You are an FY2 in the emergency department
Personal Details:
Name: Chloe Williams
Age: 32
Medical Record:
Past medical history: None significant.
Regular medication: None.
Allergies: None known.
Notes:
A 32-year-old woman presents to the Emergency Department with a 4-5 day history of lower abdominal pain.
Task:
1. Take a focused history.
2. Perform an abdominal examination.
3. Discuss the likely diagnosis and management plan.
Opening Sentence: “Doctor, I’ve got this awful pain in my lower tummy, and it’s just not going away.”
Open History (to give freely): “It’s been about five days now, a constant dull ache on the right side. Paracetamol isn’t touching it. I’ve also had this horrible greenish discharge, which smells bad. And it really hurts when my partner and I try to have sex – we’ve had to stop.”
Cues to give: “I’ve had this coil for about a year. Could it be something to do with that?”
ICE (Ideas, Concerns, Expectations):
Ideas: “I don’t know what it is. Maybe an infection?”
Concerns: “Is it related to the coil? Is my partner cheating on me? Could this affect me having kids in the future?”
Expectation: “I want to know what’s wrong and get it sorted out.”
How to Act: You are in discomfort. After the doctor discloses the possible diagnosis, you then show concerns about the possibility of your partner being unfaithful and the implications for your future fertility.
More History (only if asked):
You have been feeling hot and shivery.
You have been with your partner for two years and believe the relationship to be stable and monogamous. Your last period was two weeks ago and was normal. You have no fever or urinary symptoms. Your smear tests are up to date.
Social History: You are in a stable relationship.
Questions to ask:
“So it’s an infection? How did I get it?”
“Do I need to get the coil taken out?”
“Does my partner need treatment?”
Presenting Complaint (Pain): Tell me about the pain in your tummy. Where exactly is it? When did it start? Has it been getting worse? What does the pain feel like? Is it a sharp pain or a dull ache?
Gynaecological & Sexual History: You mentioned a discharge. Can you tell me more about that? What colour is it? You said it has a smell? You also said it hurts when you have sex. Is that a new problem?
When was the first day of your last period? Was it normal for you?
Is there any chance you could be pregnant? What do you use for contraception?
You mentioned a coil - when was that fitted? Have you had any bleeding between your periods or after sex?
Systemic & Other Symptoms: Have you had a fever or felt hot and shivery? Any pain when you pass urine or need to go more often?
ICE (Ideas, Concerns, Expectations):
What were your own thoughts about what could be causing this?
You mentioned a few worries. What is your biggest concern right now? Is it about the coil, your partner, or your future fertility?
What were you hoping we could do for you today?
Explain the situation, the likely diagnosis or DD:
Chloe, thank you for telling me all that. It sounds like you’ve been having a very uncomfortable time.”
(After examination, which would show lower abdominal tenderness)
Based on your symptoms – the lower abdominal pain, the vaginal discharge, and the pain during sex – the most likely diagnosis is a condition called Pelvic Inflammatory Disease, or PID. This is an infection of the female reproductive organs, like the womb, fallopian tubes, and ovaries.
Addressing and answering the patient’s ICE:
You asked how you might have got this and if your partner is cheating. PID is most often caused by a sexually transmitted infection, like chlamydia or gonorrhoea. However, it can also be caused by normal bacteria that live in the vagina, travelling up into the womb. The copper coil can slightly increase this risk, especially in the first few weeks after it’s put in. It doesn’t automatically mean your partner has been unfaithful, but it is something we need to test for.
Next Steps:
We need to do some tests today. I’ll need to take some swabs from your vagina to test for infections, and we’ll also do a urine test to rule out a urinary infection.
Because you had a proper period two weeks ago, which excludes the possibility of pregnancy.
We will start you on a course of antibiotics straight away, even before the results are back. It’s a combination of two different antibiotics that you’ll need to take for 14 days (Doxycycline 100 mg orally twice a day, Metronidazole: 400 mg orally three times a day for 14 days)
It is very important that your partner is also treated with antibiotics, regardless of the cause. You should both avoid having sex until you have both completed the full course of treatment. We don’t need to remove the coil unless your symptoms don’t improve with the antibiotics.
Answering the patient's question
You were worried about your future fertility. This is a very important point. If PID is not treated properly, it can cause scarring in the fallopian tubes, which can make it more difficult to get pregnant in the future. That’s why it’s so crucial that you take the full 14-day course of antibiotics, even if you start to feel better.
If your abdominal pain is getting worse, or you feel more unwell, sick or vomiting, this might mean that the infection is getting worse, so if this happens, please seek urgent advice.
Addressing ideas, concerns, and expectations: Provide a clear diagnosis. Address the sensitive question about infidelity honestly but gently. Emphasise the importance of treatment to preserve future fertility.
Prescribing/referral/reassurance: The management plan is: 1. Perform swabs and a urine test. 2. Start empirical antibiotic treatment immediately. 3. Advise on partner treatment and abstaining from sex. 4. Explain the importance of completing the course to protect fertility.
What is scenario testing? This case tests the candidate’s ability to diagnose a common gynaecological emergency. It requires sensitive communication about STIs and their implications. The key management point is to start empirical treatment immediately and to provide clear advice about partner notification and the importance of completing the treatment to prevent long-term complications like infertility.