Gen Med Station 1

Setting:

You are a junior doctor working in A+E. This patient presents with a headache.

Name: Malcom Smith

Tasks:

1. Take a history from the patient.

2. Review the initial investigations.

3. State your preferred diagnosis and reasoning to the examiner.

4. Give your initial management plan to the examiner.

You are not required to examine the patient.

Briefing

Diagnosis: SAH presenting with a headache
You are Malcom Smith (aged 71)
You have come to ED with a headache.

Appearance and Behaviour

As the patient you should be acting like you are very much in pain currently.

Opening statement

“I’ve had this headache for about 6 hours now, it’s really really painful. I can’t cope with it, please can you help me, Doctor?”

Information to Give Freely

It started 6 hours ago, I remember because I was doing my shopping and it just hit me. I had to leave my shopping and walk home. Oh gosh I don’t feel well, Doctor, please help me.

Presenting Complaint

Site - headache localised to the back of the head (occipital region).
Onset - sudden onset, it felt like I had been hit in the back of the head. No trigger or history of trauma.
Character - dull ache with throbbing pain.
Radiations - no radiation, stays localised to the back of the head.
Associated symptoms -

photophobia (it's very difficult to look at the lights, I want to be in a dark room)

stiff neck (quite mild, I just find that when I turn it’s a bit sore)

nausea (since the pain came on, but I have NOT vomited)

Timing - It was the worst right at the start (in the first 1-2 minutes), but then it slightly decreased in intensity, but it is still very painful. It’s stayed consistent since then.
Exacerbating/relieving factors - The lights and moving my neck feels uncomfortable. I haven't noticed anything else that is making it worse.
Nothing is making it better, paracetamol didn’t help at all.
Severity - it was a 10/10 when it started, now it’s probably about an 8/10. It’s still really painful.

Past Medical History

Previous similar episodes - nil
Other medical conditions - Osteoarthritis in both knees, atrial fibrillation
Previous surgeries - nil

Drug History

Prescribed - warfarin. For AF - you have been on this since 2012, but have NOT attended dosing blood tests for about 3 months. Unsure which dose you are on currently or what your last INR was (if they ask).
If the doctor ask you why you have not been to your warfarin blood tests say "I don’t see the point in going for them when I have been on warfarin for so long."
Over the counter - occasional paracetamol and ibuprofen for your arthritis.
Allergies - None

Family History

Father had a stroke at the age of 65. He did not die, but was left disabled and passed away 1 year later. You are unsure of any other details.

Social History

Smoking - 10 cigs/day for about 50 years. You are not interested in cutting down - “life is too short”.
Alcohol - 4-5 units/week (2 pints of beer/week).
Job - Unemployed
Exercise - Very active and enjoy gardening and golf.
Daily life - I live in a house with my wife. We have 2 children who have moved out but are close by. We are both independent in daily activities with no carers. No mobility aids.

Systems Review

Neuro - headache (see PC). NO loss of consciousness/change in sensation/change in movement/visual changes.
General/red flags - No fevers/weight loss/night sweats
ENT - No dizziness/hearing loss/tinnitus.
Cardio - palpitations (gets these off and on due to my AF, but has not had any in the last month). No chest pain/ankle swelling/orthopnea.
GI - some nausea
No other symptoms

Ideas / Concerns / Expectation

Ideas - “I think it could be a migraine but I’m not sure”
Concerns - “I’m worried that it might be something awful like my father’s stroke”
Expectations - “Please can you do something for the pain, Doctor?”

Discussion / Questions

If they ask you if you have any questions, then ask “What do you think is going on Doctor? Is it a stroke?”.

Please interpret these results

Name: Malcom Smith

Age: 71

Date of Results:

Observations
NEWS	0
Respiratory Rate	18
Heart Rate	89
Blood Pressure	128/75
Oxygen Saturation	98% on Room Air
Temperature	36.9
GCS	15

Blood	Results	Normal Range
Hb	141 g/L	135 - 180
Platelets	298 x109/L	150 - 400
White Cells	6.7 x109/L	4 - 11
CRP	3 mg/L	<5
Sodium	137 mmol/L	135 - 145
Potassium	3.9 mmol/L	3.5 - 5
Urea	6.0 mmol/L	2 - 7
Creatinine	65 umol/L	55 - 120
eGFR	>60	>60
Bilirubin	>8 umol/L	>3 - 17
ALT	>25 iu/L	>3 - 40
ALP	>74 umol/L	>30 - 100
INR	>8.1	>Target 2.5