You are an FY2 in a GP surgery

Personal Details:

Name: Ben Carter

Age: 30

Medical Record:

Past medical history: None.

Regular medication: None.

Allergies: None known.

Notes:

Telephone consultation.
The father of Ben who is 30-year-old man is very concerned about his son’s behaviour, which has become abnormal since he lost his job a few weeks ago. Ben is with his father, but does not believe he has a problem.

Task:

Talk to the patient (Ben). Take history, assess risk and decide management plan.

Opening Sentence: “I don’t know why my dad called you. There’s nothing wrong with me.”

Open History (to give freely): “My dad’s just overreacting. I’m fine. He’s the one who needs to calm down.”

Cues to give: “You have to be careful who you talk to. People are listening.”

ICE (Ideas, Concerns, Expectations):

Ideas: “I don’t have a problem. I’m just more aware of what’s going on around me than other people are.”

Concerns: “I’m concerned that people are following me and spying on me. I don’t need any medical treatment.”

Expectation: “I expect you to tell my dad that I’m fine so he’ll leave me alone.”

How to Act: You are guarded, suspicious, and irritable. You believe your thoughts are completely real and rational. You lack insight into your illness.

More History (only if asked): You believe a car has been following you for several days. There’s a man inside, but you can’t see his face. You are convinced he has a camera and is recording you. You don’t know why, but you feel you are being spied on. You have become very talkative, and your thoughts seem to race. You have not been sleeping well. You deny any use of recreational drugs or alcohol. You have no thoughts of harming yourself or others.

Social History: You lost your job as a warehouse worker three weeks ago. You live with your parents.

Questions to ask:

“Why would I need to see a doctor? I’m not sick.”

“Are you working with them? The people who are following me?”

Opening: Hello, I understand your father booked this appointment as he was worried about you.

History of Presenting Complaint: Do you agree with your father that you haven’t been feeling well recently? Tell me how you are feeling in yourself?

Auditor, visual hallucination and thought disorder: Are you hearing voices or seeing things that others can’t see or hear? Is this stressing you? Do you think others can read your thoughts or control what you do?

How is your mood?

Risk Assessment (Crucial): Has there been any argument or violence at home because of how you have been recently? Have you had any thoughts of harming yourself?

Physical symptoms:

How is your sleep?

Are you eating and drinking okay?

Possible triggers:

Do you smoke? Do you drink? Do you use any recreational drugs?

You mentioned cannabis. How much has he been using?

Has there been any major stress in your life recently?

ICE (Ideas, Concerns, Expectations): “What do you think is happening?

Was there anything you were worried about?

What were you hoping I would be able to do?

Explain the situation, the likely diagnosis:

Ben, thank you for talking to me. I know you don’t feel you have a problem, but it sounds like you’ve been under a huge amount of stress recently, and some of the experiences you’re having, like the feeling of being followed and watched, sound very frightening. Sometimes, when the mind is under extreme stress, it can start to play tricks on us. What you might be experiencing is something called psychosis, which is a medical condition where a person’s thoughts and perceptions are altered.

Addressing and answering the patient’s ICE:

I hear that you don’t believe you need any medical help. I’m not here to force any treatment on you. My main concern is your well-being. These experiences sound very distressing, and I want to help you feel safe again. The best way to do that is to get you assessed urgently by a specialist.”

Next Steps:

I believe you need to be seen by a specialist mental health team as soon as possible.

There are two options:

One option is to get seen in the hospital. Your father can give you a lift, or I can call an ambulance to pick you up.

The other option is to get you seen at home. I can call the Early Intervention in Psychosis team to come and see you at home today.

They are experts in helping people who are having these kinds of experiences for the first time. They can talk to you in more detail and help us understand what’s going on. This is not about forcing you into a hospital, but about getting you the right support.

Reassure

It’s really important that you feel safe. For now, stay with your father. He is trying to help you. Try to get some rest, although I know that is difficult. The specialist team will be able to provide more specific advice.

Last step if no other options

Ben, I need to be open with you. If you continue to refuse any help, and I am concerned that your health is at significant risk, I may have to consider involving services that can assess you against your will under the Mental Health Act. This is a last resort, and I would much rather we work together. The first step is to agree to see the specialist team at home. How does that sound?

Addressing ideas, concerns, and expectations: Do not get into an argument about the reality of his beliefs. Validate the distress they are causing him. Reframe the need for assessment as “getting help to feel safe” rather than “treating an illness”.

The key action is an urgent referral to the Early Intervention in Psychosis team for a same-day assessment. If the patient refuses and the risk is deemed high, the candidate should mention involving a senior and considering a Mental Health Act assessment.

What is scenario testing? This case tests the ability to engage with a patient who is actively psychotic and lacks insight. It requires a careful balance of building rapport while not colluding with delusions. The core tasks are to perform a risk assessment, recognise the need for urgent specialist intervention, and be able to explain the potential need for compulsory treatment calmly and ethically.