Virtual Patient

Alice Wills

You are an FY1 doctor in the medical admissions unit where you are clerking patients who have been sent up by their GP, it is currently 10pm.

The nursing staff have asked you to see Alice wills next because she is complaining of a headache.

Alice Wills is a 27 year old postgraduate student at Edinburgh University. She lives with her boyfriend Rupert and dog, spot. She has been sent in by her GP with a headache.

What information would you like first?

Dear Doctor,

Thank you for seeing this 27 year old lady who complained of a sudden onset severe headache this afternoon which was associated with vomiting.

I would be grateful for your review and management.

Yours Sincerely Dr A. Jacks.

I normally get migraines but this headache is completely different. It came on suddenly at about 4pm, just out of the blue; it feels like a tight band around my head. It gets worse when I make a sudden movement and nothing seems to make it any better. This is the worst headache I have ever had.

“I have also been feeling really sick and vomited once.

I have migraines and normally get them about once a month, usually when I have my period. I generally get a blurring of my vision when I get the headache and it feels completely different from this one.

On examination her pulse is 84, RR 12, BP 127/70, oxygen sats are 98% on air. Respiratory, cardiovascular and abdominal examinations are normal. On neurological examinations you find no abnormality.

Given Alice’s History What is Your Most Likely Differential Diagnosis?

This is not the most likely diagnosis in this case as the patient thinks it is not like her normal migraine.

Good, given the sudden onset, the nature of the headache and the fact that it is associated with vomiting this is the most likely diagnosis.

There are some concerning features about the nature of Alice’s headache that would be suggestive of something more serious; for example the sudden onset and that fact that she has vomited.

What Investigations Would You Request?

Excellent, a CT head will look for any evidence of an intracranial bleed. The radiology registrar phones you with a verbal report of the CT scan:

The CT scan looks completely normal but it will be formally reported and verified in the morning.

Due to the description of the headache and Alice’s ongoing symptoms I do not think that it would be safe to discharge Alice home at the moment.

She is Asking for Pain Killers. What Analgesia Will You Prescribe?

Good this is an excellent choice for first line analgesia in a patient with a headache, if the headache is severe, it can be given regularly along with a stronger pain killer.

Normally in patients not controlled with simple analgesics moving onto a weak opiate is the next step. However in patient with headache we have to be careful with codeine as this can sometimes cause headaches.

Oramorph is a good analgesic to use in somebody with severe pain.

Good, Ibuprofen is a great simple analgesic that can be given regularly along with paracetamol and opiates.