History Taking · Intermediate · O&G

Right-Sided Abdominal Pain in Woman of Childbearing Age

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

Clinical scenario

You are an FY2 doctor in an acute gynaecology clinic. Ms Farah Saleh, a 28-year-old woman, presents with acute right iliac fossa pain. She appears uncomfortable and is guarding her abdomen. Please take a focused history and discuss your differential diagnosis and initial management plan.

Background notes: PMH: Nil significant, General health good

What this station tests

  • Pregnancy test as the first investigation in any woman of childbearing age with abdominal pain
  • Ectopic pregnancy as the life-threatening differential that must be excluded before considering appendicitis
  • Classic appendicitis migration: periumbilical pain migrating to RIF
  • Broad differential in young women: appendicitis, ectopic, ovarian torsion, ruptured cyst, PID, UTI
  • USS to assess both appendix and adnexae in one investigation

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

Right iliac fossa pain in a woman of childbearing age has a wide differential: appendicitis, ectopic pregnancy, ovarian pathology, and UTI all present similarly. The candidate must exclude ectopic pregnancy first (life-threatening). Ms Saleh is 28, sexually active, with acute RIF pain since 3am. Open with: 'Ms Saleh, I need to ask you some important questions. When was your last period, and is there any chance you could be pregnant?'

Core approach

Pregnancy test first. Before anything else, establish pregnancy status. A positive test with unilateral abdominal pain shifts the differential to ectopic pregnancy (emergency). She is sexually active with her boyfriend. Ask about contraception use (reliability), last menstrual period (when, normal?), and any vaginal bleeding.

If pregnancy test negative: the differential narrows. Appendicitis: pain started periumbilically and migrated to RIF (classic migration), anorexia, nausea, low-grade fever. Ovarian cyst torsion or rupture: sudden onset, may be cyclical, associated with nausea. Ovarian cyst: may be known or new. UTI: dysuria, frequency. PID: bilateral lower abdominal pain, vaginal discharge, cervical motion tenderness.

Her symptoms (sudden onset at 3am, RIF localised, anorexia, nausea, low-grade fever) are most consistent with appendicitis. But the gynaecological differential must be excluded with pregnancy test, urinalysis, and pelvic USS if indicated.

Closing and safety netting

Investigations: urine pregnancy test (first), urinalysis, bloods (FBC, CRP, U&E), and USS (to assess appendix and adnexae). If appendicitis confirmed: surgical referral for appendicectomy. If ectopic: emergency gynaecology. If ovarian pathology: gynaecology review.

Explain: 'The pain pattern is most suggestive of appendicitis, but in any woman of your age we must first check a pregnancy test and look at the ovaries with an ultrasound to be thorough.' Safety net: 'If the pain becomes much worse, you develop severe vomiting, or you feel faint, tell the nurse immediately.' She needs to remain in the department until investigations are complete.

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for acute appendicitis. 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: Pregnancy test first. LMP and contraception asked. Pain migration established. Full differential considered. Gynaecological history taken.

Costs marks: No pregnancy test. Not asking LMP. Narrow differential.

Domain 2 (Primary focus)

Scores well: Pregnancy test, bloods, USS arranged. Surgical and gynae pathways understood. Appropriate safety netting. Patient kept in department.

Costs marks: Sending home before results. No USS. Missing ectopic.

Domain 3 (Throughout)

Scores well: Explaining why pregnancy test is needed sensitively. Addressing her appendicitis fear. Keeping her informed about the process.

Costs marks: Not explaining the pregnancy test. Being vague about the plan.

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. Not checking pregnancy test first: ectopic pregnancy can kill, and must be excluded before other diagnoses
  2. Assuming appendicitis without considering gynaecological causes: ovarian torsion and ectopic present similarly
  3. Not asking about last menstrual period and contraception: essential history in any woman of childbearing age with abdominal pain

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 an acute appendicitis history in PLAB 2?

Right iliac fossa pain in a woman of childbearing age has a wide differential: appendicitis, ectopic pregnancy, ovarian pathology, and UTI all present similarly. The candidate must exclude ectopic pregnancy first (life-threatening). Ms Saleh is 28, sexually active, with acute RIF pain since 3am.

Where are marks won and lost in this acute appendicitis station?

Examiners reward: Pregnancy test first. LMP and contraception asked. Pain migration established. Full differential considered. Gynaecological history taken. Candidates are penalised for: No pregnancy test. Not asking LMP. Narrow differential.

Where do candidates most often go wrong in this station?

Not checking pregnancy test first: ectopic pregnancy can kill, and must be excluded before other diagnoses.

Can I do well in this station without real-world experience of acute appendicitis?

This station rewards process over personal experience. The skill being assessed: Ectopic pregnancy as the life-threatening differential that must be excluded before considering appendicitis. 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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