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Practice case P2-07 · Face-to-face · simulated patient

Headache at 32 weeks pregnant

A woman who is 32 weeks pregnant has come in with a headache. She thinks she needs stronger painkillers, and she wants to be back at her desk for a two o’clock call.

Reviewed and kept current

Station family: Acute obstetric presentation in primary care · 8-minute station · 1 min 30 s reading · Last editorial review: 19 September 2026.

Candidate instructions

Read this as you would outside the room

You have 1 minute 30 seconds to read, then 8 minutes. Candidates: everything below this section is folded away — leave it closed until you have finished the station.

	Information
Your role	Foundation Year 2 doctor in a general practice, same-day appointments. Your supervising GP is in the building.
Patient	Mrs Liyana Patel, 31, accountant. 32 weeks pregnant — her first pregnancy.
Reason for appointment	“Headache for two days, not settling with paracetamol.”
Observations just taken by the practice nurse	BP 164/108; repeated after five minutes 160/106. Pulse 88. Temperature 36.7 °C. Urine dipstick: protein 3+; nitrites, leucocytes, blood and glucose negative.
Records	Booking BP at 9 weeks: 112/70. Uncomplicated pregnancy. Midwife appointment at 28 weeks: BP 124/78, urine clear. Pregnancy vitamins only. No known allergies.

Your task

•

Take a focused history.

•

You may ask for the findings of any examination you would perform; they will be read out to you.

•

Explain what you think is happening and agree with her what needs to happen now.

Folded away

For the actor and the examiner

1 · Actor script — role player only

Candidates: do not open until you have consulted.

Persona and manner

Liyana Patel, 31, accountant, in the middle of month-end. Conscientious; you do not like a fuss. You keep rubbing your forehead and you are squinting a little.
Your husband Amit is at work, 40 minutes away. You drove yourself here.

Opening line — say this verbatim

“I’ve had this headache for two days and paracetamol isn’t touching it. Is there anything stronger that’s safe for the baby? I need to be back for a call at two.”

Volunteer freely if given the space

The headache is across the front of your head, constant, about 7 out of 10, worse today than yesterday.
Your feet and ankles have been swollen for a couple of weeks — “everyone says that’s normal”.

Only if asked

Vision: since this morning, flickering lights and blurring at the edges.
Pain: since last night, a “heartburn sort of pain” under your ribs on the right.
You felt sick this morning but have not vomited.
Your hands and face are puffy — your rings have not fitted since the weekend.
The baby’s movements: “Now you mention it, she’s been quieter since yesterday.” You have felt her move this morning, but less than usual.
No fits or blackouts, no confusion, no weakness, no trouble speaking. It did not come on suddenly. No fever, no stiff neck.
No bleeding, no waters leaking, no tightenings or tummy pain lower down. No burning when you pass urine.
You do not get migraines. No previous high blood pressure, kidney problems or diabetes. Your mum “had blood pressure trouble when she was expecting me and I came early”. You are not taking aspirin.
You drove here. You will be alone at home until seven tonight.

Impact on daily life — home and work (only if asked)

You cannot look at a screen for more than a few minutes, and it is the busiest week of your month.
You have hardly slept for two nights.
You have been working ten-hour days to clear your desk before maternity leave; the nursery is half painted.

Ideas, concerns and expectations

Idea: a stress headache — too many hours at the screen.
Concern (if asked, or once you hear your blood pressure is high): “Is the baby all right? It’s too early — she can’t come now.”
Expectation: a safe painkiller, and to be back at work by two.

Cues to deliver, timed

Minute 2: shield your eyes — “Sorry, the lights in here are really bright.”
Minute 4: glance at your watch — “Will this take long? I’ve got a call at two.”
If told you need to go to hospital: “Can I go home first and pack a bag? Amit can take me tonight.”

If the doctor summarises and asks whether you want to add anything

If the rib pain has not come up: “Actually — I’ve had this pain under my ribs since last night. I thought it was heartburn.”
If it has: “She really hasn’t been moving as much. Should I be worried?”

How to respond to the doctor

If the doctor explains clearly that high blood pressure, protein in the urine and these symptoms together mean pre-eclampsia — a serious condition of pregnancy that affects you and the baby — and that you need to be assessed in hospital now and must not drive: frightened but co-operative — “OK. Can you ring Amit?”
Questions you will ask: “What will they do there?” “Will they have to deliver her?” If fits are mentioned: “Could I have a fit?”
If the doctor is vague (“just to be on the safe side, pop up to the hospital sometime today”): “I’ll go after my call, then.”
If the doctor gives you a painkiller and sends you home: thank them and leave.
If the doctor tells you the baby will certainly be fine, or certainly be delivered today: “How can you know that?”

Do not

Volunteer the visual symptoms, the pain under your ribs or the reduced movements unless asked or invited to add anything.
Act drowsy or confused — you are alert, uncomfortable and in a hurry.

Findings to give the candidate — only if asked for

If the candidate asks to examine you, or asks for observations or examination findings, read these out. Do not offer them otherwise. (Where a separate examiner is present, the examiner reads them.)

Alert and orientated. BP as recorded (164/108, then 160/106); pulse 88 regular; respiratory rate 16; SpO₂ 98%; temperature 36.7 °C. Puffy face and hands; pitting oedema to mid-shin. Mild tenderness under the right ribs / epigastrium; uterus soft and non-tender; symphysis–fundal height 31 cm. Reflexes brisk with four beats of ankle clonus. No neck stiffness, no focal neurological signs. Fetal heart heard with the hand-held Doppler at 140 per minute.

2 · Examiner mark sheet — generic scheme plus the key facts for this case

Domain marks — with the key facts that earn a 4 at this station

Domain (GMC wording) · key facts for this case	1	2	3	4	Score
1 · Data gathering, technical and assessment skills Headache characterised; pre-eclampsia symptoms sought: visual disturbance, pain under the ribs, vomiting, sudden swelling of face and hands Red flags: fits, confusion, focal weakness, thunderclap onset; bleeding, abdominal pain or tightenings; fetal movements Uses the data — BP 164/108 twice, protein 3+, booking BP 112/70; risk factors (first pregnancy, mother’s history); asks for examination findings ICE (thinks it is stress; fears an early birth) and impact — deadline, drove here, alone until tonight	☐	☐	☐	☐	/4
2 · Clinical management skills Summary and check, then names it: severe pre-eclampsia — new severe hypertension and proteinuria after 20 weeks, with headache, visual symptoms and rib pain Why not: migraine or tension headache (would not explain BP and protein); urine infection (dipstick otherwise clean); pain under the ribs makes HELLP a concern Emergency same-day admission: obstetric team and supervising GP called now; ambulance — must not drive or go home first; explains hospital care (BP treatment, bloods, monitoring the baby) Safety-net: not left alone while waiting; a fit, worsening headache or vision, bleeding or severe pain → emergency response / 999 · Follow-up: husband contacted; midwife and GP informed; BP follow-up after the birth	☐	☐	☐	☐	/4
3 · Interpersonal skills Calm urgency — conveys seriousness without panic Plain words for pre-eclampsia; no false reassurance and no catastrophising Responds to the watch and the work call; negotiates firmly but kindly Offers to ring Amit; checks she understands why now	☐	☐	☐	☐	/4
Station total					/12

Examiner's overall judgement (standard-setting only — it does not decide your result): ☐ Unsatisfactory ☐ Borderline ☐ Satisfactory ☐ Good

Marks are 1 to 4 in each domain; the generic descriptor for each mark is on the mark scheme page, and the structure of the eight minutes is on the 8-minute station page. The full standard for this case is in section 3 and the GMC feedback statements, with examples from this case, are in section 4. The examination findings that the role player gives — only if the candidate asks for them — are at the end of section 1.

3 · Expanded station-specific marking standard — what earns 4, 3, 2 and 1 here

The top row is the full picture of what a competent F2 could do at this station, including the working diagnosis with its justified differentials, the safety-net and the follow-up; lower rows describe how performance falls away. It is a debriefing aid, not a checklist to recite: nobody says every line in eight minutes, and a 4 is a judgement that the essentials — the italic key facts on the mark sheet — were done well, in plain language and at the patient’s pace. Acumen training standard — the GMC does not publish station mark sheets.

Mark	Domain 1 · Data gathering, technical and assessment skills	Domain 2 · Clinical management skills	Domain 3 · Interpersonal skills
4	Characterises the headache and asks specifically for the symptoms of pre-eclampsia: visual disturbance, pain just below the ribs, vomiting, sudden swelling of the face, hands or feet Red flags: fits, confusion, weakness or speech change, sudden onset, fever or neck stiffness; bleeding, pain or tightenings, fluid loss; fetal movements Uses the information supplied: severe-range blood pressure on two readings, 3+ proteinuria with a clean dipstick otherwise, and a normal booking blood pressure Risk factors: first pregnancy, family history (mother), previous hypertension, kidney disease, diabetes; aspirin use; medication and allergies Asks for examination findings: reflexes and clonus, abdominal and uterine tenderness, oedema, fetal heart ICE: believes it is a stress headache; fears the baby coming early; wants a painkiller and to get back to work Impact on daily living and immediate circumstances: cannot use a screen, not sleeping, month-end deadline; drove herself, would be alone until evening	Summarises and checks whether there is anything she wants to add Working diagnosis with justified differentials: severe pre-eclampsia — new blood pressure of 160/106 or above with 3+ protein after 20 weeks, against a booking BP of 112/70, together with headache, visual disturbance, pain under the ribs and brisk reflexes. Migraine or a tension headache would not explain the blood pressure and the protein; a urine infection is unlikely with an otherwise clean dipstick; pain under the ribs raises the possibility of HELLP syndrome, which needs blood tests; rarer causes of headache in pregnancy (cerebral venous thrombosis) are for the hospital to exclude Acts on it: emergency same-day admission to the obstetric unit — tells her that the on-call obstetric team, the supervising GP and a 999 ambulance are being called now Transfer by ambulance; she must not drive and must not go home first; stays with her or ensures she is not left alone Explains what will happen in hospital: medication to lower the blood pressure (labetalol first-line), blood tests, monitoring of the baby (heart tracing and scan) because movements are reduced, possibly magnesium to prevent fits and steroid injections for the baby’s lungs; birth only if it becomes necessary Does not give NSAIDs or “something stronger” and send her home Safety-net: she is not left alone while waiting for the ambulance; if she has a fit, the headache or vision suddenly worsens, she bleeds, has severe abdominal pain or feels faint, the practice emergency response is called and 999 is updated; she is told that if symptoms like these ever occur at home she calls 999 or maternity triage straight away and does not drive. Follow-up: Amit is telephoned with her consent; the community midwife and her usual GP are informed today; the F2 checks later that she arrived and was admitted; after the birth she needs blood-pressure checks, a medication review and a postnatal review at 6–8 weeks, with advice about aspirin in any future pregnancy.	Conveys seriousness calmly — urgent without alarm Explains pre-eclampsia in plain words and links it to her own symptoms Acknowledges the work pressure and the fear of an early birth; does not dismiss either Honest about uncertainty: cannot promise the baby will not need delivering, can say she is in the right place at the right time Negotiates the “can I go home first?” request firmly and kindly; offers to ring Amit and her office Checks she understands why this cannot wait
3	Pre-eclampsia symptoms and fetal movements covered and the observations used; one of the red-flag screen, risk factors, examination request or her circumstances (driving, alone) missing.	Correct diagnosis, same-day admission arranged with senior involvement, and she is told not to drive; one of ambulance transfer (for example, arranges a lift instead), the explanation of hospital care, or the differentials missing.	Clear and kind; urgency conveyed; one concern (work, baby, husband) not addressed.
2	Takes a general headache history; asks about vision but not rib pain or fetal movements; does not link the BP and proteinuria to the symptoms until late.	Recognises raised BP but under-calls the urgency: “go to the maternity unit this afternoon”; or admits without explaining why; safety-net and follow-up vague.	Either too casual (she leaves unconvinced) or alarming; explanation rushed; her questions not invited.
1	Headache history only; observations in the notes not used; no obstetric questions. Or unsafe: no relevant history; blood pressure and urine result ignored.	Treats as a headache; arranges a repeat BP or midwife review in a few days; no safety-net. Or unsafe: prescribes analgesia and sends her home or back to work; allows her to drive herself with severe hypertension and visual disturbance.	Frightens her (“you could have a fit and die”) or brushes aside her questions. Or unsafe: dismissive of her symptoms, or coercive and disrespectful.

4 · GMC feedback statements — where underperformance was identified — with case-specific examples

A feedback statement marks where underperformance was identified in the consultation. With PLAB 2 results the GMC may attach any combination of the ten statements to a station — none, one or several. The right-hand column shows what each one looks like at this station. Record the statements that applied in the practice log.

GMC feedback statement	Underperformance it signals (generic)	Case-specific examples
1 · Consultation	Disorganised or unstructured consultation	Takes a leisurely general headache history — caffeine, screens, stress — before looking at the observations; no structure linking symptoms, BP and urine.
2 · Issues	Key issues or priorities not recognised	Does not recognise an obstetric emergency: treats a headache, or gives lifestyle advice about working hours, in a woman with a BP of 164/108 and 3+ protein.
3 · Time	Poor time management	Lengthy history and explanation; has not said that the obstetric team is being called, or arranged transfer, when the station ends.
4 · Findings	Abnormal findings or results, or their implications, not identified	Ignores or misreads the data on the page — severe-range BP twice, 3+ proteinuria, booking BP 112/70 — or is given brisk reflexes with clonus and rib tenderness and does not see what they mean.
5 · Examination	Physical examination or use of instruments not competent	Does not ask for any examination findings — reflexes and clonus, abdominal palpation, fetal heart — or asks and cannot interpret them.
6 · Diagnosis	Working diagnosis or differential diagnoses not correct	“Tension headache”, “migraine” or “a bit of high blood pressure”; pre-eclampsia not named; HELLP not considered despite pain under the ribs.
7 · Management	Management plan not reflecting current best practice	Codeine or ibuprofen and home; a midwife check “in a day or two”; lets her drive herself; does not ring the obstetric team or the supervising GP; no instruction about what to do if she fits or bleeds; no plan to check she arrived.
8 · Rapport	Rapport and sensitivity to the patient’s feelings and concerns not shown	“Don’t worry, the baby will be fine”; or “this can kill you”; ignores the glance at the watch and the pressure she is under.
9 · Listening	Verbal and non-verbal cues not used; poor active listening	Misses “the lights in here are really bright” and “she’s been quieter since yesterday”; does not give her the chance to mention the rib pain.
10 · Language	Language or explanations not understandable; understanding not checked	“You have severe PET; we’ll admit for MgSO₄, labetalol, CTG and PlGF” — no plain-English version; she does not understand why she cannot go home first.

5 · Examiner points of fact and guidelines

Points of fact the examiner should have to hand

Pre-eclampsia (NICE NG133): new hypertension (140/90 mmHg or more) after 20 weeks with proteinuria (protein:creatinine ratio 30 mg/mmol or more, or albumin:creatinine ratio 8 mg/mmol or more), or with maternal organ dysfunction or uteroplacental dysfunction. A dipstick of 1+ or more prompts quantification.
Severe hypertension is 160/110 mmHg or more. NICE NG133 advises admission and treatment for everyone in this range; women with suspected pre-eclampsia need same-day hospital assessment (NICE NG201: severe hypertension — urgent referral, seen the same day).
Symptoms every pregnant woman should be told to report immediately: severe headache; problems with vision such as blurring or flashing; severe pain just below the ribs; vomiting; sudden swelling of the face, hands or feet.
Hospital treatment: labetalol first-line (nifedipine if labetalol is unsuitable, then methyldopa); intravenous magnesium sulfate for eclampsia, or for severe pre-eclampsia when birth is planned within 24 hours; antenatal corticosteroids when early birth is likely. Before 34 weeks the aim is to continue the pregnancy under surveillance unless there is an indication for planned early birth.
PlGF-based testing between 20 and 36+6 weeks helps to rule pre-eclampsia in or out (NICE HTG630, formerly DG49) — a hospital test, not a reason to delay transfer.
HELLP syndrome (haemolysis, elevated liver enzymes, low platelets) presents with epigastric or right-upper-quadrant pain, nausea and malaise. Brisk reflexes with sustained clonus (three or more beats) suggest cerebral irritability.
Reduced fetal movements need assessment without delay: confirm the fetal heartbeat with a hand-held Doppler and, from 26+0 weeks, arrange a computerised CTG at the maternity unit (RCOG Green-top Guideline 57, 2nd edition, 2026).
Risk factors (NICE NG133). High: hypertensive disease in a previous pregnancy, chronic kidney disease, autoimmune disease, diabetes, chronic hypertension. Moderate: first pregnancy, age 40 or over, pregnancy interval over 10 years, BMI 35 or more, family history of pre-eclampsia, multiple pregnancy. One high or two moderate factors → aspirin 75–150 mg daily from 12 weeks. If her mother had pre-eclampsia she had two moderate factors — a point for the debrief, not for the patient today.
NSAIDs are avoided in the third trimester (premature closure of the ductus arteriosus, oligohydramnios). “Something stronger” is not the answer to this headache.
If she fits in the surgery: call for help and 999, left lateral position, protect the airway, oxygen; magnesium sulfate is given in hospital.

Where candidates lose marks at this station

Treating the headache and not reading the blood pressure.
“Pop up to the maternity unit later today.”
Letting her drive herself.
Not asking about fetal movements.
Promising that the baby will be fine — or that she will be delivered today.

Guidelines for this station

6 · MLA content map tags for this case

MLA content map	This station
Domain 1 · Areas of clinical practice	Obstetrics and gynaecology · Acute and emergency
Domain 3 · Clinical and professional capabilities	History, examination and differential diagnosis · Emergency and acute management plans · Communication with patients, relatives and carers · Managing risk
Domain 5 · Patient presentations	Headache · High blood pressure · Vision change/ loss (acute and gradual) · Peripheral oedema and ankle swelling · Reduced/ change in foetal movements
Domain 6 · Conditions	Hypertension in pregnancy (including gestational hypertension, pre-eclampsia, eclampsia)
Station family	History, diagnosis and management — Acute obstetric presentation in primary care

7 · My marks and reflection — practice log form

Record your three domain marks, your station total, the GMC feedback statements that applied (where underperformance was identified), and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for P2-07

Revision link for this case: acumenprimarycare.com/plab-2-osce/case-07-headache-32-weeks-pregnant

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Independence & scope. Independent, formative training material from MD Acumen Ltd. Not affiliated with, endorsed by, or delivered on behalf of the General Medical Council. The GMC does not publish its station mark sheets: every mark scheme and descriptor on these pages is an Acumen training tool calibrated to the GMC's published marking domains, feedback statements and the MLA content map. Practice scores are not a prediction of examination performance. Clinical content reflects UK guidance at the date of editorial review — always check the current guideline. All patients are fictional.

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