SCA practice case · Telephone consultation
“Things haven’t been working in the bedroom since my heart attack — I don’t want another tablet on my list”
Telephone consultation
Adult patient
Typical
Gender, reproductive & sexual healthLong-term conditions & cancer
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
Harjit Sandhu · 56-year-old man
Setting
Telephone — routine appointment booked by the patient.
Past history
- Anterior STEMI 7 months ago — primary PCI with drug-eluting stent to LAD; echo LVEF 55%
- Hypertension
- Ex-smoker (stopped at MI; 25 pack-years)
Medication
- Aspirin 75 mg once daily
- Ticagrelor 90 mg twice daily (planned to stop at 12 months)
- Atorvastatin 80 mg at night
- Ramipril 5 mg once daily
- Bisoprolol 5 mg once daily (increased from 2.5 mg 4 months ago)
- Glyceryl trinitrate 400 micrograms/dose spray — as required (none issued in the last 5 months)
Allergies
No known drug allergies
Recent notes
Cardiology clinic letter (4 months ago): “Well. Completed cardiac rehabilitation — exercising 30 minutes daily, no angina. BP 138/84, HR 72. Bisoprolol increased to 5 mg. Ticagrelor to 12 months then stop. Review 6 months.” HCA (3 weeks ago, flu vaccine): BP 126/78, HR 56. HbA1c 41 mmol/mol a year ago. BMI 28.
Reason for contact
Telephone appointment: “Private — would like to discuss with doctor.”
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)
Erectile dysfunction after MI is usually multifactorial: vascular disease, medicines (beta-blockers, thiazides), anxiety about exertion, and relationship strain. Always ask about medicines bought online or over the counter — unregulated “herbal” or generic products often contain undeclared or variable doses of PDE-5 inhibitors. PDE-5 inhibitors are absolutely contraindicated with nitrates (GTN, isosorbide) and nicorandil because of profound hypotension; sildenafil SPCs also list recent MI or stroke and hypotension below 90/50 as contraindications. After an uncomplicated MI, sexual activity is usually safe once the patient can manage moderate exertion without symptoms. NICE suggests continuing a beta-blocker for 12 months after MI in people without reduced LVEF and then discussing whether to stop — a natural point to review bisoprolol with cardiology. Respecting a patient’s preference for fewer medicines often means reviewing what he already takes before adding something new.
The guidance behind it
Similar SCA cases
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