SADLER · Ectopic Pregnancy

Patient Details

Name: Rachel Sadler
Age: 30 years
Opening statement: Felt unwell over last 2 days; pain in lower right abdomen; felt faint at work

Facilitator Notes

Two-part case: (1) acute presentation with differential ranking; (2) follow-up for fit note + psychological impact
Elicit concerns about appendicitis; rank differentials (ectopic vs PID vs appendicitis)
Urgent same-day referral for suspected ectopic pregnancy
Discuss whether pelvic/speculum exam is appropriate (risk of rupturing tubal pregnancy)

Resources: NICE CKS – Ectopic pregnancy; Patient.info – Abdominal pain.

Clinical Details – Part 1 (Acute)

Open questions — give freely:

Unwell last 2 days but well enough for work this morning. Felt faint twice at work and had to sit down. Pain in RIF (lower third of right abdomen) started this morning and has persisted. Telephoned surgery at lunchtime; fitted into afternoon list.

Only if asked directly:

Pain: Site RIF, no radiation; dull ache; intensity 5/10; intermittent then continual; worse if pressed; nothing helps
Urine: Slight frequency increase today; no dysuria, blood, cloudiness or odour
GI: Vomited once yesterday; bowels normal yesterday; no abnormal bowel symptoms
Gynae: Periods regular 6 days / 30-day cycle; LMP 6 weeks ago (normal); increased vaginal discharge (not odorous, no itch/pain); no contraception; no breast changes; same partner 6 years

Very sensitive questioning only: Did not consider pregnancy due to known infertility / tubal blockage. Has not done a pregnancy test.

Patient Perspective (ICE)

Ideas: Thinks it could be appendicitis.

Concerns: May need admission / surgery.

Expectations: Doctor to explore appendicitis (knows complications).

Feelings: Worried; remains unconvinced if appendicitis not mentioned. Mention of pregnancy raises hopes (wants children) — needs careful explanation of ectopic. If PID mentioned, asks how acquired and whether husband could have given it.

Past Medical History

Investigations for infertility – Gynaecology 2 years ago
Lap and dye = tubal blockage (presumed previous pelvic infection)
Rubella immune · Last cervical smear 5 years ago

Medication

None

Social History

Married 4 years; no children
Florist · Smokes 20/day · Occasional rum & cola out
One of four sisters; visits family often in Milton Keynes

Demeanour

Reasonably intelligent; neatly dressed; looks a bit unwell; some pain on sitting/standing; mildly anxious. Amenable to advice.

Physical Examination (only if requested)

Temp 37.5°C · Pulse 90 · BP 120/80
Abdomen: mild RIF tenderness; no rebound/guarding
Pelvic: uterus normal size, anteverted; tender right fornix
Speculum: os closed, not inflamed; slight yellow offensive discharge — consider triple swabs

Note: Vaginal examination may risk rupturing a tubal pregnancy and adds little in primary care when ectopic is suspected.

Information for the Student – Part 1

Name: R Sadler · Age 30
PMH: Infertility investigations 2 yrs · Lap & dye tubal blockage · Rubella immune · Smear 5 yrs ago
Medication: None
Recent: 20 months: subfertility results discussion · 24 months: gynae appointment · 28 months: infertility referral

Part 2 – Second Consultation (Fit Note / Aftermath)

Returns 2 weeks after hospital admission for further fit note (hospital note about to expire). Traumatic admission: told she “nearly died”. Ruptured ectopic; laparoscopic right salpingectomy + blood transfusion. Discharged after 2 days; advised back to work in 2 weeks and to use contraception “just in case”. Unlikely to achieve normal pregnancy.

Does not feel ready for work. Abdomen settled but not herself: tired, poor sleep, poor concentration, bursts into tears. Husband at a loss. Cannot face colleagues (one is pregnant). Shocked by grief over never having a child — thought she had put this behind her after fertility investigations.

Demeanour Part 2: Weary; easily moved to tears. On sensitive questioning admits low mood/anxiety and opens up. Responds positively to more time off and suggestion of talking therapy / further support.

Primary Care Block · University of Buckingham