You are an FY2 in GP
Personal Details:
Name: Aisha Khan
Age: 25
Medical Record:
Past medical history: None.
Regular medication: None.
Allergies: None known.
Notes:
Aisha attended the surgery two weeks ago, complaining of irregular periods, acne, and weight gain. Your colleague arranged for blood tests and US scan. She is back today for the results.
Blood tests:
Testosterone 5.2 nmol/L (raised)
FSH: 18 iu/L
Follicular phase 3.5 – 12.5 iu/L
Mid-cycle peak 4.7 – 22.0 iu/L
Menopausal 25.0 – 135.0 iu/L
LH: 41 iu/L
Follicular phase 2.4 – 12.6 iu/L
Mid-cycle peak 14 – 96 iu/L
Menopausal 8 – 59 iu/L
FBC, TFT, liver function test, kidney function test: normal
Ultrasound:
Bilateral ovarian multiple small cysts, more than 15 cysts on each ovary with sizes varying from 5mm -20mm.
Normal uterus, and bilateral tubes, no obvious adhesions, blockage or growth.
Task:
1. Explain the test results to the patient and discuss the diagnosis of Polycystic Ovary Syndrome (PCOS).
2. Address her concerns and discuss management options.
Opening Sentence: “Hi, Doctor, you called me to come in and discuss my blood test results.”
Open History (to give freely): “I’m a bit nervous about what they might show. I’m just so fed up with my skin, and my periods are all over the place. My last one was two months ago.”
Cues to give: “I just feel really unfeminine with the hair on my face.”
ICE (Ideas, Concerns, Expectations):
Ideas: “I’m not sure what’s wrong. Maybe it’s my hormones?”
Concerns: “Is it treatable? Will this affect my chances of having children in the future? And I really don’t want to go on the pill.”
Expectation: “I want to know what’s wrong with me and what can be done about it.”
How to Act: You are anxious and have low self-esteem. You are particularly sensitive about the facial hair (hirsutism) and acne.
More History (only if asked): You have been gaining weight for the last year despite not changing your diet much. You’ve noticed darker, thicker hairs growing on your upper lip and chin. Your acne is mostly on your jawline. You are not currently in a relationship or sexually active, but the thought of not being able to have kids one day is very scary.
Social History: You work as a graphic designer. You are feeling quite down about your appearance and have been avoiding social situations.
Questions to ask:
“So what does PCOS actually mean?”
“You said it’s not curable? So I’m stuck with this forever?”
“What can I do if I don’t want to take the pill?”
Opening & Establishing Rapport:
Hi Chloe, thanks for coming in. We’ve got the results of your blood tests and ultrasound scan, which we did to investigate your symptoms.
Before we look at the results, can we just quickly recap the symptoms you’ve been experiencing? You mentioned concerns about excess hair growth, acne, and your periods being irregular. Is that right? And we also talked about finding it difficult to manage your weight?
ICE (Ideas, Concerns, Expectations):
When we arranged these tests, what were your thoughts on what might be causing your symptoms?” “What was your biggest worry?
What were you hoping the tests would show?
Assessing Impact on Life: How have these symptoms been affecting you day-to-day?
How has it affected your mood and your self-confidence?
Future Plans (Fertility): Looking to the future, is having children something you might want one day? It’s okay if you haven’t thought about it, but it’s one of the things we need to consider with this diagnosis.
Explain the situation, the likely diagnosis:
Thanks for coming in, Aisha. We have your blood results back. They show that you have a slight imbalance in your hormone levels – specifically, some of the hormones related to your menstrual cycle and a male hormone called testosterone are a bit higher than usual. When we see this pattern, along with the irregular periods and the skin and hair changes you’ve described, in addition to your ultrasound scan it leads to a diagnosis called Polycystic Ovary Syndrome, or PCOS.”
Addressing and answering the patient’s ICE:
You’re asking if it’s treatable, and that’s a great question. PCOS is a long-term condition, so we don’t have a ‘cure’, but it is absolutely treatable. We have many ways to manage the symptoms very effectively. You also mentioned being worried about having children in the future. It’s true that PCOS can make it more difficult for some women to get pregnant, but many women with PCOS conceive naturally, and for those who don’t, we have very effective fertility treatments. It’s something we can address properly when you’re thinking about starting a family.
Next Steps:
You’ve said you don’t want to take the contraceptive pill, and that’s perfectly fine; we have other options. The most effective single treatment for PCOS is lifestyle-based. Losing even a small amount of weight can significantly improve all the symptoms, from helping to regulate your periods to improving the acne and hair growth. We can refer you to a dietitian for support with this.
Lifestyle Modifications/self-help measures:
Focusing on a balanced diet and regular exercise is key. A low-glycaemic index diet, which avoids sugary foods and focuses on whole grains and vegetables, can be particularly helpful. For the acne and unwanted hair, there are specific creams (Epiduo OD for three months, or Duac OD for three months) and other treatments (oral antibiotic lymecycline 420mg OD for 3-4 months) we can try.
Because your periods are very infrequent, the lining of the womb can get a bit thick, which we like to protect against. Since you don’t want to take the pill, we can give you a short course of a different hormone tablet (POP, i.e. Desogesterol), maybe three or four times a year, to induce a period and keep the womb lining healthy. We should also arrange a follow-up appointment in about three months to see how you’re getting on with the lifestyle changes and to discuss other options if needed.
Explain the diagnosis clearly. Directly address her concerns about treatability, fertility, and her aversion to the COCP.
Offer a clear, non-COCP management plan focusing on lifestyle. Explain the need for progestogen-induced bleeds for endometrial protection. Offer referral to a dietitian and a follow-up appointment.
What is scenario testing? This case tests the candidate’s ability to explain a complex and life-changing diagnosis. It requires sensitivity, empathy, and shared decision-making, especially when the patient has a strong preference against a first-line treatment (COCP). The candidate must demonstrate a patient-centred approach, offering alternatives and focusing on lifestyle advice as the cornerstone of management.