MRCGP: CSA practice case - Pruritus in pregnancy

Play out the doctor, patient and assessor roles in a study group or plan on your own how you would approach this consultation. Dr Prashini Naidoo provides this CSA practice case.

Although no amount of reading can replace the clinical experience and time spent with patients needed to perfect your consultation skills, mock cases with your tutor or fellow registrars can be a valuable source of feedback to see how your skills are improving along the way.

Do not read the marking guide and the debrief until you have undertaken the practice case.

How to use this article

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

The 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.

While the marking grid provided with this article models an ordered, step-wise approach to data gathering, management and communication, using the debrief prompts at the end of the article is also essential to review the actual performance.

The feedback as a whole informs the doctor about his or her current knowledge and communication skills and advises how to improve on this performance for success in the CSA.

The 'patient'

The trainee playing the patient should read the 'brief to the 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 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 examiner should enter the consulting room with the patient and sit unobtrusively where the 'doctor' cannot see him or her. The examiner should mark the case using the marking guide by ticking against the positive or negative indicators as the consultation unfolds.

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 independent 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 Becky Engels, a 28-year-old married woman, currently 32 weeks pregnant with her first baby. It has been an uneventful pregnancy so far.
  • You have come to see the doctor today because you have had a severe 'all over' itch for the last three days. E45 did not help. If questioned in detail, the itch is worse over your hands and feet, but there is nothing to see.
  • You have not been in contact with anything new and have not come into contact with chickenpox. You do not feel unwell.
  • You think the itchiness may be a reaction to the powdered gloves you use at work. You work for a dental laboratory making dentures. Work switched from powdered to non-powdered gloves four years ago but you think you are having a delayed reaction to latex.
  • You are having a stressful time at work. A pregnant work colleague is being allowed to start her maternity leave at 32 weeks because she has symphysis pubis pain. You have been asked to start leave at 38 weeks.
  • If offered, you are concerned about using steroid creams and antihistamines while pregnant. You would like a week off work because you are tired and the itch is disrupting your sleep.
  • If the doctor offers a blood test or hospital referral, you want to know why. You become concerned that something is wrong and want to know what you should tell your husband. Will you have to start maternity leave soon? What should you tell work?

Doctor: Patient medical record

Download the patient medical record to print out

Name: Rebecca Engels (28 years)

Past medical history: Currently pregnant

Current medication: None

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:

Elicits details of itch, asking if it is worse at night and if it involves palms ans soles.

Also asks about other evidence of cholestasis such as jaundice, pale stools, dark urine. Possible viral hepatitis and eczema are considered.

Checks that mum is feeling well and baby is kicking (obstetric cholestasis [OC] increases the risk of IUD).

Finds out the patient's ideas about possible latex allergy or a sensitivity to powdered gloves and explains why this unlikely.

Elicits relevant work stressors.

Discovers the patient's expectations for topical treatment and time off work.

Negative indicators:

Fails to question sufficiently to explore the possibility of OC, or assumes this is dry skin or eczema.

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:

Explains the possibility of OC using jargon-free language, without alarming the patient.

Addresses concerns about antihistamines and steroid creams.

If prescribed, the medication is appropriate and evidence-based, with clear instructions on how to use it and its safety in pregnancy.

Makes balanced plans: requests the appropriate blood tests (bile salts, LFTs, viral screen), and onward referral for consultant-led care and delivery in a hospital at 37-38 weeks if LFTs and bile acids are abnormal.

Negative indicators:

Fails to explain OC.

Fails to discuss the rationale for blood tests/referral or alarms the patient inappropriately.

Prescribes inappropriately.

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:

Displays empathy to her work situation.

Empowers her so she can discuss the issue with her husband and make decisions about her work.

Involves the patient in decisions about blood tests and hospital referral.

Negative indicators:

The consultation is doctor-centred: lack of empathy; insufficient information sharing; lack of patient involvement about decisions.

Is under- or overly challenging when negotiating time off work.

Makes judgmental or non-professional statements about her boss, colleagues, or midwife.


  • Evaluate whether the doctor gathered sufficient information, from the history and examination, to arrive at a reasonable hypothesis regarding the cause of this patient's itchiness. Were red flags, such as anorexia, jaundice, a bruising tendency and a reduction in foetal movements excluded?
  • Did the doctor elicit and address Becky's idea about latex allergy causing her itch; her concerns about the medication or illness harming the baby; and her expectation of a sick note?
  • Did the doctor explain the diagnosis and management plan in jargon-free language? Did he or she refer for specialist advice, discuss that certain blood tests were needed and that birth plans may need revision?
  • Did the doctor provide the information in chunks and check the patient's understanding at each step?
  • Evaluate whether the doctor handled the request for a sick note fairly and dealt with the maternity leave issue in a way that encouraged the patient's autonomy.
  • Did the doctor involve the patient in decisions and offer the patient options? In some cases, it may be difficult to offer choice, as in this case, where a referral to obstetrics is warranted. The doctor could say: 'I think that the safest thing to do is organise blood tests and monitoring of the baby in hospital. How do you feel about that?' This allows the patient to voice any reasons why she cannot go to hospital - such as 'there is nobody at home to look after my stepson when he returns from school'. However, involving the patient in the decision-making provides the opportunity to uncover and deal with potential problems.

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 was published in January 2016.

Further reading
Royal College of Obstetricians & Gynaecologists. Obstetric Cholestasis Guideline. London: April 2011.

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