Newly Arrived Woman Asking for the Oxycodone She Was Given After Surgery Abroad — Free SCA Practice Case

Character Overview: You are Joana Figueiredo, a 39 year old accounts assistant who moved from Porto to the UK five weeks ago with your husband Rui, an engineer who took a job with a wind energy company, and your son Duarte, who is 6 and has just started school. Your English is fluent with a light accent. You started a desk job with a logistics firm two weeks ago. Four months ago you tore your right anterior cruciate ligament and a cartilage tear in a fall on a hiking trip, and you had both repaired at a private hospital in Porto. You were sent home with oxycodone tablets and your surgeon's clinic kept giving you more at each follow up. You now take six a day and have four tablets left, which is under a day's worth. You are polite, organised and quietly frightened. You are not trying to trick anyone, and you bristle if you feel treated as a drug seeker. You become quieter and faster when you talk about running out. You do not apply the word dependence to yourself.

Opening Sentence: "Hello, doctor. I registered here two weeks ago. I had knee surgery in Portugal and they gave me oxycodone for the pain. I only have four tablets left, so I need a prescription today, please."

History if Asked (Data Gathering Phase)

• ●The surgery: "Four months ago, on my right knee. The ligament at the front, the ACL, was torn and the cartilage too. They used a piece of hamstring tendon. I was on crutches for six weeks."
• ●Rehabilitation: "I had physiotherapy three times a week in Porto. Then we moved and I stopped. I haven't had a session for about five weeks and I haven't found a physio here yet. I do a few of the exercises at home when I remember."
• ●The knee now: "It aches, about three out of ten at rest. Going down stairs or standing for a long time at work takes it to five or six. It swells a little by the evening if I have been on my feet. It has not locked and it has not given way."
• ●Complications: "No fever. The scars healed well and there is no redness or discharge. No pain or swelling in my calf. No chest pain or breathlessness."
• ●The oxycodone: "The box says oxycodone, ten milligrams, the ordinary tablets and not a slow release kind. I take two in the morning, two in the afternoon and two at bedtime. At the beginning it was one, twice a day. It went up slowly over the months, and it went up more in the last six weeks because of the move."
• ●Supply: "At the hospital I was given enough for two weeks. After that the surgeon's clinic gave me a new prescription every few weeks when I went for my check. The last one was just before we flew. They never questioned it and nobody ever talked about stopping."
• ●Last dose and tablets left: "I took two this morning, about an hour ago. I have four left, so tonight's dose and the morning dose and that is it."
• ●When she runs out or is late: "Once, during the move, the box was in a suitcase and I went about a day and a half without. I thought I had the flu. I was sweating, yawning, my nose was running, my stomach was cramping and I had diarrhoea. My legs were restless and I could not sleep. It went away when I took them again. That frightens me."
• ●Why she takes them: "For the knee, yes. But honestly they also make me feel calm and they help me sleep. When I am stressed I take them a bit earlier than I should. I look at the clock. I do not take them to get high."
• ●Documents: "I have the discharge summary and the operation report. They are in Portuguese. I have a card from the clinic with the surgeon's name and the hospital's phone number and email. I also have the box with my name on the label. The surgeon speaks English."
• ●Other pain medicines: "Paracetamol, which I took in the first weeks, did very little by itself. Ibuprofen upset my stomach a little in Portugal, but it was only for a few days. I have not tried a gel or anything else."

Ideas, Concerns, Expectations

Gating note: Joana 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 the knee is still healing and that the oxycodone is what allows her to work and look after Duarte. She believes the doctor can simply carry on what her surgeon started. "The surgeon gave it to me, so I thought you would just continue."
• ●Concerns: She is afraid of the flu like feeling coming back while she is at work, and she does not know how sick leave or time off for appointments works in the UK. She is afraid of the knee pain being unmanageable. She is also afraid of being labelled an addict. "I am not an addict. I am a normal person with a bad knee. But I am scared of how I felt when I ran out. And if I am ill at work, I do not even know how sick days work here."
• ●Expectations: She came for a prescription of the same tablets at the same dose, for a month, so that she does not have to think about it. "I was hoping for a month, like in Portugal."

If Asked: Medical History and Medications

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

• ●Other health problems: "Nothing serious. No asthma, no stomach ulcers, no kidney or liver problems. Nobody has said I stop breathing at night."
• ●Medicines and supplements: "Only the oxycodone. No sleeping tablets, no tranquillisers, no pregabalin or gabapentin, no antidepressants. A multivitamin sometimes."
• ●Allergies: "None."
• ●Past substance use: "Never. I have never used any drugs. I smoked at university and stopped fifteen years ago."
• ●Family history: "My father drank heavily when I was young. Nobody else."

Mood, Alcohol and Safety

• ●Mood: "Low, since the move. I miss my mother and my friends. I cry sometimes in the car. I am not sleeping well, even with the tablets. I have never felt that life is not worth living and I would never harm myself."
• ●Alcohol: "A glass of wine, 175 millilitres, with dinner about five evenings a week. Sometimes a second glass. Never more."
• ●Driving: "I drive Duarte to school and I drive to work. I have not felt drowsy at the wheel, but I take the morning dose before I leave."
• ●Children and storage: "The box is in my handbag, or on the kitchen shelf if I am home. Duarte has never touched it. I had not thought about locking it away."
• ●Other sources: "No. I have not bought anything online or from anyone else. All of it came from the clinic."

Social History and Lifestyle Impact

• ●Work: Accounts assistant in an office, seated most of the day, in the job for two weeks. She does not know how sick leave or time off for appointments works in the UK and has not asked anyone at work, so she is worried about what she would do if she were unwell or needed time off for physiotherapy and review appointments.
• ●Home: Lives with Rui and Duarte in rented accommodation. Rui travels for work two or three days a week, so she manages school runs alone.
• ●Availability to be seen: She can come to the surgery this afternoon or tomorrow morning.

Responses to Management (The Negotiation Phase)

• ●If the doctor explains that she cannot simply continue oxycodone at the same dose for a month:
  • ●Reaction: Hurt and defensive. "Do you think I am an addict? I am a patient." If the doctor stresses that the issue is that there are no records and that this type of medicine can cause the body to depend on it even when taken as prescribed: she softens. "So it is not that you do not believe me?" If the doctor accuses her, implies she is lying, or refuses without explaining: she becomes upset, repeats that she cannot manage without it, and asks whether she should go to the emergency department tonight.
• ●If the doctor offers a small, time limited supply with a plan to reduce, or a plan for managing withdrawal symptoms if no tablets are issued:
  • ●Reaction: Wants details. "How many would I get? When would I come back? What happens when they are finished?" She accepts a short supply and a slow reduction that she helps to choose. "I can do it slowly if I am not suddenly in pain at work." If offered nothing at all and no cover: "So I will have the flu feeling tomorrow, at work? What do I do?"
• ●If the doctor asks to see the documents or to contact the surgeon:
  • ●Reaction: Cooperative. "Yes, of course. I can send you photos of the papers and translate them. I give permission for you to write to the surgeon. His clinic answers emails quickly."
• ●If the doctor suggests other pain relief, physiotherapy or an orthopaedic review:
  • ●Reaction: Interested but doubtful. "Paracetamol did not do much on its own." She accepts a regular plan with a tablet she can take safely and a gel if explained properly. "Yes, I need a physio. I stopped because of the move. Will the NHS arrange it?" She adds, "And how do I get time off for the appointments here? I do not know how it works." If the doctor suggests a different opioid, a sleeping tablet or a nerve pain tablet to replace the oxycodone: "Is that not the same problem with a different name?"
• ●If the doctor asks to examine the knee:
  • ●Reaction: Agrees readily. "Yes, please. Nobody has looked at it since the move." If asked to examine herself on camera, she declines: "Can I come in instead?"
• ●If the doctor mentions mood, safe storage, alcohol, driving, or safety netting:
  • ●Reaction: Receptive. "I did not think about locking it away. I will buy a box today." She says she will cut back the wine. If the doctor offers talking therapy or support: "I would like that. I have no one here to talk to." If the safety netting is vague: "What exactly should I look for, and who do I call at night?" She repeats back clear instructions.