Practie Station Amenorrhoea

Instructions to Candidates:

You are a Foundation doctor working in General Practice.

Susan Cole has attended because she has had no periods for 6
months.

Please take a history.

At 6 minutes the examiner will ask you questions.

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Practie Station Amenorrhoea

Station Information
Station Reference Practie Station Amenorrhoea

Station Title Practie Station Amenorrhoea

Student Description none

Author Mourad Seif

Year Group Practice 1Med Stations

Clinical Domain Mental Health,Women's Health

Clinical Competency Patient Assessment (History Taking)

Information for Site Organisers

Type of patient required:
Simulated patient (history only).

Patient information:
Female (preferably slim) 19-21 years old Wearing baggy clothes

Resources and equipment needed:

Alcogel

Candidate pink notepaper, black pens and clipboard in case the candidate wishes to make notes

Chairs x 2

Setting up the station:

The examiner’s chair should be positioned so that he/she can observe faces of both candidate and
patient/relative/colleague.

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Information for the Examiner

What is the overall aim of this station?
This station assesses the candidate's ability in taking a gynaecological based history in a clinically reasoned
and patient-centred manner.

Examiner’s role:
• 0 minutes: candidate enters station. Check their ID card, then observe & assess the candidate.
• 6 minutes: ask the candidate:
1. Which is the most likely diagnosis and why?
2. What investigations should now be done and why?
• 8 minutes: politely ask the candidate to move on to the next station. Complete marking.

Standardisation is important. Whilst you may clarify the candidate’s responses to the questions above, please
do not ask supplementary questions of your own.

What is expected of the candidate?

An example of an Amenorrhoea history framework includes:

H/o presenting complaint & duration:

• Have you had periods before?
• Age of menarche? Regular/irregular? Cycle duration + Bleeding days? Heavy/light bleeding?
• Any pain/problems? + How long did it last for?
• LMP (When was your last menstrual period?)
• Any menopausal symptoms?
• Are you on any contraceptive pill? Past use? (Post-pill amenorrhoea)
Obstetric history:
• Have you conceived in the past? Did it go to term? Was it a normal delivery?
• Did you have any problems after delivery? Any heavy bleeding? (Sheehan’s syndrome)
• Have you ever had a pregnancy terminated? Have you ever had a D&C? (Asherman’s syndrome)
• Could you be pregnant now?
Gynae history:
• H/o irregular bleeding? H/o vaginal discharge?
Other symptoms & Past Medical History:
• How is your appetite? Have you lost weight recently? Tell me about exercise? (Anorexia/Bulimia –
see below) use of laxatives / binging or vomiting?
• How are you in yourself generally? Have you had a cough or fever? Do you feel tired or unwell?
(Systemic illness)H/o renal disease, thyroid, DM? Have you ever suffered from thyroid problems?
(dislike of warm environments / tremors / sweating / the opposite) (Hyper-/hypothyroidism)
• Do you think you’re overweight? Have you noticed any changes in yourself such as facial hair, acne
or deepening of voice? (PCOS) Have you noticed any discharge from your nipples/problems with
vision/headaches? (Pituitary tumour) Have you noticed that your stomach is increasing in size or
feeling bloated or feel any swelling in your tummy? (Ovarian tumour)
Family history?
• When did you mother/sisters reach the menopause? (Perimenopausal or Premature ovarian failure)
Drug history:
• Are you on prescribed/over-the-counter/herbal medication? (Drug side-effect)
Social history:
• How are you getting on at home/work? (Stress/Emotions)
• Do you drink/smoke/take any substances and how much? (Substance abuse)

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Marking Guidance: if you award a global judgement below 'Excellent', it is

extremely important you provide constructive feedback on key areas the candidate
should develop further i.e feedback which justifies the grade awarded.
The excellent / good candidate
• Will take a structured & clinically reasoned history, quickly exploring key and red flag symptoms.
• Will explore all or almost all of the key associated symptoms, and will enquire about symptoms of
differentials.diagnoses as part of a rule in/rule out reasoning approach.
• Will, in the time allocated, complete the history including asking about past medical history, drug
history, family history, social history, etc.
• Will consider the impact of the condition on the patient/family and elicit and address the patient's
ideas, concerns, feelings and expectations.
• Will demonstrate excellent communication skills, using a structured but sensitive approach and
avoiding jargon.
• (If required) will provide a sensible ordered differential list and/or arrive at the likely diagnosis.
• Will be able to describe and justify the required next steps.
The satisfactory candidate
• Will take a structured history, although will miss asking about some key or red flag symptoms.
• Will attempt to rule in/rule out possible differentials.
• Will, at times, be unstructured in their approach but generally will have a sensitive and patient-
centred manner.
• May not fully cover all aspects of the history in the allocated time.
• Will still identify some of the likely differentials and be able to describe some of the required next
steps.
• Will demonstrate good communication skills, using a largely sensitive and structured approach, and
using minimal jargon
• (If required) will provide a reasonable differential list/ arrive at the likely diagnosis
• Will be able to describe and justify most of the required next steps.
The failing candidate
• Will have a disorganised manner throughout with an unstructured & unsystematic approach to
history taking, missing most or all key or red flag symptoms.
• Will demonstrate cognitive biases that influence their clinical reasoning
• Will NOT identify likely diagnoses (or if they do, do so in an unstructured manner/ through
guesswork).
• Will adopt a doctor-centred, disjointed approach, or show lack of compassion/sensitivity.
• Will demonstrate poor or limited communication skills, without a structured approach and using
frequent jargon.
• (If required) they will be unable to provide a reasonable differential list/arrive at the likely diagnosis.
• Will be unable to describe and/or justify most of the required next steps.

As this station involves a patient (simulated or real), the candidate should follow standard infection control
practices (e.g. clean hands with alcogel upon entering AND before leaving / clean stethoscope if used / bare
below elbows etc).If the candidate is in breach of any OR multiple infection control measures, then their
global judgement should be no more than 'GOOD', and remind them of the importance of this in their
written feedback.

Clinical information relevant to the station:

The likely working diagnosis if anorexia nervosa given the relationship of amenorrhoea with weight loss and
exercise, low self-esteem and the concerns with body image.

Investigations:

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• Measure BMI, Pregnancy Test, psychological tests eg PHQ-9 for Depression

• Blood tests: Androgen profile including Testosterone, SHBG, Free Androgen Index,Thyroid Function
Test, FSH/LH, Prolactin, Consider an ultrasound.

To meet the Diagnostic criteria for Anorexia Nervosa a further FULL history (unrealistic in 6 mins) would cover
the following features:
• Establish deliberate weight loss – BMI should be less than 17.5 or weight 15% less than expected
• Weight loss induced by means
o Restriction/avoidance of food
o Self induced vomiting
o Excessive exercise
o Use of medication: laxatives, diuretics, amphetamines, thyroxine
• Body image distortion – consider themselves overweight when clearly not, Morbid fear of ‘fatness’
• Acknowledge that endocrine changes i.e. Amenorrhoea, elevated GH and increased cortisol are part
of diagnostic criteria

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Information for the Simulated Patient

Opening statement for the patient:
‘I’ve come to see you as I am worried that I haven’t had a period for a while.’

About you:
You are Susan Cole.
You are at college repeating your A levels. Your grades were disappointing and you decided to stay on for a
year longer to try again. Most of your friends have left and gone to University.
You were going out with Jeff from college until he went off to University 7 months ago. He met someone new
in Fresher’s week. You were initially a bit low about this, your sleep has been disturbed and you have been
eating healthily as you’ve heard his new girlfriend is really tall, slim and attractive.
You smoke just when out in clubs and you drink at weekends with girlfriends.
You have joined a gym and go every day, sometimes twice and feel angry if you miss it.
You don’t like eating with your family or friends as you think they eat unhealthily and have portions that are
far too big.

Current health problem:

Menarche (age at first period) aged 14. Periods previously regular. 4-5 days every month, no pain no mood
swings.
No period now for last 6 months. Last one seemed normal.

If asked:
Was using condoms and had no sex since Jeff left.
Weight decreasing, lost 5kg in 4 months (weight now 47kg, height 1.72 m – BMI 16)
No excess hair
No chance of being pregnant
No discharge from breast
Never seen GP before about periods
You do not binge eat.
You deny self-induced vomiting
Sometimes takes laxatives.
Not happy with body image, feels fat.
No hot flushes.
Hopes getting slimmer/ fitter will get Jeff back.
Good relationship with parents who are supportive about her re-sitting exams.
Not feeling depressed or anxious, no thoughts of self-harm - though you used to cut yourself with a pencil
sharpener, when started secondary school.
If asked the following, the answer is ‘NO’: unable to tolerate hot or cold weather or feeling cold or unusually
warm, headaches, blurring of vision.

Your ideas, concerns, feelings and expectations:

You feel unattractive and fat though working on this.
You are not concerned about weight loss.
You are keen to have investigations to check up your periods.
You are concerned that you may have a serious medical problem that is causing this.
Your main concern is that your periods have stopped and the effect of this on your health and future ability
to conceive and have a normal life.

Questions:
Nil

Previous medical history:

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No previous problems. No other current issues.

Sometimes takes laxatives.

Medical problems in the family:

There are no medical problems that run in your family.

Medication:
Nil regular prescribed or over the counter
No known drug allergies

How to play the role:

You are not concerned about the weight loss, if the candidate mentions anorexia appear surprised but don’t
challenge them as this station is assessing history taking and diagnosis rather than challenging
communication.
You give information freely if you feel you have been asked appropriately.
You don’t have any questions. The examiner will ask the candidate about their proposed investigations and
diagnosis.

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Marking Domains
01. Overall conduct of the consultation with patient/relative/carer
Introduces self, states own role and checks identity of patient/ relative/ carer
Explains and agrees the purpose of consultation
Establishes and maintains rapport
Attends to the comfort, safety and dignity of the patient if applicable
Demonstrates empathy and sensitivity
Discusses patient information sensitively and with awareness of confidentiality if applicable
Maintains a fluent, coherent and competent approach
Manages time, completes task and closes appropriately
Follows appropriate infection control measures throughout

02. History Taking Skills

Appropriately uses a combination of open, probing and closed questions
Adopts a clinically reasoned approach, demonstrating the ability to differentiate relevant from irrelevant
information in order to narrow the differential diagnosis
Enquires about red flag features in order to rule in and rule out serious/ significant pathology
Uses a patient-centred and structured approach throughout
Appropriately elicits and acknowledges the patient’s feelings, ideas, concerns and expectations
Explores the impact on the patient’s life
Clarifies and summarises as appropriate
Avoids inappropriate reassurance
Demonstrates responsiveness to the social, cultural and ethnic background of the patient, and their
abilities and disabilities

04. Non-verbal Communication

Maintains appropriate body language and eye contact
Maintains a calm and composed demeanour
Demonstrates active listening (e.g. remaining focused on the patient)
Uses or offers visual methods for conveying information e.g. diagrams
Uses appropriate seating position

14. Clinical Knowledge and Diagnosis

Identifies the underlying problem(s)
Demonstrates an appropriate depth of understanding of the clinical condition/pathology
Applies reasoning skills to interpret information in the clinical context
Applies knowledge to the patient’s current situation
Generates a plausible list of differential diagnoses and if required, is able to identify which is most likely
Provides a clear justification and rationale for their diagnosis or differential diagnosis

15. Providing information to the examiner

Communicates findings clearly, if applicable
Summarises accurately and concisely if applicable
Answers examiner questions clearly and competently
Provides and prioritises answers that are reflective of routine clinical practice
Justifies answers in context of the patient’s problem

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