History Taking · Intermediate · O&G

Offensive Vaginal Discharge with Pelvic Pain

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

Clinical scenario

You are an FY2 doctor in a GP surgery. Miss Wanda Schulz, a 28-year-old woman, has presented with a complaint of offensive vaginal discharge for one week and lower abdominal pain. She is embarrassed about the symptom. Please take a focused history to determine the likely cause (including consideration of retained foreign body, infection, STI), perform appropriate examination and investigation, and discuss your management plan with the patient.

Background notes: PMH: Healthy, no significant illness. Last cervical smear 2 years ago (normal). No IUD. No previous STI

What this station tests

  • Distinguishing BV (discharge only) from PID (discharge plus pain plus tenderness): critical for management
  • Empirical PID treatment without waiting for results: delay risks tubal damage
  • Triple antibiotic regimen for PID: ceftriaxone plus doxycycline plus metronidazole
  • Cervical motion tenderness as the key clinical finding for PID
  • Fertility implications of untreated PID: tubal damage and ectopic risk

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

Offensive vaginal discharge with pelvic pain in a sexually active woman raises concern for PID alongside BV. The candidate must distinguish between them because PID requires urgent treatment to prevent tubal damage and infertility. Miss Schulz is 28, with 1 week of offensive discharge and lower abdominal pain. Open with: 'Miss Schulz, tell me about the discharge and the pain. When did each start?'

Core approach

Characterise both symptoms. Discharge: offensive fishy smell, thin grey-white (consistent with BV). Pain: bilateral lower abdominal, dull, constant, worse with movement. The combination of offensive discharge PLUS pelvic pain PLUS tenderness raises PID as a concern. BV alone does not cause pelvic pain.

Assess for PID features. Cervical motion tenderness (the key clinical finding), adnexal tenderness, fever. If present: treat as PID (do not wait for culture results). Ask about deep dyspareunia, intermenstrual bleeding, post-coital bleeding. Sexual history: new partner, unprotected sex.

Distinguish: BV alone (discharge, no pain, no fever) versus PID (discharge, pain, tenderness, possible fever). They can coexist. PID is usually caused by chlamydia or gonorrhoea ascending from the cervix.

Closing and safety netting

If PID suspected: empirical antibiotic treatment immediately (do not wait for results). Typical regimen: IM ceftriaxone 1g stat plus oral doxycycline 100mg BD for 14 days plus oral metronidazole 400mg BD for 14 days. This covers gonorrhoea, chlamydia, and anaerobes. Send endocervical swabs for NAAT.

If BV only (no pain, no tenderness): metronidazole alone for 5 to 7 days. Partner notification if PID is diagnosed. Safety net: 'If you develop severe pain, high fever, or feel significantly worse, go to A&E as you may need IV antibiotics.' Fertility counselling: untreated PID can damage the fallopian tubes. Follow-up in 72 hours to check response.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for bacterial vaginosis. 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: BV versus PID distinguished. Pelvic tenderness assessed. Sexual history taken. CMT checked. STI screen sent.

Costs marks: Not distinguishing BV from PID. Not assessing tenderness. No sexual history.

Domain 2 (Primary focus)

Scores well: Empirical PID treatment started. Triple antibiotic regimen correct. Partner notification. Fertility counselling. 72-hour follow-up.

Costs marks: Treating as BV alone. Waiting for results. No partner notification.

Domain 3 (Throughout)

Scores well: Sensitive sexual history. Addressing embarrassment. Explaining fertility risk without alarming. Partner notification sensitively.

Costs marks: Judgmental. Not explaining fertility risk. Insensitive about partner notification.

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. Treating as BV when pelvic pain is present: pain plus tenderness suggests PID which needs broader antibiotics
  2. Waiting for culture results before treating PID: delay increases tubal damage risk
  3. Not mentioning fertility implications: untreated or delayed PID can cause infertility

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

What is the best way to take a bacterial vaginosis history in PLAB 2?

Offensive vaginal discharge with pelvic pain in a sexually active woman raises concern for PID alongside BV. The candidate must distinguish between them because PID requires urgent treatment to prevent tubal damage and infertility. Miss Schulz is 28, with 1 week of offensive discharge and lower abdominal pain.

Where are marks won and lost in this bacterial vaginosis station?

Examiners reward: BV versus PID distinguished. Pelvic tenderness assessed. Sexual history taken. CMT checked. STI screen sent. Candidates are penalised for: Not distinguishing BV from PID. Not assessing tenderness. No sexual history.

Where do candidates most often go wrong in this station?

Treating as BV when pelvic pain is present: pain plus tenderness suggests PID which needs broader antibiotics.

Can I do well in this station without real-world experience of bacterial vaginosis?

This station rewards process over personal experience. The skill being assessed: Empirical PID treatment without waiting for results: delay risks tubal damage. 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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