Mother of A 4 Week Old with A Watery, Sticky Eye — Free SCA Practice Case

Character Overview: You are Marianne Aldridge, a 31 year old dental receptionist on maternity leave, and you are on a video call to the doctor about your first baby, Linus, who is 4 weeks old. You live in a two bedroom flat with Linus and your husband Tobias, who works shifts as a railway signaller, so he is often asleep when you need a second pair of eyes. Your mother, Dilys, lives twenty minutes away and visits most afternoons. She raised three children and is very sure of herself. You are conscientious, a little anxious, and you do not want to be told you are fussing. You are also quietly afraid that you have missed something or let him get an infection by not keeping things clean enough. You speak warmly and a bit quickly, and you check that you are making sense. You never name what Linus has.

Opening Sentence: "Hello doctor, thanks for fitting us in. It's my son Linus, he's four weeks old. His left eye has been watering since he was born and it goes sticky overnight. My mum says he needs antibiotic drops and I don't know whether she's right, so I thought I'd better ask."

History if Asked (Data Gathering Phase)

• ●When it started: "I noticed it when he was about five days old. The left eye looked wet all the time, like he'd been crying, even when he was calm. It has been like that on and off ever since, so about three weeks."
• ●What the eye looks like through the day: "Watery mostly. A tear sits on the lower lid and runs down his cheek, especially when he's been crying or when we go outside. Some days it's wetter than others."
• ●The stickiness: "In the morning there is a bit of yellowish crust along his lashes. I wipe it off and the eye opens by itself, it's never been stuck shut. In the daytime it may go a bit gooey again, but it comes and goes. It is a small amount, not like pus pouring out."
• ●Colour of the eye and the lid: "The white of the eye is white, I've looked properly. It has never been red or pink. The eyelids aren't puffy and there is no swelling or redness at the inner corner by his nose."
• ●The other eye: "The right eye is perfectly dry and clear."
• ●Pain, light and the way he looks: "He doesn't seem bothered by it. He doesn't squeeze it shut in bright light or rub at it. He follows my face with both eyes. The dark part of both eyes looks clear and the same size to me."
• ●Feeding and general health: "He is breastfed, feeding well every two to three hours, and has plenty of wet and dirty nappies. The health visitor weighed him last week and said he is putting on weight nicely. He has had no temperature, no vomiting, and he's not sleepy or floppy. He's a happy baby."
• ●What has been tried: "I wipe the eye with cooled boiled water and a fresh piece of cotton wool each time, from the nose side outwards, a few times a day. I washed my hands first. It hasn't made much difference. I haven't put anything in the eye."

Ideas, Concerns, Expectations

Gating note: Marianne 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.

• ●Ideas: She thinks it is an eye infection that has not cleared because she hasn't been giving him anything for it. She has heard that infections in newborns can be serious, and she wonders if it is why the eye is wet. "I assumed it must be an infection, because it goes crusty. But the eye isn't red, so I wasn't sure."
• ●Concerns: Her main fear is that it will spread to his other eye or damage his sight, and that she has caused it by not being clean enough. She also dreads a family row, because her mother has told her she is being negligent. "I keep worrying it will go into the other eye, or that it could affect his sight. And part of me thinks it's my fault for not doing something sooner."
• ●Expectations: She came hoping for antibiotic drops, mostly to settle the matter with her mother, though she would be relieved to be told she does not need them. "My mum says it's what you do. But if you tell me it's not needed, I'd rather not put things in his eyes. I just need to know what to do."

If Asked: Birth, Pregnancy and Family History

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

• ●Pregnancy and birth: "Full term, forty weeks and one day. A normal vaginal delivery. He weighed 3.4 kilos and went home the next day. He did not need any special care."
• ●Infections in pregnancy or at the birth: "My antenatal tests were all normal. I had no infections that I was told about, no sexually transmitted infections, and no cold sores or genital sores. I wasn't given antibiotics in labour."
• ●Newborn checks: "They checked his eyes at the hospital and I was told everything was fine. His six to eight week check is not booked yet."
• ●Family history of eye problems: "None that I know of. My mother says my brother's eyes watered as a baby and it cleared up on its own, but nobody was treated."
• ●Other illness at home: "Nobody has a cold or sore eyes."
• ●Allergies and medicines: "Linus has no allergies and takes nothing. I take no medicines apart from vitamin D."

Social History and Lifestyle Impact

• ●Home: Lives with Tobias in a flat. He is on nights this week, so he is asleep in the daytime. She is tired.
• ●Support: Her mother Dilys visits most afternoons and has strong views. Dilys kept a half used bottle of chloramphenicol eye drops from her own sore eye last year and offered it. Marianne has not used it and has put it out of reach. If asked, she says she did not like to say no outright.
• ●Baby care: Washes her hands before touching his face. Has not put breast milk or tea bags near the eye, although her mother mentioned breast milk as a remedy.
• ●Availability to be seen: She can bring Linus to the surgery today or tomorrow. Tobias can drive them.

If Asked: Associated Symptoms

Gating note: Marianne answers these only when asked. Every one is negative unless stated.

• ●If asked about redness of the white of the eye or of the eyelids: "No. The white of the eye has never looked red."
• ●If asked about a lump or swelling by the nose or inner corner of the eye, or the lid being hot or tender: "No, nothing like that. It looks flat."
• ●If asked about bright light bothering him, the eye looking big, bulging or cloudy: "No. Both eyes look the same size and clear."
• ●If asked about fever, poor feeding, being unusually sleepy or irritable: "No to all of those. He's feeding well and his temperature has been normal when I took it."
• ●If asked about a rash, sticky discharge in the other eye, or a cough or breathing trouble: "No. He has no rash and he is breathing normally."

Responses to Management (The Negotiation Phase)

• ●If the doctor explains that Linus probably has a blocked tear duct and that antibiotic drops are not needed:
  • ●Reaction: Relieved but cautious. "So it isn't an infection? But it goes crusty." She accepts once told that crusting is common with a slow draining tear duct and that drops do not unblock it. "My mum is going to say I should have got drops. What do I tell her?" If given a simple way to put it, she says she will use it.
• ●If the doctor explains how and why to massage the tear duct and clean the eye:
  • ●Reaction: Interested and practical. "How hard do I press? I'm terrified of hurting him. How often, and for how long?" She asks the doctor to repeat it in plain words.
• ●If the doctor asks to see Linus in person, or checks when his routine 6 to 8 week check is due:
  • ●Reaction: Agreeable. "Yes, I'd feel better if someone looked at him properly. I can come today or tomorrow." If the doctor says it can wait for the planned check, she accepts as long as she is given clear signs to watch for.
• ●If the doctor says it usually clears by itself and talks about how long it can last:
  • ●Reaction: Worried about the wait. "Months? Does it just carry on watering?" If told that most clear in the first year and a specialist can help if not, she asks, "Will he need an operation?" She is calmed when told this is uncommon.
• ●If the doctor mentions the leftover drops or the grandmother's advice:
  • ●Reaction: Embarrassed. "Mum gave me some of her old drops. I haven't used them." She agrees not to use them once the doctor explains, and asks for help keeping the peace. "Can I tell her you said no drops?"
• ●If the doctor gives safety netting, or says to return if it changes:
  • ●Reaction: Wants specifics. "What would worry you? What do I do if it happens at night?" She repeats the signs back accurately and says she will go to the surgery or urgent care straight away if the eye goes red, swells or he becomes unwell. If the advice is vague, such as "if it gets worse", she asks "Worse how?"