Mother of A 7 Year Old with Episodes of Tummy Pain and Pallor — Free SCA Practice Case

Character Overview: You are Joanna Farrington, a 38 year old office manager at a firm of solicitors, phoning about your son Felix, who is 7 and in Year 3. You live with your husband Greg, who works in IT sales and travels a lot, Felix and his sister Elodie, who is 4. You run a busy office and you are used to getting things sorted. You are brisk, articulate and a bit sharp, and you have written yourself a list of points. You are not rude, but you are frustrated that nobody has ever seen Felix while he is actually in pain. You rang 111 once and took him to the practice nurse once, and nobody has told you what the pain is. You think a scan is the obvious next step and you will push for it politely and firmly. You soften when the doctor gives you a clear explanation, takes your list seriously and does not talk down to you. You speak quickly and tidily, in full sentences.

Opening Sentence: "Hello, it's about my son Felix, he's seven. He keeps getting these attacks of tummy pain where he goes white as a sheet and just wants to lie in the dark. Nobody has seen him while it's happening and nothing has been found, which frankly isn't good enough. I'd like him booked in for a scan."

History if Asked (Data Gathering Phase)

• ●How it started: "The first one was about five months ago, on a Saturday afternoon. He suddenly said his tummy hurt, bent over and went quiet. Since then he's had five attacks altogether. The last was three weeks ago."
• ●How often: "Roughly once a month, but it's not regular. The gap has been anything from three weeks to six weeks. There's no pattern I can see."
• ●The pain: "He points to the middle of his tummy, a bit above and around the belly button. He says it's a squeezing, really bad pain, so bad that he curls up and can't talk or play. It stays in the middle and doesn't move to one side or down to the right."
• ●How long it lasts: "Usually three to five hours. The worst one was about seven. Then it just stops and he goes to sleep, and by the next morning he's completely himself."
• ●What he is like during an attack: "Grey and drawn, with dark circles under his eyes. He stops playing, curls up on the sofa and won't eat. He feels sick, and twice he was sick once, clear, nothing green. He wants the curtains shut and the telly off, and he hates noise and light. He just wants me nearby and quiet."
• ●Headache: "Now you say it, he sometimes says his head hurts a bit towards the end. It's mild."
• ●Between attacks: "He's totally normal. Running about, eating like a horse, playing football. That's what makes it so odd."
• ●What starts an attack: "I can't see anything definite. A couple of times it came after a busy day when he hadn't had much breakfast. One followed a school trip. No particular food that I've noticed."
• ●What has helped: "Not much. I gave him paracetamol once, about two hours in, and it didn't touch it. Lying in a dark room and sleeping is what ends it."
• ●Travel sickness: "Yes, he's always been car sick. I keep a bag in the car."
• ●Bowels and wee: "Normal. He goes every day, soft, no straining. Wee is normal and he's not complained of stinging."

Ideas, Concerns, Expectations

Gating note: Joanna does not volunteer any of this. 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 must be something physical that nobody has found, such as his appendix, a blockage or a problem with his bowel. A friend's child had months of tummy pain that ended up being a bowel condition. "A friend's little girl had pains for ages and it turned out to be her bowel. Nobody picked it up at first. I don't want that to be us."
• ●Concerns: She fears something serious is being missed because nobody has ever seen him during an attack: the nurse saw him afterwards and 111 was only a phone call. She is also worried about school, because his attendance has dropped and she has had a standard letter about it. She is privately afraid of being thought a fussy mother. "Nobody's seen him when it's actually happening. And school have written to me about his attendance, which is ridiculous."
• ●Expectations: She came for a scan and expects a referral if the scan finds nothing. She also wants something in writing that she can show the school. "A scan, or at least a referral to someone who can do one. And I need a letter for school."

If Asked: Medical History and Medications

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

• ●Past health: Born at term, a bit of eczema as a baby that cleared. Immunisations done. No operations and no hospital stays.
• ●Medicines and allergies: None regular. Paracetamol only, rarely. No allergies.
• ●Family history: If asked about illness in the family, she says her husband Greg gets "horrible heads" about every month or two, with flashing lights first, and has to lie down in a dark room. She dismisses it: "That's hardly relevant to a seven year old's tummy." Greg's sister has the same. No bowel disease or coeliac disease in the family.
• ●What has been done so far: Practice nurse, 4 months ago: she saw him two days after an attack, when he was completely well, tested his urine, which was normal, and said it might be constipation. No blood tests were done. NHS 111, 3 weeks ago: you rang during the last attack and an adviser asked questions by phone and said to keep him comfortable and ring the surgery the next day if it was still bad. By then he was well, so you did not. Nobody has examined him during an attack, no blood tests have been done and nobody has done a scan.

Social History and Lifestyle Impact

• ●School: He has missed about six days this term and arrived late on others, and school sent an attendance letter. His teacher, Mrs Anand, has been kind but is unsure what to do when he comes in tired after an attack. He has twice been sent home from school mid attack.
• ●Felix himself: Cheerful and sporty. In the last month he has started asking "Is it going to happen today?" on school mornings. No bullying, friends fine, no trouble at home.
• ●Home: Greg is away two nights a week, so most attacks fall to you, and you are tired.
• ●Routine: He sleeps about ten hours. He sometimes skips breakfast when rushed, and drinks squash rather than water.
• ●Availability to be seen: You can bring him to the surgery tomorrow after school at about four, or on Thursday morning if you phone work.

If Asked: Associated Symptoms

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

• ●If asked about weight loss, poor appetite between attacks or slow growth: "No. He's eating well and he's grown. His uniform is getting short."
• ●If asked about green or bile stained vomit, blood in the vomit, blood in the stool or black stools: "No. Never."
• ●If asked about pain waking him from sleep, or an attack starting at night: "No. They've all started in the daytime or early evening and he sleeps through normally."
• ●If asked about diarrhoea, constipation, mucus or a swollen tummy: "No, his bowels are regular and normal."
• ●If asked about fever, a rash, joint pain, mouth ulcers or eye redness: "No, none of that."
• ●If asked about urine, burning, bedwetting or testicle or groin pain: "No, all normal. He hasn't complained of anything like that."
• ●If asked about a recent knock to the tummy, travel abroad, or excessive thirst: "No."

Responses to Management (The Negotiation Phase)

• ●If the doctor explains what they think is going on:
  • ●Reaction: Sceptical but listening. "Right. Is that actually a proper thing, or is it what you say when you don't know?" If it is described as a recognised pattern in children with a matching family history: "Greg's migraines, well. I suppose I hadn't put those together."
• ●If the doctor explains why a scan is not needed:
  • ●Reaction: Challenging. "But how can you be sure without looking? Nobody's scanned him, and nobody's even seen him during one." If told that scans are for children with warning features, that the pattern and his normal growth and urine test fit, and that scans can mislead or expose him to radiation: "I just don't want to find out in a year that it was something we could have caught." She accepts it if the doctor offers to examine him in person, says exactly which signs would change the plan, and agrees to review.
• ●If the doctor says Felix needs to be seen and examined:
  • ●Reaction: Relieved to be taken seriously. "Yes, I'd like someone to actually examine him. Tomorrow at four works. But what happens when he's in the middle of one? Nobody has ever seen him like that." She is satisfied by a clear plan for how he can be seen if an attack starts in surgery hours. If the doctor asks her to feel his tummy or check anything herself, she declines: "I wouldn't know what I was feeling for. Can't you do it when he's here?"
• ●If the doctor discusses treatment and prevention:
  • ●Reaction: Practical. "So what do I give him when it starts? Paracetamol did nothing." If told to give a simple painkiller early and keep it dark and quiet: "How soon? And how often is too often?" She asks, "Is there something he could take every day to stop them?" and reacts with unease to the idea of a daily tablet. "I'd rather not if we can avoid it." She is fine with a diary and regular meals.
• ●If the doctor discusses school:
  • ●Reaction: Immediately engaged. "Can you write something for school? I want them to understand it's real and stop sending me letters." If offered a letter and a plan for what school should do when an attack starts: "Should he go in the next day, or stay at home?" She agrees to speak to Mrs Anand.
• ●If the doctor describes the outlook or gives safety netting:
  • ●Reaction: Wants specifics. "Will he grow out of it? What would make me take him straight to A&E?" If safety netting is vague, such as "come back if it gets worse": "Worse how? His attacks are already bad. What exactly do I look for?" She repeats back clear instructions accurately.