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Name
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Josette Wolff
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DOB
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08/09/1990 (24 years)
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Occupation
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Teacher
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History
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I am a 24 year old female teacher who
had a really severe headache on one side, one week ago that lasted for 2
days. If asked directly, I admit to seeing flashing lights before the
headache started. During the headache I had to stay in bed and shut off the
lights because they made it worse and also put ear muffs on to block out the
noise which also made it worse. I also felt sick. I have never had this
headache before but my mother did suffer from migraine. I do enjoy chocolate,
wine and cheese but have not noticed that they trigger my headache. I do not
have neck stiffness, eye pain, watery eye, visual loss and the headache is
not worsened by lying down, coughing or sneezing. I do not have a fever,
rash, weakness of my arms or legs.
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Past Medical History
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Nil
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Drug History
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Contraceptive pill started 2 weeks
ago
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Family History
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Nil
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Social History
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I’m really worried that I had a bleed
in the brain like my friend Rachel did last year. Rachel passed away. I
don't smoke or drink or use recreational drugs.
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Introduces self
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0
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1
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Confirms name & age of patient
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0
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1
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Explains reason for consultation
& builds rapport
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0
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1
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Gains consent
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0
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1
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Asks open question
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0
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1
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Establishes site
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0
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1
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Asks about onset
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0
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1
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Elicits character of pain
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0
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1
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Asks if pain radiates (specifically
asks for next stiffness)
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0
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1
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Enquires about exacerbating factors
including coughing, straining, light, sound
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0
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1
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2
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Enquires about alleviating factors
including painkillers
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0
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1
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Asks about duration and changes to
pain over time
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0
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1
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Checks severity of pain
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0
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1
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Asks for nausea and vomiting
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0
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1
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Asks for rash and recent illness
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0
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1
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Asks for visual disturbances such as
loss of vision, zigzag lines, flashing lights or haloes
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0
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1
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Asks for any warning or aura before
headache
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0
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1
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Asks for any eye watering, discharge
and floaters
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0
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1
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Asks for triggers such as period,
stress, chocolate, cheese or wine
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0
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1
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Checks for loss of sensation,
coordination impairment, weakness, seizures
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0
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1
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Asks about past medical history
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0
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1
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Asks about any family history of
disease
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0
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1
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Establishes any drugs or over the
counter medication patient is on
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0
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1
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Asks if patient has any allergies
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0
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1
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Asks if patient smokes, drinks or
takes recreational drugs
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0
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1
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Elicits patients occupation
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0
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1
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Explores and responds to ideas
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0
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1
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Explores and responds to concerns
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0
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1
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Explores and responds to expectations
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0
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1
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Shows empathy
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0
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1
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Avoids jargon
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0
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1
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Summarises back to patient
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0
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1
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Thanks patient
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0
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1
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Patient global score
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0
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1
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2
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Gives reasonable differential
diagnosis (migraine, meningitis, tension headache etc.)
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0
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1
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