SCA practice case · Telephone consultation
“My indigestion’s just worse than usual”
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
Paul Mercer · 58 years · male
Setting
Telephone — long-standing dyspepsia, now changed.
Past history
- Back pain
- Dyspepsia — long-standing
- Smoker
Medication
- Omeprazole (repeat)
Allergies
NKDA
Recent notes
⚠ Requests a higher omeprazole dose by phone. H. pylori never tested. No FBC this year. No endoscopy on record.
Reason for contact
Telephone consultation. “Can you bump up my omeprazole?”
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)
Long-standing dyspepsia that has CHANGED and become persistent despite a PPI, with unintentional weight loss, early satiety and — critically, on direct questioning — melaena (black tarry stools), is a cluster of ALARM features that mandates an urgent suspected cancer pathway referral, not a phone PPI dose increase. NICE NG12: refer using a suspected cancer pathway referral for oesophageal or stomach cancer (this replaced urgent direct-access endoscopy in 2025) at 55 and over with weight loss and upper abdominal pain, reflux or dyspepsia; the black stools also mean an in-person assessment the same day (pulse, BP, FBC, U&E), with emergency admission if bleeding is active. "Test and treat" (H. pylori) and a 4-week full-dose PPI (NICE CG184) are for uncomplicated dyspepsia WITHOUT alarm features — not here; with a possible bleed, H. pylori is tested at endoscopy. Two things are easily missed: melaena (the patient won’t volunteer it — ask specifically), and a hidden NSAID driver (daily ibuprofen not on the record, a major peptic-ulcer/bleeding risk) which must be stopped, alongside H. pylori testing at endoscopy and an FBC; the back pain then needs an NG59 plan (exercise-based care; not paracetamol alone). The examinable hidden agenda is work-driven avoidance (short-staffed, job insecurity) plus a quieter fear of bad news he can’t afford; name the seriousness without panic, problem-solve the work barrier, stop the NSAID, and safety-net the GI-bleed red flags clearly.
The guidance behind it
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