SCA practice case · Telephone consultation
“Worst headache of my life”
Telephone consultation
Adult patient
Typical
Urgent & unscheduled careNew & undifferentiated presentations
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
Luke Brennan · 34 years · male
Setting
Telephone — sudden severe headache.
Past history
- Nil significant
Medication
- No regular medication
Allergies
None recorded
Recent notes
⚠ Reception note: “bad headache since gym this morning, wants co-codamol, says not urgent”.
Reason for contact
Telephone call. “Could you just put me through some strong co-codamol?”
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 thunderclap headache — sudden onset reaching maximum intensity within seconds to a minute, often "the worst ever", classically occipital with neck stiffness and vomiting, frequently triggered by exertion/straining/sex — is subarachnoid haemorrhage until proven otherwise and is a medical emergency. The two classic traps are both present here: being falsely reassured by partial improvement ("it’s settled") and accepting the patient’s "just a migraine" reframe — the ONSET profile defines the risk, not current severity. The action is 999/A&E for urgent CT (NICE NG228: CT within 6 hours of onset is highly accurate and a negative scan then does not routinely need LP; after 6 hours, a negative CT is followed by LP at least 12 hours after onset), never a phone analgesic. The examinable hidden agenda is the cocaine taken last night, minimised from embarrassment — directly relevant (it can precipitate SAH/RCVS) and elicited only through a calm, non-judgemental drug history framed as care. Reach the buried fear (a relative’s "brain bleed") to motivate acceptance, screen briefly for meningitis features, and safety-net emphatically.
The guidance behind it
Similar SCA cases
gpreasoning.uk is not affiliated with or endorsed by the RCGP. Our cases are original teaching material written for practice; none is an exam recall. For anything official about the SCA, check the RCGP SCA pages.