History Taking · Intermediate · O&G

Headache and Hypertension in Pregnancy

Practise this PLAB 2 history taking station on Pre-eclampsia. 8-minute voice AI simulation with feedback on all 3 marking domains.

Clinical scenario

You are an FY2 doctor in the antenatal clinic. Mrs Natalie Washington, a 34-year-old woman at 32 weeks gestation, has come for her routine antenatal appointment. She mentions a severe headache and you note her blood pressure is elevated. Please take a focused history and discuss your management plan.

Background notes: PMH: Nil significant

What this station tests

  • Checking BP immediately when headache is reported after 20 weeks: do not take a full history first
  • Severity features: visual disturbance, epigastric pain, oedema, clonus, reduced fetal movements
  • Magnesium sulphate for seizure prevention in severe pre-eclampsia
  • Delivery as the only cure: balancing maternal safety with fetal maturity
  • Steroids for fetal lung maturity if delivery before 34 weeks is anticipated

How to use your 8 minutes

  • 0-1 min — Introduction: Introduce yourself, confirm identity, open question. 'What's brought you in today?'
  • 1-4 min — Systematic History: Presenting complaint detail (SOCRATES for pain, timeline, severity). Systems review. PMH, medications, allergies.
  • 4-6 min — Context and ICE: Social history (smoking, alcohol, occupation, living situation). Family history. Ideas, Concerns, Expectations.
  • 6-7 min — Summary and Plan: Summarise findings back to patient. Share differential/working diagnosis. Outline investigation and management plan.
  • 7-8 min — Closing: Safety netting with specific red flags. Arrange follow-up. Check for questions.

Consultation approach

The opening

New hypertension with headache after 20 weeks gestation is pre-eclampsia until proven otherwise. This is an obstetric emergency that can progress to eclampsia (seizures), HELLP syndrome, and maternal or fetal death. Mrs Washington is 34, 32 weeks, at a routine appointment, mentioning a severe headache since yesterday. Open with: 'Mrs Washington, a severe headache at this stage of pregnancy is something we take very seriously. Let me check your blood pressure right now.'

Core approach

Check BP immediately (do not take a full history first). If systolic is 140 or above or diastolic is 90 or above: this is pregnancy-induced hypertension and with symptoms (headache), pre-eclampsia is the working diagnosis. Check for proteinuria (urine dipstick or protein:creatinine ratio).

Screen for severity features. Severe headache (present). Visual disturbance (flashing lights, blurred vision)? Epigastric or right upper quadrant pain (liver involvement)? Sudden oedema (face, hands)? Brisk reflexes or clonus? Reduced fetal movements? These indicate severe pre-eclampsia needing immediate hospital admission.

This is her first pregnancy (nulliparity is a risk factor). Other risk factors: age over 35, BMI, family history of pre-eclampsia, autoimmune conditions.

She is terrified about the baby. Address this: fetal monitoring (CTG) and growth assessment (USS) are immediate priorities alongside maternal stabilisation.

Closing and safety netting

If BP is elevated with symptoms: urgent hospital admission today. She needs: bloods (FBC, U&E, LFTs, urate, clotting), urine PCR, fetal CTG, and senior obstetric review. Labetalol or nifedipine for BP control. Magnesium sulphate if severe features are present (prevents eclamptic seizures). Steroids (betamethasone) for fetal lung maturity if delivery before 34 weeks may be needed.

Explain honestly: 'Pre-eclampsia is a condition where your blood pressure rises and can affect your organs and the baby. The only cure is delivery, but at 32 weeks we want to gain as much time as possible for the baby while keeping you safe.' Safety net: she is being admitted. Involve her husband.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for pre-eclampsia. Domain 1 (Data Gathering) carries the most weight: expect marks for systematic coverage of presenting complaint, red flags, PMH, medications, social and family history. Domain 2 (Clinical Management) requires a clear differential, appropriate investigations, and a safe management plan with safety netting. Domain 3 (Interpersonal Skills) is assessed throughout: genuine exploration of ICE, active listening, empathic responses, and clear communication without jargon.

Domain 1 (Primary focus)

Scores well: BP checked immediately. Severity features screened. Proteinuria tested. Fetal wellbeing assessed. Risk factors noted.

Costs marks: Delayed BP. Not screening severity. Not checking proteinuria.

Domain 2 (Primary focus)

Scores well: Admission arranged. Bloods and CTG. Antihypertensive started. MgSO4 if severe. Steroids for fetal lungs. Senior obstetric review.

Costs marks: Outpatient management. No MgSO4. No steroids. No admission.

Domain 3 (Throughout)

Scores well: Addressing baby concern immediately. Honest about delivery being the cure. Involving husband. Calm, decisive manner.

Costs marks: Not addressing baby concern. Being evasive about delivery. Not involving partner.

Common examiner feedback (and how to fix it)

Did not gather sufficient information to make an adequate assessment of the patient's condition

Fix: Use a consistent framework for every history. After covering the presenting complaint, systematically move through PMH, drug history, social history, family history, and ICE. Keep a mental checklist.

Did not identify the patient's problems and/or did not develop a management plan adequately

Fix: Reserve the final 2 minutes to summarise your findings, share your working diagnosis with the patient, and outline your investigation and management plan including safety netting.

Common mistakes in this station

  1. Taking a full history before checking BP: pre-eclampsia can progress to eclampsia rapidly
  2. Not screening for severity features: visual disturbance, epigastric pain, and clonus indicate severe disease
  3. Reassuring without admitting: pre-eclampsia with symptoms requires hospital admission, not outpatient management

Resitting PLAB 2?

If you have previously struggled with history taking stations, focus on building a consistent systematic framework that you apply to every case. Practise structuring your history into clear phases (presenting complaint, systems review, PMH, social, ICE) so that even under pressure, you cover all domains. Many resitters lose marks not on knowledge but on organisation and time management.

Example opening

Good morning/afternoon, my name is Dr [Name], I'm one of the doctors here today. Could I confirm your name and date of birth please? Thank you. So, what's brought you in to see me today?

Frequently asked questions

How should I structure the pre-eclampsia history in this PLAB 2 station?

New hypertension with headache after 20 weeks gestation is pre-eclampsia until proven otherwise. This is an obstetric emergency that can progress to eclampsia (seizures), HELLP syndrome, and maternal or fetal death. Mrs Washington is 34, 32 weeks, at a routine appointment, mentioning a severe headache since yesterday.

What are examiners marking in this pre-eclampsia station?

Marks are won for: BP checked immediately. Severity features screened. Proteinuria tested. Fetal wellbeing assessed. Risk factors noted. Marks are lost for: Delayed BP. Not screening severity. Not checking proteinuria.

What is the most common mistake candidates make in this pre-eclampsia station?

Taking a full history before checking BP: pre-eclampsia can progress to eclampsia rapidly. Another frequent error: Not screening for severity features: visual disturbance, epigastric pain, and clonus indicate severe disease.

How do I prepare for this station if I have not managed pre-eclampsia in clinical practice?

Structure beats experience here. Focus on severity features: visual disturbance, epigastric pain, oedema, clonus, reduced fetal movements. Work through the consultation approach above, then rehearse it aloud under the 8-minute time pressure so the structure holds up in the exam.

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