By Samanta Zahir (Foundation Year 1 Doctor)
Name
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Anna White
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DOB
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10/18/1991 (29 years)
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Gestation
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32+5 weeks
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History
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I noticed some blood passing from down below this morning, its not continuous but it has been 8 hours now. I'm quite worried about this bleeding. If asked: Fresh blood No clots No trigger Roughly 2 cups of blood Haven't felt the baby kick in the last couple of hours
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Current Pregnancy History
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All scans and tests Was told that my placenta was "low-lying" but they said it would move No other abnormalities found with tests/scans No hospital admissions
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Previous Obstetric History
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1 previous pregnancy: 5-year-old - Emergency c-section 2015 - foetal distress - No other complications before/after delivery No miscarriages/terminations
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Past Medical History
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-
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Past Surgical History
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C-section as above in 2015
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Systems Review
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-
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Drug History
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None |
Family History
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Father had a heart attack earlier this year - aged 62
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Social History (Occupation/ Smoking/ Alcohol/ Recreational drugs)
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Smoking - Never smoked Alcohol - rare, not during pregnancy Recreational drugs - no Occupation - Accountant Living situation - House, with husband and 5-year-old child
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Ideas, concerns, expectations
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I really don't know, I'm very worried about my baby. Is my baby going to be okay?
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0 | 1 | 2 | Markscheme |
Introduces self, washes hands | |||
Confirms patient's name & date of birth, establishes gestation |
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Gain's consent & builds rapport |
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History of presenting complaint |
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Onset, duration, progression |
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Bleeding: amount, colour, clots |
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Any other bleeding episodes |
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Associated symptoms: abdominal pain, headache, discharge |
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Fetal movements |
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Current obstetric history |
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Ultrasound scan – placental location |
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Complications – previous bleeding, Hospital admissions,
pre-eclampsia |
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Rhesus status |
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Past Obstetric History |
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Previous deliveries – year, gestation, mode of delivery, birth weight,
complications |
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Previous pregnancy losses – miscarriage, termination |
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Previous pregnancy histories: GDM, pre-eclampsia, APH |
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Cervical smears - previous abnormal results when last smear was
taken |
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General Medical History |
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Past medical history / Past Surgical History |
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Drug history & allergies |
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Family history – bleeding disorders, obstetric conditions e.g. GDM |
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Social history: Smoking, Alcohol, Living situation/support |
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Systems enquiry |
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Ideas, concerns, and expectations |
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Communication |
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Summarises back to patient |
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Avoids medical jargon |
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Thank patient and close consultation |
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Examiner Questions |
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Gives reasonable differential diagnoses: Placenta praevia, Placental
abruption, Bloody show, Ectropion, Vasa praevia |
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Investigations & management plan |
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Suggests appropriate investigations (Ultrasound, CTG, relevant blood tests [see below]) |
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Gives appropriate management plan (A-E assessment, senior review, anti-D, corticosteroids) |
Questions to candidates:
Q1. What are your differential diagnoses?- Placenta praevia
- Placental abruption
- Bloody show
- Ectropion
- Vasa praevia
- Major placenta praevia is when the placenta covers the internal cervical os
- Minor placenta praevia is when the leading edge of the palcenta is in the lower segment but not covering the internal cervical os
- Admit for observation and monitoring
- ABCDE approach to resuscitaton, which may include the following if indicated:
- Two large bore cannulas
- Bloods to include FBC, clotting profile, group & save, Kleihauer test, U&E, Liver function tests
- Obstetric Examination
- Ultrasound abdomen
- CTG
- Anti-D given within 72 hours of onset of bleeding if Rh-ve
- Antenatal corticosteroids if immediate delivery not indicated
- Senior review - emergency/elective c-secton