You are an FY2 in GP

Personal Details:

Name: Mark Richards

Age: 40

Medical Record:

Past medical history: None.

Regular medication: None.

Allergies: None known.

Notes:

Mark returns for a follow-up. He first presented six months ago with persistent tiredness that started after a flu-like illness.

Extensive blood tests at the time were all normal (including FBC, CRP, TTG, liver and kidney function, vitamin B12, folic acid, TSH). His fatigue has not improved and is significantly impacting his life. He works as a lawyer.

Task:

1. Take a history focusing on the nature of his fatigue and its impact.

2. Discuss possible diagnosis and discuss a holistic management plan.

Examination: when the candidate verbalises examination, the examiner will give examination findings which are all normal (including neck, chest, and abdomen examination with no evidence of any lumps or swelling, observation normal)

Opening Sentence: “Doctor, I’m back again. Nothing has changed. I’m still exhausted all the time, and I feel like I’m at the end of my tether.”

Open History (to give freely): “It’s been over six months now. I can’t shake off this feeling of complete exhaustion. It’s not just being tired; it’s a bone-deep weariness. I can’t concentrate at work, and I have no energy for anything else. You did all those tests, and they were normal, which just makes it more frustrating.”

Cues to give: “My wife thinks I’m having an affair because I have no energy for her anymore. It’s destroying my marriage.”

ICE (Ideas, Concerns, Expectations):

Ideas: “I have no idea what’s wrong with me. I feel like a fraud because all the tests are normal.”

Concerns: “Why am I having this? Am I ever going to get better? I’m worried I’m going to lose my job and my wife.”

Expectation: “I want a diagnosis. I want to know what’s wrong with me and what can be done.”

How to Act: You are frustrated, demoralised, and tearful. You feel misunderstood and hopeless.

More History (only if asked): The fatigue is overwhelming and is made worse by any physical or mental exertion (post-exertional malaise). You also have problems with your memory and concentration (“brain fog”), and you don’t feel refreshed after sleep. You have stopped exercising because it makes you feel worse. You have started drinking more alcohol in the evenings to cope.

You haven’t had any weight or appetite change, no fever, no lumps or swelling, no chest, GI or heart symptoms.

Social History:

Occupation: Lawyer.

Substance use: Smokes 10 cigarettes/day, drinks a few glasses of wine most nights.

Relationships: Marriage is under strain.

Questions to ask:

“So it’s a real illness? It’s not just in my head?”

“What can I do? Is there a cure?”

Opening & Validating the Patient’s Experience:

Hello, I can see from your notes that you’ve been struggling with fatigue for a long time, and all your tests have been normal. That must be incredibly frustrating. I want you to know I take your symptoms very seriously.

Tell me about this fatigue.” Exploring the Fatigue and Associated Symptoms:

What does the fatigue feel like? Is it just tiredness, or is it more of an exhaustion? You mentioned you feel wiped out after activity. Can you give me an example? What happens if you try to go for a walk?

How is your sleep? Do you wake up feeling refreshed?

Apart from the fatigue, are you experiencing any other symptoms, like muscle or joint pain, headaches, or problems with concentration?

Impact on Life (Function): How has this been affecting your daily life? Your work, your hobbies, your relationships?

How has this affected your mood?

ICE (Ideas, Concerns, Expectations): “What have your own thoughts been about what could be causing all this?

What is your biggest worry about your health right now?

Given that the previous tests were normal, what were you hoping we could do for you today?

Explain the situation, the likely diagnosis or DD:

Mark, thank you for coming back in. I can see how much this is affecting you, and I want to assure you that we take your symptoms very seriously. Because your profound fatigue has lasted for more than six months, is not relieved by rest, and we have ruled out other medical causes with the normal blood tests, it is very likely that you have a condition called Chronic Fatigue Syndrome, which is also known as Myalgic Encephalomyelitis or ME.

Addressing and answering the patient’s ICE:

You asked if this is a real illness, and I want to be very clear: yes, it absolutely is. It is a recognised, complex, and disabling neurological condition. It is not ‘in your head’, and you are not a fraud. The impact it’s having on your work and your marriage is very real, and my goal is to help you manage the condition and its consequences.”

Next Steps:

You asked if there is a cure. Unfortunately, there is no single cure for CFS/ME, but there are effective ways to manage the symptoms. The key is learning to manage your energy levels. This is a concept called ‘pacing’. It means learning to listen to your body and not pushing through the fatigue, as this can make you worse. It’s about finding your energy ‘baseline’ and staying within it. We can refer you to a specialist CFS/ME service, where occupational therapists can help you with this.”

Lifestyle Modifications/self-help measures:

We also need to look at your lifestyle. While it’s tempting to use alcohol to cope, it can disrupt your sleep and make the fatigue worse. A balanced diet is also important. We don’t recommend strenuous exercise, but gentle activities like stretching or yoga, within your energy limits, can be helpful. We can also refer you for Cognitive Behavioural Therapy (CBT), which can help you develop coping strategies for living with a chronic illness.”

It sounds like the impact on your relationship is a major source of stress. It might be helpful to have a session with your wife to explain the diagnosis to her, so she can understand that this is a real illness and not a reflection of your feelings for her. The specialist service can often provide support for families as well.

Addressing ideas, concerns, and expectations: Validate his experience and provide a clear diagnosis. Reassure him that it is a recognised medical condition. Manage his expectation of a simple cure.

The management is holistic and multi-disciplinary. 1. Refer to a specialist CFS/ME service. 2. Explain the principles of energy management (pacing). 3. Offer referral for CBT. 4. Provide lifestyle advice (diet, alcohol). 5. Offer to speak with his wife.

What is scenario testing? This case tests the candidate’s ability to diagnose a complex, often misunderstood condition. It requires empathy and validation. The key is to move away from a purely medical model and towards a holistic, supportive management plan that empowers the patient to manage their own condition. It assesses knowledge of the principles of CFS/ME management, particularly ‘pacing’.