Cases/Metabolic Problems and Endocrinology

Man Buying A Weight Loss Injection Online Who Wants You to Prescribe It — Free SCA Practice Case

Man buying a weight loss injection online who wants you to prescribe it

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Marlon Ashby

Age

45 years

Consultation Type

Video

Age

Situation

Video Consultation. Routine appointment booked by the patient.

Reason for Encounter

"I'd like to talk to you about getting a weight loss injection."

Medical Records

●PMH: Obstructive sleep apnoea, confirmed on a sleep study 2 years ago, uses CPAP at night. Raised cholesterol, on treatment. No diabetes. No hypertension. No cardiovascular disease.
●Medications: Atorvastatin 20 mg at night.
●Allergies: NKDA.
●Social: IT support analyst. Non smoker.

Recent Notes

●Health check, 4 months ago: Weight 116 kg, height 1.79 m, BMI 36.2. BP 126/78. HbA1c 38 mmol/mol. Total cholesterol 4.9 mmol/L on atorvastatin.

Patient Script

For the friend playing the patient role

Character Overview: You are Marlon Ashby, a 45 year old IT support analyst at a university. You live with your wife Dionne, a dental receptionist, and your 14 year old daughter Kayla. You have been a big man since your thirties and have crept up to 18 stone 4 pounds. Your knees ache on the stairs and you cannot keep up with Kayla on walks. About two months ago Lewis, a lad from your gym, showed you the pens he injects and you ordered some from his website. You have done eight weekly injections and lost a stone, which you have never managed before. You have not told your GP. This week you have had an ache in your upper stomach after meals that you put down to your body getting used to the jabs, because Lewis had the same. You booked because the pens cost more with every dose step, the overtime has dried up, and you want the NHS to prescribe them instead. You are chatty and likeable, a bit defensive about buying online and half expecting a telling off. You make light of the stomach ache and do not feel ill.

Opening Sentence: "Hello, doctor. I've been on those weight loss jabs, tirzepatide, for about two months now and I've lost a stone, but it's costing me a fortune, so I was hoping you could prescribe it on the NHS. I've had a bit of a sore stomach this week as well, but I reckon that's just my body getting used to it."

History if Asked (Data Gathering Phase)

●The pain (if asked about the stomach ache): "It's up here, in the middle, just under my ribs. It started about four days ago, the day after my last jab. It comes on after I've eaten, a dull ache, about a three or four out of ten, and it eases off after an hour or so. I've had it most days since, usually after my tea."
●What makes it better or worse, and spread (if asked): "Greasy food sets it off. A kebab the other night was the worst, maybe a five. Sitting still it settles. It stays in the one spot and doesn't go to my back or my shoulder. It goes completely in between."
●Other symptoms (if asked about sickness, fluids, fever, skin colour, bowels or chest): "A bit queasy after I've eaten, but I haven't been sick. I'm drinking normally and my wee's normal. No fever, no yellow skin or eyes, no dark wee, bowels are normal with nothing black or pale. No chest pain or breathlessness with it."
●What he has been injecting (if asked about the dose or how he has been using it): "Once a week. I've done eight jabs. Two of the lowest one, the 2.5, then three of the 5, and then three of the 7.5, the last one five days ago. Lewis said you can go up every couple of weeks if you can stomach it, so I did. The next one's due in two days. There's a bit left in each pen."
●How he got the pens and whether the supplier is genuine (if asked): "Go on, tell me off. It's a website Lewis told me about. There was a form with my height and weight and a tick box to say I was healthy. Nobody phoned me or asked for a video. I paid by card and the pens came in the post with an ice pack. It had a UK flag and some doctor's name on the site, but I never checked if it's a proper pharmacy. The leaflet wasn't in English, so I chucked it."
●Cost (if asked): "A hundred and forty for the first one, a hundred and ninety for the next, and the 7.5 was two sixty. Getting on for six hundred quid so far."
●Weight and previous attempts (if asked): "Eighteen stone four when I started, seventeen stone four on the bathroom scales this morning. I did three months with a personal trainer, that fasting thing and a step counting app. I'd lose a bit and then it comes back. They offered me a weight management course at my health check but it was in the evenings, so I said no."
●Eating and exercise (if asked): "I graze. A breakfast roll, a meal deal at my desk, a big tea. No bingeing and I've never made myself sick. Since the jabs I'm eating much less. I've been to the gym twice a week with Lewis."

Ideas, Concerns, Expectations

Gating note: Marlon does not volunteer any of this. Each part comes out only when the doctor asks what he thinks is going on, what is worrying him, what he was hoping for, or what he will do if the NHS will not prescribe.

●Ideas: He thinks the weight loss proves the pens are the real thing, that it is the same medicine the NHS gives out so it does not matter where it comes from, and that the stomach ache is his body adjusting. "I've lost a stone in two months. It's obviously the real stuff. And Lewis had a sore stomach at the start too."
●Concerns: Mainly money. He cannot keep paying nearly three hundred pounds a month now the overtime has gone. Next his knees and breathing. "I'm only forty five and I'm puffing on the stairs." Then fear that the weight will come back. If asked about the stomach ache: "I just want it to settle. I've got a full day of meetings tomorrow and I can't be off."
●Expectations: "I was hoping you'd just do me a prescription for the same thing, then it's not costing me a penny." If asked what he will do if the NHS will not prescribe: "Lewis says there's a site doing it as a powder in little bottles for sixty quid a month. You mix it yourself. I've not ordered any yet but I've been looking."

If Asked: Medical History and Medications

Gating note: Marlon answers each of these plainly when the doctor asks about it.

●Health and tablets: "Sleep apnoea, so I wear a mask at night, and high cholesterol, so I take atorvastatin. A couple of paracetamol the once for my stomach, nothing else. No diabetes, no blood pressure problem and no heart trouble. No allergies, no operations."
●Gallstones, pancreas or liver trouble: "Never. I've never had anything like this before."
●Mood and family: "I'm all right in myself, just fed up with the weight." No family history of gallstones, diabetes or thyroid trouble.

Social History and Lifestyle Impact

●Work and home: Desk based. The on call overtime used to top up the wages and has stopped. Dionne is at work now, twenty minutes away with a car. "She said the jabs sounded dodgy and I should ask you."
●Alcohol and smoking: "Four to six pints a week, mostly at the weekend, but none this week." Never smoked.
●Lifestyle impact: "Knees, stairs, and I get breathless carrying shopping."

Responses to Management (The Negotiation Phase)

●
If the doctor tells him to stop the injections, links the ache to the medicine, or raises the gallbladder or pancreas:
- ●Reaction: Reluctant at first. "Stop it? But it's working." Once told the ache could be a reaction to the medicine: "Right, so you think the jab could be causing it? Okay, I won't take it." If a gallbladder or pancreas problem is mentioned: "Is that serious?" He settles when told it is usually treatable but needs checking. If asked to keep the pens: "Will I get in trouble?"
●
If the doctor arranges to see him in person, asks him to examine himself, or is vague (such as "see how it goes" or "come back if it gets worse"):
- ●Reaction: For a same day surgery appointment: "Today? It's an ache after my tea. I've got a full day of meetings tomorrow." Given a clear, calm reason, he agrees: "Okay, I can be there in forty minutes." For a hospital department: "Okay, Dionne can drive me." For first thing tomorrow: "That's fine, I'll start late." If asked to press his stomach or check anything himself: "I wouldn't know what I'm feeling for. Wouldn't it be better if someone looked at me properly?" If the doctor is vague, he takes the reassurance: "Right, so it's nothing to worry about then. Should I do my next jab as normal?"
●
If the doctor explains NHS eligibility or says they will not prescribe:
- ●Reaction: "So I qualify on my weight but not on the rest? I've got the sleep apnoea and the cholesterol, surely that's enough?" If told funding is being rolled out in stages: "So it's a queue, and I'm nowhere near the front. How long would that be?" Then "So what am I meant to do in the meantime?" On being refused: "Even though it's working? I suppose you can't just hand it out."
●
If the doctor warns about unregulated sellers or asks about the powder in bottles:
- ●Reaction: Challenges. "But it's worked, so it must be the real stuff." Once the warning signs are explained: "Do you think it's fake? Is that why my stomach's bad?" On the powder: "Lewis said it was exactly the same thing. You mix it yourself, you say? Okay, I'll leave that alone."
●
If the doctor discusses side effects, regain or other options such as a dietitian, weight management service or orlistat:
- ●Reaction: Dejected about regain. "So the stone comes straight back? That's eight weeks of jabs and nearly six hundred quid for nothing." If told it is not inevitable: "So what do I do then?" Interested in alternatives. "How long's the wait for the weight management lot?" For orlistat: "Isn't that the one that makes you run to the toilet?" Open to a dietitian. If told he should never restart the jabs, he asks "Ever?"
●
If the doctor gives warning signs, asks him to say the plan back or arranges follow up:
- ●Reaction: Asks one practical question. "And if it's the middle of the night, do I just ring 999 or go to the hospital myself?" Says the plan back in his own words, leaving out one small detail. "Will you ring me with the results?" Accepts a call once he has been seen.

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Marlon is 45 with a body mass index (BMI) of 36.2 at his last health check. He has injected tirzepatide pens from an unregulated website for about eight weeks, raised the dose faster than the licence allows, lost about a stone and had four days of intermittent upper abdominal pain after meals.
●Two decisions sit in one consultation. The first is safety: treat the pain as a possible adverse reaction, stop the medicine and make sure he is examined in person soon. The second is the request: NHS eligibility, the dangers of the supply, side effects, realistic expectations and a legitimate plan.
●The pain is real but not an emergency: intermittent and mild, with no vomiting, spread to the back, fever or jaundice, and normal fluids and urine.
●Model answer: stop the pens now, see him in person today with observations, abdominal examination and blood tests (for example liver function and a pancreatic enzyme where available) and request an ultrasound, with admission if the findings suggest pancreatitis or cholecystitis. Decline to prescribe, explain the staged funding, warn about the supply and give a safety net.
●Also acceptable: same day assessment in a hospital department by telephone arrangement, or an in person examination first thing next morning when the pens are stopped, he is drinking normally and the warning signs are explicit. Not acceptable: painkillers or an acid reducer with review in several days, only a routine test, or a phone plan.

Abdominal Pain on a GLP 1 Type Medicine

●Tirzepatide is a dual glucose dependent insulinotropic polypeptide (GIP) and glucagon like peptide 1 (GLP 1) receptor agonist. The British National Formulary (BNF) lists gallbladder disorders and acute pancreatitis as uncommon effects, with the advice to discontinue if pancreatitis occurs. Mild pain is often an ordinary gut effect, but the less common serious causes must not be missed.
●The Medicines and Healthcare products Regulatory Agency (MHRA) Drug Safety Update of 29 January 2026 strengthened the pancreatitis warning. It says to ask about privately obtained products, to stop the medicine if pancreatitis is suspected, not to restart it if confirmed, and to advise urgent attention for severe, persistent abdominal pain that may spread to the back.
●NICE Clinical Knowledge Summaries (CKS) on acute pancreatitis says to arrange emergency admission when it is suspected, without delaying it for blood tests or imaging in primary care. Marlon's pain does not fit that yet, but it would if it became severe, constant, spread to the back or came with vomiting.
●CKS Gallstones lists obesity and GLP 1 analogues as risk factors. Upper abdominal pain after a fatty meal that settles within hours fits biliary pain. CKS advises liver function tests, an ultrasound, and emergency admission for anyone systemically unwell with a suspected complication.
●Other causes include dyspepsia, peptic ulcer and alcohol, and a cardiac cause is worth a question in a man with raised cholesterol. None can be settled by video.

Choosing the Disposition and the Safety Net

●The decision is between emergency admission, same day assessment in person and remote management with active follow up. Marlon's features support the middle option. Emergency admission is a more cautious route that also passes.
●Give symptom specific triggers: call 999 or go to the emergency department if the pain becomes severe or constant or spreads to the back, if he vomits repeatedly or cannot keep fluids down, if he has a fever or shivers, or if his skin or eyes turn yellow or his urine turns dark.
●Tell whoever sees him about the self sourced tirzepatide, the doses and the date of the last injection.

Why Buying From Unregulated Sources Is Unsafe

●MHRA guidance on GLP 1 medicines (updated 5 February 2026) says they should be taken only when prescribed after a consultation with a healthcare professional, and should not be bought from unregulated sellers or anywhere without that consultation. Pre filled pens or tablets are the authorised forms. Powder in vials that must be mixed before injection is not authorised and poses significant risks. Counterfeit pens have been reported. People can check a pharmacy on the General Pharmaceutical Council (GPhC) register.
●Warning signs here: no consultation, a self reported form, an unidentifiable supplier, a leaflet in another language, dose advice from a friend and the plan to buy powder.
●A GP cannot verify the contents and should not take over a supply with no clinical oversight. Suspected adverse reactions and non genuine products can be reported through the Yellow Card scheme, and he should keep the pens and packaging.
●Record the use: the MHRA advises asking about GLP 1 use before procedures needing sedation or anaesthesia because of aspiration risk, and private use may not be in the notes.

NHS Eligibility for Tirzepatide

●NICE technology appraisal TA1026 (published December 2024) recommends tirzepatide, with a reduced calorie diet and more activity, for adults with an initial BMI of at least 35 and at least one weight related condition. The BMI threshold is usually 2.5 lower for some ethnic groups, and eligibility is judged on the initial BMI.
●NHS England is funding it in phases in primary care, starting with the highest BMI and the most qualifying conditions (hypertension needing treatment, dyslipidaemia, obstructive sleep apnoea needing continuous positive airway pressure, established cardiovascular disease and type 2 diabetes). Its interim guidance, last updated 2 April 2026, started with a BMI of 40 or more and four or more conditions, then widens in later years to a BMI of 35 to 39.9 with four or more conditions, and later to a BMI of 40 or more with three. The guidance is interim and dated, so check the current NHS England and local integrated care board position.
●Marlon meets the NICE criteria in principle (initial BMI 36.2, with sleep apnoea on CPAP and treated dyslipidaemia, so two qualifying conditions). On the phasing as read in October 2026 he is not in a funded primary care group. A specialist weight management service is the route by which he could be considered. Explain it as national phasing, not a judgement on him, and promise no date.

Other NHS Options When Tirzepatide Is Not Available

●NICE guideline NG246 (updated January 2026) says medicines follow dietary, activity and behavioural approaches and need support to maintain weight when stopped. Specialist services follow the full NICE criteria, and local access varies.
●Semaglutide is prescribed only in a specialist service. Orlistat can be prescribed in primary care for a BMI of 30 or more and is stopped at 12 weeks if less than 5% of the initial weight has been lost.
●Any one of these routes passes: specialist referral, dietetic or behavioural support, the local weight management programme, or orlistat once the pain has been assessed.

Dose, Side Effects and Realistic Expectations

●The BNF schedule is 2.5 mg once weekly for 4 weeks, then 5 mg for at least 4 weeks, then steps of 2.5 mg at intervals of at least 4 weeks, up to 15 mg. Marlon reached 7.5 mg in week six.
●The MHRA (October 2024) asks prescribers to warn about the common gastrointestinal effects, which can persist for days and cause severe dehydration and kidney damage, and about gallbladder disease, pancreatitis and allergic reactions.
●Results build over months and vary. NICE's committee heard that most weight lost on a related medicine is regained within a year of stopping, and that there is no long term tirzepatide data. CKS Obesity says regain may happen in many cases. It is not inevitable if habits are in place, so avoid absolute statements either way.

Running the Consultation

●Ask where the pens came from without blame: a telling off ends honesty and he may keep the powder plan to himself.
●Link the pain to the medicine in plain words without frightening him, and do not let work pressure dilute the plan.
●A stone lost is real, but it does not show that the pen is genuine.
●Declining to prescribe is not declining to help. Offer a realistic NHS plan and ask him to say it back.

Common Candidate Mistakes in This Station

●Treating the pain as an expected effect, suggesting a lower dose, or offering painkillers or an acid reducer with review in several days.
●Spending so long on the pain that eligibility, the supply and the plan are never covered.
●Giving "come back if it gets worse" with no triggers.
●Failing to ask where the pens came from, how the dose was raised, or what he will do if the NHS will not prescribe, so the powder plan stays hidden.
●Telling him the NHS does not offer these medicines, that his BMI is too low, or that he will be funded soon.
●Prescribing or offering to continue the online supply, lecturing him, presenting the medicine as a quick fix, or forgetting a record and follow up.

Mapped to the RCGP curriculum topic: Metabolic Problems and Endocrinology.

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