Cases/Urgent & Unscheduled care

Indigestion and Breathlessness for Three Hours — Free SCA Practice Case

Woman with indigestion and breathlessness for three hours

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

Josephine Adewumi

Age

63 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. Same day call requested by the patient.

Reason for Encounter

"Indigestion and feeling short of breath since lunchtime. Could I have something stronger than Gaviscon?"

Medical Records

●PMH: Type 2 diabetes for 9 years (HbA1c 58 mmol/mol last month). Hypertension. Hypercholesterolaemia. Reflux symptoms 5 years ago, settled with lifestyle changes.
●Medications: Metformin 1 g twice daily, ramipril 5 mg daily, atorvastatin 40 mg daily.
●Allergies: NKDA.
●Social: Part time cinema box office assistant. Ex smoker. Lives with her husband.

Patient Script

For the friend playing the patient role

Character Overview: You are Josephine Adewumi, a 63 year old part time cinema box office assistant. You work three days a week and today is a day off. You live with your husband Kolade, who is 65 and retired, in a terraced house. Your daughter Imani lives in Manchester and rings on Sundays. You are phoning from the sofa in your front room on the landline. Kolade went out this morning to see his brother Segun and will not be back until the evening. You are a capable, cheerful woman who hates making a fuss, tends to joke about her own symptoms, and is used to everyone else coming first. You had a very spicy lamb curry for lunch, you have had indigestion before, and you are sure that is all this is. About three hours ago you felt full and uncomfortable, and you have felt steadily worse since. You do not think of this as a heart problem, because to you heart trouble means crushing chest pain, and you have not got that. You want something stronger than Gaviscon from the doctor so you can get on with your afternoon. You will listen if the doctor is clear and kind, but if the doctor sounds unsure you will drift back to "it is only the curry".

Opening Sentence: "Hello doctor, sorry to bother you. I've had dreadful indigestion since lunch, about three hours now, and I'm a bit short of breath with it. I had a very hot curry, so I think I've only got myself to blame. Could you prescribe me something stronger than Gaviscon? Kolade's out, so I can't get to the chemist."

History if Asked (Data Gathering Phase)

●Onset: "About twenty minutes after I finished eating. It started as feeling full and uncomfortable, and it has crept up since."
●Where and what it feels like: "Upper part of my tummy, right under the breastbone. It's a heavy, tight, pressing feeling, not burning like my old reflux. About six out of ten now."
●Course: "It hasn't come and gone. It has been there all the time and slowly got worse."
●Spread: If asked about the jaw, neck, arm or back: "Now you say it, there's a dull ache in my jaw and across my left shoulder and upper arm. I thought I'd slept on it funny." Without a direct question she does not mention it.
●Breathlessness: "I get puffed just walking to the kitchen and back. I can talk, but I have to stop to catch my breath. It started with the discomfort, not before."
●Nausea and sweating: "I've felt sick since about two o'clock, but I haven't been sick. I came over cold and clammy around then. I put it down to the spice."
●What makes it better or worse: "Nothing makes any difference. Sitting, lying, walking, breathing in deeply and pressing on my tummy all feel the same. Gaviscon at half past one and again at three did nothing at all."
●Chest pain: If asked about chest pain: "Not what I'd call pain in my chest. It's higher than my stomach, behind the breastbone, and it's more heavy than sore." If asked whether it is a pressure or tightness, she agrees.
●Other cardiorespiratory symptoms: "No cough, no wheeze, no palpitations. I felt a bit light headed when I stood up earlier. My ankles are the same as always. My calves are fine and I haven't travelled or had an operation."
●Digestive symptoms: "No vomiting, no vomiting blood, no black stools, no trouble swallowing, no weight loss, no change in my bowels. My tummy isn't tender and it isn't worse when I eat."
●Similar before: "Never like this. I've had reflux years ago, but that was a burning feeling after meals and it went with antacids. I haven't had any tightness when walking uphill or on stairs."
●Today so far: "I'd done nothing heavy before it started. I had been sitting watching television. I have not taken anything for it except the Gaviscon."

Ideas, Concerns, Expectations

Gating note: Josephine does not raise any of the following herself. 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 is certain it is the curry. She thinks heart attacks are crushing pains in the middle of the chest, with the person clutching their arm, and that she would know. "Heart attacks hurt in your chest, don't they? Mine's in my tummy. It's just the curry."
●Concerns: She says she is not worried at first. If gently asked again, she admits her brother Dayo had a stent put in at 58 and she has had a small niggle in the back of her mind. Her bigger worry is being a nuisance and wasting NHS time. "I don't like to make a fuss. I'd never forgive myself if I wasted everybody's time over indigestion."
●Expectations: She expects a prescription for a stronger indigestion medicine such as the omeprazole she had before, perhaps picked up by Kolade tonight. She does not expect to be told to go to hospital.

If Asked: Medical History, Risk Factors and Medicines

Gating note: Josephine answers each of these plainly when the doctor asks about it.

●Diabetes and other conditions: "Type 2 diabetes for nine years, high blood pressure and high cholesterol. My last blood sugar check was fine. I get tingling in my toes, and have for a year, but my feet are otherwise okay."
●Medicines: "Metformin, ramipril and atorvastatin. Nothing else. No aspirin, no blood thinners, no ibuprofen or steroids."
●Allergies and aspirin safety: "No allergies. I've never had a reaction to aspirin or ibuprofen. No asthma, no stomach ulcers, no bleeding problems and I don't bruise easily."
●Smoking and alcohol: "I smoked ten a day for about twenty five years and gave up twelve years ago. A glass of wine at the weekend."
●Family history: "My brother Dayo had a stent at 58. My father had a stroke when he was 80."
●Aspirin in the house: If asked whether she has any aspirin: "Kolade keeps a box of the soluble 300 milligram ones in the kitchen drawer for his headaches. I'd have to walk to the kitchen."

Social History and Lifestyle Impact

●Who is with her: Alone in the house. Kolade is at his brother's about an hour away by car and his phone is on. Imani is in Manchester. A neighbour, Hetty, lives next door and has a spare key.
●Where she is: At home, 22 Hawthorn Close. The front door is locked.
●Driving: She drives a small car but would not drive herself anywhere feeling like this. She suggests Kolade could take her when he comes home, or Hetty could drive her.
●Work and routine: Three days a week selling tickets at a local cinema. Today is a day off.

If Asked: Examination and Observations

Gating note: Josephine cannot examine herself. She declines to take her own pulse or blood pressure and has no home monitors.

●If asked to check her pulse, blood pressure or oxygen level: "I haven't got a machine. I wouldn't know how to take my own pulse properly."
●If asked whether she looks pale or sweaty to herself: "I'm a bit clammy. My hands feel cold."
●If asked whether she can come to the surgery: "I could get there, but Kolade has the other car and I'd have to drive myself, and I don't feel like it."

Responses to Management (The Negotiation Phase)

●
If the doctor explains this may be a heart problem and that she needs an ambulance now:
- ●Reaction: Surprised. "My heart? But I haven't got proper chest pain. Surely it's the curry?" Once told that diabetes can make heart attacks feel like indigestion, with discomfort higher in the tummy, breathlessness and sweating, she goes quiet and says "That does sound like me, doesn't it." She then asks "Does it really need an ambulance? Hetty could drive me, or I could wait for Kolade." If the doctor is clear and firm that she must not drive and must not wait, she agrees. If the doctor seems unsure or offers to review later, she says she will "try another Gaviscon and see how I am in an hour".
●
If the doctor advises aspirin:
- ●Reaction: Willing but careful. "I've got Kolade's 300 milligram ones in the kitchen. Do I swallow it with water?" If told to chew one tablet slowly, she asks "Is it safe with my diabetes tablets, and what if I've got a bad stomach?" She repeats the instruction accurately once given: one tablet, chewed, now.
●
If the doctor mentions a prescription for indigestion or explains why not:
- ●Reaction: Accepts a clear reason. "So no omeprazole today? All right, if it's not the stomach, I don't want to cover it up." If the doctor still plans to prescribe, she asks "So I should carry on as I was and collect it tonight?" and delays calling for help.
●
If the doctor discusses practicalities while waiting, such as unlocking the door, sitting down, and who to ring:
- ●Reaction: Cooperative. "I'll unlock the front door and sit on the sofa. Shall I ring Kolade and Hetty afterwards?" If told to ring her husband and a neighbour after the ambulance is called, she agrees. If asked about taking her medicines and bag, she says "I'll bring my tablets and the diabetes card."
●
If the doctor offers to call 999 for her or tells her to hang up and call straight away:
- ●Reaction: Relieved to have the decision made. "Would you ring them, doctor? I'd feel silly doing it myself." If told to ring herself, she does so without argument.
●
If the doctor gives safety netting on what to do while she waits:
- ●Reaction: Wants it spelled out. "What if the pain gets worse, or I feel faint before they come?" She repeats back clearly when told to stay sitting or lying, keep the phone close, and tell the call handler if she collapses or feels worse. If the doctor does not give instructions she asks "What should I do until they get here?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

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

●Josephine is a 63 year old woman with type 2 diabetes, hypertension and raised cholesterol who phones with three hours of upper abdominal pressure, nausea and breathlessness after a spicy lunch. She has a ready explanation, she asks for an indigestion prescription, and she is alone at home. The station tests whether the candidate looks past a plausible dietary story and a missing "classic" chest pain, recognises a probable acute coronary syndrome (ACS), and acts on it within the call.
●The model plan has five parts. Take a short, focused history that identifies the cardiac features and her risk factors. Say clearly that this may be her heart. Arrange an emergency ambulance now by calling 999 for her or by telling her to call straight away. Advise her to chew one 300 mg aspirin tablet while she waits, once allergy and bleeding risks have been checked. Give practical safety instructions and make sure someone follows through.
●Acceptable alternatives: the doctor may call 999 on her behalf, or ask her to call while staying on the line, and may stay on the phone until the call is made. Asking her to ring her husband or neighbour is fine once the ambulance has been requested. Aspirin is advised after checking contraindications, and is left out if she reports a true allergy or a bleeding disorder. Examination and tests are not possible by phone and should not delay the emergency call.

Recognising ACS When There Is No Classic Chest Pain

●NICE CG95 (Recent onset chest pain of suspected cardiac origin, last updated November 2016) lists the symptoms that may indicate an ACS: pain in the chest and/or other areas such as the arms, back or jaw lasting longer than 15 minutes, and chest pain with nausea and vomiting, marked sweating or breathlessness, particularly a combination of these.
●It also states that symptoms of ACS should not be assessed differently in men and women, and that not all people with an ACS present with central chest pain as the predominant feature.
●Josephine has a heavy, constant, pressing discomfort for three hours, high in the abdomen under the breastbone, with an ache in the jaw and left shoulder, nausea, clamminess, breathlessness walking to the kitchen and light headedness on standing. She did not mention the jaw or arm until asked, so direct questions are essential.
●CKS (Chest pain, diagnosis, cardiac causes) says ACS can present with atypical features in older people or those with conditions such as diabetes, and lists epigastric pain, sweating, breathlessness and jaw or arm pain among the features that may accompany it. Her beliefs about what a heart attack feels like are common and are the reason a patient may delay.

Why Dyspepsia Is the Wrong Frame

●Symptoms that began at rest, did not change with position, eating or pressing, and did not respond to two doses of antacid, with associated nausea, sweating and breathlessness, are not typical of reflux. Her old reflux was a burning feeling after meals that settled with antacid. This is a different pattern.
●A spicy meal is a believable trigger and makes anchoring easy. Reassuring her, prescribing an acid suppressing drug or arranging a later review all delay the treatment that matters for a heart attack. If the problem were gastric, the cost of sending an ambulance would be small. If it is cardiac, delay costs heart muscle.
●Other causes are worth a brief check on the phone, and are negative here: no cough or wheeze, no calf swelling or recent travel or surgery (pulmonary embolism), no vomiting blood or black stools (upper gastrointestinal bleeding). None of these negatives should reassure the candidate into stopping at an antacid.

Emergency Referral and Why 999

●CG95 says to refer people to hospital as an emergency if an ACS is suspected and they currently have chest pain, or are pain free but had chest pain in the last 12 hours and a resting 12 lead ECG is abnormal or not available. Josephine is still symptomatic and a phone consultation cannot provide an ECG, so emergency transfer by 999 is the correct route.
●An ambulance crew can record a 12 lead ECG, start monitoring, give treatment and defibrillate if she has a cardiac arrest, and can alert a heart attack centre. A car journey with a lift from a neighbour offers none of this, and a driver cannot manage a collapse.
●She must not drive herself or wait for her husband to return. The surgery, an urgent appointment, a review by telephone in an hour or sending her to the emergency department by another means do not meet the need.
●If she worries about wasting an ambulance, the doctor can explain that this is the situation ambulances exist for, and that no one will mind if it proves to be something else.

Aspirin While Waiting

●NICE NG185 (Acute coronary syndromes, November 2020) recommends a single loading dose of 300 mg aspirin as soon as possible for people with STEMI, unstable angina or NSTEMI, unless there is clear evidence of allergy. CG95 gives the same advice for suspected ACS and asks that a record of aspirin given before hospital goes with the person.
●The BNF lists 300 mg as a single dose for myocardial infarction, to be chewed or dispersed in water. Chewing speeds absorption.
●Check first for aspirin or anti inflammatory allergy including asthma triggered by them, active peptic ulcer, bleeding disorders and anticoagulant use. Josephine has none of these and has soluble 300 mg tablets in the kitchen drawer.
●The call to 999 comes first. Aspirin should never delay it. If she must find the tablets, she can do so after the call or while the call handler stays on the line.
●Glyceryl trinitrate (GTN) is not needed. CG95 says not to use a response to GTN to make a diagnosis, and none is prescribed for her.

Practical Safety While Waiting

●She is alone, so every instruction counts. Unlock the front door, sit or lie in a comfortable position, keep the phone close, and gather her medicines and diabetes details for the crew. She should tell the call handler everything that has been done, including the aspirin and the time she took it.
●If she feels faint or the pain worsens, she should stay on the line with the call handler and lie down where she can be found. A neighbour with a spare key, her husband and her daughter should be told once the ambulance has been called, not before.
●A short, clear set of steps works better than a long list. Asking her to repeat the key steps back checks that she has understood. The doctor should stay on the line until the call is made, or check back that help has arrived. Her metformin and other regular tablets need no change from the doctor on this call; the hospital team will advise.

Handling Her Reluctance

●Josephine is polite, stoical and unwilling to cause trouble. Her ideas (it is the curry), her belief that heart attacks mean crushing central chest pain and her fear of wasting time all need exploring. Her brother's stent at 58 gives her a family history that she mentions only when asked.
●Reassurance based on the lack of "proper chest pain" is the trap. The most persuasive explanation is plain: heart attacks can feel like indigestion and breathlessness, especially in people with diabetes, and the safest course is an ambulance now.
●She will go along with a clear, confident, kind plan. If the doctor sounds uncertain, offers a review, or suggests another antacid first, she will take the easier road and delay.

Common Mistakes in This Station

●Accepting the curry explanation and prescribing or advising an antacid or acid suppressing drug.
●Asking only about burning, food and bowels, and never asking about spread, sweating, nausea or breathlessness.
●Dismissing a cardiac cause because there is no crushing central chest pain.
●Offering an urgent appointment, a review in an hour, an ECG at the surgery or a lift from a neighbour instead of a 999 ambulance.
●Allowing her to drive herself or wait for her husband.
●Forgetting aspirin, giving the wrong dose, giving it without asking about allergy and bleeding, or letting it delay the ambulance call.
●Leaving her alone with no instructions on the door, her phone, company, or what to do if she collapses.
●Ending the call before the ambulance has been requested or without any follow up.

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

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