Cases/Respiratory Health

Remote Triage of Acute Respiratory Decline & Confusion — Free SCA Practice Case

Remote Triage of Acute Respiratory Decline & Confusion

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

George Higgins

Age

86 years

Consultation Type

Telephone

Age

86 (DOB: 02/11/1939)

Caller

Sarah Higgins (Daughter and full-time carer)

Situation

Telephone Consultation (Urgent Triage).

Reason for Encounter

"Daughter calling for urgent advice. States her father has had a dry cough for 3 days and has become confused today. Refusing to get out of bed."

Medical Records (George)

●PMH: Mild Alzheimer’s Dementia, Hypertension, Mild Asthma (No exacerbations in 5 years). Housebound (mobilizes indoors with a Zimmer frame).
●Medications: Donepezil 10mg OD, Ramipril 5mg OD, Amlodipine 5mg OD, Clenil Modulite 100mcg BD.
●Allergies: Penicillin (Causes rash).

Recent Notes

●Routine dementia review 4 months ago: AMTS 8/10. Pleasant, recognizes family, independent with feeding.

Patient Script

For the friend playing the patient role

Character Overview: You are Sarah, George's 55-year-old daughter. You live with him and provide round-the-clock care. Usually, your dad is quite chatty, enjoys watching cricket, and recognizes you easily. Over the last three days, he developed a dry, hacking cough. Yesterday, he stopped eating. This morning, you walked into his room and he was terrified. He didn't know who you were, he was pulling at his bedsheets, and he was having a conversation with your mother (who passed away ten years ago). He refuses to stand up. You are completely exhausted and very frightened. You have never seen him hallucinate before. You do not know what to do. You just want medical help. You will not ask for a home visit explicitly. If the doctor asks you to bring him to the surgery, you will explain that it is physically impossible. You will not volunteer information about his breathing rate, his fluid intake, or his temperature unless the doctor explicitly asks you to act as their "eyes and ears" to assess his physical safety.

ICE — Ideas, Concerns, Expectations

(Sarah does not volunteer these unprompted. They surface only if the candidate directly explores her perspective — e.g. "What do you think might be going on?" or "What are you most worried about?")

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Ideas: Sarah thinks the cough has turned into a chest infection and that the infection is what has made her father go confused. She has no medical training but has cared for him long enough to know that this is not his dementia — it came on too suddenly. "I think the cough has gone to his chest and it's made him go delirious. I've read that infections can do that to elderly people."
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Concerns: She is terrified that he is going to die at home while she watches, and that she will not recognise the moment it becomes a real emergency. She is also privately worried that if he goes into hospital, the unfamiliar environment will accelerate his dementia permanently. "I'm scared he's going to stop breathing or something and I won't know what to do. But I'm also terrified that if he goes to hospital, the confusion will never come back to normal — I've heard that happens with dementia patients."
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Expectations: She wants a doctor to come to the house and physically examine him. She also wants clear instructions on what to watch for in the meantime so she is not sitting there paralysed with fear. "I just need someone to come and look at him properly. And I need to know what I should be watching for — what's dangerous and what's just him being poorly."

Consultation Flow & Responses:

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The Opening:
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If the doctor asks an open question: "Doctor, I don't know what to do. My Dad has had this dry cough all weekend, but today he's completely lost his mind. He doesn't know who I am, he's talking to my dead mother, and he won't get out of bed. I'm terrified."
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Data Gathering (The Layers):
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Layer 1: The Delirium Assessment (Establishing Baseline):
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If asked if this confusion is new or part of his dementia: "No, this is completely new! His memory is usually a bit fuzzy, but he always knows exactly who I am. Today he looks at me like I'm a stranger. It happened literally overnight."
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Layer 2: Remote Respiratory Audit (The Core Safety Screen):
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If asked to describe his breathing/chest: "He's breathing a bit faster than normal, I counted maybe 22 breaths a minute? He's not gasping or turning blue, but his chest is rising and falling quite quickly. It's just a dry hack, no phlegm."
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If asked about his skin color or temperature: "He feels boiling hot to touch. I don't have a thermometer, but he's sweating through his pajamas."
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Layer 3: Fluid Intake & Urine (The AKI Screen):
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If asked what he is drinking or about his urine: "He hasn't drank a drop of water since yesterday afternoon. He's got a urine bottle by the bed, but it's completely empty today."
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Layer 4: Exploring the Logistical Barrier:
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If the doctor asks you to bring him to the clinic: "Doctor, I can't. He's hallucinating and terrified, and his legs keep giving way. I cannot physically carry an 86-year-old man down the stairs and into my car."

If Asked — Medical History and Medications

(Sarah manages all of George's medications and knows his medical history well. She does not volunteer medication details unless asked.)

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If asked about his regular medications: "He's on quite a few. There's the one for his memory — Donepezil, he takes that every morning. Then he's got two blood pressure tablets, Ramipril and Amlodipine. And he has a brown inhaler for his asthma, the Clenil one, he uses that twice a day. I make sure he takes everything."
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If asked whether he has been taking his medications during this illness: "I managed to get his morning tablets into him yesterday, but today he spat them out. He won't swallow anything — he doesn't trust me because he doesn't know who I am."
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If asked about allergies: "Yes — penicillin. He came out in a terrible rash years ago. It's on his records."
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If asked about his asthma: "It's been fine for years, honestly. He hasn't had an attack in as long as I can remember. The brown inhaler is more of a precaution. He doesn't use a blue one anymore."
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If asked about his last dementia review or memory assessment: "He had a review about four months ago at the surgery. The doctor said he was doing well — he scored eight out of ten on that memory test. He was chatty, recognised everyone. That's why today is so shocking."
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If asked about his blood pressure: "The nurse checks it when he has his reviews. They've never said there was a problem with it, so I assume the tablets are working."

Social History and Lifestyle Impact

(Sarah speaks naturally about their daily life if the conversation allows — she does not deliver this as a monologue.)

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Sarah gave up her part-time admin job three years ago to care for George full-time after his dementia diagnosis. She has no other siblings and her mother passed away ten years ago. She is George's sole carer with no formal care package in place.
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If asked about their daily routine or how they manage: "Normally we have a routine — I get him up, washed, dressed, breakfast, and then he sits in his chair and watches the cricket or whatever's on. He can feed himself and get to the toilet with his frame. But today none of that is possible. He won't leave the bed, he's terrified of me, and I can't even get water into him. I haven't slept properly in three nights because of the coughing."
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If asked about support or other carers: "It's just me. I don't have any brothers or sisters. We looked into carers but Dad got so distressed with strangers in the house that we stopped. Normally I manage fine, but today I am completely out of my depth."

If Asked — Associated Symptoms

(Sarah answers based on what she has directly observed. She is not medically trained but is an attentive carer.)

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If asked about coughing up blood: "No, nothing like that. It's just a dry, hacking cough — no blood, no phlegm."
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If asked about chest pain: "He hasn't said anything about chest pain, but to be honest he's so confused today I'm not sure he could tell me even if he had it."
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If asked about a rash or skin changes: "No, no rash. Just the sweating."
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If asked about leg swelling: "No, his legs look normal to me."
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If asked about recent falls: "No, he hasn't fallen. He's barely moved from the bed in two days."
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If asked about neck stiffness or sensitivity to light: "I haven't noticed him being bothered by the light. He's not complained about his neck, but like I said, he's not really making sense today."
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If asked about seizures or fitting: "No, nothing like that. He's been agitated and pulling at the sheets, but no shaking or fitting."
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If asked about vomiting or diarrhoea: "No vomiting, no diarrhoea. He just won't eat or drink."
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If asked about a sore throat or ear pain: "He hasn't mentioned either. I don't think it's a sore throat — it's more in his chest."
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If asked about recent contact with unwell people: "Not that I know of. We don't really have visitors. I did have a bit of a cold myself last week, but it was nothing much."
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If asked about COVID vaccination or recent infections: "He's had all his COVID jabs. He hasn't been unwell recently apart from this."
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If asked about wheezing or noisy breathing: "I haven't noticed any wheezing. It's more that he's breathing fast — but it's quiet, not wheezy."
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If asked about his conscious level or responsiveness: "He's awake, his eyes are open. He's talking — but it's nonsense. He keeps calling me by my mother's name and asking where the dog is. We haven't had a dog in twenty years."
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Negotiation & Collaborative Management Plan:
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If the Doctor dismisses it as his dementia getting worse and advises "rest and fluids":
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Reaction: "But I just told you this is completely different from his normal dementia! Are you not even going to check his chest?" (Candidate critically fails for missing acute delirium and respiratory infection).
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If the Doctor tells you to call a 999 ambulance immediately without checking his breathing first:
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Reaction: "An ambulance? Is he having a heart attack? He hates hospitals, the noise terrifies him. Do we really have to do that right now?" (Candidate fails for inappropriate resource use without establishing clinical red flags).
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If the Doctor proactively offers a Home Visit:
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Reaction: "Oh, thank you. Yes, please. Just knowing you are coming later today makes me feel less panicked. I will try and syringe some water into his mouth while I wait."
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If the Doctor provides interim "Red Flag" safety netting:
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Reaction: "Okay, I understand. So if his lips go blue, or if he starts struggling for breath or goes completely unresponsive before you arrive, I call 999. I will sit with him and watch his breathing."

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

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 / 8 indicators checked+0−0

Positive (0/4)

Negative (0/4)

Clinical Learning Points

Atypical Presentations of Respiratory Infection in Older Adults

●In frail, elderly patients, immunosenescence blunts the classic inflammatory response to infection. High fever, pleuritic chest pain, and productive sputum are frequently absent.
●The earliest — and sometimes only — sign of serious respiratory infection or early sepsis in an older adult is an acute change in cognition. A dry cough with new-onset confusion in an 86-year-old is lower respiratory tract infection or community-acquired pneumonia until proven otherwise.
●A respiratory rate of ≥20 breaths per minute is the first objective sign of physiological compromise in respiratory infection (NEWS2 amber threshold). A rate of ≥25 is a significant red flag. Do not wait for cyanosis or oxygen saturations — by then, decompensation is advanced.

Delirium vs. Dementia — The Diagnostic Distinction

●Dementia has a chronic, insidious onset (months to years), preserved consciousness, and a broadly stable trajectory. Hallucinations are uncommon in mild-to-moderate Alzheimer's disease.
●Delirium has an acute onset (hours to days), a fluctuating course, altered consciousness, prominent inattention, and frequent visual hallucinations. It is always driven by an underlying cause — most commonly infection, dehydration, medication, or metabolic disturbance.
●The key clinical question is: "Is this new, and did it come on suddenly?" A clear premorbid baseline — such as a recent AMTS score — is invaluable in distinguishing the two.
●Use the 4AT tool in face-to-face assessment: it screens for alertness, orientation (AMT4), attention (months of the year backwards), and acute onset/fluctuation. A score of ≥4 indicates probable delirium.
●Families almost universally mistake delirium for permanent deterioration of dementia. Explaining that delirium is a temporary, reversible neuroinflammatory response to acute physical illness — and that cognition typically returns towards baseline as the underlying cause is treated — is one of the most therapeutically important communications a GP can make in this context.

Remote Physiological Assessment — Empowering the Caller

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In a telephone triage of a housebound patient, the caller is your clinical proxy. Explicitly instruct them to observe and quantify:
- ●Respiratory rate — "Can you count how many chest rises he makes in 60 seconds?" (≥20 = concern; ≥25 = significant)
- ●Work of breathing and cyanosis — "Is he grunting or struggling to breathe? Are his lips or fingertips blue?"
- ●Skin temperature and perfusion — "Does he feel hot or cold and clammy to touch?"
- ●Conscious level — "Can he respond to you when you speak to him, even if he's confused?"
●This information directly informs the triage decision and provides a defensible, documented basis for your management plan.

Severity Stratification — CURB-65 in Community Pneumonia

●CURB-65 (NICE CKS / BTS) scores one point each for: new Confusion, Urea >7 mmol/L, Respiratory rate ≥30, Blood pressure <90 systolic or ≤60 diastolic, age 65 or over.
●George scores a minimum of 2 at the time of the call (age ≥65 + new acute confusion), with a likely third point for respiratory rate (~22 bpm approaching threshold) — placing him in the moderate-severity group (CURB-65 2–3).
●NICE CKS guidance: CURB-65 score of 2 warrants hospital assessment consideration; score of 0–1 supports home management. In this case, clinical context — frailty, dehydration, medication risk, non-transportability — tips the balance towards urgent same-day home assessment with a low threshold for admission.
●CURB-65 is a risk stratification tool, not a referral mandate. Clinical judgement, frailty, patient preference, and social context all inform the final decision.

Triage Decision — When to Visit, When to Admit, When to Call 999

●For a frail, acutely delirious, housebound patient who is not cyanosed and is maintaining their airway, the correct pathway is an urgent same-day home visit — not an instruction to attend the surgery, and not an immediate 999 call without first establishing clinical red flags.
●Indicators that would justify a 999 call from triage: cyanosis, respiratory rate >30, inability to maintain airway, unresponsiveness, seizure, or suspected meningitis (neck stiffness, photophobia, non-blanching rash).
●Indicators that support home visit over immediate admission: stable airway, no cyanosis, RR <25, partial responsiveness, and the clear logistical barrier to safe transport.
●The home visit threshold must be proactively offered — do not place the burden on the carer to request it.

Sick Day Rules — Withholding Nephrotoxic Medications

●A dehydrated, oliguric, febrile patient on an ACE inhibitor (Ramipril) is at high risk of acute kidney injury (AKI). ACE inhibitors reduce efferent arteriolar tone and impair the renal autoregulatory response to hypoperfusion.
●Ramipril should be withheld during the acute illness until George is drinking normally and urine output has returned to baseline. This is consistent with NICE CKS sick day rules guidance.
●Amlodipine (calcium channel blocker) carries lower direct nephrotoxic risk but should also be reviewed in the context of acute illness and haemodynamic compromise — withholding or continuing should be documented with a clear rationale.
●Donepezil should be continued where possible, as abrupt discontinuation carries a risk of rapid cognitive and functional decline. Attempt re-administration when cooperation allows; do not advise stopping it.
●Advise the carer explicitly: "Do not give the Ramipril or the blood pressure tablet today — his kidneys need protecting while he's not drinking. The memory tablet, try again later when he's calmer."

Antibiotic Choice — Allergy-Aware Prescribing for CAP

●Amoxicillin is contraindicated — George has a documented penicillin allergy (rash). All penicillins must be avoided, and cross-reactivity with cephalosporins should also be considered.
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Per NICE CKS Community-Acquired Pneumonia guidance, first-line alternatives in penicillin-allergic patients:
- ●Doxycycline 200 mg stat, then 100 mg once daily for 5 days (preferred in outpatient CAP)
- ●Clarithromycin 500 mg twice daily for 5 days (alternative; note interactions with Donepezil — both prolong QTc; use with caution and consider ECG if clinically indicated)
●The antibiotic plan should be confirmed at the home visit following clinical examination and pulse oximetry. Do not prescribe blind over the telephone without a face-to-face assessment.
●Note: in frail patients with suspected severe CAP or sepsis, co-amoxiclav + clarithromycin (or doxycycline as monotherapy) remains the standard — allergy documentation must be checked before prescribing.

Safety Netting — Interim Red Flags Before the Home Visit

●Do not leave the carer without specific, actionable instructions for the waiting period. Generic advice ("call if you're worried") is insufficient.
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Instruct the caller to dial 999 immediately if, before the GP arrives:
- ●His breathing becomes significantly more laboured or his respiratory rate increases markedly
- ●His lips, fingertips, or face turn blue
- ●He becomes completely unresponsive or cannot be roused
- ●He has a seizure or develops a non-blanching rash
●Instruct the caller to call the surgery back (not 999) if his condition appears to be changing but none of the above features are present.
●Check understanding: ask the carer to repeat back the key escalation triggers before ending the call.

Delirium in Dementia — Post-Illness Implications

●A delirium episode in a patient with pre-existing Alzheimer's disease carries a significant risk of accelerated cognitive decline that may not fully reverse. This is well-established and should be discussed sensitively with the family.
●Following recovery, arrange a formal dementia review (AMTS or equivalent) to document the new baseline. This provides a defensible record and informs future triage decisions.
●The delirium episode itself should be formally documented in the notes, including the precipitant, clinical severity, and management — both for continuity of care and for future capacity and advance care planning discussions.
●Consider whether this episode prompts a conversation about advance care planning — particularly around future hospital admission, resuscitation preferences, and the patient's expressed wishes while he retains capacity or has documented them previously.

Carer Assessment and Social Support

●A sole, unsupported carer who has not slept for three nights and is at their coping limit is a safeguarding-adjacent risk. Carer breakdown directly endangers the patient.
●At the home visit, explicitly assess Sarah's own wellbeing and capacity to continue providing care safely. Acknowledge her exhaustion and fear — do not treat her solely as a source of clinical information.
●Signpost to: GP carer support, social care referral (to establish a formal care package), and Carers UK / local carers' services. Note that previous attempts to introduce carers were discontinued due to George's distress — this is a relevant history that needs revisiting in the context of increasing care complexity.
●Consider whether a carer's assessment (entitled under the Care Act 2014) has been completed. If not, this should be initiated.

Free MRCGP SCA practice case for GP registrars covering Remote Triage of Acute Respiratory Decline & Confusion — Respiratory Health. 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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