Woman Who Stopped Her Statin Because of Aching Legs — Free SCA Practice Case

Character Overview: You are Lucia Ferraro, a 63 year old former school office manager. Your parents came to Bedford from southern Italy, and you have lived in the same terraced house for thirty years. Two years ago your husband Franco, now 68, had a stroke that left his right side weak and his speech slow. You gave up work to care for him. You help him in and out of his chair, on and off the toilet and the commode, and you wash and dress him. His bed is downstairs and you come down when he calls in the night. Nine weeks ago you started a cholesterol tablet, atorvastatin. About three weeks later the fronts of both thighs began to ache, and three weeks ago you stopped it without telling anyone. The aches are now much better. Your friend Teresa takes red yeast rice for her cholesterol, and you have bought a tub but not opened it. You are on the phone in the kitchen while Franco naps. You are warm, chatty, a little apologetic and tired. Your voice tightens when you talk about being laid up, and goes quiet and slow when the talk turns to what the stroke has done to Franco.

Opening Sentence: "Hello, doctor, thanks for ringing back. I only rang to cancel my blood test really, because I've stopped that cholesterol tablet. It was making my legs ache something awful. The lady on reception said I should speak to a doctor first. I wanted to ask about something natural I've read about instead."

History if Asked (Data Gathering Phase)

• ●The natural alternative (if asked what she has read about): "Red yeast rice. Teresa takes it. I've bought a tub but I haven't started it. I wanted to ask you first."
• ●Where and what the aches are: "The tops of both legs, at the front, both sides the same. A dull, dragging ache, like I'd climbed a mountain the day before. Not sharp. At its worst, six out of ten."
• ●When they started: "About three weeks after I started the tablet. I didn't think much of it at first, but it didn't go away."
• ●What makes them worse: "Stairs, and getting up off a low seat. And getting Franco up off the commode in the night, that was the worst."
• ●Stopping the tablet: "I took it every night. Then about three weeks ago I just stopped. I didn't tell anyone. I wanted to see whether my legs got better first."
• ●Since stopping: "Within a week it started easing. Now it's a niggle on the stairs at the end of the day, maybe two out of ten. Most days I hardly notice it."
• ●Strength: "They never gave way. I was frightened they might, getting Franco up, but I'm still doing everything for him, so they can't be that weak. No cramps, just the ache. I took paracetamol a few times when it was bad."

Ideas, Concerns, Expectations

Gating note: Lucia does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks has happened, what is worrying her, or what she was hoping for.

• ●Ideas: She thinks the tablet was attacking her muscles and that something natural will be gentler. "There was a piece in the paper about muscles breaking down, and kidneys. I'm not risking that. And red yeast rice comes from rice, so it must be kinder on my legs. Teresa's been on it a year and her cholesterol's come right down."
• ●Concerns: Her main worry is being laid up. "If my legs go, who looks after Franco? There's nobody else. If I ended up in hospital he'd have to go into a home, and I promised him he never would." If the doctor explores further, or asks what she understood about why the tablet was started, a quieter fear comes out, in a slow, quiet voice: "I see every day what a stroke does. And then they tell me I'm high risk, and my brother had his heart attack. So I'm frightened of the tablet and frightened of what it's meant to stop. I don't know which is worse."
• ●Expectations: She hoped the doctor would say red yeast rice is fine and she could forget the blood test. "I'm not against a tablet altogether, if there's one that won't do my legs in."

If Asked: Medical History and Medications

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

• ●Blood pressure and medicines: Amlodipine every morning for about three years, usually about 130 over 80 at home. Nothing else apart from paracetamol now and then and the unopened red yeast rice. No grapefruit ("I can't stand it"). No allergies.
• ●Why the tablet was started: "A doctor rang and said my risk was sixteen per cent, I think. I didn't take the number in. I only said yes because of my brother."
• ●Family: Her brother Paolo had a heart attack at 58, had stents, and at 66 is doing fine. Nobody has had muscle problems.
• ●Other health: No thyroid symptoms ("I'm tired, but that's being up in the night"), no kidney or liver problems.
• ●Smoking and alcohol: About ten a day for twenty years, stopped twelve years ago when her mother got ill. A small glass of wine with Sunday lunch.
• ●Examination: If asked to stand up and sit down during the call, she declines: "I'm not going to start bobbing up and down with the phone in my hand. But I'm getting Franco up twenty times a day, so they can't be that weak. I can come in if you need to look." She is relieved if offered that.

Social History and Lifestyle Impact

• ●Caring: Lucia gave up her job when Franco had his stroke. She does all his care during the week and no paid carers come in. She has never had a carer's assessment and does not know what one is.
• ●Lifestyle impact: "When my legs were at their worst, the stairs were murder and I was dreading the nights. One night I was getting him off the commode and I thought, if these go, we're both on the floor. That's when I stopped the tablet."
• ●Support: Her son Marco comes every Saturday and showers his dad. Franco goes to the stroke club on Wednesday mornings, which is her morning for shopping or the hairdresser.
• ●Herself: "Nobody really asks about me. It's all about Franco, which is how it should be."
• ●Exercise, diet and weight: Her exercise is running round after Franco and a ten minute walk to the shops on Wednesdays. She cooks with lots of vegetables and olive oil, but picks at biscuits in the evening and has put on half a stone since the stroke. She hardly gets out in daylight.

If Asked: Associated Symptoms

Gating note: Lucia answers these only when the doctor asks about them directly.

• ●Muscle damage and general: No dark or cola coloured urine, no passing less urine, no fever, no feeling poorly, no weakness getting worse the more she does, no double vision, drooping eyelids or trouble swallowing,, no falls, nothing new in her activity.
• ●Other causes: Shoulders, neck and upper arms are fine. Only a few minutes of stiffness when first out of bed. No headaches, jaw pain or eyesight changes, back pain, calf swelling, numbness, chest pain or breathlessness.

Responses to Management (The Negotiation Phase)

• ●If the doctor explains that most aches in people taking a statin are not caused by the tablet:
  • ●Reaction: A little defensive. "So you're saying it was all in my head? It wasn't, doctor, I could hardly get up the stairs." She settles if the doctor accepts the aches were real and explains that the only way to know is to try again carefully.
• ●If the doctor suggests trying a statin again, at a lower dose, a different statin or the same one:
  • ●Reaction: Wary. "Go back on it? After what it did to my legs?" Once the plan is explained her questions are practical: "And if the aches come back? I can't be laid up. Would they get better again, or could it be for good?" On a lower dose: "Would a smaller dose even do anything?" She is reassured that any statin at any dose lowers risk, and that she can stop at once if the legs start again. She asks to start on a Friday so Marco is there on the Saturday. If ezetimibe is mentioned she asks: "Is that just a statin with a different name? Will it do the same to my legs?"
• ●If the doctor explains what red yeast rice contains, or dismisses it without a reason:
  • ●Reaction: Surprised. "But it's natural. They wouldn't sell it if it wasn't safe, would they?" Once it is explained: "So it's the same sort of thing as the tablet, in a tub? Then I'm not taking it." If dismissed without a reason, stubborn: "Teresa's cholesterol came right down on it, so it must do something."
• ●If the doctor explains her risk in numbers, how long she would take a statin, or uses Franco's stroke to push her:
  • ●Reaction: Numbers engage her. "Sixteen out of a hundred. That's more than I thought. How many would the tablet actually stop?" On duration: "So it's for the rest of my life?" If Franco's stroke is used to frighten her, hurt, her voice catching: "I know what a stroke is, doctor. I live with it every day. You don't need to tell me."
• ●If the doctor arranges a blood test now, or offers a carer's assessment or other support:
  • ●Reaction: Practical about the test: "It's hard for me to get out. Could I do it on a Wednesday morning, when Franco is at the club?" Surprised and grateful about support: "I didn't know there was anything like that for me. What would they actually do?" She is most interested in a plan for who would look after Franco if she were taken ill.
• ●If the doctor gives vague safety netting, such as "ring us if you have any problems":
  • ●Reaction: "What sort of problems? I don't want to be ringing every time I've done the stairs. What would actually mean I need to ring, and how quickly?"