Cases/Respiratory Health

Worsening Cough and Weight Loss, Still Smoking — Free SCA Practice Case

Ex-radiotherapy patient with a worsening cough and weight loss, still smoking

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

Martin Deakin

Age

58 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"My cough is getting worse and I've lost weight. I saw a doctor here a fortnight ago and was told my chest was clear, but I'm not right."

Medical Records

●PMH: Non-small-cell lung cancer — treated with radiotherapy with curative intent (completed 2 years ago); currently discharged from routine oncology follow-up. Suspected COPD (spirometry not completed).
●Medications: Salbutamol inhaler PRN.
●Allergies: NKDA.
●Recent notes (2 weeks ago): Attended with cough. Chest examination normal; observations normal. Advised it was likely viral; safety-netted; advised to return if not improving. No imaging arranged at that visit.
●Smoking: Current smoker, 10/day (reduced from 30/day).

Patient Script

For the friend playing the patient role

Character Overview: You are Martin, a 58-year-old former scaffolder. Two years ago you had lung cancer treated with radiotherapy, given with the intention of curing it, and you were later discharged from routine hospital follow-up. Over the past two months your cough has been getting steadily worse, you bring up clear phlegm (no blood), and you have lost about a stone in weight without trying. You can only manage about 100 metres before you have to stop for breath, which is worse than before. You have no chest pain and no wheeze. You saw a doctor here two weeks ago who examined your chest, said it was clear and probably viral, and told you to come back if it did not settle — it has not. You still smoke 10 a day, down from 30, and you feel guilty and defensive about it. Underneath you are frightened the cancer has come back but you have not said so out loud.

Opening Sentence: "Hello Doctor. My cough's been getting worse for a couple of months now, and I've lost about a stone without trying. I came in a fortnight ago and was told my chest was clear and it was probably a virus, but it hasn't settled — if anything it's worse. I had radiotherapy for lung cancer two years ago."

History if Asked (Data Gathering Phase)

●The cough: "Worsening over about two months. Clear phlegm, no blood at all. It's worse than a normal chest infection cough."
●Weight loss: "About a stone over the same couple of months. I haven't been dieting."
●Breathlessness: "I can do about 100 metres and then I have to stop. It used to be much further."
●Cancer history: "Lung cancer two years ago. They gave me radiotherapy to try to cure it. I was signed off from the hospital follow-ups a while back."
●Previous consultation: "I was seen a fortnight ago. They listened to my chest, said it was clear, probably viral, come back if it doesn't settle. It hasn't."
●Smoking: "I still smoke 10 a day. I was on 30, so I have cut down. I know, I know — you don't need to tell me."

ICE — Ideas, Concerns, Expectations

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

●Ideas: Martin has been told it was viral, but does not believe that any more; he privately suspects the cancer has returned. "They said it was a virus. I don't think it is. If I'm honest, I think the cancer's back."
●Concerns: His dominant concern is recurrence of the cancer, and — beneath that — guilt and fear that his smoking has caused it. He is also frightened of what treatment would mean. "I'm scared it's back. And I'm scared it's my own fault for still smoking."
●Expectations: He wants to be properly investigated this time, not reassured again. "I want it looked into properly — a scan or an X-ray, something."

If Asked — Recurrence, Differential, and Red-Flag Screen

The patient answers these only when directly asked.

●If asked about haemoptysis: "No blood in the phlegm at all."
●If asked about weight loss quantity and appetite: "About a stone in two months. My appetite's not great."
●If asked about hoarseness, difficulty swallowing, or neck lumps: "No hoarseness, no trouble swallowing, no lumps I've felt."
●If asked about chest, shoulder, or bone pain: "No chest pain. No bone pain."
●If asked about fever, night sweats, or purulent sputum (infection): "No fever, no night sweats, and the phlegm is clear not green."
●If asked about wheeze: "No wheeze."
●If asked about headache, confusion, or neurological symptoms: "No headaches, nothing like that."
●If asked about exercise tolerance change over time: "Definitely worse — it's dropped off over these two months."
●If asked about the exact radiotherapy field/dates or oncology follow-up: "Two years ago, to the chest. I was discharged from follow-up after a while — I've got no oncology appointments now."
●If asked about asbestos or occupational exposure: "I was a scaffolder — I might have been around asbestos on old sites, I couldn't say for sure."
●If asked about smoking and readiness to stop: "Ten a day, down from 30. I do want to stop properly — I just haven't managed it."
●If asked about mood and support: "It's playing on my mind. My wife's worried too. I've not told her what I really think it is."

Responses to Management (The Negotiation Phase)

●If the Doctor explains a normal examination does not exclude recurrence — key: "So my chest being clear on examination doesn't mean it's fine? That's what I couldn't understand." (The tested point is recognising and explaining that a normal examination does not exclude recurrence or intrathoracic disease.)
●If the Doctor arranges urgent imaging: "You want an urgent chest X-ray? And possibly a scan? Yes — that's what I wanted." (The tested point is arranging urgent imaging rather than a further period of watchful waiting.)
●If the Doctor explains the referral pathway back to the specialist team: "So you'd send me back to the lung specialists? Even though I was discharged?" (The tested point is re-referral to the lung/oncology team for suspected recurrence.)
●If the Doctor raises smoking without blame — key: "I expected a telling-off, to be honest. You're saying it's still worth stopping now, and you'll help?" (The tested point is offering cessation support without blame, and correcting the belief that it is too late for it to matter.)
●If the Doctor addresses his unspoken fear: "Yes… I have been thinking it's come back. I haven't said it out loud, not even to my wife." (The tested point is eliciting and addressing the unspoken cancer fear honestly.)
●If the Doctor safety-nets: "What should I watch for while I'm waiting for the tests?"

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 / 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

New or Worsening Symptoms in a Previously Treated Cancer Patient

●Progressive cough, unintentional weight loss, and declining exercise tolerance in a patient previously treated for lung cancer must be investigated as possible recurrence. Prior cancer history changes the threshold entirely — do not default to COPD or "another virus".

A Normal Examination Does Not Exclude Intrathoracic Disease

●Chest examination is frequently normal in lung cancer and recurrence. A normal examination must never be used to withhold imaging when the history is concerning, and symptom progression despite previous reassurance is itself a reason to investigate.

Urgent Imaging — and Its Limits

●Arrange an urgent chest X-ray within 2 weeks in line with the suspected-cancer pathway. Crucially, a normal chest X-ray does not exclude lung cancer or recurrence — in a patient with this history, CT and specialist assessment are still required.

Re-Refer to the Specialist Team

●Re-refer to the lung cancer/oncology team via the suspected-cancer pathway even if the patient has been discharged from routine follow-up. Do not let previous discharge delay re-entry into specialist care.

Consider the Radiotherapy-Related Differential

●Radiation pneumonitis (typically weeks to months after treatment) and radiation fibrosis (later) can cause cough and breathlessness and may be difficult to distinguish from recurrence — both need specialist assessment and imaging.

Do Not Let the COPD Work-Up Delay Cancer Investigation

●Spirometry and COPD management are appropriate in their own right, but must not delay urgent investigation for suspected malignancy.

Smoking Cessation Without Blame

●Offer behavioural support plus pharmacotherapy, acknowledge any reduction already achieved, and avoid blame or moralising — particularly where the patient already feels guilty. Cessation remains beneficial at every stage, and framing it supportively is what makes it effective.

Common Candidate Mistakes in This Case

●Attributing symptoms to COPD or a virus: the central failure — missing possible recurrence.
●Being reassured by the normal examination: or accepting a normal chest X-ray as excluding recurrence.
●Not re-referring: leaving a patient with suspected recurrence outside specialist care because he was previously discharged.
●Blaming him for smoking: shaming a guilty, defensive patient instead of offering supportive cessation help.
●Missing the unspoken fear or the follow-up loop: leaving his cancer fear unaddressed, or failing to ensure results are actioned.

Free MRCGP SCA practice case for GP registrars covering Worsening Cough and Weight Loss, Still Smoking — 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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