Gen Med Station 4

 

Station 4

A headache

 

Candidate Instructions

Setting:

You are a junior doctor working in GP/family medicine. This patient presents with a headache.


Name: Sheila Johnstone


Tasks:

1. Take a history from the patient.

2. State your preferred diagnosis to the examiner.

3. Explain to the patient any need for further investigation.

You are not required to examine the patient.

Simulated Patient Instructions

Briefing

Diagnosis: Space Occupying Lesion
You are Sheila Johnstone, aged 63.
You have presented to the GP with a headache.

Opening statement

“Hello there Doctor, I’ve come to see you because I’ve got this terrible headache, please can you help me?”

Information to Give Freely

I’ve had a really bad headache for the past couple of months. It is very painful and I need some painkillers- my usual ones just aren’t cutting it anymore.

Presenting Complaint

Site - headache felt across the front of my head.
Onset - it’s been getting steadily worse over the past 3 months. This morning it was particularly bad.
Character - quite dull and achy, can’t get away from the pain.
Radiations - ometimes I feel it behind my eyes.
Associated symptoms -
  • This morning the headache was so severe that it made me vomit, I’ve vomited twice today.
  • Everytime I vomit the pain is excruciating.
  • I have been feeling dizzy and losing my balance the last few months.
    • Timing - it’s usually worse in the mornings
    Exacerbating/relieving factors - it seems to be better if I lie down. It feels worse when I vomit, open my bowels, or cough.
    Severity - it was a 10/10

    Past Medical History

    Previous similar episodes - I have been having headaches for the past 3 months. They seem to be getting more frequent and more painful. I thought I was just stressed with my husband being unwell.
    Other medical conditions - hypertension, hypercholesterolaemia, obesity.
    Previous surgeries - total hip replacement (L) following a fall 1 month ago. (Fell due to dizziness - which they said the GP would look into but i’ve not heard from them yet)

    Drug History

    Prescribed - Paracetamol 1000mg QDS, Atorvastatin 20mg nocte, Lisinopril 5mg
    Over the counter - Nil
    Allergies - Penicillin

    Family History

    Nil

    Social History

    Smoking - ex smoker- gave up 20 yrs ago. Previously 10 per day for 10 yrs (5 pack years).
    Alcohol - Occasional glass of wine
    Home - Fully indepenent, carer for your husband who has a recent diagnosis of Parkinsons Disease.

    Systems Review

    General/red flags - loss of appetite with weight loss (5kg in 2 months), lethargy, irritability. NO fevers or malaise.
    ENT- paroxysmal dizziness, NO hearing loss.
    Neuro - No loss of consciousness, no change in sensation. You have had some vision changes (general blurring).
    Resp - Nil
    Cardio - Nil
    GI - nausea and vomiting
    GU - Nil
    Joints - Nil

    Ideas / Concerns / Expectation

    Ideas - “I think it could be a migraine.”
    Concerns - “I need to get home so I can look after my husband.”
    Expectations - “Please can I get some morphine so I can go home and get on with things?”

    Discussion / Questions

    The candidate will suggest that further imaging is required in hospital. When this is suggested, initially insist you just want to stay home and that this is nothing but “a bad migraine”.
    If they explain the possibility of a lesion intra cranially, take them seriously and agree to get it looked at.
    If they don’t show empathy then look visibly upset and worried.
    If the candidate states you need a scan to investigate for a lesion ask “does this mean I have a brain cancer doctor?”

    Start the Timer and Begin

    Intro

     

    Presenting complaint

     

    Obtains clear history of presenting complaint, establishing:

    Past Medical History

     

    Drug History

     

    Family History

     

    Social History

     

    Systems Reviews

     

    Ideas, Concerns, Expectations

     

    Examiner Instruction

     

    At this point please direct the candidate to give their main differential diagnosis.

    Diagnosis & Interpretation

     

    Other acceptable differentials include any causes of raised ICP including; hydrocephalus, aneurysms, chronic brain bleeds, idiopathic intracranial hypertension, malignant hypertension, CSF infections (meningitis and encephalitis). Given the red flag symptoms, a space-occupying lesion should be high on the differential list and needs ruling out.

    Examiner Instruction

     

    At this point please reveal that the senior GP partner has requested an urgent CT head in the hospital to rule out a possible space-occupying lesion, they have asked you to explain this to the patient, they are being referred on the 2-week wait pathway. Please proceed.

    Explaining Skills

     
       
    ? The candidate should be able to explain to the patient their rationale for the scan. They should be able to clearly communicate their concerns and why this scan should not wait. They are not expected to definitively diagnose an intracranial tumor and break this as bad news, but the patient should be aware this is a differential that needs excluding as a matter of urgency.

    Summary

     

    Unfortunately despite your careful counseling, your patient missed their initial CT scan. They later attended ED with new left-sided neglect which developed after they saw you. The MRI below shows their result. A large right-sided cerebral lesion is seen which explained their symptoms of increased intracranial pressure. Raised ICP headaches are typically worse in the morning, and with coughing/laughing/posture changes/raised intra abdominal pressure They are also associated with vomiting. These are red flags you should ask when considering differentials in a headache history.

    Submit for Scoring

    Tags | Neuro and neurology | space occupying lesion | Headache

    Station Written by: Dr Megan Burns

    Peer Reviewed by: Dr Benjamin Armstrong

    Want to suggest an edit?

    Comment below and we'll get right to it!