Presyncopal Young Female: Examination Expected — Free SCA Practice Case
Presyncopal Young Female: Examination Expected
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Five cases are free: a live 12-minute consultation with an AI patient each, marked, and no card.
Materials for Candidate
Please review before starting the consultation
Full Name
Sarah Jenkins
Age
24 years
Consultation Type
VideoAge
24
Situation
Video Consultation (Urgent Triage).
Reason for Encounter
"Patient booked an urgent same-day video call. Triage note states: 'Feels extremely unwell today. Sweating, lightheaded, and heart is racing. Thinks it might be a severe stomach bug.'"
Medical Records
- ●PMH: Chlamydia infection treated successfully at age 19.
- ●Medications: Microgynon 30 (Combined Oral Contraceptive) - adherence reported as 'patchy' at last review.
- ●Allergies: NKDA.
Patient Script
For the friend playing the patient role
Character Overview: You are Sarah, a 24-year-old retail manager. You are speaking to the doctor on your mobile phone from your bed. You look visibly unwell: you are pale, sweating profusely, and breathing quite fast. You woke up this morning feeling incredibly dizzy, to the point where you nearly fainted when you tried to walk to the bathroom. Your heart is pounding in your chest. You also have a constant, severe ache in your lower abdomen, which started late last night. You assume this is a severe episode of gastroenteritis or food poisoning, though you have not actually vomited. The Clinical Reality (Ruptured Ectopic Pregnancy): You are actively bleeding into your abdominal cavity.
- ●Gynecological History: If asked, your last period was about 6 weeks ago, but you have been spotting dark blood for the last few days. You missed a few contraceptive pills last month. You have not taken a pregnancy test because you assumed the spotting was your period starting.
- ●Shoulder Pain: You have a strange, sharp pain at the tip of your right shoulder. You think you slept on it funny.
ICE — Ideas, Concerns, Expectations
These are surfaced only if the candidate directly explores the patient's perspective. Do not volunteer any of the following unprompted.
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Ideas: You think you have a really bad stomach bug or food poisoning. You ate a takeaway last night and assumed that must be the cause. It has not crossed your mind that this could be anything gynaecological — you think the spotting is just your period being irregular because you missed a couple of pills.
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Concerns: You are frightened by how unwell you feel — you have never felt this dizzy or weak before and it is scaring you. You are also worried about missing work; you are the only manager on shift today and feel guilty about letting the team down.
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Expectations: You want the doctor to tell you what is wrong with you and give you something to make you feel better quickly so you can get back on your feet. You are expecting a prescription for anti-sickness tablets or something similar.
If Asked — Medical History and Medications
The following are actor guidance responses for when the candidate asks about items from the medical records. Do not volunteer these unless directly asked.
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If asked about past sexual health history or previous STIs: "I had chlamydia when I was about 19. I got treated for it at the time — took the antibiotics and it cleared up. I haven't had any problems since."
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If asked whether she completed the chlamydia treatment or had a test of cure: "Yeah, I took all the tablets. I think I went back for a check-up and they said it was all clear."
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If asked about the contraceptive pill: "I'm on Microgynon. I've been on it for a couple of years. I'm not great at remembering to take it every day though — I probably miss one or two a month, sometimes more."
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If asked about allergies: "No, no allergies to anything."
Social History and Lifestyle Impact
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Occupation / daily life context: You are a retail manager at a busy high-street clothing store. You are responsible for opening the shop and managing a team of five staff. You live in a flat-share with one flatmate.
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Lifestyle impact of the condition: You could not get out of bed this morning without nearly passing out. You had to call your assistant to cover the shop opening, which has never happened before. You feel awful about it — there is a big delivery due today and no one else knows the stock system. Even reaching for your phone on the bedside table made you feel like you were going to black out. You are genuinely frightened because you have never felt this weak or helpless.
If Asked — Associated Symptoms
The following are actor guidance responses for when the candidate asks about specific symptoms. Do not volunteer these unless directly asked.
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If asked about fever or temperature: "I don't think I have a temperature. I feel cold and clammy, not hot."
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If asked about chest pain: "No, no chest pain. My heart is just going really fast."
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If asked about shortness of breath: "I feel a bit breathless, yeah — like I can't quite get enough air, but it's not like I'm wheezing or anything."
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If asked about urinary symptoms (pain, frequency, blood in urine): "No, nothing like that. Going to the loo is fine."
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If asked about bowel symptoms (diarrhoea, constipation, blood in stool): "No diarrhoea, no blood. I haven't been to the loo properly since yesterday, but that's not unusual."
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If asked about vaginal discharge: "No unusual discharge — just that dark brown spotting I mentioned."
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If asked about pain during sex (dyspareunia): "No, nothing like that recently."
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If asked about previous pregnancies or miscarriages: "No, I've never been pregnant before."
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If asked about recent sexual activity: "Yes, I have a boyfriend. We've been together about fourteen months."
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If asked about contraception use by partner (condoms): "We don't usually use condoms because I'm on the pill."
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If asked about appetite or eating: "I haven't eaten anything today. I feel too sick to eat, but I haven't actually vomited."
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If asked about thirst: "I feel really thirsty, yeah. My mouth is dry."
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If asked about headache: "No headache, just the dizziness."
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If asked about leg pain or swelling: "No, nothing like that."
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If asked about rash or skin changes: "No, nothing."
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If asked about recent travel: "No, I haven't been anywhere."
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If asked about alcohol or drugs: "I drink socially at the weekend, nothing heavy. No drugs."
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If asked about smoking: "No, I don't smoke."
Consultation Flow & Responses:
- ●The Opening:
- ●If the doctor asks an open question: "Hi Doctor. I feel terrible. I woke up this morning and I couldn't stand up, the room was spinning. I'm sweating buckets, my heart is absolutely racing, and I've got this awful cramping in my lower stomach. I think I've caught a really bad stomach bug."
- ●Data Gathering (The Layers):
- ●Layer 1: The Shock Screen (ABCDE):
- ●If asked about the dizziness/fainting: "If I try to sit up, my vision goes black at the edges. I have to stay lying flat."
- ●If asked about bleeding from the bowel or vomiting (ruling out GI bleed/gastro): "No, I haven't been sick, and no blood when I go to the toilet. Just this stomach pain."
- ●If asked about your heart rate or whether your heart is racing: "It's going absolutely crazy — I can feel it pounding really fast and hard in my chest."
- ●If asked to describe the abdominal pain in more detail: "The whole lower part of my stomach is rock hard and the pain is unbearable — even breathing or moving slightly makes it so much worse."
- ●Layer 2: The Gynecological Screen:
- ●If asked about periods or pregnancy: "My last proper period was about six weeks ago. I'm on the pill, but I did miss a couple last month. I've had some dark brown spotting since Tuesday. Do you think I'm pregnant?"
- ●If asked about any other pains (Shoulder tip): "Actually, yes. The tip of my right shoulder is really aching. I thought I just slept in a weird position."
- ●Negotiation & Collaborative Management Plan:
- ●If the Doctor agrees it is a stomach bug and prescribes anti-emetics/buscopan:
- ●Reaction: "Okay, thank you Doctor. I'll ask my flatmate to pick them up." (Candidate critically fails for missing hypovolemic shock and leaving a fatal internal hemorrhage at home).
- ●If the Doctor diagnoses an ectopic pregnancy but tells you to get a taxi or have a friend drive you to A&E:
- ●Reaction: "A taxi? Doctor, I can't even sit up without passing out. How am I going to make it to the hospital?" (Candidate fails for unsafe logistical disposition of an unstable, shocked patient).
- ●If the Doctor identifies the shock, diagnoses suspected ruptured ectopic, and dispatches a 999 Ambulance:
- ●Reaction: "Internal bleeding?! Oh my god. Okay. I'll stay exactly where I am. Should I drink some water, I feel so thirsty?"
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Recognising Haemodynamic Shock in a Remote Consultation
The clinical priority in this case is not the pelvic pain — it is the shock. Tachycardia, near-syncope, diaphoresis, and pallor in a young woman of childbearing age constitute a haemodynamic emergency until proven otherwise.
- ●Class III haemorrhagic shock (estimated 1,500–2,000 ml blood loss) produces postural hypotension (vision blackening on sitting), sympathetic activation (profuse sweating, tachycardia >120 bpm), and preserved consciousness — but this is a narrow physiological window that can close rapidly.
- ●A resting heart rate of 130 bpm in a supine young adult is not anxiety. It is compensatory tachycardia driven by intravascular depletion. Treat it as such.
- ●The absence of vomiting or diarrhoea should immediately challenge a gastroenteritis diagnosis in a patient this unwell systemically.
The Remote Proxy Examination
In a video consultation where a patient is too unstable to attend in person, the clinician must actively use the remote medium to establish objective findings — not default to a purely conversational history.
- ●Pulse: Instruct the patient to place two fingers on the radial pulse and count beats aloud for 15 seconds. Multiply by four. A count of 32 beats in 15 seconds = 128 bpm — this is an objective clinical finding.
- ●Pallor and diaphoresis: Ask the patient to move the camera to show their face. Visual pallor and sweating are examinable remotely and constitute positive examination findings.
- ●Abdominal peritonism: Instruct the patient to press gently on the lower abdomen with one finger. Guarding, rigidity, or exquisite tenderness to light touch are peritoneal signs and indicate intra-abdominal pathology. A rock-hard, diffusely tender abdomen is a surgical emergency.
- ●Capillary refill: Ask the patient to press a fingernail for 5 seconds and release — assess refill time on camera.
The Gynaecological Screen in Every Woman of Childbearing Age
In any woman of reproductive age presenting with lower abdominal pain and systemic compromise, a structured gynaecological history is mandatory — regardless of the patient's own hypothesis.
- ●Last menstrual period (LMP): A 6-week amenorrhoea in a woman on patchy contraception is a pregnancy until proven otherwise.
- ●Contraceptive adherence: Missed combined oral contraceptive (COC) pills reduce contraceptive efficacy. Microgynon 30 requires consistent daily ingestion — missing pills in the first or last week of the pack carries the highest pregnancy risk.
- ●Abnormal vaginal bleeding: Dark brown spotting in early pregnancy is characteristic of implantation or decidual shedding in an ectopic — not reassuring as a sign that the period has arrived.
- ●Shoulder tip pain (Kehr's sign): Blood in the peritoneal cavity irritates the diaphragm via the phrenic nerve (C3–C5). Referred pain to the shoulder tip is a classic and diagnostically critical sign of haemoperitoneum. Ask specifically — patients will not volunteer it.
Ectopic Pregnancy: Risk Factors and Diagnostic Reasoning
Ectopic pregnancy occurs when a fertilised ovum implants outside the uterine cavity — most commonly in the fallopian tube. It complicates approximately 1 in 80–90 pregnancies in the UK and carries significant mortality risk if rupture is delayed in diagnosis.
Key risk factors (NICE CKS):
- ●Previous pelvic inflammatory disease (PID) or sexually transmitted infection, particularly chlamydia — even successfully treated infection causes tubal scarring and ciliary dysfunction that impairs ovum transport
- ●Previous ectopic pregnancy
- ●Previous tubal surgery
- ●Use of an intrauterine device (IUD) — note: COC failure is a less common but real risk factor when adherence is poor
- ●Assisted reproduction
Diagnostic triad of ruptured ectopic:
- ●Haemodynamic instability (tachycardia, postural hypotension, pallor, diaphoresis)
- ●Lower abdominal pain with peritonism
- ●Referred shoulder tip pain (Kehr's sign)
A pregnancy test, serum beta-hCG, and transvaginal ultrasound are the definitive investigations — but in a ruptured ectopic presenting in haemorrhagic shock, the clinical diagnosis mandates emergency response before any investigations are available.
Emergency Disposition: Why 999, Not a Taxi
Recognising that a diagnosis requires emergency response is necessary but not sufficient. The mode of transport is a clinical decision with direct patient safety implications.
- ●A haemodynamically unstable patient with suspected active intra-abdominal haemorrhage must travel by emergency ambulance with paramedic crew, not by private vehicle or taxi.
- ●Paramedics provide: IV access, fluid resuscitation, continuous monitoring, pre-alert capability, and the ability to manage cardiac arrest in transit.
- ●Self-transport risks: unmonitored deterioration, loss of consciousness whilst sitting upright, cardiac arrest without resuscitation capability.
- ●If the patient tells you she cannot sit up without blacking out, she cannot safely travel without clinical support. This is not a grey area.
Pre-Hospital Directives
The GP's duty of care continues until the ambulance crew takes over. In a remote emergency, four pre-hospital instructions are mandatory:
- ●Supine positioning: Instruct the patient to lie completely flat. This preserves venous return to the heart and maintains cerebral perfusion. Sitting up risks syncope and a fall.
- ●Nil by mouth (NBM): Hypovolaemic patients feel intense thirst — the body's attempt to restore intravascular volume. Explicitly forbid oral intake. The patient is likely to require emergency surgery (laparoscopy or laparotomy) under general anaesthetic within the hour.
- ●Access for paramedics: Confirm whether the patient is alone. Instruct her — or her flatmate — to unlock the front door immediately, before she risks losing consciousness. A locked door with a collapsed patient behind it delays life-saving intervention.
- ●Continuous clinical oversight: Offer to remain on the video call, or arrange for a colleague to stay on the line, to monitor conscious level and clinical status until the ambulance arrives. Do not end the call after dispatching 999.
Hospital Pre-Alert and Structured Handover
Calling 999 activates the ambulance service. Pre-alerting the receiving hospital activates the surgical team.
- ●Communicate directly with the ambulance crew (or via the 999 dispatcher) that this patient requires a pre-alert to the emergency department and gynaecology/surgical on-call.
- ●A structured SBAR (Situation–Background–Assessment–Recommendation) handover should include: patient age and sex, working diagnosis, haemodynamic status (HR, level of consciousness), and anticipated surgical need.
- ●Pre-alert enables the receiving team to prepare theatre, activate the major haemorrhage protocol if indicated, and have a surgical team ready on arrival — reducing time to definitive haemostasis.
Managing Diagnostic Uncertainty
This is an acute undifferentiated presentation. Ectopic pregnancy has not been confirmed by blood tests or imaging at the point of clinical decision-making.
- ●Communicate the diagnosis as a strong clinical suspicion, not a confirmed fact: "I think there is a serious chance this could be a problem with a pregnancy in one of your tubes, which is causing internal bleeding. I need to send an ambulance to you urgently."
- ●The threshold for emergency response in a shocked patient must not wait for diagnostic certainty. Clinical urgency is determined by haemodynamic status, not by confirmation of the underlying diagnosis.
- ●Uncertainty should be named — both for accuracy and to prepare the patient for the investigations that will follow in hospital.
Safety-Netting: Deterioration Before the Ambulance Arrives
The highest-risk window for this patient is the period between the end of the call and ambulance arrival. Safety-netting must address this explicitly.
- ●Instruct the patient (and any person present): if she loses consciousness, feels her heart racing faster, or stops being able to speak, call 999 again immediately and report a change in condition.
- ●If a flatmate is present, they should be briefed on what is happening and given a direct role: stay with the patient, keep the door unlocked, and stay on the phone with emergency services.
- ●Do not assume the ambulance will arrive before deterioration. The patient with a ruptured ectopic can decompensate rapidly once compensatory mechanisms are exhausted.
Common Candidate Errors in This Case
- ●Accepting the patient's self-diagnosis: A patient attributing systemic shock to a stomach bug is not reassuring — it is a diagnostic trap. The candidate's job is to evaluate the clinical picture, not validate the patient's hypothesis.
- ●Missing the gynaecological screen: Candidates who fail to ask about LMP, contraceptive adherence, or vaginal bleeding in a young woman with lower abdominal pain will not arrive at the correct diagnosis. This is a mandatory domain of history-taking.
- ●Unsafe disposition: Telling a patient in haemodynamic shock to "get a taxi to A&E" or "ask a friend to drive you" is a patient safety failure. The instability of this patient makes self-transport actively dangerous.
- ●Ending the call after dispatching 999: The consultation is not over when the ambulance is called. Remaining on the line to monitor the patient is an expected component of emergency remote management.
- ●Ignoring Kehr's sign: Shoulder tip pain is almost never volunteered. Candidates who do not ask for it specifically will miss a pathognomonic sign of haemoperitoneum and lose a key diagnostic indicator.
Mapped to the RCGP curriculum topic: Urgent & Unscheduled care.
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