Anna's Vaginal Bleeding

 By Samanta Zahir (Foundation Year 1 Doctor)

Name	Anna White
DOB	10/18/1991 (29 years)
Gestation	32+5 weeks
History	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
Current Pregnancy History	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
Previous Obstetric History	1 previous pregnancy: 5-year-old - Emergency c-section 2015 - foetal distress - No other complications before/after delivery No miscarriages/terminations
Past Medical History	-
Past Surgical History	C-section as above in 2015
Systems Review	-
Drug History	None  No known allergies
Family History	Father had a heart attack earlier this year - aged 62
Social History   (Occupation/ Smoking/ Alcohol/ Recreational drugs)	Smoking - Never smoked Alcohol - rare, not during pregnancy  Recreational drugs - no  Occupation - Accountant  Living situation - House, with husband and 5-year-old child
Ideas, concerns, expectations	I really don't know, I'm very worried about my baby. Is my baby going to be okay?

0	1	2	Markscheme
			Introduces self, washes hands
			Confirms patient's name & date of birth, establishes gestation
			Gain's consent & builds rapport
			History of presenting complaint
			Onset, duration, progression
			Bleeding: amount, colour, clots
			Any other bleeding episodes
			Associated symptoms: abdominal pain, headache, discharge
			Fetal movements
			Current obstetric history
			Ultrasound scan – placental location
			Complications – previous bleeding, Hospital admissions, pre-eclampsia
			Rhesus status
			Past Obstetric History
			Previous deliveries – year, gestation, mode of delivery, birth weight, complications
			Previous pregnancy losses – miscarriage, termination
			Previous pregnancy histories: GDM, pre-eclampsia, APH
			Cervical smears - previous abnormal results when last smear was taken
			General Medical History
			Past medical history / Past Surgical History
			Drug history & allergies
			Family history – bleeding disorders, obstetric conditions e.g. GDM
			Social history: Smoking, Alcohol, Living situation/support
			Systems enquiry
			Ideas, concerns, and expectations
			Communication
			Summarises back to patient
			Avoids medical jargon
			Thank patient and close consultation
			Examiner Questions
			Gives reasonable differential diagnoses: Placenta praevia, Placental abruption, Bloody show, Ectropion, Vasa praevia
			Investigations & management plan
			Suggests appropriate investigations (Ultrasound, CTG, relevant blood tests [see below])
			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 

  Q2. What is the difference between major and minor placenta 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

  Q3. How would you manage this patient?

• 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

Chen's Suicide

By David Tang (5th year Medical Student)

Name	Chen Siu
DOB	04/11/1989 (28 years)
Occupation	Lawyer
History	Note for actor/actress: Quiet, silent, and expressionless. Not receptive to normal conversation. Not responsive if the interviewer is asking question at a normal, lively pace and tone. Unable to look at the interviewer in the face. Only answer if the questions are short and empathic. Do not volunteer information unprompted.  I want to die…  There’s no point in me living anymore. I left my family just to be with my partner…  Even she chose left me…  I have no one now. I am even bad at work. I could not concentrate, and I get agitated at my clients. My boss told me to take time off.  I took paracetamol… loads… enough to kill me I went to different pharmacies and buy them separately so that I won’t be found.  My colleagues at work came to check on me.  They got worried when they couldn’t get through to me.  They called the police.  I regret being found…  I would rather die. I left a note.  I want Dominica (my ex-partner) to regret that she left me…  I don’t see a point in living on…  I don’t know what to look forward to in life…  I have no interest in my job which I used to enjoy, I have no energy  They keep telling me that I’m worthless…  [When prompted about hallucinations] I hear voices, in my head… when no one is in the room. I can’t stop them talking to me. It happened after I lost Dominica…  [When prompted about what I want to do if I’m being sent home] I wanna go home. I don’t need to be in the hospital… I just want to lie in my bed and be away from people.  [When prompted about my intention on committing suicide] I’ll jump right in front of the tube. That ought to do the trick…
Past Medical History	None
Drug History	None. No allergies
Family History	Mother was quite depressed after I was born but this got better. She had a lot of complications with massive bleeds when I was born
Social History	Occasional alcohol, non-smoker. Work colleagues always have it together and there is no room for slacking. If they find out they will fire me. My mother went through so much to have me, she would not understand

Introduction & consent
Name, age, occupation
Establishes duration of thoughts on self harm or suicide attempt
Establishes triggers/stressors/life events
Explores planning for most recent occurrence e.g. finances, letter, buying equipment or medication
Asks if this has occurred previously
Explores any precautions made
Explores method used
Explores purpose
Explores expectation of lethality
Asks how they were found
Asks how they feel about it now
Asks how they feel about being alive
Explores views of the future
Asks if they are likely to harm themselves again and reasons why (not)
Screens core symptoms of depression (low mood, anergia, anhedonia)
Screens for cognitive symptoms: feeling hopeless, worthless, helpless, poor memory/concentration and guilty
Screens hallucinations or delusions
Explores available support
Identifies level of insight and willingness to accept treatment
Looks for substance misuse
Previous medical & psychiatric history
Family history of psychiatric or medical disorders
Drug history, alcohol, smoking and allergies
Ideas "Was there anything you thought it might be?"
Concerns "What about it is worrying you in particular?"
Expectations "Is there anything in particular you were hoping we would to today?"
Communication skills (empathy and avoids jargon)
Summarises back to patient
Classifies immediate risk of further self harm & suicide and whether patient can be safely discharged

Questions to candidates: 

Q1. How would you manage the patient?

I would ensure that the patient is physically stable. Then I’ll perform a mental state examination and take a full psychiatry history. I’ll assess the patient’s capacity if she refuses medical treatment. I will also refer the patient to liaison psychiatry team for further assessment of her depression.

 Q2. What are the risk factors of suicide?

• Life events and stressors 
• Extreme social class (Class I and V) 
• Social isolation 
• Stressful occupation 
•  History of mental health illnesses: depression, schizophrenia 
• Previous attempts of suicide and self-harms 
• Substance abuse and dependence 
• Personality disorder 
• Chronic physical illness 
• Family history of suicide

Holly's Anxiety

By David Tang (5th year Medical Student)

Name	Holly Ryman
DOB	06/10/1982 (35 years)
Occupation	Housewife
History	I am fit and well. I recently moved to this area with my husband and my son and I am now registered to this practice. I do not have any medical illness as far as I am concerned. Always fit and well.  [When asked about regular medications] However, I am currently taking 4mg of lorazepam daily for my ‘anxiety’ for two months now.  [When prompted] I have butterflies in my stomach and difficulty breathing. I also experience numbness and chest discomfort, almost like an out-of-body experience, as though my own body isn’t real. It has been around a year now since I first noticed the issue.  [Only if asked] The attack comes in episodes and it happens out of the blue and came unprovoked. It stops after 10 minutes or so but it’s difficult to get the timing right when I was in that state. It’s the worst feeling ever, and I wouldn’t wish my worst enemy to go through that. I find it difficult to concentrate because I keep worrying that the ‘episode’ will come back. No suicidal or self harm ideation. Initially very reluctant to appreciate this might be a "mental health" or "psychiatric" issue but is willing to accept help if persuaded convincingly. Beginning to use alcohol with the lorazepam to extend the effect.
Past Medical History	Glandular fever during university
Drug History	Vitamin D, Lorazepam
Family History	Father passed away from a stroke
Social History	Occasional alcohol, non-smoker, no support network as only recently moved to area

Introduction & consent
Name, age, occupation
Establishes duration of symptoms
Establishes triggers/stressors/life events
Explores pattern of anxiety
Explores content of obsessions
Screens if they are recurrent and unpleasant
Screens if they are resisted/senseless
Screens for physical symptoms of anxiety (sweating, palpitations, dry mouth, dizziness, nausea)
Screens psychological symptoms of anxiety (sleep, derealisation, fear, hypervigilance)
Explores methods to reveal anxiety (compulsions, substance misuse)
Explores views on consequences of behaviours
Screens for risk to others and self (including suicide)
Screens for depression (low mood, anergia, anhedonia)
Explores impact on occupation or social life
Explores available support
Identifies level of insight and willingness to accept treatment
Looks for substance misuse
Previous medical & psychiatric history
Family history of psychiatric or medical disorders
Drug history, alcohol, smoking and allergies
Ideas "Was there anything you thought it might be?"
Concerns "What about it is worrying you in particular?"
Expectations "Is there anything in particular you were hoping we would to today?"
Communication skills (empathy and avoids jargon)
Summarises back to patient
Gives reasonable differential diagnosis (Panic attack disorder, GAD, Depression, Organic)

Management point:

• Consider how the patient was dispensed with a 2-month supply of lorazepam (benzodiazepine). It is classed as a controlled drug and it should not be prescribed more than 30 days, unless in special circumstances. Most NHS trusts do not go beyond 14 days for prescriptions of controlled drugs. 
• Advise and education is important as psychoeducation improves patients’ understanding of their own illness. 
• A referral for psychotherapy such as cognitive behavioural therapy might benefit some patients.
• Other medications such as antidepressants and beta blockers can help to control the unpleasant adrenergic symptoms of panic attacks. Benzodiazepines are used to bridge the therapy until the antidepressant takes effect but often it should not be part of the long-term maintenance therapy. Expert psychiatry input can be sought regarding commencement and dosing of the medications. 

Top differentials: 

1. Panic disorder – characterised by episodes of unprovoked anxiety attacks like in this history rather than constant feelings of anxiety as in GAD. 
2. Generalised anxiety disorder – often, the feeling of anxiety spans a continuous duration of time in GAD 
3. Depression – if symptoms of affective disorders, ie depression preceded the panic attack or the criteria for diagnosis has been fulfilled, diagnosis of depression takes precedence. 
4. Substance abuse – withdrawal symptoms can often mimic episodic panic attacks 
5. Organic disorders – endocrine disorders such as phaeochromocytoma, paraganglioma, and carcinoid syndrome could mimic panic attacks.

Emma's Eating Disorder

By Yasser Al-Obudi (5th year Medical Student)

Name	Emma Smith
DOB	12/01/2001 (17 years)
Occupation	College Student
History	I was brought in by her mother. She is worried that I am using things to help look after myself [If pushed] I am looking after myself to lose weight. I am very proud of going from a size 14 to a size 8 because of how healthy I am feeling and looking. I have done so well in the last 6 months!  "I can't be ill, I'm doing so well in school". I am aiming for A* in my A-level exams and I am doing very well.  My mother doesn't know what a healthy diet is. It is important not to eat often and so I always tell my mum that I feel full. I refuse to open up about my diet, only stating that I eat very healthily.  [Very reluctantly] Becomes angry and agitated when asked. "Please don't ask stupid questions."  I have been unhappy with my looks since the age of 10. I always thought I was ugly, my friends just lie that I'm pretty to make me feel better.  [If asked about laxatives directly] I got some laxatives from the pharmacy because the food I was eating wasn't coming out. It is only for constipation. I sometimes take a couple of doses a day until I'm getting it all out.   [Physical symptoms] My periods have stopped. "It is ok, I checked - I'm not pregnant". Volleyball tires me out very quickly these days.  She denies vomiting up any food or using any illicit drugs. She denies any recent episode of self-harm or any suicidal thoughts. Her mood is good, and she enjoys going to school.
Past Medical History	General anxiety as a teenager Anaphylaxis (4 years ago) - unclear cause  1 episode of self-harm (cutting her arm) 6 years ago – but she regretted doing this
Drug History	None. Allergic to penicillin
Family History	None
Social History	Occasional cigarettes when hungry, no alcohol as that would be unhealthy.  Lives with mother, father and one younger brother in a five-bedroom house. Father runs a very successful business and mother is a primary school headteacher.  She regularly goes out with friends and is the captain of the girls’ volleyball team.

Introduction & consent
Name, age, occupation
Establishes duration of symptoms
Establishes triggers/stressors/life events
Explores pattern of eating disorder
Explores eating habits
Screens for vomiting and laxative abuse
Screens for exercise and drug use
Explores body image perception (body shape ideas, fear of fatness, perception of normal weight)
Screens for episodes of bingeing
Evidence of physical signs (cold, dizziness, weakness, thin hair)
Endocrine dysfunction (amenorrhoea, libido)
Explores views on consequences of behaviours
Looks for risk to self including suicide
Screens for Anxiety (feeling anxious, physical symptoms)
Screens for depression (low mood, anergia, anhedonia)
Explores impact on occupation or social life
Explores available support
Identifies level of insight and willingness to accept treatment
Looks for substance misuse
Previous medical & psychiatric history
Family history of psychiatric or medical disorders
Drug history, smoking and allergies
Ideas "Was there anything you thought it might be?"
Concerns "What about it is worrying you in particular?"
Expectations "Is there anything in particular you were hoping we would to today?"
Communication skills (empathy and avoids jargon)
Summarises back to patient
Gives reasonable differentials & discusses risk (Anorexia Nervosa, Body dysmorphia)