Sinusitis Asking for Antibiotics Before A Work Trip — Free SCA Practice Case

Character Overview: You are Kwame Asante, a 40 year old commissioning engineer for a company that makes ultraviolet disinfection units for water treatment works. You live in Wolverhampton with your wife Michelle and your two sons, aged 11 and 8. You are taking this call in your work van at lunchtime, parked outside a site. You are friendly, practical and direct, quick to make a joke at your own expense, and you like a straight answer with a reason behind it. You are polite but persistent, because you have decided what you need.

A cold started last Thursday, five days ago, with a scratchy throat and a runny nose, and you felt hot and shivery for the first couple of days. On Saturday morning your nose blocked up on both sides and your face started aching either side of your nose and above your eyes. On Thursday you fly to Porto for three days on site starting up new units, and you fly home on Saturday evening. You are the only engineer in your team trained on this model.

Three years ago a flight home from Copenhagen with a heavy cold ended in stabbing pain above your right eye as the plane came down. You believe you let that infection take hold, so this time you want antibiotics before you fly. You do not mention that flight, or how much it frightened you, until the doctor asks about flying, your worries, or why the antibiotics matter so much.

Opening Sentence: "Hi doctor, thanks for ringing back, I'm on my lunch so I'll be quick. I've had a cold that's gone to my face. My nose is blocked solid and my face is throbbing either side of my nose and up into my forehead. I'm flying to Portugal for work on Thursday, so I was hoping you could sort me some antibiotics before I go."

History if Asked (Data Gathering Phase)

• ●When it started and how it is changing: "The cold started last Thursday, five days now. Scratchy throat and runny nose. On Saturday I woke up completely blocked and my face was aching. About the same since, if anything a touch better this morning. It hasn't gone off and come back worse."
• ●The face pain: "Both sides, either side of my nose and over my eyebrows. Throbbing more than sharp. Worst first thing and when I bend down. Five out of ten."
• ●The nose and smell: "Blocked on both sides. When I blow it first thing it's thick and yellowy green, then clearer later in the day. I can't smell a thing at the moment, so food tastes of nothing."
• ●Temperature (if asked): "I felt hot and shivery on Thursday and Friday. Not since. I haven't got a thermometer, but I don't feel feverish now."
• ●What he has tried (if asked): "Paracetamol, two of the normal 500 milligram tablets four times a day since Friday. Michelle had me doing steam over a bowl with a towel on my head last night. I haven't tried ibuprofen or any sprays."
• ●How he is in himself (if asked): "Working, eating a bit less than usual, drinking fine."
• ●The trip (if asked): "Thursday morning, twenty to seven from Birmingham to Porto, about two and a half hours. Back Saturday evening. I'm the only one in our team trained on this model, so it can't be anyone else."
• ●Flying before (if asked whether he has had problems flying, or flying with a cold): "Three years ago I flew back from Copenhagen with a stinking cold. As we started coming down I got this pain above my right eye like someone pushing a skewer in. My eyes were streaming, I couldn't think straight. When I blew my nose in arrivals there was blood. It eased off over about an hour, but my forehead ached for a couple of days." He adds, more quietly: "Honestly, I never want to go through that again." He saw nobody about it.
• ●Ears (if asked): "A bit full, and they crackle when I swallow. No pain, no discharge, hearing's fine."
• ●Negatives (if asked about each): No swelling or redness around the eyes, no double or blurred vision, no pain moving his eyes. No swelling on the forehead. No severe headache, neck stiffness, light hurting his eyes or rash. No confusion, drowsiness, weakness or numbness: "I'm sharp enough to be arguing with you." Not shaking or shivering. No toothache or jaw pain. Both sides equally blocked, no blood or crusting this time. No itchy eyes or sneezing fits. The sore throat has gone, with a bit of cough at night from it dripping down. Chest fine.

Ideas, Concerns, Expectations

Gating note: Kwame 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 believes the green mucus means it has turned bacterial, and that bacteria need antibiotics. He thinks a few days of antibiotics would dry everything up before Thursday, and that the Copenhagen flight went wrong because he let that infection take hold. "When it goes green, that means it's turned bacterial, doesn't it?"
• ●Concerns: First, the pain on the plane coming back. If Copenhagen has not already come out, he tells it here. "What I'm really dreading is the plane coming down. I genuinely thought something had burst in my head." Second, being stuck ill on his own in a hotel abroad. "If I'm laid up, the whole start up slips, and it's my name on it."
• ●Expectations: A course of antibiotics today, so that he has had a couple of days of them before he flies.

If Asked: Medical History and Medications

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

• ●Past health: Fit as a fiddle. A keyhole operation on his right knee eight years ago. Never been to the doctor with his face like this and never had nasal surgery.
• ●Medicines and allergies: Nothing regular. No allergies. He has had penicillin type antibiotics years ago and they were fine. None in the last few years.
• ●Other conditions: No diabetes, immune problems or steroids. No heart, blood pressure, lung, kidney or stomach problems, no ulcers, no asthma, no glaucoma and waterworks are fine. The nurse said his blood pressure was fine a few months ago.

Social History and Lifestyle Impact

• ●Home and work: Nobody else at home is ill. He travels abroad roughly once a month. The welfare cabin on site is at the far end of the yard. His company arranges travel insurance for every trip. His health card for Europe is in a drawer at home somewhere.
• ●Lifestyle impact: "I'm running on empty because I can't breathe at night."
• ●Smoking and alcohol: Never smoked or vaped. A couple of pints at the weekend, nothing since this started.

Responses to Management (The Negotiation Phase)

• ●If the doctor explains this is most likely a virus that will settle on its own and antibiotics are not needed:
  • ●Reaction: Doubtful, then frustrated but polite. "But it's green. I always thought green meant it had gone bacterial." He accepts it if told coloured mucus is common with a cold. Then: "I'm getting on a plane on Thursday feeling like this. Could you not give me a few to take with me, just in case? I wouldn't touch them unless I had to." He settles when told what to do if it turns nasty out there: "I don't speak a word of Portuguese." If told about side effects such as diarrhoea: "The site toilet is a portable cabin at the far end of the yard. Point taken."
• ●If the doctor explains that pain on landing comes from pressure in blocked spaces, not from the infection getting worse:
  • ●Reaction: Thoughtful. "So it wasn't that I'd let it get worse? It was the pressure? That actually makes sense. It came on exactly as we started coming down."
• ●If the doctor advises about flying, whether putting the trip back or going with precautions:
  • ●Reaction: If told not to fly or to delay: resistant. "I really can't move it. There's nobody else trained on these units. Is it dangerous?" Given an honest answer and left to decide: "Right. I'll ring my manager this afternoon and see if it can shift. If it can't, I'll do everything you've said." If told flying is reasonable: "So what do I actually do on the plane? When exactly? I usually sleep the whole way." Once the flight has been discussed: "Be honest with me. Am I going to be alright on that plane on Thursday?"
• ●If the doctor suggests things for the blockage, such as a decongestant spray, tablets, salt water rinses or a steroid spray, or says the steam will not help:
  • ●Reaction: Interested and practical. "How many days can I use a spray for? Can I take a spray and tablets, belt and braces?" About a steroid spray: "Will it have kicked in by Thursday?"
• ●If the doctor asks him to press on his face, take his temperature or look in his nose, or offers to see him in person:
  • ●Reaction: "I'm sat in the van, doctor, I haven't got a thermometer. I can tell you it hurts when I bend down. I can come in after five if you think you need to look at me. Will it change anything?"
• ●If the doctor gives safety netting, mentions the health card or insurance, explains how long it will last, or asks him to say the plan back:
  • ●Reaction: If vague, such as "get help if it gets worse": "Worse how, though? I'll be in Portugal. What am I actually looking out for?" If specific: "Right. Eyes, bad headache, really unwell. And out there I ring the emergency number, and for anything less I find a doctor or a chemist? Can you text me that?" About duration, deflated: "Two or three weeks? So I'll still be bunged up on the plane? And if I'm still like this when I get home?" Asked to say the plan back, he repeats it roughly in his own words.