Cases/Urgent & Unscheduled care

Examination Expected — Free SCA Practice Case

Remote Triage of the Acute Headache - examination expected

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

Jake Thorne

Age

22 years

Consultation Type

Video

Age

22 (DOB: 11/04/2004)

Caller

Chloe (Girlfriend)

Situation

Video Consultation.

Reason for Encounter

"Girlfriend requesting an urgent house call. Triage note states: 'Jake has a severe headache and has been vomiting all morning. Too weak to come to the surgery. Please come and examine him.'"

Medical Records (Jake)

●PMH: Nil significant. University student.
●Medications: None.
●Allergies: NKDA.

Recent Notes

●None in the last 12 months.

Patient Script

For the friend playing the patient role

Character Overview: You are Chloe, Jake's 22-year-old girlfriend. You share a university flat. You are speaking to the doctor on a video call from the hallway outside Jake's bedroom. Jake started feeling "flu-y" yesterday evening. However, this morning he woke up with an agonizing headache that he describes as his head "bursting." He has vomited forcefully three times. He is currently lying in bed with the curtains tightly drawn because the light hurts his eyes. You want the GP to drive out to the flat, examine him, and give him an anti-sickness injection so he can sleep it off. You assume it is a severe migraine or a bad virus. The Remote Examination Reality: Jake is fully conscious but very unwell. If the doctor asks you to take the phone/tablet into the room to examine him on video, you will comply.

●Lights: He will groan and cover his eyes if you turn the lights on (Photophobia).
●Neck Stiffness: If the doctor asks him to touch his chin to his chest, he cannot do it; it causes severe pain shooting down his neck and back.
●Rash: He does not currently have a rash. You will not volunteer information about his aversion to light or his stiff neck unless the doctor specifically enquires or asks to perform a remote examination.

ICE — Ideas, Concerns, Expectations

Actor guidance: Chloe does not raise these unprompted. They surface only if the candidate directly explores her perspective or asks what she thinks is going on.

●Ideas: "Honestly, I think it's either a really bad migraine or some sort of flu virus. He's never had anything like this before, but his flatmate had a stomach bug last week so I thought maybe he'd caught that — but the headache is way worse than anything I'd expect from a bug."
●Concerns: "I'm scared because he's never been this ill. He can't even lift his head off the pillow and he's not the type to make a fuss. I just want someone to actually see him properly and make sure it's nothing serious."
●Expectations: "I was hoping you'd come out to the flat and check him over — maybe give him something for the sickness so he can at least keep water down and sleep. I just need someone to tell me he's going to be okay."

If Asked — Medical History and Medications

Actor guidance: Chloe can relay the following if the candidate asks about Jake's medical background. She knows him well and lives with him.

●If asked about past medical history: "He's never really been ill before, honestly. No operations, nothing. He's one of those annoyingly healthy people — or he was until today."
●If asked about regular medications: "He doesn't take anything. No tablets, no inhalers, nothing."
●If asked about allergies: "Not that I know of, no. He's never mentioned any allergies."
●If asked about drug or alcohol use: "He'll have a few beers on a night out, maybe once a week, but nothing heavy. He doesn't smoke and he definitely doesn't do drugs."
●If asked about recent illness or contacts: "His flatmate Tom had a stomach bug about a week ago — vomiting and diarrhoea for a couple of days. I wondered if Jake had caught it, but Tom didn't have a headache anything like this."

Social History and Lifestyle Impact

Actor guidance: Chloe will share this naturally in conversation if the candidate asks about Jake's daily life or how the illness is affecting him.

●Occupation / daily life context: Jake is a third-year university student — final year. They share a flat near campus. He had a deadline for a major dissertation chapter due on Monday and was working late on it yesterday before he started feeling unwell.
●Lifestyle impact of the condition: "He was supposed to submit a huge piece of coursework on Monday and now he can't even look at a screen. But honestly that's the least of my worries right now — I've never seen anyone look this ill. He can't keep water down, he won't eat, and he just lies there groaning. I had to help him to the bathroom earlier because he was so dizzy he nearly fell over."

Consultation Flow & Responses:

●The Opening:
●If the doctor asks an open question: "Hi Doctor. Jake is in a really bad way. He's got this agonizing headache and he's throwing up everywhere. He can't even stand up. Can you please come out to the flat and examine him? Maybe give him an injection for the sickness?"
●Data Gathering (The Layers):
●Layer 1: The Timeline (SAH vs. Meningitis):
●If asked if the headache was sudden ("thunderclap") or gradual: "It wasn't like a sudden crack, it just built up really fast overnight. But now it's constant and severe."
●Layer 2: The Red Flag Screen:
●If asked about fever: "He feels boiling hot to touch, but he's shivering."
●If asked about a rash: "I haven't noticed any spots, no."
●Layer 3: The Video Examination (Crucial):
●If the doctor asks to see him on video: "Okay, let me take the phone into the bedroom. It's very dark in here."
●If the doctor asks you to turn on the light or asks him to look at the screen: "Jake, look at the doctor. [Roleplay Jake groaning: "Turn it off, it burns my eyes!"] Sorry Doctor, the light is really hurting him."
●If the doctor asks you to check his neck movement (Chin to Chest): "Jake, the doctor says can you touch your chin to your chest? [Roleplay Jake trying and failing: "I can't, it's too stiff, my neck is killing me."]"

If Asked — Associated Symptoms

Actor guidance: Chloe relays these on Jake's behalf if the candidate asks. She is with him and can ask him or observe directly.

●If asked about sensitivity to noise: "Actually yes — I was washing up earlier and the clinking of the plates made him shout at me to stop. He said the noise was going through his head."
●If asked about drowsiness or confusion: "He's not confused exactly — he knows who I am and where he is — but he's really sluggish and just wants to be left alone in the dark."
●If asked about fits or seizures: "No, nothing like that. He's not had any kind of fit."
●If asked about weakness or numbness in arms or legs: "No, he can move everything. He's just too weak and dizzy to stand up properly."
●If asked about any change in vision (double vision, blurred vision): "He hasn't mentioned anything about his eyesight — just that the light hurts."
●If asked about ear pain or discharge: "No, he hasn't mentioned his ears at all."
●If asked about recent head injury: "No, he hasn't banged his head or anything like that."
●If asked about travel abroad recently: "No, we haven't been anywhere. We've been stuck revising all term."
●If asked about sore throat or cold symptoms before this: "He said he felt a bit achy and 'flu-y' yesterday evening — sore muscles, bit of a sore throat — but nothing that made either of us think twice."
●If asked about joint pain or body aches: "He said his whole body aches, like really bad flu. But no specific joint swelling or anything."
●If asked about appetite or fluid intake: "He hasn't eaten anything since last night and he can't even keep water down — it comes straight back up."
●If asked about urine output or last time he passed urine: "I don't think he's been to the toilet to wee since last night, actually. He's had nothing to drink because it all comes back up."
●If asked about breathing difficulties: "No, his breathing seems okay. He's not gasping or anything."
●If asked about a stiff or painful back: "He hasn't mentioned his back specifically, but he doesn't want to move at all."
●If asked about cold hands or feet, or unusual skin colour: "His hands do feel a bit cold and clammy, now you mention it. And he looks really pale — kind of grey, actually."

Negotiation & Collaborative Management Plan:

●If the Doctor agrees to a Home Visit:
●Reaction: "Thank you so much. We'll leave the front door unlocked for you. See you later this afternoon." (Candidate critically fails. Meningitis is a time-critical emergency; a routine GP house call will fatally delay IV antibiotics).
●If the Doctor tells you to drive him to A&E yourself:
●Reaction: "Drive him? I don't have a car! And he can't even sit up in a taxi, he's vomiting continuously. How am I supposed to get him there?" (Candidate fails for poor logistical safety and failing to recognize a 999 mandate).
●If the Doctor diagnoses suspected Meningitis and dispatches a 999 Ambulance:
●Reaction: Panicked but compliant. "An ambulance? Meningitis?! Oh my god. Okay. What should I do while we wait? Should I look for a rash?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 2: Clinical Management and Medical Complexity

0 / 18 indicators checked+0−0

Positive (0/9)

Negative (0/9)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

Distinguishing Bacterial Meningitis from Subarachnoid Haemorrhage

●The two most immediately dangerous causes of acute severe headache are bacterial meningitis and subarachnoid haemorrhage (SAH), and differentiating them during data gathering has direct diagnostic and communication implications.
●SAH classically presents as a thunderclap headache — sudden, explosive onset reaching maximum severity within seconds, often described as "the worst headache of my life." It may be associated with exertion, brief loss of consciousness, or a preceding sentinel headache (the "warning leak").
●Bacterial meningitis typically produces a headache that is severe but builds over hours, accompanied by systemic infective features — fever, rigors, malaise — and signs of meningeal irritation: nuchal rigidity, photophobia, and phonophobia.
●In this case, the headache built rapidly overnight with accompanying fever, vomiting, and inflammatory signs — a pattern far more consistent with meningitis. The absence of a thunderclap onset does not lower the clinical urgency: both diagnoses mandate immediate 999 transfer.
●Performing this differential explicitly during data gathering demonstrates diagnostic precision and protects against premature diagnostic closure on "migraine" or viral illness.

Remote Video Examination as a Clinical Tool

●A video consultation does not remove the obligation to examine a critically unwell patient. The video link must be actively used as a clinical instrument, with the third-party proxy directed to perform a structured bedside screen.
●Nuchal rigidity (neck stiffness): Instruct the proxy to ask the patient to touch their chin to their chest, and position the camera to observe the movement. Inability to complete the manoeuvre, or pain shooting into the neck and back on attempting it, is a positive finding.
●Photophobia: Do not simply ask "does light hurt?" — instruct the proxy to turn on the room lights and observe the patient's response directly on camera. An unambiguous pain response to light is a clinical sign, not just a reported symptom.
●Skin inspection: Instruct the proxy to inspect all skin surfaces systematically — including the abdomen, back, buttocks, and inner thighs — for petechiae or purpura. These areas are frequently covered and must be specifically requested.
●Phonophobia (sensitivity to noise) is an additional feature of meningeal irritation and should be elicited when other meningism signs are present.

The "No Rash" Trap — Why Absence Does Not Exclude the Diagnosis

●A non-blanching petechial or purpuric rash is a sign of meningococcal septicaemia secondary to disseminated intravascular coagulation (DIC). It is a late-stage manifestation, not a prerequisite for the diagnosis of bacterial meningitis.
●Meningitis can present with the full clinical triad of headache, nuchal rigidity, and photophobia in the complete absence of a rash. Withholding or downgrading the diagnosis on this basis represents a critical reasoning failure.
●NICE CG102 is explicit that suspected bacterial meningitis is a clinical diagnosis based on the presenting features — rash is one supportive feature, not a gating criterion.
●Candidates must state clearly to the proxy: "The fact that there's no rash right now doesn't reassure me — it can develop quickly, so I need you to keep checking." This also sets up the ongoing rash surveillance instruction.

NICE CG102 — Pre-Hospital Antibiotics and Emergency Disposition

●NICE CG102 (Bacterial Meningitis and Meningococcal Septicaemia) recommends that primary care clinicians administer parenteral benzylpenicillin 1200 mg IM in suspected meningococcal disease at the earliest opportunity — provided it does not delay transfer to hospital.
●In a face-to-face consultation, this means administering it before the ambulance arrives. In a remote consultation, the clinician is geographically separated from the patient: attending the flat to administer benzylpenicillin would introduce a delay greater than direct 999 ambulance dispatch.
●The correct decision in this scenario is to prioritise the fastest route to definitive intravenous therapy. Candidates must articulate this reasoning explicitly: "Normally I would give an antibiotic injection, but in this situation the ambulance will reach Jake faster than I can — and the hospital team will give IV antibiotics immediately on arrival."
●Penicillin allergy: If the patient has a documented penicillin allergy, cefotaxime is the alternative. In this case, Jake has no known drug allergies.
●Do not withhold 999 dispatch pending antibiotic administration in a remote scenario — this inverts the clinical priority.

Investigations

●In the pre-hospital and primary care setting, no investigations are indicated before emergency transfer. Bacterial meningitis is a clinical diagnosis at the point of triage; investigations must not delay 999 dispatch.
●In secondary care, the key investigations are: blood cultures (before antibiotics if feasible without delay), lumbar puncture (LP) for CSF analysis — but LP is contraindicated until CT head has excluded raised intracranial pressure or a space-occupying lesion.

Interim Management While Awaiting the Ambulance

●
Provide specific, actionable instructions to the proxy — not generic reassurance:
- ●Maintain a dark, quiet environment to reduce meningeal irritation.
- ●Nil by mouth — ongoing vomiting makes aspiration a risk, and IV access for fluids will be established by the ambulance crew.
- ●Position: Semi-recumbent or lateral recovery position if he is less alert or vomiting, to protect the airway.
- ●Monitor consciousness continuously — any deterioration in responsiveness should prompt an immediate call to the 999 operator.
●If Jake has a seizure before the ambulance arrives: do not restrain him, clear the immediate environment of hazards, time the seizure, and place him in the recovery position when convulsing stops. Call 999 immediately if not already done.

Referral and Emergency Disposition

●This presentation mandates an immediate Category 1 (life-threatening) 999 ambulance call. It is not appropriate to arrange a routine GP home visit, advise transport by taxi or private car, or defer pending further symptom evolution.
●The GP must take active clinical responsibility for the emergency decision — initiating the 999 call directly from the surgery or instructing the proxy to call 999 immediately while remaining on the video call for support and oversight. Leaving a distressed lay proxy to independently decide whether to call an ambulance is a management failure.

Notifiable Disease and Contact Prophylaxis

●Suspected meningococcal disease is a statutory notifiable condition under the Health Protection (Notification) Regulations 2010. The duty to notify the local Health Protection Team (HPT) / UKHSA applies at the point of suspicion — not after confirmation.
●Chemoprophylaxis for close contacts must be arranged urgently. UKHSA guidance recommends ciprofloxacin 500 mg single oral dose (first-line) for all close household contacts; rifampicin is an alternative where ciprofloxacin is contraindicated.
●Close contacts include flatmates, intimate contacts, and anyone who has had prolonged close contact in the preceding 7 days.
●In a university / congregate living setting, the HPT will typically lead a broader contact-tracing exercise and may recommend prophylaxis across the flat or floor. The university health service should be alerted.
●Candidates are not expected to initiate prophylaxis during the emergency consultation — but demonstrating awareness of the public health obligation distinguishes a pass from a clear pass.

Meningococcal Vaccination — Pre-Test Probability

●The MenACWY vaccine is offered routinely to adolescents in the UK (school Year 9 programme and university freshers offer). It covers serogroups A, C, W, and Y but does not cover serogroup B, which remains the commonest cause of bacterial meningitis in UK adolescents and young adults.
●MenB vaccine (Bexsero) is routinely offered to infants on the NHS childhood schedule but is not routinely offered to adults or adolescents outside of at-risk groups.
●Vaccination history modifies pre-test probability but does not exclude the diagnosis. A vaccinated patient can still develop meningococcal disease — particularly serogroup B — and vaccination status must not downgrade clinical suspicion in a symptomatic patient.

Safety Netting and Post-Hospitalisation Continuity

●Once emergency services are en route, provide Chloe with specific, jargon-free contingency advice: if Jake has a seizure or becomes unconscious, stay on the line with the 999 operator.
●The GP practice retains an ongoing role after discharge: receiving the hospital discharge summary, reviewing for sequelae (sensorineural hearing loss, neurological deficits, fatigue, post-infectious psychological effects), supporting return to university, and coordinating any ongoing follow-up with secondary care.
●Chloe should be advised that the GP is available for follow-up support — this maintains therapeutic continuity at a moment of acute distress.

Free MRCGP SCA practice case for GP registrars covering Examination Expected — 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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