Practice Cases For The CSA 2020

DEA C NCE N AND
E EC A N
AC ICE
CA E FO HE
C A
D HA DE AL
MRCGP MBCHB PGDIP DERMATOLOGY
PRACTICE CASES FOR THE

CSA
3 cycles of 39 different clinical cases to test you before the big day.
DR HAIDER ALI
MRCGP MBCHB PGDIP DERMATOLOGY
MANCHESTER UNIVERSITY PBL TUTOR AND OSCE EXAMINER
FY2 SUPERVISOR

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Before you start:
It is important to know what to expect on the day of the exam.
The RCGP has an excellent run down of what to expect and what happens in the exam, i.e.
what general areas are tested.
Here is a link to that:
http://www.rcgp.org.uk/training-exams/mrcgp-exams-overview/mrcgp-clinical-skills-
assessment-csa.aspx
Different people learn in various styles. For me I wanted to do as many stations as possible to
see as much as possible before the exam. This worked for my confidence and helped me pass.
However I would say there really aren’t any good alternatives to seeing patients regularly in
your clinics , as close as possible to 10mins (have plenty of breaks if you aren’t quite there
yet), as this will give you more cases in your 12 months than any number of books you’ll read.
Don’t ever forget to Ask ICE – as blatant as it may be, there are points for doing this and you
can miss the nub of the case.
Be yourself, and treat it like any other clinic. They are not there to trick you. If you’re safe and
sensible, you’ll be passed without a problem, we need more gps!
Make sure you know your guidelines!
As with any exam, if you feel something went badly on a station, put it out of your mind, it
more than likely doesn’t matter. You have 13 stations and doing ‘not great’ in 2-3 and ‘ok’ in
the rest will really be enough.
Go on a course – there are lots out there and use your budget for it. This is not ABSOLUTELY
necessary but you find it will give you a heads up on what to expect. The RCGP does one that
shows you the rooms and CSA examiners are on hand to hopefully alleviate your questions
and trepidations for the forthcoming exams.
A little about myself.
I am a GP based in Central Manchester.

I have a passion for teaching, currently training to be a GP trainer and looking forward to
someday being a CSA examiner too.
I have a lot of interests in medicine, particularly in dermatology and weight loss through
directed physical activity.
This book is free so please pass it to anyone you think could make use of it.
If you have any feedback on how I can expand this or make it better email me !
Haider.ali1@nhs.net
Good luck!

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Csa cases
1 – STI
2-Knee pain
3-Psoriasis
4- Letter /Depression
5- Erectile Dysfunction
6- Angry mother/Contraception (tele consult)
7-Indigestion/heart burn
8- Emergency Contraception
9 – Dysphagia
10- Infection on methotrexate
11- Medication Request (Acne)
12- Benign Essential Tremor
13 – Fibroids results

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Cycle 1
Case 1 “STI”
Candidate information:
John Bloggs , age 34.

PMH: IBS, appendicectomy, allergic reaction to latex gloves.
DH: mebeverine nkda
Simulated patient information:
You are a busy teacher, who has had a recent break up 3months ago, having had your partner
of 2 years break up with you out of the blue.
Feeling annoyed at having invested so much time in what you felt was a long term
relationship heading places you have re-evaluated your thoughts on the immediate future and
decided to ‘have fun’ and have ended up speed dating numerous times, including quite a few
one nights stands over the last 6-8 weeks.
You are confident you have contracted a STI but have never had one before. You hope it is just
a urinary tract infection and will not divulge /suggest anything else unless directed asked.
You take your health seriously most of the time, are a regular gym goer and eat quite
healthily, having a ‘break’ at the weekends where you afford yourself a drink with the ‘boys’
at the pub and a take away.
SH: You don’t smoke, nor do you use any recreational drugs.
You live alone now, in a semi detached house which you have no problems affording despite
the recent break up.
FH: There are no medical problems that run in your family
Divulged openly:
You have been passing urine frequently without blood in the urine (if asked). There has not
been any pain but there has been a pressure to pass urine. This has even caused you disturbed
sleep for the last 2-3 days. You have not had this problem before.
If asked directly – there is a yellow discharge from the penis, without blood.
You have no other symptoms of , no fevers, no joint swellings, eye problems.
You have not had a STI in the past but suspect you may have one now due to your recent
sexual activity.
You are heterosexual. You practice penetrative vaginal intercourse as well as anal and do not
always use a condom.
You hope the GP can give you some antibiotics .

If directed you will grudgingly accept that you need to visit the GUM clinic but will also do a
Chlamydia/gonorrhoea test at the GP surgery if prompted.
On examination: (OFFER A CHAPERONE )
Genital examination reveals:
Discharge noted from penis

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Nil testicular abnormalities
Nil local groin lymphadenopathy
Erythema noted to the head of the penis
Apyrexial, heart rate 87 regular, blood pressure 134/65
Examiner information:
Data gathering:
Gather a thorough history of events, to include a sexual history.
Duration, and chronology of symptoms.
Note if any system problems – joint pains, fever, weight loss, rashes, lymphadenopathy, joint
swellings.
Enquire about other risky behaviour including drug use (iv/oral), previous noted STis if
relevant.
Management:
Discuss the likelihood that this is a STI and the need for further testing to rule this out.
Make patient aware that we can offer investigations in house but also recommended a full
check up at the local GUM clinic taking into account the multiple sexual partners and
therefore increased risk of other STIs.
Discuss contact tracing and explain how this can be done covertly via the GUM clinic.
Offer a follow up with the patient after they have been to the GUM clinic.
Safety net as appropriate – pain/feeling unwell/ongoing symptoms.
See link below for common types of sexually transmitted diseases.
https://www.nhs.uk/conditions/sexually-transmitted-infections-stis/#common-stis

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CASE 2 Knee pain
You’re a salaried GP who has not seen this patient before.
Jessica Jones. 27years old.

PMH: nil of note
DH: naproxen 250mg prn usage NKDA
Nil else of note
Opening statement:
“Hi Doc, I have come to talk to you about my gammy knee!”
Simulated patient History:
You are Jessica , a 27 year old accountant and keen runner.

You have come to the GP today to discuss some right sided knee pain which has been
bothering you for the last 3 weeks. You are quite chatty and will openly reveal anything
relevant asked by the GP.
You have been encouraged by your neighbour to train for a 10k run for charity so have been
doing a lot of running with her recently. Training has been going well and you are well on your
way to reach your target of doing it under 1 hour.
Unfortunately whilst playing netball 3 weeks ago, you came down in a funny angle and twisted
your knee. It was immediately painful and your knee became swollen. You were able to limp
off the court and had the local first aider assess you. You were told you had jarred your knee
and have avoided netball for the last 2 weeks to give it a rest.
On returning to netball you found your knee felt ‘clicky’ and painful when you would run on
the normally comfortably indoor courts in your local leisure centre.
Frustratingly you felt your knee ‘lock’ and this caused you to have a fall twice in the past few
weeks whilst attempting to play netball. Following the games you would get some swelling but
not as bad as the initial injury.
You feel frustrated as training has been going very well but this has put a spanner in the
works.
Your neighbour Emily , the physiotherapist has examined you and suggested you have
damaged some cartilage in your knee and encouraged you to see your GP if resting it doesn’t
help.
You have been able to continue going to work, albeit the knee pain has been an unwanted
distraction it has not stopped you from your day to day activities.
You are sleeping ok, but sometimes have to take an ibuprofen with paracetamol to help you
drift off to sleep.
ICE:
You think your neighbour is right and that you have damaged some cartilage but are unsure
what needs to be done.
You are concerned this will mean you wont be able to reach your under 1 hour target or even
miss the 10k run. You are further concerned that doing the 10k run will cause permanent

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damage to your knee. You hope the doctor can give you some strong pain killers or suggest a
good knee brace that will help you ‘get on with it’.
PMH: You have no medical problems.
DH: you take the very infrequent Naproxen for joint aches if you have done a lot of running or
done a lot of sports without taking much rest in between. This has been needed specially if you
have been at a netball tournament which you attend once a month.
SH: you are teetotal, and you do not smoke.

You live with your sister and enjoy working as an accountant.
Your parents are alive and well and live around 20mins away.
FH: nil of note.
On examination: (candidate will be expected to perform a general knee /lower limb exam but
not a meniscal test)
Normal gait.
Nil muscle wasting.
Some lateral knee swelling noted with joint line tenderness
ACL Draw test reveals laxity to the knee
Mcmurrays test is positive (candidate will be given information and will not be expected to
perform this test as it can be painful to perform)
Fully weight bearing, nil evidence infection to joint
Neurovascularly intact
Proprioception normal.
Observations – all normal – BP/Pulse/temperature

BMI 22.
INFORMATION FOR THE EXAMINER:
Gathers a succinct history of events.

Establishes the mechanism of injury, duration of symptoms and the effects on the patient
including any restrictions on the patients daily activities/routines.
Performs a knee exam including a gait assessment .
checks temp rules out a ‘hot joint’
Clinical management:
Discusses the diagnosis – likely ACL tear with associated meniscal damage.
Options include – physio with or without meniscal repair +/- ACL repair if knee becomes
unstable.
Likely as active , a meniscal tear causing locking will need surgery as will continue to cause
joint irritation , swelling and in this case locking of the knee.
Discuss the need for further investigations including a MRI scan and referral to
MSK/Orthopaedics.
Explain the role of the meniscus and ACL in a normal healthy knee as appropriate.
Offer leaflets about ACL /Meniscal tears /signpost to patient.co.uk where leaflets can be found
.

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Safety net RE: signs of infected/hot knee, if reduced mobility, locked knee that will not unlock
will need to seek immediate medical attention.
https://www.nhs.uk/conditions/knee-ligament-surgery/
Simple overview of ligament surgery
http://www.wheelessonline.com/ortho/anterior_cruciate_ligament
Doctor Article – complex on ACL repair techniques and current methods

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Case 3:
Psoriasis Case:
Samantha Wild. 24years old.

PMH: Psoriasis, tennis elbow
DH: Aqueous cream, fucibet , Microgynon NKDA
Opening Statement:
“Hi Doc, I’m just here for a sick note please”
Simulated patient History.
You are a newly qualified teacher, in a private school where you teach physical education .
You love your job and have found getting this position is a dream come true.
Your parents live nearby which is a bonus as having lived away at uni for the past 3 years and
then been on a working holiday in Australia you feel it is nice to have family around.
Unfortunately with leaving the sunny climates of the land down under , you have found your
skin has not been as good for some reason. As a result you have suffered with several flare ups
of your psoriasis since coming back. Some have been so bad you have felt you cannot go into
work. This has happened twice in the last 11months, requiring you to self-certify for 3 days on
the first occasion and get a Med3 on the other when the flare up required high dose steroids –
betnovate to clear it.
When you studied at uni you found your skin was largely well controlled and would flare up
during cold spells, around exams and once when you broke up with a long term boyfriend
when you started work and moved away from Uni.
You are aware you do not regularly moisturise whereas when you were first diagnosed with
psoriasis at 18 you regularly applied emollients, used soap substitutes and had regular check-
ups with your gp . Since then, ‘life has got in the way’. This has mostly been a positive thing as
you have achieved a long life dream of becoming a teacher and working in your home town.
You are a very positive person and do not feel depressed about your skin but recognise people
can become depressed if their skin was bad all the time.
Your psoriasis does not affect your joints and has never caused you to be hospitalised nor see
a specialist.
You have a fairly good understanding of what Psoriasis is and do not expect the doctor to go
through that with you again.
Ideas Concerns Expectations
Ideas – Essentially you are here to request a sick note for your psoriatic flare up.
Concerns – You are concerned if you teach PE looking the way you do , the pupils will think
you have something contagious and it will affect your normally excellent rapport with them.
You feel people do not understand psoriasis and a lot more can be done to educate people
around it.
Expectations – you hope the GP can help you with the sick note as well as maybe help you
reduce the amount of flare ups you are having.

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SH: non smoker, drink on the weekends but only 1-2 glasses of wine 2 Sat/Sunday. No
recreational drug use. You are single but dating.
FH: Both parents have eczema, an aunt has psoriasis.
O/e: Examiner will give you a card with pictures of affected skin on asking only.
Flexural areas – arms and legs , plaque psoriasis.

Nil in scalp
Nil nail involvement.
Obs all stable including temp, bp.
Management:
Discuss option of sick note. Advised not a problem however worth while discussing with
superior/line manager to make them aware of why she is off. Most bosses can be very
understanding. Discuss would be self certification but could be ‘upgraded’ to Med3 if unwell
for over 7 days. Private note otherwise and would cost.
Discuss wording on sick note would have to be either non specific – unwell but suggest better
to be specific – leave this up to the patient.
Consider an opportunity to educate young adults about a common skin condition and show
before and after pics of arms and legs so when flare up occurs they know and less of an issue
maybe going forward?
Discuss general management of psoriasis. Offer to explain condition.

Explain need to use moisturisers regularly , specially during times of ‘normality’ as this will
help reduce flare ups.
Discuss use of Vitamin D analogue vs Dovobet (combination with steroid) as a regular once a
day treatment.
Offer follow up .
Useful online links about Psoriasis:
https://patient.info/health/psoriasis-leaflet
https://www.dermnetnz.org/topics/psoriasis/

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CASE 4 – letter request (depression and the army)
Roger Smith. 32years old.

PMH: Anxiety with depression, cluster headaches, pernicious anaemia
DH: Citalopram 20mg, propranolol 10mg tds prn
Seen by your colleague Dr Joy several times in the past :
Jan 14th : Depression, PHQ 9 18, nil suicidal ideation, ‘feels lost’, good support network at
home. Starting citalopram today. Med 3 for 4 weeks given.
Feb 2nd: Depression Review : PHQ 9 15 – feels a bit better, ‘taken the edge off’ – feels there is
lots more to improve. Unsure about the future, denies thoughts of deliberate self harm. Med 3
for 4 weeks given.
March 12th: Depression Review: PHQ 9 6 – new lease on life. Still has odd occasional bad day,
but short lived. Back to work.
Opening statement:
“I need your help with a form doctor”.
Simulated Patient History.
You are Roger Smith, a Male nurse who has been working in the nhs for just under 10 years.
You used to love your job, but unfortunately due to witnessing some rather traumatic events
with poor patient care which you felt was down to lack of staffing that you could not continue
in your line of work. You took up a non clinical job for about 18months but felt the complaints
you had been flagging as clinical staff were now coming to you and ‘protocol’ meant you
couldn’t do anything about it. You had now become part of the system you hated and therefore
took the decision to quit for your mental health and well being.
Since doing so you’ve kept busy working as a part time male nurse for Nuffield Health , having
flexible hours and no drama in a inner city private practice that essentially does health
checks for the well off.
You always knew this was going to be a stepping stone to doing something more worthwhile
once you figured out what that was going to be.
Someone in your clinic invited you to join them for an open evening to being a nurse in the
army – the ‘TA – Territorial Army’. You fell in love with the idea of making a difference again
but the glee soon turned to dismay as you read that mental health problems were a potential
contraindication to joining. You do not know if that means being depressed in the past as you
feel better now means you still are not eligible but you feel at a crossroads as this is what you
see yourself doing and the uncertainty to whether you’d be allowed to or not is causing you a
lot of stress.
With respect to your anxiety and depression, although things started very rocky with good
and bad days you have felt back to your normal self for the last 2 years approximately.
During your worst time, you contemplated accessing the home based treatment team /Crisis

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team at the hospital but managed to avoid this. You have never self harmed, nor had
persistent thoughts of deliberate self harm.
SH: You live with your fiancé Emily, who has been very supportive over the past 18months +
and you feel has been the main reason you have managed to get through your mental health
problems.
You do not smoke but enjoy a glass of wine most nights .
DH: you still take citalopram 20mg once a day, but feel back to your normal self and have felt
this way for at least 18months – 24months. You still have propranolol on your script but this
is only there as a precaution in case you have a panic attack which you have not had for the
same period of time.
FH: Aunt had depression, Mom had anxiety. Nil else of relevance.
ICE
Ideas – You are aware you feel much better and could probably start coming off the tablets.
Your main agenda today is to try to get a supportive letter to say you are fit to work in the
capacity of a nurse in the challenging environment in the army.
Concerns – you are worried the GP will either refuse to help you or state you are not fit for the
coveted role of army nurse.
Expectations – you hope the GP can help you with a supportive letter.
O/E:
PHQ9 – given if you state you wish to perform one or a mental state exam = 4
Denies suicidal ideation.
Well kempt, good eye contact, normal affect. Subjectively has positive thoughts for the future.
Information for the examiner:
Gathers information regarding current mental state including potential suicidal ideation.
Discussed patient fears regarding missing out on this job opportunity.
Discusses writing a letter , but stating the need for facts. We cannot write a patient is fit for a
certain duty unless the criteria are clear.
The British army specifies contraindications to joining from a psychiatric point of view are as
follows:
- Schizophrenia, obsessive compulsive disorder, alcohol or drug dependence and post
traumatic stress disorder.
Based on this current guidance we can reassure the patient that for someone who is well and
‘stable’ from a general mental health point of view it is unlikely to lead to not being seriously
considered for a job in the army.
Point out the fact that it is important to highlight the fact that he has overcome a major
obstacle in his life as significant as anxiety and depression and that this may well in fact stand
in his favour. Also point out that the army will request factual information about past
diagnosis, current and past medication and in doing so will do a thorough background check.
Trying to hide any information can only reflect badly on the application and would almost

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certainly lead to painting the potential candidate in a very bad light and inevitably make it
very unlikely they’ll be accepted into the army.
Offer follow up once the letter has been written, this can be in the form of a telephone consult
to see if they’re happy with the letter.

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Case 5 – Erectile Dysfunction.
Peter Harrison. 37years old.

PMH: knee OA, chronic lower back pain
DH: Naproxen 250mg on acute, Diclofenac gel 2.32%
Blood results from last week.
FBC: HB 135, normal mcv. WCC 8

LFTS: Alt: 85 rest all normal
U&Es: normal kidney function, all normal
Urine: NAD
HBA1C: 34mmol/l
CRP: 8
Thyroid function tests: TSH 2 T4: 13
BP: 115/70
Opening statement: “I’m here for my blood results doctor”
You are P. Harrison, a senior barrister who is enjoying the fruits of your labour after so many
years of ‘grafting’ to get to where you are at. You came from a poor background and worked
your way up knowing that you wanted to be a law specialist/barrister from the start.
You have always kept fit, but since becoming the senior partner at your firm you have lots
more time than you have had in the past and lead a supporting advisory role with minimal
hands on other than the occasional specialist case that requires your particular set of skills in
court. Generally speaking you are in court 2 days a week with 1 day in the office and the rest
you ‘work from home’.
This new found extra time has made you invest in your personal health further. You have
joined a high end gym and have had a personal trainer for the last 18months. Julie has
worked hard with you over this period of time and you feel you’ve had an outstanding change
that you are both surprised and proud of. Despite your good family life – you have a long term
partner, a high school teacher , Emma but no kids, you somehow developed a romantic
interest in Julie and to your surprise at first found this was reciprocal.
The reason you have booked blood tests is as since you have started a physical relationship
with Julie you have found you are not ‘performing’ well in the bedroom department. At first
there were no problems at all, however in the last 2months you have been unable to maintain
an erection , sometimes not being able to get one at all. This has been occurring with both
Emma and Julie.
You always use protection when with Julie.
You have had no trauma to your genital area and have not suffered any STIs in the past.
Other than your affair with Julie you have had no one night stands nor any other sexual
partners.
There has been no discharge from your genitalia, nor any swellings or pain.
On a few occasions you have resorted to using Viagra which you have bought online or have
been given to you through a friend at work.

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As far as you can remember you have never had a problem with erectile dysfunction and feel
generally well otherwise.
Emma has not put any pressure on you to ‘perform’ in the bedroom department and has
actually encouraged you to see the doctor as she has seen how upset you have been at times
when this has happened. She has been very supportive of you.
You always get a morning erection, you can still masturbate and have been able to on several
occasions have penetrative intercourse with both partners.
SH: you do not smoke, but enjoy a bottle of wine on Friday night, the only day of the week you
drink.
You live with your long term partner Emma and have a Labrador together.
DH: You take the occasional naproxen and voltarol gel when you have done a lot at the gym ,
but mostly have it in your cupboard for ‘bad days’. You have no drug allergies and do not use
non prescribed medication – other than the online bought Viagra.
FH: nil of note
ICE:
Ideas - You are here to collect some blood test results
Concerns – You are worried that the doctor will say there is nothing wrong and you’ll end up
with long term ED problems. You will not open up to this fact unless the doctor specifically
asks you why you had the bloods taken and the issue of ED comes up.
Expectations – You hope the doctor will be able to diagnose the problem and a solution or give
you a script for Viagra.
On Examination:
Nothing abnormal detected on external genitalia exam.

BMI 23. BP: 110/65
Information for the Examiner:
Data Gathering:
Elicit ED history to determine if psychological or physical cause.

Enquire about early morning erections, maintenance of erections, the ability to masturbate,
ejaculate and whether or not they have been able to have penetrative intercourse.
Ask about any illicit drug use, medications used over the counter/bought online.
Explore mental health – depression, anxiety, insomnia , including home /work difficulties
Explore possibility of other causes of ED – screen for signs of diabetes, anaemia, thyroid
problems, physical trauma.
Management:
Depends on the cause – options include medication or sexual health counselling
Diagnose E.D.

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Explain the condition can be caused by physical and non physical causes such as
stress/guilt/anxiety/stress.
Be non judgemental about his situation. Explain sometimes we can subconsciously ‘react’ or
feel what we are doing is not right. This can translate into Erectile Dysfunction.
Appreciate this is a tough situation and that ‘we do not choose who we love’.
Relay that everything you discuss is naturally confidential and that you’ll try your best to
help the patient if this has not been made clear already.
Discuss the benefit of exploring further blood tests including prolactin and Testosterone
although unlikely to be an issue if the patient is keen on that idea.
Discuss the option of medication.
Offer follow up in the next few weeks to see what the results of the tests show and how he’s
gotten on.
More info:
https://patient.info/health/erectile-dysfunction-impotence
https://sexualadviceassociation.co.uk/taking-a-sexual-history/
(useful for taking a sexual history)

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Case 6 - The angry mother!
Telephone consultation
Call waiting from Emma Gilchrist

Age 45.
DH: Mirena Coil implant (last year February), Tegretol, Atorvastatin 20mg NKDA
PMH: Epilepsy, hypercholesterolaemia
last consult – Review of results with Practice Nurse – ‘general improvement, attending regular
gym classes, doing well’.
You have never met Emma before.
Simulated patient history.
You are Emma, mother of Samantha Gilchrist who is 14.

You were cleaning Sam’s room when you found a box of Microgynon contraceptive tablets.
You instantly felt a sense of shock, became upset then felt betrayed by the GP practice.
How could someone prescribe a child a contraceptive pill without speaking to their
guardians/parents first?
You work as an accountant and do not have any medical knowledge other than recognise the
name of the tablets as you used to be on these prior to your long acting contraceptive device
was inserted last year.
You have strong feelings about the decline of social etiquette/morals of young people and feel
it is the older generations’ responsibility to make sure young ones do not go astray. You would
imagine most people if not all would aspire to that notion and feel astounded that somewhere
like the doctors would seemingly be so blaze as to prescribe something like the pill without
prior consultation with the parents/guardians.
You confronted Sam when you found the box , and admit to being very upset, shouting at her,
threatening to call her dad and the rest was a blur as you saw ‘red’. You have never hit your
child nor would you ever but you feel you lost your temper for the first time ever.
Sam became very upset and ran into her room locking it refusing to speak to you.
SH: you are religious and regularly go to your local Baptist church. You drink but only on
weekends and it tends to be a shandy . You feel you keep to well within the recommended
limit.
You do not smoke. You have 3 children, 2 who are at university (Ben and Jacob Twins – 19
years old) and Samantha 14. You are married to John also an accountant at your work.
DH: as above – Mirena coil, Tegretol and atorvastatin. NKDA
FH: nil relevant.
ICE:
Ideas – you think the GP has been haphazard and prescribed a contraceptive . The main aim of
the call is to challenge the premise behind this and see what can be done to prevent this from
happening in the future. You are unhappy with what has happened and you are contemplating
making a formal complaint.

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Concerns: You are worried Sam will fall pregnant as plenty of young people are forgetful as
you were and this would change her life. You do not feel she is mature enough to make major
life decisions like this and feel she may fall prey to some devious boy.
Expectations: you want an explanation to how this could have happened and what can be done
to prevent it. If you are not happy you are both willing to complain and take this to the local
ombudsman.
You know that Dr Smith , another GP at the practice prescribed the medication , yesterday
judging by the date on the prescription.
If you do not feel satisfied by the doctor or feel they are unsympathetic to your
fears/concerns, you pursue a complaint.
Examination: - nil needed in this station.
Information for Examiner/Management

Do not breach confidentiality. It is difficult in this case as we do not have access to Dr Smiths
consultation however in the event one did or it is requested we go into the records state that
you cannot for obvious reasons.
Explore the mother’s concerns. Has past experience made her feel this way about her
daughter?
Explore what Emma knows about the pill. Did she forget to take it when she was on it?
Talk broadly about that contraception has many uses other than preventing pregnancy.
Period regularity, pain reduction, mood improvement in those getting premenstrual tension,
acne improvement in those who get period related skin changes and of course contraception.
Discuss that you acknowledge her concerns and reflect that this shows you she is after the
best interest of her daughter which is good to see. Reassure her that we have the same aim at
the practice.
Discuss again generally speaking in cases where young people decide to embark on a sexual
intimate relationship with someone and they are as young as Sam we make sure they are
Frasier Gillick Competent. Explain what this means. Explain also that we generally encourage
getting parental support/involvement in such decisions, but would prescribe if criteria were
met as the outcome of not giving anything may well lead to an unwanted pregnancy.
Signpost Emma to the practice policy complaints procedure and explain this if she is still
unhappy and wishes to complain. Suggest a joint consultation if needed with Emma and Sam
but only if Sam agrees and not under any form of duress.
Offer follow up tele consult if wanted.
Useful reading:
https://www.nspcc.org.uk/preventing-abuse/child-protection-system/legal-definition-child-
rights-law/gillick-competency-fraser-guidelines/
https://www.fpa.org.uk/factsheets/under-16s-consent-confidentiality

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Case7 – Indigestion.
Gemma Smith. 29 years old.

PMH: Nil of note
DH: Orlistat
Last consult: Practice nurse discussed prediabetic bloods and encouraged weight loss
management.
2 previous DNA’s with HCA’s weight loss clinic
Simulated patient history:
Opening Statement: “Doc, I think there’s something up with my heart!”
You are Gemma Smith, a 29 year old single mother of 2. You work predominantly from home,
where you have an online jewellery business. You sell things on facebook, Instagram and ebay.
You do quite well but find yourself isolated at home quite a lot of the time which has been both
a blessing and a curse as you have found yourself to be increasingly sedentary which has lead
to weight gain. This is something you are attempting to address.
The reason you have come to the doctors today is because you have been experiencing chest
pains. It has not been very sharp or lasted that long but you feel it is getting worse and makes
you feel sick You recently saw something on a bus stop that made you think you should speak
to the doctor about this.
Your pain can come on at anytime but seems to be most apparent at night time. It can start
centrally in your chest but can also start from your lower chest wall, just under your breasts,
moving upwards.
You can feel flushes, sickly and hot when this happens. Several times in the last 2 months you
have had disturbed sleep and have found sleeping sat upright relieves the pain.
Somewhat surprisingly when you were trying to encourage one of your children to have her
milk, you had a glass with her and that made your chest pain better.
You have found that eating spicy food, large meals or consuming fizzy or alcohol beverages
can lead to the pain as well.
You admit that your diet is poor, mostly due to the long hours you have. You make an effort
with the kids meals but neglect yourself and have fast food mostly. You also have a sweet
tooth but have done your best to limit this to weekends. This has been a recent change in the
last 2 weeks only however.
On further questioning you appreciate that the pain is more like a burning, and like a
background constant gnawing discomfort with the occasional flare up when you have one of
your triggering factors as aforementioned.
You have never been short of breath, this pain has not come on during exercise or physical
exertion. You have not lost weight, had swallowing problems nor have you noticed blood loss
in any vomit or in your stool.

20
SH: drink 1 glass of wine at night, sometimes 2 if it’s been a stressful morning. You enjoy
drinking fizzy drinks. Single mother of 2 children, aged 12 and 13 – Sam and Emily.
Non Smoker.
PMH: as above – overweight, on orlistat awaiting weight loss clinic appt .
FH: nil cardiac hx . nil other of note.
ICE:
Ideas – you are concerned there may be something wrong with your heart as you know chest
pain symptoms are serious. You delayed coming to the GP because you were worried they’d
confirm your fears.
Concern – that there is permanent damage that is not reversible due to waiting so long to
come see the gp.
Expectations – to be referred to a heart specialist to give you the expert help you feel you
need.
O/e:
One is not required in this station but you should ask to do one and will be provided with the
following findings:
Abdo exam: SNT. Nil signs jaundice. Nil masses. Normal bowel sounds, normal PR
Normal heart sounds. Pulse 88 regular, BP 138/79 , Apyrexial. BMI 36
- Ensure candidate takes a thorough hx including red flag signs.

- Exclude signs cardiac pathology
- Consider ecg (although not needed in this situation)
-
Management:
Diagnose GORD. Explain what this means.

Explain this is a generally well managed condition in primary care and you are confident you
can help.
Discuss that management is a combined effort, and highlight the fact that treatment will to a
large part revolve around lifestyle changes which they are looking to address already.
Namely weight loss and dietary changes.
Discuss modern methods of exercise that can be done from home and that do not require
hours of exercising. Mention national recommendations that suggest we should all be doing
30mins of some form of exercise 5 days of the week. Signpost to online exercises –
HIIT/Aerobics/going for a brisk walk.
Offer dietician referral if warranted/wanted as an option .

Offer Omeprazole +/- gaviscon
Discuss portion control, reduction alcohol and fizzy drinks. Avoid late night meals.

21
Safety net re: chest pain ongoing or feeling worse to call back/seek immediate medical
attention
Useful reading:
Indigestion
https://patient.info/health/dyspepsia-indigestion
When to worry about indigestion

https://patient.info/health/dyspepsia-indigestion/features/when-to-worry-about-indigestion

22
Case 8 – Emergency Contraception
Gemma Smith. 27 years old.

PMH: Asthmatic,
DH: Microgynon
Salbutamol inhaler 2 puffs QDS/PRN
Last consult 12/5/17: Asthma review. No recent admissions or exacerbations. Inhaler

technique checked, good. Peak flow 96% of expected . Doing well, continue.
Simulated patient Hx:
Opening Statement “I’ve come for the morning after pill doctor”
You are recently qualified teacher, at a local school. Life is going well at the moment, specially
since your long term boyfriend John asked you to move in. You see this as a major step in
your life and you are generally very positive about the future.
John works as a teacher at your school as well but teaches the A level students where as you
teach the year 7s. It is nice to be able to have lunch together.
You have a lot of things going on, including doing a management diploma in order to be a head
of year or principal in the future. You have your goals set quite high but you know what you
want.
Unfortunately as part of trying to multitask and having a lot on, you are often forgetful and do
not always take your contraceptive pill on time and often forget to take it. As a result you and
your boyfriend John decided to practice ‘safe sex’ through the withdrawal method or the use
of condoms. As luck would have it, you were both in the mood yesterday and you had no
condoms available, so decided to rely on the withdrawal method which was frustratingly
relies on John – who’s not very reliable in that department – hence you being here!!!
You find this quite funny but realise that you are both not ready to start a family and do not
want to get pregnant. You have had the morning after pill before, around 3 months ago in a
similar situation.
You had levonelle last time and tolerated this fine.
You have had a previous partner when you were at uni, but have had no other sexual partners
since then other than John. You have never suffered with any Sexually transmitted diseases.

23
You have quite regular periods, and had a period around 10 days ago. You bleed for around 3-
4 days, they are normally light with no clots and generally not that painful.
You have never had bleeding after intercourse, nor pain during intercourse. To your
knowledge you have never had a bleed in between your periods.
You had a smear about 2 years ago and was told this was normal.
You do have mild asthma but this is well controlled on Salbutamol. You used to be on a steroid
preventer about 18months ago, but have since been stepped down and coped very well. You
still get a hard time if you have a cold which is the only time you feel you need to use your
salbutamol. You have not had any major exacerbations however in the last 12 months and no
hospital admissions for over 5 years.
DH: salbutamol, nkda
FH: Asthma, eczema, hypertension
SH: 12 units alcohol a week. You do not smoke.
Last consult – fall off your bike, resulting in scrapes, came in for assessment of sprained ankle.
Diagnosed with soft tissue injury and given short course of topical nsaids and codeine.
ICE
You are aware that you should be more careful specially as neither you nor John want to fall
pregnant at the moment.
I – You have been considering long acting contraception but you have little knowledge about
the types, and what they involve. You are happy to be briefly informed about them however
your priority today is to get the morning after pill.
C – you are both concerned you will get pregnant and also concerned that if you take the
morning after pill several times or long acting contraception for too long that you have not
have ‘good fertility’ as you’ve read on facebook that people have been unable to conceive after
being on the depot or implants for a long time.
E – You are hoping you can get the Morning after pill.
Examination:
Normal obs, blood pressure : 100/65

24
All other examination normal.
Data G:
Time of last unprotected intercourse, Basic Gynae history to include – Menstrual cycle, any
signs infection (discharge, PCB, IMB)
Discuss current if any contraceptive methods used.
Discussed Emergency contraception, limitations and options. Discuss options of Long acting
contraception role as an emergency contraception.
Management
Discuss types Emergency contraception available – Levonelle (3 days), Ullipristal (5 days)

and IUD .
Discuss that the sooner a pill is taken if chosen as an option the better chance it will work.
Discuss need to retake pill if vomiting occurs in first 2 hours/3hours (levonelle/Ullipristal)
Discuss common side effects with their usage – i.e one off change to timing of period, can be
late, early. Offer GUM check up if relevant.
Discuss Follow up for choosing/exploring LARC further if taken up on this offer.
Useful Reading :
Good overview of contraceptive methods
https://patient.info/doctor/contraception-general-overview

25
Case 9 – Dysphagia
Samantha Geoffries. 77 years old.

PMH: GORD, Severe bilateral knee OA, Bilateral hip replacements
DH: Omeprazole 20mg BD, Naproxen 250 mg prn, diclofenac gel 2.32% BD PRN, Codeine
15mg 1-2tablets QDS PRN
Last consult was to discuss pain relief. Samantha had been on a walking holiday 1 month prior
and this had caused her knee pain to flare up to such an extent she required a steroid
injection to her left knee.
Simulated Patient History
“Good morning doctor, I am so sorry to waste your time with this, my son made me come
today”
You are Sam, a 77 semi retired pub landlord.

You used to run and own the local pub up until three years ago when you handed it down to
your son. You really enjoy talking to people and found that when you stepped down you felt
quite low as you were no longer the ‘go to ‘ person. Everyone would tell you their ‘woes’ when
you’d pull a pint or be pottering around the pub doing various things. Your son agreed to have
you on as a floating role where you’d be able to do as much or as little as you’d like. You even
renovated the loft and have a nice studio at the top of the pub. This has really given you a new
lease on life as you still feel important and you have something to do everyday.
You do not feel stressed or rushed at work.
Other than your arthritis ‘wear and tear’ to your knees you feel quite well in general.
You have a young up and coming sous chef that cooks at the pub who makes you your meals.
The sous chef Emily , your sons fiancé is the first that rang alarm bells when she noticed you
were looking quite gaunt despite the meals she was preparing for you. Your son in turn grew
alarmed and stressed you needed to see the GP. He is sat in the waiting room to make sure you
came and to show you support.

26
You admit, you have not felt much of an appetite at all over the last 12-18months but put this
down to being lonely up until recently when you’ve had your role back.
You have also started preferring soups, and softer diet as you’ve noticed it can be difficult to
swallow food and at times painful , specially when things get stuck and you get a set of violent
coughs that eventually bring it up. On one occasion last week you vomited and that made you
feel unwell for quite a few days. You do not want to feel like that again.
You have had no trouble swallowing/eating soup, and sometimes eat it with some soft bread
that you make sure you thoroughly soak in the soup and eat small bits that are very
thoroughly chewed.
You do not feel there is anything wrong with you and put your lack of appetite down to the
throat pain/discomfort /difficulty in swallowing and old age.
You resonate that not a lot of old people are ‘fat’ because we tend to eat indoors and just what
we need.
You do not have any problems passing a bowel motion, you open your bowels once a day,
sometimes twice depending if you’ve had something spicy to eat! This has been the norm for
as long as you can remember. There is no blood or mucous in your stool.
You have not noticed any pain on passing urine or blood.
You do have a long term dry cough but admit to being a long term smoker of 20-30/day for at
least 20-25 years.
You do not check your weight, but have been told by friends that you look slimmer, and at a
push you admit that despite not trying you have noticed your clothes being looser and have
needed to tighten the belt buckle.
There is a family history of diabetes , your dad and mom had this, and several aunts but they
were all overweight and had a sweet tooth.
You enjoy the odd pint of shandy every other day and a small glass of wine on the weekends.
Again you ruminate that you are just a bit old , getting on and a bit more tired than you used
to be because most 77 year olds don’t work in a busy pub!
SH: smoker 30/day, 12 units a week, lives alone at the top of her sons pub
FH: diabetes, nil else of relevance.

27
ICE
I – You feel guilty you are taking up the busy doctors time. You feel glad that your son and his
fiancé are making a fuss out of you as you feel cared for but you feel it is all a bit over the top.
You are not concerned about being ill as you don’t feel particularly unwell.
C – You are concerned the doctor will send you into hospital to have tests where you have to
stay overnight. You have had a phobia of hospitals after your husband died of a brain bleed
there.
E – You are sure the doctor will tell you that you need to focus on your eating. You will be
happy to be referred to a dietician as they may recommend soft food and foods that have a
smaller chance of getting stuck in your throat.
O/e:
Abdominal examination – nad
PR NAD
ENT Exam NAD
Chest exam nad
Obs: all stable, apyrexial.
Weight 48kilogram BMI 18
Data Gathering
Explore the symptoms in depth – swallowing difficulties with water/solids/lumps in throat

developing?/halitosis.
Review Red flags to include blood loss from GI tract, GU, Quantify weight loss where possible.
Review ‘normal diet’.

28
Management
Discuss the need to rule out potential sinister diagnosis. Offer to bring in son to discuss with
him if wanted.
Explain the need for further investigations but reassure OPD and not generally hospital stay.
Recognise that this requires a 2ww.
In house investigations should include FBC, LFT, TFT, Haematinics, U&Es +/- Chest Xray due
to smoking history.
Be sensitive when breaking bad news in this scenario as the patient is not expecting it and
this is made clear by her ideas concerns and expectations.
Useful reading:
https://patient.info/doctor/dysphagia
Overview for patients
https://patient.info/health/difficulty-swallowing-dysphagia

29
CASE 10 - Sore Throat on Methotrexate
Jeremy Smith . 29 years old.

PMH: Rheumatoid arthritis, eczema, depression
DH: Mirtazepine 15mg nocte, Methotrexate 7.5mg once weekly, Folic Acid 5mg once weekly,
allergic to hydroxychloroquine
Last consult: Travel vaccination clinic 4 weeks ago to discuss what he needed prior to
travelling to Bali with his girlfriend.
Opening statement
“ Hi doc, hopefully a quick one for you, help me sort my sore throat out, that ibuprofen aint
doing anything…”
You are an accountant working for Barclays bank. You have recently been given a promotion
which you have worked very hard for over the last 3 years.
Things have been very good in the last few years both health wise and socially. Your Girlfriend
of 4 years proposed to you in the last leap year! This came as a welcome surprise!
You have both now come back to Sale where both your families live and where you grew up.
You feel in the future it would be a great place to start a family with lots of social support for
when you have kids etc. You are both optimists and have a great outlook on the future.
This was not always the case , specially when you were first diagnosed with rheumatoid
arthritis about 5 years ago . However an excellent rheumatologist trialled you on a few
medications and since you’ve been on methotrexate things have been brilliant. Most of the
time if you didn’t have to remember to take the medication you wouldn’t know you had
anything wrong with you.
You are quite positive now that you have been able to feel ‘normal’. At the start of your illness
you were in and out of work due to medication not working or having side effects to the
medication and waiting for it to ‘stabilise’. You first had a lot of diarrhoea, and nausea but this
soon settled and you have not suffered with any symptoms secondary to the medication that
you are aware of.
7-8day hx of sore throat without any other systemic signs of illness.

You do not have a fever, you have managed to eat and drink although with difficulty.
You have been very appropriate with regards to taking your methrotrexate and have never
missed a dose unless told to stop it by your rheumatology specialist nurse. You had to do this
once when you have a urine infection and needed abx.
You have been taking methotrexate for 5 years now.

You have 3-4monthly blood tests to check your body is coping ok with this medication.
You’ve been on a sabbatical with work in Canada so had no time to have the bloods done and
got so busy at work you forgot to have them done abroad but have felt well until now.
ICE

30
Ideas – you are convinced you are coming down with an infection of some sort, as you have
had a sore throat for the last 7-8 days approximately. You have not had any major flu like
symptoms and had hoped you could ride this out yourself.
Concern – you are worried you’ll have to have time off work if it gets worse and for the last
12months you have managed not to have 1 day off even when you’ve been significantly under
the weather. You want to make a good impression in order to get higher up in the company.
Expectations – you hope the GP will give you some antibiotics.
PMH: Rheumatoid arthritis diagnosed 5 years ago. Eczema – well controlled on dermol and
infrequent use of hydrocortisone for flare ups.
Depression – you were quite low when you first got diagnosed with R. Arthritis but have since
coped well and feel in a much better place.
DH: Methotrexate 15mg weekly, Folic acid 5mg once weekly . Citalopram 20mg . Dermol
500ml BD, Hydrocortisone 2% prn
SH: non smoker. Drink infrequently – usually a shandy if you are going to drink and a glass of
wine at new year/Christmas or birthdays.
FH: nil relevant.
On Examination.
Ears and nose NAD
Throat : inflamed tonsils, nil pus/exudate. No lymphadenopathy in the neck.
Obs: apyrexial. Pulse 88

Blood pressure: 110/65
Any other examination attempted or asked for – normal.
D. Gathering
Check when last bloods done – were they normal? Has the patient had to stop medication
before due to blood abnormalities? Do they take them regularly?
Management
Explains this may be serious and not just a ‘viral/bacterial’ infection.

Urgent bloods – FBC and speaks to rheumatology services regarding need for further action .
Usually FBC done urgently with follow up if any deterioration is enough but worthwhile
discussing with rheumatology.
STOP the medication until results back.
Safety net about deterioration in general. Discuss general symptoms methotrexate.
Useful reading:

31
https://patient.info/medicine/methotrexate-maxtrex-metoject
https://patient.info/doctor/disease-modifying-antirheumatic-drugs-dmards-pro

32
Case 11 – Medication Request (acne)
You are a salaried GP seeing this patient for the first time.
Fatima Smith
22 years old.
PMH: Acne
DH: oxytetracycline 250mg bd, microgynon
SH: Teetotall, non smoker.
Last consultation : Pill review. Not keen on long acting contraception. Remembering to take
pill appropriately . Nil MEC contraindications to pill. Continue
“Hey Doc, I can’t carry on like this – I look like a lepur!”
You are a student on a scholarship from Saudi Arabia. Currently studying for a PHD in
biomedicine.
You are in your fourth year of being abroad and in the UK and thoroughly enjoy your
academic work and life at the moment. You have found that you can be yourself without the
restrictions of a strict country.
Although you were raised in a strict environment you are not practicing and enjoy a western
lifestyle. You’re currently dating a guy called Erik enjoy spending time with him . He is a
fellow PHD student from Sweden.
You feel well supported by family and get a few WhatsApp messages from your parents. Your
dad is English and your mom Saudi. They also met whilst studying abroad.
Dad has been sending you suggestions of things to explore in England which you’ve been doing
on your weekends off from studying etc.
When you lived in Saudi your sibling Sarah had what you considered quite severe acne , which
is less severe than your skin and she was given a tablet medication called ‘Roaccutane’. It
cleared her skin up quite well. You have been frustrated with the UK’s poor doctors who just
want to cheaper tablets. You’ve been on Oxytetracycline for 4 months and have not noticed
any major improvement at all.
You have been told that your diet is poor, as you have a sweet tooth and know you need to
change this in order to improve your skin. You were also told to wash your face more
frequently , but this has made no difference.
You consider yourself otherwise fit and well and have no medical issues nor any regular
medication that you take other than the acne tablets.
You are frustrated but not depressed with your acne and just want it better.
If the doctor refuses to prescribe you Roaccutane you will request a referral to a specialist.
If the doctor explains why this is not suitable you will consider this and may agree to
alternative medication/management.
SH: you live in a studio apartment in the city centre.

DH: oxytetracycline 250mg bd, microgynon, nkda
FH: your dad had psoriasis, but has been well controlled on this. Nil else significant .

33
ICE
I – You are convinced you have severe acne that can only be treated with expensive strong
medication.
C – you are worried that the delay in treating your skin may have left you permanently
disfigured with the acne. You are further worried that Erik will eventually be put off your
appearance and break up with you.
E – that you will be prescribed Roaccutane today.
O/E:
(pics of acne)
https://www.healthline.com/health/beauty-skin-care/types-of-acne#pictures
Moderate acne with no scarring .
Patient denies acne to back , shoulders or chest and states is only to the face.
Some comedones noted with white heads.
Data Gathering:
How long has she had treatment for?
What other treatments if any has she had? Has anything made the skin better or worse?
Did she have any other skin problems, including psoriasis, eczema, generalised dry skin? Is
there a family history of acne?
Ask where the acne is located – chest, shoulders, torso ?
Elucidate the patients Ideas, concerns and expectations.
Explain how Roaccutane prescriptions go. Specialist only, lots of guidelines, generally for
severe Acne.
Explain that many different medications exist for treating acne, everyone is different and
respond differently.
Offer a routine referral to dermatology, but explain based on her appearance it is very
unlikely they would prescribe Roaccutane.
Explain that other treatments (Lymecycline, other tetracyclines, Topicals containing
retinoids may have more success with her).
Useful reading:
https://www.dermnetnz.org/topics/acne-vulgaris/
Offer early follow up 6 weekly.

34
Case 12 – Benign Essential Tremor
You are a Salaried GP at a rural practice. You have not met Colin before but he has been at
your practice since his birth.
Colin Rogers
57 years old
PMH: hypertension, hypercholesterolaemia.
DH: Ramipril 5mg, Atorvastatin 20mg nkda
SH: 10 units a week. Non smoker.
Recent bloods from last week:
FBC NAD
Thyroid function NAD
Vitamin D NAD
Folate, Ferritin, Vitamin B12 NAD
LFT GGT 100, Alk phosph 200.
U&E NAD
HBA1c NAD
Lipids: total Cholesterol . 5.2 (last 6.8 from 6months ago) LDL 3.8 (last 4.6 from 6months
ago)
Last consultation – came to discuss request for diazepam as nervous on flights and wanted 2 ,
2 mg tablets for flight to Dubai and back.
“Hiya Doc, I’m sorry to waste your time, but I’ve got the shakes real bad”
You are a mechanical engineer that works for Shell, and have done so for the past 20 years +.
You have been troubled recently by the amount of administrative tasks you have to do but
then you recognise that you are in a managerial position and less on the ‘shop floor’ than
you’d like to be. On balance this is probably for the best as you have been developing an
annoying and increasingly debilitating shaking to your hands and sometimes your head.
You have noticed this shaking to have existed for around 8-10 years now but always as a
background thing and it had always seemed worse when you had been stressed, physically
exhausted from doing a laborious set of tasks or emotional/angry. You had resonated to
yourself that this was normal.
Interestingly you have found at times when you are concentrating on a particular task you
can control the tremor, but this has become more difficult in the last 6-12months.
You have not noticed that the tremor disturbs your sleep, in fact you sleep quite well and
wake up rested.
The shaking has been noticed on both sides. You are convinced that your neck and head have
been shaking a bit as well , particularly if you have had coffee or at the end of a long day that
has been stressful.
Frustratingly in the past 2-3 years it would be an intermittent thing but now you feel you have
it all the time with flare ups where the tremor/shaking gets worse.
You have noticed that during weekends when you watch the footie on tv and have a pint that
the shaking gets much better. You know it is probably not the best solution but you have been
drinking regularly in order to stop the shaking and have found this to be quite useful.

35
Your wife Laura has noticed that you are drinking regularly and has made you come to the GP
. You didn’t put up much of a fight as you feel there is an underlying problem too.
You are otherwise fit, other than a blood pressure and cholesterol problem which you were
diagnosed with , but you have been making strides to conservatively improve things by
attending the gym /walking and eating better. You hope to be able to come off the medications
with time
You have had no symptoms of being generally unwell, sweating, losing weight, or a cough.
You have had no memory loss and have not felt depressed.
You have noticed writing is difficult as when you write the handwriting is very messy as your
shaking is quite bad. You resort to dictating your emails, mostly because of the shaking and
also because you’ve never been a good typist!
ICE
I – You are concerned you may have parkinsons as you remember one of your sports heroes
Muhammad Ali having that but you cant be sure. You seem to recollect him shaking like you
are but worse in recent TV interviews prior to his death.
C – You worry for your wife and how you’d support her if you were to go off on the sick not
being able to do your job if the tremor/shaking got worse.
E – You want to get your blood results and hopefully a diagnosis to know what is going on. You
have read that there are some medicines Parkinsons sufferers can have to slow things down
but this was off some ‘mumsnet’ type online article.
SH: live with Wife of 30 years. 2 kids , twin boys Sam and Erik, both moved out.
Drinking 2-3 pints at night now. Non smoker.
FH: nil of note – you were adopted so cannot be sure .
On Examination:
You have a normal gait.

Titubation noted at rest – head shaking gently.
Fine tremor noted in both hands.
Blood pressure 135/75
RR normal
Apyrexial
Cranial nerves normal (result given wont be expected to perform) Equally fundscopy if
requested NAD.
No evidence wasting of muscles, and otherwise neurologically grossly normal
Power reflexes all normal.
Explanation - An essential tremor is a type of uncontrollable trembling of a part of your body,

or often parts of your body. Most commonly the hands are affected but this is not limited to
this area. Your head, lips, eye lids can also be affected as well.
Often people notice this tremor when trying to hold something/hold ones position or trying to
perform a task such as writing. Some people have it affect one side of the body, others both.
It is relatively common and affects men and women at the same rate. It is thought 4/100
adults aged over 40 are affected.
Management:

36
There is no cure for a tremor however there are many effective management tools. Which one
we choose depends on how bad your symptoms are and which ones you want to try.
Propranolol and primidone are the most effective and popular to be used, but have side effects
. We can explore these in greater detail once you’ve chosen a treatment type.
Other medication include – Topiramate, atenolol, alprazolam and clonazepam.

Botulinum toxin A has been used for those with head tremor.
DBS – Deep brain stimulation is an option for severe cases or those not tolerating/not wanting
other conservative medication.
In rare cases Thalamotomy is considered for resistant severe cases.
Discuss need to reduce alcohol intake.

Discuss largely normal results – note LFts and incorporate to need to reduce alcohol intake.
Offer support if needed/wanted by patient.
Offer follow up in the next 3-4 weeks to see progress.
Further reading:
https://patient.info/doctor/tremor-pro

37
CASE 13 – Fibroids and Infertility
Laura Jones
24 years of age.
DH: Nil NKDA Fexofenadine 120mg PRN

SH: non smoker, 2 units alcohol a week
PMH: chronic urticaria
Last consult: Review of itching – well controlled. Needing to take fexofenadine approx. 1-2
times a week unless flare up then takes daily. Happy to stay on fexo. Continue. See as needed.
Ultrasound scan findings:
“ 30-40mm multiple intramural, subserous fibroids in the body of the uterus. Endometrium
normal. Ovaries normal. No adnexal masses noted.”
“hi Doc, ive come to talk about the results of my scan”
Simulated patient History:
You have been trying to get pregnant for the last 2 years. As you have not been able to get
pregnant you and your fiancé Stephen decided to go for fertility tests.
You are aware that your husbands sperm tests are all normal.
You have irregular periods, and they are often quite heavy and painful. This has been the case
for as long as you can remember.
Stephen hasn’t got any children from previous relationships nor have you.
You teach reception and have done so for 3-4 years. You feel really settled and have been busy
planning your wedding since getting engaged 2 years ago.
FH : nil relevant.
SH:
you live together with Stephen and your border collier Max.
Stephen works as an online PT so works from home most of the day which is great as you see a
lot of each other.
You don’t smoke and you only drink on special occasions.
Whilst your period pains have been so bad you have managed to control it using naproxen,
tranexamic acid and paracetamol.
ICE
Ideas – You are not sure what to think is the cause of your infertility but you’ve seen an
episode of friends where a character was not able to have children due to their womb being a
‘hostile environment’. You wonder whether you have something like this.

38
Concerns – you are concerned that you may be told that you cannot get pregnant and that
Stephen will not want to get married to you.
Expectations – To get your results and hopefully be told how you can fix the problem!
Diagnosis – Fibroids.
Fibroids are non – cancerous growths of the womb. They can both increase and decrease In
size. Some disappear with time (usually nearer the menopause).
They can actually grow anywhere in the womb.
Most with fibroids have little to no symptoms depending on how large they are.
If they are large, they can cause heavy or painful periods.
Some get symptoms of bloating, swelling, or even have to pass urine more frequently in cases
where the fibroids put a lot of pressure on the bladder.
Some patients actually have pain during intercourse where the fibroids are growing close to
the neck of the womb/vagina.
Even more frustrating is that they can affect fertility and cause problems during pregnancy.
These problems include making the baby present as a ‘breech’, early labour, increasing the
chances of it being a C section. The list is not exhaustive by any means.
Management:
Some elect to treat the fibroids before proceeding to try to get pregnant, this should be
discussed and a patient centred plan organised and agreed upon.
Medication:
Hormone treatment that reduced the level of oestrogen leading to the fibroids shrinking.
Treatment is given for a maximum of six months. (Goserelin, leuprorelin acetate). Often given
a few months prior to having a myomectomy.
Ulipristal – blocks the effects of progesterone which is thought to play a role in fibroid
development. This is used as an alternative to the oestrogen lowering treatments.
Please note there is a current ‘temporary’ ban on this medication whilst safety concerns are
investigated with respect to some women developing liver problems whilst on it.
Surgery:
Hysterectomy – (clearly not an option in this case)

Myomectomy – removing fibroid affected area only.
Uterine artery embolization – injecting a substance into the artery that supplies the fibroid
blocking it , making it shrink.
Myolysis – shrinking the fibroid surgically, via endometrial ablation or MRI guided focused
ultrasound or Ultrasound guided high intensity focused ultrasound.
Consider specialist referral early as this patient is obviously young and keen on having
children.

39
Further Reading:
https://patient.info/doctor/fibroids-pro
https://cks.nice.org.uk/fibroids

40
Circuit 2
Case1 - A patient requests Superastatin (new drug on trial)

Case 2 – Paternity Test
Case 3 – Obesity – ‘I cant lose weight doctor, I’ve tried everything’
Case 4 – Oligospermia
Case 5 – Menorrhagia
Case 6 – Premature Ejaculation
Case 7 – Eating disorder
Case 8 – Fatigue
Case 9 – AF
Case 10 - snoring
Case 11- swallowing difficulty
Case 12 – hypothyroidism
Case 13 – Sterilisation gone wrong / confidentiality

41
CASE 1 – Superastatin
Michael Corben 45 year old
PMH: hypercholesterolaemia, hypertension.
DH: Amlodipine 5mg, atorvastatin 20mg. NKDA
Last consult: Vaccinations for travel to Malaysia
Michael , 45, is married with 4 children.

Up until last year you had led quite a sedentary lifestyle having enjoyed a senior IT position
where you do most your work from home. Having had a ‘well man check’ which revealed a
high cholesterol (6.5) and blood pressure of 156/98 you were advised that your risk of having
significant heart problems was unacceptably high .
Acknowledging you have room for improvement you ‘took the bull by its horns’ , joined a gym,
changed your diet as a family and decided to have six monthly health checks.
In fact the last cholesterol check you had showed an improvement do 4.3 and your blood
pressure is now 130/75.
Your hopes are that one day you can come off the medication altogether and that is your aim.
You have noticed that not only do you feel better, but you have more energy. You have been
lucky not to suffer with longstanding symptoms with the statins although when you first
started you were bothered by the aches in your thighs and arms but that soon settled.
You are married to Emily who has been very supportive of you in general and you have 4
children together all girls who followed in your footsteps and are all teachers. They live close
by and you see each other at least once a week for a family meal . People are always popping in
and out of your family home. You have a good family support network.
You have a friend who has been talking to you about a recent study he has been enlisted in
where they are experimenting/trialling a new drug “Superastatin”. He only takes this drug
once a month and it acts much quicker than any other statin on the market with no side
effects!!!
You are a busy man and obviously want the best for your own health.
You don’t know much about this drug other than knowing your friends practice which is about
2mins down the road is offering it via this new trial. Your friend is the same age as you and
was on the same medication that you are on now. As far as you know even after 2 months
your friends cholesterol improved beyond yours and he doesn’t even exercise!
You have heard that this new drug can allow you to ‘indulge’ and still keep cholesterol levels
down and you quite fancy having a break from being ‘sensible’.
ICE
Ideas – You are here to enquire about the new trial drug
concerns – You do not have any major concerns at present but want what is best for your
health and want to know why you can have this drug if it is not available at your practice
Expectations - You hope the GP can prescribe you this medication today or refer you to
someone who can.

42
SH: lives with wife Emily.
Non smoker, drinks 4-5 units on the weekend.
O/e:
Bp 125/70 heart rate 80 weight 78kg BMI 24

All other obs/examinations normal.
Management:
Explore patients knowledge about the drug Superastatin

Admit to not hearing about this drug before.
Be open to learning/reading more about it and getting back to the patient.
Explore patients understanding of how trials work, strict criteria for inclusion, local funding
for specific practices as part of trial.
Discuss variants of trials – blind trials, placebos etc.
Discuss health concerns and state the obvious that he has actually achieved a lot already and
is well on the way to not needing any statin.
Discuss that in moderation he can enjoy/have a break from being strict with his lifestyle
choices. i.e can afford a take away/choc/treat now and again.
Suggest follow up once you’ve found out more about this medication. Be open to exploring
whether the fellow neighbouring practice will entertain inclusion of non current residents to
trial – advice unlikely however based on how these things generally run.
Further reading on medical trials and how they are regulated:
https://www.nhs.uk/conditions/clinical-trials/#how-are-trials-regulated-and-judged-ethical

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Case 2 – Paternity testing
Jermaine Lang 40 year old

Pmh: nil DH: nil
Last consult : well man check – results were all normal.
You are a 40 year old accountant who has recently separated from your partner Samantha of
12 years.
You are not depressed by the situation but rather frustrated of the betrayal of finding out your
ex was having an affair with her best friend and family friend Jim.
You grew up together with Jim and remember introducing him to your then partner.
You have 2 children from your ex, John who is 4 and lily who is 8 months old. Both children
stay with Samantha, but you have agreed shared care and although you are meant to have
them on the weekends , you have maintained an amicable relationship mostly for the benefit
of the children and in so doing you end up seeing them more often.
Despite the positive, adult way of dealing with the break up, you are pursuing a divorce and
have your suspicions that Lily is not your daughter. You’ve always joked she doesn’t look
much like you and since finding out about the affair those thoughts have intensified. This is a
heart breaking situation to think about and you are keen on finding out if the gp can arrange
for a genetic test. This would not only give you peace of mind but also would mean it would
affect what maintenance you’d be required to pay .
You are otherwise fit and well and have no major health concerns.
You do not take any medication, you do not smoke and only drink on special occasions.
At the start of the break up you were more shocked than upset, but this later turned to
frustration and a sense that you didn’t deserve this.
You have had great support from colleagues and friends as well as your family who live
nearby.
You have had no thoughts about self harm and have found solace in talking about your
frustrations to your support network as well as exercising.
You have read online that there is a test you can do and wonder if the GP can order this for
you, explain how to do it and generally support you in this endeavour.
If it is not available on the NHS you will pay for it or consider going to a private provider if one
is known to the GP.
Ideas – find out about paternity testing

Concerns – that you need consent of Samantha to do it
Expectations – to get information and support from the GP
O/e: nil examination physically needed

No signs depression.
Admits to being stressed. Has not impacted work or activities of daily living.

44
Management:
Obtain ICE.
Explore patient understanding of how paternity testing works.
How will they use the results once obtained?
Screen for anxiety and depression. Offer support if appropriate.
Acknowledge difficult situation with having children and having to face testing to check they
are his or not.
Discuss implications of having paternity testing done, including future relationship with lilly
etc.
Discuss private services, discuss private kit use.
Paternity tests are NOT available on the NHS.

Important pointers to consider include – is this in the best interest of the child – think of how
it will impact the relationship with the family.
Counselling is available for these kind of tests which is important rather than ‘just’ having an
online kit ordered.
Consent – each person must consent to a sample being taken. Children under age of 16 can
have the person with parental responsibility consent on their behalf, unless the child/young
person understands the issues involved. In those cases the child’s opinion should be
considered.
There are court directed paternity tests were the court can in caes where it considers the
results to be important to the childs best interest will order tests to go ahead.

45
Case 3 Obesity
Samantha Groot
34 years old
PMH: PCOS, Back pain
DH: Ibuprofen PRN, Amitriptyline 10mg nocte, metformin nkda
Last consult : blood tests by the HCA.
FBC – NAD
U&E – NAD
LFTs Alk phosp 184 , all rest normal.
HBA1c – 43
TFT – NAD
Folate, ferritin, vitamin b12 – NAD
Urine – NAD
Chol: total 6.1 , trigl 2.3, ldl 4.3, hdl 0.7
Patient simulated history:
You have reached a decision to change your life.

Fat and being overweight have been ways to describe you as far as you can remember.
You have always convinced yourself that you eat well , three portions a day and only snack on
healthy things like kale crisps and fruit.
You consider yourself one of the thinnest in your extended family. Dad, mom and your
siblings are all on the big side.
You consider yourself a lover of food and indulge in ‘Groupon’ offers quite often to try
expensive restaurants at discount. At other times you enjoy cooking for your nephews and
nieces, this inevitably ends up as an extra meal.
You have not really wanted to have that bikini body, but have had a few things happen
recently that made you think you could do with losing weight. Your back pain for example
which despite seeing physiotherapy for over 4 months have suggested the only thing that will
help is losing weight at this stage. You have had to take amitriptyline every night to help the
back pain. It has helped take the edge off over the last 2 months but you are still in quite a lot
of discomfort.
You have tried losing weight before but found you rebound after losing 3-4kgs in 2-3weeks
you then get lazy and are unable to keep this weight off.
You’ve tried various diets including going on crash gym ‘fat loss 12 week’ programmes, you’ve
spent about £1000 on personal trainers. In your combined frustrations they have suggested
you should see your gp to investigate whether you have a condition that is causing your
inability to lose weight.
Your fiancé John and yourself have been trying for a baby for almost 3 years.
You have consulted a obstetric consultant who has put you on a tablet to help increase your
chances of falling pregnant – metformin. You found the consultant quite rude when they said,
you are fat and that’s why you aren’t pregnant. You are sure they know what they are talking
about but didn’t feel they had much compassion.

46
SH: you drink 12-14 units a week, sometimes more depending on the week you’ve had at
work.
You work as a postoffice employee in a quite sedentary desk job.
You do not smoke.
You attend gym 3 times a week and have a walk with John on the weekends.
FH: obesity – mom had gastric band fitted, nil else
Last week you had some bloods done by the practice nurse and have come today to find out
the results and see what the GP can offer you going forward.
If the GP says everything is normal and that they cannot offer anything then you want to
enquire about having a gastric band fitted like your mom did. She lost a lot of weight. You are
not ultra keen on this due to the prospect of surgery which you do not fancy. Your mom lost
over 4 stone in the first six month and has kept it off.
Diet wise:
You never have breakfast, usually have a few ‘healthy’ breakfast bars before lunch – Granola
usually. Lunch is usually a marks and spencer Ploughmans with some soup and a bag of
crisps. You drink 1 fizzy drink with this. Before you get home you often have 1 banana , an
apple and lots of grapes which are your favourite.
Dinner is usually fries and chicken. You love fries but have them done in the oven so you know
they wont be very bad for you. To avoid having breakfast you have a small bowl of cereal
before bed time and feels this keeps you satiated in the morning.
ICE
Ideas – you are convinced you have a blood disorder causing you to not lose weight.
Concern – you are worried that you will be told that everything is normal and that there is
nothing that can be done to help. You feel at your wits end .
Expectation – you hope the doctor will be able to give you an option to help you lose weight.
O/E:
BP 135/80
BMI 32, hirsute
All other examination normal.
Clinical Management:
Discuss ICE.
Discuss valid attempts at weight loss which albeit short lived have shown she can lose weight.
Discuss weight loss strategies in general ;
Conservative – lifestyle changes (not diet), dietician support. Calorie counting (many apps do
this now and popular with younger patients (‘my fitnesspal’ is one of many free ones)
-Medical : Orlistat – Surgical: discuss option of gastric band , however doesn’t satisfy nhs
criteria, but option as private.

47
Sympathise with patient that having PCOS actually can cause difficulties in losing weight due
to insulin resistance. General weight loss for patients remains the same specially in sedentary
office workers – high fibre low sugar diet, eat smaller more frequent meals to aid digestion and
importantly get a good 30mins exercise a day on most if not all days
Offer follow up to see how getting on or if any difficulties with any proposed methods .
Further Reading:
Doctors article
https://patient.info/doctor/obesity-in-adults
Patient friendly article
https://patient.info/health/obesity-overweight

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Case 4 – Oligospermia
Michael Goner
32
DH: nil nkda
PMH: nil
SH: smokes 20/day 12 units a week.
Sperm results:
Oligospermia : Sperm count < 5 X 10million, all other characteristics normal (PH, morpholog,
velocity)
You are a 32 year old computer programmer and keen chess player.
You have lived most your life in Norway, but moved to Manchester following a position
opening up in your company. You’ve always wanted to live in England and see more football –
you are a huge fan of Manchester United.
The move to England was a very positive one as you met your now wife at work. Things have
been going very well and you are now planning to start a family together.
Unfortunately you have not had much luck yet and have found despite trying actively you
have not fallen pregnant in the last 18months.
Your wife Emily (29) is generally fit and well as are you. Neither of you have had children
from previous partners.
You have been advised that smoking is bad for you and can affect your fertility. You have not
taken much heed of this as your dad and grandad smoked and have all had kids, you would
stop however if the doctor corroborated that advice.
You believe it is more likely that there will be something that needs medical
attention/medication to improve your wifes fertility. You had not expected to need to have
tests yourself but had been informed as part of fertility testing a couple needs testing together
and as such you had a semen test last week.
You were instructed on the strict criteria of abstaining from masturbation/sex for 3 days and
having the sample at the lab within 1 hour of producing it. You met all these criteria.
You are here today to find out the results of your tests.
ICE
I – to get presumably a normal test result back

C- to be told you need to have IVF as a couple as you have heard this can be expensive and
although you both make a good living you are not sure how big an impact this would have on
your savings which may in turn limit what you can afford in the future as you hope to get a
mortgage together soon having rented for many years previously
E- To be told a normal result and that you are awaiting your wives tests.
SH: smoker 20/day 12u alcohol/week.

PMH: nil DH: nil regular medication
NKDA

49
O/e: ask to examine external genitalia (will not be expected to do and will be told normal
result)
Management:
Explain diagnosis.
Confirm specimen was kept warm and sent to lab within an hour of production. Confirm
abstinence of sexual activity including masturbation for 3 days.
Usually a second sperm test Is not required if a normal sample.

If there is a spermatozoal deficiency aka azoospermia or severe oligozoospermia – repeat test
asap.
• Oligozoospermia: <15 million spermatozoa/mL.
• Asthenozoospermia: <32% motile spermatozoa.
• Teratozoospermia: <4% normal forms.
Further tests include – Hormone analysis – FSH and testosterone.

FSH raised with impaired spermatogenesis.
Genetic testing.
USS – if having urinary symptoms or abnormalities detected on examination.
Viral Screening: if considering IVF – test for HIV, hep B, C.
Conservative management:
Wear loose fitting underwear (decreased scrotal temp, as high temps associated with poorer
semen quality).
If obstruction is noted or cryptorchidism/azoospermia – orchidopexy may be needed.
Testicular biopsy and sperm extraction may be indicated.
Offer follow up and referral to fertility specialist.

50
CASE 5: Menorrhagia:
45 . Cassandra Smith
PMH: nil DH: migraleve PRN nkda

SH: ex smoker, 8 units alcohol a week.
“I’m feeling exhausted doc, it’s like I’ve run a marathon”
Patient Simulated History:
45 year old sous chef, working part time in a local restaurant.

Having moved up the ranks at work enjoys part time hours without any stress that she once
had to endure whilst learning the ropes.
She has been struggling to cope with her 9-5 job, even though she has for the last 10 years had
no problems, specially as she only works 3 days a week and enjoys long weekends.
She has noticed despite a good 7-8 hours sleep she is feeling tired in the mornings and by the
end of her shift she feels like she could go back to sleep.
She normally enjoys doing a lot of exercise, including having completed a ‘tough mudder’
obstacle course in the last 12 months and was hoping to do another one. Rather frustratingly
she has felt both tired and dizzy as well on several occasions.
Her work responsibilities have not changed and she has found that despite taking a week off
to go away on a short holiday to spain , that this did not help her feel reenergised and she
continued to feel exhausted whilst away.
She lives with her partner Emily, and their 2 dogs.

Cassandra enjoys visiting with her nieces and nephews who live nearby.
She considers herself fit and does not take any medications prescribed or otherwise.
She has noticed a change in menstrual cycle, they have become much heavier in the last 2
years, particularly in the last 6 months. She normally bleeds for 5-6 days, with 4 of them
being very heavy with clots. Her periods have also started becoming irregular, with not being
on time and sometimes her bleeding period drags on 7-8 days.
In the past she wanted to try the combined contraceptive pill , however due to her having
migraines was told she was not able to have those. She was offered coils and implants but was
not keen at the time.
Diet : meat eater. Eats a well balanced diet with plenty of vegetables.
Her partner Emily works as a dietician at the local hospital and makes sure they both eat well.
Ideas – she thinks maybe she is getting close to being ‘burnt out’ from always working .
Concerns – She is worried that things will get worse and does not know how to stop herself
from continuing to get more and more tired.
Expectations : she hopes the doctor can refer her to a specialist or start her on some
medication in order to make her start feeling better.
She has no bleeding in between her periods, no pain during intercourse, no weight loss.
Her last smear was normal. All her previous smears have been normal.

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O/e:
Obs all stable.
Chest clear
Heart sounds normal
Apyrexial.
Neurology grossly normal.
PHQ9 – 0
Subjectively patient does not feel depressed.
Management.
Diagnosis – Menorrhagia.
Define the condition.
Explain various causes (fibroids, endometriosis, infections, polyps, endometrial ca – albeit
more likely in those aged 50 +, PCOS, thyroid dysfunction, pelvic infections, being on blood
thinners, blood clotting disorders)
Discuss variety of management options including:
USS of the womb .

HVS swabs to investigate for infections.
Endometrial Sampling – depending on if she has tried treatment options and they are not
helping .
Bloods – TFT, FBC, INR, clotting factors (if suspecting bleeding disorder)
Treatment options:
Some people don’t need any treatment if the bleeding is not disruptive to the patient.
Mirena coil.
Medication such as tranexamic acid which reduces bleeding by reducing blood clot breakdown
in the womb.
Anti inflammatories which help blood loss and pain.
The combined contraceptive pill – not for this patient due to having migraines.
Long active progesterone devices – implant or injections.
Norethisterone tablets
GNRH Analogues – specialist treatment.
Surgical treatment.
Allow the patient time to have a think about her options. Review asap if acute chest pain, sob,
collapse or feeling worse in general.
Offer follow up.

52
Further reading:
https://patient.info/doctor/menorrhagia

53
CASE 6 – Premature Ejaculation
John Able
38 year old .
“Hey doc, ive got a bit of an bedroom problem….”
PMH: nil relevant.

DH: nil nkda
SH: non smoker , drinks on special occasions, lives alone.
Simulated Patient History:
This 38 year old high school teacher has been troubled by ‘finishing’ too quickly.
He has not been in a relationship for a while as he had spent the last 2 years on a working
holiday in Dubai, teaching English.
Having moved back to Manchester he has become settled in a local school and developed a
relationship with Emma a Biology teacher at the same school.
They have been going slowly as they didn’t want this to be a work place fling and last week
when things were going further to john’s excitement, he was disappointed that he ejaculated
shortly after things had got steamy.
Emma laughed it off and suggested it was because he has been overthinking things and did not
appear phased by this.
They have been intimate a number of times since but John feels he isn’t ‘lasting very long’ and
is worried this will put Emma off him quickly.
He admits he has never had a problem like this before and has had relationships during
university and since then, as well as one or two one night stands where he has not had an
issue ‘performing’.
He has had no surgery and has never had any trauma to his genitalia.
His libido is intact.
He wakes up with an early morning erection and is able to masturbate with no problems.
Being a sports teacher – (he teaches PE), he keeps himself quite fit and enjoys going to the
gym.
He’s been reading about pills that can help you stay strong for longer like Viagra and wonders
if that is an option for him.
ICE:
Ideas – he has something wrong with himself now that he has gotten a bit older and that he
will always ejaculate quickly unless he gets something for it.
Concerns – that he will not be able to get a ‘quick fix’ and will end up having Emma break up
with him.
Expectations : he hopes the gp will be able to sort him out with something.
O/e:
BMI normal
External genitalia nad.
All other examinations normal.

54
Explain what premature ejaculation is.
That this is a process where you achieve orgasm soon after or sometimes even before putting
your penis inside your partner.
Generally speaking there are 3 features used to describe this problem.
These include; ejaculation occurring always or almost always within a minute of penetration
occurring and that this has always been the case since being sexually active.
-Alternatively If you have not had this problem before, it is defined that one has Prem
ejactulation if one ejaculates within 3 mins)
-you feel you always are unable to delay ejaculation
-you find sex frustrating or even distressing and that the issue is affecting your
life/relationship.
Discuss possible causes of Premature Ejactulation;
Largely unknown cause.

Factors commonly attributed to this include:
Being in a new relationship , where things are seen to improve better with time.
Being Anxious about sex or your feelings during ones first few sexual experiences.
Recreational drugs – cocaine, amphetamine or cabergoline for patients suffering from
parkinsons disease.
Infection/inflammation of the prostate gland.
Multiple sclerosis and peripheral neuropathy are associated with this condition also.
General treatment includes:
Noting that often this is a temporary condition and the need to have patients and wait it out.
Sometimes increasing the frequency of having intercourse can help delay orgasm. Some
advice masturbation prior to having sex which can delay ejactulation.
- There are some condoms that have sensation reducing properties

- Position – where your partner is on top can reduce premature ejactulation
Medication include: Sildenafil (aka Viagra), SSRIs have been found to be helpful,
Dapoxetine – a relatively new ssri , 1-3 hours before having sex can help.
Offer follow up to see how the patient is getting on or if they want to take some time to
consider their options.
Further reading:
https://patient.info/doctor/premature-ejaculation-pro
https://www.baus.org.uk/patients/conditions/8/premature_ejaculation

55
CASE 7 – Eating disorder
Emily 24
PMH: amenorrhoea, hair loss, ‘tired all the time’, right humerus fracture 2009
DH: nil of note nkda
Emily is today accompanied by her mother who she has consented to being present in her
consultation. Her mother is a a patient at the practice.
“Hi Doc, thanks for seeing us today, we really need to talk about Emily’s behaviour”
Patient simulated history.
Emily is a 24 year old history teacher, who lives with her parents and other than a humerus
fracture in 2009 and a short lived episode of 4-5months of amenorrhoea is not a regular at the
practice.
She considers herself fit and well.
She doesn’t actually feel there is anything at all wrong with her but has consented to her mom
coming with her today as she is very upset with her.
Emily’s mom Karen feels Emily has been manipulative and hiding an eating disorder.
She thinks this because she has noticed Emily getting thinner and recently has noticed her
buying size 6 clothes when she was a 10 previously. She estimates she has lost 2 stone over
the last 6-12months.
Karen does most of the talking, with Emily replying yes and no if directly asked.
Things at home have been quite turbulent since Emily’s step dad broke it off with Karen and
declared he was cheating on her with someone from work. Emily has also struggled with her
boyfriend and as a result of these 2 events appears to have become more withdrawn and
avoiding any socialising with the immediate family , work colleagues and has stopped doing
what she likes to do (gym, book club with her other sister Jane, and her regular theatre
outings).
When asked directly, she does not feel depressed, but feels frustrated.
She feels there is nothing wrong per say with her but wants to be ‘healthier’ and in control so
has been watching what she eats. She has decided she doesn’t need to eat if she is not hungry
and mostly survives on a liquid diet.
She will often have hot water for breakfast, with some green tea for lunch and an apple.
Dinner will be a large salad with kale and tofu.
She has a treadmill in her room and spends 2 hours everyday walking on it.
Her periods have stopped for the past 9 months but she has associated this with her being
frustrated with things at home as she has read this can lead to periods stopping.
Emily does not feel forced to be here and cares about her mother so doesn’t want to make her
upset by not turning up.
She feels her diet is the one real thing in her life that she can control in a life that as of late has
been extremely unhinged and out of control.
She does not purge.

56
ICE:
Ideas – Karen feels Emily has an eating disorder and is concerned about this.
Concerns – Karen feels Emily may end up with a long standing health condition that stops her
from having children if she wants in the future.
Expectations – to get some form of help , counselling or a tablet to make her act more normal.
She admits she does not really know what the best ‘move’ is and hopes the doctor can help.
She has read a lot about eating disorders and is aware that each case is treated differently and
that most patients have no insight into their problems.
o/e:
Gaunt looking slim girl.

Weight 44kg
Bp normal
Heart rate 55
All other obs normal.
Denies thoughts of self harm or of being depressed.
Normal affect
Management:
Discuss that this is likely Anorexia Nervosa.

Praise Emily for coming despite her feeling nothing is wrong.
Explain that if she consents there are a lot of things that can be done to help her feel better
and more in control of her life in general.
NICE – recommends immediate referral to a community based age appropriate eating disorder
service for assessment/treatment.
Individual eating disorder focused CBT – 40 sessions over 40 weeks is one method.
There are other psychological treatments available including Maudsley Anorexia Nervosa
Treatment for adults and Specialist supportive clinical management – however the waiting list
for all of the above is very long Some wait up to 8months to be seen.
Some people consider private routes to access the above.
Explain the need to monitor the physical health as well:

ECG and bloods (u&es) – supplement electrolyte imbalances as per need.
Consider multivitamins to replenish lack of important minerals and vitamins not obtained in
diet.
Consider Food supplements like fortijuice or complan.
Consider Dietician referral.
Discuss the role of anti depressants for getting an appetite – SNRI’s like Mirtazapine have
been shown to be effective.

57
Discuss the avoidance of excessive exercise.
Support both Emily and Karen with the offer of follow up.
Safety net that if she feels weak, collapses, has irregular heart beat/chest pain or feels
otherwise unwell to call in asap or attend A&E immediately.
Further reading:
https://www.beateatingdisorders.org.uk/?gclid=EAIaIQobChMI-
_eotp3y2gIV7pztCh3tcAd7EAAYASAAEgL9XPD_BwE
https://patient.info/doctor/anorexia-nervosa-pro

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Case 8 – Polymyalgia Rheumatica
Jane hofsteddar 55yrs old
Has been feeling exhausted lately and asked for blood tests via her GP to exclude any
problems.
She has come today to review those bloods.
Thyroid function tests normal

FBC – normal
Vitamin D – normal
Haematinics normal
ESR – 50
U&E – normal
Rheumatoid screen normal.
PMH: knee OA, bilaterally, tennis elbow, back pain chronic.

Nil surgical history.
DH: allergic to penicillin, Gastric ulcer 2002,

Omeprazole 20mg once a day, Ibuprofen PRN
Patient simulated History:
Over the last 2 weeks Jane feels she has gone from a very active, lady who enjoys 3 circuit
training sessions at her local gym. She works as a professor of physics and does relatively
long hours. However she feels this is not why she is tired as she has been doing these classes
for the last 20 years!
Jane feels she feels like an old person and is quite upset by this as it has come out of the blue.
She enjoyed beating her PB in last years 10k run in 50mins and felt at the peak of her fitness.
She has had no headaches, blurred vision and not been systemically unwell , but mentions she
is achey all over and sometimes things are so bad she even struggles to get up off a chair or
sofa.
Her PRN ibuprofen has made no difference.
She has not noticed any joint swelling and has had no falls or loss of vision.
She has noticed morning stiffness to her neck, shoulders, and pelvic area.
This stiffness has caused her to be extra slow when trying to get dressed.
ICE:
Ideas – she thinks her age has finally caught up with her but hopes you can find something in
the blood results to explain how she feels and that something has a solution.
Concerns – she worries that there will be nothing wrong with her bloods and that this is truly
age related

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Expectations: she hopes you will be able to review her bloods and offer her some form of
elixir/pick me up.
O/e:
Proximal muscle weakness, reflexes normal

Grunts and struggles when getting up of chair.
Fundoscopy normal
No scalp tenderness
Cranial nerves – nad
Gait normal.
Rest neurology and examination normal.
Management:
Explain she likely has Polymyalgia Rheumatica.
This is a condition that causes a lot of inflammation around the body. We are unsure of the
exact cause. Characteristically people suffer with morning stiffness, weakness particularly to
the neck, shoulders and pelvic girdle. These areas are often associated with pain also.
Specialist referral is needed to confirm diagnosis and for ongoing care and advice.
Oral steroids are important in this condition – special note of her PMH as she has had an ulcer.
Consider physio and OT referrals as patients may well need some help at home to cope in the
initial stages of the condition.
Offer screen for conditions that patient will be at increased risk of due to ongoing steroid use
(will need for up to 2 years sometimes more) > Diabetes, hypertension, osteoporosis, mental
health problems – may get worse on steroids – acute psychosis.
Screen for symptoms of Giant cell arteritis and explain to look out for these with immediate
medical attention being sought if any develop.
Start with 15mg prednisolone daily
Discuss Prevention and treatment of steroid induced osteoporosis.

Patients aged 65 or older or prior fragility fracture will need bisphosphonate and calcium +
vit D supplementation.
These patients are deemed high fracture risk.
Those without high fracture risk will need calcium and Vit D supplementation when starting
steroid therapy. Dexa Scan is recommended - > start bisphosphonates if T score is 1.5 or
lower.
Offer follow up in 1-2 weeks time with regular bloods every 4 weeks to monitor (ESR usually).

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Further Reading:
https://patient.info/doctor/polymyalgia-rheumatica-pro
https://www.vasculitisfoundation.org/education/forms/polymyalgia-
rheumatica/?gclid=EAIaIQobChMIqt6rgZ7y2gIVC7TtCh2FrwnAEAAYASAAEgJz9_D_BwE

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CASE 9 – AF
53 year old John Crisp
PMH: Rheumatoid arthritis, Hypothyroidism

DH: levothyroxine 100mcg daily, methotrexate, folic acid nkda
SH: non smoker, drinks rarely.
Hiya doc, im feeling a bit out of sorts…
Simulated patient history
John is an accountant that has previously been very active and well in himself, however over
the last 8-10 years as his rheumatoid arthritis got worse, he had to stop going to the gym and
swims 3 times a week instead as he finds this helps his joint aches. He has been looking
forward to doing more now he has been well controlled on the methotrexate which was
started around 18months ago.
Luckily because of the work John does, he has not lost money and been able to work from
home.
As things have started to look up he has been getting out for long walks and found his joints
have not been more painful.
He has been keeping in regular contact with Jane his rheumatology specialist nurse who has
guided him through the rehab process.
He has not been depressed , although in the first few years of being bad with his joints he felt
low and kept questioning “why me?” .
John lives with his fiancé Samantha and their 2 kids, Erik and Emily who are twins and aged
10.
Life is going quite well at the moment and they are all planning a trip to Disney Land in
France this coming Christmas.
FH: Dad and mom have rheumatoid arthritis, brother Adam has an underactive thyroid.
Over the last 2-3 weeks John has felt quite out of sorts.
He has had what he first thought were palpitations. He describes these as a flurry of beats in
his chest that then slow down, to an uncomfortable unusual beat where he feels it takes a very
long time before his heart beats again.
He has only felt like this once in his university days when he had , had too much to drink.
This is not the case now, and hasn’t been the case ever since his diagnosis of rheumatoid
arthritis as he has had to watch the interaction between alcohol and the medication he is on.
He does not experience dizziness, or chest pain. He has not collapsed or had fits.
Other than this he has been completely normal in himself.
ICE
Ideas – that his methotrexate is causing this. He was told that you can sometimes get unusual
horrible side effects that can affect your immune system.

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Concerns – that he will need to go onto another medication that will make him unfit and
unable to do much again , leading to him in great likelihood missing the proposed Disneyland
trip
Expectations – to be offered a medication that does have such bad side effects where possible.
On examination.
Chest clear
Rr normal
Apyrexial.
Heart rate : irregular – 90 – 140 .
ECG : shows AF as above
Diagnosis Atrial Fibrillation – Define and explain what this is.
Consider admission
Identify any underlying causes where possible – note has rheumatoid arthritis and thyroid
dysfunction which can be triggers.
Consider rate control with beta blockade
Consider referral for rhythm control treatment – cardioversion as new onset AF
Assess CHA2DS2VASC
Arrange follow up if not admitting
What are the indications for immediate admission?

Rapid pulse greater than 150/minute, or systolic less than 90.
Loss of consciousness, severe dizziness, chest pain, increasing breathlessness.
Complications of AF – stroke, TIA, acute heart failure.
Further Reading:
https://patient.info/doctor/atrial-fibrillation-pro
http://www.heartrhythmalliance.org/afa/uk/atrial-
fibrillation?gclid=EAIaIQobChMIw_2br57y2gIVy53tCh2uhg49EAAYAiAAEgK63fD_BwE
https://www.stroke.org.uk/resources/atrial-fibrillation-af-and-
stroke?gclid=EAIaIQobChMIw_2br57y2gIVy53tCh2uhg49EAAYAyAAEgKgLfD_BwE

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CASE 10 – Snoring
Alex Oregan 44 years old

DH: nkda
PMH: nil relevant
SH: social drinker , smokes 20/day.
Heya Doc, we’ve got to do something about this here snoring!
Alex is an physician assistant at a local gp practice.

He works 4 days a week and enjoys long weekends.
Lives with his girlfriend Caoimhe who Is a practice nurse at work.
He knows he should be doing more exercise and has grudgingly been trying to do more as his
work is quite sedentary.
His girlfriend is a keen gym goer and has been a good influence on him in terms of increasing
his activity levels.
Since living together the past 4 months she has complained about his snoring.
At first it was quite funny but now it has caused some annoyance.
Alex notices that if he has had a lot to drink he snores more.
On some occasions Caoimhe has elected to sleep in the guest room in order to get some sleep.
Alex has no somnolence in the morning , none during watching tv, reading , or whilst driving.
He has lost some weight in the last 4months but has never really been overweight.
Last week he suggested his girlfriend get hearing aids which upset her, but also found they
didn’t make a big difference! Embarassingly he was shown a video recording of his snoring
and admits if he was exposed to that he too would struggle sleeping.
He has had no apnoeic breathing, nil has been noted. It occurs every night, but more so if has
been drinking. There has been no daytime sleepiness. There is no history of nasal
obstruction/problems.
He does not use any sedatives.
I – I don’t think I snore more than anyone else but it is quite loud. My girlfriend has
highlighted how loud my snoring is!
Concerns – I worry that if things continue in this way she will break up with me
Expectations – to get some medication that may help!
On examination:
Weight 70kg
Height 5Foot5
RR normal

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Epworth sleep scale (if asked for ) normal.
Collar size 40cm
Heart sounds normal, heart rate normal.
Chest exam normal , Nil goitre noted.
Diagnosis – Generalised Snoring.
Explain this is a very common condition affecting about 40% of people in the UK.
Snoring can be caused by noisy turbulent breathing at the level of the nose, the soft
palate/uvula, tonsils or base of the tongue.
Simple snoring is what we call snoring with normal regular breathing that is not associated
with hypoxia. The patient is not somnolent in the morning.
Other factors that can contribute to problems include an underactive thyroid, nasal
congestion, blockages or deviations of the septa.
Social factors include – drinking to excess, smoking, being older, lying in a supine position.
Management: weight loss if appropriate – not in this case.

Lifestyle advice – less alcohol and stop smoking.
Posture adjustment – try avoid being in a supine position to see if this helps.
Consider professionally molded ear plugs which may work better than ‘normal otc ‘ ones.
Consider decongestants /nasal steroid sprays.
Consider ENT referral to investigate for a non obvious cause of an obstruction.
Follow up .
Consider seeing both Alex and Caiomhe together.
Red flag – if apnoeic episodes noted to get in touch as soon as possible.
Further reading:
https://patient.info/doctor/snoring-pro

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CASE 11 – swallowing difficulty
James osmand 54 years old
Hey there doc, wondering if you can help me with my throat…
You’re a civil engineer, working abroad most of your life in Dubai which you enjoyed.
For the past 12 months you returned to work in Manchester with your brother.
You live with your wife who is an architect.
You have 2 children who are both living abroad in Dubai and work as engineers too.
ICE
Ideas – you have some sort of infection that is getting worse and needs to be cleared with some
strong antibiotics. You’ve read about infections causing pain and difficulty in swallowing but
were hoping it was something viral. However it has gone on for over 2 years .
Concern – you worry it is something that needs an operation, maybe a bacterial infection that
has been left to go on for too long. Your fear is what time you will need off work if there is a
need for an operation.
Expectations – To be told what you need and preferably some antibiotics to clear this problem.
SH:
You are a long term smoker, smoking since the age of 14.
Alcohol 4-5 units a week, sometimes more but rarely. You drink socially , birthdays, football
games but not otherwise.
You do not suffer with depression or low mood, but are frustrated by this ongoing swallowing
problem you have had.
History of Presenting complaint:
Generally you feel well without any obvious complaints.

Your recent problems have been 2 fold. You have had a lot of heartburn as well as finding that
food is getting stuck in your throat.
The heart burn you’ve experienced as a burning deep sensation that starts in your mid gut ,
travelling to your throat. You’re used to this which is partially due to the oily spicy food you
eat. You often drink milk or gaviscon to improve this.
You have noticed that both this and your ability to swallow solids have been getting worse.
Now you have noticed that everytime you eat you swallow it ok but it gets stuck in your chest
area somewhere or so it feels.
Foods like meat, chicken, fish are the hardest to swallow , you have noticed that softer
consistency foods like soups, potatoe mash, vegatables are far easier to swallow and you have
made a subconscious decision that you prefer those anyway so have stuck to just eating those.
On a few occasions you have had food get stuck and been unable to pass anything down your
throat. This made you quite worried and you made yourself vomit in order to clear your
throat. This made things ‘better’. Since then you have not had any meat, chicken or fish.

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Your appetite remains good. You have not lost weight. Your preferred foods include take
aways, processed meats and generally what you describe as junk food.
You have not lost any blood in your vomit, nor anywhere else. Your bowels remain normal,
opening them once a day without strain.
You have not found that your ability to swallow liquid has been affected.
Your ability to swallow soft consistency foods remains the same and has not got worse.
PMH: nil of note
FH: Dad passed away from MI at 80, but smoked most of his life and ate unhealthily as well.
Your mom is alive and well. Your younger sister has had reflux most of her life and had
treatment with antacids called omeprazole.
DH: otc Gaviscon nkda
O/e:
Abdo exam : soft and non tender.

Nil organomegaly
BMI normal
Rest of obs normal.
Management:
Bloods: fbc, ferritin, folate

Upper GI endoscopy – consider this as a routine referral as no red flag signs.
Diagnosis:
There is a differential here, however the most likely thing is a peptic stricture aka benign
oesophageal stricture secondary to reflux disease.
Scarring is as a result of severe and chronic gastro –oesophageal reflux disease.
Safety net , if food bolus obstruction, persistant to attend a&e immediately.

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CASE 12 – Hypothyroidism
Samantha Vuze 35
Im here for my bloods results doc.
FBC – normal
Haematinics – normal
LFT – normal
Thyroid function: TSH 25 T4: 5.6
You work as an acrobat, and have done for many years now.
These past few years you mostly do aerobics classes, pole dance and fitness classes as there is
most money in doing that you’ve found.
You consider yourself quite fit as other than your classes that you hold daily you spend a fair
amount of time keeping yourself fit.
Worriyingly you have found yourself quite exhausted, but not in keeping with the activities
you are doing.
This has been the case for the last 14 weeks at least, maybe more.
Considering yourself quite resilient you chose to ignore the signs of tiredness initially and
went on to just ‘get on with it’. Recently you have felt things haven’t improved despite taking a
break from your classes on a 2 week holiday . That is when you started to get worried that
there may actually be something wrong with you.
The reason you initially got the blood test is because someone mentioned you may be anaemic,
something you disputed as you eat well, and have very light periods so couldn’t understand
why you would be, but decided to have some bloods just in case.
You have found despite doing the classes you have started not joining in as much and leaving
the clients to do the work . Normally you would do the class with them.
You are sleeping well at night but have found you are napping throughout the day.
Your weight is steady, but you have noticed because of the weights you do at the gym, you
know how to maintain your physique quite well and as aforementioned you eat well counting
your calories as you find being in shape is vital to attract clients to your fitness work. Your
body is your best advertisement.
You have found yourself a bit more sluggish in general, getting constipated regularly and
having to use over the counter laxatives at times or drinking plenty of juice. You have also
noted that you feel cold quite a lot of the time.
SH: you live alone, non smoker. Occasionally drink alcohol , but nothing regular.
DH: nil nkda
FH: nil of note
Ideas – you are not sure what is causing your problems but have thought about being anaemic
or being low on some vitamin.
Concern – that you will have to stop doing your classes and all the exercise that you enjoy
doing.

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Expectations: Results and to find out how to get better if the doctor knows.
O/e:
Nil goitre noted

Throat exam nad.
Respiratory rate normal
Heart rate regular and normal
BMI normal
Diagnosis:
Explain that the patient has an underactive thyroid hormone.

The thyroid is a gland that sits in the middle of the neck, producing a hormone called
Thyroxine. This hormone helps maintain the bodies functions, something we call metabolism –
which helps cells and tissues in the body work correctly.
The gland can sometimes make too much or too little of this hormone for various reasons.
In your case for some reason your gland is making too little hormone and it can readily
explain why you feel tired.
Management:
Start with a relatively low dose of thyroxine 50mcg -100mcg with a repeat blood test in 4-6
weeks to check if you need to titrate this further.
Once the TSH is normal (the stimulating hormone) we know you are at the right level. After
this you will have yearly tests to check all is in order.
Treatment is for life
Side effects to be aware of.

Itching, skin rash, angioedema, abdominal pain, nausea, vomiting and diarrhoea, fever , joint
pains, wheezing and generally feeling unwell.
Safety net that if any of the above happens to get in touch asap/a&e.
Further reading:
https://patient.info/doctor/hypothyroidism
https://www.gp-update.co.uk/files/docs/Hypothyroidism.pdf

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Case 13 – sterilisation gone wrong
Samantha Southgraine
33yrs old
Last consult: Dr J Smith, saw patient and referred for sterilisation.
PMH: IVDU, 3 dvts, currently in detox on methadone

DH: methadone, trazodone prn 4 tablets /2 weekly nkda
“im not happy with that Dr Smith from yesterday!”
You are a 33 years old and have been through a lot.

Having spent most your life in blackpool, you had relocated to chorlton in south Manchester
due to getting in with a bad crowd and being warned by the police that the best thing would be
to get away from the area in case you got attacked.
You have been abusing drugs most of your life however you are currently doing your best to
stop.
Currently reducing your methadone to 15ml/day. You have been unsuccessful in the past but
you blame this on being around bad people.
You do not buy any other medications on the street but you have been known to do so which
may have been part of the reason you relapsed so many times.
You have been the most stable you have ever been since getting into a healthy relationship
with Mick a prison officer.
You have no real contact with any family and your only friends have either died from OD’s or
are in prison back in blackpool.
You have had children from previous relationships who were taken away from you, however
you are set on staying on the ‘straight and narrow’ in an effort to get them back. Mick has
been really supportive about this and has met your kids a few times, getting on really well
with them and vice versa.
On a recent health check up in the GUM – sexual health clinic, you were devastated to find out
that your past has caught up with you as you have been diagnosed with hepatitis C – which
you refused further help with for fear it would lead to you never getting your children back.
You have asked for this to remain confidential and have therefore refused further care from
the hospital doctors as you refused to see them.
You suspect the hospital has breached your confidentiality and told the surgery.
‘its all part of the system, the system that is against you’. You don’t trust the ‘system’ , the
government and feel it is out to get the common ‘man’. You think medical professionals are
part of the problem and you find it hard to trust them.
Your consultation yesterday to discuss female sterilisation as you are convinced you have
completed your family. Your partner Mick, does not want children despite not having any of
his own.
Your aim is to demonstrate how good a parent you are and how you can provide for your
children.
Dr Smith was helpful in that sense and agreed for the referral to take place.

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Ideas concerns and expectations
Ideas – you have come today to make sure the details of your referral have not included the
fact that you have hepatitis C. You did not tell the GP that you have this but are convinced
that he has found out somehow.
Concerns: You are worried that if the hospital find out about your hepatitis C status you will
never be able to look after your children.
Expectations: you demand that the GP does not include this in the referral. Doctors in the
hospital should expect everyone to have a potential illness like HIV or hepatitis and therefore
take precautions.
O/e: nil examination required.
Management:
Explore the patients fears further.

Discuss how well she has done in continuing with her detox and reinforce the fact that she is
entitled to have her information kept as confidential.
Explain the diagnosis of Hepatitis C is not on the system as she declined to allow the GUM
clinic to share it with the GP. Doctors and nurses take confidentiality seriously.
Explain that you recognise that confidentiality is important to all patients. Patients should
know that we understand without this , patients wouldn’t openly tell us what is wrong with
them or what they are worried about and as such we would not be able to help them as well as
we could otherwise.
All patient’s are entitled to good standards of care, regardless of any infective status, what
disease they may have or how they acquired it.
There are exceptions when for example the doctors/nurses involved in their care must take
certain precautions in order to protect themselves from accidental exposure or the patients
children i.e. in a c section.
Explain that having a disease such as hepatitis C , HIV etc does not impact the eligibility
/chances of caring for ones children/being a legal guardian.
Explore the patients understanding about the need to protect against further spread of
Hepatitis C , i.e sexual contact
The GMC states:
Standard infection control measures determined according to the extent of possible exposure
to blood or other body fluids should be taken on the basis that all blood, tissues and some body
fluids should be regarded as potentially infectious. These precautions should not be
determined by knowledge or speculation about the infectious status of a high risk patient. It

71
would logically be inappropriate to take fewer precautions with a patient that had not
declared their status, or did not know if they had a blood-borne virus/undiagnosed HIV etc.

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Case
1, Domestic violence
2, Renal Colic
3, Generalised Anxiety Disorder
4, Diabetic – DKA – abdo pain
5, The persistant cough (ace inhibitor)
6, Alopecia Areata
7, Hyperhidrosis
8, Frozen Shoulder
9, Gallstones
10, FGM
11, Cauda Equina
12, Bed wetting
13, Memory loss

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Cycle 3
Case 1 – Domestic violence
Bibi Begum
20year old.
PMH: several admissions with self limiting musculoskeletal injuries

DH: nkda nil regular medication
“sorry to waste your time again today doctor, I’m not hearing very well “
Simulated patient History
This is Bibi, she has recently got married and joined her husband in Manchester.
Her husband is an engineer , Javaid, 42.
She had never met him before and felt under pressure to say yes to getting married.
She had felt pressurised by her relatives to make the move to England because in her native
Pakistan she was convinced she had no real life ahead of her.
What she knew of her husband was that he was a successful busy man , who had been married
before and divorced. She was not keen on marrying someone twice her age which she didn’t
feel was very attractive but this was the status quo and how her parents had married.
When she just moved to Manchester things had been pretty good, Javaid had taken her on
many trips around the UK.
Some weeks after she felt she was quite isolated. Javaid worked long hours and would come
home expecting food and would sleep with her then go to the gym. She was spending very
little time with him and was never invited to spend time with him on his outings after work.
A few times when she was on skype with her family she had noticed it had made him quite
upset.
He has been shouting at her numerous times when he’s not been impressed with the food.
Last week she had gone out without her husband to do some shopping and explore and he had
come home earlier than usual. He was quite vexed on this occasion and gave her a punch to
her right ear.
She has become quite introverted since and has not left the home without her husband.
The reason she has come to see the doctor today is to make sure she has not made permanent
damage to her right ear.
She has not been able to hear much through the right side. The pain has reduced although
initially she had to take regular paracetamol, codeine and ibuprofen.
Javaid has no criminal record. He has never had problems with the police.
He drinks alcohol, but mostly on the weekends. A few occasions when he has gotten drunk, he
has forced himself on her and raped her. She was quite upset about this but when she spoke to
her mother in law and own mother about this they said she’s married now and her job is to
satisfy her husband whenever he pleases.
When he’s been drunk he has hit her a few times but never as bad as this last week.
She has often felt afraid of him and this is often around the time when he’s been drunk.
In the last week when she had been out to explore by herself he had said in a fit of anger
before hitting her that he would kill her if she did it again.

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ICE
Ideas – I have some damage in my ear , maybe an infection

Concern – that there is permanent damage to my ear
Expectation – hopefully to be told there is temporary damage that will get better on its own.
O/e: right ear drum perforated, some blood in the ear canal.
Shy and not easily forthcoming patient.
Well kempt.
All other observations normal.
H – Humiliation – in the last year have you been humiliated or emotionally abused in other
ways by your partner? Does your partner make you feel bad about yourself? Do you feel you
can do nothing right? (Yes)
A – Afraid: In the last year have you been afraid of your partner or ex partner? What does
your partner do that scares you? (forces himself on her and hits her)
R – Rape : In the last year have you been raped by your partner or forced to have any kind of
sexual activity? Do you ever feel you have to have sex when you don’t want to? Are you ever
forced to do anything that you are not comfortable with? (incidence of Rape)
K – Kick: in the last year have you been physically hurt by your partner? Does your partner
threaten to hurt you?
Management:
Discuss implications of perforation and general management.
Discuss her relationship and what to do if she ever feels unsafe.
Make her aware of organisations to contact if she feels unsafe, including the police or the
practice.
Offer to give number to practice to arrange ‘subterfuge’ appointment where you can have IRIS
– domestic violence assessment done.
Advise if feels at risk at any point to call 999 or to run away and call 999 from her mobile
phone, or go to any local police station or public place where people will assist her including
your own gp practice.
These are some of the resources available that you can make those suffering from domestic
violence aware of:
• 24-hour National Domestic Violence Helpline: 0808 2000 247
• Police Domestic Violence Officers: 0845 3300 222 (999 in an emergency)
• Women's Aid: 0808 2000 247, www.womensaid.org.uk

• Refuge: 0808 2000 247 (in partnership with Women's Aid, refuge.org.uk
• Victim Support: 08453 030 900, www.victimsupport.org.uk
• Mankind (for male victims of domestic violence): 01273
911680, www.mankindcounselling.org.uk
• ManKind Initiative (for male victims of domestic violence): 01823
334244, www.mankind.org.uk

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• Men's Advice Line: 0808 801 0327, www.mensadviceline.org.uk
• Childline. 0800 1111, www.childline.org.uk
• Respect Phoneline: (help for perpetrators of domestic violence) 0808 802
4040, www.respectphoneline.org.uk
Follow up: arrange for a meeting with you and the patient in 1-2 weeks time,sooner if things
escalate.

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Case 2: Renal Colic
Saif Ahmed 39yrs old

PMH: nil DH: nil
“hey doc, my back has been killing me”
Patient simulated history
You are a 39 year old gym instructor.

Your passion lies in helping people get fit, and you have recognised your health and body is
your best advertising tool.
The last 2 weeks however you have been getting extremely bad flares of right sided back pain.
It travels to your groin. You always have an ache but have flare ups which cripple you. You
collapse to the floor , with a cramping throbbing pain.
You admit to having had back pain in the past, but nothing like this. The pain has been getting
worse everyday and today you cant bear it. Pain score is 10/10.
In the last 2 months you have been training for an ultra marathon but admit to not hydrating
as well as you should.
You do not drink or smoke.

You have not had any surgery in the past nor are you on any regular medication.
You are not allergic to anything.
You are happily married to Fatima and have 2 kids, Zarah and mohammad .
You have not identified anything that can have triggered his pain, nor anything that has
helped.
The pain can last 15mins as a sharp pain but then dies down to a background ache.
There has been no pain on passing urine, nor has he had a temperature, but he has felt
extremely sick and vomited a few times in the last 24 hours.
Nil problems with passing urine or stool.

Nil cauda equina signs
DH: nkda nil

SH: lives with Fatima, 2 kids. Non smoker non drinker
FH: nil significant
Ideas concerns expectations
I: thinks he has damaged some ligament in his back

C: worries he wont be able to exercise and end up getting fat, losing his credibility
E: To get strong pain killers and a physio referral.
O/e: Back examination – Full range of motion. Nil restriction of movement

Neurology lower limbs normal
Urine : blood +++ rest nad
Bp normal

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Apyrexial.
Heart rate 110
Rest exams nad
Diagnosis: Renal Colic
Renal colic is a type of pain you experience when you get urinary stones blocked in any part of
your urinary tract (kidneys , ureters, bladder or urethra).
Management:
Pain relief – Intramuscular diclofenac or equivalent.

Consider anti emetic as vomiting.
Weigh up whether patient requires urgent hospital admission. In this case it appears the
patients pain is progressively getting worse and is not able to keep much down.
Option of giving anti emetic and hydrating with out patients tests such as KUB/ USS renal
system is an option.
Discuss with the patient if they want to try a ‘conservative’ approach and attempt to hydrate
following anti emetic medication and pain relief. If no major improvement in the next hour
admit to hospital. That is unless the patient feels they cannot cope or they have not had any
benefit from treatment suggested.
Consider Urgent hospital admission if:

Signs shock/systemic infection
Risk of AKI eg if has only 1 kidney or a transplated kidney, pre-existing kidney disease or
suspicion exists for bilateral obstructing stones.
Pregnant patient
Clinical dehydration/cant take fluids due to ongoing vomiting
Diagnosis uncertain
Rapid recurrence of severe pain
Conservative management includes:

Pain relief : anti inflammatories and Anti Emetics
Normal fluid intake – in this case increase fluid intake due to excessive exercising
Safety net:
If not admitted - > severe pains recurring or not getting better to go straight to hospital
If patient develops rigors, pains worsen or they develop a fever to seek immediate medical
attention.
Urgent referral to urology within 7 days in cases where patient has not needed emergency
admission.
Further Reading:
https://patient.info/doctor/urinary-tract-stones-urolithiasis
https://cks.nice.org.uk/renal-or-ureteric-colic-acute

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Case 3: - Generalised Anxiety Disorder
Janet Crane
42 year old
DH: microgynon, propranolol nil else
SH: drinks 1 glass of wine on the weekends on Saturday and Sunday, non smoker
“Heya Doc, ive come about my heart”
You are a senior accountant at LMC corporate. Having worked here for 20 years you have
gradually gone up in seniority.
Half your time at work is spent supervising junior accountants workings and organising
regional meetings. You also have a large portfolio to handle for various health care firms .
In the last 6months you earned a promotion that came with a healthy pay increase but also a
large increase in your working hours.
You don’t feel depressed, but have had several moments where you have noticed your heart
racing for short bursts for 20s – 2mins. This can happen at anytime but you have noticed it
happening when turning up at work or before a major presentation.
Quite a few times you have felt an impending sense of doom at the prospect of going into work.
When you have not been in work you have still had these episodes but far less than when in
work.
You enjoy keeping active, and make sure you end up at the gym at least 3 times a week. You
do a mixture of long bicycle rides or gym classes.
You enjoy drinking 2-3 cups coffee in the morning, and another 2-4 throughout the day. You
enjoy 1 glass of wine on Saturday and Sunday.
There are no conditions that run in your family, both parents are alive and well.
You have grown increasingly concerned about your heart racing as it has made you feel
unwell.
You have felt ‘woozy’ and sob 2-3 times this week only. You do not suffer chest pain and have
never had any swelling to your ankles, you don’t have any problems sleeping flat and have not
suffered any losses of consciousness.
Your weight is steady. You do not have any symptoms of heat intolerance. Your periods are
normal.
ICE
Ideas – You are convinced you have an undiagnosed heart condition. This is based on your
increasingly worsening heart symptoms.
Concerns: you are worried you will need to take a lot of time off work and be demoted due to ill
health which you have seen happen to other people in your position formerl
Expectations: You hope the doctor can refer you for medical tests as relevant to see what the
best treatment is .

79
O/e:
Heart rate 70 regular Heart Sounds normal.

Chest clear
Apyrexial.
Sats 100%
GAD – 15 (generalised anxiety disorder score)
Diagnosis –
Generalised Anxiety Disorder / Anxiety
This is a condition where you have a lot of symptoms of feeling worried and tense as well as
anxious. Some explain it as having a constant level of anxiety a lot of the time.
There can be many triggers, and these tend to be around social issues – work, relationships,
however at times people do not readily know what they are anxious about.
Common conditions affecting around 1/50. 2:1 Female to male ratio.
Causes are multiple. Genetics, previous significant events such as trauma /bereavement.
Generalised anxiety disorder can be mistaken for other conditions due to the physical
symptoms, i.e palpitations. As such we need to rule out other potential triggers, these include:
Excess intake of caffeine through medication or drinks, including alcohol.

Thyroid dysfunction and other conditions such as diabetes.
Management includes:
CBT
Anxiety Management courses face to face or online via self help groups online.
Medications: SSRI/SNRI – Buspirone is commonly used when the ‘usual’ options don’t work,
Pregabalin equally has a role where other medications have not been helpful.
Beta blockers such as propranolol have a role for acute anxiety/panic attacks but as an
adjunct to other treatment options not on their own.
Explain the need to do a bloods screen including checking for Thyroid function, and general
bloods to make sure she is not anaemic which can cause some of the symptoms described.
Follow up:
Form a patient centred plan and agree to follow up in the next 2- 3 weeks as suits patient.
Agree that if mood deterioration to get in touch sooner, as soon as possible if develops suicidal
ideation.

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Further reading:
https://patient.info/doctor/generalised-anxiety-disorder-pro
https://www.mqmentalhealth.org/mental-
health/conditions/anxiety?gclid=EAIaIQobChMI0N3I1qrz2gIVD5ztCh1Xbgn0EAAYASAAEgJ
ig_D_BwE
https://www.anxietyuk.org.uk/anxiety-type/generalised-anxiety-disorder/

81
Case 4 - DKA
George Smith 18
“hi Doc, my stomach is killing me”
DH Nil nkda
SH Nil
You are a student at the University of Liverpool. Home for the weekend to see your parents.
You’ve been feeling a bit under the weather and have thought that you were just coming down
with a virus as a lot of your house mates have had similar.
You are in your 2nd year of studying business and management and have really enjoyed the
experience of living away specially as this is the first time you’ve had a ‘proper relationship’.
You have been seeing Lucy, a fellow student on your course who is also from Manchester. She
has been nagging you to see the GP as you have been feeling unwell and have not got better as
quickly as you normally do.
You have felt fatigued, sleepy, and excessively thirsty for the last 2-3 weeks. A lot of
headaches have been associated with this as well but without any rashes having developed.
You have been passing a lot of urine and this has made you extra tired as it has disturbed
your sleep. You have joked about having a large prostate like your dad who is 74.
What pushed you to book an appointment is stomach pains which started around 24 hours
ago.
You have not had any vomiting or diarrhoea. You are opening your bowels as per normal and
have not noticed blood or mucous in them.
You don’t drink and do your best to keep healthy by frequently going to the gym or going for
jogs with Lucy.
You take the occasionally paracetamol for headaches but nothing regular and you do not have
any allergies.
FH: 2 of your uncles have thyroid problems, but you are not sure what these are. You are not
aware of any other conditions.
Ideas Concerns Expectations
Ideas – You think you have a virus of some sort that is upsetting your stomach
Concerns – you are worried you are going to miss out on university with a sickness and hope
to avoid that as you spend most your time with Lucy and also don’t want to fall behind on your
busy course.
Expectations – you are hoping the GP can provide some antibiotics or other remedy to calm
your symptoms and make you get better again.
O/E:
Abdo: Tender throughout – nil guarding , nil organomegaly

Heart rate 110
RR 24

82
Sats 97%
Urine: glucose +++ ketones +++ nil blood protein +++ nil else
BM: 28
All other examinations normal
Diagnosis: Type 1 Diabetes / DKA
Explain it appears he has Type 1 diabetes and a dangerous complication that requires
immediate hospital admission.
DKA is a dangerous complication that occurs when the body runs out of insulin.
This results in the body burning off fatty acids which produce what are called ketones. This
can result in vomiting, dehydration, fruity breath, deep rapid breathing, a rapid heart beat,
confusion and eventually Coma and death.
Management:
Immediate hospital admission via ambulance
Agree to discuss diabetes and what future changes will need implementing.
Understand that you are breaking bad news effectively of a diagnosis unknown to the patient
that will have long term effects on them.
Follow up when the patient is better to answer any questions they may have.

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Case 5: Ace inhibitor Cough
John Smithson 51year old
DH: amlodipine 10mg, Ramipril 2.5mg, bendroflumethiazide 2.5mg nkda
“heya doc, I’ve got this cough that I can’t shift”
You are a somewhat overweight and have been told this is contributing to your blood pressure
which was high last time.
You work as a university lecturer and spend a lot of your evenings marking papers , or
watching tv. Unfortunately, as part of this you eat a fair amount of junk food, something
you’ve been trying to change.
Your gp convinced you to start a new medication – Ramipril as your blood pressure was
160/100 and you were suffering headaches.
You started these tablets about 3 months ago. Since then your headaches have gone away and
you’ve felt better.
The reason you have come to to the GP today is because you have been suffering with a cough
for the last 8 weeks.
It’s a dry cough, associated with rib pain in the last 2-3 weeks. It has affected your ability to
concentrate at work.
You have been abroad recently to Oslo for a conference. You were aware of the need to move
and wear compression stockings due to your weight in order to reduce the changes of a clot in
your legs.
Since being back around 8 weeks ago you have not suffered with any swellings to your legs or
felt more short of breath than normal, however you have had an annoying cough that you
can’t quite shift.
It is present throughout the day and is more of a nuisance than a hindrance most of the time.
The persistent nature of it has caused you to ruminate over its cause which in turn has lead to
distraction and procrastination from work.
You do not feel depressed, but recognise you have a lot of pressure to contend with , in keeping
to deadlines and schedules of marking etc.
You have not had any chest pain, have not experienced any shortness of breath, have not had
any ankle swelling and have not suffered any paroxysmal dyspnoea.
You have not had any high temperatures and no one at home is unwell.
You have not had any weight loss, nor have you ever smoked.
No one at home smokes.
SH: live with wife Sandra 48. Your children are all moved out.
DH: as above – nkda.

Started Ramipril 3 months ago.
ICE

84
Ideas – You are concerned that you have a chest infection
Concerns – You are worried that if this goes untreated that you’ll fall further behind your
work and you’ve seen lecturers lose their job after a while of this happening despite how little
time you and your colleagues have already to do the job properly
Expectations – to get some antibiotics
O/E:
Chest clear
RR normal
Throat nil signs infection
Saturations 100% Heart rate 80 regular.
Diagnosis: Explain – likely cough is secondary to the Ramipril medication
Medication induced cough.
Discuss that some people get an allergic reaction of sorts to Ramipril and drugs in that
‘family’.
This is the most likely cause and that there are alternatives to try instead of Ramipril.
Discuss options of using an ARB.
If symptoms do not clear in the next 2-4 weeks consider referral to Respiratory physician
with a full blood screen.
Follow up:
Review in the next 2-4 weeks as suits the patient
To be seen ASAP if suffering with acute shortness of breath or feeling generally unwell.
Further reading:
https://patient.info/medicine/ramipril-an-ace-inhibitor-tritace-triapin-altace#nav-4

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Case 6 – Alopecia Areata
Telephone consultation with Jeremy Linton
Results recently in from consultation last week:
FBC – normal
Vitamin b12, folate and ferritin – normal
Thyroid function normal
Vitamin D normal
34-year-old math teacher
DH: nil nkda

SH: social smoker, occasional drinker
Jeremy saw your registrar earlier in the week and had some pictures taken of an issue with
his scalp.
He has been losing his hair quite quickly over the past 4-5 weeks and has grown quite
frustrated with the lack of progress with current treatment received.
He had been seeing Dr Rogers the registar for the last 2 months and been given an antifungal
shampoo as well as antibiotic cream – fusidic acid which had not helped.
The most recent thing Dr Rogers was querying was a potential deficiency in Jeremy’s blood.
You have never had hair loss before. Your dad is 84 and has all his hair albeit white now.
There is no family history of hair loss.
You keep quite fit and regularly take part in park runs as well as do the Marathon every year
in London.
You have not tried any new hair shampoos, or hair dyes. You have not noticed any leaking
from your scalp or any pain. You have not been started on any other medications prescribed
by your gp or anyone else.
ICE
Ideas – you think there is a condition the gp has not been able to diagnose and you are
convinced there must be some form of a skin infection.
Concerns: you fear that if you don’t get to see a specialist you will lose all your hair.
Expectations – referral to a dermatologist.
O/e: Viewed on computer records:

86
Please look at the following link for example images: https://dermnetnz.org/topics/alopecia-
areata-images/
All other examinations normal. Obs all stable.
Diagnosis:
Alopecia Areata - a condition leading to hair loss resulting in round bald patches to occur
suddenly. These often occur on the scalp, but can occur anywhere that carries hair.
Management:
There is no one treatment that has been found to be reliable. Reassuringly, in the vast
majority of cases, regrowth occurs without intervention. Any topical treatment used may lead
to temporary regrowth which may result in renewed hair loss once they are stopped.
Topical steroids, minoxidil solution and dithranol are all solutions used in such
circumstances.
Injections of corticosteroid into the patchy scalp or affected area may speed up regrowth
albeit at times temporary.
Oral steroids short term have a role, their long term use is unjustifiable due to their side
effects.
Immunotherapy agents such as diphencyprone are sometimes used. In rare cases, simvastatin,
ezetimibe have shown some promise.
87
Consider counselling for those with persistant alopecia or camouflaging hair loss with a wig
etc.
Follow up : routinely to see how any proposed treatment works.
Further reading:
https://www.dermnetnz.org/topics/alopecia-areata/

88
CASE 7 - Hyperhidrosis
Jennifer Schmidt 24
DH: orlistat, amlodipine, nkda

SH: non smoker, 5 units alcohol a week
Recent bloods:
“I think there’s something wrong with me doc, I can’t stop sweating”
Patient simulated History
You have been struggling with excessive sweating since you can last remember.
You work as a high school teacher, which is quite a sedentary job.
You have noticed that even when you are not trying to be active , sweat so much you get
embarrassing armpit sweat that goes through your t shirt.
In the past you have seen your gp about this who suggested you were overweight and that this
was the main cause for your sweating. You were 90kg but made a concerted effort to diet and
be more active you have lost 20 kgs and now have a normal BMI.
Your sweating however has not changed .
You feel well and fit in yourself . You do not suffer with night sweats.
You have noticed that you tend to sweat more when you’re anxious or after eating something
spicy.
You have suffered with this for the last 8months. You predominantly have sweating to the
palms, soles and armpits. You get the symptoms on both sides and you have noticed at night
you do not have any sweating.
You have not had any recent travel.
SH: live with boyfriend Henry. Long term partner. Neither of you have ever had any STI’s
Non smoker and you drink very occasionally.
ICE
Ideas – You are convinced you have some sort of infection most probably from one of the kids
you teach at school that has not been clearing.
Concern: You are worried that you are going to smell and people at work will make fun of you.
You’ve also heard that people can have lung cancer that starts like this.
Expectations: - Referral to cancer specialist/further investigations urgently.
O/e:
Chest clear
Apyrexial.
Heart rate 80
Perspiration excessive – sweating from axillae bilaterally , feet and foreheads.

89
Diagnosis:
Hyperhidrosis – the medical term for excessive sweating.

There are many different reasons for this to occur .
Primary focal hyperhidrosis can affect the armpits, palms, soles or scalp and has no
underlying cause.
It can occur at any age, commonly starts at childhood or adolescence. For patients that have
sweating affecting the entire body it is most commonly caused by medical conditions or drugs.
This condition affects about 1% of the population. Usual onset of primary hyperhidrosis is 14-
25.
Generalised hyperhidrosis has many causes, and they include the following:
-Anxiety
-Pregnancy
-Drugs: anticholinesterases,
-antidepressants
-substance abuse/withdrawal
-Heart failure, ischaemic heart disease, shock
-Respiratory failure
-Infections – TB, brucellosis, HIV, abscess and malaria
-Malignancy: lymphoma
-Endocrinology:Thyrotoxicosis, hypoglycaemia, phaeochromocytoma, acromegaly, carcinoid
tumour, hyperpituitarism, obesity, gout or the menopause
-Parkinsons disease, rare genetic disorder: Riley-Day Syndrome
Typical investigations:
FBC: blood film looking for malarial parasites may be useful and wcc looking for infection
ESR , CRP
Renal function tests and electrolytes
LFTs, HBA1C, TFT
CXR – to rule out intrathoracic neoplasm or a cervical rib
HIV testing
Management
Look for underlying cause – if dealing with generalised hyperhidrosis.
With this case – primary focal hyperhidrosis the follow can be suggested:
-wear loose fitting clothing, avoiding nylon.

-soap substitutes (these reduce skin irritation)
-use antiperspirants for armpits
-change socks twice daily or more and use absorbent foot powder twice daily. Wear leather
shoes , non occlusive foot wear aka sports shoes that ‘hug’ the feet.
-Avoiding triggers i.e. spicy food, caffeinated drinks and alcohol.
Aluminium chloride hexahydrate can be applied to armpits, feet, hands or the face at night
and washed off in the morning.

90
In cases predominantly affected/driven by anxiety CBT has beenf oudn to be useful.
Secondary care management:
-50% aluminium salts, iontophoresis, Botulinum A toxin intradermally
-Surgery – endoscopic thoracic sympathectomy.

Suction curettage debriding subcutaneous tissues , clearing glands in the problem areas.
Offer follow up regardless of the trial method offered.

Discuss websites available for support.
https://hyperhidrosisuk.org/

91
Case 8 – Frozen Shoulder
Janet singleton 34
DH: codeine 30mg, naproxen 500mg nkda

SH: tee total, social smoker
“hey doc my arm is killing me”.
You are Janet, you are a piano teacher. Something you have enjoyed doing for over 10 years
now.
You used to study then work at the royal northern school of music where you occasionally
teach.
You have found you enjoy working from your studio which is at your own home.
Much like most musicians you have suffered with some tendonitis in your wrists from
repetitive strain injuries when doing a lot of jobs and teaching at the same time. This is
something you recognise quite well and cope through taking short courses of anti
inflammatory tablets with paracetamol.
You’ve been attending your local gym regularly however have not done anything out of the
ordinary nor do you recall hurting your shoulder at any point.
In the last 9 weeks or so however you have developed a gradual pain that has steadily been
getting worse and now plateaued to a persistant pain. You find it very difficult to deal with a
lot of activities of daily living. You have found that trying to dress yourself, reaching for your
cell phone in your back pocket or reaching into cupboards makes it more painful.
You actually saw Dr Smith, the other GP about 3 weeks ago and had a steroid injection into
your right shoulder. You did not feel that helped at all.
You have actually been waiting on a physio referral for the last 2 weeks so got fed up as you’ve
not heard anything. You are considering seeking private physio if you cant get an expedited
appointment.
You have been taking regular codeine and naproxen which just about takes the edge off but
does very little else.
ICE
Ideas – you think you may have torn a ligament. Your friend did a lot of weights at the gym
and you recall he had a torn shoulder ligament which needed surgery.
Concerns - that the pain will get worse and you’ll be further crippled by it.
Expectations – to be referred to a specialist and to get your physio appointment expedited.
O/E:
Nil signs of swelling or inflammation at shoulder.

92
Reduced range of motion in all directions. Shoulder flexion to 80 degrees, abduction to 80 as
well as lateral rotation to 10 degrees. Pain noted on all cuff and impingement tests. Patient
unable to put his hand behind his back.
Diagnosis:
Frozen shoulder – also known as adhesive capsulitis of the shoulder.

This is a condition when there is pain and stiffness to the shoulder leading to a reduction in
some or all shoulder movements. In some patients it gets completely limited/frozen. One
theory for why this happens is due to scar tissue forming inside the shoulder joint or ‘capsule’.
The good news is that even without treatment most frozen shoulders improve on their own
,albeit it can take up to 3 years.
The typical phases frozen shoulders go through include;
Freezing – 2-9months : pain, stiffness and limitation of movement. Pain worse at night
Frozen stiff – 4-12 months: pain eases, stiffness and limitation remain or worsen
Thawing 1-3 years – pain and stiffness gradually improve
Management:
Pain killers – Nsaids/opiates, topical agents.
Shoulder exercises to keep the shoulder from further stiffening up
Physiotherapy – for further shoulder exercises, the use of TENS – transcutaneous electrical
nerve stimulation.
Steroid injections – which this patient has tried already
Surgery – often has a good rate of success for most but not all people.
-Arthroscopic capsular release – wher ethe tight capsule of the joint is released.
-Manipulation under anaesthetic.
Follow up for review in the next 2-3 months, sooner if feeling worse, asap if signs of infection
*always discuss with patient.

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Case 9 – Gallstones
Jane Hereby 42
DH: Ramipril 2.5mg, metformin 500mg tds nkda

SH: drinks 20 units/week, non smoker
PMH: diabetes, hypertension.
Last consult: fit for change weight loss referral to the gym.
“I’ve got that bug that’s going around doc”
You have been having intermittent stomach pains for the last 2 weeks. You have not
experienced any diarrhoea or vomiting however there have been times where you have been
close to vomiting.
You have noticed fullness and pain particularly following eating. Aggravating factors include
spicy food, oily food, alcohol or eating a large late night meal which you sometimes do when
watching a movie on Netflix which is one of your favourite pastimes.
Your pain is intermittent. It is a background level of 4/10 but when it flares up gets to 8/10.
You experience most your pain on the right side which you have noticed moves to the back
and the right shoulder. It can last for a few hours.
You are aware you are quite overweight and have recently been referred to a health
management gym course which has not started yet.
You have struggled with the idea that you need to change your lifestyle in order to lead a
healthier life specially as you enjoy eating and due to not working you often nibble on things.
A lot of your neighbours have come down with food poisoning and you’re concerned you have
caught this off them due to having tea at a neighbours house recently. You know this
neighbour was diagnosed with an E coli infection which required antibiotics through a drip
and a stay in hospital.
You have not seen a swelling to your abdomen, no weight loss, no swallowing difficulties and
no bleeding from any orifice other than your regular period.
FH: diabetes, high blood pressure, heart attacks.
DH: as above.
ICE
Ideas – You are quite sure you have contracted E coli like your neighbour.
Concern: you are worried you will become as unwell as your neighbour and need hospital
hydration and IV antibiotics.
Expectations: To get some antibiotics to treat the infection .
O/e: RUQ pain, murphy sign positive

94
Nil guarding.
Apyrexial.
BMI on request – 30
RR normal
Urine nad
Diagnosis: Cholecystitis
This is a painful condition caused by an inflamed gallbladder. The commonest cause is

gallstones.
Women tend to be affected more commonly than men.
Most people with gallstones are not aware of having them as they are without symptoms.
However in some patients the gallstone gets stuck in one of the tubes that drains the bile from
the gallbladder. This results in bile build up in the gallbladder that leads to it being stretched
which in turn leads to it becoming inflamed and painful and on occasion infected due to the
inflammation.
Management:
If the symptoms are severe – hospital admission for initial pain relief is important.
Non surgical treatment: Initially treat with opiods such as NSAIDs through suppository/IM or
morphine/pethidine
Avoidance of triggers – losing weight, avoiding fatty oily foods, eating small meals and
avoiding late night meals. Reduce or avoid alcohol.
Surgical – Laparoscopic cholecystectomy
Advise the patient if they do not choose hospital admission or if they are well enough not to
need admission to refer them urgently and to be aware if they develop acute abdominal pains
to seek immediate medical attention.
Further reading:
https://patient.info/doctor/gallstones-and-cholecystitis

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Case 10 – Female Genital Mutilation
Jasmine Ahmed 32
DH: Ramipril 1.25mg , Metformin 500mg tds , Omeprazole od
Notes on record: Multiple DNAs . Has not attended any of her smears. Last consult was with
practice nurse for travel vaccinations prior to a Sudan trip. On that visit it was noticed her
blood pressure was just above normal at 144/86 – something she put down to having had an
argument with her neighbour. In the past she had normal Blood pressures. You advised her to
get a blood pressure check when she got back.
She has not responded to any letters inviting her for a routine check on her blood pressure so
her last medication request was rejected with a message to book in.
You attended first with the nurse who checks your blood pressure – 105/60 today.
“Hi doctor, I’m going to be travelling again to Sudan and needed my blood pressure medication
please”.
Type 2 diabetic with some proteinuria which vastly improved on being started on a blood
pressure tablet called Ramipril. You are aware that you need it for this purpose and not for
high blood pressure.
You have been in the UK for around 7 years, travelling back to the Sudan 2-3 times a year to
visit family. You feel well established in the UK where you have pursued your interest in
health care - working your way up to a nursing student.
The purpose of your visit today is to check your blood pressure is normal and to be able to get
some blood pressure tablets. You are apologetic for missing the previous letters but didn’t
think there was a need to come in if you were ok as you had checked your own blood pressure
on the ward at work and it had been fine always being around 110/60.
If the doctor asks you about the reason for the missed smear tests you reluctantly open up
about the real reason . Initially you will say you fear the smear is going to be painful. If the
doctor enquires further you state you have problems down below.
If posed with open questions you reveal that as a child you were forced to have female genital
mutilation. Since getting married 3 years ago you have found you have not had any pleaure
with sex but it has not been painful.
You have regular periods without any irregular bleeding/abnormal bleeding.
You have 1 child and had a normal pregnancy.

You feel deeply conflicted although you love your husband you feel betrayed by your family.
You would never allow your children to go through FGM .
You do not agree to the request for the GP to report the FGM.

96
ICE
Ideas – you feel upset about being forced to undergo Female circumcision against your will
however despite your reservations and feelings of betrayal you visit them regularly.
Concerns – you are worried your children will forcibly be removed from you if people find out
about your previous procedure.
Expectation – you are hoping to get your medication today and somehow avoid having a
smear for the aforementioned reasons.
SH:
you live with your husband and daughter who is 1 year old. Your daughter was born in the
Sudan with no complications.
You do not smoker or drink
FH:
you have 3 cousins who have also gone through FGM. They all live in the Sudan.
O/e:

If chaperone is offered you will allow an examination – and be shown results.
Examination in keeping with female genital mutilation
Rest of the examinations normal.
You deny being depressed.
Management:
Explain that FGM is illegal and be understanding of her not wanting to report it.
As the patient is an adult it is not mandatory to report FGM.
Explain that in future pregnancies she should be aware of reporting this to her midwife as
FGM patients can suffer obstetric complications.
Justify the need to document the existence of FGM in the notes for that reason.
Offer review by specialist Gynaecologist and/or psychological support.
For patients that have had FGM - deinfibulaton is possible – where the vagina is opened up.
This is suitable for women who are unable to have sex or have difficulty passing urine. It is
also suitable for pregnant women at risk of problems during labour or delivery as a result of
FGM.
Basic principles of FGM:

FGM – form of child abuse and it is against the law.
IF a child is identified as being at risk of FGM urgent action to safeguard the child must be
undertaken.
We have a professional and legal responsibility to report this event and to protect the patient
as a result.
https://www.nhs.uk/conditions/female-genital-mutilation-fgm/
(extra reading on the topic)

97
Case 11 – Cauda Equina
Emily Sanderson 33
DH: gabapentin 300mg tds, cocodamol 30/500, naproxen 250mg tds nkda
SH: teetotal, social smoker.
“hey doc, my backs been killing me”
You are a postal woman who’s got a past medical history of chronic back pain. You first
started with this pain around 6-7 years ago following a bad car accident when you were
shunted from behind by a lorry. You didn’t require any surgery but had extensive
physiotherapy for around 6months and a lengthy period off work.
You first returned to a phased return doing mostly clerical duties, but in the last 3-4 years you
have been able to get back to a moderately physical job without much difficulty. This has
largely been as a thanks to the pain team who started you on regular gabapentin and
occasional cocodamol. Occasionally you get a flare up of your back pain but this usually settles
with a short course of your naproxen tablets.
You live with your partner Sarah and your kids Samantha and Laura – 2 adopted twins (aged
4).
Life has been good in the past few years however unfortunately in the last 4 months due to
Sarah being made redundant from her engineering job you have had to take more shifts that
have in your opinion lead to your constant worsening back pain.
At first you really only struggled in the mornings, with a background pain that continued
throughout the day but that you got used to and managed. Now however you have found you
have been going on intermittent time off from work which has been causing you stress, due to
feeling trapped in an ‘old woman’s body’ and being aware of your financial restrictions.
The pain starts just above your right buttock, and travels down your leg , thigh and just below
your knee. There are times when you get spams into your lower back that can floor you.
Despite taking the cocodamol, naproxen and gabapentin regularly for the last week you feel
the pain is getting worse. You feel it intensified in the last 48-72 hours and you’ve noticed this
pain is now in both sides of your back and travels down both legs .
Sometimes the pain is so bad you don’t quite make it to the bathroom and find you have soiled
yourself. Very bizarrely you have found that you have actually wet yourself 2-3 times in the
last 48 hours without knowing. You’ve put this down to the combination of medications you’ve
had.
When you wipe down below you have found at times it’s all feeling a bit weird and numb.
You’ve been quite constipated as well for the last 4-5 weeks , even before you took the
cocodamol regularly. You found this bizarre as cocodamol has never caused you to be
constipated before.

98
ICE
Ideas – you feel your back pain is getting worse due to having to do extra shifts and these have
had more of a physical component to them.
Concerns – you are worried that you may lose your job and have to foreclose on the mortgage
if things continue in this fashion.
Expectations – you hope the doctor can give you stronger pain medication and maybe book
you a scan if they think that will be helpful.
O/e: (ask for chaperone)
Weakness to lower limbs bilaterally (Power 3/5)

Reflexes weakened bilaterally
Upgoing plantars noted on right side
Saddle anaesthesia and perianal anaesthesia noted
Diagnosis: Probable Cauda Equina Syndrome.

This is where the nerve roots at the level of where the spinal cord terminates are compressed.
This directly causes bladder , bowel dysfunction of varying degrees. Some suffere sexual
dysfunction, weakness and various neurological deficits dependant on the level and degree of
nerve root compression.
Management:
This is a medical emergency and requires immediate referral for investigations . If confirmed
requires surgical decompression.
Cauda Equina Syndrome:
1-3/100 000.
Aetiology: herniated lumber disc most common cause.

Tumours, trauma, infection (abscesses), congenital issues, advanced ankylosing spondylitis,
haematomas following surgery and sarcoidosis are some of the causes found.
Clinical presentation varies and is certainly not straight forward.

Low back pain with a combination or unilateral or bilateral sudden onsetn progressive pain/
sensory deficit.
Lower limb motor and sensory weakness can occur. This usually is associated with loss or
vastly weakened reflexes.
Bowel/bladder dysfunction is common .PR often shows loss of anal tone and sensation.
Investigations include:

99
Clinical history and examination.
Emergency MRI scan.
Further reading:
https://patient.info/doctor/cauda-equina-syndrome-pro

100
Case 12 - Bed Wetting
George Gardener Aged 5
Telephone consultation – David , George’s Dad is expecting a call about George. He is

concerned about some problem behaviour. You do not know much more as he was unwilling to
divulge further information whilst booking the telephone consult. You gave in a urine sample
for George to check if he has a urine infection last week and have been told the results are
back in.
URINE RESULTS - NAD
You are David Gardener, a successful banker working between London and Manchester.
You are quite concerned lately as George seems to have a problem holding his urine.
For the last 3 months you’ve noticed that Georgie has been wetting the bed.
This has been quite traumatic for everyone. You are quite disappointed in the kid because he
took so long to stop bedwetting In the first place.
You had stopped bedwetting by the age of 4, he was only 5 and a half when he stopped wetting
himself and now he’s started again after almost 6 months of being normal – finally!
You admit to shouting at George a few times in the past but breathed a good sigh of relief when
he managed to keep dry at night.
You know George has been doing very well in school.

He captains his field hockey team and is quite popular in school. You’ve been quite surprised
at how confident he has been at school and hear 3 girls asked him to the school dance
recently.
George was born at term. He spent no time in SCBU.

His delivery was uncomplicated for him but it caused his mom, your now ex wife quite a a big
tear down below . You find after she gave birth her body was never the same and she was
more interested in your son than you.
You remind the doc that this is the exact reason you never wanted children.
There were lots of reasons for the divorce and admittedly you started having an affair with
your secretary who’s younger and more attentive to your needs. You felt guilty 3 months into
it and told Katherine your ex wife about it , following which you both agreed to start divorce
proceedings.
Georgie lives with you on weekends and with Samantha during the week, an arrangement that
suits you both.
George is an only child.

101
There are no diseases that run in your family.
Around 8 months ago your ex Katherine used some funny looking charts she referred to as
stars and some stupid alarm that kept waking you up when he started wetting himself.
You admit that despite hating that alarm after a couple of weeks it worked very well and he
started having more dry nights .
ICE
Ideas – you are sure this has happened because Georgie isn’t as manly as she should be. You
feel he should start doing things like karate, and rugby.
Concerns – You are worried that if this issue is not fixed soon you wont be able to spend much
time with him because you are waking up to clean the bed at night and not able to concentrate
as well as you would normally in the morning.
Expectations – You’re hoping that the doctor can diagnose the issue at hand to help your dire
situation. You’re willing to pay for a private doctor to get it sorted as soon as possible.
Diagnosis: Secondary Enuresis – “bedwetting” when a child is asleep.
Explanation – Most children 4/5 are dry at night by the age of 5. 1/10 are still bedwetting at
the age of 10. We largely consider this to be normal up until the age of 5.
Boys suffer with this condition at a ratio of 2 to 1 compared to girls.

The commonest cause is a genetically determined delay in acquiring sphincter competence.
2/3rds of affected children have a first degree relative that had the same problem.
Equally important, is the need to not stress a child emotionally as this can cause a secondary
bedwetting i.e once a child has been dry and then becomes a bedwetter again.
There are sometimes what are called ‘organic’ causes of bedwetting , however this is quite
uncommon. Causes include:
UTI’s, being constipated to a degree that the bladder neck becomes dysfunctional, chronic
kidney disease or diabetes and behaviour problems including children with learning
difficulties.
Management:
Advise parents to not punish children, consider use of star charts (earning praise and a star
for helping the parent to clean the bed sheets , not for having a dry night. Consider the use of
an Enuresis alarm – this is an alarm attached to the child’s pants or underneath them . It gets
activated when wet , prompting the child to get up to go to bed and then with the help of an
adult clean the bed again. This should be done in a matter of fact way and nothing to be
frustrated at by a parent/guardian as it will lead to a set back in progress.
Those above the age of 7 ideally can have a medicine called desmopressin when other methods
have failed to work. It is suitable in situations when the above 2 methods have not worked or
when the need requires it and there is a time restriction i.e an impending holiday or sleep
over at a friends/school trip with an overnight stay.

102
Plenty of self help groups – ERIC – the childrens bowel and bladder charity.
Further reading:
https://patient.info/health/bedwetting-nocturnal-enuresis

103
Case 13 – Memory loss
Emily Sanderval
75 years old
DH : voltarol gel 1.16%, paracetamol nkda

SH: non smoker, 5 units a week.
“Heya Doc, Sorry to waste your time today, John insisted I come”
Patient simulated history.
You are a retired school teacher who now enjoys your time looking after the grandchildren
(Jimmy and Jill , 5 and 7 respectively).
You help at the school occasionally when they are short around exam time but only 2 half
days a week and really enjoy the lack of pressure.
You have kept quite active, and feel you don’t feel your age generally speaking, other than the
odd knee pain and shoulder pain which you’ve been told previously is wear and tear from
getting older. You accept this and have just learnt to take occasionally pain killers for bad
days.
A few times when the pain has been very bad, usually when you’ve done a few back to back
extra shifts at the school , you find you control the pain with paracetamol and voltarol gel.
You live with John , your husband of 30 years. He still works but it is for an accounting firm
and he works entirely from home so you enjoy your time together.
He has been increasingly worried about you as he feel you have been a bit more forgetful than
is normal for you.
You admit to being a bit more forget than usual and that this has been getting a bit worse
according to John. Examples include, forgetting to do the shopping , leaving the cooker on ,
but this happened just once and being forgetful of things like family members having passed
away. Admittedly this only happened when you were quite poorly with a chest infection and
had a very high temperature.
You are convinced John is just being too much of a worrier. That’s been the case since you
were admitted with the chest infection last year and were quite poorly. You spent a week and
a half in hospital but recovered back to what you consider your normal level of health since.
You have no problems with your hygiene needs. You have no continence issues and handle all
your economic matters well and independently.
You are quite active in the community and take part in the neighbourhood watch, the local
bowls club and a book club with your fellow retirees.
You and john continue to keep fit by going for 2 long walks a week and attend the gym 2 times
a week for badminton.
John’s sister Olivia was similar to you and developed Alzheimers Dementia , dying a short
time after.
You suspect that is why John is so worried about you. You are not concerned however as
Olivia was quite an unwell lady most her life , a heavy smoker and did no exercise.

104
ICE
Ideas – you feel you are well and other than a moment of delirium during your inpatient stay
your memory has been in keeping with a lady of your age.
Concerns – your husband job is concerned that you are developing dementia
Expectations – to get some tests to check whether you have dementia or are developing it and
getting treatment if that is the case.
O/E:
All obs normal.

MMSE 248/30
Diagnosis: Mild cognitive dysfunction (MCI)
Explanation – this is a condition where someone has a minor problem with cognition. This can
include some of their mental abilities, such as thinking or memory but commonly do not
persistently interfere significantly with their daily life.
5-20% of people aged over 65 are estimated to have MCI.
The benefits of identifying someone with MCI is to both support the patient and the family, as
well as keep a close eye on them , looking for further deterioration.
Treatment does not exist unfortunately.

In the past , medications used to treat Dementia were used to help treat or slow down
cognitive decline, however no trial to date has shown any benefit of people using these for
MCI.
Lifestyle changes such as adopting a healty lifestyle, stopping smoking or reducing alcohol
intake are some of the conservative ways in which to slow the progression of
MCI/development of dementia.
Alzheimers societies recommend that as well as keeping fit and active, one is to keep mentally
engaged – through doing crosswords, reading and socialising.
General tips for patients with MCI
Avoid stress /anxiety as it can cause distraction and memory loss albeit short term.
Quit smoking (help is available)
Utilise calendars /diaries/phone reminders to keep intrusion through memory loss as little as
possible
Maintain physical activity – aiming for 30mins a day , five times a week.
Maintain a healthy diet with fruit and vegetables.

105
Further reading:
https://www.alzheimers.org.uk/info/20007/types_of_dementia/16/mild_cognitive_impairmen
t_mci

106
AC ICE CA E FO
HE C A
Top Tips before our big da :
Get plent of sleep.

Ha e a good meal.
Go on a practice course.
Get used to seeing patients in 10mins.
Make sure ou practice common areas ou
dont often see through simulation or ith
our colleagues.
Make sure ou kno our guidelines and
common emergencies in general practice.
Finall , be ourself, the e aminers are not

there to trick ou, e ant ou to succeed
and join us.
Feedback is elcome:
Haider.ali1@nhs.net
107

Practice Cases For The CSA 2020

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Practice Cases For The CSA 2020

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DEA C NCE N AND

PRACTICE CASES FOR THE

It is important to know what to expect on the day of the exam.

Here is a link to that:

Make sure you know your guidelines!

A little about myself.

I am a GP based in Central Manchester.

John Bloggs , age 34.

Simulated patient information:

FH: There are no medical problems that run in your family

You hope the GP can give you some antibiotics .

On examination: (OFFER A CHAPERONE )

Genital examination reveals:

Discharge noted from penis

Apyrexial, heart rate 87 regular, blood pressure 134/65

See link below for common types of sexually transmitted diseases.

You’re a salaried GP who has not seen this patient before.

Jessica Jones. 27years old.

“Hi Doc, I have come to talk to you about my gammy knee!”

Simulated patient History:

You are Jessica , a 27 year old accountant and keen runner.

PMH: You have no medical problems.

SH: you are teetotal, and you do not smoke.

FH: nil of note.

Observations – all normal – BP/Pulse/temperature

INFORMATION FOR THE EXAMINER:

Gathers a succinct history of events.

Simple overview of ligament surgery

Doctor Article – complex on ACL repair techniques and current methods

You’re a salaried GP who has not seen this patient before.

Samantha Wild. 24years old.

“Hi Doc, I’m just here for a sick note please”

Simulated patient History.

Ideas Concerns Expectations

FH: Both parents have eczema, an aunt has psoriasis.

Flexural areas – arms and legs , plaque psoriasis.

Discuss general management of psoriasis. Offer to explain condition.

Useful online links about Psoriasis:

You’re a salaried GP who has not seen this patient before.

Roger Smith. 32years old.

Seen by your colleague Dr Joy several times in the past :

“I need your help with a form doctor”.

Simulated Patient History.

Information for the examiner:

You’re a salaried GP who has not seen this patient before.

Peter Harrison. 37years old.

Blood results from last week.

FBC: HB 135, normal mcv. WCC 8

Opening statement: “I’m here for my blood results doctor”

Simulated Patient History.

FH: nil of note

Nothing abnormal detected on external genitalia exam.

Information for the Examiner:

Elicit ED history to determine if psychological or physical cause.

Depends on the cause – options include medication or sexual health counselling

Call waiting from Emma Gilchrist

Simulated patient history.

You are Emma, mother of Samantha Gilchrist who is 14.

DH: as above – Mirena coil, Tegretol and atorvastatin. NKDA

FH: nil relevant.

Examination: - nil needed in this station.

Information for Examiner/Management

Offer follow up tele consult if wanted.