Headache: For the benefit of Step 2 CS candidates.

A 18 yr old Black female Jessica comes to you with a complaint of  headaches.

Vitals are as follows -  BP 124/84 mmHg . Temp 98.6 F;  R.R 20/ min ; H. R 88/min

Simulated Encounter

Before you enter the room, make a  mental note for DD and write down patient's name name on paper

Knock before you enter but need not wait to get permission to enter.

"Hello, Ms Jessica Good Morning, My name is Dr. Hastings…Nice to meet you. How are you doing today? What brought you in today?
Jessica: Doc I am having  headaches?
Doc: How long have you been having  headaches for? Jessica: For the past few hrs
Doc: Do you remember how it started? Or when did you first feel the pain or notice it?(onset) Jessica: It started suddenly
Doc: How do you describe pain ? is it intermittent or a constant pain? Jessica: Its intermittent
Doc; Can you please show me exactly where the pain is? (Location)  Jessica: forehead
Doc: Does the pain go anywhere else? (Radiate) Jessica : No
Doc: what were you doing before you noticed the headache? Jessica: I was studying for my exam
Doc: On scale of 1-10 (1 being the least pain possible and 10 being the most pain possible), which level would say  your pain is? Jessica: Its 6-8/10
Doc: Is there anything that makes your pain better or relieves it?  Jessica: Yes, staying in a dark room
Doc: Is there anything that makes your pain worse? Jessica: Light and moving here and there
Doc: Have you had any nausea or vomiting? Jessica: nausea yes but not vomiting (very little nausea)
Doc: have you ever had this type of pain before?  Jessica: Yes, few times in the last two months.
Doc: When you get these headaches, how long do they last, do you get to know that you are going to have a headache? (Asking primordial / premonitory symptoms)  Jessica: No
Doc: Do you have any blurring or double vision now?  Jessica: No
Doc: Is it affecting your daily activities?   Jessica: Not really.
Ask question below very quickly and give an opportunity for  the SP to reply.
Doc: Ok let me ask you some other questions. I will go through a list of symptoms - if you have any, stop me and let me know. Do you have any fever, Chills, Neck stiffness, watering in eyes, nasal discharge? Jessica: no doc
Doc: Have you had any head injury/trauma? Have you had any weakness in your arms and legs or sensory changes like numbness or tingling?
Always ask or say some thing in transition before moving to other topic
DOC: I am going to ask you about your Past Medical History. (PMH) Jessica : Sure.
Doc: Do you have any other medical problem? High Blood Pressure, Blood Sugar, Thyroid problems, etc… (Multi organ disease) Jessica: No
Doc: Have you ever been hospitalized over night before? Jessica: No
Allergy
Doc: Are you allergic to anything? Like substance or medicine. Jessica: Yes I am allergic to Penicillin
Medication
Doc: Are you taking any prescription or over the counter medications? Jessica: No
Doc: Have you ever taken recreational drugs/Do you do any drugs? Jessica: No - only what I get from the doctor if I am sick anytime. Or may say that I take some vitamins - (then take vitamin/herbals history)
Doc: Do you use birth control pills? (Hormonal contraceptive) Jessica: No
Family history (FH)
Doc: Please tell me a  little bit about your family members your parents and siblings? Does in any one of your family have headaches? Or any other illness which runs in family? Jessica: Every one is fine. No one in my family complains of headaches - as far as I know.
Social History (SH)
Doc: What do you do for a living? Jessica: I am a student and my parents support me.
Doc: Do you smoke …….smoked? Jessica: I never smoked.
Doc: do you drink Alcohol? (If yes how much and how often and type whisky, rum, or beer?) Jessica: Yes, I do drink on weekends with my friends. Generally 1-2 beers.
Sexual History (Cautious before you ask)
Say something like: Being your doctor I would like to ask you some personal questions about your sexual history. As you know, it remains confidential.
Doc: Are you sexually active?  Jessica: Yes, I do have sex with my boy friend.
Doc: Have you changed your sexual partner in last six months? Jessica: No, I am with my boy friend for last two years.
Doc: Is there any problem in your sexual life? Jessica: No
Physical Examination:
Wash your hands, and take consent before you do any examination.
Fundoscopy or Otoscopy exam is very important (you need not be good enough to pick out abnormalities but must know the method)
Systemic exams (very brief)
Complete Neurological exam and MMSE.
Counseling and Discussion:
Tell the subject patients about few possible diagnosis (never give confirm diagnosis), talk about investigations and further work plan.
Call the patient by name and acknowledge discomfort.

Mnemonics to remember patterns of interviews/examination. You may jot them down on your rough paper sheet
SCP PAD F GAS = Social Chief Present Past Allergy Drugs Family   General Active Systemic
Why social before anything else? In a non distressed patient, it is nice to know the person. 
In the Distressed patient it is first better to know the medical problem.
CP PAD FS GAS = Chief Present Past Allergy Drugs Family Social   General Active Systemic
In a life threatening state know the allergy so that you do not harm the patient in case of loss of consciousness. The examination and history in such a patient can/should be going on concurrently.
ACP GAS PDF S   = Allergy Chief Present Past Drugs Family Social   General Active Systemic

Differential Diagnosis and brief discussion about each.

Investigations
Migraine - typically young, females > males, nausea, +/- vomit, photophobia, audiophobia, disrupts work, transient neurological phenomenon. DOC - Imitrex/other triptans.

Tension Headache - depression, tense situation, bilateral, fronto-occipital,

Cluster headache - unilateral, peri-orbital, nocturnal, frequent/daily for a few days. DOC - O2, Demerol.

Sub arachnoid hemorrhage (CVA) - Sudden - "Thunder-clap" headaches. Worst headache of lifetime, with or without neurological deficit, PMH HTN

Sinusitis - facial pain, stuffy nose, fever, nasal discharge,

Tumor/ pseudo tumor - Excessive vitamin A intake

Meningitis, temporal arteritis, Refractory errors

 CBC differential - abnormal in infections, polycythemia, hyperviscosity

ESR - Temporal arteritis, sinusitis, other infections

CRP - elevated in infection but not in TA

Sinus X-ray

CT brain without contrast - Hemorrhage is better without contrast.

CT with contrast - shows tumors and possibly inflamed areas

LP if febrile

MRI Brain if no abnormality found in above

MRI C-spine

Things written in this color should not be written in the exam sheet but are here to explain the relevance of each item.

What should you do if a patient who is in a lot of pain asks you for treatment even before you have made a diagnosis? For instance someone with severe abdominal pain or headache or chest pain etc
Members access Key pointers, the answer to this and a lot more....