SCA practice case · Video consultation
“I just need the steroids and antibiotics I usually get — don’t start on about the smoking”
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
Frank Dolan · 61 years · male
Setting
Video consultation — a COPD exacerbation in a current smoker.
Past history
- COPD (FEV1 about 45% predicted)
- Current smoker, about 40 pack-years
Medication
- COPD inhalers per repeat list
- Previous steroid and antibiotic rescue courses
Allergies
Check record
Recent notes
⚠ Four days of more breathlessness, more cough and green sputum. Wants his usual steroids and antibiotics.
Reason for contact
“I just need the steroids and antibiotics I usually get — don’t start on about the smoking.”
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 COPD exacerbation in a smoker must be treated competently AND used as a teachable cessation moment. First GRADE severity and exclude the sinister mimics — pneumonia (fever), PE (pleuritic pain, sudden onset, calf swelling), heart failure (orthopnoea, oedema), pneumothorax (sudden severe breathlessness) and lung cancer (haemoptysis, weight loss) — checking speech, breathing effort and conscious level on video (sats only with a home oximeter), with a same-day face-to-face assessment if in doubt; talking in full sentences with no fever, pain or haemoptysis is reassuring for a straightforward infective flare but the exclusion must be explicit, and admit if severe. Treat correctly: increase the short-acting bronchodilator, give oral PREDNISOLONE 30 mg once daily for 5 days, and decide on an ANTIBIOTIC by NICE NG114 judgement — sputum colour change with increased volume or thickness, previous exacerbations and admissions, complication risk and previous sputum results (here supporting amoxicillin, doxycycline or clarithromycin for 5 days) — not reflexively for every flare — plus inhaler optimisation and a personalised self-management/rescue-pack plan. Keep the NICE NG12 (Suspected cancer: recognition and referral, last updated April 2026) LUNG criteria in mind: an urgent CXR (within 2 weeks) for anyone aged 40 and over who has ever smoked with 1 or more unexplained symptoms (cough, fatigue, breathlessness, chest pain, weight loss, appetite loss), and a suspected cancer pathway referral for unexplained haemoptysis at 40 and over, and image rather than let repeated rescue packs mask a tumour if a flare does not resolve. The examinable communication is the cessation OFFER done as Very Brief Advice (ask permission, advise plainly that stopping is the single most effective intervention and helps even now, act by offering combination NRT/varenicline/bupropion or vaping harm-reduction plus a stop-smoking-service referral), reading the patient’s defensiveness as guilt/shame/fatalism, earning trust by treating the flare well, and respecting autonomy — neither colluding with "don’t mention it" nor hectoring. Safety-net for deterioration and follow up.
The guidance behind it
Similar SCA cases
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