Dwight's Headache

Name	Dwight Newman
DOB	13/08/1992 (22 years)
Occupation	English student
History	I’ve had a continuous headache today. The headache started gradually and has got worse; it is all over and feels dull and radiates down the back of my neck. I didn’t have any warning of the headache. If pressed, I admit to an untreated chest infection for a few days prior to onset of headache. The light makes it worse but nothing else changes it at all. If asked directly, I admit to a red spotty rash, which I haven't checked with a glass. I also have neck stiffness and fever. I tried paracetamol but that did not help. I do have nausea but it isn’t worse in the morning or when I strain myself whilst coughing/sneezing. I have no weakness or loss of sensation or have I lost consciousness. I have not travelled abroad recently nor have a history of trauma. No previous headache or other symptoms
Past Medical History	Nil
Drug History	Nil. Allergy to penicillin causing anaphylaxis.
Family History	Nil
Social History	I don't smoke or drink or have I ever taken recreational drugs. I just want some strong painkillers to go home with. I don't wanted to be admitted to hospital

Introduces self	0	1
Confirms name & age of patient	0	1
Explains reason for consultation & builds rapport	0	1
Gains consent	0	1
Asks open question	0	1
Establishes site	0	1
Asks about onset	0	1
Elicits character of pain	0	1
Asks if pain radiates (specifically asks for next stiffness)	0	1
Enquires about exacerbating factors including coughing, straining, light, sound	0	1	2
Enquires about alleviating factors including painkillers	0	1
Asks about duration and changes to pain over time	0	1
Checks severity of pain	0	1
Asks for nausea and vomiting	0	1
Asks for rash and recent illness	0	1
Asks for visual disturbances such as loss of vision, zigzag lines, flashing lights or haloes	0	1
Asks for any warning or aura before headache	0	1
Asks for any eye watering, discharge and floaters	0	1
Asks for triggers such as period, stress, chocolate, cheese or wine	0	1
Checks for loss of sensation, coordination impairment, weakness, seizures	0	1
Asks about past medical history	0	1
Asks about any family history of disease	0	1
Establishes any drugs or over the counter medication patient is on	0	1
Asks if patient has any allergies	0	1
Asks if patient smokes, drinks or takes recreational drugs	0	1
Elicits patients occupation	0	1
Explores and responds to ideas	0	1
Explores and responds to concerns	0	1
Explores and responds to expectations	0	1
Shows empathy	0	1
Avoids jargon	0	1
Summarises back to patient	0	1
Thanks patient	0	1
Patient global score	0	1	2
Gives reasonable differential diagnosis (meningitis, subarachnoid haemorrhage and non-classical (without aura) migraine etc)	0	1

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