MRCGP SCA Consultation Skills Course
Mock 2 · Palpitations
Video consultation — full 12-minute exam frame, 3 minutes' reading · Mental health · Prescribing · Investigations and results · Mock SCA 2 · 16:10–16:45
A 41-year-old has had three normal emergency-department work-ups for a racing heart and tight chest; the only thing that helped was diazepam, and she wants more.
Candidate brief
Read this as you would in the exam. Three minutes' reading, then twelve minutes. You may ask the patient for examination findings; there is no reference material.
| Patient | Fatima Begum, 41, teaching assistant |
| Reason for appointment | Palpitations, chest tightness (booked by patient) |
| PMH | Nil. Non-smoker |
| Medication | None. Allergies: none |
| Recent entries | Three ED attendances in 8 weeks with chest tightness, palpitations, tingling: ECG ×3 normal; troponin ×2 negative; chest X-ray normal; TFT, FBC normal. ED letter: 'likely panic attacks; GP to review; diazepam 2 mg ×5 given.' Caffeine and alcohol not recorded. Father: MI at 58 (died) |
Role-player script — tutors only
Delegates: please do not open this section until you have consulted at this station.
Open the role-player script (519 words)
Persona and manner
- Anxious, articulate, clutching her phone; watches the doctor's face for reassurance; apologises for 'being dramatic'.
- Rational when calm; catastrophises fast. Cultural weight: she must not be 'seen like this'.
Opening line — say this verbatim
- "I keep getting these attacks — my heart races, my chest goes tight, my hands tingle and I honestly think I'm dying. A&E gave me diazepam and it's the only thing that stopped it. Can you prescribe some more?"
Volunteer freely if given the space
- Attacks 'out of nowhere', three or four a week, 10–20 minutes; she avoids the supermarket and driving; 'the hospital found nothing'.
Only if asked
- Symptoms: palpitations, tightness, tingling in hands and lips, dizziness, 'unreal', fear of dying; no exertional chest pain; no syncope; no wheeze; no thyroid symptoms; no pregnancy.
- Coffee five or six cups; energy drinks 'for the school run'; sleep poor; no alcohol; no drugs.
- Father died of a heart attack at 58 — 'that's what I think about every time'.
- Stress: her son 'in trouble at school'; husband working abroad on contracts; extended Bangladeshi family nearby — 'I can't let anyone see me like this'.
- Mood low 'because of the attacks'; no suicidal thoughts. No previous mental health contact.
- The diazepam 'made me calm — I've got two left'. Has not tried anything else; has looked up 'heart scans'.
Ideas, concerns and expectations
- Idea: 'my heart, like Dad — they've missed something'.
- Concern: dying in front of the children; 'going mad'; the family finding out.
- Expectation: diazepam, 'and maybe a heart scan'.
Cues to deliver, timed
- Minute 1: 'I honestly think I'm dying.'
- Minute 4: 'like Dad.'
- Minute 7: 'I can't let anyone see me like this.'
How to respond to the doctor's plan
- If the doctor uses the normal results explicitly, explains the panic cycle (adrenaline, hyperventilation, the tingling) in plain terms, names panic disorder as real and treatable, explains why diazepam makes it worse over time and will not be prescribed, offers CBT (NHS Talking Therapies self-referral) and an SSRI (sertraline, with expectations and early jitteriness), addresses caffeine and energy drinks, teaches a breathing technique, respects the family concern, safety-nets (new exertional pain, syncope → reassess), and reviews in 2–4 weeks: she is calmer — 'so it's not my heart? And the tablets won't make me a zombie?'
- If the doctor prescribes diazepam: 'thank you so much' — the examiner will not.
- If the doctor says 'it's just anxiety': 'that's what they said at the hospital' — and withdraws.
Examination findings if requested
- Pulse 88 regular; BP 128/82; sats 98%; heart sounds normal; chest clear; no tremor; no goitre.
Background you can draw on if asked
- The first attack was in the supermarket car park; she thought it was a heart attack and drove herself to hospital with the children in the back — 'I shouldn't have'.
- Her mother has 'nerves' and was 'never treated'; her aunt takes 'tablets from Bangladesh' she cannot name.
- She has stopped attending the mosque women's group because of the attacks; she prays at home. Her husband rings nightly and 'doesn't understand'.
- She would consider therapy if it can be 'private and in the evening'; she would not tell her sisters-in-law.
Do not
- Volunteer the caffeine, the father's death or the family concern unless asked.
- Accept an SSRI or CBT until the diagnosis has been explained in a way she can repeat.
Mark scheme
Delegates: open after your consultation. Examiner-observers: open during it.
Generic mark scheme — identical at every station
Domain grades
| Domain | CF (0) | F (1) | P (2) | CP (3) | Points |
|---|---|---|---|---|---|
| Data Gathering and Diagnosis | ☐ | ☐ | ☐ | ☐ | /3 |
| Clinical Management and Medical Complexity (×1.5) | ☐ | ☐ | ☐ | ☐ | /4.5 |
| Relating to Others | ☐ | ☐ | ☐ | ☐ | /3 |
| Total | /10.5 |
Global rating: ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass (CF Clear Fail · F Fail · P Pass · CP Clear Pass)
Feedback statement(s) — tick the one (at most two) you would attach
| Domain 1 | Domain 2 | Domain 3 |
|---|---|---|
| ☐ 1.1 Insufficient data | ☐ 2.1 Referral | ☐ 3.1 Cues / listening / formulaic |
| ☐ 1.2 Notes not used | ☐ 2.2 Prescribing | ☐ 3.2 Agenda / beliefs |
| ☐ 1.3 Psychosocial | ☐ 2.3 Investigations | ☐ 3.3 Circumstances / culture |
| ☐ 1.4 Unsystematic | ☐ 2.4 Prevention | ☐ 3.4 Explanations |
| ☐ 1.5 Prioritisation | ☐ 2.5 Risk management | ☐ 3.5 Judgemental |
| ☐ 1.6 Implications of findings | ☐ 2.6 Co-morbidity | ☐ 3.6 Respect / sensitivity |
| ☐ 1.7 Differentials | ☐ 2.7 Uncertainty | ☐ 3.7 Ownership |
| ☐ 1.8 Diagnosis / decision | ☐ 2.8 Follow-up / safety-net | ☐ 3.8 Teamwork |
| ☐ 2.9 Time management | ☐ 3.9 Safeguarding |
Timing checkpoints (Observer)
| Checkpoint (12-minute exam frame) | Done | Minute |
|---|---|---|
| Patient allowed to open without interruption (≈1 min) | ☐ | |
| ICE and psychosocial context elicited by 4:00 | ☐ | |
| Red flags covered; examination findings requested by 6:00 | ☐ | |
| Working diagnosis verbalised; gear change by 6:00–7:00 | ☐ | |
| Options shared; patient's preference used | ☐ | |
| Specific safety-net and follow-up by 11:30 | ☐ | |
| Understanding checked; finished inside 12:00 | ☐ |
Key points for this station — customised standard
Key points for this station
| Domain | Pass requires | Clear Pass adds | Fail if |
|---|---|---|---|
| Data Gathering & Diagnosis |
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| Clinical Management & Medical Complexity |
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| Relating to Others |
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Global rating guide: Pass = panic explained and named, no benzodiazepine, CBT and/or SSRI offered, safety-net. Diazepam is a Clear Fail in Clinical Management.
Teaching points
- NICE CG113: panic disorder — CBT first-line; an SSRI if drug treatment is chosen; benzodiazepines are not to be used for panic disorder (harm in the longer term); explain the expected course and the early side-effects.
- The normal results are a therapeutic tool when read aloud with meaning: 'three ECGs, two troponins — your heart has been checked more thoroughly than most people's ever is'.
- Statement 3.3: 'I can't let anyone see me like this' needs a response that respects her community without assumptions about it.
Guidelines for this station
Your reflection
Record your grades, the statement attached, what you will keep and change, and your own reflection. Your entry is emailed to you as a record of this station; this page stays live so you can revisit the full case during revision.
Write my reflection for Mock 2
Revision link for this case: mdacumen.com/sca-mock2-palpitations
Editorial stamp · MRCGP SCA Consultation Skills Course · Station pages v1.0 · 11 September 2026 · Prof Rajesh Varma, Course Director · MD Acumen. Formative training material; not a prediction of exam performance. Not for onward distribution.