SCA practice case · Video consultation
“I ache everywhere and I’m exhausted — I just want a scan to find out what’s causing it”
Video consultation
Adult patient
Typical
New & undifferentiated presentationsLong-term conditions & cancerInvestigations & results
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
Joanne Riley · 46-year-old woman
Setting
Video — follow-up of blood tests for widespread aches and tiredness.
Past history
- Low mood 2019 — sertraline for 9 months, stopped
- Irritable bowel syndrome
- Migraine without aura (infrequent)
Medication
- Co-codamol 30/500 mg, 2 tablets up to four times a day when required — started by a locum 3 months ago; issued 4 times since
- Sumatriptan 50 mg when required
Allergies
No known drug allergies
Recent notes
Bloods 3 weeks ago for “aching all over and exhausted”: FBC, ESR 8, CRP 3, U&E, LFT, bone profile, TSH, CK, HbA1c, ferritin 64 µg/L, vitamin D 58 nmol/L, coeliac serology — all normal. Physiotherapy letter (2 weeks ago): “Widespread soft-tissue tenderness. Full range of movement in all joints, no synovitis. Neurological screen normal. Very fatigued and tearful. Reluctant to exercise — worried it will make the pain worse.”
Reason for contact
Video appointment to discuss her results and “next steps”.
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)
Chronic widespread pain with fatigue, unrefreshing sleep and cognitive symptoms, normal inflammatory markers, thyroid and CK, and no synovitis or neurological signs is fibromyalgia — classified by NICE as chronic primary pain. The skill is a positive, validating diagnosis after a targeted screen for alternatives (inflammatory arthritis, connective tissue disease, PMR over 50, myositis, hypothyroidism, neurological disease, malignancy features), not a diagnosis of exclusion delivered as “there’s nothing wrong”. Address the specific fear (here MS) by naming the features that would change the plan; more imaging finds incidental abnormalities and reinforces illness worry. NICE recommends supervised group exercise programmes, psychological therapies (CBT or ACT), acupuncture within a defined course, and considering an antidepressant (amitriptyline, citalopram, duloxetine, fluoxetine, paroxetine or sertraline) for pain, quality of life and sleep after discussing benefits and harms. Do not start opioids, gabapentinoids or other antiepileptics, NSAIDs, paracetamol, benzodiazepines, antipsychotics or ketamine for chronic primary pain; if she is already taking them, review and agree a shared, gradual reduction. Daily codeine with morning headaches suggests medication-overuse headache. Screen mood and suicidal thoughts; support work with a fit note and adjustments.
The guidance behind it
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