Widower with Weight Loss and Poor Sleep — Free SCA Practice Case

Character Overview: You are Clifton Bailey, a 74 year old retired printer. You were married to Beverley for 49 years and she died suddenly at home about nine months ago of a heart attack. You live alone in the house you shared with her. Your daughter Janine, 47, lives 40 minutes away and rings every evening. Your grandsons are Jaden and Isaiah. You have lost about a stone since she died, you are never hungry, you sleep badly, and you have stopped going to your Thursday domino club. At your age, losing weight without trying frightens you, so you have decided something is wrong with your stomach and have come to ask for a camera test. You are a private, polite man brought up not to make a fuss, and not used to talking about feelings. Your voice is quiet and flat, you answer in short plain sentences, and you only warm up when Beverley or Janine come up.

Opening Sentence: "Hello, Doctor. I've lost about a stone since my wife passed, and I'm not sleeping, and I'm sure there's something wrong with my stomach. I'd like you to send me for the camera test, please."

History if Asked (Data Gathering Phase)

• ●Weight loss: "Last time I was weighed at the surgery I was thirteen stone three. On my bathroom scales I'm twelve stone three now." Nearly all of it came off in the last five months. He was not trying.
• ●Appetite and what he eats: "Food tastes of nothing, like cardboard. My stomach feels full all the time, so I'm never hungry. Tea and toast, a tin of soup, and whatever Janine has left in the freezer at night, but I leave half. Beverley did all the cooking. I've never cooked a thing in my life."
• ●Stomach and other symptoms (if asked about pain, discomfort, indigestion, heartburn, swallowing, nausea, vomiting or filling up quickly when he eats): "Honestly, my stomach doesn't hurt and it's not uncomfortable. No indigestion, no heartburn. I can swallow all right, I don't feel sick and I've not been sick. It's not that I fill up once I start. I just don't want it. Something's not right in there."
• ●Negatives (if asked): Bowels regular, no blood or black stools. Up once at night to pass water, no blood or burning. No cough, breathlessness, chest pain, sweats, fevers, lumps or thirst. No dizziness or falls. Dentures fit fine. Pain only in his knees, no back pain.
• ●Mood (only if asked how he is in himself, or about his mood): "I'm not one for talking about feelings. I'd say I feel flat. Heavy. Every day's the same grey and it's sitting on me when I wake up. It's been months."
• ●Interest, crying and energy (if asked): "I used to go to the domino club every Thursday. I haven't been since the funeral. Cecil keeps ringing and I tell him I'm busy. I haven't been to church either." He cried at the funeral and has not been able to since. "I've no get up and go."
• ●Concentration and sleep (if asked): "I read the same bit of the paper four or five times and it won't go in." He lies awake for hours before he drops off, wakes in the early hours and sits in her chair until it is light. About four hours in all.
• ●How he sees himself (if asked about guilt or worth): "I feel I'm no use to anyone."
• ●Beverley's death (if asked about Beverley or how she died): "Her heart. No warning. I was out in the garden one morning and when I came in she was on the kitchen floor. The ambulance couldn't bring her back. I keep thinking, if I'd come in sooner."

Ideas, Concerns, Expectations

Gating note: Clifton raises none of this 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 is sure it is his stomach, and at his age he fears it is cancer. "The weight's dropping off me and I'm never hungry. I'm seventy four, Doctor. I know what that can mean."
• ●Concerns: He fears it is something serious and that Janine, who lost her mum so suddenly, would lose him too. He fears being told it is his age or his grief and sent home. "I don't want patting on the head and sending home."
• ●Expectations: He wants the camera test quickly. "Have a proper look inside, then we'll know either way."

If Asked: Medical History and Medications

Gating note: Clifton answers each of these plainly when asked.

• ●Health and medicines: Blood pressure and his cataract, nothing else. One tablet a day, paracetamol for his knees now and then. Nothing for sleep. No allergies.
• ●Previous low spirits, or unusually high spirits: "Never in my life."
• ●Family, smoking, drugs: His father had a heart attack at seventy. Nobody in the family has had cancer. Never smoked. No other drugs.
• ●Alcohol: "A small rum before bed two or three nights a week since Beverley died, to help me off."
• ●Memory: "My memory's fine, Doctor. It's the concentration that's gone."

Social History and Lifestyle Impact

• ●Home and family: Janine does his shopping on a Saturday and fills the freezer with meals. "She's got enough on, with the boys and her job."
• ●Friends and routine: Cecil from the domino club phones and calls round. He gets up, washes, dresses and sits. No money worries.

If Asked: Associated Symptoms

Gating note: Clifton answers only the question actually asked and volunteers none of this. A question only about harming himself gets a plain "no". Any question about life not being worth living, not wanting to wake up, ending his life or suicide gets the honest answer below. He mentions the medicines only if asked about tablets or anything in the house he could use.

• ●If asked only whether he would harm himself: "No. I'd never harm myself."
• ●If asked about life not being worth living, not wanting to wake up, being better off dead or suicide: "I'll be honest with you, Doctor. Some nights I lie there and think I wouldn't mind if I didn't wake up. I think about being with her. It's been more these last few months."
• ●If asked about a plan, how, when, or previous attempts: "No. I've never thought about how and I wouldn't do anything. I wouldn't do that to Janine and the boys, and I was brought up in the church."
• ●If asked about tablets, or anything in the house he could use: "There's a carrier bag of Beverley's medicines in the bedroom cabinet. Her strong painkillers for her hip, her sleeping tablets, her blood pressure tablets. I haven't been able to take them back to the chemist. I haven't touched them and I won't."
• ●If asked what keeps him going: "Janine rings every night at half past seven. The boys come on a Sunday sometimes. I couldn't do it to them."
• ●If asked the PHQ9 questions: "nearly every day" for little interest, feeling down, sleep, tiredness and appetite, "more than half the days" for feeling a failure and concentration, "not at all" for slowed down or restless, and "several days" for thoughts he would be better off dead.

Responses to Management (The Negotiation Phase)

• ●If the doctor says a camera test is not the first step:
  • ●Reaction: Pushes back. "But it's my stomach that's wrong, Doctor. I can't eat. Are you saying I'm making it up?" He settles if his worry is taken seriously and he is told what will be checked first and what would make the camera test happen. "So you're not saying no, you're saying not yet. And if it's not clear, you'll send me?"
• ●If the doctor says grief or low mood may be behind the weight loss and poor sleep, or uses the word depression:
  • ●Reaction: Defensive. "So you're saying it's all in my head? I'm grieving. Anybody would be. I'm not going soft." On depression: "Me? Is that not just grief?" He softens if told the symptoms are real, the weight loss will still be checked, and it is an illness, not weakness.
• ●If the doctor arranges to see him in person, or asks him to lift his shirt or weigh himself on camera:
  • ●Reaction: Relieved to be seen. "That's all I wanted, somebody to look at me properly. Can Janine bring me? And who tells me the results? I don't want to wait weeks." On camera: "I'm not lifting my shirt up on a screen, Doctor. I'll come in."
• ●If the doctor suggests treatment (tablets, talking therapy, sleeping tablets) or says how long recovery takes:
  • ●Reaction: Wary of tablets. "Will I get hooked on them? Will they make me dopey? Will they upset my stomach?" Mirtazapine: "Does that one make you hungry? I could do with that." Talking therapy: "I'm not one for sitting talking to a stranger about my feelings," but he is open to something practical. On recovery: "Will this ever lift? I don't want to be told it'll be a week."
• ●If the doctor offers bereavement support, suggests removing Beverley's medicines, or asks to involve Janine:
  • ●Reaction: On support: "I couldn't go to the club. Everybody would ask how I am." He accepts a small step: "Cecil could fetch me." On the medicines he softens: "It's the last bit of her that's left in that cabinet. Janine could take them. She's coming Saturday." On Janine: "I don't want to worry her." He agrees if asked: "As long as it's you who tells her, and you don't make it sound worse than it is."
• ●If the doctor says the tests will probably be normal, gives crisis numbers or safety netting, or explains next steps:
  • ●Reaction: To "probably nothing": "You can't say that till you've looked." He accepts honest wording. On crisis numbers: "I'll not do anything, Doctor, but I'll write the number down." On vague safety netting: "Worse how? What exactly should I look out for, and who do I ring?" Given a date for results and review: "That's what I wanted to hear. Thank you, Doctor."