Starter Station A · Indigestion

Candidates: do not open until you have consulted.

Persona and manner

• Daniel Okafor, 38, an IT project manager; pleasant, articulate, slightly impatient; you have done your research online and arrive with a conclusion. You check your watch once at minute four; you have a meeting after this.
• Not hostile. If the doctor listens, you soften quickly and become collaborative.

Opening line (verbatim)

• “I've had this burning in my chest and stomach for about six weeks, the omeprazole from the chemist helps a bit, and I really think I need a scan to be safe.”

The story

• “A burning pain high in my stomach and behind the breastbone, worse after meals and when I lie down at night.”
• “Bloating and belching after eating. It feels like a brick in there.”
• “The omeprazole from the chemist takes the edge off but it comes back.”
• If asked: no difficulty swallowing; food does not stick; no vomiting; no weight loss, “if anything I've gained”; no black stools; no blood.
• If asked about painkillers: ibuprofen most days for a gym shoulder injury, about eight weeks, two or three tablets a day, from a big pack.
• Alcohol: four or five pints on Friday and Saturday, wine with dinner two or three nights in the week; about 25 units. You under-estimate at first (“a few pints”) and correct yourself if asked to count.
• Coffee: five cups a day, mostly before lunch. You smoke socially, perhaps five a week.
• Sleep poor, waking at three. Work has been brutal: a deadline and two colleagues off sick.
• Your father “had stomach problems”; on gentle questioning, an ulcer at 60, treated with tablets, no cancer.
• No previous camera test; no previous test for the stomach bug; no aspirin or steroids.

Ideas, concerns and expectations

• Idea: “An ulcer like my dad's, or something worse.”
• Concern: Cancer. “You read things.” You say the word only if asked what worries you most.
• Expectation: A scan, or “the camera”, so you can stop worrying. You do not know which; you want the reassurance a test would give.

Impact

• Work: a project deadline; “running on caffeine and adrenaline”.
• Home: you live with your partner; no children.
• Gym: the shoulder injury is a real frustration; you have not trained for a month.

Red flags

• Absent: No dysphagia, no weight loss, no vomiting, no haematemesis, no melaena, no anaemia symptoms; under 55; no previous ulcer or surgery.

Hidden facts and their triggers

• The daily ibuprofen for the shoulder — released only if asked about painkillers, or if the doctor follows the shoulder cue
• The true alcohol total — released only if asked to count the drinks
• Your father's ulcer — released only if asked about the family
• The cancer fear — released only if asked what worries you most
• The poor sleep and the deadline — released only if the doctor picks up “knackered”

Behaviour

• Minute 2: as an aside, “…and I'm just knackered all the time, to be honest.” Do not repeat it unless the doctor picks it up.
• Minute 5: rub your right shoulder and mention the gym injury. This opens the ibuprofen line if the doctor is curious.
• If the doctor explains that there are no warning features, proposes a test for the stomach bug, a course of a stronger stomach tablet, stopping the ibuprofen with something else for the shoulder, cutting the alcohol and coffee, and explains why a camera test is not needed now and what would change that: accept with visible relief and ask, “And if it doesn't work?”
• If the doctor refers for a camera test without any discussion: accept quickly. “Great, thanks.”
• If the doctor refuses a scan without explaining why: push back once. “So you're saying it's definitely nothing?” Then subside.
• If asked to stop the ibuprofen: ask what you can use for the shoulder instead.

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: no tenderness that you can find pressing your own upper abdomen; no lumps; BMI 29 from the nurse; you look well.

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

• Missing the shoulder cue, so the daily ibuprofen that drives the symptoms is never found (statement D1)
• Referring for a camera test to be safe, or refusing one without explaining why, instead of exploring what a scan would tell him (statement R2)
• Prescribing another course of the acid tablet with no test for the stomach bug and no end date (statement C3)

What the examiner is listening for in the last four minutes

By 8:00 the working diagnosis should have been stated: uninvestigated indigestion without alarm features, driven by the ibuprofen and the alcohol. The examiner is listening for: the ibuprofen stopped with an alternative for the shoulder; the stool test two weeks off the acid tablet and the four-week course; the alcohol and coffee as his choices; the reasoning against a camera test now and the criteria that would change it; a safety-net that names difficulty swallowing, vomiting blood, black stools and weight loss; the follow-up with the result; and his own words on the plan.

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 people with uninvestigated dyspepsia and no alarm features, offer full-dose proton pump inhibitor therapy for four weeks, or test and treat for Helicobacter pylori; review NSAID use, alcohol, smoking and weight; endoscopy is not routinely needed. NICE — CG184 Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management, section 1.3, uninvestigated dyspepsia, 2014, last updated October 2019, checked 10 Oct 2026
2. Refer people using a suspected-cancer pathway for oesophageal or stomach cancer if they have dysphagia, or are aged 55 and over with weight loss and any of upper abdominal pain, reflux or dyspepsia; consider a non-urgent direct-access endoscopy for people with haematemesis or, at 55 and over, with treatment-resistant dyspepsia, upper abdominal pain with low haemoglobin, or raised platelets with other symptoms. NICE — NG12 Suspected cancer: recognition and referral, section 1.2, upper gastrointestinal tract cancers, 2015, last updated 2025, checked 10 Oct 2026
3. Test for Helicobacter pylori with a carbon-13 urea breath test or a stool antigen test; the person should not have taken a proton pump inhibitor within two weeks or an antibiotic within four weeks of the test; offer eradication therapy to those who test positive. NICE — CG184 Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management, section 1.5, Helicobacter pylori testing and eradication, 2014, last updated October 2019, checked 10 Oct 2026
4. NSAIDs are a common cause of dyspepsia and peptic ulcer; stop the NSAID where possible, and if it must continue, offer a proton pump inhibitor alongside it; paracetamol or a topical NSAID are alternatives for musculoskeletal pain. NICE CKS — NSAIDs: prescribing issues, adverse effects: gastrointestinal, current online version, checked 10 Oct 2026
5. Lifestyle advice for dyspepsia and reflux includes losing weight if overweight, reducing alcohol, caffeine and smoking, smaller and earlier evening meals, and raising the head of the bed for night-time symptoms. NICE CKS — Dyspepsia, unidentified cause, management: lifestyle advice, current online version, checked 10 Oct 2026
6. The UK Chief Medical Officers' low-risk drinking guideline is not more than 14 units a week spread over three or more days; 25 units a week with most of it on two days is a pattern at which brief advice is indicated. NICE CKS (citing the UK Chief Medical Officers' 2016 guideline) — Alcohol, problem drinking, background: the low-risk drinking guideline and unit calculation, current online version, checked 10 Oct 2026
7. In CG184 a full-dose proton pump inhibitor is omeprazole 20 mg once daily, lansoprazole 30 mg, esomeprazole 20 mg, pantoprazole 40 mg or rabeprazole 20 mg; low dose is half of this and double dose twice it. If uninvestigated dyspepsia does not respond to a four-week course, the other strategy (test and treat for Helicobacter pylori, or the course if testing came first) is used; if symptoms persist after both, a histamine-2 receptor antagonist is offered, and specialist referral is considered for unexplained or treatment-resistant symptoms at any age. NICE — CG184 Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management, section 1.3, uninvestigated dyspepsia: treatment steps; dose definitions for proton pump inhibitors; section 1.8, referral, 2014, last updated October 2019, checked 10 Oct 2026
8. First-line eradication of Helicobacter pylori is a seven-day, twice-daily course of a proton pump inhibitor with amoxicillin 1 g and either clarithromycin 500 mg or metronidazole 400 mg; in penicillin allergy, a proton pump inhibitor with clarithromycin 250 mg and metronidazole 400 mg; an antibiotic the person has had before for other infections is avoided. Re-testing after eradication is not routinely offered but is considered where symptoms persist; a second-line course uses the antibiotic not used first time. NICE — CG184 Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management, section 1.5, Helicobacter pylori eradication: first-line and second-line regimens; re-testing, 2014, last updated October 2019, checked 10 Oct 2026
9. People who need long-term management of dyspepsia symptoms have an annual review and are encouraged to step down to the lowest dose that controls symptoms, or to stop and use treatment as needed; a proton pump inhibitor course is not open-ended. CG184 also asks the GP to review medicines that can cause dyspepsia, for example calcium-channel blockers, nitrates, theophyllines, bisphosphonates, corticosteroids and NSAIDs, and to offer advice on weight, smoking, alcohol, coffee and the timing of meals. NICE — CG184 Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management, section 1.2, common elements of care: medicines that cause dyspepsia; lifestyle; section 1.3, long-term review, 2014, last updated October 2019, checked 10 Oct 2026
10. NG12 uses faecal immunochemical testing in primary care to guide suspected-cancer referral for colorectal cancer in adults with an abdominal mass, a change in bowel habit or iron-deficiency anaemia, or aged 40 and over with unexplained weight loss and abdominal pain, under 50 with rectal bleeding and abdominal pain or weight loss, 50 and over with rectal bleeding, abdominal pain or weight loss, or 60 and over with anaemia; 10 micrograms of haemoglobin per gram of faeces or more prompts referral. FIT has no place in assessing upper gastrointestinal symptoms. NICE — NG12 Suspected cancer: recognition and referral, section 1.3, lower gastrointestinal tract cancers: faecal immunochemical testing, 2015, last updated 2025, checked 10 Oct 2026
11. Factors that increase the risk of NSAID-related gastrointestinal bleeding or ulceration include age 65 and over, a history of peptic ulcer or gastrointestinal bleeding, a high dose or prolonged use, more than one NSAID, concurrent aspirin, anticoagulants, corticosteroids or SSRIs, Helicobacter pylori infection, heavy alcohol use and smoking. Where an NSAID cannot be stopped in a person with such factors, a proton pump inhibitor is co-prescribed; an NSAID bought over the counter and taken daily for eight weeks is counted as prolonged use. NICE CKS — NSAIDs: prescribing issues, adverse effects: gastrointestinal risk factors; gastroprotection, current online version, checked 10 Oct 2026
12. The Gastroenterology Topic Guide expects the GP to manage uninvestigated dyspepsia in primary care using test-and-treat and empirical acid suppression, to recognise alarm features and apply the suspected-cancer referral criteria, to review medicines and alcohol as causes, to explain the reasoning for and against endoscopy so that the patient can share the decision, and to arrange follow-up with the result. RCGP — GP curriculum: Gastroenterology, Topic Guide: dyspepsia and reflux; Helicobacter pylori; upper gastrointestinal cancer referral, 2025 curriculum (Being a GP), checked 10 Oct 2026

Working references for this station

12 statements, 731 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-STARTER-A