Dog Walker Who Found A Tick On Her Leg This Morning — Free SCA Practice Case

Character Overview: You are Jaswinder Dhillon, known as Jas, a 55 year old self employed dog walker. You walk other people's dogs five days a week, usually four to six at a time, mostly in the New Forest and the woods near your home in Totton. You are practical, quick and friendly, with no patience for fuss. You are ringing from your van between walks, so you want this sorted without a long chat, but you are polite and you listen.

This morning, getting dressed, you found a tiny dark tick stuck to the back of your right calf. You took it off straight away with your fingernails, squeezing as you pulled. You were in the Forest yesterday afternoon. You feel completely well. Ticks are part of the job, but your friend Glenys, another dog walker, was ill for most of a year after a tick bite and lost her round, and it has unsettled you. You want antibiotics "to be on the safe side" and half expect to be told no.

You do not volunteer why you are really worried until the doctor asks what you think is going on or what is worrying you. You never name any illness yourself. You call it "what Glenys had". You speak fast and plainly, quieter when you talk about Glenys.

Opening Sentence: "Hello, doctor. Sorry to ring in the middle of the day, I'm between walks. I found a tick on my leg this morning and I've pulled it off, but could I have some antibiotics just to be on the safe side, please?"

History if Asked (Data Gathering Phase)

• ●When and where she was exposed: "I did a long walk in the Forest yesterday, about half one till half four, with four dogs. One of them's a bolter so I was in the bracken and long grass near Lyndhurst a fair bit."
• ●When she found it, what it looked like and how long it was on: "This morning, about seven, when I was getting dressed. The back of my right calf was itching, and there it was. It was teeny, dark brown or black, about the size of a poppy seed, flat, little legs. Not fat and round like the ones you find on a dog after a few days. It can't have been on longer than since yesterday afternoon, and I'd guess less."
• ●How she took it off: "I'll be honest, I pinched it between my nails and pulled, with a bit of a squeeze, to get it off quickly. It came away in one go as far as I could tell, legs and all. It's in the bin at home. I've got one of those plastic tick hooks in the glove box, never used it."
• ●The bite site now: "A little pink dot where it was, about the size of a lentil, with a tiny bit of pinkness round it. It's a bit itchy. It's not hot, not sore, nothing weeping, and it's the same as this morning."
• ●Any spreading, ring or rash elsewhere: "No ring, nothing spreading, no other marks. I checked my legs and round my waistband properly this morning."
• ●Other ticks: "I get them off the dogs most weeks, two on a client's spaniel yesterday. One got me on the arm years back and nothing came of it."
• ●Her habits in the Forest: "I check the dogs when we get back, but I don't always check myself. I wear cropped walking trousers that stop mid calf and short socks. I've never used repellent on myself. The clients' owners sort the tick treatment for their dogs."

Ideas, Concerns, Expectations

Gating note: Jas does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for from the call.

• ●Ideas: She thinks the tick may have put something into her and that a few days of tablets would knock it on the head before it can settle. She assumes antibiotics do no harm. "A few tablets can't hurt, can they? Better safe than sorry."
• ●Concerns: Her friend Glenys. "She got bitten a couple of years ago and never saw a mark. She just felt rotten, achy and tired for weeks. Her doctor said it was a virus and then stress. Eventually her face dropped down one side and her knees swelled up, and by the time they found out it was from the tick she'd lost most of a year. She lost her round as well." If the doctor explores further: "I'm self employed, no sick pay, and I've got fourteen regular dogs and a round that took me eleven years to build. What scares me most is being fobbed off like Glenys was. She kept ringing and kept being told it was nothing."
• ●Expectations: She wants a prescription today. "Even a short course would do." If the doctor suggests not taking antibiotics: "Then I want to know exactly what to look for, and I want your word that if I ring, somebody will take me seriously."

If Asked: Medical History and Medications

Gating note: Jas answers each of these plainly when the doctor asks about it.

• ●Health: "Amlodipine, five milligrams. Bit of wear and tear in both knees, I use a gel. Nothing else. No steroids, no tablets for my immune system, no cancer, no diabetes."
• ●Allergies and antibiotics: "None. I had amoxicillin for a tooth last year and it was fine."
• ●Other: Periods stopped three years ago. Never smoked, a glass of wine at the weekend.

Social History and Lifestyle Impact

Gating note: Jas mentions this naturally when talking about her work or her worries. It does not come out as a speech.

• ●Work: She has run her own round for eleven years, with about fourteen regular dogs, out five or six hours a day. "If I can't walk, I don't get paid, and people don't wait for you, they find someone else."
• ●Home: Lives in Totton with her husband Harjit, who works for the council. They have one dog.
• ●Lifestyle impact: "I'm not going to stop going in the Forest, it's the best bit of the job. I just don't want to end up like Glenys."

If Asked: Associated Symptoms

• ●Fever, shivers or sweats, headache, neck stiffness, sensitivity to light or confusion: "No, nothing like that. I haven't taken my temperature but I've felt perfectly normal, I'm completely with it."
• ●Aches in muscles or joints, swollen or hot joints, or tiredness: "Just the usual knees, no different, and nothing's swollen. I'm up at half five most days."
• ●Facial weakness, drooping, tingling or numbness, palpitations, dizziness, fainting, chest pain or breathlessness: "No, my face is fine, no pins and needles, and I've been walking the dogs all morning with no trouble."
• ●Sore throat, swollen glands, eyes, diarrhoea, vomiting, or changes in weight, appetite or sleep: "No, nothing. I'm a bit wound up about it, that's all."

Responses to Management (The Negotiation Phase)

• ●If the doctor says she will not prescribe antibiotics, or explains the risk and what antibiotics can do:
  • ●Reaction: Disappointed, then pushes once. "Not even a short course? What's the harm? Better safe than sorry." If told most bites pass nothing on: "How unlikely? Glenys's was just a bite as well. Can you tell me I'll be alright?" If the doctor says she cannot promise: "Fair enough, I'd rather have a straight answer." If promised she will be fine: "How can you be sure?" On side effects: "Being sensitive to the sun would be a nuisance when I'm outdoors all day, but I take your point." If prescribed antibiotics or a standby course, she is relieved and pleased.
• ●If the doctor says no blood test or tick test is needed, or offers one:
  • ●Reaction: Puzzled. "Why not? Glenys had loads of tests." She accepts it if told the test can be wrong this early and would not change what happens now. If offered a test she is keen. About the tick: "It's in the bin at home, do you want me to fish it out?" She is happy to leave it.
• ●If the doctor explains how to remove a tick properly, or gives prevention advice:
  • ●Reaction: Surprised. "Squeezing it is bad? I didn't know that. I've got that plastic hook in the glove box, I'll use that next time." She gets defensive if criticised: "I was only trying to get it off quickly." On prevention: "I'm not giving up the Forest, it's my job." She accepts practical steps: "Trousers tucked in, spray, check myself as well as the dogs. That's easy enough."
• ●If the doctor lists warning signs, or says what happens if it develops:
  • ●Reaction: If vague: "Unwell how? Glenys just felt a bit fluey for weeks and nobody put it together. And how long am I watching for?" On a rash: "I'm brown, doctor. Would I even see a red ring on me?" She is reassured to hear it can look like a bruise or flat darker patch and that Harjit can check the backs of her legs. On a drooping face: "That's what happened to Glenys. Would I ring you or just call 999?" On treatment: "So I'd get tablets straight away without waiting for a test? How long would I be on them?"
• ●If the doctor offers to see her in person, asks her to look at her legs again, or offers to text the warning signs:
  • ●Reaction: Practical. "I could come in, but it's tiny. Would you do anything different if you saw it? I could come tomorrow before my first walk." She declines to look or measure during the call: "I'm in the van with the dogs, I checked this morning and again before I rang." "Yes please, text me. I'll never remember it all driving."
• ●Once a plan has been agreed without antibiotics:
  • ●Reaction: Settled but wants a commitment. "Okay, I'll go along with that. But if I ring and say it's a tick, someone does see me, yes? I don't want to be told to book for next week."