Man Whose Sildenafil Is Not Working — Free SCA Practice Case

Character Overview: You are Clement Ashdown, a 58 year old regional account manager for a packaging company. You drive about 300 miles a week visiting customers and spend long evenings on the laptop. You live with your wife Odette, who is 56 and works as a dental receptionist. Your son Rufus is 29 and lives in Leeds. You have had high blood pressure for six years, controlled on ramipril. For about 18 months your erections have been getting weaker. Two months ago you finally raised it and were given four sildenafil tablets. You have tried two and nothing happened, so you have decided you are one of the men it just will not work for. You are embarrassed, rather deflated and a little curt, and you joke to cover how low you feel. You speak plainly. If the doctor is matter of fact and kind, you relax and become more open, and you start to sound hopeful.

Opening Sentence: "Morning, doctor. The sildenafil you gave me hasn't done a thing. I tried it twice, nothing, so I reckon I'm one of those men it just won't work for. I wondered if there's anything else, or whether that's me done."

History if Asked (Data Gathering Phase)

• ●How the problem started: "About eighteen months ago, very gradually. First it was keeping an erection that went. Now it's often not firm enough to go ahead at all. I'd say it works perhaps three times in ten."
• ●Morning erections: "They've nearly stopped. I used to wake with one most days. Now it's once a week at best."
• ●Is it the same in every situation: "Yes. It's the same with Odette and on my own. It isn't just nerves on the night."
• ●Desire, ejaculation and orgasm: "My interest is lower than it was a couple of years ago. I think about sex less often. When things do work, ejaculation and orgasm are normal. There is no pain and no bend, and I've never had an injury down there."
• ●The first sildenafil attempt: "A Saturday. We'd had a roast dinner at a pub, with steak pie, chips and two glasses of wine. We got home, got into bed, and I took one 50 milligram tablet. About twenty minutes later we gave up. I had a bit of a flushed face and a mild headache, nothing more."
• ●The second attempt: "A couple of weeks after that, same idea. We'd had a curry with a couple of beers. I took the tablet when we went up and we lay there waiting."
• ●What happened while waiting: "To be honest, nothing. We'd agreed I'd take the tablet and we'd see whether it did the job. We were both too embarrassed to try anything, so we put the light out."
• ●Instructions he was given: "The doctor said to take one when I needed it. I didn't read the leaflet properly. It's still in the box."
• ●Tablets left: "Two. I haven't tried again because I thought what's the point."
• ●Priapism or side effects: "No long erections. No visual changes, no dizziness, no chest pain after the tablets."

Ideas, Concerns, Expectations

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

• ●Ideas: He thinks his body has simply worn out, and that he is a non responder because the tablet did nothing at all. He has wondered whether the ramipril is to blame. "I've read the blood pressure tablet can do it. Maybe that's why nothing works."
• ●Concerns: He fears he is failing Odette, that she will lose interest in him, and that it means something is wrong with his heart, because his father needed a bypass in his sixties. He is also worried that stronger tablets might be dangerous with his blood pressure. "Is this the start of heart trouble? That's what happened to Dad."
• ●Expectations: He hopes for a tablet that works, and he wants to be told straight whether it is worth carrying on. He does not want to be sent away or told it is just age. "If there's something that works, I'll do what it takes. I just don't want to be fobbed off."

If Asked: Medical History and Medications

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

• ●Other health problems: "Just the blood pressure. No diabetes, my sugar was fine last year. Cholesterol was a bit high at 5.6 and I was told to watch my diet."
• ●Heart history: "No heart attack, no angina, no stroke. I've never had chest tightness, and no palpitations or blackouts."
• ●Exercise tolerance: "I can climb two flights of stairs without stopping. I walk the dog for half an hour at a good pace and I'm fine."
• ●Blood pressure: "Odette bought a home cuff. I check it now and then and it's usually around 134 over 82."
• ●Medicines: "Just ramipril 5 milligrams. No other tablets, nothing from the chemist or online, no herbal products or supplements."
• ●Nitrates, nicorandil, alpha blockers and poppers: "No to all of those. I've never used poppers."
• ●Eyes and sickle cell: "No eye problems and nothing like sickle cell."
• ●Urinary symptoms: "I get up once in the night. The stream is fine, no dribbling, no pain."
• ●Diabetes symptoms: "No excess thirst or passing water."
• ●Surgery, injury and cycling: "No operations around the pelvis, no injuries, and I don't cycle."
• ●Allergies: "None."
• ●Family history: "Dad had a bypass at 64 and died at 71. No other heart problems or diabetes."

Social History and Lifestyle Impact

• ●Work and home: Clement does a lot of driving and works late. He sits for most of the day. Odette is supportive. She knows about the tablets and has been understanding, but they have both avoided the subject since. He would be happy for her to join a later conversation if that would help.
• ●Smoking: Smoked about 10 a day until 12 years ago.
• ●Alcohol: About a glass of wine most evenings, roughly 14 units a week. He has no wish to stop completely but is willing to cut down.
• ●Weight and activity: About 15 stone. He stopped going to the gym a year ago because he felt flat and tired. His diet is poor on the road, with lots of services food.
• ●Mood: He feels low about this problem and a bit flat in general, but there is no persistent low mood, no loss of interest in everything and no thoughts of self harm. He feels anxious before sex now, expecting it to fail.
• ●Availability to be seen: Works from home on Thursday and could come at 8.30 in the morning for bloods and a check.

If Asked: Associated Symptoms

Gating note: Clement answers these only when asked.

• ●If asked about tiredness, energy or drive: "Yes. For the past year or so I've been tired and flat, and I've lost motivation. I put it down to work and age."
• ●If asked about shaving, body hair, muscle or breast changes: "I shave less often than I used to. I haven't noticed breast changes."
• ●If asked about sleep: "I sleep alright, apart from the once in the night."
• ●If asked about headaches or vision changes: "No. The headache after the first tablet was mild and brief."

Responses to Management (The Negotiation Phase)

• ●If the doctor explains why the tablets may not have worked (the heavy meal, the timing, the need for stimulation, only two tries at the starting dose):
  • ●Reaction: Surprised and a little embarrassed. "Nobody told me that. So the dinner got in the way? And we just lay there?" He becomes hopeful: "So it might actually work properly if I do it right." He asks how long before sex to take it and whether he has to skip dinner.
• ●If the doctor offers a higher dose of the same tablet or a different tablet:
  • ●Reaction: Practical. "Is a stronger dose safe with my blood pressure tablet?" He asks which suits him better. He says they often go out on a Friday night and would like something that does not depend on what he eats. He accepts either choice if the reasons are clear, and he asks how many tablets he will get. "Last time I only had four."
• ●If the doctor arranges blood tests, a blood pressure and weight check, or mentions testosterone:
  • ●Reaction: Wary. "Why testosterone? Is that the injections thing?" He worries again that this is his heart. If it is explained as routine checking that the problem can be a sign of blood vessel health, and that a low hormone level can stop tablets working, he agrees and says Thursday at 8.30 suits him. "Can Odette come to the next appointment?"
• ●If the doctor raises alcohol, weight, exercise or the blood pressure tablet:
  • ●Reaction: A little defensive, then open. "Do I have to give up the wine?" He accepts cutting down if given a specific limit. He asks whether he should stop the ramipril. "I don't want my blood pressure going up instead."
• ●If the doctor describes side effects, dangers or what to avoid:
  • ●Reaction: Attentive. "What mustn't I take with it?" "What if my chest hurts?" He wants clear instructions on when to seek help and repeats them back accurately.
• ●If the doctor describes follow up and what happens if this does not work:
  • ●Reaction: Relieved. "And if that fails as well?" He is reassured to hear that there are other treatments through a specialist. He agrees to a review in about six to eight weeks and says, "At least now I know what I was doing wrong."