• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a junior doctor in general practice

Patient: A 19 year old female patient has come in with headaches

Task:

– Take a focused history from the patient

– After 6 minutes you will be asked a series of questions by the examiner.

– Answer any questions that the patient may have

Note to actor: Try to restrain yourself from volunteering too much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested. The aim of the exercise is to take a focused history; short answers are required.

You are a 19 year old university student who is now in the third year of study. You have come into see your doctor because you have been experiencing headaches about 6 months ago but they have no been more frequent and more severe.

You only give information if prompted:

  • You do not have the headache at the moment
  • The headaches occur on the right hand side and are sharp / throbbing in nature
  • The headaches come on suddenly
  • You have been having a couple of attacks a week for the last couple of months
  • When they do come on the pain is a 10/10, you become very nauseous, feel dizzy and you do not like bright lights
  • You have noticed that laying down in a dark room and sleeping helps with the headaches
  • You have noticed that coffee and feeling more stressed brings on the headaches
  • You have been taking paracetamol and ibuprofen for the pain but this does not really help

You have noticed before the headaches start you have some strange zig-zag lines at the corner of your vision about 20 mins before the headaches start.

ICEF

You are really stressed about the headaches as you have not been able to attend lectures and you are worried you will not be able to pass the year with your attendance. You are scared about leaving the house if these headaches come on.

PMH
No ongoing medical issues

No previous operations

DH

Microgynon 30

No known drug allergies

SH

You stopped smoking about 4 months ago

You drink about 20 units per week

You live with 3 of your friends, they are very supportive

University is stressful at the moment as it is your final year and you have a lot of exams and assignments

No recreational drug use

If the candidate appears to have finished early remind them how long is left at the station and enquire if there is anything else they would like to ask, or whether they have finished. If they have finished, please remain silent and allow the candidate that time for reflection.

Category Question
Done
Excellent
Introduction Candidate appropriately introduced themselves with:
Full name
Medical school / year / grade
Clarifies who they are talking to
Asks patient for preferred name


PC Presenting complaint
Site of pain
Onset - acute / chronic
Length of duration of headache
Character - throbbing / sharp
Radiation - none


Presenting complaint extended
Relieving factors - dark room, sleep
Exacerbating factors - coffee, stress
Severity - 10/10
Timing - last couple of months, twice per week


Presenting complaint extended
Visual symptoms - zig-zag lines
Nausea and vomiting
Trauma - no


Red flags
Neck stiffness / rash
Decreased level of consciousness
Sudden onset, worst headache ever / ‘clapping headache’
Seizure or neurological deficit
Reduced visual acuity
Headache worse when laying down with early morning nausea


Constitutional symptoms
Weight loss
Night sweats +/- fever
Loss of appetite


PMH Past medical history
No past medical history
No previous operations


DH Drug history

Microgynon 30
No known drug allergies
No recreational drug use


SH Social History
Alcohol
Smoking
Job / education
Living situation


FH Family history
Family history appropriately asked about


ICEF
Explores ideas, concerns, expectations, feelings


Question Given your history, what are your differentials?
Migraine with aura
Cluster headache
Tension headache
Medication overuse headache
Space occupying lesion
Meningitis
Sub-arachnoid headache
Temporal arteritis
Trigeminal neuralgia
Other appropriate answer


Question What examination/s would you like to do?
Blood pressure
Temperature
Observation for rash
Neck stiffness
Palpation of temporal region
Upper limb neurological examination
Lower limb neurological examination
Visual examination including - fundi, visual acuity, gait


Questions Are any further investigations required in this patient?
No


Question What migraine assessment severity score is used in general practice?
Migraine disability assessment score


Question This patient wishes to try tablets for future attacks, what medications would you prescribe?
Triptan and example e.g sumatriptan (50-100mg PO)
Naproxen 500mg BD or Paracetamol 1G QDS
Antiemetic e.g prochlorperazine 5mg


Question What non-pharmacological measures can this patient take?
Psychological = stress reduction
Food = avoid foods and drinks that bring on episodes e.g alcohol, caffeine, chocolate, citrus fruits, cheese, red wine
Sleep = being overtired, changes in sleep patterns
Keep a diary for potential triggers


Question What medication can be used as prophylaxis for migraines?
Propranolol (1st line)



Score