Blocked Nose for Months Asking for Something Stronger — Free SCA Practice Case

Character Overview: You are Hannah Price, a 34-year-old secondary school English teacher. For about six months your nose has been blocked most days, and since the new school term started in September it has been much worse. You are friendly and chatty but clearly worn down and tired. In July you and your partner moved into an older rented flat with fitted carpets and heavy curtains. You are otherwise well. You have been relying on a blocked-nose spray from the chemist, and privately you are embarrassed and worried that you cannot stop using it. You only mention the spray if the doctor asks what you have tried or what you are using.

Opening Sentence: "Hi, thanks for seeing me. My nose has been blocked for months now and it's really getting me down. I'm not sleeping, I'm shattered at work, and I was hoping you could give me something stronger."

History if Asked (Data Gathering Phase)

• ●The nose: "It's blocked on both sides, most of the time. Lots of sneezing first thing in the morning, and a runny nose, clear, like water. It itches inside too."
• ●Timing and pattern: "It started around the spring, but it's been much worse since September. It's every day now. Mornings are the worst, and it's bad at night in bed."
• ●Where it's worse: "Definitely worse at home, especially in the bedroom. When I stayed at my mum's for a weekend it was a lot better."
• ●Sleep and work: "I wake up with a really dry mouth because I'm breathing through it all night. My partner says I've started snoring. I'm exhausted at school, and by Friday my voice is going."
• ●Eyes: "My eyes itch a bit in the mornings, but it's mainly my nose."
• ●Sense of smell: "When it's really blocked I can't smell much, but it comes back."
• ●Home: "The flat's quite old. Carpets everywhere, heavy curtains, and honestly it's pretty dusty. No pets. I haven't noticed any damp or mould."

What You Have Tried (only if the doctor asks what you have tried or are using)

• ●Decongestant spray: "I've been using one of those blocked-nose sprays from the chemist, the xylometazoline one. It works brilliantly for about an hour and then it's worse than before. I've been using it for about six weeks now, four or five times a day. If I'm honest, I can't get to sleep without it."
• ●If asked whether she knows how long it should be used for: "The box says no more than five days. I know. But every time I stop, I can't breathe at all."
• ●Antihistamine: "I take cetirizine from the supermarket most days. It helps the sneezing a bit, but I feel a bit groggy in the mornings."
• ●Steroid nasal spray: "I tried a steroid nasal spray in the summer for three or four days. It didn't do anything, so I stopped."
• ●If asked how she used the steroid spray: "I tipped my head right back and gave it a big sniff. Most of it ran down the back of my throat."

Background (only if asked)

• ●Asthma: "I had asthma as a kid but I grew out of it. No wheeze now, no cough, and I'm not short of breath."
• ●Other allergies: "I had eczema as a child. My dad gets bad hay fever."
• ●Medicines and other health: "No other medicines. I'm not pregnant and we're not trying at the moment. I don't smoke."
• ●Work: "School's fine. It's more when I'm at home."

Warning Symptoms (answer only when directly asked)

• ●If asked whether it is one side or both: "Both sides."
• ●If asked about blood from the nose or nosebleeds: "No, no blood."
• ●If asked about pain in the face or teeth, or swelling: "No pain, it just feels stuffy."
• ●If asked about thick or coloured discharge, or a temperature: "No, it's always clear. No temperature."
• ●If asked about lumps in the neck, hearing problems, or weight loss: "No, nothing like that."

ICE — Ideas, Concerns, Expectations

She does not volunteer these unless asked.

• ●Ideas: She wonders whether she is allergic to something in the new flat, maybe the dust, or whether she just keeps catching colds from the children at school. "Either I'm allergic to the flat or I'm catching every cold going at school."
• ●Concerns: She is worried she is hooked on the decongestant spray and may have damaged her nose. She is also worried about her voice and about being exhausted at work. "I'm a bit embarrassed, honestly. I think I'm addicted to that spray. Have I wrecked my nose?"
• ●Expectations: She hoped for a stronger spray on prescription, and she would like an allergy test to find out exactly what she is allergic to. "Could I have something stronger? And can I get tested to see what it is?"

Responses to Management (The Negotiation Phase)

• ●If the doctor explains that the decongestant spray is causing rebound blockage: "So the spray's actually making it worse? That makes sense. It's been wearing off quicker and quicker." She is relieved to have an explanation.
• ●If the doctor advises stopping the decongestant spray: At first she is anxious: "But I won't be able to breathe at night." She agrees if she is given a practical way to come off it and told it should settle within a week or two.
• ●If the doctor recommends a regular steroid nasal spray: "I tried one of those and it didn't work." She is willing to try again if it is explained that it has to be used every day and takes time to work, and if she is shown how to use it properly.
• ●If the doctor explains how to use the spray: She is interested and repeats the steps back in her own words.
• ●If the doctor suggests a different antihistamine: "One that doesn't make me groggy would be great."
• ●If the doctor suggests salt-water rinses or changes at home: "Washing the bedding on a hot wash every week, I can do. I can't get rid of the carpets, it's rented, but I can hoover more and keep the bedroom tidier."
• ●If the doctor does not arrange an allergy test today: She is a little disappointed but accepts it if it is explained why, and that it remains an option if she is still struggling. "Okay, as long as it's an option if this doesn't work."
• ●If the doctor arranges a review: "Yes, a check in a few weeks would be good."