SCA practice case · Telephone consultation
“The nurse said my heart tracing wasn’t quite right — what does that mean?”
Telephone consultation
Older adult patient
Typical
Investigations & resultsLong-term conditions & cancerOlder adults
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
Tariq Mahmood · 72-year-old man
Setting
Telephone — results call after an ECG taken by the practice nurse at a routine review this morning.
Past history
- Hypertension (2014)
- Type 2 diabetes (2019)
- Osteoarthritis of both knees
Medication
- Amlodipine 10 mg once daily
- Ramipril 5 mg once daily
- Metformin 500 mg twice daily
- Aspirin 75 mg once daily (started 2016 — no vascular event recorded)
- Ibuprofen 400 mg — bought over the counter, “most days for the knees” (nurse note)
Allergies
No known drug allergies
Recent notes
Practice nurse, diabetes review this morning: pulse irregular, about 110/min. BP 146/88 (repeat 142/86). SpO2 97%. “No symptoms.” 12-lead ECG (nurse-acquired, 25 mm/s, 10 mm/mV): ventricular rate 112/min; rhythm irregularly irregular; no discernible P waves, fine fibrillatory baseline; QRS axis +20°; PR not measurable; QRS 94 ms; QT/QTc 340/432 ms; no ST elevation or depression; T waves normal; no LVH by voltage criteria; no pathological Q waves. No previous ECG on file. Bloods 2 weeks ago: Hb 138 g/L, platelets 210, creatinine 92 µmol/L, eGFR 68, K 4.6, ALT 22, TSH 1.8, HbA1c 52 mmol/mol. Weight 82 kg.
Reason for contact
Telephone call to discuss his ECG result.
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)
New AF found incidentally needs a structured telephone consultation: confirm the ECG findings (irregularly irregular, no P waves, rate 112, no ischaemia), screen for features requiring emergency or same-day care (haemodynamic instability, chest pain, heart failure, syncope, stroke symptoms, onset under 48 hours if rhythm control is being considered), and make a shared anticoagulation decision. NICE uses CHA2DS2-VASc for stroke risk (anticoagulate if 2 or more; consider in men with 1) and ORBIT for bleeding risk, addressing modifiable bleeding risks (here aspirin without a vascular indication and over-the-counter NSAIDs). Offer a DOAC (apixaban, dabigatran, edoxaban or rivaroxaban) dosed by creatinine clearance, age and weight. Do not withhold anticoagulation on the basis of falls risk or age alone, and do not use aspirin for stroke prevention in AF. Rate control (beta-blocker or rate-limiting calcium-channel blocker) is first-line for most; arrange echocardiography; check TFT, U&E, FBC, LFT; consider triggers such as alcohol and sleep apnoea. DVLA: Group 1 drivers need not notify AF unless it causes distracting or disabling symptoms. Explain risk with natural frequencies and address personal fears, such as a relative’s bleed on warfarin and travel plans.
The guidance behind it
Similar SCA cases
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