SCA practice case · Telephone consultation
“Since the stroke clinic gave me these tablets I feel dizzy and achy — I want to stop them”
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
Gloria Mensah · 58-year-old woman
Setting
Telephone — routine appointment requested by the patient 12 days after a TIA clinic review.
Past history
- TIA 15 days ago — right arm weakness and expressive dysphasia for 25 minutes
- Hypertension (10 years)
- Pre-diabetes (HbA1c 44, last year)
Medication
- Amlodipine 10 mg once daily
- Losartan 100 mg once daily (increased from 50 mg by TIA clinic 12 days ago)
- Atorvastatin 80 mg at night (new)
- Clopidogrel 75 mg once daily (new)
Allergies
Ramipril — persistent dry cough (2019)
Recent notes
TIA clinic letter (12 days ago): “Probable left hemisphere TIA. CT and CT angiography: no acute abnormality; carotids <50% stenosis bilaterally. ECG sinus rhythm; 72-hour monitor: no atrial fibrillation. LDL 3.9 mmol/L, non-HDL 4.6. BP 154/86 (three readings, lowest 150/84). Plan: clopidogrel 75 mg, atorvastatin 80 mg, losartan increased to 100 mg — please check U&E in 1–2 weeks and titrate BP to below 130/80. Advised not to drive for one month.” No U&E since.
Reason for contact
Telephone appointment: “Side effects from new tablets.”
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)
When a patient blames new medicines, take the symptom seriously and look for a mechanism before stopping anything. Ask exactly how each tablet is taken — duplicated doses after a change (old stock in a pill organiser plus a new box) are common. Remote consultations can still gather data: a validated home monitor gives seated and standing readings (a systolic fall of 20 mmHg or more, or a diastolic fall of 10 or more, is postural hypotension). After a TIA, antiplatelet therapy and high-intensity statin are the key preventive treatments; the BP target is usually below 130/80, but postural symptoms and falls take priority. An ARB dose increase needs U&E (creatinine, potassium) in 1–2 weeks. For statin muscle symptoms: check CK; if 4–10 × the upper limit of normal or symptoms are intolerable, stop for 4–6 weeks (more than 10 ×: same-day assessment); otherwise consider a pause and rechallenge, a lower dose or another statin. Change one medicine at a time so the cause can be identified. A Black African or Caribbean family origin is relevant to antihypertensive choice (ARB rather than ACE inhibitor) — and here she also has a documented ACE-inhibitor cough. Car drivers must not drive for one month after a TIA.
The guidance behind it
Similar SCA cases
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