ℹ️ This is the case information for the doctor.

Name

Sarah Williams

Age

Address

The Orchard House, Lower Green, Ashdown, GL10 2RW

Social history

Living arrangements: Lives in a detached house in a rural village in Gloucestershire with her husband, Mark, who works from home. Their grown-up daughter lives in London.
Occupation: Senior manager in a telecoms business. Mainly office-based but drives to meetings and commutes about 30 miles each way.
Smoking status: Never smoked.
Alcohol intake: A couple of glasses of wine at weekends.
Physical activity: Previously ran and cycled regularly.

Past history

Previously fit and well.
No chronic illnesses. No cardiac, neurological or psychiatric history.
Cervical screening and breast screening up to date.

Investigation results

From the A&E attendance 2 months ago:

FBC, U&E, LFT, TSH and glucose: all within normal limits.
12-lead ECG: sinus rhythm, no abnormality.
Blood pressure: 128/80 mmHg.

Since then:

Transthoracic echocardiogram: performed 3 weeks ago. Report not yet available.
EEG: performed last week. Report not yet available.
No brain imaging performed.

Cardiology clinic letter, Severnvale General Hospital (6 weeks ago)

Dear Dr,

Re: Mrs Sarah Williams, 50

Thank you for referring this lady from the Emergency Department. She has had two episodes of transient loss of consciousness, both while walking briskly uphill, about a month apart. No prodrome other than brief dizziness, no chest pain or palpitations. Her ECG in clinic was normal and I could not hear a murmur.

Impression: Exertional syncope. A structural or arrhythmic cardiac cause needs to be excluded.

Plan:

Transthoracic echocardiogram (requested).
Exercise test to be arranged depending on the echo result.
I have advised her not to drive.
We will review her in clinic with the results.

She has also been referred to the neurology first seizure clinic by the Emergency Department.

Yours sincerely,

Cardiology Registrar, for Consultant Cardiologist

Medication

No regular medication.
No known drug allergies.

Booking note

Video consultation. "Would like to discuss hospital results and when she can drive again."

ℹ️ This is the information for the person role playing the patient.

Case overview

Name

Sarah Williams

Age

Address

The Orchard House, Lower Green, Ashdown, GL10 2RW

Social history

Living arrangements: Lives in a detached house in a rural village in Gloucestershire with her husband, Mark, who works from home. Their grown-up daughter lives in London.
Occupation: Senior manager in a telecoms business. Mainly office-based but drives to meetings and commutes about 30 miles each way.
Smoking status: Never smoked.
Alcohol intake: A couple of glasses of wine at weekends.
Physical activity: Previously ran and cycled regularly.

Past history

Previously fit and well.
No chronic illnesses. No cardiac, neurological or psychiatric history.
Cervical screening and breast screening up to date.

Medication

No regular medication.
No known drug allergies.

Opening statement

Hello doctor, I'm really hoping you can help. I'm desperate to find out what's going on with me. I've been waiting for my results and I'm getting nowhere ringing the hospital. I also want to ask when I can drive again, because not driving is affecting every part of my life.

Information freely divulged

Initial information given in response to a general opening question

You are Sarah Williams, 50, a senior manager in a telecoms business. You live with your husband Mark in a village in rural Gloucestershire.
About three months ago you had "a funny turn" while rushing up a hill walking back from the shops. You felt suddenly lightheaded and "came round" sitting on the grass with no idea how you got there. Mark was with you and said you were out for about a minute. You weren't shaking or jerking.
About a month later it happened again while you were walking quickly uphill to your car after a work meeting. You felt dizzy, your vision went briefly, and you woke up on the pavement. A passer-by helped you. You weren't hurt. An ambulance took you to A&E, but you felt back to normal quickly.
You've been seen by cardiology, who arranged a heart scan (echo), and you had a brain wave test (EEG) last week. You are waiting for both results.
You have rung both departments many times. You get answerphones or "someone will call you back", but no one ever does.

Ideas, concerns and expectations

At the echo, the technician said "there might be a problem" but wouldn't say what. That has been playing on your mind ever since.
"I'm very worried about what's going on and whether there might be something really wrong."
You want the doctor to help you get your results and to tell you when you can drive again.

Symptoms

Both times there was no warning apart from the dizziness. You had no chest pain, no palpitations, no sweating and you didn't bite your tongue.
You have had no episodes since, which is about two months now.

Lifestyle information

Your employer is supportive, but you really need to drive for work. You are using up your annual leave at the moment.

Family history information

None

Medical history information

After the second episode, A&E did blood tests and a heart tracing, which were normal, and referred you to the heart doctors and the neurologists.

Information given on questioning

Further symptom details

Details of the episodes (if asked):

No incontinence, no tongue biting, no confusion when you came round. Within a few minutes you felt normal.
No palpitations before or after. No chest pain.
Both times you were walking fast uphill. Neither happened after you stopped, or when standing still, or when getting up from sitting.

Since the last episode (if asked):

No further blackouts or near blackouts.
No chest pain, palpitations, breathlessness or ankle swelling.
You get a bit puffed walking uphill, but you think that is because you have been less active. It is no worse than before.

Relevant risk factors and exclusions

Exercise (if asked about activity or exercise):

You used to run three times a week and cycle at weekends. You stopped all exercise after the second episode because Mark was worried.

Driving (if asked):

You haven't driven since the second episode. The heart doctor told you not to drive "until we've got to the bottom of it".
You haven't told the DVLA. You thought it was just until the results came back, so you didn't think you needed to.
Mark has been driving you, but he has his own work. There is one bus a day from the village.

Further medical history

The echo was about three weeks ago.
You are not taking any medicines, supplements or anything bought over the counter. No allergies.

Further family and social history

No one in your family has died suddenly or young. No family history of heart conditions, epilepsy or blackouts. Your parents are both alive and well in their seventies.
You have never smoked. You drink a couple of glasses of wine at weekends. No recreational drugs.
Work and money (on direct questioning): you need to drive to meetings and to the office, about 30 miles each way. You have used most of this year's annual leave. You haven't asked for a fit note because you didn't know you could, and you aren't "ill". You have income protection insurance through work, but you don't know whether you can claim. Your car insurance renews next month and you don't know whether you need to tell them.

Further ideas, concerns and expectations

Ideas: You don't know what it is. You have always been fit and well and you can't believe it could be something serious. Since the technician's comment, you have been wondering whether it is your heart.
Concerns: What the underlying cause might be: "I've always been so well, I can't believe this could be something serious." Not being able to drive, and how long you will be banned for, especially with your job and where you live. Whether you can keep working if you can't drive, and the effect on your income and your professional standing. Your mental health: "I'm just worrying about what comes next."
Expectations: "I really want you to chase the results. Is there anything you can do to speak to someone at the hospital or get me a proper answer?" You hope the doctor can tell you if you can drive yet, or what needs to happen before you can. "If I went privately, would it speed things up at all? Could I get the results more quickly if I paid?" You would like follow-up with the same doctor so you don't have to explain everything again. You want to know if anyone can help you practically, for example with getting about or understanding your insurance. You would like to be pointed to any support for people who can't drive for medical reasons.

Information requiring sensitive or specific questioning

When good rapport is established: you are sleeping badly and lie awake worrying about what the echo showed.
When good rapport is established: you feel low and tearful at times, which isn't like you. "My mental health's taking a battering." You have no thoughts of harming yourself. Mark is very supportive.
When good rapport is established: you feel isolated: "It's just that you feel a bit stuck out here in the middle of the sticks with absolutely no control over your own health or your future."

Behaviour

Initial disposition and manner

You are business-like at first but frustrated and anxious.
You become more emotional when you talk about not driving and the lack of answers.

Emotional triggers and shifts

You pause and have to steady your voice when you talk about the impact on your work, your life and your mood.
If the doctor seems dismissive, vague or unhelpful, become more upset: "I feel like nobody wants to take ownership of this!"
If the doctor asks how you are coping and listens, you open up about your sleep, mood and feeling isolated.

Response to clinical explanations

If the doctor asks what the technician said, repeat it and say it has really frightened you. If the doctor acknowledges this and explains what they will do about it, you become more trusting.
If the doctor tells you that you must tell the DVLA, you are upset: "So I'm going to lose my licence?" If the doctor explains kindly why, and that how long you are off the road depends on what the tests show, you accept it and agree to tell the DVLA.
When you ask about going privately, if the doctor explains honestly what it would and wouldn't change, you accept this. If the doctor simply says "no" or "yes" without explaining, you are unsure what to do.

Response to clinical management and proposals

If the doctor offers to chase the cardiology team urgently and get back to you as soon as they hear, you are very relieved and visibly calmer.
If the doctor offers practical help, such as a fit note, talking to your employer or occupational health, a social prescriber, transport support or help with insurance, you become more hopeful and less overwhelmed.
If continuity with the same doctor is agreed, you thank the doctor warmly.

Key role-player instructions

You are polite but persistent. If the doctor doesn't clearly address chasing the results or driving, ask again.
Mention the technician's comment when you talk about your results.
Only mention that you haven't told the DVLA if the doctor asks about driving or the DVLA.
Ask specifically to see the same doctor each time because you are exhausted from repeating your story.
Only talk about your sleep, mood and isolation once good rapport is established.

ℹ️ To mark data gathering & diagnosis select from the descriptors below.

Positive descriptors

Negative descriptors

Data gathering was systematic and targeted ensuring patient safety:

Opens with open questions and lets Sarah describe both episodes, what has happened since and what she most needs today.
Clarifies the circumstances of each episode, especially that both happened while walking fast uphill.
Checks for further episodes and cardiac symptoms since, such as chest pain, palpitations and breathlessness.

Data gathering was incomplete, lacking structure and focus:

Does not establish that both blackouts happened during exertion.
Jumps between results, driving and work without a clear structure, leaving key safety questions unasked.

Makes effective use of existing information and considers the wider context:

Uses the notes and the cardiology letter to confirm the normal ECG and bloods, the outstanding echo and EEG, and the planned exercise test.
Notices that the letter advises no driving but says nothing about telling the DVLA.
Explores her rural home, 30-mile commute and work driving to understand what not driving means for her.

Fails to use the information provided or understand the wider context:

Repeats questions already answered in the notes and the cardiology letter.
Does not ask how Sarah gets about, what her job involves or how far she lives from work.

The presence or absence of relevant red flags was established:

Recognises that blackouts during exertion are a red flag for a cardiac cause.
Asks about chest pain, palpitations, new breathlessness and any family history of sudden death at a young age.
Asks what the technician said at the echo and treats the comment as a possible abnormal result.

Fails to assess key information necessary to determine risk:

Does not ask about chest pain, palpitations or breathlessness.
Misses the significance of the technician's comment or the family history.

Information gathered placed the problem in its psychosocial context:

Explores the impact of not driving on Sarah's job, income, independence and sense of identity.
Recognises her isolation in a rural village with one bus a day.
Asks about sleep, mood and support, and checks for thoughts of self-harm.
Asks about money worries, annual leave and her income protection insurance.

The social and psychological impact of the problem was not adequately determined:

Focuses only on the results and the episodes.
Misses her low mood, poor sleep, isolation and financial worries.

Uses an understanding of probability based on prevalence, incidence, and natural history to aid decision-making:

Recognises that most blackouts are faints, but that blackouts during exertion carry a higher risk of a serious heart cause.
Uses this to explain why the echo result matters and why driving must wait.

Choice of diagnosis and or investigations does not reflect disease likelihood:

Falsely reassures Sarah because she has been well for two months and her ECG was normal.
Arranges extra tests in primary care instead of chasing the specialist results already done.

Revises hypotheses as necessary in light of additional information:

Escalates the urgency of chasing the echo when Sarah reports the technician's comment.
Changes the driving advice when Sarah reveals she has not told the DVLA.

Rigid consulting with new information not adequately considered and integrated into the working diagnosis:

Carries on with routine advice after hearing the technician's comment.
Does not respond when Sarah says she has not told the DVLA.

ℹ️ To mark clinical management & medical complexity select from the descriptors below.

Positive descriptors

Negative descriptors

Offers management options that are safe and appropriate:

Advises Sarah not to drive and explains her legal duty to tell the DVLA.
Advises her to keep avoiding strenuous exercise until cardiology says it is safe.
Chases a cardiology opinion urgently through advice and guidance, rather than leaving her to wait.

Fails to provide appropriate and or safe management choices:

Suggests Sarah can drive once she feels well, or does not mention the DVLA.
Leaves the echo unchased.

Continuity of care is prioritised:

Agrees to be Sarah's named GP for this problem and books follow-up with the same doctor.
Records a clear plan so that colleagues can pick it up if the doctor is away.

Ongoing care is uncoordinated:

Leaves Sarah to keep ringing the hospital herself.
Makes no plan for who will follow up the results.

Refers appropriately being mindful of resource:

Chases the existing cardiology and neurology investigations rather than making new referrals.
Explains honestly that going privately might speed up a specialist opinion but would not change the DVLA rules.
Signposts to a social prescriber, community transport and Access to Work.

Sends patients for specialist input unnecessarily:

Makes duplicate referrals or sends Sarah to A&E without a new reason.
Does not offer support services despite her isolation and practical needs.

Practises holistically, promoting health, and safeguarding:

Recognises and responds to Sarah's low mood, poor sleep and isolation.
Offers support for her mood, such as NHS Talking Therapies, and follow-up.
Offers a fit note with amended duties so that she does not have to use up her annual leave.

Fails to safeguard patient welfare:

Focuses only on the results and driving, ignoring her mood and isolation.
Misses the financial and work pressures that are adding to her distress.

Manages uncertainty, including that experienced by the patient:

Acknowledges that the cause is not yet known and that the technician's comment may or may not be significant.
Explains that the length of time off driving depends on what the tests show.
Agrees a clear plan for what happens next, whatever the result.

Struggles with uncertainty, leading to inconsistent decisions:

Speculates about the echo result or gives false reassurance.
Gives Sarah a fixed date for driving again before the cause is known.

Adapts thinking to overcome challenges, creating practical and effective solutions:

Uses advice and guidance to get an urgent cardiology opinion instead of relying on the hospital phone lines.
Finds practical ways to keep Sarah working, such as a fit note with amended duties, home working and Access to Work.

Fails to adjust thinking when faced with obstacles, leading to ineffective or impractical solutions:

Tells Sarah there is nothing more the practice can do except wait.
Offers no interim plan for work or transport while she waits.

ℹ️ To mark relating to others select from the descriptors below.

Positive descriptors

Negative descriptors

Shows ability to communicate in a person-centred way:

Acknowledges Sarah's frustration at chasing her results with no reply.
Explores what being "stuck out here" with no control feels like for her.
Uses plain words such as "blackout" rather than "syncope".

Communication is doctor centred and lacks empathy:

Focuses on test logistics and rules.
Does not acknowledge Sarah's distress or what this is doing to her life.

Shows understanding of medical-legal principles and regulatory standards:

Explains that Sarah must not drive and has a legal duty to tell the DVLA.
Explains that the time off driving depends on what the tests show and that the DVLA makes the decision.
Documents the driving advice.

Fails to give appropriate regard to key legal aspects of consulting:

Gives unclear or wrong advice, such as "you can drive once the results are back".
Does not mention the DVLA, leaving her unaware of her legal duty.

Demonstrates an empathic approach, and a willingness to help and care for the patient:

Responds to her cue about her mental health taking "a battering".
Shows a clear willingness to help, for example by offering to chase cardiology urgently through advice and guidance.

Lacks empathy and fails to be recognise emotional cues:

Ignores the pauses and the shaky voice when she talks about work and her mood.
Responds in a detached way to her sense of isolation.

Works collaboratively in a team showing respect for colleagues:

Advocates for Sarah with the hospital team while respecting their role.
Involves the practice team, such as the social prescriber and reception, to support follow-up.

Fails to work effectively with team members to deliver optimal care:

Criticises the hospital or the technician in front of Sarah.
Does not use the wider practice team.

Respectfully challenges unhelpful health beliefs or behaviours:

Corrects her belief that she only needs to stop driving until the results come back, without making her feel foolish.

Fails to maintain a productive therapeutic relationship:

Tells her off for not telling the DVLA.
Creates conflict that makes her less likely to follow the advice.

Takes ownership of decisions, whilst being aware of personal limitations:

Takes responsibility for chasing the results and coordinating with the hospital.
Is honest that the diagnosis and driving clearance depend on the specialists and the DVLA.

Does not take ownership or show awareness of personal limitations:

Passes responsibility back to the hospital or to Sarah.
Oversteps by guessing the echo result or telling her when she can drive.

ℹ️ Insights from the examiner

📝 Section 1: Case Overview and Consultation Priorities

Case at a glance

Sarah is a 50-year-old senior manager living in a rural village. She has had two blackouts, both while walking fast uphill, three and two months ago. Her ECG and bloods were normal. Cardiology suspect a heart cause and have done an echo; neurology have done an EEG. Both results are outstanding, and she has had no reply from either department.

At the echo, the technician said "there might be a problem". She has stopped driving on hospital advice but has not told the DVLA. She is anxious, sleeping badly and feels isolated. Her job and her life depend on driving.

The GP is not expected to make the diagnosis. The task is to recognise the risk, take ownership of getting the results reviewed, give accurate driving advice, and support her while she waits.

GP trainee performance focus

A strong GP trainee should demonstrate the ability to:

Use the notes and the cardiology letter rather than starting again.
Recognise that blackouts during exertion are a red flag for a heart cause.
Treat the technician's comment as a possible abnormal result that needs an urgent cardiology opinion.
Take ownership: chase a cardiology opinion urgently through advice and guidance, and agree how she will hear back.
Advise her to keep avoiding strenuous exercise until cardiology says it is safe.
Explain that she must not drive, must tell the DVLA, and that the time off driving depends on the cause.
Answer her question about private care honestly.
Offer continuity and practical support for work, transport and insurance.
Respond to her low mood and isolation.

What this case is testing

Using existing information from secondary care.
Recognising red flags in a patient who currently feels well.
Taking ownership and coordinating care across the primary and secondary care interface.
Knowledge of the DVLA rules for blackouts and the patient's duty to notify.
Managing uncertainty while results are outstanding.
Honest discussion of NHS and private options.
Psychosocial assessment, including mood, work and finances.
Continuity of care.

Patient priorities and concerns

Sarah wants:

Someone to chase her results and give her a proper answer.
To know when she can drive again.
To know if paying privately would speed things up.
To see the same doctor each time.
Practical help with getting about and understanding her insurance.
Support for people who can't drive for medical reasons.

She is frightened by the technician's comment, worried about her job and income, and her mood is suffering.

Central challenge

The central challenge is that the GP cannot give Sarah the two things she most wants: her results and permission to drive. The trainee has to turn this into a plan she can trust: what the doctor will do now, what she must do, and what happens next.

At the same time, the trainee must recognise that this is not just an administrative problem. Two blackouts during exertion, and a hint that the echo may be abnormal, mean the results need urgent attention. The trainee also has to give her an unwelcome message: she must tell the DVLA.

The trainee should avoid:

Treating this as a simple results-chasing request.
Reassuring her because she has been well for two months.
Guessing what the echo shows.
Telling her she can drive once the results are back.
Criticising the hospital in front of her.

Must-not-miss issues

Blackouts during exertion. These suggest a possible structural or rhythm problem with the heart. NICE treats blackouts during exertion as a red flag needing urgent cardiovascular assessment.
A possible abnormal echo. The technician's comment, together with the history, means the result should be reviewed by cardiology urgently, not left in a queue.
Driving and the DVLA. She has not told the DVLA because she thought the restriction was temporary.

Red flags and high-risk features

Features that raise concern in this case:

Blackouts during exertion.
No warning apart from brief dizziness.
A comment that the echo may show a problem.

Features to ask about:

Chest pain, palpitations or new breathlessness.
Further blackouts or near blackouts.
A family history of sudden death at a young age or an inherited heart condition.

When to seek urgent help:

Call 999 for a further blackout, chest pain, or palpitations with feeling faint or breathless.

Common GP trainee pitfalls

Accepting the "just chasing results" framing and missing the clinical risk.
Not asking what the technician said, or brushing it off.
Telling her she can drive when the results are back, or not mentioning the DVLA.
Giving a fixed date for driving again.
Saying private care will or won't help without explaining why.
Making a new referral instead of chasing the existing tests.
Leaving her to keep ringing the hospital.
Missing her low mood and isolation.
Criticising the hospital team.

What good looks like

A strong trainee acknowledges Sarah's frustration early, uses the cardiology letter, and quickly establishes that both blackouts happened on exertion. They ask about cardiac symptoms, family history and the technician's comment, and find out she has not told the DVLA. They take ownership: they will send an urgent advice and guidance request to cardiology and contact her when the reply comes back, usually within a couple of days. They explain clearly and kindly about driving and the DVLA, advise her to keep avoiding strenuous exercise, answer her question about private care honestly, offer practical support and continuity, respond to her mood, and check she has understood.

"I can hear how frustrating this has been. I can't give you the results today, but I can take this on. I'll send an urgent request to the cardiology team today. They usually reply within a couple of days, and I'll contact you myself as soon as I hear."

Learner checkpoint

Have I recognised the risk behind this request, and does Sarah leave knowing what I will do, when she will hear back, and what she must do herself?

📝 Section 2: Patient-Centred Consultation and Data Gathering

Start with an open question

Acknowledge her frustration, then let her tell her story:

"It sounds like you've had a really difficult few months. Can you tell me what's been happening, from the start?"

Let her speak without interruption. She is organised and articulate, and much of the history will come out if given space.

Time-efficient data gathering

The notes and the cardiology letter cover the normal ECG and bloods, the outstanding echo and EEG, the planned exercise test and the advice not to drive. Use them, and focus on:

The circumstances of each blackout, especially exertion.
Any further episodes or cardiac symptoms since.
Family history of sudden death or inherited heart conditions.
What the technician said.
What she has been told about driving, and whether she has told the DVLA.
Her work, transport and money worries.
Her mood, sleep and support.
Her ideas, concerns and expectations.

High-yield questions

The episodes

What were you doing just before each one?
Did you get any warning?
How quickly did you come round, and how did you feel afterwards?

Red flags

Any chest pain, palpitations or breathlessness, then or since?
Any more blackouts or near blackouts?
Has anyone in your family died suddenly or young, or had a heart condition?

Results

What did they say at the echo?
What have you been told about what happens next?

Driving

What did the hospital tell you about driving?
Have you been in touch with the DVLA?

Work and money

How is this affecting work?
How are you managing financially?

Ideas, concerns and expectations

What have you been thinking might be going on?
What worries you most?
What were you hoping I could do today?

Functional, psychosocial or contextual assessment

Explore:

Her commute and work driving.
How she gets about in a village with one bus a day.
The pressure on Mark, who is driving her.
Her annual leave, income protection and car insurance.
Her sleep, mood and any thoughts of self-harm.
Her sense of isolation and loss of control.

Explore ideas, concerns and expectations

Sarah's ideas:

She doesn't know the cause and can't believe it is serious, as she has always been well.
Since the technician's comment, she wonders if it is her heart.

Sarah's concerns:

What the cause might be.
How long she will be unable to drive.
Her job, income and professional standing.
Her mental health.

Sarah's expectations:

For the GP to chase her results.
To know when she can drive.
To know whether private care would help.
Continuity with the same doctor.
Practical help and signposting.

Recognise and respond to cues

Cues include:

Her repeated frustration: "I'm getting nowhere ringing the hospital."
The technician's comment, which she keeps returning to.
Pauses and a shaky voice when she talks about work and her mood.
"My mental health's taking a battering."
"Stuck out here in the middle of the sticks with absolutely no control."

A strong response:

"You said your mental health is taking a battering. That's a lot to carry on top of everything else. Can you tell me a bit more about how you've been feeling?"

Useful consultation phrases

"I'm sorry you've been left chasing this yourself."
"What exactly did the technician say?"
"Have you had a chance to contact the DVLA?"
"I can't tell you what the scan shows, but I can make sure the right person looks at it quickly."
"I'll take this on. I'll ask the cardiology team for an urgent opinion and contact you as soon as they reply."
"Would it help if I were your named doctor for this, so you don't have to repeat your story?"
"Can you tell me in your own words what we've agreed?"

Consultation flow and signposting

Acknowledge her frustration and invite her story.
Clarify the episodes, especially exertion.
Check for red flags and further episodes.
Ask what the technician said.
Ask about driving and the DVLA.
Explore the impact on work, money, mood and support.
Signpost: "There are a few things I'd like to cover: your results, keeping you safe while you wait, driving, and how we can support you."
Explain your thinking and the uncertainty.
Agree how you will chase the results and how she will hear back.
Advise on driving, the DVLA and avoiding strenuous exercise.
Answer her question about private care.
Offer practical and emotional support and continuity.
Safety-net, agree follow-up and check understanding.

Summarising and checking understanding

"So, you've had two blackouts, both walking uphill, and you've had tests with the heart and brain teams but no results. The technician said there might be a problem, and that's really worrying you. You haven't driven since, it's affecting your job and your mood, and you want someone to take charge of this. Is that right?"

At the end:

"We've covered a lot. Can you tell me what I'm going to do, and what you're going to do about driving and the DVLA?"

Data gathering self-check

Before moving to management, the trainee should know:

That both blackouts happened during exertion.
Whether there have been further episodes or cardiac symptoms.
The family history.
What the technician said.
That she has not told the DVLA.
The impact on her work, finances, mood and support.

Assessment domain mapping

Data gathering

Uses the notes and cardiology letter.
Identifies the exertional pattern and checks red flags.
Finds out about the technician's comment and the DVLA.
Explores the psychosocial impact.

Clinical management

Takes ownership of chasing the results urgently.
Advises no driving, notifying the DVLA and avoiding strenuous exercise.
Discusses private care honestly.
Offers continuity, practical support and mood support.
Safety-nets and arranges follow-up.

Relating to others

Acknowledges her frustration and distress.
Explains the DVLA rules clearly and kindly.
Respects the hospital team while advocating for her.
Challenges her belief about driving respectfully.
Checks understanding.

📝 Section 3: Clinical Reasoning and Personalised Management

Prioritised clinical reasoning

Most blackouts are simple faints. Blackouts that happen during exertion are different: they raise the possibility of a structural heart problem or a heart rhythm problem, which carry a risk of further blackouts and serious harm. This is why cardiology have prioritised an echo and plan an exercise test.

Sarah's episodes have no features that suggest a seizure: no tongue biting, incontinence or confusion afterwards. The neurology tests are still worth chasing, but the cardiac result is the priority.

The likely causes, in order of concern:

A structural heart problem.
A heart rhythm problem.
A faint (less likely, as it happened during exertion rather than after it).
A seizure (unlikely, as there are no seizure features).

The GP's reasoning task is not to make the diagnosis. It is to recognise the risk, make sure the right person sees the echo result quickly, and keep Sarah safe in the meantime.

Clinical reasoning script

"Most blackouts are simple faints, but when they happen during exercise we take them more seriously, because sometimes the heart is involved. That's why the heart team want to see your scan results. I can't say whether the technician's comment means anything, but I don't want you to be left waiting, so I'll ask the team for an urgent opinion today. Until we know more, it's safest not to drive and to avoid strenuous exercise."

Decision points

Does anything need emergency action today? No, unless she has new symptoms.
Does the outstanding echo need urgent attention? Yes.
Should she do strenuous exercise? No, until cardiology says it is safe.
Can she drive? No.
Must she tell the DVLA? Yes.
Is a new referral needed? No. Chase the existing tests.
Does she need support for her mood, work and transport? Yes.

Management priority

The main management priorities are:

Getting the echo result reviewed by cardiology urgently.
Advice to avoid strenuous exercise until cardiology says it is safe.
Accurate driving advice and her duty to tell the DVLA.
Continuity and a clear plan for follow-up.

Management options

1. Chasing the results

Send an urgent advice and guidance request to cardiology today. A reply usually comes back within a couple of days.
Explain the history and the technician's comment, and ask for the echo to be reviewed and her follow-up brought forward.
Ask about the EEG result and the neurology plan.
Contact Sarah as soon as the reply comes back.

2. Exercise

Advise her to keep avoiding strenuous exercise until cardiology tells her it is safe.

3. Driving

Advise her not to drive.
Explain that she has a legal duty to tell the DVLA.
Explain that the time off driving depends on the cause. If no cause is found, two unexplained blackouts mean 12 months off driving from the most recent one. If a cause is found, the DVLA rules for that condition apply, and if it is treated she may be able to drive sooner.
Explain that the DVLA makes the final decision.
Document the advice.

4. Private care

Explain honestly that a private cardiology opinion might be quicker, but it would not change the DVLA rules or the time off driving.
Explain that the scans already done are NHS records and that the quickest route to her results is usually through the NHS team.
Support her decision either way.

5. Work, transport and money

Offer a fit note with amended duties (not driving), so she can work from home without using annual leave.
Encourage her to talk to her employer and occupational health about adjustments.
Signpost to Access to Work for help with travel to work.
Refer to the social prescriber for community transport, local support and help with insurance and benefits.
Suggest she checks her income protection policy and talks to her insurer.

6. Mood and support

Explore her mood, sleep and any thoughts of self-harm.
Offer NHS Talking Therapies and follow-up.
Recognise Mark's role and the strain on him.

7. Continuity

Agree to be her named doctor for this problem.
Book follow-up with the same doctor.
Record the plan clearly for colleagues.

Personalised plan

Sarah's plan should take into account:

Her rural home and one bus a day.
Her 30-mile commute and work driving.
Her senior role and her worry about professional standing.
Her dwindling annual leave and income protection.
Mark, who is driving her and working from home.
Her low mood and poor sleep.
Her need for one doctor to take charge.

For example:

The GP sends an urgent advice and guidance request to cardiology and contacts her when the reply comes back.
She keeps avoiding strenuous exercise for now.
She tells the DVLA online.
She takes a fit note with amended duties to her employer.
The social prescriber helps with transport and insurance questions.
She self-refers to NHS Talking Therapies.
Follow-up is booked with the same GP.

Shared decision-making

The trainee should involve Sarah in:

Whether to seek a private opinion, with honest information about what it would and wouldn't change.
How she wants to be contacted with updates.
Which practical supports would help most.
Whether she wants support for her mood now.

Some points are not negotiable: not driving, telling the DVLA and avoiding strenuous exercise. The trainee should explain these clearly, with reasons, while respecting her feelings about them.

Safety-netting

Sarah should know:

Call 999 if she has another blackout, chest pain, or palpitations with feeling faint or breathless.
Contact the practice if she has a near blackout or new breathlessness.
Expect to hear from the GP when the cardiology reply comes back, usually within a couple of days, and contact the practice if she hasn't heard.
Contact the practice if her mood gets worse or she has thoughts of harming herself.

Ethical, legal and safeguarding considerations

Driving

Sarah has a legal duty to tell the DVLA.
The doctor's duty is to advise her not to drive, explain her legal duty to tell the DVLA, and record the advice.
If she continued to drive against advice and others were at risk of serious harm, GMC guidance says the doctor should tell the DVLA, after trying to tell her first.

Insurance

Driving against medical advice, or without telling the DVLA when required, may invalidate her car insurance.

Confidentiality

Information shared with her employer or occupational health should be with her consent.

Documentation points

Document:

The history of exertional blackouts and the absence of other red flags.
The technician's comment and the action taken to chase the echo.
Advice to avoid strenuous exercise.
Advice not to drive and to tell the DVLA.
The discussion about private care.
Mood assessment.
Fit note, signposting and the follow-up plan.
Safety-netting.

Common unsafe management plans

Reassuring Sarah because she has been well for two months.
Leaving the echo in the queue.
Telling her she can drive once the results are back, or not mentioning the DVLA.
Giving her a date when she can drive again.
Making duplicate referrals.
Ignoring her mood.

Follow-up and coordination with other professionals

Send an urgent advice and guidance request to cardiology about the echo and her follow-up.
Check the EEG result and the neurology plan.
Contact Sarah with the outcome when the reply comes back.
Review her with the same GP once the results are known.
Involve the social prescriber and, with her consent, her employer's occupational health.

Learner checkpoint

Have I made sure the echo will be seen quickly, and kept Sarah safe on exercise and driving while she waits?

📝 Section 4: Key Guidance, Resources and References

Relevant guidance areas

Assessment and referral after a blackout.
Red flags for a heart cause.
Safety advice while waiting for cardiovascular assessment.
Driving and the DVLA.
Confidentiality and disclosure to the DVLA.

NICE guidance

NICE CG109: Transient loss of consciousness ('blackouts') in over 16s. Covers red flags needing urgent cardiovascular assessment (including blackouts during exertion), exercise testing for syncope during exercise and advice to avoid exercise until assessed, information for people waiting for assessment, and advice not to drive while waiting.
NICE NG197: Shared decision making.

GMC, DVLA or safeguarding guidance

DVLA: Assessing fitness to drive: a guide for medical professionals.
GMC Confidentiality: good practice in handling patient information.

RCGP and SCA resources

RCGP SCA Toolkit: Consultation Structure.
RCGP SCA Toolkit: Recognising cues.

Patient information websites

NHS website: Fainting.
British Heart Foundation.
STARS (Syncope Trust And Reflex anoxic Seizures).

Relevant research or educational references

Roger Neighbour, The Inner Consultation.
Roberts C, Atkins S, Hawthorne K (2014). Performance features in clinical skills assessment: linguistic and cultural factors in the Membership of the Royal College of General Practitioners examination. King's College London and The University of Nottingham.

Key principles to remember

A request to chase results can hide a clinical risk. Ask why the test was done.
Blackouts during exertion are a red flag for a heart cause.
Ask what the patient was told at the test.
Advise avoiding strenuous exercise while waiting for cardiovascular assessment after syncope during exercise.
Use advice and guidance to get an urgent specialist opinion when a patient is stuck waiting.
Always ask about driving and the DVLA after a blackout.
The time off driving depends on the cause, so avoid giving a date.
Take ownership and agree who will contact the patient.
Be honest about what private care can and can't change.

Transferable learning for future cases

When a patient asks you to chase results:

Find out what the test was for and why it was done.
Check for new symptoms or red flags.
Ask what they have been told so far.
Decide how urgently the result needs to be seen, and act on it.
Give safety advice for the waiting period.
Agree who will contact the patient and when.
Address the impact on work, money and mood.

Supervisor or examiner lens

An examiner is likely to look for:

Recognition that blackouts during exertion are a red flag.
Exploration of the technician's comment and action to get the echo reviewed urgently.
Use of advice and guidance to get an urgent cardiology opinion.
Accurate driving advice, including the duty to tell the DVLA.
An honest answer about private care.
Ownership, continuity and a clear follow-up plan.
Recognition of her low mood and isolation.
Respect for the hospital team while advocating for the patient.

Final learner takeaway

When a patient asks you to chase results, ask why the test was done: two blackouts on exertion and a worrying comment at the echo make this a safety problem, not an admin one.

Start the quiz

Two Exertional Blackouts: Chasing Results and Driving Advice

Case overview

Opening statement

Information freely divulged

Information given on questioning

Behaviour

📝 Section 1: Case Overview and Consultation Priorities

📝 Section 2: Patient-Centred Consultation and Data Gathering

📝 Section 3: Clinical Reasoning and Personalised Management

📝 Section 4: Key Guidance, Resources and References

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