SCA practice case · Telephone consultation
“My leg’s gone cold and dead — it’s just my circulation”
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
Derek Hammond · 71 years · male
Setting
Telephone — sudden cold, painful, pale leg.
Past history
- Peripheral arterial disease (claudication)
- Atrial fibrillation: anticoagulation declined
- Diabetes
- Smoker
Medication
- See repeat list (no anticoagulant)
Allergies
NKDA
Recent notes
⚠ Telephone triage note: right leg cold, pale and painful at rest for a few hours, tingling and numb. Requesting stronger painkillers or a water tablet. Declined anticoagulation for AF (documented).
Reason for contact
Telephone appointment. “My circulation’s worse than usual.”
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)
Sudden onset of a painful (rest pain), pale, perishingly cold, paraesthetic ± pulseless/paralysed leg is ACUTE LIMB ISCHAEMIA — the 6 Ps — a limb-threatening surgical emergency (ESVS 2020, international: tissue is damaged within hours; about 6 hours is a commonly quoted rule of thumb), and it must be distinguished from the patient’s usual exertional claudication (which is brought on by walking and relieved by rest). The likely source here is an arterial embolus from ATRIAL FIBRILLATION that is not anticoagulated (the AF + acute cold leg is the give-away), on a background of PAD. The only safe action is IMMEDIATE emergency vascular assessment (999 ambulance, phone handover to the vascular team — ESVS 2020, international; if he declines, a Mental Capacity Act 2005 assessment of an informed refusal); painkillers and a diuretic are the dangerously wrong response, and advanced features (fixed numbness/paralysis, rest pain) signal a threatened limb needing the fastest possible intervention. The examinable hidden agenda is hospital avoidance driven by amputation fear (a friend lost a leg) and stoicism, paradoxically risking the very loss he dreads. Overcome it fast and compassionately — early treatment SAVES limbs, delay loses them — address any regret about declining anticoagulation without blame, give first-aid (leg dependent, body warm not the leg, nil by mouth), and get him transferred this minute.
The guidance behind it
Similar SCA cases
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