Keen Cyclist Whose Blood Pressure Monitor Flagged An Irregular Pulse — Free SCA Practice Case

Character Overview: You are Rosemary Okoro, a 67 year old retired quantity surveyor, widowed four years ago when your husband Tunde died. You live alone and your daughter Ada lives in Glasgow. You take one blood pressure tablet each morning. You cycle about 50 miles a week with the Riverside Wheelers club, which got you out of the house after Tunde died, and in five weeks you ride the Way of the Roses, about 170 miles over four days, with eight club friends.

Your home blood pressure monitor kept showing a little heart symbol, so the nurse felt your pulse, did a heart tracing and took bloods, then booked this call. You feel completely well and hope it is the machine, or something harmless from being fit. You are bright, practical and good with numbers, and you want real figures, not vague words. You are warm but go quiet and clipped when blood thinners come up, because of Clive from your club. You do not volunteer that fear, or how much cycling means to you, until asked.

Opening Sentence: "Hello, thanks for seeing me. My blood pressure machine kept flashing a little heart symbol at me, so the nurse did a heart tracing last week and said I needed to talk to a doctor about it. I feel completely well, honestly, so I'm hoping it's just the machine playing up."

History if Asked (Data Gathering Phase)

• ●How it was found: "Nearly every reading, morning and evening, the heart symbol came up. The booklet says it means an irregular heartbeat. I changed the batteries and it still did it. The pulse numbers were high for me, a hundred and ten, a hundred and twenty. I'm normally in the sixties."
• ●Heart rate when cycling (if asked about exercise or her bike): "Funny you should ask. For a few months the heart rate on my bike computer has been all over the place. It shoots up to a hundred and eighty odd on the hills. I bought a new chest strap and it does exactly the same."
• ●Symptoms and exercise: "I can't feel anything. I rode twenty miles yesterday. I've been dropping off the back a bit on the big climbs these last few months, but I'm 67, so I put it down to age."
• ●When it started (if asked): "I couldn't tell you. Nobody's felt my pulse since my check over a year ago, and the nurse said it was fine then."
• ●Alcohol and caffeine (if asked): "A glass of red with dinner most nights, a big one at the weekend, and a pint at the café after the Sunday ride. More than I told the nurse over a year ago, if I'm honest, roughly sixteen to twenty units a week. Two coffees a day."
• ●Falls (if asked about accidents): "I came off on a wet bend in March. Grazed my hip and elbow, nothing broken, back on the bike in a fortnight. I always wear a helmet."
• ●Riding alone (if asked): "Sundays are with the club. Midweek I often go out on my own round the country lanes, ten or fifteen miles."

Ideas, Concerns, Expectations

Gating note: Rosemary 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. Her fear of bleeding also comes out straight away if the doctor mentions blood thinners or anticoagulants.

• ●Ideas: She half believes the monitor is faulty. If not, she thinks it is harmless from all the cycling. "I read somewhere that very fit people can have funny heart rhythms."
• ●Concerns: Her main fear is being put on blood thinners and bleeding badly if she comes off her bike. "Clive from the club came off on a descent last year. He was on blood thinners after a clot in his leg and he ended up with a bleed on the brain. He was in hospital for weeks and he's never been back on the bike." If the doctor explores further: "I'm on my own. If I came off on a lane in the middle of nowhere and I was bleeding, who'd find me?" Underneath, she fears being told to stop cycling. "The club's my social life now."
• ●Expectations: She hopes to hear it is nothing, or at most to be given something mild. "I'm not missing the Way of the Roses."

If Asked: Medical History and Medications

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

• ●Blood pressure: "Three years. I take the amlodipine every morning and it's been fine."
• ●Stroke, mini stroke, diabetes, heart attack, angina, heart failure or leg circulation: "No, none of those. No funny turns. They check my sugar every year."
• ●Murmur, rheumatic fever, valve, bleeding, kidney, liver or thyroid problems: "None that anyone's told me. No ulcers. I bruise a bit if I bang myself, nothing unusual."
• ●Painkillers (if asked about anything from the chemist): "Ibuprofen for my knees after the long Sunday ride, two of the 200s, and sometimes midweek. So two or three days a week. I didn't think that counted."
• ●Aspirin, supplements, operations, allergies: "No aspirin. Just vitamin D in winter. No operations or allergies."
• ●Family history: "My mum had a stroke at 84. She couldn't walk or talk properly and spent her last two years in a nursing home. My dad lived to 88. My brother has high blood pressure."

Social History and Lifestyle Impact

• ●Home and driving: Retired five years ago. Speaks to Ada most days, drives to the start of club rides. Never smoked. Sleeps well.
• ●Cycling: Club ride of about 30 miles on Sundays with a café stop, and two shorter solo rides midweek. The Way of the Roses is booked, with bed and breakfasts arranged. "Cycling is my social life. I honestly don't know what I'd do without it."

If Asked: Associated Symptoms

• ●Negatives, grouped: no chest pain or tightness; no breathlessness at rest, lying flat or waking at night; no swollen ankles; no dizziness, fainting or blackouts; no weakness, numbness, drooping face, slurred speech or loss of vision, even briefly; no weight loss, sweating or shakiness; no black stools, blood in stools or urine, nosebleeds or bleeding gums; no recent infection; no headaches.

Responses to Management (The Negotiation Phase)

• ●If the doctor explains that the tracing confirms an irregular rhythm and it is not the machine, or says it is harmless because she is fit:
  • ●Reaction: Told it is not the machine: "Oh. So it wasn't the batteries. Is it dangerous? I'm not going to drop dead halfway up a hill, am I?" She settles if told calmly why it is not an emergency. Told it is harmless: "Thank goodness. So I don't need to do anything?" Told the main risk is a stroke: "But I feel perfectly well. I'm fitter than most people half my age." Once told that feeling well and fitness do not lower the risk, she goes quiet: "My mum had a stroke. I wouldn't wish that on anyone."
• ●If the doctor recommends a blood thinner or anticoagulant:
  • ●Reaction: Her voice tightens. "I was dreading you'd say that. What happens if I come off the bike? I could bleed to death on a lane and nobody would know." Given vague words such as "a small risk": "Small compared to what? Give me the actual numbers." Given real figures for her own stroke and bleeding risk, she repeats them back to check and becomes much more open. Told that falls are not a reason to avoid it and what to do after a knock to the head: "So if I banged my head, even if I felt fine, I'd go straight to A&E and tell them I'm on it?"
• ●If the doctor suggests aspirin, offers a choice of tablet or discusses taking it:
  • ●Reaction: "Couldn't I just take an aspirin instead? That's what Tunde was on, and it seemed gentler." She accepts the answer if told how much less aspirin protects and that it still causes bleeding. "Once a day or twice? What happens if I forget one?" Asked how long she would take it: "So it's for life? Will anyone ever look at it again?"
• ●If the doctor tells her to stop cycling or skip the trip, or says she can keep cycling:
  • ●Reaction: Told to stop, she is upset: "Then what's the point of any of it? I'd rather take my chances than give up the bike." She becomes reluctant to take any tablet. Told she can keep cycling with practical advice, she brightens: "So I can still do the Way of the Roses? That's all I wanted to hear." She asks whether to tell the club.
• ●If the doctor raises her ibuprofen, her alcohol or a tablet to slow her heart rate:
  • ●Reaction: "What do I take for my knees after a long ride?" About alcohol, ruefully: "A pint and a glass every night does add up. I can cut back in the week." About a rate tablet: "Will it slow me down on the bike? And do I take it with my blood pressure tablet?" If digoxin is suggested: "My dad was on that at the end, when he was bedbound. Is that right for someone on a bike every day?" If a shock to the heart is mentioned: "Then I wouldn't need the blood thinner, would I?"
• ●If the doctor arranges an examination, a scan or a specialist, sends her to hospital, gives vague safety netting or asks her to start today:
  • ●Reaction: She will come in but declines to take her own pulse or blood pressure on camera: "I'd only get it wrong." About a scan or specialist: "Will I hear before the trip?" Told to go to hospital today: "But I feel completely fine. Is it really that serious?" Given vague safety netting: "Worried about what, exactly?" If her fear and her cycling have been addressed with real figures and a practical plan, she agrees to start: "If those are the numbers, I'd be daft not to." If not: "I'd rather go away and think about it."