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You are an F2 in A&E and are asked to clerk a 23 year old woman who has come in with abdominal pain.

Please take a focused history and perform an appropriate examination.

PC: You are Kerry Tin, a 23 year old dental nurse. You were out for dinner with your boyfriend (although didn’t have much of an appetite) when you had a pain across the bottom of your tummy. It was much worse than a period cramp. It was quite sudden and has been constant since it started and hasn’t moved. You took two paracetamol which helped a little. The pain is about 6/10. No vomiting, bowel changes, urinary problems.

If asked what worried you enough to come to A&E (or directly about bleeding), you have also noticed a bit of blood but you don’t think your period is due. Although you aren’t sure when your last one was… you’ve been really busy at work and moving house. If asked: you try to use condoms as contraception, but sometimes forget so he just pulls out. He is your only sexual partner and you have sex 2-3 times a week. You’ve never been pregnant or had an abortion before.

PMH: You have some anxiety but cope quite well. If asked directly, you are not on any contraception.

DH: You take sertraline for anxiety but nothing else. No allergies that you know of.

FH: No illnesses you know of that run in your family, your dad just has Type 2 Diabetes and asthma. Both parents are alive.

SH: You smoke 5 cigarettes a day and drink 1-2 glasses of wine on a Saturday night. You work as a dental nurse and live with your boyfriend.

ICE: You are wondering if you might have appendicitis, which your sister had a few years ago. If it gets brought up, you’re embarrassed about the bleeding. You’re expecting to need an operation to remove your appendix. It hasn’t occurred to you that you could be pregnant.

The candidate should take a full history and perform an abdominal examination and mention the need for a pelvic exam. Differentials may include appendicitis, UTI, miscarriage, and ectopic pregnancy.

Topics of discussion may include: - investigation and management – expectant/surgical/medical management – risk factors for ectopic pregnancy – management of a ruptured ectopic pregnancy – counselling women on fertility after an ectopic pregnancy.