be done until next morning.What you must do:
Assess the patient and discuss further management.
Patient information:
- Opening sentence “ Doctor, can I go home now?”
- You are an 18-year-old lady who has presented to the emergency department with right side lower abdominal pain.
- The nurse has performed a urine test on you which has turned out positive
- You performed a pregnancy test at home and you know that you are pregnant
- You suspected that you could be pregnant because your periods are late by 2 weeks.
- You spoke to your boyfriend about this but he acted angrily .
- You do not want your parents to know about your pregnancy as they do not know that you are even sexually active.
- You are not keen to get admitted because your parents would know in such a case.
- If the doctor asks you to discuss with your parents tell her/him that you do not want but if the doctor persists then say ‘I will think about it but at the moment you do not want to do so”.
- At the age of 14 you had chlamydia infections. Your boyfriend is also 21 year of age.
- Your last menstrual period was 6 weeks ago
- She has got spotting per vaginal.
- If the doctor says you need a scan, tell him that “but the scan is due till tomorrow morning, Can i come back tomorrow”
- If the doctors talks about the complications.
- Tell the doctor that “ I live close by, if i have any problem i will come back”
- When you told your boyfriend about it he was not happy and you had a fight with him.
Emotions And Attitude
- You are sitting on the couch, with a canula in your arm and you are wearing a hospital gown.
- You are upset if the doctor says that, your pregnancy could burst and you are crying.
- If the doctor explains well, You agree.
Scenario B:
- You did a pregnancy test at home and it was positive. Therefore, you know that you are pregnant. * You came to hospital because of tummy pains.
Examiner’s Prompt:
Scenario A
- If the candidate says that he/she would like to peform abdominal examination, Please tell them that examination is normal.
Scenario B
- You should allow the candidate to examine the patient
- When the doctor says “I would like to examine you”, You should take off your top and lie on the couch immediately.
Approach:
- GRIPS: Loud, confident, smile. Use a supportive and understanding approach.
- How can I help? Or What brought you to the hospital today?
- History taking:
- SOCRATES
- Is there anything you think could be the cause of your tummy pains?
- Is there any chance you could be pregnant?
- Offer confidentiality (If you feel that the patient is with holding the information)
- Ask about PV discharge or bleeding
- Differential diagnosis (Appendicitis,PID, Gastroenteritis, UTI, ectopic pregnancy)
- Personal history: Menstrual history andSexual history and previous STI
- Explain that you suspected an ectopic pregnancy i.e. pregnancy outside the womb.
- Check for the risk of ectopic pregnancy (previous STI or use of an IUCD)
- P3MAFTOSA
- Explain that you would like to perform an examination of the tummy and also perform an USG to confirm.
- Examinations: Observations,( temperature,bp,pulse,hr,rr,o2 sats) abdominal exam (pain)
- Pv exam (cervical tenderness)
Diagnosis
- Explain that you are suspecting a condition called ectopic pregnancy. This is a condition in which the pregnancy is located outside the womb. This is why she is experiencing this type of pain.
- Explain that the chlamydia infection that you had at the age of 16 has contributed to you have an ectopic pregnancy, because it’s a risk factor for ectopic pregnancy.
Managemnet
- USS would confirm whether it is inside the womb or not. Explain that the Ultrasound has been requested but it can’t be done until the morning. But this condition needs monitoring until the scan can be done.
- Would it be okay for you in stay in the hospital until tomorrow so that we can keep a close eye on you?
- If the patient is afraid that the parent would know –explain that her parents were also her age once and they may understand what she is going through.
- But reassure her that everything we are discussing would remain confidential .You will not inform her parents unless she tells you herself.
- Ask if the boyfriend knows that she is in the hospital?
- Ask if the boyfriend can come and support her?
- Do your parents know that you are in a sexual relationship?
- Ask if there is any particular reason why she did not inform her parents.
- Explain that the parents were also of her age and they may understand.
- They may be supportive in this situation.
- Explain that the scan cannot be performed until tomorrow morning. Unfortunately, and it is dangerous for you to go home and stay in place where you are not monitored.
Management:
Urgent USG because if pregnancy is outside it can burst anytime and cause serious complications.
- If pregnancy is outside the womb we would like to do Laprascopic key hole surgery to locate and remove it.
- Is it ok if you were admitted?
No I cannot stay because I don’t want my parents to know about it. They do not know that I am sexually active. - Is it ok if you could inform your parents?
I do not know Doctor. - At the moment is it ok if you stay at the hospital? Because if we do not do the investigations and treat you there will be a lot of complications such as bleeding, infertility, ectopic pregnancy, dysmenorrhoea and risk to life.
- Laparoscopy is what is required now needed.
- Advise her to inform the parents.
Reassure about confidentiality:
- if she does not want to tell her parents, even the medical team will not inform them.