Cases/Dermatology

Shingles Asking Whether He Can Attend His Pregnant Daughter's Party — Free SCA Practice Case

Man with shingles asking whether he can attend his pregnant daughter's party

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

Paul Whitmore

Age

56 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"I've got shingles and my daughter's baby shower is this weekend — she's pregnant. I need to know if I'm safe to go, or whether I'll put her or the baby at risk."

Medical Records

●PMH: Type 2 diabetes (well controlled, diet only). Otherwise well. No immunosuppression.
●Medications: None regular.
●Allergies: NKDA.

Examination (Visual provided during consult)

●Photograph (uploaded before the call): A band of grouped vesicles and early crusting in a single dermatomal distribution over the left lower chest/flank, not crossing the midline. Some lesions are crusting; a few still appear vesicular. No involvement of the eye or the tip of the nose. No signs of spreading cellulitis.

Uploaded photo of dermatomal shingles rash — ASSET TO CREATE

Patient Script

For the friend playing the patient role

Character Overview: You are Paul, a 56-year-old man. You are practical and family-oriented. Your daughter is expecting her first baby and her baby shower is this weekend — it means a great deal to you and you desperately do not want to miss it, but you are anxious about being a danger to her or the baby. You are in a fair amount of discomfort from the rash but your main agenda is the risk question. You are reassured by clear, sensible advice.

Opening Sentence: "Hello, Doctor. I've come out in this painful rash — the pharmacist reckoned it's shingles. The big thing for me is my daughter's baby shower this Saturday. She's about six months pregnant. I'm terrified of giving her or the baby something. Can I still go?"

History if Asked (Data Gathering Phase)

●The rash: "It's a band across my left side, ribs round towards my back. Blisters, some are starting to scab over now. It's sore — burning, stinging."
●Timing: "The pain started about... nine days ago? The rash came up a day or two after that. So it's been over a week now. Some of the blisters are drying up and crusting."
●The daughter and the shower: "It's her first baby, she's around 26, six months gone. The shower's Saturday. I'd be gutted to miss it."
●Daughter's chickenpox history: "Funny you should ask — she definitely had chickenpox as a kid. I remember it, she was covered in it, off school for ages."
●His own health: "I'm generally well. Type 2 diabetes but it's just diet-controlled, no tablets. Nothing that affects my immune system."

ICE — Ideas, Concerns, Expectations

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

●Ideas: Paul thinks he could give his daughter shingles directly, and that this would be dangerous to the pregnancy. He is unclear about how the virus spreads and whether her having had chickenpox changes anything. "I assumed I could just give her shingles and that'd be bad for the baby. I don't really understand how it passes on."
●Concerns: His overriding concern is harming the baby or his daughter. Missing the shower is a real disappointment but he would sacrifice it in a heartbeat if it were truly risky. "If there's any real chance of hurting that baby, I won't go, simple as that. But it would break my heart to miss it if I don't have to."
●Expectations: He wants a clear, definite answer on whether he can attend, and what precautions to take. "I just need you to tell me straight — can I go or not, and what do I need to do to be safe?"

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●Diabetes: "Type 2, diet-controlled. Last check was fine. No insulin, no tablets."
●Immune status: "No, nothing that weakens my immune system. No steroids, no chemo, nothing like that."
●Chickenpox himself: "Yes, I had chickenpox as a kid — that's how you get shingles later, isn't it?"
●Previous shingles: "No, first time I've had it."
●Allergies: "None."

Social History and Lifestyle Impact

Paul is a warehouse team leader. He lives with his wife. His daughter and her partner live nearby.

●Family: "Very close family. This first grandchild is a huge deal for all of us."
●Work: "I've taken a couple of days off — the pain's been getting me down and I'm tired."
●Others at the event: "It'll be mostly family. My sister's bringing her newborn, actually — that's just occurred to me. And there might be other little ones."
●Smoking/alcohol: "Don't smoke. The odd pint."

If Asked — Associated Symptoms

The patient answers these only when directly asked.

●If asked about whether new blisters are still appearing: "I think they've mostly stopped coming now — the newest ones are a few days old and they're drying up. No fresh crop today."
●If asked about the rash crossing the midline / distribution: "No, it's all on the one side, doesn't go across the middle."
●If asked about eye involvement / rash on the nose / eye pain / visual change: "No, nothing near my eye or nose, and my eyes are fine."
●If asked about fever or feeling generally unwell: "A bit run down and tired, but no real fever."
●If asked about pain severity and impact: "It's a burning, stinging pain, worse than I expected. Painkillers take the edge off."
●If asked about the lesions being coverable by clothing: "Yes, it's on my flank, easily covered by a shirt."

Responses to Management (The Negotiation Phase)

●If the Doctor explains the risk to the daughter is negligible because she has had chickenpox: "So because she's already had chickenpox, she can't catch anything from me? Even though she's pregnant?" (The tested point is explaining that prior chickenpox means she is immune to varicella-zoster, so the risk to her and the pregnancy is negligible.)
●If the Doctor explains he cannot give someone shingles: "So I can't actually give her 'shingles'? I thought that's what would happen."
●If the Doctor raises the newborn and other children at the event: "Ah — I hadn't thought about my sister's new baby. Is that a problem?" (The tested point is recognising that non-immune contacts — neonates, non-immune pregnant women — are the ones at risk.)
●If the Doctor advises covering the lesions: "So if I keep it covered up, that helps? For how long — until when?"
●If the Doctor explains antivirals are unlikely to help now: "Shouldn't I be on those antiviral tablets? Why not, if it's a virus?"

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 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Shingles (Herpes Zoster) — The Basics

●Shingles is reactivation of latent varicella-zoster virus (VZV) in a sensory ganglion, producing a painful, unilateral, dermatomal vesicular rash that does not cross the midline.
●Pain often precedes the rash by a day or two. Lesions progress from vesicles to pustules to crusting over roughly 7–10 days.

Transmission — The Key Concept

●You cannot catch shingles from someone with shingles. Direct contact with the vesicle fluid can transmit VZV to a non-immune person, in whom it causes chickenpox (not shingles).
●Shingles is less infectious than chickenpox (no respiratory spread in localised zoster) and is infectious only while lesions are moist — once all lesions have crusted, the person is no longer infectious.

Who Is at Risk from Exposure

●Only people who are not immune to VZV are at risk: those who have never had chickenpox or been vaccinated. The main vulnerable groups are non-immune pregnant women, neonates, and immunocompromised people.
●A contact who has had chickenpox (as this patient's daughter has) is immune — the risk to them, and to a pregnancy, is negligible. This is the pivotal point in this case.
●The genuinely at-risk contact here is the sister's newborn and any other non-immune individual.

Chickenpox/Shingles Exposure in Pregnancy

●Risk in pregnancy arises only when a non-immune pregnant woman is exposed to VZV. If exposure occurs, check immunity (VZV IgG) and consider post-exposure management promptly per specialist guidance.
●Maternal chickenpox in the first 28 weeks carries a small risk of fetal varicella syndrome; around delivery it risks neonatal varicella — hence the importance of the mother's immune status.
●A pregnant woman who is immune (prior chickenpox) is not at risk from a shingles contact.

Antiviral Treatment — Timing Matters

●Oral antivirals (aciclovir, valaciclovir, famciclovir) are most beneficial when started within 72 hours of rash onset, particularly in those over 50, with severe rash/pain, or with truncal/facial involvement.
●Beyond 72 hours, antivirals are generally not started in an immunocompetent adult with localised disease unless new vesicles are still forming, or there is ophthalmic involvement, immunosuppression, or severe/complicated disease.
●At ~day 9 with crusting lesions and no fresh crop, this immunocompetent patient is past the window — antivirals would add little.

Ophthalmic Shingles — Do Not Miss It

●Herpes zoster ophthalmicus (trigeminal V1 involvement) threatens sight. Hutchinson's sign (lesions on the tip/side of the nose) predicts eye involvement.
●Any eye pain, redness, visual change, or nasal-tip lesions warrant urgent ophthalmology assessment and antiviral treatment regardless of timing.

Infection-Control Advice

●Advise covering the rash, hand hygiene, and avoiding contact with high-risk non-immune individuals (non-immune pregnant women, neonates, immunocompromised people) until all lesions have crusted.
●Covered, crusting lesions on a clothed area (as here) pose minimal risk to immune contacts.

Pain and Post-Herpetic Neuralgia

●Acute zoster pain is neuropathic; manage with simple analgesia and, if needed, neuropathic agents (amitriptyline, gabapentin, or pregabalin).
●Post-herpetic neuralgia (pain persisting after the rash heals) is commoner with age; warn about it and arrange follow-up if pain persists.

Prevention

●The shingles vaccine (offered to eligible older adults and immunosuppressed groups per the UK schedule) reduces the risk of zoster and post-herpetic neuralgia — worth noting for future prevention.

Common Candidate Mistakes in This Case

●Advising him not to attend at all: failing to establish the daughter's immunity and needlessly making him miss the event.
●Not asking about the daughter's chickenpox history: missing the single decisive piece of information.
●Overlooking the newborn: reassuring about the daughter while ignoring the genuinely at-risk non-immune neonate.
●Prescribing a late antiviral pointlessly — or missing an exception: not understanding the 72-hour window, or conversely missing ophthalmic zoster where treatment is still needed.
●Getting the transmission concept wrong: telling him he could "give his daughter shingles," perpetuating the core misconception.

Free MRCGP SCA practice case for GP registrars covering Shingles Asking Whether He Can Attend His Pregnant Daughter's Party — Dermatology. 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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