Cases/Urgent & Unscheduled care

Breathlessness and Sharp Chest Pain — Free SCA Practice Case

New mother 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

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Kavita Desai

Age

33 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. Urgent call requested by the patient.

Reason for Encounter

"I've been out of breath on the stairs for two days and I've got a sharp pain in my chest. I think it's just tiredness."

Medical Records

●PMH: Emergency caesarean section 5 weeks ago, first baby. Enoxaparin injections for 10 days after discharge. BMI 31 at booking. Panic symptoms aged 24.
●Medications: None on repeat.
●Allergies: NKDA.
●Social: Conveyancing paralegal, on maternity leave. Lives with husband and baby. Never smoked.

Recent Notes

●Postnatal: Health visitor contact at 2 weeks.

Patient Script

For the friend playing the patient role

Character Overview: You are Kavita Desai, a 33 year old conveyancing paralegal at a firm of solicitors, currently on maternity leave. You live in a two storey house with your husband Jai, a regional sales manager, and your daughter Anaya, who is five weeks old and your first baby. Anaya was born by emergency caesarean after a long labour that stopped progressing. You have been home for about four and a half weeks. Jai is away at a work conference two hours away and is not back until tomorrow evening, so you are alone with Anaya today. Your mum, Usha, lives nearby. For two days you have been getting out of breath on the stairs, and since yesterday morning you have had a sharp pain low on the right side of your chest when you breathe in. You are sure it is tiredness and anxiety, because you sleep three or four hours a night and your health visitor said new mums often feel anxious. You are polite and apologetic, keen not to be a nuisance, and you play things down. You sound a little breathless between phrases but speak in full sentences.

Opening Sentence: "Hi, sorry to bother you. I've been getting out of breath on the stairs for a couple of days and I've got a sharp pain in my chest when I breathe in. I think it's probably just tiredness and my anxiety, but my husband's away and I wanted to check."

History if Asked (Data Gathering Phase)

●The breathlessness: "It started two days ago. I go upstairs to change Anaya and I have to stop halfway and get my breath back. Today I got breathless walking from the lounge to the kitchen. If I sit still I'm fine. About a week ago I walked to the shop and back with the pram and was okay, so it's new."
●The chest pain: "It started yesterday morning. It's low down on the right side of my chest, a sharp stabbing pain, when I take a deep breath in or cough. About six out of ten when I breathe in deeply. When I sit still and breathe gently it's barely there."
●What it is not like: "It doesn't spread to my arm or jaw, it isn't a heavy or squeezing feeling, and it doesn't come on when I walk unless I take a big breath. Leaning forward doesn't change it. Paracetamol didn't do anything."
●How it feels to talk now: "I can talk fine, I just need a breath every so often. I'm not struggling when I'm sitting on the sofa."
●Pulse: "My smartwatch said my resting heart rate was 108 this morning. It's normally in the seventies. I did notice my heart thumping when I came downstairs."
●Dizziness: "I felt a bit light headed when I stood up yesterday, but I held the wall and it passed. I haven't fainted."
●Cough and temperature: "An occasional dry tickle, no phlegm, and I haven't coughed up any blood. I haven't felt hot or shivery."
●The legs: "Now you mention it, my right calf has been aching for about ten days. It's tender if I squeeze it and it looks a bit fatter than the left. I thought it was from sitting curled up on the sofa feeding Anaya."
●Timing: "It's the same today as yesterday, maybe the breathlessness is a little worse."

Ideas, Concerns, Expectations

Gating note: Kavita does not volunteer any of this. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her or what she was hoping for.

●Ideas: She thinks it is tiredness, anxiety and being unfit after the operation. "At the antenatal class they said new mums get anxious. I had a panic attack once when I was 24 and this feels a bit like that, tight and breathless. I'm just out of shape after the caesarean."
●Concerns: She does not want to waste anyone's time on a busy day. Under that, if asked what worries her most, she is afraid it could be her heart, because her father had a heart attack at 58. She is also afraid of going anywhere and leaving Anaya with nobody to look after her. "I feel stupid even ringing. But my dad had his heart attack at 58 and I did wonder. And I can't just leave the baby, can I?"
●Expectations: She hoped for reassurance over the phone, perhaps a blood test for iron or her thyroid, and something to help her sleep and calm down. "I thought you might say it's anxiety and give me something. Or send me for bloods next week."

If Asked: Medical History and Medications

Gating note: Kavita answers each of these when asked.

●Pregnancy and birth: "A normal pregnancy. I was induced after my due date, the labour stopped progressing and I had an emergency caesarean. I lost an ordinary amount of blood and didn't need a transfusion. I was in hospital three days. The scar is healed with no discharge, redness or fever."
●Injections: "I did the blood thinning injections in my tummy for ten days after I came home and I did every single one. I stopped about three weeks ago."
●Previous clots and family: "I've never had a clot. Nobody in the family has had one that I know of. My mum has varicose veins. My dad had the heart attack at 58."
●Other health and medicines: "Nothing apart from the panic attack at 24. I take occasional paracetamol and nothing else. I'm not on any contraception yet. No allergies."
●Smoking: "I've never smoked."
●Bleeding: "The bleeding after the birth stopped about three weeks ago and I haven't had any since."

Social History and Lifestyle Impact

●Home today: Kavita is alone with Anaya, who is asleep in her Moses basket and is due a feed in about forty minutes. Jai is two hours away and cannot get back before tomorrow evening. Usha does not work and could be at the house within twenty minutes of a phone call, and can drive. Kavita has not driven since the operation.
●Feeding and sleep: Anaya has been on formula since the second week. Kavita gets three or four broken hours a night and has been tearful on and off, but not low, and she is enjoying Anaya.
●Alcohol and drugs: None.
●Availability to be seen: She can do whatever is needed as long as someone can have Anaya. She would call Usha.

If Asked: Associated Symptoms

Gating note: Kavita answers these only when asked. Every one is negative unless stated.

●If asked about breathlessness lying flat or waking at night short of breath: "No, I sleep flat when I get the chance."
●If asked about swollen ankles or both legs swollen: "No, only the right calf."
●If asked about fever, a productive cough or a chest infection: "No."
●If asked about chest pain on exertion, pain spreading, sweating or nausea: "No, nothing like that."
●If asked about mood, low mood or thoughts of harming herself or the baby: "I cry now and then when I'm exhausted but I'm not low and I love her to bits. No thoughts of hurting myself or her."
●If asked about heavy bleeding, tiredness beyond normal or looking pale: "No heavy bleeding. I'm tired but no more than you'd expect."

Responses to Management (The Negotiation Phase)

●
If the doctor says she needs to go to hospital now or today for assessment:
- ●Reaction: Apologetic and doubtful. "Today? Are you sure? I really thought it was just anxiety and I don't want to waste anyone's time." She accepts if the doctor explains calmly that this can be serious after a recent birth and needs checking quickly. "Okay. If you think I should. Jai is away and I've got Anaya." If offered a routine slot, a blood test next week or reassurance that it is probably anxiety: "Okay, if you think that's alright. I'll wait and see how I am tomorrow." She does not press for an urgent plan unless the doctor leads her to it.
●
If the doctor asks how she will get there, or suggests an ambulance:
- ●Reaction: Practical. "I can't drive myself. My mum can drive me if you think that's better than an ambulance. She'd be here in about twenty minutes." If told to call 999 instead, or not to delay: "Right, I'll ring now." She asks, "Should I wait for my mum or go straight away?" and "What do I do about Anaya?"
●
If the doctor says it could be a blood clot or explains why she is at risk:
- ●Reaction: Taken aback. "A clot? But I did all my injections. Doesn't that mean I'm protected?" She asks, "Is it from my leg?" and "Could I have had it for days?" She is frightened but steadier when the doctor explains the reasons plainly.
●
If the doctor explains what will happen at hospital:
- ●Reaction: Wants specifics. "Will they scan me? Will I need injections? Will I have to stay in?" She asks, "Can I take Anaya with me?" and "How long will I be there?" She is comforted if told that someone can be called to take Anaya or come to the hospital.
●
If the doctor offers to pass on her details or call ahead:
- ●Reaction: Relieved. "Oh good, so they'll know I'm coming? I wouldn't know what to say." She asks which hospital and where to go.
●
If the doctor gives safety netting while she waits for her mum or an ambulance:
- ●Reaction: Wants specifics. "What if I get worse before she gets here?" If safety netting is vague, such as "ring if it gets worse": "Worse how? What would make me dial 999 rather than wait?" She repeats it back clearly when given specific symptoms, such as worse breathlessness, fainting, coughing up blood or severe chest pain.

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

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 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Kavita is 33 and five weeks after an emergency caesarean. She has two days of new breathlessness on the stairs, a day of sharp right sided pain on breathing in, and a right calf that has ached for ten days. She is sure it is tiredness and anxiety, and she apologises for ringing. The station tests whether the candidate recognises a possible pulmonary embolism (PE, a clot in the lung arteries) in the postnatal period and arranges immediate hospital assessment, despite a plausible and reassuring explanation offered by the patient.
●The model plan has six parts. Take a focused history that finds the calf symptoms, the postnatal risk and her current stability. Say plainly that a clot in the lung is possible. Arrange assessment in hospital today, without waiting, by ambulance or with her mother driving her straight there, not by driving herself. Telephone ahead. Arrange care for the baby. Give specific advice on when to call 999 while she waits.
●Acceptable alternatives: calling 999 for an ambulance, or accepting a lift from her mother if she leaves at once and her condition is no worse. Either is reasonable because she is breathless on exertion but comfortable at rest and speaking in full sentences. Directing her to the emergency department or to a local acute assessment unit (medical or obstetric) is equally acceptable, as long as she is seen the same day without delay. A candidate who starts interim anticoagulation because transfer will be delayed is also within guidance, but it is not expected for this call.

Why the First Six Weeks After Birth Matter

●NICE Clinical Knowledge Summaries (CKS, Pulmonary embolism, revised September 2023) list pregnancy, and in particular the six weeks after delivery, among the major risk factors for PE. Other contributors here are emergency caesarean surgery, a body mass index (BMI) above 30 and reduced mobility.
●Venous thromboembolism (VTE) remains a risk after preventive injections end. Kavita's belief that finishing enoxaparin protects her is understandable, but the injections lower the risk without removing it, and she is still inside the six weeks.
●This is a typical anchoring trap. A tired, anxious young woman offers an innocent explanation, and breathlessness and a fast pulse overlap with panic. The pain on deep breathing, the calf and the heart rate of 108 do not fit.

Recognising Possible PE on the Telephone

●CKS advise suspecting PE in someone with breathlessness, chest pain, haemoptysis (coughing up blood), syncope or presyncope, a fast breathing rate or features of deep vein thrombosis (DVT), especially when risk factors are present. A pleuritic pattern is classic: sharp pain that is worse on a deep breath or cough and barely present when still.
●The key discriminators to elicit are calf pain, tenderness or swelling on one side, a resting heart rate above her normal, light headedness, no fever or productive cough, and no wound infection. Asking about the legs is essential, because Kavita does not volunteer it.
●Safe disposition depends on stability. Breathlessness at rest, fainting, low blood pressure, a very fast heart rate, or any difficulty speaking in sentences should lead to 999 rather than a lift. Kavita is stable at present, which is why a mother driving her is acceptable.
●The wider differential (pneumonia, pneumothorax, an acute coronary event, pericarditis, peripartum cardiomyopathy, anaemia, anxiety) cannot be excluded by telephone, and the hospital pathway covers it.

Why Risk Scores and D Dimer Are Not Used Here

●For most adults with suspected PE, CKS and NICE guideline NG158 (Venous thromboembolic diseases) use the two level PE Wells score to estimate clinical probability. A score above 4 points means PE is likely and leads to immediate computed tomography pulmonary angiogram (CTPA). A score of 4 or less leads to a D dimer test with the result within 4 hours.
●CKS make an explicit exception. Immediate hospital admission should be arranged for anyone with suspected PE who is haemodynamically unstable, or who is pregnant or has given birth within the past 6 weeks. The reasons given are that there is no evidence supporting the Wells score in pregnancy and that D dimer is often raised in pregnancy and so is of limited use.
●This is the central knowledge point. Kavita is within six weeks, so she does not go through a score or a blood test in the community. A candidate who works out a score in their head and still sends her to hospital is safe. One who uses the score or a D dimer to decide whether she needs to go is not.

Transport, Escort and the Baby

●She has not driven since the operation and should not drive. Waiting until her husband returns tomorrow evening is not safe. Her mother can reach the house in about twenty minutes and drive, so either an ambulance now or her mother taking her directly is reasonable.
●Whoever takes her should bring Anaya or arrange care for her, so the baby does not become the reason Kavita delays. Asking her to ring her mother during the call is a practical safety step.
●The candidate should telephone the receiving unit with the history, the findings and the mode of transport. This allows imaging to be organised quickly and avoids Kavita repeating her story while breathless.

What Hospital Will Do and What Follows

●Hospital assessment is likely to include observations, an ECG and chest X ray, and then definitive imaging (CTPA or, in some units, a ventilation perfusion scan). Anticoagulation is commonly started before imaging when clinical suspicion is high and imaging is delayed, and CKS describe offering interim therapeutic anticoagulation in that situation.
●If PE is confirmed, she will be anticoagulated, and treatment continues for a period set by the hospital team. Primary care follow up should check that treatment is monitored, that she has an anticoagulant booklet and alert card, and that her wellbeing and postnatal check are not forgotten.
●Contraception will need review once the diagnosis is known, because combined (oestrogen containing) hormonal contraception is UKMEC category 4 (unacceptable risk) after a VTE, while progestogen only and copper methods are options to discuss. This belongs to the follow up and should not be raised in a way that distracts from the urgent plan.

Safety Netting While She Waits

●Advice should be specific and tied to an action. If she becomes more breathless, feels faint or collapses, coughs up blood, has worsening chest pain, or feels her heart racing and unwell, she should call 999 immediately and not wait for her mother. Until help arrives she should sit upright, stay still and keep the front door unlocked.
●"Ring again if it gets worse" is not enough; she must be told which changes mean an emergency.

Common Mistakes in This Station

●Accepting the anxiety and tiredness explanation, offering reassurance, a sleep aid, bloods next week or a routine appointment.
●Not asking about the legs, so the likely clot source is missed.
●Using a Wells score or D dimer to decide whether she needs hospital, or asking her to come to the surgery for tests first, when she is within six weeks of delivery.
●Assuming that completing the injection course made a clot unlikely.
●Letting her drive herself, or waiting for her husband to return, or not dealing with who will look after the baby.
●Giving a vague safety net, not phoning ahead, and not recording what was done.
●Frightening her by stating she definitely has a clot, or reassuring her falsely that her heart is fine.

Mapped to the RCGP curriculum topic: Urgent & Unscheduled care.

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