OBGYN Station 1

Setting:

You are a junior doctor working in GP/family medicine. This patient presented with vaginal bleeding.

Name: Janet Stone

Tasks:

1. Take a focussed history from the patient.

2. Give your preferred diagnosis to the examiner.

3. Explain your management to the patient.

You are not required to examine the patient.

Briefing

Diagnosis: Endometrial Cancer
In this scenario we are asking you to role play a patient attending your GP after you noticed some vaginal bleeding.
Patient Name: Janet Stone (age: 65)

Opening statement

“I got my period again last week, but I thought I’d already been through menopause.”

Information to Give Freely

It started a couple of weeks ago and you think it’s very strange because nothing like this has happened since you went through the menopause.

Presenting Complaint (bleeding)

Site - Where exactly did the blood come from? - Vaginal bleeding (ie not from urethra).
Onset - How many times/when? - Intermittent - First episode was 2 weeks ago, second was 3 days ago.
Character -

Colour? - Dark red

Amount? - First episode: spotting on a pad, Second ep: filled 2 pads over the course of a day

Clots? - Not that you’ve noticed

Pain? - None

Radiation - Bleeding from any other areas? - No
Timing - How has it progressed over time? - There is now a larger amount of blood
Exacerbating/relieving factors - Has anything triggered it or made it better? (e.g. post coital) - No

How is it impacting your life - you're very worried about it. You've had to start using sanitary pads to stop the flow. You are getting through multiple per day.

Obs and Gynae History

At what age was your first period? - 9 years old
How long were your cycles? - 28 days
Were they regular - Yes
Any abnormalities or issues (eg menorrhagia) - No
When was your last period - 4 years ago (age 61)
Sexually active? - No
Last smear? - 2 years ago - normal
No previous pregnancy (including terminations)

Past Medical and Drug History

Previous similar episodes - None
Past medical - Diabetes Type 2 (on Metformin)
Past medical - Hypertension (on Ramipril)
Past medical - No history of Gynae conditions, or surgery.
Contraceptive use - you have only ever used condoms
No history of hormone replacement therapy, or tamoxifen use.
No Allergies

Family History

Breast cancer - none
Gynae cancer - none
Colorectal cancer - none

Social History

Smoking - ex smoker, 10 a day for 5 years (quit 40 years ago)
Alcohol - Half a glass of red wine on the weekend.
Home - You live alone in a bungalow
ADLs - You can self care well but the bleeding is starting to get in the way as you don't know when it will start.
Job - Teacher, now retired.

Systems Review

Nothing of note.

No infective symptoms.

Weight loss/night sweats/fevers - No

Anaemia Sx - No (no breathlessness, pallor, dizziness, or faints)

Deranged thyroid symptoms - No

Appetite change/abdo pain/bloating - No

Urinary symptoms/incontinence - No

Abnormal vaginal discharge - No

Vaginal dryness - No

Back pain - No

Ideas / Concerns / Expectation

Ideas - “Is it something to do with the menopause?”
Concerns - “There will be no way to stop the bleeding which will effect your daily life”
Expectations - “I just want to know how to stop the bleeding”

Discussion and Questions

After taking the history the candidate will have a prospective diagnosis of endometrial cancer confirmed to them by the examiner.

Following this they will inform you of investigations they would like to do. This may include blood tests, urine dip and a physical exam all of which you should be receptive to. They should also inform you that they would like to refer you onwards for further testing.

If the candidate states: They are referring you on a 2 week wait pathway - Respond “Isn’t that the cancer pathway”:

If the candidate is adequately reassuring (eg telling you there are many other more common causes but they would like to rule out the most serious one) then you should allow them to move on.

If the candidate is not reassuring - Actor to use creative licence in being upset about the cancer pathway until reassurance given. (Make it realistic - ie don’t shout, leave the station… flip a table)

If the candidate does not state a time scale/urgency for the referal:

Prompt candidate to give timescale or to at least mention it is an urgent referral, then react as above.

The candidate may then inform you of what to expect at the appointment (ie physical exam, Ultrasound scan +/- biopsy) and again you should be receptive to this.