Jared's Headache

Name	Jared Roberts
DOB	12/01/1959 (55 years)
Occupation	Lawyer
History	I am a 55 year old male lawyer. The last week I have this sharp shooting pain on the right side of my face when I brush my teeth, talk, shave or even drink anything too hot or cold. It shoots from the corner of my mouth to the rest of my jaw. The pain lasts only a few seconds and it’s really painful (9 out of 10). There’s no other pain nor any other symptoms. I do not have pain in my chest, scalp or at my temples. I do not have a fever. The pain is so bad I have to hold my face when I talk to stop it occurring. It doesn't come on or worsen with exercise but it does get worse in the cold.
Past Medical History	I have never had my cholesterol checked. Nil else.
Drug History	Nil
Family History	Father and brother had heart attack at 50. Mother has diabetes.
Social History	I smoke 30 cigarettes per day for 20 years, drink around two glasses of red wine every night to protect my heart. I don’t take any recreational drugs. I am fairly active playing squash three times a week. I am worried I might be having a heart attack and keep asking if it could be. My father who had a heart attack attack when he was 50 had only jaw pain as a symptom. He has diabetes. My mother also has diabetes which was diagnosed last year. My 50 year old brother also had a heart attack last month.

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
Checks for associated scalp pain particularly on combing hair	0	1
Checks for jaw pain when eating and shoulder/hip muscle ache	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 or flashing lights	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 (trigeminal neuralgia, migraine, anxiety, atypical myocardial infarction etc.)	0	1

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