SCA practice case · Telephone consultation
“They said it was my fault for eating wrong”
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
Tomasz Wójcik · 38 years · male
Setting
Telephone — diabetes review; tablets not seeming to work.
Past history
- “T2DM” — diagnosed 4 months ago (HbA1c 79)
- BMI 23 at diagnosis
Medication
- Metformin
- Gliclazide
Allergies
NKDA
Recent notes
⚠ Coded as type 2 diabetes on HbA1c alone. No ketones, GAD antibodies or C-peptide on file. Gliclazide added for rising glucose.
Reason for contact
Telephone: “Sugars still high despite tablets — wants stronger medication.”
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)
The classic SCA diabetes trap: a slim, young adult labelled "type 2" on the HbA1c alone who is actually insulin-deficient — LADA / late-onset type 1. The flags are unmistakable once looked for: slim build, unintentional weight loss, marked osmotic symptoms, no family history of T2DM, a viral prodrome, and rapid failure of oral agents. The danger is twofold: ongoing wrong treatment (a sulfonylurea that depends on the beta cells he is losing, plus dietary restriction that worsens catabolism and ketosis) and an evolving DKA that no one has screened for. Assess acute safety first (ketones, DKA features, low threshold to admit), get urgent specialist input, consider antibodies/C-peptide because the type is uncertain (NICE NG17: not routine, but considered when the type is in doubt) without delaying safety, and recognise he needs insulin not stronger tablets. The examinable hidden agenda is the blame: family and the initial diagnosis framed it as his dietary fault, and he is shamefully starving himself to atone. Lift that blame explicitly — autoimmune diabetes is not caused by eating badly — stop the self-starvation, and deliver the reframe with both compassion and urgency.
The guidance behind it
Similar SCA cases
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