Station 14 · Tired and cold

Candidates: do not open until you have consulted.

Persona and manner

• Lily Turner, 16, Year 12; polite, guarded, a large hoodie, brief answers; you glance at the scales; you want a blood test and to be left alone.
• Trust builds slowly if the doctor explains confidentiality and asks without accusation. You cry only at the end.

Opening line (verbatim)

• “I've just been really tired and cold all the time. I think it's my iron or something. Can I just have a blood test?”

The story

• “Tired. Cold. Stressed with A-levels. My periods are irregular.”
• If asked: no period for four months.
• If asked about eating: “Healthy. I cut out junk.” On gentle questioning: you skip breakfast, salad at lunch, “a small tea”; you count calories, about 700 a day; you exercise every day; you weigh yourself twice a day; “I still feel big.” No vomiting; no laxatives.
• Dizzy on standing; your hair is falling out; you feel faint after PE; you cannot concentrate; your mood is low, “numb”.
• If asked directly and kindly about hurting yourself: you scratch your arm “sometimes”; no thoughts of ending your life.
• Friends “worry”; a friend “was in hospital for it”.
• You know your mum phoned: “She does that.” You do not want your mum “told everything” but “I suppose she can know I've seen you”. Your form tutor is “safe”.
• If asked whether you can decide about your own care: “I'm sixteen. Yes.”
• If asked what you want: “to get better but not to get bigger”. You have looked at recovery accounts online.

Ideas, concerns and expectations

• Idea: Iron, or stress.
• Concern: Being made to eat; being sectioned; your mum “going mad”.
• Expectation: A blood test, and to be left alone.

Impact

• School: predicted A grades; a teacher has had a word about you looking unwell; you left PE early twice.
• Sleep: you wake at four, cold, and lie awake planning food. Mood worst in the evening.
• Home: your brother teases you about not eating; your mother “cooks and cries”.

Red flags

• Present: A pulse of 52, a blood pressure of 98/60 with a postural drop of 12 and dizziness, a temperature of 35.9, 15 kg lost since 14, amenorrhoea for four months, daily exercise on 700 calories, scratching her arm.
• Absent: No vomiting, no laxatives, no fainting with loss of consciousness, no chest pain, no confusion.
• Absent: No thoughts of ending her life.

Hidden facts and their triggers

• The calorie counting, the twice-daily weighing and “I still feel big” — released only only on gentle, non-accusing questions about eating and how she sees herself
• The four months without a period — released only if asked what “irregular” means
• The scratching — released only only if asked directly and kindly about hurting herself
• That she knows her mum phoned and what she is willing for her mum to know — released only if the doctor raises her mum, or asks who she trusts
• “To get better but not to get bigger” — released only if the doctor asks what she wants

Behaviour

• Minute 1: the hoodie; a glance at the scales.
• Minute 3: “I still feel big.”
• Minute 5: “My friend was in hospital for it.”
• If the doctor builds trust, explains confidentiality and its limits, gently explores eating and how you see yourself, recognises from this morning's readings that this is a physical emergency as well as an illness of the mind, explains that a same-day referral to the eating-disorder service and same-day bloods and a heart tracing are needed and why, discusses involving your mum with your agreement, asks about hurting yourself and your mood, and safety-nets specifically: cry quietly. “Will they make me eat?” and “Do you have to tell my mum?”
• If the doctor orders a blood test and reassures: “Thanks.” Leave.
• If the doctor leads with “your mum rang”: shut down. “So she's told you what to think.”
• If the doctor lectures about eating: look at the door; answer in single words.

Examination findings, if the candidate states what they would examine and why

• In the room: if the candidate states what they would examine and why, use this morning's readings and add: BMI 17.3, below the 0.4th centile for age; fine downy hair on the forearms; cool hands; capillary refill three seconds; she needs to use her arms to stand from a squat. If asked to show her arm: fine scratches on the left forearm, not deep.

Domain grades — with the key facts that earn a clear pass at this station

Global rating (recorded, not added to the total): ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass

The domain grades (RCGP descriptors): CP clear pass — above the standard of a newly qualified, independent GP · P pass — sufficiently demonstrated at the standard · F fail — insufficiently demonstrated at the standard · CF clear fail — clearly demonstrated below the standard.

The RCGP grades each domain CF, F, P or CP and weights clinical management and medical complexity against the other two domains; the examination's maximum is 126 over twelve cases, which is 10.5 per case. The RCGP does not publish the mark each grade carries. MD Acumen's training sheet uses CF 0 · F 1 · P 2 · CP 3, with clinical management weighted ×1.5 (0 · 1.5 · 3 · 4.5), so that a case is marked out of 10.5 and a twelve-case circuit out of 126. A P in all three domains is 7.0; MD Acumen treats that line as the training standard for a case. The examination's pass mark is set by borderline regression for each diet and is published in the RCGP's diet summary reports; it is not a fixed fraction of 126.

Weighting rationale, in the RCGP's words: “To reflect the capability coverage within the clinical management and medical complexity domain this is weighted in comparison to the other two domains.”

Written to the standard of a newly qualified independent GP; the clear-pass row describes practice above that standard. It is a debriefing aid, not a checklist: the grade is a judgement that the essentials, the italic key facts on the mark sheet, were done well, at the patient's pace and in plain language. MD Acumen training standard; the RCGP does not publish case mark sheets.

Where candidates lose this station

• Accepting “I think it's my iron” and ordering a blood test without an eating history, so that the readings are never interpreted (statement D6)
• Leading with “your mum rang”, so that she shuts down and the consultation is over at minute two (statement R6)
• Making the referral depend on a BMI threshold, or sending it as routine, for a girl with a pulse of 52 and a postural drop (statement C1)

What the examiner is listening for in the last four minutes

By 8:00 the working diagnosis should have been stated: an eating disorder with physical compromise. The examiner is listening for: the same-day call to the eating-disorder service and the same-day bloods and ECG, explained in her words; what would need the hospital; the limits of confidentiality said before they are needed and her mother involved by agreement; a safety-net that names fainting, chest pain, confusion and collapse; the named contact and the follow-up within days; and her own words on what happens next and what she wants from it.

The ten statements below are postulated: the feedback an examiner would most likely attach at this station, chosen from the RCGP's standardised list of 26 feedback statements that applies to every SCA case and spans the three marking domains (Data Gathering and Diagnosis; Clinical Management and Medical Complexity; Relating to Others). They are a prediction from the case content, its complexity and the marks that matter, not an examiner's record: any statement on the full list can be attached to any case, and feedback plays no part in the mark. Record the statements that applied in the practice log.

The full list of 26 statements, with the generic meaning of each, is on the exam and the mark scheme.

Points of fact the examiner should have to hand

Each statement is drawn from the named guideline, in its current version, with the date it was checked. The examiner marks against these facts; the candidate is not expected to quote them.

1. Refer people with a suspected eating disorder immediately to a community eating-disorder service for assessment; do not use single measures such as BMI or duration of illness to determine whether to offer treatment; the service for children and young people offers a first appointment within one week for urgent cases. NICE — NG69 Eating disorders: recognition and treatment, section 1.2, identification and assessment; section 1.3, principles of care, 2017, last updated December 2020, checked 10 Oct 2026
2. Medical risk markers in eating disorders include a heart rate below 50 (red below 40), a blood pressure below 90/60, a postural drop in systolic pressure of more than 20 mmHg, a temperature below 35.5 degrees, rapid weight loss (more than 1 kg a week), muscle weakness (unable to rise from a squat without arms) and electrolyte disturbance; several amber or red markers call for same-day assessment and an ECG. Royal College of Psychiatrists — CR233 Medical emergencies in eating disorders (MEED): guidance on recognition and management, risk assessment framework (table), May 2022, checked 10 Oct 2026
3. Assess physical health in people with an eating disorder, including an ECG for those with a low heart rate or electrolyte disturbance, and blood tests including electrolytes, glucose, magnesium and phosphate; monitor for refeeding syndrome when nutrition is restarted. NICE — NG69 Eating disorders: recognition and treatment, section 1.9, physical health assessment and monitoring, 2017, last updated December 2020, checked 10 Oct 2026
4. A young person aged 16 or 17 is presumed to have capacity to consent to their own treatment; confidentiality is owed to them as to an adult, and information is shared without consent only where it is necessary to protect them or others from serious harm, and then they are told what will be shared and why. GMC — 0 to 18 years: guidance for all doctors, paragraphs 24 to 29, assessing capacity; paragraphs 42 to 53, confidentiality, 2007, updated 2018, checked 10 Oct 2026
5. Ask young people who present with low mood or an eating disorder about self-harm and suicidal thoughts directly; self-harm in a young person is assessed for risk and the person is offered follow-up and a safety plan. NICE — NG225 Self-harm: assessment, management and preventing recurrence, section 1.5, assessment and care by healthcare professionals, September 2022, checked 10 Oct 2026
6. Secondary amenorrhoea (no period for three months or more in a woman with previously regular cycles) warrants assessment; low body weight and excessive exercise are among the causes, and a pregnancy test is part of the assessment. NICE CKS — Amenorrhoea, diagnosis: causes of secondary amenorrhoea, current online version, checked 10 Oct 2026
7. Family members and carers of children and young people with an eating disorder should be involved in treatment where the young person agrees, and offered information and support; where the young person declines involvement, the clinician explores the reasons and keeps the question open. NICE — NG69 Eating disorders: recognition and treatment, section 1.1, general principles of care: working with family members and carers, 2017, last updated December 2020, checked 10 Oct 2026
8. Be alert to an eating disorder in a young person with an unusually low or high body weight or BMI for age, rapid weight loss, dieting or restrictive eating, excessive exercise, amenorrhoea or other menstrual disturbance, social withdrawal, unexplained physical symptoms, or a family member reporting a change in eating; do not use a screening questionnaire such as SCOFF as the sole basis for deciding whether an eating disorder is present, and refer on clinical suspicion rather than waiting for a diagnosis. NICE — NG69 Eating disorders: recognition and treatment, section 1.2, identification and assessment, 2017, last updated December 2020, checked 10 Oct 2026
9. First-line treatment of anorexia nervosa in a child or young person is outpatient: anorexia-nervosa-focused family therapy, delivered as single-family or multi-family sessions, typically 18 to 20 sessions over a year, with individual eating-disorder-focused CBT or adolescent-focused psychotherapy if family therapy is unacceptable or ineffective. Medication is not offered as the sole treatment. Admission is for a person whose physical health is severely compromised or who needs intensive support, and the aim is the least restrictive setting that is safe. NICE — NG69 Eating disorders: recognition and treatment, section 1.3, treating anorexia nervosa in children and young people; inpatient and day patient treatment, 2017, last updated December 2020, checked 10 Oct 2026
10. High risk of refeeding syndrome is any one of: BMI below 16, unintentional weight loss of more than 15% in three to six months, little or no intake for more than 10 days, or low potassium, phosphate or magnesium before feeding; or any two of: BMI below 18.5, weight loss of more than 10% in three to six months, little intake for more than five days, or a history of alcohol misuse or certain drugs. A 15 kg loss from 62 kg is 24%: refeeding is supervised with electrolyte monitoring. NICE — CG32 Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition, section 1.4, what to give: people at high risk of refeeding problems, 2006, last updated August 2017, checked 10 Oct 2026
11. A person with an eating disorder at high medical risk who refuses treatment has their capacity assessed for that decision, recognising that the illness itself can impair the ability to weigh the risk of not eating. Where capacity is lacking, or the criteria for detention are met, the Mental Health Act allows treatment of the disorder, and nutrition is treatment for anorexia nervosa under section 63. Compulsion is a last resort: engagement with the person and the family is sought first, and most treatment is voluntary. Royal College of Psychiatrists — CR233 Medical emergencies in eating disorders (MEED): guidance on recognition and management, legal and ethical considerations: capacity, consent and compulsory treatment, May 2022, checked 10 Oct 2026
12. The Children and young people Topic Guide treats adolescents and young people aged 10 to 25 as a distinct group: the GP is expected to assess consent and competence in older children and adolescents, to apply the law and guidance on confidentiality when a parent asks for information, to be opportunistic in assessing mental wellbeing, to recognise eating disorders and self-harm early, to safeguard, and to work with CAMHS and the eating-disorder service while keeping the young person at the centre of decisions. RCGP — GP curriculum: Children and young people, Topic Guide: knowledge and skills, Being a GP, 2025 curriculum, checked 10 Oct 2026

Working references for this station

12 statements, 754 words. Every statement is signed by the Course Director before it is published; a station whose facts have changed since signature carries no signature line until it is signed again.

Record your three domain grades, your case total out of 10.5, your global rating, the RCGP feedback statements that applied, and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for SCA-14