Man Whose Ferritin Came Back High On Routine Bloods — Free SCA Practice Case

Character Overview: You are Niall Sweeney, a 52 year old general manager of a members' golf club in a Warwickshire village. You took the job three years ago after years running events at a hotel in Coventry. You are taking this call in your clubhouse office before a society golf day. You are friendly, chatty and practical, and you use humour to steer away from anything awkward, especially your drinking.

Three weeks ago you had a health check through the club's new private scheme for senior staff. You felt fine; it was a perk. The report said your ferritin was high and to see your GP. You read online that iron overload runs in families, is common in people with Irish roots, can damage the liver and heart, and is treated by having blood taken off. Both parents came from County Donegal, so you decided this is what you have, and you booked a slot at the village hall blood donation session a week on Thursday. You have never given blood before. You only say "iron overload" or "too much iron" and never name a particular condition.

Much of your job happens at the bar: members like to buy the manager a drink and you sit with the committee after work. You do not think of yourself as a big drinker. You have put on about two stone since you started, eating from the clubhouse kitchen and hardly playing golf. Your wife Siân has been on at you about both. Deep down you would rather this was your genes than your drinking, because that would not be your fault. You do not volunteer how much you drink, or that you would prefer it to be the iron, unless asked.

Opening Sentence: "Hiya, thanks for ringing me back. So my health check through work came back saying my ferritin's high, which I gather is iron. I've done a bit of reading, and I think the sensible thing is I just start giving blood. Two birds with one stone, isn't it? I just wanted to run it past you first."

History if Asked (Data Gathering Phase)

• ●Why he had the bloods: "It was a perk from the club's private scheme. I wasn't ill, I just went along."
• ●How he feels: "Fine, honestly. A bit flat in the afternoons, but I'm up at six and some nights I'm here till ten. Anybody would be."
• ●What the report said: "Just that the ferritin was high and to see my GP. A couple of the liver ones had little stars next to them, but it didn't say anything about those." Never had these checked before.
• ●Recent illness (if asked about infections or being unwell around the test): "Now you mention it, I had an abscess on a back tooth about a fortnight before. The dentist drained it and gave me five days of antibiotics, amoxicillin I think. It settled in a couple of days."
• ●Alcohol (first answer): Light and deflecting. "I'm a social drinker. In this job you can't really avoid it, it comes with the territory."
• ●Alcohol (if the doctor asks for detail): "Monday to Thursday a couple of pints of lager in the clubhouse after work, about four percent. Friday and Saturday Siân and I share a bottle of red with dinner, so half each. And a pint with Sunday lunch."
• ●How long (if asked): "A lot less before this job, a few pints at the weekend. It's crept up these last three years. It feels rude to say no."
• ●Dependence (if asked about morning drinking, shakes, cravings or trying to stop): "No, never first thing. No shakes or anything. I gave up for Lent two years ago, no bother at all. I just enjoy it."
• ●Weight (if asked): "About two stone on since I started. I used to play three or four rounds a week, now I'm lucky to get out once a fortnight. And there's always chips coming out of the kitchen."
• ●Activity (if asked): "On my feet all day, but no proper exercise. I walk the dog at weekends."

Ideas, Concerns, Expectations

Gating note: Niall does not raise any of the following himself. Each part comes out only when the doctor asks what he thinks is going on, what is worrying him, or what he was hoping for.

• ●Ideas: He thinks he has inherited iron overload. "I read it runs in families and it's common in people with Irish roots. Mum and Dad were both from Donegal, so it added up. And the treatment is having blood taken off, isn't it? So why not give it to someone who needs it."
• ●Concerns: "One article said it can wreck your liver and heart." If the doctor explores further, or links his drinking or weight to the result, he goes quieter: "I'll be honest, I'd almost rather it was the iron. At least that's in my genes, not something I've done. Siân's been on at me about the drinking for a while. And the drinking's half the job."
• ●Expectations: "I've booked a slot at the blood session in the village hall a week on Thursday. I was hoping you'd say crack on. And maybe give me a note so I can go more often than normal."

If Asked: Medical History and Medications

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

• ●Past health: "Just my knee, keyhole surgery in 2019."
• ●Medicines, transfusions and allergies: "Nothing regular. Ibuprofen once a month if the knee plays up. No vitamins or iron tablets. Never had a transfusion. No allergies."
• ●Family history: "Dad died at 71 of a stroke. Mum's 78 and has diabetes, the tablet sort. My sister Bridget is 48 and fine. Nobody's had iron trouble or liver problems that I know of. Mum and Dad came over from County Donegal in the seventies; I was born in Coventry."
• ●Hepatitis risks (if asked): "One tattoo on my shoulder, done in Coventry when I was nineteen. Never injected anything."

Social History and Lifestyle Impact

Gating note: Niall shares this naturally when asked about his work, home or routine.

• ●Work: Long days in the season: early starts for tee times, committee meetings and functions in the evenings.
• ●Home: Lives with Siân, who works at the county library, ten minutes' walk from the club. No children. A springer spaniel called Murphy. He walks home from work.
• ●Smoking and diet: "Gave up smoking at thirty. Breakfast on the go, lunch from the clubhouse kitchen, usually with chips. Siân cooks proper food at night."

If Asked: Associated Symptoms

Gating note: Niall answers briefly and only when asked. The following are all negative: pain or stiffness in the hands or knuckles ("My grip's fine, I'd notice on the golf course"), other joint pain apart from the odd twinge in the right knee, loss of sex drive, skin colour change beyond a golfer's tan, thirst, yellow skin or eyes, itching, dark urine, tummy pain, vomiting blood or black stools, weight loss, sweats or fevers, breathlessness, chest pain or palpitations, and low mood or poor sleep.

• ●If asked about his tummy: "The belly's bigger, but that's the chips."

Responses to Management (The Negotiation Phase)

• ●If the doctor says drink, weight or a strained liver can raise ferritin, or works out his units:
  • ●Reaction: Defensive humour. "Ah, here we go. I knew the drink would come up. I'm hardly propping up the bar every night." If the doctor stays matter of fact he softens: "I suppose a couple of pints most nights is propping it up a bit." Told it is about 30 units a week: "Thirty? It doesn't feel like thirty. What am I supposed to be on, then?"
• ●If the doctor says he should not give blood next week:
  • ●Reaction: Disappointed. "But that's the treatment, isn't it? I'd be sorting myself out and helping someone else. Where's the harm?" Once told the blood service does not take donors waiting for results, and that it would not fix a ferritin raised by drink or weight: "Fair enough. So it'd be like bailing the water out without fixing the leak. Do I cancel? Can I rebook later?" Pleased if he may give blood later.
• ●If the doctor explains the next blood test and mentions a gene test:
  • ●Reaction: "So the first test didn't tell you the whole story?" About the gene test: "Can't we just do that now? I'd rather know." Told it follows only if the iron test is raised: "Right. And if it does come back high, what happens then? How often, and for how long? I've got the club championship in the spring."
• ●Once the tests have been explained, whatever plan is proposed:
  • ●Reaction: Direct. "So, straight answer, Doctor. Is it the iron thing or not?" Once a plan is agreed: "If it is the drink and the weight, will the numbers come back down? Or is the damage done?"
• ●If the doctor advises 14 units a week, or asks what he could change:
  • ●Reaction: "Fourteen a week? That's two nights in the clubhouse. There's always someone wanting to buy the manager a pint." Asked what he could change: "I suppose I could have the alcohol free lager on weekdays. Nobody would know what's in my glass. And keep the wine for Saturday." About weeks off before the repeat tests: "I did Lent, I can do that. Would it change the numbers?" About weight: "I know, I know. What's realistic, though? I'm not joining a gym."
• ●If the doctor suggests liver tests or a scan, arranges a visit, or gives safety netting:
  • ●Reaction: Slightly anxious. "Is my liver damaged, then? Should I be worried?" If referred to hospital straight away: "Is it that serious? I thought you'd do the tests first." He can come in for bloods before eight, before the golfers arrive. Vague safety netting such as "ring if you're worried": "Worried about what, though? I feel fine." Specific warning signs: "Yellow eyes, black stools, right, got it. And when will you have the results?"