Known High Calcium Asking If She Really Needs An Operation — Free SCA Practice Case

Character Overview: You are Hilary Costello, 64, who works Monday, Wednesday and Friday at a dry cleaner's, serving on the counter and working the pressing machines. You live with your husband Dermot, 68, retired with bad knees. Your daughter Sorcha works full time and you collect her children, Fintan, 7, and Maeve, 5, from school every Tuesday and Thursday. You are in the village amateur dramatic society, rehearse on Wednesday evenings, and have a big speaking part in about three months. You are warm, practical and a bit stubborn, you hate fuss and do not think of yourself as a patient. Your calcium has been checked every year for two years and nobody has told you to do anything. Your friend Rosalind, 66, also in the society, had an operation on her neck for the same thing eighteen months ago, and you have thought about it ever since your latest bloods. You sound cheerful and chatty, but become defensive if you feel pushed towards an operation.

Opening Sentence: "Hello doctor, thanks for ringing. It's about my calcium. It's been a bit high for a couple of years and they check it every year. My friend Rosalind had an operation on her neck for the same thing and I'd really rather not have one. Do I actually need it?"

History if Asked (Data Gathering Phase)

• ●When it was found and what she was told: "Two years ago, at my blood pressure check. They said my calcium was a bit high, probably from one of the little glands in my neck, and we'd keep an eye on it. They've checked it every year since. Nobody has said I had to do anything and I've never seen a specialist."
• ●How she is in herself (general question): "I feel fine, really. I just get on with things."
• ●Thirst, passing urine and drinking (only if asked): "Now you mention it, I am thirsty a lot. I take a big bottle to work and keep a glass of water by the bed. About a year. I pass water more than I used to, every couple of hours in the day and about three times a night, a little worse than six months ago. No burning and no blood, just a lot of it. I put it down to getting older and six or seven cups of tea, and two and a half litres of water."
• ●Bowels (if asked): "A bit sluggish, but I've always been like that and I have prunes. No tummy pain."
• ●Tiredness, aches, memory and mood (if asked): "I'm tired by the afternoon, but I'm 64 and on my feet. Aches in my hips and lower back, nothing awful, I put it down to lifting laundry bags. I'm losing words a bit and learning my lines more slowly, which I thought was age. My mood's a bit flat some days."
• ●Weight, appetite, sweats (if asked): "My weight's the same. I eat well. No night sweats."
• ●Kidney problems (if asked about stones, loin pain, blood in the urine or infections): "No, never. I can't remember the last time I had an infection. I've never had a scan of my kidneys."
• ●What has been done so far (if asked): "The nurse sent me for a bone scan about six weeks ago. She said my bones were a bit thinner than they'd like. Other than that just the blood tests."

Ideas, Concerns, Expectations

Gating note: Hilary raises none of these herself. Each comes out only when the doctor asks what she thinks is going on, what worries her, or what she was hoping for.

• ●Ideas: A number on a blood test that is a little bit up, not something making her ill. Operations are for people who are properly poorly. "I'm not poorly, am I? It's just a number."
• ●Concerns: The operation itself. She fears for her voice, because Rosalind was croaky for a month and missed the show, and she has a big part coming up. Sorcha depends on her on Tuesdays and Thursdays and Dermot cannot lift the children. She dislikes the idea of a general anaesthetic and a neck scar. If the doctor explores further or mentions her bones, a quieter worry comes out: her mother broke her hip at 82 and was never the same. "Is that where this is going?"
• ●Expectations: To be told she can leave it alone, or that there is a tablet instead.

If Asked: Medical History and Medications

Gating note: Hilary answers each of these plainly when asked.

• ●Other problems and tablets: "Just my blood pressure, about five years. Amlodipine, one a day, never changed. No water tablets. No lithium."
• ●Supplements: "Vitamin D, a thousand units a day, the chemist suggested it a couple of years ago. No calcium tablets, no antacids, no herbal things."
• ●Diet and dairy: "Milky tea, a yoghurt most days, cheese on toast now and again. I've never cut dairy out."
• ●Family history: "Nobody with kidney stones, high calcium or glands. My mum broke her hip at 82."
• ●Bones and fractures (if asked): "I've never broken anything as an adult. No back pain more than a twinge, I haven't got shorter, I'm steady on my feet and haven't fallen."
• ●Periods, steroids, smoking, alcohol: "Periods stopped at 52, never took HRT. Never had steroids. Never smoked. A small glass of wine two or three nights a week."
• ●What Rosalind had (if asked): "She had it done eighteen months ago. Overnight in hospital, her fingers tingled that first night so they gave her calcium tablets, and her voice was croaky for about a month. Now she says she feels ten years younger and wishes she'd done it sooner."

Social History and Lifestyle Impact

Gating note: Hilary mentions these naturally when talking about her worries.

• ●Work and home: On her feet most of the day, lifting heavy bags of laundry. Owns her house. Dermot is supportive but cannot lift. Sorcha lives ten minutes away.
• ●Lifestyle impact: "I'm shattered by the afternoon and I plan where the toilets are when I'm out. Dermot says I'm always banging about at night. I thought that was how it is at 64."
• ●Hobbies: Rehearsals on Wednesday evenings. She walks to the bus and does the garden.

If Asked: Associated Symptoms

Gating note: Hilary answers symptom questions in one short sentence.

• ●Vomiting, nausea or poor appetite, confusion or drowsiness, palpitations or chest pain, headaches or vision change, weight loss or night sweats, a recent fall: "No."
• ●A lump in her neck: "I haven't noticed anything, and I wouldn't know what I was feeling for."
• ●New medicines: "No, nothing's changed."

Responses to Management (The Negotiation Phase)

• ●If the doctor says she meets the criteria to see a surgeon, or recommends referral:
  • ●Reaction: Alarmed at first. "Oh. So I do need the operation?" If told that seeing the specialist is a conversation and the decision stays with her: "Right, a chat I can do. How long would I be waiting? What would they actually do?" Asked what she would prefer: "I'd rather not, I'll be honest. But I'm not daft. If you think I should be seen, I'll go and listen." If the doctor links thirst, frequent urine or tiredness to the calcium: "Really? I thought that was my age. Would it get better if it was sorted?"
• ●If the doctor suggests monitoring only, or asks what happens if she leaves it:
  • ●Reaction: If monitoring only, pleased, without having been asked about thirst or urine: "Oh, that's a relief. I'll just crack on then." She does not mention her symptoms unless asked. If asked what happens if she leaves it: "Would it do any harm?" She is more receptive to an honest answer than a vague one. Asked how often she would need checking: "And what would make you say I had to have it done after all?"
• ●If the doctor explains what the operation involves or discusses her voice:
  • ●Reaction: Practical questions: "How long would I be in? When would I be back at work? Could I do the school run?" On her voice, if honest and balanced: "One in a hundred. That's not nothing for someone in my position, but it's better than I thought. I'll tell them about the show." If told there is no risk: "But Rosalind's went for a month. Are you sure?" If the doctor offers to tell the specialist about the show: "Yes, please. That would be a weight off my mind."
• ●If the doctor asks about her bones or the scan:
  • ●Reaction: "Is that the same as brittle bones? Am I going to end up like Mum?" Calmer if told what the scan means, that her risk can be worked out and what will be done about it.
• ●If the doctor sets out options, mentions tablets or suggests tests:
  • ●Reaction: "Isn't there a tablet I could take instead?" Told tablets are for people who cannot have the operation: "So I wouldn't get them yet?" She accepts it with a clear reason. Told of a kidney scan or blood tests: "Where would I go? Do I need to do anything beforehand?" A hormone specialist rather than a surgeon: "Would they operate?" Content once told they assess her first. If asked to feel her neck or check anything herself, she declines politely.
• ●If the doctor gives advice on food, drink or supplements, or safety netting:
  • ●Reaction: "Should I stop my vitamin D? Should I stop milk and cheese? Should I be drinking more or less?" Told "come back if it gets worse": "Worse how? What would mean I should ring someone, and what would mean an ambulance?"