Abstract
This section of the journal is intended to aid GP registrars in refining their consultation skills for the Simulated Consultation Assessment (SCA). The section includes a ‘Doctor’s sheet’ and a ‘Patient’s sheet’ to facilitate practicing consultations with your trainer and colleagues. An ‘Examiner’s sheet’ describes the areas trainees need to display in each of the marking domains and finishes with key points and tips for the trainee.
Doctor’s sheet
Name: Miss. Kate Gordon
Age: 24 years
Medical History: Acne
Current Medications: Lymecycline 408mg once daily (OD), progesterone only pill
Allergies: Nil
Recent Investigations:
Thyroid stimulating hormone (TSH): 3.8 mU/L (normal)
Prolactin: 280 mIU/L (normal)
Follicle stimulating hormone (FSH): 4 IU/L
Luteinising hormone (LH): 10 IU/L
Total testosterone: 3.3 nmol/L (elevated)
Sex hormone-binding globulin (SHBG): Low
Free androgen index: Raised
HbA1c: 41 mmol/mol
Patient’s sheet
Name: Miss. Kate Gordon
Age: 24 years
Background
Kate has booked an appointment to discuss her recent blood test results after attending with concerns about irregular periods and excess facial hair.
Opening line
‘I received a message to book an appointment to discuss my results. Is it something serious?’
Behaviour
Appears worried that the results are quite abnormal.
Information given freely
She explains that her periods occur every 2–4 months and have been irregular since her teenage years. She has noticed worsening acne and increased hair growth on her chin and upper lip over the last few years.
Information to be provided on appropriate exploration and a non-judgemental approach
She has gained approximately 7 kilograms over the past 2 years. Her BMI is 31 kg/m² (Class 1 obesity). She is not currently trying to conceive but hopes to have children in the future. She is in a stable relationship. After checking her results on the NHS app, she has searched online and is concerned that she may not be able to bear children.
She has no headaches, visual disturbance, galactorrhoea, deepening of the voice or rapid onset of symptoms. Her mood is generally good, although she feels self-conscious about facial hair.
Examiner’s sheet
Data gathering and diagnosis
The candidate should explore the patient’s ideas, concerns and expectations, particularly fertility concerns. They should clarify patient’s menstrual history and inquire about features of hyperandrogenism. They should exclude alternative causes of menstrual irregularity, such as pregnancy, thyroid dysfunction and hyperprolactinaemia. It is important to identify lifestyle factors, including weight gain, diet and exercise; as well as psychosocial impact, including self-esteem and body image. It is expected that the candidate recognises the patient fulfils two of the Rotterdam criteria (irregular periods and biochemical hyperandrogenism) to diagnose polyendocrine metabolic ovarian syndrome (PMOS).
Red flags
It is important that the candidate checks for the relevant red flags, especially those related to pituitary tumours, adrenal hyperplasia and depression.
Clinical management and medical complexity
Management should be individualised and should include explanation and reassurance that PMOS is common and treatable. Weight loss through diet and exercise can improve ovulation and reduce symptoms. Consider combined oral contraceptive pill if not contraindicated. Endometrial protection is important if periods remain infrequent. The candidate should touch upon hirsutism and acne management and arrange for periodic monitoring for type 2 diabetes, hypothyroidism and lipid abnormalities. The majority of women with PMOS can conceive. Ovulation induction with letrozole or clomiphene may be used when pregnancy is desired ().
Relating to others
The candidate should deliver the diagnosis in a clear and compassionate manner. They should address Kate’s fertility concerns directly. It is important to avoid overwhelming the patient with information. In such cases it is important to explore what matters most to the patient, and what requires clinically urgent input. Other issues could be mentioned briefly with follow-up arrangements made for further discussion.
Discussion with registrar
Consider the following questions:
What are the Rotterdam criteria for diagnosing PMOS?
When is pelvic ultrasound necessary?
Why is endometrial protection important in women with infrequent periods?
When should markedly elevated testosterone prompt urgent specialist referral?
Top tips
Blood tests in suspected PMOS are primarily used to exclude alternative diagnoses and confirm biochemical hyperandrogenism
Two Rotterdam criteria are sufficient for diagnosis; ultrasound is not always required
Fertility concerns are common and should be addressed early and clearly
Management should focus on the patient’s priorities and future reproductive plans
Lifestyle modification remains the cornerstone of treatment
