Door prompt
Setting: Emergency department
Patient: Ms. Priya Rahman, 29 years old
Presenting concern: Lower abdominal pain and light vaginal bleeding in early pregnancy.
Your task: Take a focused history, explain your initial impression, and discuss the immediate investigations and next steps. You do not need to perform a physical examination, but you should describe the focused examination you would complete.
Candidate instructions
- Open with introduction, identity confirmation, consent, privacy, and a brief agenda.
- Clarify gestational age, last menstrual period, pregnancy test status, pain features, and bleeding severity.
- Prioritize ectopic pregnancy and hemodynamic instability.
- Ask reproductive, gynecologic, STI/PID, fertility treatment, surgical, medication, allergy, and Rh status history.
- State urgent investigations: vital signs, pregnancy confirmation, quantitative serum β-hCG, CBC, blood group/Rh, type and screen, and transvaginal ultrasound.
- Use clear, calm, patient-centred language and provide safety-net advice.
Examiner checklist
Focused history
- Confirms identity, obtains consent, and ensures privacy for sensitive reproductive history.
- Asks last menstrual period, estimated gestational age, home/clinic pregnancy test, and whether an intrauterine pregnancy has been confirmed.
- Characterizes pain: onset, location, unilateral/bilateral, severity, radiation, shoulder-tip pain, triggers, progression, and associated symptoms.
- Clarifies bleeding: amount, clots/tissue, pad count, duration, dizziness, syncope, fever, discharge, urinary symptoms, and gastrointestinal symptoms.
- Screens for ectopic risk: previous ectopic pregnancy, PID/STIs, tubal surgery, pelvic surgery, infertility treatment/assisted reproduction, IUD use, and smoking.
- Reviews obstetric history: gravidity/parity, miscarriages, terminations, complications, and current pregnancy care.
- Asks medications, anticoagulants, allergies, medical history, and Rh status if known.
Assessment and management
- States that ectopic pregnancy must be excluded urgently in early pregnancy pain/bleeding.
- Describes focused exam: vitals, general appearance, abdominal tenderness/peritoneal signs, pelvic/speculum/bimanual exam with consent and appropriate chaperone when indicated.
- Orders quantitative serum β-hCG, CBC, blood group/Rh, type and screen, urinalysis, and transvaginal ultrasound.
- If unstable: calls for urgent help, establishes IV access, gives fluid/blood resuscitation as needed, keeps patient NPO, and urgently involves OB/GYN/surgery.
- If stable: explains the need for ultrasound/serial β-hCG depending on findings and close follow-up until pregnancy location is confirmed.
- Addresses analgesia, antiemetics if needed, Rh immune globulin if Rh-negative with bleeding according to local protocol, and clear return precautions.
Oral questions
1. What are your top differential diagnoses?
Ectopic pregnancy, threatened miscarriage, early pregnancy loss, corpus luteum cyst rupture, ovarian torsion, pelvic inflammatory disease, urinary tract infection, appendicitis, and gastroenteritis. Ectopic pregnancy is the time-sensitive diagnosis because it can cause life-threatening intra-abdominal bleeding.
2. What initial investigations are required?
Vital signs and hemodynamic assessment, quantitative serum β-hCG, CBC, blood group/Rh, type and screen, urinalysis as indicated, and transvaginal pelvic ultrasound. If the patient is unstable, resuscitation and urgent gynecology/surgical involvement should not be delayed while awaiting all results.
3. How would you explain the situation to the patient?
“Because you are pregnant and have abdominal pain with bleeding, we need to urgently confirm where the pregnancy is located. Most causes are treatable, but a pregnancy outside the uterus can be dangerous if it bleeds internally. We will check your blood work and perform an ultrasound today, monitor your vital signs, control your pain, and involve the gynecology team if needed.”
4. What discharge or safety-net advice is essential if she is stable?
Return immediately for worsening abdominal or shoulder-tip pain, fainting, severe dizziness, heavy bleeding, fever, or feeling clinically unwell. She should avoid being alone if symptoms are evolving, attend all repeat β-hCG/ultrasound appointments, and avoid intercourse or strenuous activity until the cause is clarified if advised by the treating team.
Scoring feedback
Strong performance
You identify ectopic pregnancy as a must-not-miss diagnosis, assess stability early, ask key risk factors, order β-hCG plus transvaginal ultrasound, and communicate the plan without alarming or minimizing the patient’s symptoms.
Common unsafe omissions
Failure to ask pregnancy status/gestational age, delaying urgent care in an unstable patient, omitting Rh status, forgetting ectopic risk factors, or giving simple reassurance before confirming pregnancy location.