One Blocked Nostril for Two Months — Free SCA Practice Case

Character Overview: You are Yvonne Baptiste, a 61 year old retired joiner. You served your apprenticeship making staircases, doors and sash windows, then spent your last twenty years at a small workshop making fitted kitchens and furniture, mostly in oak, beech, walnut and mahogany. You were often the only woman on the shop floor and you are proud of it. The workshop closed two years ago and you retired. You live with your husband Desmond, a retired school caretaker, and you look after your two grandchildren after school three days a week.

You have had hay fever every early summer since your twenties: sneezing, itchy eyes and a runny nose on both sides, which settles after a few weeks of tablets. About two months ago the right side of your nose started to block, and it has got steadily worse. You assumed your hay fever had hung on, so you bought a steroid spray from the chemist. It has made no difference. Desmond has been on at you to see someone, and you booked this appointment mainly to stop him nagging. You came hoping for the hay fever injection your sister in law Gloria has every year.

You are practical, cheerful and brisk, with a dry sense of humour. You answer plainly and do not volunteer which side is blocked, the blood, your old job or the watery eye until asked. If something serious is raised, you go quiet for a moment and sound shaken, and then you become very direct and want straight answers.

Opening Sentence: "Hello, Doctor. It's my hay fever. It's gone on far longer than usual and that spray I got from the chemist isn't touching it. My nose is bunged up all the time and I'm fed up with it, to be honest."

History if Asked (Data Gathering Phase)

• ●Which side (if asked whether it is one side or both): "It's the right side. Just the right. The left one's fine, I can breathe through that no bother."
• ●How long and how it has changed: "About two months. It started as a stuffy feeling on the right and it's got steadily worse. Now that side's blocked solid, day and night."
• ●What her hay fever is normally like (if asked): "Normally it's early summer, when the grass is out. Sneezing fits, itchy eyes, runny nose, both sides. A few weeks of tablets and it's gone. This time there's no sneezing and no itching at all. It's just blocked."
• ●Anything coming out of the nose (if asked about discharge, crusts or bleeding): "I get crusty bits up the right side. Brownish, and sometimes there's blood in them. A few times a week I blow my nose and there's bright red on the tissue."
• ●Nosebleeds (if asked directly): "It's properly dripped twice. From the right side, only for a minute or two, and it stopped on its own both times."
• ●When the crusts started, and smell (if asked): "Now I think about it, they were there before I bought the spray. That's partly why I bought it." No nasty smell or taste. "My sense of smell's a bit duller than it was, but nothing I'd have bothered you about."
• ●Sleep: "I can't lie on my right side because it bungs up even worse, and I wake up with my mouth bone dry."
• ●What she has tried and how (if asked): "A steroid spray from the chemist, the hay fever one. Two sprays each side, morning and night, for about six weeks. Not a scrap of difference. My usual hay fever tablets did nothing either." Technique: "Head tipped forward a bit, nozzle pointing out towards the side, not the middle, and a gentle sniff. The pharmacist showed me. I'm good with instructions." She has used no decongestant sprays.

Ideas, Concerns, Expectations

Gating note: Yvonne 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 her hay fever has dragged on, and that the crusts were the spray drying her nose out. "I reckon the hay fever's just hung on. And I thought the crusty bits were the spray drying me out."
• ●Concerns: Mostly practical. The blocked side is spoiling her sleep, and she is embarrassed about always dabbing at her nose in front of the grandchildren. "It's the nights, mainly. And I'm forever dabbing at my nose in front of the kids." If asked what made her book now or whether anyone else is worried: "Desmond's the worrier. He keeps saying it's not right, one side like that." If asked whether she has wondered herself whether it could be serious: "I don't go looking for trouble. I'll be honest though, I didn't like seeing red on the tissue."
• ●Expectations: She wants the injection her sister in law has. "Gloria has an injection every year before the summer, at a private clinic. She swears by it. I wondered if you could do me one of those." It is a steroid one, she says.

If Asked: Medical History and Medications

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

• ●Hay fever and cholesterol: "Hay fever since my twenties, just the summer, just tablets from the supermarket. I'm on a cholesterol tablet at night. The nurse checked it all a few months back and said it was fine."
• ●Other medicines: "Just the cholesterol tablet and the nose spray. No aspirin, no blood thinners."
• ●Nose problems before: "Never. Never broken it, never had nosebleeds before this. Nothing's gone up there, and no, I've never taken drugs, Doctor, I'm 61."
• ●Allergies: "None that I know of, apart from the grass."

Social History and Lifestyle Impact

• ●Work (if asked what she did, or about dust or chemicals at work): "I was a joiner, forty odd years. Staircases and doors when I started, then fitted kitchens and furniture. Oak, beech, walnut, a lot of mahogany in the early days. Sawing, planing, sanding all day long."
• ●Dust and masks (if asked): "For the first twenty years hardly anyone wore a mask. You'd go home with sawdust in your eyebrows and blow your nose black. The last workshop had extraction and proper masks, but by then I'd been at it two decades." No metals, leather or chemicals other than varnish and glue.
• ●Woodwork now: "I still potter in my shed. Bird boxes, a dolls' house. I wear a decent mask now."
• ●Home: Lives with Desmond. She has her daughter's two children after school on Mondays, Tuesdays and Wednesdays.
• ●Smoking and alcohol: "Never. My dad smoked enough for all of us. A glass or two of wine at the weekend."
• ●Lifestyle impact: "I'm not sleeping properly, and I'm tired with the kids in the afternoons."

If Asked: Associated Symptoms

Gating note: Answers are brief and natural. Everything below is negative unless a detail is given.

• ●Her eyes: "Now you mention it, my right eye's been watering more than the left for the last few weeks. I put that down to the hay fever." No double vision, blurred vision, bulging or swelling around the eye ("I see fine with my glasses").
• ●Face, mouth and ears: No pain, swelling or numbness in her face or cheek. "All my own teeth, none loose." Nothing odd in her mouth. Ears and hearing fine.
• ●Neck and head: No lumps in her neck, no headaches.
• ●General: Weight, appetite and clothes unchanged, no night sweats, no fever, well in herself apart from tiredness. No cough, coughing up blood, joint pains or rashes. Voice fine apart from sounding bunged up. Swallowing fine.

Responses to Management (The Negotiation Phase)

• ●If the doctor explains that this does not behave like her usual hay fever:
  • ●Reaction: Thoughtful, conceding the point. "Well, it's not like my usual, I'll give you that. No sneezing at all this time, and only the one side."
• ●If the doctor says something needs to be ruled out, or that cancer needs to be ruled out:
  • ●Reaction: If no word is given, direct: "Rule out what, though? You can be straight with me, Doctor." If cancer is raised, she goes quiet and sounds shaken. "Cancer. Right. I came in about hay fever. How likely is that, then?" She steadies if told honestly that this needs checking quickly and that most people sent this way do not have cancer. If told it is definitely cancer: "Definitely? Nobody's even looked up my nose yet."
• ●After cancer has been raised and she has taken it in:
  • ●Reaction: She asks about her old job. "Is it the wood? For the first twenty years we never wore masks." She is relieved if the doctor treats it as useful information rather than her fault. Later: "And if it is something bad up there, can they sort it?" She settles with an honest answer that does not promise either way.
• ●If the doctor explains the urgent referral, the camera test or the timescale, or offers an in person look:
  • ●Reaction: Practical. "How quick is quick? And what are they going to do to me?" About the camera: "Up my nose? Am I awake for that?" She settles once told it is a thin camera with a numbing spray. If she hears nothing: "What do I do then?" She declines to show her nose on camera ("It's all crusty up there") but welcomes an in person look: "Yes please. I can come any morning."
• ●If the doctor declines the injection, or offers it, steroid tablets, antibiotics or a different spray instead of a referral:
  • ●Reaction: If declined, a little disappointed. "Oh. Gloria swears by it." She accepts a reason and asks: "So what do I do about the blocked side in the meantime?" If offered one of those instead of a referral, pleased: "Lovely. That's what I was after."
• ●If the doctor gives safety netting or nosebleed advice, or asks how she will tell Desmond:
  • ●Reaction: If safety netting is vague: "Worse how? It bleeds a bit most weeks as it is." About a nosebleed: "Pinch where, the bony bit at the top?" She accepts the correction. About Desmond: "He'll want to come. He'll have a list of questions as long as your arm."