Who you are:
You are an FY2 in GP surgery.Who the patient is:
Dave, aged 39, presented with headache.What you should do:
Talk to the patient; take history, assess her and discuss the plan of management with the patient.
(Don’t forget to ask about stress in his life)
P1 (SOCRATES)
Doctor: How can I help you today?
Patient: I have a headache.
D: Tell me more about it? Where exactly do you have the pain? (site)
P: All over my head.
D: When did it start? (onset)
P: I have had it for the past 2 months.
D: What were you doing when you first began to feel this pain?
P: I was not doing anything. Usually, I have this headache after I come home from my work. (+ve finding)
D: Was it continuous or comes and goes?
P: It is continuous in the evening.
D: What type of pain is it? (character)
P: Dull.
D: Does the pain go anywhere? (radiation)
P: No.
D: Is there anything that makes the pain better?
P: After I rest it gets better.
D: Is there anything that makes the pain worse?
P: I don’t know.
D: Could you please score the pain on a scale of 1 to 10? With 1 being no pain and 10 being the most severe pain you have ever experienced. (score)
P: 5.
D: Apart from the headache, is there anything else?
P: No.
D: Anything else concerning you? (concern)
P: Nothing else.
DDs
D: Any problem with looking at light? (Meningitis, SAH)
P: No.
D: Would you consider this the worst headache of your life? (SAH)
P: No.
D: Any neck stiffness? (SAH)
P: No.
D: Any early morning vomiting or headache? (SOL)
P: No.
D: Any weakness in your body? (SOL)
P: No.
D: Any pain while chewing or combing hair? (GCA)
P: No.
D: Any history of any trauma to your head?
P: No.
D: Any red eye or watery eye? (Cluster headache)
P: No.
D: Do you see coloured haloes around light? (Glaucoma)
P: No.
+FLAWS
P2
D: Have you ever had this headache in the past?
P: No.
D: Have you been diagnosed with any medical condition in the past?
P: No.
D: Any other medical conditions like HTN, migraine and kidney disease?
P: No.
MAFTOSA
D: Are you taking any medications including OTC or supplements?
P: No.
D: Any allergies from any food or medications?
P: No.
D: Has anyone in your family been diagnosed with any medical condition?
P: No.
D: What do you do for a living?
P: I am a lawyer.
D: I hear it’s a stressful job, how do you find work?
P: Yes, it’s so stressful these days! I have a lot of cases. (+ve finding)
D: You mentioned that you have had this pain for the last 2 months, how this affecting your life?
P: It’s ok, I’m coping with it.
D: Does is it affect your work or daily activities?
P: No.
D: How’s your mood?
P: It’s fine thanks
DESA
D: Do you smoke?
P: Yes.
D: How much do you smoke?
P: I smoke 5 cigarettes a day on average. Been smoking for the past 3 years.
D: Do you drink alcohol?
P: No.
D: Tell me about your diet?
P: It is fine, pretty healthy I think.
D: Do you do physical exercise?
P: I don’t get time.
Don’t forget ICE
Examination
General physical and neurological examination.
Provisional Diagnosis:
From the chat we had (mention the positive findings) you told me that you have had a headache and the stress in your work is increasing, so I suspect you may be having a tension headache. Tension-type headaches are not life-threatening and are usually relieved by painkillers or lifestyle changes.
Management:
Senior.
Symptomatic.
-
Painkillers
– Painkillers such as paracetamol or ibuprofen can be used to help relieve pain. Aspirin may also sometimes be recommended. Children under 16 should not be given aspirin.
– If you’re taking these medicines, you should always follow the instructions on the packet.
– Paracetamol is usually the best choice if you’re pregnant. Do not take ibuprofen during pregnancy without speaking to us first.
– Medicine should not be taken for more than a few days at a time.
– If you are not getting better, we may prescribe for you more potent painkillers (such as medicines containing codeine, such as co-codamol).
– Taking painkillers over a long period (usually 10 days or more) may lead to medicine-overuse headaches developing.
– In some cases, an antidepressant medication called amitriptyline may be prescribed to help prevent chronic tension-type headaches. It does not treat a headache instantly but must be taken daily for several months until the headaches lessen. -
Lifestyle changes
– Relaxation techniques can often help with stress-related headaches. This may include:
• Yoga
• Massage
• Exercise or applying a cool flannel to your forehead or a warm flannel to the back of your neck.
– Preventing tension headaches
• If you experience frequent tension-type headaches, you may wish to keep a diary to try to identify what could be triggering them.
• It may then be possible to alter your diet or lifestyle to prevent them occurring as often.
• Regular exercise and relaxation are also important measures to help reduce stress and tension that may be causing headaches.
• Maintaining good posture and ensuring you’re well rested and hydrated can also help.
• Guidelines from the National Institute for Health and Care Excellence (NICE) state that a course of up to 10 sessions of acupuncture over a 5- to 8-week period may be beneficial in preventing chronic tension-type headaches.
Safety netting.
You should seek immediate medical advice for headaches that:
- Come on suddenly and are unlike anything you have had before.
- Are accompanied by a very stiff neck, fever, nausea, vomiting and confusion.
- Follow an accident, especially if it involved a blow to your head.
- Are accompanied by weakness, numbness, slurred speech or confusion.
These symptoms suggest there could be a more serious problem, which may require further investigation and emergency treatment.
Follow up.