MRCGP: CSA practice case - Low mood in a menopausal patient

For use individually or in a study group with someone playing the doctor, patient and assessor. Includes, a marking guide and a debrief.

The clinical skills assessment (CSA) tests the candidate's ability to gather and assess medical information, make structured, evidence-based and flexible decisions and communicate with patients in a way that moves the consultation forward in an ethical and responsible manner.

The candidate passes if he or she is able to ask the patient the right questions, at the right time, in the right way, perform the right examination correctly and communicate effectively, all within 10 minutes.

Mock cases with your trainer or fellow registrars are a valuable source of feedback to see how your skills are improving along the way. In this series of mock CSA cases, patient and doctor roles are provided along with examiner feedback to see how you score across the three marking domains of the CSA.

Do not read the marking guide and the debrief until after you have conducted the test. The marking guide and debrief also provide useful pointers towards the knowledge base needed for passing a CSA consultation such as this.

How to use this article

This article is designed to help GP trainees prepare for the CSA. It is written for use in a study group, ideally consisting of three trainees.

While the marking grid in this article models an ordered, step-wise approach to data gathering, management and communication, the group debrief, using the prompts at the end of the article, is essential to review the actual performance and reflect on what a candidate needs to know.

The feedback as a whole informs the doctor about his current knowledge and communication skills and advises him on how he can improve his performance for success in the CSA.

The 'patient'

The trainee playing the patient should read the 'brief to patient' section to enable her to understand the expectations of the patient so she can then answer the doctor's questions.

If an examination is expected, the patient is briefed about the findings and may have to make up a card containing the relevant information prior to starting the consultation. If the patient brief does not contain this information, for example a BP reading, and the doctor wishes to examine the patient, the patient should allow the examination to occur.

Performing irrelevant or unjustified examinations eats into the consultation time. Intimate examinations are not permitted.

The 'doctor'

The doctor should only read the 'patient medical record' section at the start of consultation because it contains a summary of the patient's relevant details.

A recent test result, such as a fasting glucose result, may be provided. Sometimes, a copy of the last patient consultation is given.

The background information often provides a clue about the consultation or gives important data relevant to management decisions.

The 'examiner'

Ideally, the third trainee playing the examiner should enter the consulting room with the patient and sit unobtrusively where the 'doctor' cannot see him.

The examiner should mark the case using the marking guide by ticking against the positive or negative indicators. At the end of the consultation, the examiner should also make a global judgment of whether the 'doctor', based on this consultation, is fit for practice.

The 'examiner' times the case, sounding an alarm when the 10 minutes are up.

Patient: Brief to patient

Download the brief to patient to print out.

You are Amanda Shaw, a 51-year-old hospital nurse, divorced and living alone.

  • Amanda has come to see the doctor today as an emergency on the advice of her friend, whom she is staying with for a few days. Her friend is extremely worried about her low mood.
  • Amanda feels 'stressed at work' mainly because the ward manager is piling on a lot of work in preparation for a CQC visit in two weeks. The manager expects Amanda to carry a clinical and administrative workload and undermines her in front of team members. Amanda feels unable to talk to her because she is abrasive and does not listen.
  • If asked specifically, Amanda admits to having a low mood for two months, increasing irritability, crying easily, a loss of confidence, difficulty sleeping, panic and moments when she feels very anxious. Amanda is not suicidal and has not suffered from depression before.
  • If questioned in detail, Amanda admits to stopping HRT three months ago after developing vaginal bleeding. The hysteroscopy was 'horrible' and she does not want to restart HRT. About once a fortnight, Amanda is woken up by hot flushes.
  • Amanda thinks she has 'work stress' and difficulty dealing with it because of the menopausal symptoms.
  • Amanda would like a sick note for three weeks, until after the ward visit, so she can stay with her friend and 'get her head around issues'.
  • Amanda is worried her manager and team will think she is a 'shirker' if she requests annual leave. However, she is also concerned that her lack of concentration will result in errors at work, which will cause trouble.
  • Amanda does not want medication or a referral. She feels the problem lies with her manager.
  • Amanda cries intermittently throughout this consultation.

Doctor: Patient medical record

Download the patient medical record to print out

Name: Amanda Shaw (51 years).

Past medical history: Not known - patient is a temporary resident.

Examiner: Marking guide

Generic indicators for targeted assessment domainsDescriptors - positive and negative

A. Data gathering, technical and assessment skills:

Gathering of data for clinical judgment, choice of examination, investigations and their interpretations.

Demonstrates proficiency in performing physical examinations and using diagnostic and therapeutic instruments.

Positive indicators:

Asks open questions (to explore work issues) followed by closed questions to clarify the extent of depressive symptoms.

Enquires about menopausal symptoms and explores their contribution to today's presentation.

Excludes red flags, such as ongoing postmenopausal bleeding and active suicidal ideation.

Negative indicators:

Questioning is not selective. Should question about bullying at work.

Menopausal low mood should be ruled out.

Too much focus on the biomedical aspects.

Appears disorganised or fails to explain why certain questions are asked

B. Clinical management skills

Recognition and management of common medical conditions in primary care. Demonstrates flexible and structured approach to decision making.

Demonstrates ability to deal with multiple complaints and co-morbidity and to promote a shared approach to managing problems

Positive indicators:

Explained clearly what they feel is the appropriate diagnosis and verbalised their reasoning to the patient.

Management options, including occupational advice, were openly discussed and offered to the patient.

Management, including any prescription, is appropriate to the patient's level of risk.

Negative indicators:

Fails to make an adequate diagnosis, namely 'mild to moderate depression with a low suicide risk'.

Management plans, including prescribing, are not appropriate or in line with current best practice.

Follow-up arrangements are inadequate.

C. Interpersonal skills

Use of recognised communication techniques that enhance understanding of a patient's illness and promote a shared approach to managing problems.

Practises ethically with respect for equality and diversity in line with accepted codes of professional conduct.

Positive indicators:

Displayed good listening skills; identified the patient's dilemma and fears.

Developed a shared management plan, which incorporates the patient's specific concerns about work.

Time off work and follow-up is skilfully negotiated.

Negative indicators:

Interrupts inappropriately; appears judgmental or doctor-centred.

Formulaic questions are employed; the questioning on depressive symptoms sounds like a reading of a questionnaire.

Fails to empathise with how this problem has changed the patient's life and her self-perception.


  • Assess the doctor's verbal and non-verbal response to the patient's request for a sick note. Did the doctor seem genuinely interested and respectful? Was touch used overly and out of context?
  • Was the consultation 'chunky' and lacking in natural flow? Were rote questions and phrases used? Was the patient given time to answer questions? Were questions replicated and ground covered repeatedly? Did the doctor feel confident, once sufficient data was gathered for a diagnosis, to smoothly move onto management?
  • Was there a shared management plan that incorporated the patient's concerns and expectations?
  • The most common reason for failure in the CSA is that the doctor 'does not develop a management plan (including prescribing and referral) that is appropriate and in line with current best practice or make adequate arrangements for follow-up and safety-netting'. Evaluate if the management of this case (mild-moderate depression) was correct, safe and broad enough to eliminate the differential (menopause).

Dr Naidoo is a GP trainer in Oxford. She has written three books on how to pass the CSA. The latest book CSA Practice Cases for the MRCGP Paperback was published in Jan 2016.

Resources for revision

  • McAvoy BR, Workplace bullying. BMJ 2003; 326: 776
  • Advice on bullying from the Advisory, Conciliation and Arbitration Service (ACAS)

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