Cases/Urgent & Unscheduled care

Temperature Who Thinks It Is Just A Cold — Free SCA Practice Case

Woman on chemotherapy with a temperature who thinks it is just a cold

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

Lynsey Wardle

Age

52 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. Same day request.

Reason for Encounter

"Temperature and sore throat. Would like something for my throat."

Medical Records

●PMH: Sigmoid colon cancer, resected 4 months ago (stage III). Hypertension.
●Medications: Capecitabine (twice daily, days 1 to 14 of each 3 week cycle). Oxaliplatin given in hospital on day 1. Amlodipine 5 mg once daily.
●Allergies: NKDA.
●Social: Credit controller at a furniture maker. Lives with her husband. Never smoked.

Recent Notes

●Oncology clinic letter: Adjuvant chemotherapy, cycle 2 of 6 started 9 days ago. No central venous line.

Patient Script

For the friend playing the patient role

Character Overview: You are Lynsey Wardle, a 52 year old credit controller at a family run furniture maker. You live with your husband Martyn, who manages a carpet showroom about ten minutes' drive away. Your daughter Kelsey, 26, lives on the other side of town with her little boy. You had an operation about four months ago to remove a cancer from your bowel and you are having chemotherapy every three weeks to make sure it does not come back. You are on your second of six cycles. You are brisk, practical and used to getting on with things, and you think of yourself as someone having treatment rather than as a patient. You are working from home and are on the phone in your kitchen, a little hoarse and tired but calm. You are not afraid of the doctor. You simply think this is a cold.

Opening Sentence: "Hello, it's Lynsey Wardle. I woke up with a temperature and a sore throat, and I think I've caught my daughter's cold. Is there anything you can give me for my throat?"

History if Asked (Data Gathering Phase)

●The sore throat: "It started yesterday evening, a scratchy feeling, and this morning it hurts to swallow. It's on both sides. My voice is a bit croaky. No white bits that I know of, I haven't looked."
●The temperature: "I woke up shivery and felt hot, so I took my temperature. It was 38.2. I took it again just now and it says 37.6, but that's because of the paracetamol." If asked whether she has taken anything: "Two paracetamol, 500 each, about two hours ago. I do feel a bit better for them."
●How she feels generally: "Tired and achy, shivery on and off. I've had tea and toast but I'm not hungry. I feel a bit worse than I would with an ordinary cold, to be honest, but it'll pass."
●Cough and chest: "A tiny tickle, no real cough, no phlegm. I'm not breathless."
●Water works and bowels: "Normal. I've passed water this morning, nothing burning. My bowels are fine, no diarrhoea."
●Mouth and skin: "My mouth is okay, no ulcers. My hands are a bit tender from the tablets, that's normal for me. No rashes, and the needle site looks fine."
●Contacts: "Kelsey and her little boy came for tea last week and they were both streaming with colds. I think I've caught it from them."
●Light headedness (only if asked about dizziness, fainting or feeling faint): "When I stood up to make tea I did go a bit light headed, but it passed in a few seconds."
●Other severe symptoms (only if asked about each): No shaking chills so far, though she felt shivery. No confusion. Her heart might be going a bit quickly but she has not counted it. No pain in her tummy, no new headache or neck stiffness, no vomiting.

Ideas, Concerns, Expectations

Gating note: Lynsey 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 thinks it is a cold caught from her daughter. "I'm sure it's just Kelsey's cold. It's the same sore throat she had."
●Concerns: If asked what worries her, she says she doesn't think she should worry about it. If the doctor explores further or says it might need hospital: "If I end up in hospital, will they delay my next one? It's in about twelve days, and I really want to get through all six. And will they keep me in for days? I've got work, and Martyn can't be off."
●Expectations: She hoped for a throat spray or lozenges, or perhaps a few days of antibiotics, and to get on with her day. "I was hoping for something like a spray or some tablets for my throat, and I'd carry on."
●Why she has not rung the unit (only if asked): "I do have the card with the 24 hour number on it, it's in my handbag. But I thought that was for the really poorly ones. I wasn't going to ring a cancer ward over a cold. I thought I'd see my own doctor instead."

If Asked: Medical History and Medications

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

●The cancer: "They found it after I had some bleeding. I had an operation about four months ago and it was in the lymph glands too, so I'm having chemotherapy to be safe. Six cycles, one every three weeks. I'm on number two."
●This cycle: "I had the drip in hospital nine days ago, and the tablets, capecitabine, twice a day for two weeks. I took this morning's with breakfast. I'll finish them in about five days." She has no port or line, just a needle in the arm on the day. Her bloods were fine before this cycle. If told not to take this evening's tablets until the team says so: "All right, I'll leave them in the box then."
●Other health problems: "My blood pressure, I take amlodipine 5 mg. Nothing else." The first cycle caused only tiredness and sore hands, with no infections.
●Allergies: "None. I had antibiotics after my operation and they were fine."
●The helpline card: The nurses told her to ring the number for a temperature, but she thought "they meant a high one, like 39". If the doctor says that the number is for any temperature of 37.5 or above or feeling unwell, she says "Oh, I didn't realise it was that low."

Social History and Lifestyle Impact

●Home: "I'm on my own at the moment. Martyn's at the showroom and could be home in ten minutes if I rang him. He'd come straight away. Kelsey's at work and has her little boy to collect later. I haven't called either of them."
●Work: "I chase unpaid invoices for a furniture maker. I've been working from home since the chemo. I've got a call at two with a customer that I'd like to keep."
●Hospitals (only if asked where she has treatment, which hospital is near, or where she would go): "My treatment is at the cancer centre, which is forty minutes away. The hospital in town is only twenty minutes, but they don't know me there."
●Lifestyle: Never smoked, a glass of wine at the weekend, not drinking since the chemotherapy began.

If Asked: Associated Symptoms

Gating note: Answers are brief. All of the following are negative: chest pain, breathlessness, cough with phlegm, burning on passing water, diarrhoea or black stools, abdominal pain, vomiting, rash, redness or swelling anywhere, new headache, neck stiffness, confusion, swelling of the legs and any recent travel.

Responses to Management (The Negotiation Phase)

●
If the doctor says this could be a serious infection and she needs to go to hospital today:
- ●Reaction: Surprised and a bit resistant. "Really? But it's just a cold. Kelsey had it and she was fine. Can't I ring the unit tomorrow if it's not better, or you could give me antibiotics first?" She softens if the doctor explains calmly that chemotherapy lowers her defences against infection, so a temperature needs checking quickly even if it feels like a cold. "Oh. I didn't think of it like that. I didn't realise it could be that quick." She then asks "Which hospital, though? The one in town is twenty minutes, but my cancer centre is forty. Which one?"
●
If the doctor says she should not take any more paracetamol or suggests she can have lozenges or sips instead:
- ●Reaction: "Not even one? My throat is really sore." She accepts when told the tablets hide the temperature that the hospital needs to see. "All right. I suppose I can have a lozenge, can't I?"
●
If the doctor raises the delay to her next cycle or her fear of staying in:
- ●Reaction: "Will they hold it up? I've been so determined to get all six done. And how long will I be in? Days?" She accepts an honest answer that the oncology team decides, that treating infection comes first, and that antibiotics through a drip usually need some time in hospital, but how long is not known until she is seen. If the doctor promises she will be home tonight, she says "Are you sure?" and is not reassured. If the doctor is honest and kind: "I'd rather know. Okay."
●
If the doctor asks how she will get there, who can take her, or where she should go:
- ●Reaction: "Martyn can be here in ten minutes. The hospital in town is twenty minutes, but my cancer centre is forty. Which one?" If the doctor will check with the helpline and follow its advice: "Right, whichever they say. Shall I wait by the phone?" If the doctor names the town hospital: "Will they know what to do with me there? My team's at the cancer centre." She is reassured when told that someone will phone ahead and that treatment starts as soon as she arrives. If the doctor names the cancer centre without checking: "Forty minutes, is that all right?" She goes along with a reason. If the doctor says she should not travel alone, she agrees: "No, I wouldn't. I'll ring Martyn." If the doctor suggests an ambulance: "An ambulance, for this? Is it that serious? I don't want to take one from someone who needs it more." She agrees if given a reason.
●
If the doctor offers to ring the helpline or the unit for her, or asks her to ring them:
- ●Reaction: Relieved. "Would you? I'd feel awkward, to be honest. Do they need me to say anything?" She will say whatever the doctor asks. If told to ring them herself, she is happy to but would prefer the doctor to speak to them first.
●
If the doctor gives vague safety netting such as "ring us if you get worse":
- ●Reaction: "Worse how? Like what would I notice? And what if Martyn isn't here yet?" She wants specific things to look out for and when to dial 999.

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

The Core Dilemma and the Model Plan

●Lynsey is on day nine of her second cycle of chemotherapy for bowel cancer, with a temperature of 38.2, shivering and a sore throat. She calls it a cold and wants something for her throat. The skill is recognising suspected neutropenic sepsis behind an ordinary looking illness, getting her to hospital for antibiotics straight away, and persuading a minimising, practical woman to accept this.
●Model plan: treat it as a medical emergency and do not offer a throat remedy or oral antibiotics as the plan. Answer her question about which hospital by ringing the acute oncology helpline, or staying on the line while she rings, and following its direction, with the nearest emergency department or 999 as the fallback. Whichever route is chosen, she goes now and antibiotics start on arrival. Hand over her regimen and cycle day, choose the transport by how unwell she is, ask her to avoid further paracetamol, take her chemotherapy card and tablets, answer the cycle delay worry honestly, give specific 999 triggers and check she has gone.
●Also acceptable: a direct call to the receiving ward or emergency department; sending her in by ambulance, or by her husband if she stays alert and well; the nearest emergency department when the helpline cannot be reached quickly. What is not acceptable is delay, a surgery visit first, or oral antibiotics at home.

Why This Is an Emergency

●Chemotherapy suppresses the bone marrow, and the white cell count typically reaches its lowest point in the first one to two weeks after treatment, so day nine falls in the risky window. A person can be neutropenic with no warning signs other than a temperature or feeling unwell.
●NICE guideline CG151 (neutropenic sepsis in people with cancer) says to suspect neutropenic sepsis in anyone having anticancer treatment who becomes unwell, and to refer immediately for secondary or tertiary care assessment. It treats suspected neutropenic sepsis as an acute medical emergency with empirical antibiotics offered immediately. The GP cannot know the neutrophil count over the phone and does not need to.
●The CG151 definition for confirmed neutropenic sepsis uses a temperature above 38 degrees or other signs of clinically significant sepsis. In practice cancer services tell patients to ring the helpline for 37.5 or above, or for feeling unwell, and her paracetamol means the true temperature may be higher.
●The oncology regimen here is capecitabine and oxaliplatin, as in many adjuvant bowel cancer plans, but the principle holds for any chemotherapy. Ask for the alert card or record.
●A good clinician is not reassured by a viral explanation. Her daughter's cold may be the cause, but chemotherapy makes a minor infection potentially dangerous.

What Happens in Hospital, and the Cost of Delay

●She will be assessed by an acute oncology or emergency team: history, examination and bloods including cultures and lactate, with intravenous broad spectrum antibiotics started immediately and not after the results. CG151 names piperacillin with tazobactam as the usual first choice unless there is an allergy or a local policy, but that is not the GP's decision.
●Delay lets a localised infection become septic shock. Describe harm accurately: she can deteriorate quickly and needs treatment now, but most patients treated promptly recover. Give no statistics.
●Do not wait for a blood count result, a surgery visit or a callback. Sending her to the practice for bloods first, or prescribing oral antibiotics for a sore throat, are the main unsafe choices.

Where She Goes and How She Gets There

●She asks the practical question herself: the hospital in town is twenty minutes away, but her cancer centre is forty. Do not leave her to choose. The best answer is to ring the acute oncology helpline, or stay on the line while she rings it, and follow its direction, because it can say where she will be seen and prepare the team.
●If the helpline cannot be reached quickly, or she worsens, the fallback is the nearest emergency department, or 999. What harms her is delay, not the choice of building, so a debate about twenty minutes against forty must not hold her up. Whichever route, she goes now, not after her two o'clock call, and antibiotics start on arrival (CG151).
●Choose the transport by how she is now. NICE sepsis guidance for adults (NG253, which replaced NG51) lists high risk features in the community such as new confusion, a very high heart or breathing rate, mottled or ashen skin, or no urine passed in the previous 18 hours. If any were present, she needs 999 and the GP should not wait for a lift.
●Lynsey is alert, talking in full sentences, and only briefly light headed, so either an ambulance or Martyn driving her in directly is reasonable. Both routes must start now and include the instruction to ring 999 if she worsens on the way.
●A patient on chemotherapy who is unwell should not drive herself, because she could faint or become confused on the road, and should not travel alone by taxi or public transport. She does not suggest driving in this station, but a safe plan still names who takes her.
●Whoever calls ahead, whether the GP, ambulance control or the helpline, should give the cycle day, regimen, symptoms, paracetamol time and allergy status so that the team expects her and treats her at the door.

Paracetamol and the Chemotherapy Card

●Paracetamol and ibuprofen can hide fever and delay recognition. Ask her not to take any more until she has been assessed. Sips of water or a lozenge for her throat are fine. Many oncology services advise avoiding ibuprofen too.
●She should bring her chemotherapy alert card or clinic letter, her tablets in their boxes, a medicines list and a phone charger.
●The capecitabine patient leaflet tells patients to stop the tablets and contact their doctor with a temperature of 38 or above, so advising her not to take this evening's dose until the oncology team has reviewed her is correct. The team decides when to restart. Pass on that she took this morning's dose.

Answering the Worry About the Next Cycle

●Say honestly that the oncology team decides, that treating the infection comes first, and that delays or dose changes after infection are common and are managed by the team to give her the best chance of completing treatment. Do not promise she will go home tonight or that the next cycle will go ahead on time.
●Be realistic about admission. Intravenous antibiotics usually need some time in hospital. How long is for the hospital to decide after the blood results and how she responds, so give no number of days.
●Acknowledge the work call and Martyn's job. A short statement that her treatment plan is protected by dealing with infection quickly is likely to be what moves her.

Persuading a Patient Who Minimises

●Her reluctance is not stubbornness. She believes that the helpline card is for serious cases, that a cold is not worth ringing a cancer ward about and that people who are properly ill need the unit. Name that kindly and confirm that the helpline is there for exactly this call.
●Explain in plain language that chemotherapy lowers her defences, so an infection that looks like a cold needs a check in hospital. Avoid the jargon of counts.
●Be clear that this is today, and invite her to agree rather than simply instructing her. Ask her to ring Martyn there and then, and ask her to repeat what she will do.
●If she insisted on refusing, you would explore, explain the risk again calmly and offer an ambulance, but here she agrees once she understands.

Safety Netting and Follow Up

●While waiting for her husband: call 999 immediately for confusion or marked drowsiness, fainting or feeling about to faint, shaking chills, trouble breathing, a racing heart, or if she cannot stand. Do not wait for Martyn in those cases.
●Never say only "ring us if you get worse". Name the symptoms and what to do.
●Ask her to ring the practice when she leaves, or arrange to ring the unit later to check that she arrived. Record the temperature, advice, handover and agreed plan in her notes.

Common Mistakes in This Station

●Accepting the cold and prescribing a throat spray, antibiotics or advice to rest.
●Offering a same day surgery appointment or bloods first, or telling her to ring the unit tomorrow.
●Leaving the call to her without ringing the oncology team.
●Letting her drive herself or travel alone, or saying she can leave after her two o'clock call.
●Leaving her to choose between the two hospitals, or letting twenty minutes against forty delay her leaving.
●Advising more paracetamol or ibuprofen as the main treatment.
●Promising she will be home that night or that her next cycle will not be delayed.
●Vague safety netting, or not asking whether she is alone.

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

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