Lorry Driver Falling Asleep During the Day Whose Wife Reports Loud Snoring — Free SCA Practice Case

Character Overview: You are Trevor, a 52-year-old lorry driver (HGV), married with two grown children. For about a year you have been exhausted during the day, no matter how long you sleep. You doze off watching television every evening, and — this is what has finally brought you in — you have caught yourself nodding off briefly at the wheel on a long motorway stretch, which frightened you badly. Your wife says you snore very loudly and that she has seen you stop breathing and then gasp during the night. You are overweight, smoke about 15 a day, and drink four or five pints most evenings. You do not want to lose your licence — driving is your living and you have a mortgage. You are worried and cooperative, but if you sense your licence is at risk you become anxious and try to minimise the sleepiness.

Opening Sentence: "Hello Doctor. I'm exhausted all the time — I could sleep anywhere. My wife's been on at me because I snore terribly and she says I stop breathing in the night and then gasp. And… I've caught myself nodding off at the wheel a couple of times on the motorway. That's really shaken me up. I'm a lorry driver."

History if Asked (Data Gathering Phase)

• ●The sleepiness: "About a year of it. I wake up unrefreshed however long I've slept. I doze off in front of the telly every night. And twice now I've nodded off driving on a long motorway run."
• ●The snoring/apnoeas: "My wife says the snoring is terrible and that I stop breathing and then gasp. It's driven her into the spare room."
• ●His job: "I drive an HGV — long-distance. It's my living. I've got a mortgage."
• ●Lifestyle: "I've put on a fair bit of weight. I smoke about 15 a day. I have four or five pints most evenings, if I'm honest."
• ●What he wants: "I want to know what's wrong and get it sorted. But I can't afford to lose my licence."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

• ●Ideas: Trevor thinks his tiredness is due to being overweight, working long hours, and poor sleep. "I've assumed it's my weight and the hours I do."
• ●Concerns: His dominant concern is losing his HGV licence and his livelihood; underneath, he is frightened by having fallen asleep at the wheel and by what his wife has described. "My biggest fear is losing my licence — that's my income gone. But nodding off at the wheel terrified me."
• ●Expectations: He wants to be diagnosed and treated, and hopes to keep driving. "I want it sorted, and I want to keep working."

If Asked — OSA, Differential, and Risk Screen

The patient answers these only when directly asked.

• ●If asked about witnessed apnoeas and choking/gasping arousals: "My wife says I stop breathing and then gasp and choke. It happens a lot."
• ●If asked to quantify the sleepiness (e.g. situations he falls asleep in — an Epworth-type assessment): "Watching TV every night, as a passenger in a car, sitting quietly after lunch — and twice while driving." (Severe excessive daytime sleepiness.)
• ●If asked specifically about falling asleep or nearly falling asleep while driving: "Twice on long motorway stretches. I jolted awake. It frightened the life out of me." (Crucial for the DVLA discussion.)
• ●If asked about morning headaches, dry mouth, or nocturia: "I do wake with a headache and a dry mouth, and I'm up once or twice in the night to pass water."
• ●If asked about mood, concentration, and irritability: "My concentration's poor and I'm short-tempered. Not depressed as such."
• ●If asked about weight change and neck size: "I've gained about two stone over a few years. My collar size has gone up."
• ●If asked about alcohol, smoking, and sedatives: "Four or five pints most nights, 15 cigarettes a day. No sleeping tablets."
• ●If asked about snoring position/nasal obstruction: "Worse on my back. My nose is often blocked."
• ●If asked about symptoms of hypothyroidism or anaemia (alternative causes of fatigue): "No weight gain apart from my eating, not particularly cold, no heavy bleeding or pallor mentioned."
• ●If asked about cardiovascular symptoms: "No chest pain, no palpitations, no ankle swelling."
• ●If asked about his blood pressure and adherence: "I take the amlodipine most days. My BP has run high."
• ●If asked about family history: "My brother uses one of those breathing machines at night, actually."

Responses to Management (The Negotiation Phase)

• ●If the Doctor explains this is likely obstructive sleep apnoea: "Sleep apnoea — like my brother's machine? So my breathing keeps stopping and that's why I'm exhausted?" (The tested point is explaining OSA and its mechanism.)
• ●If the Doctor advises he must stop driving and notify the DVLA — the key point: "Stop driving? But that's my job. Do I really have to tell the DVLA?" (The tested point is clear, correct, unambiguous advice on driving cessation and DVLA notification, including the stricter Group 2 standard — delivered with empathy.)
• ●If the Doctor explains the referral and that treatment often restores licensing: "So if I get treated and it works, I could get back to driving? That's the first bit of good news." (The tested point is offering realistic hope — effective treatment often allows licence restoration.)
• ●If the Doctor explains CPAP and lifestyle measures: "A mask at night? And losing weight and cutting the drink would help too?" (The tested point is explaining CPAP as the mainstay plus weight, alcohol, smoking, and positional measures.)
• ●If the Doctor addresses his livelihood worries practically: "What do I do about work and money in the meantime?"