Cases/Urgent & Unscheduled care

Breathlessness and Sharp Chest Pain — Free SCA Practice Case

Asthmatic pilot on the pill with breathlessness and sharp chest pain

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Priya Nair

Age

28 years

Consultation Type

Telephone

Age

Situation

Urgent Telephone Consultation.

Reason for Encounter

"I've been getting short of breath and a sharp pain in my chest. I think my asthma's playing up — can I have some steroids?"

Medical Records

●PMH: Asthma (mild; diagnosed in childhood, generally well controlled).
●Medications: Inhaled corticosteroid/formoterol inhaler. Combined oral contraceptive pill — started 3 months ago.
●Allergies: NKDA.
●Recent notes: Asthma review 7 months ago — good control, no exacerbations in the previous year, no oral steroid courses.
●Occupation recorded: Commercial airline pilot (long-haul).

Patient Script

For the friend playing the patient role

Character Overview: You are Priya, a 28-year-old long-haul commercial pilot. For the past two days you have been breathless — noticeably worse than your usual asthma — and since yesterday you have had a sharp pain in the right side of your chest that is worse when you breathe in deeply. Your reliever inhaler has made no difference at all, which is unusual for you. You returned four days ago from a long-haul rotation involving two flights of over ten hours each. You started the combined pill about three months ago. Your right calf has been aching for a few days, which you put down to being on your feet. You feel your heart racing at times. You have no cough, no wheeze, no fever, and no phlegm. You have assumed this is an asthma flare and you want a course of steroids so you can get back on the flight roster. You are articulate and used to being decisive; you will push back initially if told you need urgent assessment, because it will affect your roster.

Opening Sentence: "Hi Doctor. I've been short of breath for a couple of days and I've got a sharp pain on the right side of my chest when I breathe in. I'm asthmatic, so I assume it's a flare — my inhaler isn't touching it though. Could I get a course of steroids? I'm due back on the roster."

History if Asked (Data Gathering Phase)

●The breathlessness: "Two days now. Worse than my usual asthma — I'm breathless just walking around the flat."
●The chest pain: "Sharp, right side, definitely worse when I take a deep breath in. It came on yesterday."
●Response to her inhaler: "That's the odd thing — the inhaler has made no difference at all. Normally it helps straight away."
●Absence of usual asthma features: "No wheeze, no cough, no phlegm. That's not like my asthma either, now I think about it."
●Recent travel: "I got back four days ago from a long-haul rotation — two flights over ten hours each."
●The pill: "I started the combined pill about three months ago."
●What she wants: "Steroids, and to be signed fit for the roster. I've got a flight in three days."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.

●Ideas: Priya is convinced this is an asthma exacerbation. "It must be my asthma — that's the only chest problem I've ever had."
●Concerns: Her dominant concern is being taken off the flight roster and the effect on her career; when explored, she is also unsettled that her inhaler is not working. "Honestly, my worry is the roster and my licence. But it does bother me that the inhaler isn't doing anything."
●Expectations: She expects oral steroids and to carry on working. "A course of steroids and I'll be fine."

If Asked — PE, DVT, and Differential Screen

The patient answers these only when directly asked.

●If asked about pleuritic quality (pain worse on deep inspiration): "Definitely worse when I breathe in deeply, and when I cough."
●If asked about calf pain or swelling — key: "My right calf has been aching for a few days. I thought it was from standing around in airports. It might be a bit swollen, actually." (DVT symptoms.)
●If asked about palpitations or a racing heart: "Yes, my heart feels like it's racing at times."
●If asked about haemoptysis: "No, I haven't coughed up any blood."
●If asked about syncope, presyncope, or dizziness: "I felt light-headed standing up yesterday, but I haven't fainted."
●If asked about long-haul flights and immobility — key: "Four days ago. Two flights of over ten hours each, and I was sitting for most of them."
●If asked about the combined pill — key: "Started three months ago. Nobody mentioned clots to me."
●If asked about previous VTE, or family history of clots: "No previous clots. My aunt had a clot in her leg after an operation, I think." (Possible family history.)
●If asked about recent surgery, immobility, trauma, or malignancy: "No surgery, no injuries, nothing like that."
●If asked about pregnancy: "Not pregnant — I'm on the pill and my last period was normal two weeks ago."
●If asked about smoking: "I don't smoke."
●If asked about fever, productive cough, or coryzal symptoms: "No fever, no cough, no cold symptoms." (Argues against infection.)
●If asked about peak flow (if she has a meter): "I've got a meter. I did it this morning — it's actually near my normal best, which surprised me." (Argues strongly against an asthma exacerbation.)
●If asked about whether she can speak in full sentences / severity now: "I can talk to you fine, but I'm breathless moving about."

Responses to Management (The Negotiation Phase)

●If the Doctor explains this does not sound like asthma — key: "So the fact my inhaler isn't working, my peak flow is normal, and I've got no wheeze — that all points away from asthma? I hadn't put that together." (The tested point is not anchoring on the asthma label.)
●If the Doctor raises the possibility of a blood clot on the lung: "A clot? On my lung? Because of the pill and the flying?" (The tested point is recognising and explaining PE risk.)
●If the Doctor explains she needs same-day assessment — the negotiation: "Today? I've got a flight in three days and I really can't afford to be grounded." (The tested point is converting this into same-day assessment and holding firm.)
●If the Doctor explains the calf symptoms: "So my calf might be where the clot started? I genuinely thought it was just from standing about."
●If the Doctor explains the occupational implications: "If it is a clot, what does that mean for my licence and flying? I'd need to know." (The tested point is acknowledging the occupational dimension honestly.)
●If the Doctor safety-nets: "And if I get suddenly worse, or collapse, or cough up blood — 999. Understood."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 24 indicators checked+0−0

Positive (0/12)

Negative (0/12)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Beware the Diagnostic Anchor

●A pre-existing label such as asthma is a powerful anchor. Features that should prompt a rethink include pleuritic pain, absence of wheeze or cough, no response to the usual reliever, and a peak flow near personal best. Always ask what is different this time.

Recognising Suspected Pulmonary Embolism

●Suspect PE with breathlessness, pleuritic chest pain, tachycardia or palpitations, haemoptysis, syncope or presyncope, particularly with risk factors. Always examine or ask about the legs — concurrent DVT symptoms are common and highly informative.

Thrombotic Risk Factors

●Key risk factors include combined hormonal contraception, prolonged immobility including long-haul travel, pregnancy and the postpartum period, recent surgery, trauma, or immobilisation, malignancy, previous VTE, thrombophilia and family history, obesity, smoking, and increasing age. Here two significant factors coincide — the combined pill and repeated long-haul flights.

Same-Day Assessment and the Diagnostic Pathway

●Suspected PE requires same-day assessment. The pathway uses clinical probability scoring (e.g. Wells), with D-dimer only meaningful in the appropriate probability group, and CTPA (or V/Q scanning where indicated) for definitive diagnosis. Escalate to 999 if the patient is haemodynamically unstable or severely breathless.

Do Not Treat the Wrong Diagnosis

●Prescribing oral corticosteroids for a presentation that is not an asthma exacerbation both fails to treat the real problem and delays diagnosis of a potentially fatal condition.

Contraceptive and Occupational Consequences

●If VTE is confirmed, the combined hormonal contraceptive must be stopped and alternative contraception arranged. Consider occupational implications honestly — for a commercial pilot, a confirmed PE has consequences for fitness to fly and aviation-medical certification, and she should not fly pending assessment.

Safety-Netting

●Safety-net explicitly for worsening or resting breathlessness, collapse or syncope, haemoptysis, or severe chest pain → 999, and hand over to the receiving service so the patient is expected.

Common Candidate Mistakes in This Case

●Anchoring on asthma: prescribing steroids and managing remotely — the defining error.
●Not asking about the legs: missing the concurrent DVT symptoms that make PE far more likely.
●Missing the risk factors: failing to connect the combined pill and long-haul flying to thrombotic risk.
●Allowing her roster to delay assessment: yielding to the patient's timetable on a time-critical presentation.
●Ignoring or fudging the occupational implications: giving falsely reassuring answers about flying and her licence.

Free MRCGP SCA practice case for GP registrars covering Breathlessness and Sharp Chest Pain — Urgent & Unscheduled care. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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