Station 1A

Scenario:
You are a medical student in general practice. You have been asked to take a history
from a 26-year-old female patient presenting with abnormal vaginal bleeding. Please
take a thorough history. You may be asked questions at the end of the station.
History:

HPC:
 Patient has been experiencing some abnormal bleeding for the last few weeks
(3 weeks). The bleeding occurs after sex, and is, if asked, associated with
some pain The blood is bright red, there is no clots, it is not heavy. There has
also been some spotting at other times.
 Patient has also experienced increased discharge that is thicker than normal.
Not noticed a change in smell or colour.
 Patient has pain during sex, but this is not a deep pain.
 No skin changes noticed.
 No rectal symptoms. No urinary symptoms.
 No systemic symptoms.

ICE: worried about cervical cancer. Mother had cervical cancer when she was 32
and patient has seen posters that says bleeding after sex is a sign of cancer.
Wanting investigation.

Sexual history:
 Last sexual contact was 1 week ago with a casual partner that have been
seeing for 1 month. Partner is 29-year-old male. Sexual contact was
consensual.
 Engaged in penetrative vaginal sex, gave and received oral sex.
 Did not use barrier contraception as on the pill and partner said they were
clean.
 Haven’t seen casual partner in the last week so unaware if they have any
symptoms.
 No other sexual partners in the last 3 months.
 Never had a sexually transmitted infection. Last sexual health screen was 6
months ago after ending 2-year relationship.

Menstrual history: menarche at age 14. LMP 2.5 weeks ago. Cycle is usually 29
days and usually bleed for 6 days. Not particularly painful or heavy.

Gynae history: no previous problems. Had HPV vaccines in secondary school. Never
attended cervical screening, thought that this was just for older women.

Obstetric history: had a termination at 7 weeks gestation, age 22.

PMH: no significant PMH. Previous appendectomy.

DH: medication for hayfever. No allergies.

SH: patient smokes 1-2 cigarettes when they go out, maybe once every 2 weeks.
Patient drinks when they go out maybe once every 2 weeks, usually about 5 double
gin and tonics. (approx. 2 units per double). Works in marketing. Lives at home with
her cat.

Examiner questions:
1. What are your differentials?
 2. What is your top differential?
3. What would your next steps be?
a. Examination with speculum
b. Vulvovaginal swab for nucleic acid amplification testing.
c. Counsel to go sexual health clinic for full sexual health screen +
contact tracing/partner notification and to avoid all sexual contact until
treatment completed.

Examiner notes:
1. Does the student approach the topic sensitively? Does the student explain
confidential nature of consultation? Does the patient signpost to discussion of
sexual history?
2. Does student explore history of presenting complete fully? Does the student
also ask about urinary, rectal and systemic symptoms?
3. Does the patient clarify the nature of sexual contact clearly and
professionally?
Station 1B

Scenario:
The patient mentioned that they have not attended cervical screening as they
thought it was just for older patients. Please counsel them on the NHS cervical
screening programme, including how a sample is taken, what testing is involved and
what happens after.
Cervical screening programme:
 Cervical cancer
o Cervical cancer is a highly preventable cancer when picked up early.
o Incidence for cervical cancer is highest in young females between 30-
34.
o Most cervical cancer is caused by the HPV virus (HPV-16 and 18 are
oncogenic, HP-6 and 11 cause genital warts)
 Cervical screening programme
o Introduced to reduce incidence and mortality from cervical cancer by
detecting cell changes early.
o Screening is available to all people with a cervix from age 25-64.
Patients are invited to screening every 3 years between 25-49, and
then every 5 years from 50-64. Some people may have screening more
regularly if they are at risk e.g. HIV positive patients.
o Benefits of screening:
 Early detection - regular screening can prevent 70% of cancers
developing.
 Reduced cervical cancer mortality – estimated to save around
4500 lives every year in England and mortality from cervical
cancer has halved since programme introduced.
o Harms of screening:
 Psychological distress of minor abnormalities
 False reassurance – no test is 100% effective, and some
abnormalities can be missed.
 Discomfort during procedure.
 Taking a cervical sample – ALSO KNOWN AS A SMEAR
o All professionals that take cervical samples are specially trained.
o At the appointment, you will be asked to undress your lower half
including your underwear and given a blanket to cover yourself.
o There will be a chaperone present to keep you and the professional
taking the sample safe and comfortable.
o The professional will ask you to lay on the coach with your knees apart.
They will gentle insert a speculum to be able to visualise the cervix and
then will use a small brush to collect cells for testing.
o The procedure may be uncomfortable but should be over quickly. The
professional will stop at any time if it is too uncomfortable.
o Sometimes there may be a little bleeding after a smear.
 Testing:
o The cervical cells are tested in stages.
 First, they are tested for the HPV virus.
 If the results are negative (normal), you will return to
routine screening.
 If the results are positive for HPV, the cells will undergo further
testing where a specialist will look at them under the microscope
to assess for any abnormalities.
 Those who are HPV-positive and cytology negative
should have a repeat test in 12 months.
 If patient is still HPV-positive after 12 months, they should
have another repeat test at 12 months.
  If HPV remains positive, patient should be referred to
colposcopy.
 If HPV is negative at 24 months, the patient can be
returned to routine recall.
 If sample is inadequate, the sample should be repeated in 3
months. If there are two consecutive inadequate samples,
patients should be referred to colposcopy.
o Colposcope is assessment of the cervix in detail using a special
microscope. Chemicals are applied to the cervix to detect abnormal
areas.
 Acetic acid = abnormal areas turn white
 Iodine = normal tissue stains brown
 HPV vaccination

o HPV vaccination protects against HPV infection, which protects against

cancer and genital warts.
o The new vaccine (Gardasil-9) protects against 9 strains of HPV.
o It is offered now to boy girls and boys aged 11-14, as well as those at
higher risk of HPV and its consequences.
Examiner notes:
 Does the student check what the patient already knows and what they would
like to know? Does the student signpost to different parts of the discussion?
Does the student check understanding?
 Does the patient use clear language without jargon?
WRISKE

Nucleic acid amplification testing confirms a diagnosis of chlamydia. Please

prescribe appropriate treatment for the patient using an FP10.

Patient details:
Sarah Brown
12/02/1996
Address: 123 Happiness Road, Newcastle upon Tyne, NE1 1BH