Heartburn in a Night Shift Nurse — Free SCA Practice Case

Character Overview: You are Maricel Dizon, a 41 year old staff nurse on the acute medical unit at the local general hospital. You have worked permanent nights for six years: three long nights a week, from half past seven in the evening to eight in the morning, and for the last six months or so an extra bank night most weeks. You live with your husband Joel, a chef at a hotel whose hours were cut back about six months ago, and your children Bianca, 17, who is doing her A levels, and Rafael, 13.

For about three months you have had a burning pain at the top of your tummy. You call it heartburn and put no other name to it. For about ten weeks you have bought omeprazole from the pharmacy counter at the big supermarket near the hospital. Last week the pharmacist told you to speak to your GP, so you sent an online request asking for it on repeat, mainly to save money. You are on days off today.

About four months ago you hurt your lower back at work and have taken ibuprofen most days since. You have not connected it with your stomach, and mention it only if asked about painkillers or other medicines. You are friendly, quick and down to earth, and expected a two minute call. Today you are the patient and you do not diagnose yourself.

Opening Sentence: "Hi, thanks for ringing me back. Hopefully this is a quick one. I've been buying omeprazole from the supermarket for my heartburn for a couple of months and it's costing me a small fortune, so I was wondering if you could just put it on repeat for me?"

History if Asked (Data Gathering Phase)

• ●The pain: "A burning, gnawing feeling right at the top of my tummy, just under where my ribs meet in the middle. Sometimes it creeps up into my chest a bit." About three months, coming on out of nowhere. Bouts last an hour or two, at worst six out of ten. It is never brought on by exertion, never spreads to the arm, neck or jaw, and has no link with fatty food.
• ●When it comes on: "Worst on shift, around three or four in the morning, and again after my food when I get home and lie down to sleep. On my days off it's not as bad." Eating calms it for a while. Chalky antacids barely touched it. She is sometimes queasy but never sick.
• ●The omeprazole (if asked): "One 20 milligram tablet a day, most days, for about ten weeks. I buy the packs of 14 and take one when I'm home from a shift. It settles it within a couple of days." She ran out for a few days a few weeks ago and the burning was back by the third day. Last dose this morning. She has never had a camera or breath test, and no antibiotics for years.
• ●Why she is asking now (if asked): "The pharmacist said I really needed to speak to my GP. So I thought, if it's on repeat I can order it on the app and save myself the money."
• ●Painkillers (if asked about painkillers, other medicines or anything she buys): "Ibuprofen, for my back. Two of the 200s at the start of a night, again about three in the morning, and sometimes another lot when I get home. On days off, once or twice a day." Nearly every day for about four months. The burning began a few weeks after she started it: "I'd never put the two together." The three o'clock dose is usually with a cup of tea and nothing else: "Yes, I'm aware how that sounds. I'd have a word with a patient who did that."
• ●The back (if asked): "A patient fell on the unit about four months ago and one of the healthcare assistants and I got him up off the floor. Something went in the bottom of my back." It is an ache across the lower back, worse at the end of a run of nights, eased by a hot bath. Paracetamol in the first week did not touch it. She never reported it, and has not seen physiotherapy or occupational health.
• ●Back warning signs (if asked): Nothing down her legs, no pins and needles or numbness, normal waterworks and bowels, no fever, no weight loss, no history of cancer, and it does not bother her lying still.

Ideas, Concerns, Expectations

Gating note: Maricel 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.

• ●Ideas: She thinks it is the night shifts and eating at odd hours. "It's the nights, isn't it?" If asked about the ibuprofen: "But I've been taking the omeprazole alongside it. That's what we do on the ward, if someone's on regular anti inflammatories they get stomach cover. So I thought I was covered."
• ●Concerns: Money, and coping at work. "Every few pounds matters at the moment." If ibuprofen comes up: "If you're going to tell me to stop it, I honestly don't know how I'll get through a run of nights." If the doctor explores further, her voice goes quieter: "We get people up from A&E who've been bringing up blood. A couple of times lately, on a quiet night, I've caught myself thinking, what if that's me, halfway through a shift?"
• ●Expectations: She wants omeprazole on repeat so she can order it on the app, with no big conversation.

If Asked: Medical History and Medications

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

• ●Past health: Two uncomplicated deliveries and nothing else. "I've always had a cast iron stomach until this." Hormone coil since 2023, "definitely not pregnant". No allergies.
• ●Other tablets: Only a vitamin D tablet. No aspirin, steroids, mood tablets or herbal remedies.
• ●Family: Nobody has had stomach or gullet trouble. Mum has high blood pressure and Dad is diabetic.

Social History and Lifestyle Impact

Gating note: Maricel shares this naturally when asked about work, eating or home life, in the flow of conversation rather than as a list.

• ●Work and home: "Joel's hours were cut back about six months ago, so things are tight. That's why I'm doing the extra nights."
• ●Eating on nights: "I don't get a proper break. I live on toast and biscuits from the ward kitchen. Then I'm home about half eight, I have a big plate of rice and whatever's left from the family's tea, and I'm in bed within the hour."
• ●Drinks, alcohol and smoking: Two or three mugs of tea a shift, no coffee, hardly any alcohol, never smoked. Weight unchanged.
• ●Sleep and mood: She sleeps from the morning into the afternoon, and the burning sometimes wakes her. "It's grinding me down." She is stressed about money but not low.

If Asked: Associated Symptoms

Gating note: Maricel answers briefly, in a sentence or two. All of the following are negative: difficulty swallowing or food sticking, weight loss, vomiting blood or coffee grounds, black or tarry stools, feeling full quickly, a lump in the tummy, yellow skin or eyes, breathlessness, dizziness, a racing heart, bowel change, a cough or hoarse voice, and fever. She is tired, but "no worse than usual on nights".

Responses to Management (The Negotiation Phase)

• ●If the Doctor links the burning to the ibuprofen, or says omeprazole only lowers the risk:
  • ●Reaction: Surprised, then sheepish. "But I've been taking the omeprazole with it. That's what we do on the ward. I thought I was covered." Once explained: "So I've been treating the smoke and not the fire?" If an ulcer or bleeding is mentioned she goes quieter, "Is that where this was heading, then?", and shares the fear about bleeding if she has not already. She settles with an honest answer and a clear plan.
• ●If the Doctor advises stopping the ibuprofen and offers alternatives for her back:
  • ●Reaction: Frustrated. "It's the only thing that gets me through a run of nights. What am I supposed to do about my back?" Paracetamol: "I tried that. It didn't touch it." Codeine: "I'd rather not. I drive home after nights." Physiotherapy: "When am I meant to fit that in?", but she accepts days off or a self referral. Occupational health: anxious about the unreported injury, relieved if it is about support, not blame.
• ●If the Doctor suggests a test for a stomach infection:
  • ●Reaction: Curious. "Is that the breath test? How would I have picked that up?" If told to stop omeprazole for two weeks first: "Two weeks without it, on nights? I'll be climbing the walls." She settles if given something to use meanwhile.
• ●If the Doctor will not put omeprazole on repeat, or prescribes a course instead:
  • ●Reaction: Irritated if no reason is given: "So I just carry on paying for it, then?" Given a course: "So you will prescribe it, just not on repeat? What happens when the four weeks are up?" If told about long term use: "I thought omeprazole was about as harmless as they come."
• ●If the Doctor gives advice about her eating, or says she does not need a camera test:
  • ●Reaction: "Easy to say. I'm starving when I get home." If told to eat her main meal before her shift: "That might actually work." On the camera: "We send people for cameras all the time. Would I not need one?" She accepts a clear explanation. If asked to examine her own tummy she declines: "Nurses make terrible patients. I can come in. I'm off Thursday and Friday."
• ●If the Doctor gives safety netting:
  • ●Reaction: To "ring back if it gets worse": "What exactly would you want me to ring about? I'm not going to ring the surgery at three in the morning." To specific warning signs: "Okay. And in the middle of the night, that's 999 or A&E, not waiting for the morning?" Once a plan is agreed she asks whether she will ever be able to take ibuprofen again, and admits: "I might be tempted on a bad night. But I'll try."