CCE-CE-208

CASE INFORMATION

Case ID: PCOS-003
Case Name: Sarah Thompson
Age: 26
Gender: Female
Indigenous Status: Non-Indigenous
Year: 2025
ICPC-2 Codes: X99 (Polycystic Ovary Syndrome – PCOS)

COMPETENCY OUTCOMES

Competency DomainCompetency Element
1. Communication and Consultation Skills1.1 Establishes rapport and engages the patient effectively
1.3 Uses a patient-centred approach when discussing reproductive health
1.5 Explains medical information in a way that is understandable and reassuring
2. Clinical Information Gathering and Interpretation2.1 Takes a comprehensive history, identifying key clinical features of PCOS
2.2 Orders and interprets appropriate investigations for PCOS
3. Diagnosis, Decision-Making and Reasoning3.1 Applies the Rotterdam Criteria to confirm a PCOS diagnosis
3.4 Considers differential diagnoses and evaluates alternative explanations
4. Clinical Management and Therapeutic Reasoning4.2 Provides an individualised management plan tailored to the patient’s concerns (e.g., fertility, metabolic health, cosmetic concerns)
4.4 Considers a multidisciplinary approach involving dietitians, endocrinologists, and gynaecologists
5. Preventive and Population Health5.2 Educates the patient on long-term risks of PCOS (e.g., diabetes, cardiovascular disease, infertility)
6. Professionalism6.2 Provides empathetic, non-judgmental care, recognising the emotional burden of PCOS
7. General Practice Systems and Regulatory Requirements7.2 Uses appropriate referral pathways (e.g., fertility specialists, endocrinologists, dietitians)
9. Managing Uncertainty9.1 Addresses patient concerns regarding diagnosis and prognosis
10. Identifying and Managing the Patient with Significant Illness10.1 Recognises and manages complications of PCOS, including insulin resistance and infertility

CASE FEATURES

  • Primary complaint: Irregular periods and difficulty losing weight
  • Classic PCOS symptoms: Menstrual irregularities, weight gain, acne, and excessive hair growth
  • Patient concerns: Fertility, metabolic health, and cosmetic impact of PCOS
  • Importance of early intervention: Prevention of diabetes and cardiovascular disease
  • Multidisciplinary care: Involvement of endocrinologists, dietitians, and mental health support

INSTRUCTIONS

You have 15 minutes to complete the tasks for this case.

You should treat this consultation as if it is face-to-face.

You are not required to perform an examination.

A patient record summary is provided for your information.

Perform the following tasks:

  1. Take an appropriate history.
  2. Outline the differential diagnosis and key investigations required.
  3. Address the patient’s concerns.
  4. Develop a safe and patient-centred management plan.

SCENARIO

Sarah Thompson, a 26-year-old woman, presents to your general practice with concerns about irregular periods and difficulty losing weight. She reports having only four to five periods per year since she was a teenager and often goes three months or more without a period.

She has been trying to lose weight for over a year but finds it extremely difficult, despite following a low-calorie diet and exercising regularly. She also mentions new acne breakouts on her jawline and upper back and excess hair growth on her chin and upper lip, which she finds distressing.

PATIENT RECORD SUMMARY

Patient Details

Name: Sarah Thompson
Age: 26
Gender: Female
Gender Assigned at Birth: Female
Indigenous Status: Non-Indigenous

Allergies and Adverse Reactions

  • Nil known

Medications

  • None

Past History

  • No previous gynaecological conditions or surgeries

Social History

  • Occupation: High school teacher

Family History

  • Mother diagnosed with Type 2 Diabetes at age 50
  • Aunt had fertility issues but no known diagnosis

Smoking

  • Non-smoker

Alcohol

  • Drinks occasionally (1-2 times per month, socially)

Vaccination and Preventative Activities

  • Up to date with cervical screening (last test 1 year ago, normal result)

ROLE PLAYER INSTRUCTIONS

Just like a consultation with a doctor, the candidate will ask you a series of questions.
The OPENING LINE is always to be said exactly as written. This is the only part of the script
which will be the same for all candidates. Where the candidate goes after the opening line is
up to them.

The remainder of the information is to be given based on the questions asked by the
candidate.

The information in the following script are core pieces of information. The core pieces of
information will not necessarily follow the order in the script but should be given when cued
by the candidate’s question.

GENERAL INFORMATION can be given relatively freely. After the opening line, most
candidates will ask an open question like “Can you tell me more about that?” You can provide
the GENERAL INFORMATION in response to that sort of question.

SPECIFIC INFORMATION should only be given when the candidate asks a relevant question.
Candidates don’t need to ask for all the information in the SPECIFIC INFORMATION section,
but all the relevant information is given there should they want to.

Each line or dot point in the SPECIFIC INFORMATION section is an appropriate chunk of
information which can be provided to the candidate when asked a relevant question.

Do not give extra information than asked.

Do not provide details which are not given in the information chunks (i.e.: do not elaborate
or ad-lib).

If the candidate asks a question that is not given in the script, the best way to respond is with
a generic response indicating there is no problem. For example:

Candidate: “How many hours do you sleep?”
Response: “I’m sleeping fine.” / “I don’t have any concerns about my sleep.”

The case may have specific QUESTIONS to ask the candidate. You can start asking the
QUESTIONS if the candidate asks about your ideas or concerns or questions.

Ask the other questions in a conversational way. You do not need to ask all the questions. The
aim should be to ask most of the questions but without interrupting the candidate.

The Patient Record Summary is also included. This is not part of the script but is included for
your general information.

If you need help in understanding any of the medical information in the script, ask the College
examiner who will be with you, and they can help to explain the terms or the conditions.

ROLE-PLAYER SCRIPT

Opening Line

“Doctor, my periods are all over the place, and no matter what I do, I can’t seem to lose weight. I feel like something’s wrong with me.”

General Information

(Freely Given if Asked Open-Ended Questions)

  • Menstrual Irregularities: Periods have been irregular since menarche. On average, she has about 4-5 periods per year, sometimes going 3-4 months without one. When she does get a period, it is usually heavy and lasts 6-7 days.
  • Weight Concerns: Over the past two years, she has been trying to lose weight through exercise and diet but finds it extremely difficult. She has been following a low-calorie diet and exercising 3-4 times per week, but the weight has barely changed.
  • Acne and Hair Growth: Over the past year, she has developed persistent acne on her jawline and upper back. She has also noticed increased hair growth on her chin, upper lip, and lower abdomen, which she plucks or waxes regularly.

Specific Information

(Only Given if Asked Direct Questions)

Background Information

  • Family History: Her mother was diagnosed with Type 2 Diabetes at age 50, and her aunt had fertility issues, although she isn’t sure if it was PCOS.
  • Energy Levels: She often feels tired, sluggish, and low on energy, particularly after meals. She has noticed cravings for sugary foods, but she doesn’t experience dizziness or fainting.
  • Reproductive Health Concerns: She is in a long-term relationship and is starting to think about having children in the next few years. She has read online that PCOS can make it hard to get pregnant, and this worries her a lot.

Menstrual and Reproductive History

  • No history of pregnancy or miscarriage.
  • No history of contraception use, as she hasn’t needed it.
  • No pelvic pain, abnormal bleeding, or unusual discharge.
  • Has never been investigated for infertility but is worried about the future.

Metabolic Health and Family History

  • Has never been diagnosed with diabetes or high blood pressure, but she is worried about her risk because of her mother’s history.
  • Feels fatigued most days, even with enough sleep.
  • No history of thyroid disease.
  • Occasionally feels bloated after eating carbs but hasn’t connected it to any specific foods.

Acne and Hair Growth

  • Acne is worse before her period but never fully clears.
  • Uses over-the-counter acne treatments, but they don’t seem to help much.
  • Hair growth has worsened in the last year, requiring more frequent plucking/waxing.

Emotional Cues

  • Frustrated and discouraged about her inability to lose weight despite efforts.
  • Worried and anxious about future fertility issues.
  • Embarrassed about excess hair and acne, saying, “I feel so self-conscious all the time.”
  • Relieved when the doctor listens carefully and validates her concerns.

Patient Concerns and Expectations

  • Wants to know if she has PCOS and how it is diagnosed.
  • Concerned that she might not be able to conceive in the future.
  • Wants to understand why losing weight is so hard and if there’s something wrong with her metabolism.
  • Curious about treatment options, especially for irregular periods, acne, and hair growth.
  • Wants to know if she is at risk for diabetes and whether she can prevent it.

Questions the Patient Might Ask

  1. “Do I have PCOS? How do you diagnose it?”
  2. “Does this mean I won’t be able to get pregnant?”
  3. “Why is it so hard for me to lose weight?”
  4. “Is there a cure for PCOS?”
  5. “What treatments are available for the acne and hair growth?”
  6. “Am I at risk for diabetes?”
  7. “Do I need to see a specialist?”
  8. “Will I need to take medication for the rest of my life?”

Escalating the Scenario Based on the Candidate’s Approach

  • If the candidate dismisses her concerns or fails to show empathy, the patient will become more withdrawn and hesitant to discuss symptoms further.
  • If the candidate only focuses on weight loss without discussing other symptoms, the patient will feel frustrated and unheard.
  • If the candidate offers a thorough explanation and reassures her, the patient will open up more and engage in discussion.
  • If the candidate provides a structured management plan, the patient will feel relieved and motivated to make changes.
  • If the candidate doesn’t discuss long-term risks (e.g., diabetes, infertility), the patient will ask directly if she is at risk and whether she needs to worry about her health in the future.

Final Patient Reactions Depending on the Consultation Quality

  • If the candidate provides a compassionate, clear, and structured response, the patient will say:
    “Thank you, Doctor. I feel so much better knowing what’s going on and what I can do about it.”
  • If the candidate is vague or dismissive, the patient will hesitate and say:
    “I guess I’ll just wait and see what happens, but I still feel confused.”
  • If the candidate focuses too much on weight loss and not the broader symptoms, the patient will respond:
    “So you’re saying I just need to lose weight? That’s what I’ve been trying to do for years, but it’s not working.”
  • If the candidate reassures her but doesn’t provide a clear management plan, the patient will ask:
    “So what do I actually do next? Should I take medication, or do I need more tests?”

THE COMPETENT CANDIDATE

The competent candidate should be able to:

Task 1: Take an appropriate history, focusing on menstrual patterns, metabolic health, and other key PCOS symptoms.

The competent candidate should:

  • Establish rapport and create a safe, non-judgmental environment for discussing sensitive issues.
  • Use open-ended questions to explore the nature and duration of menstrual irregularities.
  • Clarify metabolic symptoms, including weight changes, insulin resistance symptoms, and fatigue after meals.
  • Assess clinical features of hyperandrogenism, such as hirsutism, acne, and scalp hair thinning.
  • Ask about lifestyle factors affecting weight management, such as exercise, diet, and sleep patterns.
  • Screen for psychological impact, including body image concerns, anxiety, and depression.
  • Explore family history of PCOS, diabetes, or infertility.
  • Ask about contraceptive history and fertility concerns, given the patient’s desire for future pregnancy.

Task 2: Outline the differential diagnosis and your rationale for considering PCOS.

The competent candidate should:

  • Apply the Rotterdam Criteria, which require at least two of the following three features:
    • Oligo- or anovulation (irregular or infrequent periods).
    • Clinical or biochemical hyperandrogenism (hirsutism, acne, elevated testosterone).
    • Polycystic ovaries on ultrasound (≥12 follicles in one ovary or ovarian volume >10 mL).
  • Consider alternative diagnoses, including:
    • Hypothyroidism (fatigue, weight gain, menstrual irregularities).
    • Hyperprolactinaemia (galactorrhoea, menstrual disturbances).
    • Cushing’s syndrome (central obesity, striae, muscle weakness).
    • Non-classical congenital adrenal hyperplasia (early onset hirsutism, menstrual irregularities).
  • Explain why PCOS is the most likely given the combination of menstrual irregularities, weight concerns, hirsutism, and acne.
  • Outline appropriate initial investigations, including:
    • Hormonal tests (FSH, LH, testosterone, SHBG, prolactin, TSH).
    • Fasting glucose and insulin levels (to assess for insulin resistance).
    • Pelvic ultrasound (if diagnosis remains unclear).

Task 3: Explain your management plan to the patient, addressing lifestyle modifications, pharmacological treatment, and fertility considerations.

The competent candidate should:

  • Reassure the patient that PCOS is a manageable condition and does not necessarily mean she will have infertility.
  • Lifestyle modifications:
    • Weight management: Even 5-10% weight loss can improve symptoms and fertility.
    • Exercise: Regular aerobic and resistance training helps with insulin resistance and weight loss.
    • Dietary advice: Low-GI diet, reducing processed sugars, and increasing lean proteins and fibre.
  • Pharmacological options (depending on patient’s goals):
    • COCP to regulate periods, manage acne, and reduce hirsutism.
    • Metformin for insulin resistance and weight management.
    • Anti-androgens (e.g., spironolactone) for excessive hair growth and acne.
  • Fertility considerations: If pregnancy is desired in the future, discuss:
    • Ovulation induction medications (letrozole, clomiphene).
    • Referral to a fertility specialist if natural conception is difficult.

Task 4: Discuss referral options and follow-up to ensure ongoing monitoring and support.

The competent candidate should:

  • Refer appropriately based on patient needs:
    • Endocrinologist for complex metabolic concerns or insulin resistance.
    • Dietitian for sustainable weight loss strategies.
    • Gynaecologist if fertility treatments are needed.
    • Psychologist if significant anxiety, depression, or body image concerns are present.
  • Long-term monitoring:
    • Annual metabolic screening (BP, glucose, lipids).
    • Review symptoms and medication effects regularly.
    • Provide contraception advice if pregnancy is not desired immediately.
  • Safety-netting advice:
    • Encourage patient to return if weight gain worsens, mental health declines, or periods stop entirely.

SUMMARY OF A COMPETENT ANSWER

  • Uses a patient-centred approach with empathy and clear communication.
  • Takes a thorough history, covering menstrual irregularities, metabolic health, and psychological impact.
  • Applies the Rotterdam Criteria correctly and rules out alternative diagnoses.
  • Develops an individualised management plan, including lifestyle changes, pharmacological options, and fertility planning.
  • Provides appropriate referrals and ensures long-term follow-up and preventive care.

PITFALLS

  • Failing to establish rapport, making the patient feel dismissed or judged.
  • Focusing only on weight loss without addressing hormonal, reproductive, and emotional concerns.
  • Not considering differential diagnoses, such as thyroid dysfunction or hyperprolactinaemia.
  • Providing a one-size-fits-all approach, rather than tailoring management to the patient’s specific goals (e.g., fertility, cosmetic concerns, metabolic health).
  • Neglecting the psychological impact of PCOS, such as body image distress and anxiety.
  • Failing to discuss long-term complications, including diabetes, cardiovascular risks, and infertility.

REFERENCES

MARKING

Each competency area is assessed on the following scale:

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Communicates effectively and ensures patient comfort in discussing sensitive concerns.
1.3 Uses patient-centred communication when discussing reproductive health.
1.5 Explains medical concepts clearly, including diagnosis and management options.

2. Clinical Information Gathering and Interpretation

2.1 Takes a comprehensive history, identifying key clinical features of PCOS.
2.2 Orders and interprets appropriate investigations for PCOS diagnosis.

3. Diagnosis, Decision-Making and Reasoning

3.1 Applies the Rotterdam Criteria correctly to confirm PCOS.
3.4 Considers alternative diagnoses and rules them out systematically.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops an individualised management plan based on patient goals.
4.4 Incorporates a multidisciplinary approach, involving dietitians, endocrinologists, and gynaecologists.

5. Preventive and Population Health

5.2 Educates the patient on long-term risks, including diabetes and cardiovascular disease.

6. Professionalism

6.2 Provides empathetic and non-judgmental care, recognising the emotional burden of PCOS.

7. General Practice Systems and Regulatory Requirements

7.2 Uses appropriate referral pathways for specialist input when needed.

9. Managing Uncertainty

9.1 Addresses patient concerns about the diagnosis, treatment options, and prognosis.

Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD