Gen Med Station 8

 

Station 8

A headache

 

Candidate Instructions

Setting:

You are a Foundation Year doctor working in the AMU. This patient has presented with a headache.


Jeremy Colins


Tasks:

1. Take a history from the patient.

2. Request investigations to the examiner

3. Interpret the results to the examiner.

4. Give your initial management plan to the examiner.

Simulated Patient Instructions

Briefing

Diagnosis: Bacterial Meningitis
You are Jeremy Collins, age 22.
You have been referred to AMU from the GP with a headache.

Opening statement

“My GP sent me in because she seemed to be worried about my headache.”

Information to Give Freely

I’ve had a headache for about 28hrs, and it seems to be getting worse. I’m finding it hard to concentrate at university. I’m aching all over, all my muscles seem to be sore.

Presenting Complaint

Site - Headache felt throughout head, no specific sites. ‘Hurts all over’.
Onset - Yesterday, it came on fairly quickly and has been getting worse.
Character - Pulsing/throbbing and severe. Eye pain.
Radiations - Feels like the headache is spreading towards my neck, neck hurts.
Associated symptoms -
  • I’m feeling quite tired and unable to concentrate.
  • All of my muscles feel achey and sore, as if I have the flu.
  • I feel quite hot.
    • Timing - Can’t tell if there’s a time of day that’s worse, seems to gradually be getting more painful.
    Exacerbating/relieving factors - Paracetamol and ibuprofen haven’t helped. Can I have some morphine?
    Severity - Began as a 5/10 now closer to 8/10

    Past Medical History

    Previous similar episodes - Nil
    Other medical conditions - Asthma, hayfever.
    Previous surgeries - Appendectomy 5 years ago.

    Drug History

    Prescribed - Salbutamol inhaler.
    Over the counter - Paracetamol and ibuprofen for the pain
    Allergies - Nil
    Recreational drugs- Uses cannabis irregularly

    Family History

    Nil

    Social History

    Smoking - smokes 5/day, usually socially on nights out
    Alcohol - drinks 10 units in one sitting regularly. Does not have a daily drinking pattern. Last went out 3 days ago and drank lots has been feeling rough since.
    Home - Lives in shared accomodation with flatmates. No one else is sick. Normally fully independent.

    Systems Review

    General/red flags - Fevers and lethargy
    Neuro - No focal neurology
    Resp - Nil
    Cardio - Nil
    GI - Nil
    GU - Nil
    Joints - Nil

    Ideas / Concerns / Expectation

    Ideas - “I think i've maybe overdone it on the drinking”
    Concerns - “None”
    Expectations - “I'd like some painkillers and to go home.”

    Discussion / Questions

    Can I go home?- The candidate should be able to effectively communicate the need for this patient to remain in hospital for further tests. They can offer suggestions of serious pathology that needs to be excluded. This should be done in a calm way.

    Start the Timer and Begin

    Intro

     

    Presenting complaint

     

    Obtains clear history of presenting complaint, establishing:

    Past Medical History

     

    Drug History

     

    Family History

     

    Social History

     

    Systems Reviews

     

    Ideas, Concerns, Expectations

     

    Examiner Instruction

     

    At this point please direct the candidate to give their initial investigations.

    Investigation

     

    Examiner Instruction

     

    At this point please direct the candidate to interpret the following investigations.

    Diagnosis & Management

     

    Summary

     

    Learning points;

    1. The classic triad of fever, neck stiffness and altered mental status only occurs in approx 45% of patients.

    2. Headache presents in 87% of cases.

    3. Take blood cultures before antibiotics ideally.

    4. LP should not delay giving antibiotics when clinical suspicion of meningitis is high.

    5. LP’s are contraindicated if there is a clinical risk of cerebral herniation; this can be indicated by dropped GCS, papilloedema, focal neurology, and seizures. This is why a careful clinical examination is key.

    Submit for Scoring

    Tags | Neuro and neurology | Bacterial Meningitis | Headache

    Station Written by: Dr Megan Burns

    Peer Reviewed by: Dr Polly McGrath

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