SCA practice case · Video consultation
“I’m here for my hand X-ray and blood results — the one test was negative, so that’s good, isn’t it?”
Video consultation
Adult patient
Typical
Long-term conditions & cancerInvestigations & resultsGender, reproductive & sexual health
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
Sofia Marchetti · 29-year-old woman
Setting
Video — results follow-up booked after a locum GP examined her hands and requested tests.
Past history
- No significant past history
- Combined pill — last prescription 6 months ago, not re-issued
Medication
- No regular medicines recorded
Allergies
No known drug allergies
Recent notes
Locum GP (face-to-face), 12 days ago: “10 weeks of pain, swelling and stiffness of both hands, worse in the morning (over an hour), also balls of both feet. O/E: soft-tissue swelling and tenderness 2nd and 3rd MCPs both hands; MCP squeeze test positive bilaterally; MTP squeeze positive left. Wrists, elbows, knees normal. No rash, no nail changes. Temp 36.8 °C. Plan: bloods, X-ray hands and feet, results with GP.” RESULTS (see packet): Rheumatoid factor 26 IU/mL (reference less than 20); anti-CCP antibody 4 U/mL (reference less than 10 — negative); ESR 48 mm/hour (reference 1–20); CRP 21 mg/L (reference less than 5); Hb 114 g/L (115–165), MCV 86 fL (80–100); platelets 428 × 10⁹/L (150–400); WCC 8.1 × 10⁹/L (4.0–11.0); U&E, LFT, bone profile and TSH normal. X-ray both hands and feet (reporting radiographer): “Periarticular osteopenia at the MCP joints. Small marginal erosion at the radial aspect of the right 2nd metacarpal head and at the left 5th metatarsal head. Joint spaces preserved. Appearances suggest an early inflammatory erosive arthropathy.”
Reason for contact
Video appointment to discuss blood test and X-ray results.
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)
In suspected inflammatory arthritis, serology is supportive, not decisive: around a third of people with rheumatoid arthritis are seronegative, and early erosions with raised inflammatory markers and clinical synovitis of the small joints make the diagnosis probable whatever the anti-CCP shows. NICE NG100 recommends urgent referral for persistent synovitis of unknown cause, especially if the small joints of the hands or feet or more than one joint are affected, and the quality standard is assessment within 3 weeks of referral — erosions at ten weeks make this even more pressing. The GP role is not to start disease-modifying treatment but to refer quickly, give honest information, manage symptoms safely and spot what will change specialist decisions. Here the key question is about pregnancy: NSAIDs may reduce fertility and are generally avoided in pregnancy, methotrexate and leflunomide are teratogenic, while hydroxychloroquine, sulfasalazine and some biologics are compatible with conception and pregnancy. Telling her that a pregnancy plan is part of rheumatology care — not an obstacle to it — turns fear into a plan.
The guidance behind it
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