SCA practice case · Video consultation
“I’ve had this cough for three months — the heart doctor said to see you about it.”
The candidate brief
This is what you would read in the 3-minute window before the patient connects. Read it once, note two or three hypotheses and one thing you must not miss, then stop.
Patient
Hamid Karimi · 58-year-old man
Setting
Video — routine appointment after the cardiology clinic discharged him.
Past history
- Anterior ST-elevation myocardial infarction — primary PCI with drug-eluting stent to LAD, 9 months ago
- Smoker (cutting down)
Medication
- Ramipril 10 mg once daily (increased from 5 mg 4 months ago)
- Bisoprolol 5 mg once daily
- Aspirin 75 mg once daily
- Ticagrelor 90 mg twice daily (12 months from MI — 3 months remaining)
- Atorvastatin 80 mg once daily
Allergies
No known drug allergies
Recent notes
Cardiology clinic letter, 3 days ago: “Excellent recovery. Completed cardiac rehabilitation. Asymptomatic from a cardiac point of view. BP 124/72, HR 62. Echo LVEF 50%. Chest clear on auscultation. He reports a dry cough for about 3 months — may be smoking-related; we have asked him to see his GP. Smoking down to 4 a day — strongly advised to stop. Discharged from cardiology follow-up.” DVLA: Group 2 (PCV) licence — relicensed after exercise test (letter 4 months ago). U&E 4 months ago (after ramipril increase): creatinine 88 µmol/L, eGFR 82, K+ 4.6. No chest X-ray in the last 2 years.
Reason for contact
Video appointment — “cough, as advised by cardiology”.
Practise this case
The full case is in the Hot Seat with the Gold plan. You get a 12-minute timer, a role-player script with facts released only when asked, examiner checkpoints by the three RCGP domains, a model consultation and the guidance behind it.
What this case tests
Show the learning points (spoiler: read after you have practised)
A persistent dry cough in someone on an ACE inhibitor should prompt a medicines timeline: ACE-inhibitor cough affects around 1 in 10 people, can begin weeks or months after starting or increasing the dose, and usually settles within 1–4 weeks of stopping (occasionally up to 3 months). After myocardial infarction, NICE NG185 recommends an ACE inhibitor and, for people who are intolerant, an angiotensin-II receptor blocker instead — a switch that can be made safely in primary care with monitoring of renal function, potassium and BP. Do not let a probable drug cause close the differential: a man over 40 with a cough who has smoked meets NICE NG12 criteria for a chest X-ray within 2 weeks. Side effects often cause silent non-adherence, here driven by work; asking about missed doses in a normalising way protects secondary prevention. Vocational drivers raise specific DVLA questions — after acute coronary syndrome Group 2 relicensing depends on functional testing, and cough syncope is a separate driving issue — so ask about faintness with coughing and give honest information about what must be reported.
The guidance behind it
Similar SCA cases
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