Recurrent Vomiting Who Left A&e, Regular Cannabis User — Free SCA Practice Case

Character Overview: You are Chloe, a 24-year-old who works in retail. You are worn down by these repeated attacks and a bit embarrassed. You are guarded about your cannabis use at first — you do not think it is relevant and you are wary of being judged. You are not hostile, and if the doctor is non-judgemental you will open up. You have discovered that very hot showers are the only thing that helps during an attack, though you have not mentioned this to anyone because it sounds odd.

Opening Sentence: "Hi Doctor. So I keep getting these episodes where I'm violently sick for hours — can't keep anything down, retching, tummy cramps. It's happened three or four times over the last year. I went to A&E last week but the wait was massive so I gave up and came home once it eased off. I just want to know what's causing it."

History if Asked (Data Gathering Phase)

• ●The episodes: "They come on suddenly, usually early morning. Really intense — vomiting over and over, retching, cramping tummy pain. It lasts hours, sometimes a day or two, then it just stops and I'm completely fine again for weeks."
• ●Between episodes: "Totally normal in between. Eating fine, no pain, nothing. That's what's confusing."
• ●Hot showers (only if asked directly): "This is going to sound weird — the only thing that helps is really hot showers or baths. I'll be in there for ages, as hot as I can stand it. It's the one thing that calms it down. I haven't told anyone that, it sounds mad."
• ●Cannabis (guarded initially): "I mean... I smoke a bit of weed, yeah. Most days, if I'm honest. Have done for a few years. But loads of people do — that wouldn't cause being sick, would it?"
• ●Why she left A&E: "The wait was hours, I was exhausted, and by the time I'd have been seen the worst had passed. I felt like I was wasting their time."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.

• ●Ideas: Chloe thinks she might have a "dodgy stomach," an ulcer, or a food intolerance. She has firmly not connected the vomiting to her cannabis use and would be surprised — and initially resistant — to that link. "I've wondered if it's an ulcer or something I'm eating. I really don't think it's the weed, if that's where you're going."
• ●Concerns: She is worried something serious is being missed, and is quietly distressed at how the attacks disrupt her life and work. "I'm scared there's something properly wrong that keeps getting missed because I never get seen. And it's affecting my job — I've had to call in sick."
• ●Expectations: She wants a diagnosis and something to stop the vomiting. She is not expecting, and may resist, being told cannabis is the cause. "I want an answer, and ideally something that actually stops it. I wasn't expecting to be told to give up weed."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

• ●Pattern over time: "It's definitely been happening more over the last year, as my smoking's crept up."
• ●Cannabis detail: "Most days, sometimes more. I've been smoking for about four years. It's got heavier recently."
• ●Other drugs/alcohol: "I drink a bit at weekends. No other drugs."
• ●Pregnancy possibility: "I've got a boyfriend, we're not always careful. I suppose I could be pregnant, I hadn't thought about it."
• ●Medications: "Nothing regular. I've tried over-the-counter anti-sickness tablets, they don't touch it."

Social History and Lifestyle Impact

Chloe works in retail and lives with her boyfriend.

• ●Work: "I'm on my feet in a shop all day. These attacks mean I have to call in sick, and I'm worried about my job."
• ●Cannabis context: "It's just part of my routine, evenings mostly, to wind down. More lately because work's stressful."
• ●Diet/weight: "I've lost a bit of weight I think, from not eating during the attacks. Otherwise okay."
• ●Home: "My boyfriend's supportive. He smokes too, actually."

If Asked — Associated Symptoms and Red-Flag Screen

The patient answers these only when directly asked.

• ●If asked about relief from hot showers/baths: "Yes! Really hot water is the only thing that helps. How did you know to ask that?" (Key diagnostic clue.)
• ●If asked about vomiting blood: "No blood, no. Just food and then bile when there's nothing left."
• ●If asked about abdominal pain between episodes: "No, completely fine between attacks."
• ●If asked about headache, neck stiffness, visual symptoms (to exclude neuro causes): "No, none of that."
• ●If asked about weight loss: "A little, from not eating during the attacks."
• ●If asked about fever or diarrhoea: "No fever. Bowels are normal."
• ●If asked about dehydration (dizziness, not passing urine, unable to keep fluids down) now: "Right now I'm okay — the attack's passed and I'm drinking and weeing normally. During an attack I can't keep anything down though."
• ●If asked about relationship to cannabis timing: "I've never really thought about whether it's linked to smoking. I smoke around it, but I smoke most days anyway."

Responses to Management (The Negotiation Phase)

• ●If the Doctor explains the vomiting is likely caused by cannabis (cannabinoid hyperemesis): "You think the weed is causing this? But it's supposed to help with feeling sick, not cause it. Are you sure?" (The tested point is explaining the paradoxical link between chronic cannabis use and cyclical vomiting, and the hot-shower clue, without lecturing or alienating her.)
• ●If the Doctor advises stopping cannabis as the definitive treatment: "So the only thing that fixes it is stopping completely? That feels like a big ask." (The tested point is conveying that cessation is the only effective long-term treatment, and offering support, without moralising.)
• ●If the Doctor raises a pregnancy test: "Why do I need a pregnancy test? What's that got to do with being sick?"
• ●If the Doctor addresses the A&E attendances: "I know I keep leaving, but I never get seen in time. What am I supposed to do?"
• ●If the Doctor safety-nets about dehydration: "So when would I actually need to go in and stay, rather than ride it out at home?"