SCA practice case · Telephone consultation
“I’ve got COPD and I’m more breathless — it’s just another flare, can you sort it over the phone?”
Telephone consultation
Older adult patient
Hard
Urgent & unscheduled careLong-term conditions & cancerOlder adults
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
Ivy Marchetti · 69 years · female
Setting
Telephone consultation — increased breathlessness in known COPD.
Past history
- COPD
Medication
- COPD inhalers per repeat list
Allergies
Not recorded — check
Recent notes
⚠ Telephone request: more breathless than usual; believes it is another flare.
Reason for contact
“Could you call me in some steroids and antibiotics? I’m too wiped out to come down.”
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)
Telephone triage of "more breathless" in a known COPD patient must NOT anchor on "just another flare". A structured history actively distinguishes a typical infective exacerbation (gradual build, increased purulent sputum) from SOMETHING NEW: PULMONARY EMBOLISM (sudden onset, pleuritic chest pain, haemoptysis, unilateral calf swelling, immobility/long travel/recent surgery/prior VTE, with tachycardia and breathlessness disproportionate to a clear chest found only on examination), HEART FAILURE (orthopnoea, paroxysmal nocturnal dyspnoea, ankle oedema, weight gain), PNEUMONIA (fever, focal symptoms, confusion in the elderly), PNEUMOTHORAX (sudden unilateral breathlessness/pain), arrhythmia, and lung cancer (haemoptysis, weight loss — NICE NG12 (Suspected cancer: recognition and referral, last updated April 2026)). Telephone assessment can take a careful history and gauge severity (speech in sentences, exhaustion, confusion) but cannot examine, take a pulse, measure saturations or perform an ECG, and with PE likely (Wells more than 4) NICE NG158 moves straight to an immediate CTPA or interim anticoagulation rather than a D-dimer, so any PE picture, concerning "not a flare" feature, or significant severity mandates URGENT face-to-face assessment or admission rather than a phoned-in rescue pack; only a clear-cut mild flare with a negative red-flag screen is suitable for remote management (prednisolone per NICE NG115; an antibiotic only on NICE NG114 judgement). The hidden agenda — exhaustion, inconvenience and minimisation ("just call it in, I’m too wiped out to come") — must not deflect the discriminating questions; when red flags emerge (here sudden onset, pleuritic pain, a swollen calf and a recent long coach journey — a PE picture), explain clearly and kindly why she must be seen urgently, arrange the route to assessment, refuse to collude with the phone-prescription request, and safety-net robustly with explicit 999 red flags.
The guidance behind it
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