Scenario 4 - Awkward patient and antibiotics

Hello. Is that Mr Smith?

Hello mate.

Hello Mr Smith, my name is Shawn, I am one of the urgent care practitioners from the doctor's out of hour service. I am just ringing about your call this evening. Before we go any further Mr Smith, can you just confirm your full name and date of birth, so I know I have got the right notes in front of me.

Name is Mark Smith.

Yes.

Date of birth, 15/4/1960.

I have got your details in front to me Mr Smith, now I can see that you have rung this evening, you have got some ongoing problems with your ear and you have...

Ongoing?

Yeah, have you had a couple of courses of antibiotics for this ear problem, is that right?

It ain't do nothing.

Which ear is it? Your left or right? Sorry.

Me right ear.

Right ear, Okay.

My GP is shit.

Let me just try and clarify a couple of points first, Mr Smith and then we will see what we can do.

All I want is antibiotics, mate. Just give me some antibiotics, I will get off the phone, I will collect them from my chemist, and we will get rid of it that way.

Okay, I understand what you are asking of me Mr Smith but unfortunately, the chemist... There is not many chemists open now, because it is overnight. Let me do an in-depth assessment and then we will try and decide what we need to do for you. And I need to know a little bit more detail about your ears, you say your right ear is the problem, is it painful?

Yep.

Any discharge at all from your ear?

No. There was a discharge but I have not got any discharge at the moment.

Okay. And have you banged your head or banged your ear specifically?

No, they told me if I had anything like that, it is my ear and I need some tablets for it.

Okay, if you touch your right ear, does it feel warm to the touch on the outside bit?

As it has done for the last three weeks. Yes.

Okay, and if you feel behind your ear where the ear meets the skull, if you press down there at the lower part, is there any pain around the back of the ear?

No.

So there is no pain there.

Are you going to give me any tablet stuff because I am wasting my time?

Well, you are not wasting your time because we are gonna get the most appropriate treatment, I just need to probe a little bit further to make sure we are going down the right avenue, to be honest, Mr Smith. Which antibiotics have you taken so far?

Amoxicillin?

Amoxicillin.

And another one beginning with F. And neither of them worked.

Flucloxacillin?

I am not having any more of them. Do not bother.

Was it Flucloxacillin, the other one?

Sounds about right, yeah.

Okay. And when you were given these, did the doctor actually look at your ear?

That is it mate. Nobody has seen me. I phone up, they give me tablets and they do not work, nobody wants to say... I have told you, mate, the GP is a pile of shit.

Okay, so you have not been seen by your own GP and he has given you two courses of antibiotics now. Yeah? And they not seem to be working?

Nothing is working. That is why I am phoning you.

Understand that. Can you just tell me if you have been taking any pain relief, at all Mr Smith?

Yeah, they do not work.

What have you been taking?

Paracetamol, Co-codamol and Ibuprofen.

Okay. And Ibuprofen, yeah? You have not been taking... Can I just you have not been taking the Paracetamol and the Co-codamol at the same time, have you?

I cannot take them together... The twat, the chemist told me that.

Okay, because they have got Paracetamol in both, that is correct. Can I just ask you about your previous medical history as well, Mr. Smith?

Nothing. I am alright. I am alright. I have worked all my life, mate.

And any allergies at all?

No.

And who do you live with at your home address, Mr Smith, please?

With my wife.

And is she with you at the moment?

She is in bed. She always goes to bed early.

Okay, and are you working at the moment? Normally fit and active?

I am not working, mate. All I am calling you for is some tablets for me ear.

I understand that.

That is all I want.

So I can see from what you telling me, Mr Smith, that you have got a problem with your right ear at the moment and it is not responding to two courses of antibiotics. The issue we have got at the moment is, you have not been seen by the only healthcare professional to actually look in your ear. Is that correct?

Nobody has seen me, I have told you.

Okay, I think what we need to do, Mr Smith, is we need to actually see you face-to-face tonight. I would like...

Well, that is not going to happen because my doctor is shut. Do not see anybody.

Yeah. Well, we are the out of hours doctors and we have got an urgent care centre open this evening, we can see you and somebody could look in your ear and make sure that the care you are getting is most appropriate. We could also look at the level of pain relief that you are taking. And if it is Mr Smith, that you come to us and the doctor or the practitioner is not happy with the findings of the ear inspection, we will be able to refer you across to the ENT services across in the hospital itself. If I arrange an appointment for you and I know it is not what you want to hear this evening because you think you will benefit from the third course of antibiotics. But what my concern is you have been taking these now for two weeks at least and you are not getting any relief at all and there may be something more sinister going on. I would really appreciate if you came to the centre and we actually looked in your ear.

So you are telling me. You are telling me, I have had two lots of antibiotics and now you are telling me, I have got to get in my car, drive down there, I have got to wait, which will probably be four hours because you know the way it is and then you are going to see me. You are going to poke and prod in my ear and then you are going to send me to another doctor.

Let me just stop you, Mr Smith. First of all, you will not be crossing the ED so you will not be waiting for four hours. You will come on an appointment system. You will come into the centre, at an appropriate time, we will see you in that time slot, and then we will give you the most appropriate care following the assessment and if we need to refer you, we can do. I think what we need to remember, Mr Smith is, you have not seen your own doctor yet, so this would be really beneficial to see one of our clinicians. And I know you are quite frustrated, I can tell from your voice, but I am more concerned with making sure that this problem is actually responding to medication and nothing more sinister is going on. So can I put you down for a centre appointment this evening?

Well, where is it?

It is at the Royal Stoke Hospital, opposite the emergency department.

Well, I am in Cannock.

I am afraid that is the only centre that is open at the moment and I really do need you to be seen tonight, I am afraid, Mr Smith.

I will definitely get tablets, yeah?

I cannot say you will get tablets... Maybe, if it is more sinister, you will get referred across to the main hospital, but I cannot stress enough on you, how important this is that we look inside this affected ear tonight. So I would really urge you to come for this appointment. If you cannot get in to see your own GP, at least you are going to be seen by a clinician tonight. So can I make... Can I get somebody to ring you back with an appointment time, Mr Smith?

When are they phoning me back, then?

They will ring you back within the next 10 minutes.

Alright.

Okay, so if you keep this line clear now, Mr Smith, somebody will ring you for an appointment slot, tell you what time to be at Stoke for. If there is any problems before you get to this appointment, you must ring us back on 111. That is if anything changes or the pain becomes more worse and you decide to use another alternative open to you such as going to the emergency department, but if we do not hear from you, then we will assume that you are coming to this appointment, to the Royal Stoke Urgent Care Centre tonight. Is that okay for you, Mr Smith?

Alright, where am I going then?

The Royal Stoke... The Royal Stoke University Hospital, North Midland, which is at Stoke on Hilton Road. Do you need the postcode at all for your SATNAV?

Hang on, let me get me phone out. Alright. Yeah. Okay.

So you know where you are coming to. It is immediately opposite the emergency department where the ambulances park. It is down from the grass bank opposite... It is a bungalow set back there. If you cannot find us, ring 111 and they will direct you to where we are. Okay?

Righto.

And then we will get you seen tonight. Thanks for calling Mr Smith anyway, I hope you go on alright.

Alright, thank you mate.

You look after yourself now, bye-bye.