Pernicious Anaemia Asking to Switch From Injections to Tablets — Free SCA Practice Case

Character Overview: You are Kayode Ogunleye, a 60 year old piano tuner and technician for a piano showroom in Leicester. You were born in London to Nigerian parents and have lived in Leicester for thirty years with your wife Bisi, 58, who works as a school cook. Most days you drive to customers' homes, schools and churches across Leicestershire and Northamptonshire, and your jobs are booked three or four weeks ahead. About nine years ago you were found to be very low in B12 and have had an injection from the practice nurse every three months since. You were told you would need them for life and took in little else. Lenny, who works in the showroom workshop, takes a B12 tablet every morning, and you have asked for this call hoping to swap your injections for tablets too. You are taking the call in your van, parked on a customer's drive between jobs. You are warm, chatty and practical, a little hurried, and you play down anything to do with your own health.

Opening Sentence: "Hello, doctor, thanks for ringing me back. It's about my B12 injections. I've had them every three months for about nine years now, and a chap I work with just takes a tablet every morning for his. I'd much rather do that than keep trying to fit in the nurse. Oh, and my feet have been a bit tingly lately, but I'm sure that's just my age."

History if Asked (Data Gathering Phase)

• ●Where the idea came from: "Lenny in our workshop takes one every morning. If it's the same vitamin, why am I trailing into the surgery every few months?" If asked why Lenny takes tablets: "His diabetes tablets made his B12 drop, that's what he told me."
• ●What he knows about his own B12 problem (if asked): "They found it about nine years ago. I kept nodding off in the van and Bisi said I looked washed out. They said it was an autoimmune thing and I'd need the jabs for life. I'll be honest, I didn't take in much more than that."
• ●Last injection and missed appointments (if asked): "Must be six or seven months ago? I've cancelled a few. The nurse only does them in the daytime, and the last few months have been my busiest. Then I thought I'd sort out the tablets instead." He cancelled three in all and none is booked.
• ●Supplements (if asked about other medicines, vitamins or anything from the shops): "I bought a tub of vitamin B tablets from the supermarket about three weeks ago and I take one a day. I thought it'd tide me over. I haven't noticed any difference."
• ●The tingling: "The soles of both feet and my toes, both the same. It started about six weeks ago, maybe a bit more. It's a fizzing, like when your foot's been asleep and it's coming back, and a bit numb underneath, like thick socks. It's not painful, just odd. It started in my toes and now it's the whole of the sole, but it hasn't gone above my ankles. It's there most of the time, and I notice it most in bed at night." If asked about his hands: "No, my hands are fine. I'd soon know, with my job."
• ●Energy (if asked how he has been in himself): "If I'm honest, I've been flagging a bit in the afternoons this last month or so. A bit like before they found it, but nowhere near as bad as then."

Ideas, Concerns, Expectations

Gating note: Kayode 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.

• ●Ideas: He thinks the injections may not do as much as they used to, and that a tablet every day would keep him topped up instead of one big dose that wears off. He puts his feet down to sitting in the van all day, or getting older. "With a tablet every day you'd be topped up all the time, wouldn't you? The feet, I put that down to sitting in the van all day." He has not connected the tingling with the late injection: "No. It never crossed my mind."
• ●Concerns: His first worry is work. "Every time I come in it's half a morning gone, and my jobs are booked weeks ahead." If the doctor explores further, especially about his feet, a bigger worry comes out, and his voice goes quieter: "If I'm honest, it's my brother. Femi's got diabetes and he lost the feeling in his feet. He had a sore on his foot he didn't even know was there, and last year they took one of his toes off."
• ●Expectations: He hoped the doctor would put tablets on his repeat prescription today so he could stop the injections. "I was hoping you could just put the tablets on my repeat, and then I wouldn't need to book the nurse at all."

If Asked: Medical History and Medications

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

• ●Other health problems and medicines: "Just my blood pressure. I've been on amlodipine for about six years, one a day, no problems with it. Nothing else apart from those supermarket vitamin tablets. No allergies that I know of."
• ●Blood sugar: "At my health check a couple of years ago they said my sugar was borderline. I couldn't fit the course round work. I don't think it's been checked since." He is not especially thirsty and is up once in the night for the loo, as always.
• ●The injections themselves: "I don't mind needles. It's the getting there that's the problem." If asked about giving them himself: "I've never done anything like that. I'd have a go if somebody showed me. Bisi's braver than me, mind."
• ●Family: "My brother Femi's 64, he's had diabetes for about fifteen years. Mum and Dad both lived well into their eighties."

Social History and Lifestyle Impact

• ●Work: Kayode is employed by the showroom, but part of his pay depends on the number of jobs he completes. He leaves home about half seven and is often not back until six. He is in Northampton all day Thursday and has a church in Market Harborough on Friday.
• ●Lifestyle impact: "It's just always there, and it bothers me when I'm trying to get off to sleep."
• ●Hobbies, alcohol and diet: "Two pints of bitter on a Friday, and two on a Sunday after church. That's it. Never smoked."

If Asked: Associated Symptoms

• ●If asked about unsteadiness (particularly in the dark or with his eyes closed), falls, weakness or stiffness in the legs, bladder or bowel problems, or back pain: "No, I'm steady. I get up for the loo in the night without the light on and I'm fine. My legs are strong, and my bladder and bowels are normal. No back trouble."
• ●If asked about eyesight, memory, concentration or mood: "All fine. I'm just fed up with the feet."
• ●If asked about breathlessness, chest pain, indigestion, trouble swallowing, being sick, weight loss, black stools or recent illness: "No, none of that. My weight's about the same."
• ●If asked about cuts, sores or burns on his feet: "Not that I've noticed." If asked about driving: "I can feel the pedals fine. It's just the fizzing."

Responses to Management (The Negotiation Phase)

• ●If the doctor says tablets are not suitable for him, or that the injections are for life:
  • ●Reaction: Pushes back once, good naturedly. "But Lenny's fine on them. What's the harm in giving them a go?" If the doctor explains that his body cannot take in B12 from tablets the way Lenny's can: "So it's not that the tablets are weaker. It's me that can't take them in." If strong daily tablets are mentioned as a possibility later: "So it's not a never. Can we look at that again once my feet are sorted?"
• ●If the doctor links the tingling to the late injection, or says he needs injections more often for a while:
  • ●Reaction: Sheepish. "I did cancel a few. So this is my own fault, then?" He settles if he is not made to feel blamed. About more frequent injections he is taken aback, then practical: "More often, not less. That's the opposite of what I rang for. How often? I'm in Northampton all day Thursday and I've got a church in Market Harborough on Friday." He agrees if the doctor works out a plan he can keep.
• ●If the doctor offers to teach him or Bisi to give the injections at home, or to book a run of appointments:
  • ●Reaction: Interested. "I'd never have thought of that. I'd give it a go if someone showed me properly. Can I start straight away?"
• ●If the doctor asks him to come in to be examined, or to test his own feet or balance on the phone:
  • ●Reaction: Relieved to be seen. "Yes, I'd rather someone had a proper look at my feet, to be honest." He asks whether he can come early in the morning or after four. If asked to test his feet or balance himself: "I'm sat in the van on a customer's drive. I'd rather you had a look at them properly."
• ●If the doctor arranges blood tests, or discusses the supermarket tablets:
  • ●Reaction: "What are you checking for? Is that my sugar? That's how Femi's started." He also asks: "Will you check my B12 level while you're at it?" About the supermarket tablets: "So should I keep taking them, or are they a waste of money?"
• ●If the doctor talks about recovery, the stomach risk of his condition, or safety netting:
  • ●Reaction: About recovery: "If it is the B12, does the feeling come back? Or is this how they'll stay now?" He is reassured by an honest answer. About the stomach risk, surprised: "Nobody's ever told me that. What should I look out for?" If safety netting is vague, such as "ring back if it gets worse": "Worse how? It's just fizzing at the moment. What would mean I shouldn't wait?"