You are an FY2 in GP

Personal Details:

Name: Laura Williams

Age: 30

Medical Record:

Past medical history: Gravida 2, Para 1. Currently 23 weeks pregnant.

Regular medication: Nil

Allergies: None known.

Notes:

Laura, who is 23 weeks pregnant, presents with a one-week history of pain and bleeding when passing stools. She has also been constipated.

Task:

1. Take a focused history.

2. Address her concerns and discuss the likely diagnosis.

3. Examine the patient and discuss safe management options.

Opening Sentence: “Hi, Doctor, I’m having some problems when I go to the toilet. It’s really painful, and I’ve seen some blood.”

Open History (to give freely): “It’s been going on for about a week. I’ve been a bit constipated, and it really hurts to pass a stool. I’ve noticed bright red blood on the toilet paper afterwards. I had this in my first pregnancy, too.”

Cues to give: “I’ve just been using some cream I had left over from last time.”

ICE (Ideas, Concerns, Expectations):

Ideas: “I assume it’s just piles again, but it seems worse this time.”

Concerns: “Is the bleeding dangerous for the baby? How can you help me with the pain?”

Expectation: “I need something to stop the pain.”

How to Act: You are uncomfortable and in some pain, but you are also pragmatic, as you have experienced this before. Your main concern is safety during pregnancy.

More History (only if asked): The pain is sharp when you pass a stool and then becomes a dull ache. The blood is only a small amount, fresh and bright red, seen on the paper when you wipe. It is not mixed in with the stool. You have no abdominal pain, fever, or other symptoms. Your pregnancy is going well, and all your antenatal checks are up to date.

Social History: You are on maternity leave from your office job.

Questions to ask:

“Do you really need to examine me down there?”

“What can I do to stop this from happening?”

Examination findings when you verbalise that you want to examine the patient: Painful PR exam, tinge of blood on the gloves. No lumps or swelling.

Opening & Normalising the Symptom

Thank you for coming in. I know it can be embarrassing to talk about these things, but it’s a very common problem, especially in pregnancy, so you’ve done the right thing.

Tell me what’s been happening.

History of the Bleeding: You mentioned bleeding when you go to the toilet. When did this start? What colour is the blood? Is it bright red or a darker colour? How much blood is there? Is it on the paper, in the toilet bowl, or mixed in with the stool? Crucially, are you having any bleeding from the vagina?

Associated Symptoms: Is it painful when you pass a stool? What does the pain feel like? Have you noticed any lumps, bumps, or swelling around your back passage? Have you been feeling more constipated than usual? What are your stools like?

Pregnancy Context: And how many weeks pregnant are you now? How has the pregnancy been otherwise?

ICE (Ideas, Concerns, Expectations): What were your own thoughts about what could be causing the bleeding?

What was your biggest worry? Were you concerned it was related to the baby?

What were you hoping we could do for you today?

Explain the situation, the likely diagnosis or DD:

Thanks for coming in, Laura. It sounds very uncomfortable. Based on what you’re describing – the constipation, the sharp pain on passing stool, and the fresh, bright red blood on the paper – it is highly likely that you have haemorrhoids, or ‘piles’, and possibly a small tear called an anal fissure. These are incredibly common and often recur in pregnancy due to hormonal changes and the pressure from the growing baby.

Addressing and answering the patient’s ICE:

You’re worried about the baby, which is completely natural. I can reassure you that this type of bleeding is from the veins around your back passage and is not related to the baby or the pregnancy itself. It poses no danger to your little one. We can certainly help you manage the pain.

Examine the patient:

To be certain about the diagnosis and to make sure we’re not missing anything else, it would be best for me to have a quick and gentle look at the area. This would allow me to confirm the diagnosis and prescribe the most appropriate treatment. I will ask one of my colleagues to join me during the examination as a chaperone.

Self-help measures if relevant:

The most important thing is to tackle the constipation, as that’s what’s causing the problem. We need to make your stools softer so they are easier to pass. You can do this by drinking plenty of water, increasing the fibre in your diet with things like fruits, vegetables, and whole grains. I will also prescribe a pregnancy-safe laxative for you to help get things moving more comfortably. (You can give Fibogyle one sachet BD)

I can prescribe a cream that contains both a local anaesthetic and a mild steroid to help with the pain and inflammation (Anusol HC), which we know is safe to use. You should also avoid straining on the toilet and use moist toilet paper instead of dry to reduce irritation.

Addressing ideas, concerns, and expectations: Reassure her that the condition is common in pregnancy and not harmful to the baby. Explain the need for an examination and get her consent.

The management plan involves: 1. Explaining and consenting for a rectal examination. 2. Providing detailed lifestyle advice for constipation (diet, fluids). 3. Prescribing a pregnancy-safe laxative and topical haemorrhoid treatment.

What is scenario testing? This case tests the candidate’s ability to manage a common but uncomfortable problem in pregnancy. It requires good communication skills to explain the need for an intimate examination, knowledge of safe prescribing in pregnancy, and the ability to provide effective lifestyle and self-care advice.