Mock 2 · Palpitations

Candidates: do not open until you have consulted.

Persona and manner

• Fatima Begum, 41, a teaching assistant; anxious, articulate, clutching your phone; you watch the doctor's face for reassurance; you apologise for “being dramatic”.
• Rational when calm; you catastrophise fast. You must not be “seen like this” by your family.

Opening line (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?”

The story

• “They come out of nowhere. Three or four a week. Ten or twenty minutes. I've stopped going to the supermarket. I've stopped driving. The hospital found nothing.”
• If asked: palpitations, tightness, tingling in your hands and lips, dizziness, a sense that things are not real, a fear of dying; no chest pain on exertion; no faints; no wheeze; no thyroid symptoms; not pregnant.
• Five or six coffees a day; energy drinks “for the school run”; sleep poor; no alcohol; no drugs.
• If asked about the family: your father died of a heart attack at 58. “That's what I think about every time.”
• Stress: your son is in trouble at school; your husband works abroad on contracts; your extended family is nearby. “I can't let anyone see me like this.”
• Mood: low “because of the attacks”; no thoughts of ending your life; no previous contact with mental health services.
• The diazepam “made me calm”; you have two left. You have not tried anything else. You have looked up heart scans.
• If asked about the first attack: in the supermarket car park; you thought it was a heart attack and drove yourself to hospital with the children in the back. “I shouldn't have.”
• If asked about therapy: you would consider it if it can be private and in the evening; you would not tell your sisters-in-law.

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.

Impact

• Driving: you have stopped driving after the car-park attack; the school run is by bus.
• Home: your husband rings nightly and does not understand; you have stopped attending the women's group at the mosque and pray at home.
• Work: you have had two attacks at school and hidden in the toilets.

Red flags

• Present: Avoidance spreading to driving and shopping; a benzodiazepine that has already become the solution in her mind; a father who died at 58, which drives the fear.
• Absent: No exertional chest pain, syncope, breathlessness on effort or thyroid symptoms; three normal ECGs, two negative troponins, a normal chest X-ray, normal thyroid and blood count.
• Absent: No thoughts of ending her life; no alcohol or drug use.

Hidden facts and their triggers

• The caffeine and the energy drinks — released only if asked about coffee, tea, energy drinks or what you drink in the day
• Your father's death and what it does to you in an attack — released only if asked about the family, or what you think is happening
• “I can't let anyone see me like this” — released only if asked about your family's view, or who knows
• The car-park drive with the children in the back — released only if asked about the first attack
• That you would consider therapy if private and in the evening — released only if the doctor asks what would make help possible

Behaviour

• Minute 1: “I honestly think I'm dying.”
• Minute 4: “Like Dad.”
• Minute 7: “I can't let anyone see me like this.”
• If the doctor uses the normal results explicitly, explains the cycle (adrenaline, fast breathing, the tingling) in plain terms, names the condition as real and treatable, explains why diazepam makes it worse over time and will not be prescribed, offers therapy you can self-refer to and a daily tablet with honest expectations, deals with the caffeine, teaches a breathing technique, respects the family concern, safety-nets, and reviews in two to four weeks: 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.”
• If the doctor says it is just anxiety: “That's what they said at the hospital.” Withdraw.
• If the doctor speaks fast or in long sentences: watch the screen; nod; retain nothing.

Examination findings, if the candidate states what they would examine and why

• Video: no examination today. If the candidate states what they would examine and why, give the emergency department's findings and the nurse's from last week: pulse 88 regular; blood pressure 128/82; oxygen saturation 98%; heart sounds normal; chest clear; no tremor; no goitre.
• If asked to count your pulse now: 92, regular.

Domain grades — with the key facts that earn a clear pass at this station

Global rating (recorded, not added to the total): ☐ Fail ☐ Bare Fail ☐ Bare Pass ☐ Pass

The domain grades (RCGP descriptors): CP clear pass — above the standard of a newly qualified, independent GP · P pass — sufficiently demonstrated at the standard · F fail — insufficiently demonstrated at the standard · CF clear fail — clearly demonstrated below the standard.

The RCGP grades each domain CF, F, P or CP and weights clinical management and medical complexity against the other two domains; the examination's maximum is 126 over twelve cases, which is 10.5 per case. The RCGP does not publish the mark each grade carries. MD Acumen's training sheet uses CF 0 · F 1 · P 2 · CP 3, with clinical management weighted ×1.5 (0 · 1.5 · 3 · 4.5), so that a case is marked out of 10.5 and a twelve-case circuit out of 126. A P in all three domains is 7.0; MD Acumen treats that line as the training standard for a case. The examination's pass mark is set by borderline regression for each diet and is published in the RCGP's diet summary reports; it is not a fixed fraction of 126.

Weighting rationale, in the RCGP's words: “To reflect the capability coverage within the clinical management and medical complexity domain this is weighted in comparison to the other two domains.”

Written to the standard of a newly qualified independent GP; the clear-pass row describes practice above that standard. It is a debriefing aid, not a checklist: the grade is a judgement that the essentials, the italic key facts on the mark sheet, were done well, at the patient's pace and in plain language. MD Acumen training standard; the RCGP does not publish case mark sheets.

Where candidates lose this station

• Prescribing diazepam because it is the only thing that has helped (statement C2)
• Saying it is just anxiety, so that she says “That's what they said at the hospital” and withdraws (statement R4)
• Taking the family history without asking what it does to her in an attack, so that “Like Dad” is never answered (statement R2)

What the examiner is listening for in the last four minutes

By 8:00 the working diagnosis should have been stated and named as real and treatable, with the three normal work-ups read aloud with their meaning. The examiner is listening for: no diazepam, and why; CBT she can reach privately; the SSRI with honest expectations if she chooses it; the breathing technique taught; the caffeine plan; driving advice during attacks; a safety-net for new exertional symptoms; the review date; and her own explanation of what happens in an attack and what she will say to her husband.

The ten statements below are postulated: the feedback an examiner would most likely attach at this station, chosen from the RCGP's standardised list of 26 feedback statements that applies to every SCA case and spans the three marking domains (Data Gathering and Diagnosis; Clinical Management and Medical Complexity; Relating to Others). They are a prediction from the case content, its complexity and the marks that matter, not an examiner's record: any statement on the full list can be attached to any case, and feedback plays no part in the mark. Record the statements that applied in the practice log.

The full list of 26 statements, with the generic meaning of each, is on the exam and the mark scheme.

Points of fact the examiner should have to hand

Each statement is drawn from the named guideline, in its current version, with the date it was checked. The examiner marks against these facts; the candidate is not expected to quote them.

1. For panic disorder, offer individual CBT as the psychological intervention; if drug treatment is chosen, offer an SSRI licensed for panic disorder; explain the likely side-effects, the delay in onset of effect and the risk of discontinuation symptoms; review within two weeks of starting. NICE — CG113 Generalised anxiety disorder and panic disorder in adults: management, section 1.4, panic disorder: steps 2 and 3, 2011, last updated June 2020, checked 10 Oct 2026
2. Benzodiazepines are associated with a less good outcome in the long term and should not be prescribed for the treatment of panic disorder; sedating antihistamines and antipsychotics are also not to be prescribed for panic disorder. NICE — CG113 Generalised anxiety disorder and panic disorder in adults: management, section 1.4, panic disorder: pharmacological interventions, 2011, last updated June 2020, checked 10 Oct 2026
3. A panic attack is a discrete period of intense fear with at least four of: palpitations, sweating, trembling, shortness of breath, choking, chest pain, nausea, dizziness, chills or heat, paraesthesia, derealisation, fear of losing control, fear of dying, peaking within minutes; hyperventilation produces the tingling and light-headedness; organic causes to consider include thyrotoxicosis, arrhythmia, caffeine and stimulant use and hypoglycaemia. NICE CKS — Generalised anxiety disorder (includes panic disorder), diagnosis: panic disorder; differential diagnosis, current online version, checked 10 Oct 2026
4. NHS Talking Therapies for anxiety and depression accept self-referral in England; CBT for panic disorder can be delivered individually, by telephone or online, which allows a person to choose a time and setting that is private. NHS England — NHS Talking Therapies for anxiety and depression, 2024, checked 10 Oct 2026
5. Sertraline is licensed for panic disorder; start at 25 mg daily for a week then 50 mg; an initial increase in anxiety, agitation or sleep disturbance can occur in the first weeks and is explained in advance; it is not addictive, and it is stopped by gradual reduction. BNF (NICE) — Sertraline, indications and dose: panic disorder; side-effects; patient and carer advice, current BNF online, checked 10 Oct 2026
6. Caffeine and stimulant drinks provoke palpitations and anxiety symptoms and are reduced or stopped as part of the management of panic disorder; abrupt cessation can cause headache, so a stepped reduction is advised. NICE CKS — Generalised anxiety disorder (includes panic disorder), management: self-help and lifestyle, current online version, checked 10 Oct 2026
7. A person who has symptoms during an attack that impair their ability to drive safely (dizziness, derealisation, a feeling of losing control) should not drive during attacks; anxiety disorders do not usually require DVLA notification unless symptoms affect driving or medication causes impairment. DVLA — Assessing fitness to drive: psychiatric disorders, anxiety and depression, 2024 edition, checked 10 Oct 2026
8. CG113 stepped care for panic disorder: recognition and diagnosis; treatment in primary care; review and alternative treatment in primary care; referral to specialist services. The options, by durability of benefit, are CBT (7 to 14 hours in total, weekly over about four months), an SSRI, and self-help based on CBT principles, chosen by the person; the more severe of coexisting depression and panic is treated first. Medication is reviewed at 2, 4, 6 and 12 weeks; imipramine or clomipramine may follow an SSRI that has not helped by 12 weeks. NICE — CG113 Generalised anxiety disorder and panic disorder in adults: management, section 1.4, panic disorder: the stepped-care model; psychological interventions; pharmacological interventions; review, 2011, last updated June 2020, checked 10 Oct 2026
9. CKS Palpitations: a 12-lead ECG for everyone, with full blood count, thyroid function, urea and electrolytes and glucose; ambulatory monitoring when episodes are frequent and the resting ECG is normal (a 24-hour recording if daily, an event recorder if less often). Admit or refer urgently where palpitations occur with syncope or near-syncope, chest pain or breathlessness, during exertion, with a family history of sudden cardiac death under 40 or an inherited cardiac condition, or with an abnormal ECG. A parent's infarction at 58 is not among them. NICE CKS — Palpitations, management: investigations; features requiring admission or urgent referral, current online version, checked 10 Oct 2026
10. Benzodiazepines are indicated for the short-term relief (two to four weeks only) of anxiety that is severe, disabling or causing unacceptable distress, and not for mild anxiety; dependence and withdrawal symptoms follow regular use, tolerance develops, and they impair driving and skilled tasks, an effect increased by alcohol. Diazepam is one of the drugs named in the drug-driving offence with a specified blood limit; a person taking it as prescribed and not impaired has a statutory defence. When a prescribed benzodiazepine is being stopped, the dose is reduced gradually. BNF (NICE) — Diazepam, indications; dependence and withdrawal; drugs and driving, current BNF online, checked 10 Oct 2026
11. An adult patient's information is not disclosed to relatives or others without her consent unless disclosure is required by law or can be justified in the public interest. The doctor establishes what information the patient wants shared, with whom, and in what circumstances, and respects that; a patient who fears her family learning of a diagnosis can be told that nothing will be shared with them, and this applies to appointments, correspondence and the content of the record. GMC — Confidentiality: good practice in handling patient information, disclosures with consent; sharing information with those close to the patient, 2017 (updated 2018), checked 10 Oct 2026
12. The Mental health Topic Guide expects the GP to diagnose anxiety disorders including panic disorder, to exclude physical causes using the history and the results already available rather than repeating investigations, to assess risk and the effect on function, work and relationships, to prescribe safely and avoid benzodiazepine dependence, to know the routes into psychological therapies including self-referral, and to consult with sensitivity to culture and faith without making assumptions. RCGP — GP curriculum: Mental health, Topic Guide: anxiety disorders; safe prescribing; psychological therapies; cultural competence, 2025 curriculum (Being a GP), checked 10 Oct 2026

Working references for this station

12 statements, 714 words. Every statement is signed by the Course Director before it is published; a station whose facts have changed since signature carries no signature line until it is signed again.

Record your three domain grades, your case total out of 10.5, your global rating, the RCGP feedback statements that applied, and what you will keep and change. The form is already labelled with this case and its web address; a copy of your entry is emailed to you, so your practice log builds up in your inbox and can be downloaded.

Record my marks and reflection for SCA-MOCK-2