ℹ️ This is the case information for the doctor.

Name

Amal Mohamed

Age

19 years

Address

14 Parklands Close

Social history

Education/employment: First year university student), part-time job at a café

Smoking/Alcohol: Non-smoker, does not drink alcohol

Past history

Recurrent urinary tract infections since early adolescence (1–2/year, last one 4 months ago).
No known allergies.
No known long term conditions

‍

Investigation results

Past urine cultures from GP records have shown E.Coli, no atypical pathogens.
Renal ultrasound from last year (requested due to recurrent UTIs) – normal
No previous imaging or investigations for gynaecological symptoms.

Medication

None

Booking note

Painful periods.

ℹ️ This is the information for the person role playing the patient.

Case overview

Name

Amal Mohamed

Age

19 years

Address

14 Parklands Close

Social history

Education/employment: First year university student), part-time job at a café

Smoking/Alcohol: Non-smoker, does not drink alcohol

Past history

Recurrent urinary tract infections since early adolescence (1–2/year, last one 4 months ago).
No known allergies.
No known long term conditions

‍

Medication

None

Opening statement

I wanted to talk about my periods – they’re always so painful, and I don’t really know what to do about it.

Information freely divulged

The pain is mostly cramping and starts just before her period, lasting for the first 2–3 days.
Pain is in the lower abdomen; sometimes it radiates to her back and tops of her legs.
Pain is bad enough that she has to miss classes sometimes, especially on the first day.

‍

Information given on questioning

Menstrual history

Over-the-counter painkillers (ibuprofen/paracetamol) give limited relief.
Periods last about 6 days, flow is moderate but never extremely heavy.
Has also suffered from recurrent water infections since her early teens.
No history of vaginal discharge or unusual bleeding.
Says she has never had a sexual relationship.

FGM history

If directly asked (or if the doctor establishes safety, empathy, and trust): she reveals that she underwent a traditional ‘cutting’ ceremony when she was 6, while visiting relatives in Sudan. This was arranged by family friends. She uses vague language at first, calling it “what they do to girls there,” and only clarifies it is FGM if sensitively prompted. She has never spoken about this to anyone outside her family.
If specifically asked about symptoms: sometimes finds passing urine a little uncomfortable during her period, but not otherwise. She sometimes feels a ‘tight’ or ‘blocked’ sensation in the vagina, especially during her period.
If directly asked about her sister or family: Her mother and 16-year-old sister have also ‘had it done’ back in Sudan.
If sensitively asked about psychological effects: Admits she feels shame and confusion about what happened, avoids talking about it, and has some anxiety and low mood around her period or during intimacy discussions with her boyfriend.

Sexual history

If asked about sex and relationships: Keen to be close with her boyfriend but absolutely terrified it will be painful or impossible, and afraid he might leave her if he finds out or she can't have sex.
If asked about expectations or desired outcomes: Hopes for some pain relief, wants to know if there’s anything that will help her have less painful periods; quietly hopes for some advice about the future (sex, relationships, fertility) but is initially too embarrassed to ask up front.

ICE

Ideas about her problem: Thinks she must just be unlucky with bad periods; wonders if the recurrent UTIs are related but doesn’t know much about why.
Concerns: Worried she might have something seriously wrong with her, feels isolated and ashamed about her FGM, worried about talking to police or social services if she tells the doctor – “I don’t want any trouble for my family.” Afraid disclosure might bring shame or trouble to her family, or risk her sister being 'taken away' from the parents.
Expectations: Wants to keep everything confidential, does not want police or social services involved, wants decent period pain relief and advice about sex and relationships, and to be listened to without judgement.

Family history

Family history: FGM is common among the older generations in her mother’s community. No known family history of bleeding disorders, endometriosis, or other gynaecological conditions.

‍

Behaviour

At the start: Slightly anxious and embarrassed, struggles to make eye contact for the first few minutes.
Becomes more open if the doctor is warm, non-judgemental, and explains things gently.
If direct, intrusive, or judgemental questioning occurs, she may shut down, offer one-word answers, or appear on the verge of tears.
Shows visible relief if offered reassurance, empathy, and the chance to talk confidentially.
Fearful if the doctor suggests that police or social services might need to be informed, especially if not handled with warmth and a clear explanation of the law.
Deeply values confidentiality and respect for her privacy. If the doctor is clear, compassionate and honest about safeguarding duties (especially in relation to her sister), she may be sad, worried, and a little angry, but will eventually accept it if it is explained that her sister’s safety is the priority and that support will be available for the family.
If offered information about specialist FGM services or emotional support, will appear grateful but may need encouragement to accept help and may initially refuse out of fear/embarrassment.
Becomes more relaxed and trusting if given control over decisions about her own care; wants to be heard and not judged, and to protect her family's dignity.

ℹ️ To mark data gathering & diagnosis select from the descriptors below.

Positive descriptors

Negative descriptors

Data gathering was systematic and targeted ensuring patient safety.

Uses open questions to gently explore Amal’s experience of painful periods, urinary symptoms, and how these impact her day-to-day life.
Progresses to focused, non-judgmental closed questions about symptom nature, severity, duration, and triggers—including clarification of menstrual history, pain characteristics, and prior management.

‍

Data gathering was incomplete, lacking structure and focus.

Fails to establish a rapport to allow Amal to describe her symptoms, skipping between unrelated topics.
Omits key questions related to urinary symptoms or menstrual difficulties, missing the opportunity to clarify the clinical picture and safeguarding risks.

‍

Makes effective use of existing information and considers the wider context.

Recognises and integrates Amal’s past history of recurrent UTIs and connects these with her current menstrual and urogenital complaints.
Considers risk factors for FGM; her Sudanese heritage, family history, social circumstances, medical history,.
Appreciates the influence of culture and migration on her health and beliefs.

‍

Fails to use the information provided or understand the wider context.

Overlooks or disregards Amal’s personal history, current notes, or the relevance of her background.
Fails to explore her FGM risk, family setting, cultural context, or the impact this may have on her health needs and engagement with care.

‍

The presence or absence of relevant red flags was established.

Identifies safeguarding red flags, such as evidence of FGM in a minor (her sister), risk of coercion, or new plans for travel to at-risk countries.

Checks red flag symptoms such as haematuria, persistent pain, systemic symptoms (fever, weight loss), signs of infection, or acute retention.

‍

Fails to assess key information necessary to determine risk.

Omits enquiry about safeguarding red flags i.e. minors in the household at risk.
Fails to check for red flag indicators of pelvic infection.

‍

A working diagnosis was reached using a structured, evidence-based approach.

Asks logically sequenced questions to narrow the differential: distinguishes primary dysmenorrhoea, UTI, and mechanical/gynaecological complications related to FGM.
Demonstrates an understanding that painful periods and UTIs can be sequelae of FGM and that the relationship between symptoms and cultural background informs the diagnosis.

‍

The evidence collected was inadequate to support the conclusions reached.

Jumps to conclusions (e.g., attributing symptoms to “normal periods” or “simple infection”) without adequate clinical reasoning or fails to synthesise information about FGM sequelae.
Does not demonstrate understanding of possible pathologies linked to Amal’s age, symptoms, or sociocultural risk factors.

‍

Information gathered placed the problem in its psychosocial context.

Explores Amal’s emotional response, shame, fear, and anxiety related to her symptoms, sexuality, and past traumatic experience of FGM.
Assesses the impact of her health on personal relationships, academic/work life, and her fears around disclosure and confidentiality.

The social and psychological impact of the problem was not adequately determined.

Ignores the psychological burden or social/sexual repercussions of FGM, neglecting emotional distress, isolation, or fear of judgement.
Does not enquire about the influence of her cultural background, familial beliefs, or impact on intimate relationships.

‍

Revises hypotheses as necessary in light of additional information.

Demonstrates flexibility: adapts the line of questioning when Amal’s body language, reluctance, or partial disclosure hints at FGM or trauma, and follows up accordingly.
Reappraises the working diagnosis when recurrent UTIs, painful periods, and sexual fears emerge, integrating the likelihood of FGM-related complications into the clinical reasoning.

‍

Rigid consulting with new information not adequately considered and integrated into the working diagnosis.

Maintains a rigid approach, failing to respond to new cues, subtle disclosures, or emerging safeguarding information.
Does not revise or expand the differential diagnosis in response to increasing evidence of psychological distress or FGM sequelae.

‍

ℹ️ To mark clinical management & medical complexity select from the descriptors below.

Positive descriptors

Negative descriptors

Offers management options that are safe and appropriate:

Explains the possible causes of painful periods (post FGM scarring), including the physical impact of FGM sensitively, and offers appropriate options for symptom control (e.g., analgesia, referral to a specialist FGM clinic, counselling).
Sensitively discusses the legal duty placed on healthcare professionals to report FGM in minors.

‍

Fails to provide appropriate and/or safe management choices:

Omits consideration or explanation of FGM as a probable cause and fails to address its impact on Amal’s symptoms or sexual concerns.
Neglects to offer or signpost specialist support (such as an FGM clinic) or does not suggest appropriate symptomatic management, leaving the patient at ongoing risk of physical or psychological harm.

Continuity of care is prioritised:

Clearly outlines a follow-up plan ensuring ongoing review for both physical and psychological sequelae of FGM.
Coordinates shared care between general practice and specialist services (such as sexual health, FGM clinic, mental health), encouraging Amal to access regular support as her circumstances evolve.

Ongoing care is uncoordinated:

Fails to establish a follow-up plan or coordinate care, risking breakdown in the monitoring of symptoms, safeguarding, and emotional wellbeing.
Does not arrange any review or check-in, missing the opportunity to reassess risk or address evolving needs (including future sexual health or family planning).

‍

Empowers self-care and independence:

Provides clear information about self-care strategies for dysmenorrhoea and urinary symptoms, and encourages Amal’s involvement in decisions affecting her health.
Signposts relevant resources (e.g., FGM support organisations, sexual health education) and provides tailored advice regarding emotional and physical self-care.

Management fails to foster self-care and patient involvement:

Does not address Amal’s concerns about sex or encourage her to participate in care planning.
Offers no information on resources or support avenues, leaving Amal without means to manage her symptoms or take control of her health.

Arranges appropriate follow up:

Agrees concrete, timely plans for review of Amal —including timeframe for symptom monitoring, mental health check-in, and safeguarding follow-up concerning her sister.
Ensures clear safety netting (advising what red flags Amal should look out for, and how and when to seek urgent help).

Unclear or inadequate follow up:

Leaves Amal without clarity on when or how further help will be provided, or how her ongoing symptoms or emotional needs will be reviewed.
Omits safety netting on what to do if symptoms worsen or if further safeguarding concerns arise.

‍

Manages uncertainty, including that experienced by the patient

Validates Amal’s anxiety about sharing information, and explains both the limits and obligations of confidentiality with transparency.
Acknowledges the uncertainties about future sexual wellbeing and outlines the range of possible outcomes sensitively, offering support and flexible planning.

‍

Struggles with uncertainty, leading to inconsistent decisions:

Offers ambiguous or conflicting advice regarding confidentiality or safeguarding, leading to confusion for Amal.
Avoids or disregards Amal’s concerns about the unknowns or future risks arising from her FGM or the legal context.

Tailors management options responsively according to circumstances, priorities and preferences:

Adapts explanations and options to Amal’s level of knowledge, cultural background, emotional readiness, and stated fears, checking her understanding and involvement at every stage.
Considers Amal’s desire for confidentiality, cultural norms, and preferences in planning support, ensuring she feels respected and included.

‍

Management options fail to adequately consider patient preference and circumstance:

Delivers one-size-fits-all advice or rigid management without sensitivity to cultural, emotional, or individual priorities.
Pushes ahead with processes (such as safeguarding or clinical referrals) without including Amal in reasoning, leading to mistrust and reduced engagement.

‍

ℹ️ To mark relating to others select from the descriptors below.

Positive descriptors

Negative descriptors

Shows ability to communicate in a person-centred way:

Recognises Amal’s visible discomfort and anxiety, using open, non-judgmental body language and allows time to speak without pressure.
Picks up on cues regarding embarrassment when discussing her symptoms, provides reassurance about confidentiality, and validates her distress without rushing to solutions.

‍

Communication is doctor centred and lacks empathy:

Directly questions Amal about FGM or sexual issues in abrupt, clinical terms, not considering her discomfort or cultural sensitivities.
Focuses solely on medical or forensic details, failing to show understanding or compassion for Amal’s emotional experience.

‍

Makes effective use of existing information and considers the wider context.

Recognises and integrates Amal’s past history of recurrent UTIs and connects these with her current menstrual and urogenital complaints.
Considers risk factors for FGM; her Sudanese heritage, family history, social circumstances, medical history,.
Appreciates the influence of culture and migration on her health and beliefs.

‍

Decisions fail to prioritise the patient’s rights and interests:

Shows bias or insensitivity by making assumptions about Amal’s values or beliefs based on heritage.
Dismisses or minimises her right to confidentiality, or shames her for her reluctance to talk.

‍

Shows understanding of medical-legal principles and regulatory standards:

Clearly explains obligations regarding safeguarding and confidentiality, especially the distinction between Amal’s case and her underage sister.
Informs Amal about mandatory reporting for her sister, ensuring that reasons and processes are transparent, and seeks to minimise distress while protecting safety.

‍

Fails to give appropriate regard to key legal aspects of consulting:

Gives unclear, inaccurate or contradictory information about confidentiality and safeguarding duties.
Does not mention or explain the requirement to report the sister’s FGM, risking legal/professional breaches and loss of patient trust.

‍

The patient’s agenda was understood:

Actively elicits Amal’s priorities—such as personal dignity, privacy, fears about sex, and emotional wellbeing—and demonstrates understanding by responding to her main worries.
Checks back with Amal to confirm her key concerns have been addressed as the conversation develops.

‍

The patient’s agenda was not well explored:

Assumes Amal’s primary concern is physical pain, without exploring or clarifying her ideas, concerns or expectations.
Misses non-verbal cues of distress, allowing her main hopes or fears to go unspoken.

‍

Demonstrates flexibility of communication adapting to the patient and scenario:

Adjusts explanations to avoid jargon and uses culturally sensitive language suited to Amal’s understanding and experience.
Adapts approach if Amal is hesitant or emotional, slowing down, offering pauses, or using resources (e.g., leaflet, specialist advocate) to support communication.

‍

Consults rigidly, providing generic explanations and management plans:

Repeats information verbatim or uses only standard leaflets without gauging Amal’s understanding or emotional readiness.
Fails to modify approach when Amal is distressed, pressing on with the same style or level of questioning regardless of her response.

‍

Respectfully challenges unhelpful health beliefs or behaviours:

Gently discusses misconceptions around FGM (e.g., that suffering is normal or necessary), giving clear information without criticism.
Supports Amal in understanding the true health impacts and the UK’s stance while keeping trust and openness intact.

‍

Fails to maintain a productive therapeutic relationship:

Rebuts Amal’s beliefs bluntly, lectures, or scolds regarding FGM, or validates harmful traditions.
Damages openness by dismissing cultural sensitivities or demonstrating intolerance.

‍

ℹ️ Insights from the examiner

Case summary: Amal Muhammad, a 19-year-old British-Sudanese woman experiencing painful periods, recurrent UTIs, and the complex impact of past FGM. Amal is anxious about intimacy and concerned about the implications of disclosure, especially for her younger sister (age 16) who has also undergone FGM.

1. Time efficient data gathering

Encouraging the patient’s narrative is key to developing rapport and efficiency of data collection, especially around sensitive issues. Inquire gently about her symptoms using open questions. For example;

"Can you tell me more about your period pains how they affect you?"

If sexual concerns arise, display patience and allow silences to invite Amal to elaborate. You might ask,

"You say you're worried about not being able to have a physical relationship, why do you feel that way?"

Use responses to guide further exploration, for example asking about the pattern, severity, and emotional impact.

Be alert to cues that suggest there are deeper issues (shame, evasiveness, avoidance, background risk factors).
Inquire sensitively about family or cultural experiences if relevant to symptoms.

Reference: RCGP SCA Toolkit

‍

2. Language

Adapt explanations to Amal’s background and health literacy. Avoid jargon and medically complex language, but do not patronise. For example

"I understand this is a sensitive topic and I want to help"

"I know that other women have gone through similar experiences."

Use culturally sensitive terms if used by the patient (for FGM, ‘cutting’ may be more familiar) and check understanding.
Express empathy about fears regarding sex, pain, and confidentiality.

Reference: Linguistic and cultural factors in MRCGP examination

‍

3. Cues

Watch for verbal/non-verbal signals revealing unspoken concerns—such as hesitancy, downcast eyes, reluctance to discuss relationships, or protectiveness about her sister. Recognise and respond to these with empathy, for example:

"I sense that there might be things that are hard to talk about, and that's okay. I'm here to support you and won't judge."

Acknowledge her fear about disclosure to authorities transparently and honestly, explaining confidentiality and exceptions (e.g., sister under 18).

‍

4. Goals

Co-construct the agenda so Amal feels involved from the outset:

"What would you hope we can achieve in this consultation today?"

"Are there particular worries you'd like me to help with?"

Revisit and confirm her goals during the session (pain relief, emotional support, safety for herself and her sister, clarity over confidentiality, relationship concerns).

‍

5. Flow

Let the questioning follow the flow of Amal’s story—don’t leap straight to the safeguarding aspects. If she brings up menstrual pain, acknowledge it before asking about sexual or psychological impact.

"I hear the periods are really painful and that’s been hard for you. How are you coping?"

If you suspect a history of FGM etiology, ask gently about family practices or childhood experiences, if she’s willing.
Always check consent before deeper exploration of traumatic issues.

‍

6. Differential

Given the presentation, the most likely causes are:

1. Dysmenorrhea secondary to FGM-related scarring/adhesions
2. Primary dysmenorrhea unrelated to FGM
3. Urinary tract infection (secondary to altered anatomy from FGM)
4. Genital tract infection
5. Endometriosis
6. Psychological distress/trauma-related pain amplification
7. Renal or urological pathology unrelated to FGM

Relevant NICE guidance: Urinary Tract Infection | Endometriosis

‍

7. Impact

Explore physical, psychological, and social impacts:

"How do these symptoms affect your life at college and your mood? Has it made you worry about future relationships?"

Ask about coping with studies, family expectations, emotional wellbeing, fears of intimacy or isolation.
Consider impact on her relationship and future plans.

‍

8. Conciseness

Frame explanations tightly and clearly. Use simple but honest explanations:

"Sometimes pain with periods or water infections can be linked to changes after procedures in childhood. There is support available if that’s the case."

Summarise lengthy safeguarding/legal explanations in a clear way, checking her understanding.

‍

9. Sharing

Make your clinical reasoning explicit:

"Your symptoms suggest a possible link to scarring or changes from your past experience. I want you to feel comfortable to share what you want, but also to understand your options for support."

Explain the steps you’ll need to take regarding her sister, and clarify these are legal requirements designed for protection.

‍

10. Options

Offer evidence-based, culturally sensitive and holistic management options,;

Pain management (analgesia – NSAIDs, paracetamol as per BNF guidance)
Bladder care advice (hygiene, hydration, cranberry products – per NICE)
Referral to specialist FGM services
Psychological support/counselling (including trauma-informed therapy)
Discussion of future sexual health – provide relevant sex education resources and support for first sexual experience
Signposting FGM charities/support groups (e.g., Forward UK, NSPCC FGM helpline 0800 028 3550)
Safeguarding referral for her younger sister – explain legal obligations
Confidential discussion about documentation and NHS Digital FGM Enhanced Dataset – honest about what will be recorded, and how her data is used
Offer a follow-up plan for review and ongoing support
Practical advice on managing periods (warm packs, rest, healthy routines)
Discuss possible urogynaecology referral for recurrent UTIs

If Amal expects absolute confidentiality, explain the limits of confidentiality lawfully and empathically. FGM NHS Information

‍

11. Understanding

Check and reinforce understanding throughout:

"Does what I’ve said about the reasons for the pain and what we can do about it make sense? What questions do you have?"

Invite questions, repeat/simplify as needed, and acknowledge that some things may be hard to take in at once.

‍

12. Bespoke solutions

Individualise care by tailoring the plan to Amal’s needs, fears, and priorities:

“Given your concerns about confidentiality and your wishes for your sister’s safety, I can walk you through exactly what happens next and make sure you have emotional support during this process.”
Involve Amal in safeguarding discussions, and provide written leaflets in her preferred language or with culturally appropriate advocates if required.
Ensure Amal feels in control of what is shared and understands each step—where possible, obtain consent unless the law and safety dictate otherwise (as for her minor sister).
If she wishes, enable advocacy or support through community or FGM specialist organisations of her choosing.

UK Government FGM Safeguarding Guidance‍

‍

Additional examiner-relevant themes & best practice

Recognise/Establish Red Flags: Consider heavy bleeding, persistent fever/infection, urinary retention—seek urgent/specialist help as indicated.
Holistic Practice: Enquire about mood, mental health, academic performance, relationships, isolation, and risks of further harm.
Medico-legal Principles: Demonstrate familiarity with the Female Genital Mutilation Act (2003), mandatory reporting for minors, Caldicott principles, and safeguarding pathways.
Ethical Approach: Respect Amal’s autonomy and dignity. Balance confidentiality with legal/safeguarding duties, ensuring your actions are justifiable and proportionate.
Coordinate with the wider team: Liaise with safeguarding leads, local FGM clinics, and patient advocates where available. Document thoroughly.
Self-awareness and Limitations: If unsure, seek senior advice early and transparently explain this to the patient.

‍

Key References:

Start the quiz

Female genital mutilation

Case overview

Opening statement

Information freely divulged

Information given on questioning

Behaviour

1. Time efficient data gathering

2. Language

3. Cues

4. Goals

5. Flow

6. Differential

7. Impact

8. Conciseness

9. Sharing

10. Options

11. Understanding

12. Bespoke solutions

Additional examiner-relevant themes & best practice