History Taking · Foundation · O&G

Sudden Onset Lower Abdominal Pain with Vaginal Bleeding

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

Clinical scenario

You are an FY2 doctor in a GP surgery. Miss Zoya Khan, a 29-year-old woman, has come in with sudden onset sharp left-sided lower abdominal pain and light vaginal bleeding. She thinks she might be pregnant but is unsure of her dates. Please take a focused history and discuss your assessment and next steps.

Background notes: PMH: Irregular menstrual cycles (25-35 days), Appendectomy age 12

What this station tests

  • Pregnancy test as the immediate first step: ectopic is the life-threatening diagnosis to exclude
  • Haemodynamic assessment: tachycardia and hypotension suggest rupture requiring emergency surgery
  • Shoulder tip pain as a late sign: diaphragmatic irritation from intraperitoneal blood
  • Risk factors: previous surgery, PID, IUD, previous ectopic, smoking, assisted conception
  • Three management options: expectant, methotrexate, or surgery depending on stability and hCG

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

Unilateral lower abdominal pain with vaginal bleeding in a woman of childbearing age is ectopic pregnancy until proven otherwise. This is life-threatening. Miss Khan is 29, with sudden left-sided pain and light bleeding. She thinks she might be pregnant. Open with: 'Miss Khan, sudden abdominal pain like this in a woman who might be pregnant is something we treat as urgent. I need to check a pregnancy test right now.'

Core approach

Pregnancy test immediately. If positive with unilateral pain and bleeding: ectopic pregnancy is the working diagnosis. Assess haemodynamic stability: is she pale, tachycardic, hypotensive? These suggest rupture and internal bleeding (surgical emergency). If stable: urgent USS and serum beta-hCG.

Her history supports ectopic risk. Irregular cycles (may have missed the pregnancy). Pain is sudden, sharp, left-sided, constant. Light vaginal bleeding (not heavy like miscarriage). She may have shoulder tip pain (diaphragmatic irritation from blood in the peritoneum, a late and sinister sign). Previous appendicectomy (pelvic surgery is an ectopic risk factor). PID history, IUD use, previous ectopic, smoking, and assisted conception are other risk factors: ask about these.

She is frightened. She thinks she is having a miscarriage. Ectopic is different and more dangerous: the pregnancy is in the fallopian tube and can rupture causing life-threatening internal bleeding.

Closing and safety netting

If stable: urgent transvaginal USS and serum beta-hCG. Refer to early pregnancy assessment unit (EPAU) today. If ectopic confirmed: treatment depends on size, hCG level, and symptoms: expectant management (very early, falling hCG), methotrexate (medical management), or laparoscopic salpingectomy (surgical).

If unstable (tachycardia, hypotension, severe pain): emergency surgical referral, do not wait for USS. Two large-bore cannulae, crossmatch, IV fluids.

Explain sensitively: 'If the pregnancy test is positive, the pain and bleeding suggest the pregnancy may be in the wrong place, in your tube instead of your womb. This needs urgent assessment and treatment.' Safety net: 'If you feel faint, develop shoulder pain, or the pain becomes much worse, call 999.'

How examiners mark this station

Examiners will focus on the thoroughness and structure of your history taking for ectopic pregnancy. 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. Haemodynamic assessment. Shoulder tip pain asked. Risk factors checked. LMP and contraception.

Costs marks: No pregnancy test. Not assessing stability. Missing risk factors.

Domain 2 (Primary focus)

Scores well: Urgent EPAU referral. USS and beta-hCG. Emergency pathway if unstable. Three treatment options known.

Costs marks: Delayed referral. No hCG. Outpatient management of suspected ectopic.

Domain 3 (Throughout)

Scores well: Explaining sensitively. Using 'pregnancy in the wrong place' rather than jargon. Addressing her fear. Clear 999 safety netting.

Costs marks: Being blunt. Not explaining what ectopic means. Vague safety netting.

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 kills and must be excluded immediately
  2. Not assessing haemodynamic stability: a ruptured ectopic needs emergency surgery, not USS
  3. Not asking about shoulder tip pain: this is a sinister sign indicating intraperitoneal bleeding

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 do I approach the consultation in this ectopic pregnancy station?

Unilateral lower abdominal pain with vaginal bleeding in a woman of childbearing age is ectopic pregnancy until proven otherwise. This is life-threatening. Miss Khan is 29, with sudden left-sided pain and light bleeding.

What does a strong performance look like to the examiner in this station?

Strong performances show: Pregnancy test first. Haemodynamic assessment. Shoulder tip pain asked. Risk factors checked. LMP and contraception. Weak performances: No pregnancy test. Not assessing stability. Missing risk factors.

What is the biggest pitfall in this ectopic pregnancy station?

Not checking pregnancy test first: ectopic kills and must be excluded immediately. Another frequent error: Not assessing haemodynamic stability: a ruptured ectopic needs emergency surgery, not USS.

How should I prepare for ectopic pregnancy if I have never seen it in practice?

This station rewards process over personal experience. The skill being assessed: Haemodynamic assessment: tachycardia and hypotension suggest rupture requiring emergency surgery. Use the domain breakdown on this page to target your preparation, then practise the station aloud so your structure survives exam pressure.

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