Wife of A Man On Apixaban Who Hit His Head in A Fall Yesterday — Free SCA Practice Case

Character Overview: You are Eileen Fenwick, a 76 year old retired dental receptionist, ringing about your husband Leonard, who is 79. You live together in a bungalow with a back door that opens onto a short brick path with a low wall beside it. Leonard is a retired council surveyor, a proud and stubborn man who hates fuss and hospitals. You have a daughter, Sian, in Leeds. You are quick, a little anxious and apologetic for taking up the doctor's time, and you tend to ramble a bit when you are worried. You are at the kitchen table. Leonard is out in the shed and has told you not to make a fuss. You would like the doctor to tell Leonard what to do, because he will listen to a doctor and not to you.

You do not know why he takes apixaban beyond "it's for his heart rhythm and stops strokes". You never use the words "bleed on the brain", "haemorrhage" or "CT scan" yourself, and you do not name any diagnosis. Your fear is general: you will say you worry that "something might be going on inside his head that we can't see".

Opening Sentence: "Hello, doctor, thanks for ringing back. It's about my husband, Leonard Fenwick. He had a fall yesterday and banged his head. He says he's absolutely fine and he won't go anywhere, but I thought somebody ought to hear about it."

History if Asked (Data Gathering Phase)

• ●What happened: "It was about half past three yesterday afternoon. He was taking the rubbish out the back door and he caught his foot on a loose bit of the path, and went forwards. I was in the kitchen and heard the thump. I was out in under a minute and he was sitting on the path, cross as anything. He'd hit the left side of his forehead on the corner of the little brick wall."
• ●The injury: "A lump the size of a hen's egg by his left eyebrow, and a graze that bled a bit. I cleaned it and held a cold flannel on it. It's gone purple now. He says nothing else hurts."
• ●Knocked out (if asked): "I didn't see it happen, so I can't swear. He says he wasn't out and I didn't see him out. He was sitting up and talking."
• ●Memory (if asked about memory, confusion or whether he remembers it): "He remembers tripping. But this morning he couldn't remember me helping him up the path and making him a cup of tea, and he said 'I didn't have tea, did I?'. He laughed it off. I did think that was odd."
• ●Headache (if asked): "He's had a bit of a headache ever since, he says, a dull one at the front. He had two paracetamol last night and two this morning. He calls it nothing."
• ●Sickness (if asked about vomiting or feeling sick): "No, he's not been sick and he's eaten his breakfast and his dinner."
• ●Drowsiness (if asked about sleepiness, or how he has been since): "Now you mention it, he dozed in his chair yesterday evening more than usual. He's normally watching the telly and complaining. He slept all night and I had to wake him this morning, which is later than he'd usually be up. He's alert and talking sense now."
• ●Weakness, speech, vision, fits, neck (if asked): "His speech is normal, his face looks the same, and he's walking about without any trouble and using both hands. He hasn't had a fit or a funny turn. His eyes are fine, no double vision. He hasn't said anything about his neck."
• ●Why he fell (if asked about dizziness, blackouts, heart racing): "He just tripped. The path has been loose for months and I've told him to get it fixed. He wasn't dizzy and he didn't black out. He said his heart was fine. He's had a couple of near trips on that path before, but he's never fallen."
• ●Apixaban (if asked about his tablets): "He takes one apixaban in the morning and one in the evening, five milligrams. I fill his weekly pill box on a Sunday so I know he's not missed any. He had last night's at about half past seven and this morning's with his breakfast at about eight. He's had them for three years since they found his irregular heartbeat."
• ●Other tablets and drink (if asked): "Ramipril, a statin, and paracetamol. No aspirin or anti inflammatories. No drink since the weekend."
• ●Bleeding or head history (if asked): "No head injury before, no brain operations, no bleeding problems. He just bruises easily."

Ideas, Concerns, Expectations

Gating note: Eileen does not raise any of these 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 believes Leonard has had a knock that has bruised him, and she knows blood thinners make everything bleed more. She does not know that a problem inside the head can develop slowly. "I thought it was just a big bruise, but he's on those tablets, so I wasn't sure."
• ●Concerns: She is frightened that something might be going on that nobody can see from the outside. A man from Leonard's darts team, Colin, knocked his head on a cupboard door and was dead within the week. She is also anxious about being caught between Leonard's temper and her own worry. "Colin from his darts team had a bang on the head, and he was gone within a week. I keep thinking about it, and Leonard won't hear a word."
• ●Expectations: She hoped the doctor would tell Leonard what to do, or perhaps send someone to look at him at home. She does not expect to be told he needs to go in. "Can't somebody just come and have a look at him? He'd listen to you."

If Asked: Medical History and Medications

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

• ●Heart, kidneys and general health: "He has the irregular heartbeat, blood pressure tablets and a bad right hip. His blood tests are always fine."
• ●Allergies: "None."
• ●Memory generally: "He's sharp as a tack. He does the crossword and the accounts."

Social History and Lifestyle Impact

• ●Home: Eileen and Leonard live alone in the bungalow. Eileen is with Leonard all day and will be with him tonight. Their daughter Sian is a three hour drive away.
• ●Transport: Eileen drives, a small car, and has the keys. The hospital is about 25 minutes away. Leonard still drives but has not today.
• ●Leonard's reasons for not going: He once waited nine hours in the emergency department when he fell and hurt his hip, and he swore he would never go again. He also fears being kept in and told to stop his tablets.
• ●Speaking to Leonard (if the doctor asks): She goes out to the shed. When she returns, she says Leonard does not want to come to the phone, but he says he will speak to the doctor if the doctor insists. He is not confused and he understands what is being asked.

If Asked: Associated Symptoms

Gating note: Eileen answers these only when asked. Every one is negative unless stated.

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  If asked about numbness, pins and needles, weakness in an arm or leg, drooping of the face or slurred speech: "No, nothing like that."

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  If asked about fluid or blood from his nose or ears, or bruising behind his ears or around his eyes: "No, nothing like that. Just the bruise on his forehead."

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  If asked about neck pain or any other injury: "No. He's got a sore right knee, but that's his arthritis and it isn't from the fall."

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  If asked about his walking or balance since: "He's walking normally." Responses to Management (The Negotiation Phase)

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  If the doctor explains that he needs to go to hospital today for a scan:

  • ●Reaction: Taken aback, then anxious. "Today? But he looks fine. Why does he need a scan if he's walking about and eating?" She accepts a clear explanation that a bleed can build up slowly, especially on a blood thinner, and can show no signs at first. "So it's about the tablets, not the bump?" She asks, "Will they keep him in?" and "Will it be another nine hours?"
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  If the doctor asks to speak to Leonard, or asks Eileen to explain the plan to him:

  • ●Reaction: Nervous. "He won't like it. He'll say I'm making a fuss." She goes to speak to him and comes back with his objections: the long wait, being kept in, and being told to stop his tablets. If the doctor has already spoken to him directly and explained, she says, "He's grumbling but he's put his shoes on."
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  If the doctor suggests watching him at home, or offers a routine appointment:

  • ●Reaction: Relieved but unsure. "Oh, that would be easier. What do I look out for?" If the doctor explains this is not safe because the scan cannot wait, she agrees. "I didn't think so. It's been bothering me."
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  If the doctor says the hospital will be told he is coming:

  • ●Reaction: Reassured. "So they'll know he's coming and why? That might make him feel better. Should he take his evening tablet?" She wants to know what to do about the apixaban and whether to bring anything.
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  If the doctor gives safety netting:

  • ●Reaction: Wants specifics. If it is vague, such as "come back if he gets worse": "Worse how? What would mean I ring an ambulance?" She repeats back the signs clearly if they are given and says whether she can take him in her own car or must call an ambulance.
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  If the doctor discusses the apixaban or what happens after the hospital visit:

  • ●Reaction: Worried. "Will he have to stop the apixaban for good? I'd hate him to have a stroke because of this." She is relieved to hear the fall does not by itself mean the tablets must stop, and that the hospital will advise on the next dose. If the doctor mentions painkillers: "He only takes paracetamol. Can he carry on with that?"