New Morning Headaches and Muddled Words — Free SCA Practice Case

Character Overview: You are Barnaby Teasdale, a 63 year old mechanic at a city bus depot. You have worked on the engines and brakes in the depot workshop for 38 years, using the inspection pits and the vehicle lift, and you hold an ordinary car licence only; the drivers move the buses, not you. You live in a semi detached house with your wife Fenella, who works part time at a garden centre and is there until three today. Your daughter Verity lives about twenty minutes away. You smoked about twenty a day from the age of seventeen and stopped ten years ago. You are practical, dry and a bit gruff, you play things down, and you do not like fuss. You are speaking from home on a rest day. Fenella made you ring. You answer questions directly. Your tone becomes quieter and more careful when the talk turns to the cancer, and a bit flat and stubborn when it turns to giving up the car or work.

Opening Sentence: "Morning. It's probably nothing, but my wife's nagged me into ringing. I've had headaches first thing for a few weeks and she says I'm muddling my words. I reckon it's my new glasses, to be honest."

History if Asked (Data Gathering Phase)

• ●The headaches (if asked about them): "About three weeks now. I wake up with it, across the front and the top, both sides, like a tight band. Five out of ten. It's usually gone to a dull ache by lunchtime. I've never really had headaches before, just the odd one after a long shift."
• ●What makes them better or worse (if asked): "Bending down to pick up tools makes it throb, and coughing or sneezing does too. I've started using an extra pillow because lying flat seems to make the mornings worse. Paracetamol takes the edge off, but only just. They've got a bit worse over the last week."
• ●Sickness (if asked): "Some mornings I feel sick when I get up. I was actually sick once last week, and I never get sick."
• ●Sudden or severe features (if asked about a thunderclap, fever, stiff neck, rash or head injury): "No. It builds when I wake. No temperature, no stiff neck, no rash, and I haven't banged my head."
• ●Words (if asked about speech, words or thinking): "Fenella says I stop halfway through a sentence. I know what I want to say, then the word just isn't there. On Sunday I called a spanner 'the thing', and I've lost my thread twice while talking to her. I understand everything people say. I can read the paper fine and my speech isn't slurred."
• ●Memory and mood (if asked): "My memory's all right. Fenella says I've been shorter tempered than usual, which I'd put down to the headaches."
• ●The hand (if asked about weakness, clumsiness or dropping things): "I dropped my mug last Thursday. It just slipped out of my right hand. Since then my grip feels clumsy, buttons are fiddly and my writing on the job cards is scruffy. My right arm feels heavy by the end of the day. My left side is fine, my legs are fine, my face is fine and there's no numbness."
• ●Vision and balance (if asked): "Things are a bit blurry when I read, which is why I blame the glasses. I got the varifocals about two months ago. No double vision, no bits missing from my sight. My balance is fine and I've had no falls."
• ●Turns, blackouts or twitching (if asked about seizures): "No blackouts, no jerking, no funny smells or tastes, and I've never bitten my tongue."
• ●Chest and general health (if asked about cough, blood, weight, breathlessness or pain): "No new cough, no blood, my weight's steady and my appetite is fine. I'm a bit puffed on hills, but no worse than since the operation. No bone or back pain, and no lumps. I'm a bit tired lately, I suppose with the headaches."
• ●The cancer (if asked about the lung cancer and follow up): "Two years ago they found a cancer in the top of my right lung after a cough that wouldn't clear. It was early. I had the top lobe out, five days in hospital, and no chemo or radiotherapy. They said they'd got it all. I've had a scan every six months since, and the last one, six months ago, was clear. The next one is due in about six months. The lung nurses gave me a card with a number, but it's in a drawer somewhere."
• ●Driving and work (if asked): "I drive to the depot every day, about twenty five minutes each way, and I drove to the shop yesterday. Fenella's car is at the garden centre today. At work I'm on the pits and the lift, using heavy tools, so the job needs a steady hand. I'm off today and back tomorrow at half six."
• ●Today at home (if asked who is with him): "I'm on my own until Fenella gets back about half three. Verity is twenty minutes away and she has a car."

Ideas, Concerns, Expectations

Gating note: Barnaby 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. The one exception is the glasses, which he mentions at the start.

• ●Ideas: He thinks the new varifocals are the cause, or that he is overtired because the depot is short of staff. "I got new glasses and it all started after that. Plus we're short at work and I've been pushing it."
• ●Concerns: Asked what worries him, he goes quiet. "If I'm honest, in the middle of the night I've wondered whether the cancer's come back. But I had a clear scan, so I told myself off for being daft." He is also worried about losing his licence and his job. "I couldn't get to work without the car, and I couldn't do the job if my hand's not right." He does not want to worry Fenella.
• ●Expectations: He hoped for stronger painkillers or a note to see the optician. He thought it best to wait for his next scan in six months and not bother the hospital. "They've got proper poorly people to see. I didn't want to make a fuss."

If Asked: Medical History and Medications

• ●Past history: High blood pressure and high cholesterol. No heart trouble, no stroke and no epilepsy. The lung operation is the only operation.
• ●Medicines: Amlodipine 5 mg in the morning and atorvastatin 20 mg at night. Paracetamol for the headaches, two tablets, a few times in the last fortnight.
• ●Allergies: None.

Social History and Lifestyle Impact

• ●Home: Lives with Fenella in a house they own. Verity, their daughter, has two children. It was Fenella's idea to ring.
• ●Alcohol and smoking: About eight units a week, a few pints at weekends. Smoked twenty a day from seventeen to fifty three, then stopped for good.
• ●Work: Mechanic at the depot for 38 years. A supervisor, Ged, would need to be told if he were off. Sick pay is decent, but the job is how he sees himself.

If Asked: Associated Symptoms

All negative unless already stated: no facial droop, no difficulty swallowing, no bladder or bowel changes, no night sweats. Appetite and weight are stable.

Responses to Management (The Negotiation Phase)

• ●If the doctor says the symptoms could mean the cancer has come back or spread to the brain, and he needs to be assessed today:
  • ●Reaction: Silent for a moment, then flat and shaken. "Today? But I had a clear scan. Are you saying it's definitely back?" Once told it is not certain but needs checking quickly: "Right. You'd better tell me what happens." If the doctor mentions the six month scan: "So the scan doesn't mean I'm safe in between?" He accepts when the reasoning is explained calmly.
• ●If the doctor advises him to stop driving, or explains the DVLA:
  • ●Reaction: Resistant at first. "I drove yesterday and I was fine. How do I get to work?" Once the reason is clear (a sudden seizure or weakness at the wheel could hurt him or someone else): "I wouldn't forgive myself if I hurt a kid." He asks how long he would be off the road, whether he has to tell the DVLA himself and whether his insurance is affected. He agrees not to drive, including to the hospital.
• ●If the doctor arranges assessment through the acute oncology team, the lung team or the emergency department, or asks how he will get there:
  • ●Reaction: Practical. "Fenella finishes at three. Can I ring her to come home early? Or Verity can run me." He asks where to go, whom to ask for, how long it will take, and whether to bring his scan letter, his tablets and an overnight bag. If told the doctor will phone ahead: "That'd be a relief. I'd only get sent from pillar to post."
• ●If the doctor discusses what the tests might show, or what it could mean for him:
  • ●Reaction: Quiet, careful. "If it is back in my head, is that it, then?" Told that it is too early to say, that scans will show what is going on, and that there are treatments and a team who will talk it through: "Fair enough. Straight answers is what I want." If the doctor over reassures, he goes along but sounds unconvinced.
• ●If the doctor asks about work, offers a fit note or mentions the lift and the pits, or offers pain relief:
  • ●Reaction: "I'll ring Ged. I suppose I shouldn't be under a bus on a lift with this hand." He asks whether he can take paracetamol for the headache and whether ibuprofen is fine. He accepts a fit note.
• ●If the doctor gives specific safety netting, or says what to do if he cannot be seen quickly:
  • ●Reaction: Takes it seriously and repeats it back. "If I have a fit, or the headache gets terrible, or I get drowsy or can't get my words out, I ring 999." If the doctor is vague ("come back if it gets worse"): "Worse how? What exactly would mean I need an ambulance?"