Headache 1

Name: George Green

Age: 20 Years Old

Date of Birth: 1st January 2004

Location: GP Clinic

Occupation: College Student

I've recently visited the college’s clinic. (Offer if asked)

Vital signs showed: 

• Heart rate : 140 beats per minute, regular rhythm, strong volume

• Respiratory rate : 18 breaths per minute 

• Blood pressure : : 150/100 mmHg 

• SpO2 : 100% under RA

• Temperature : 37°C

“I have been having headaches for the past 1 month”.

• Site : Whole head (if questioned, around my head) 

• Onset : 1 months ago, first time

• Character : Throbbing and aching 

• Radiating : Non-radiating 

• Associated symptoms :

  • Palpitations, intermittent, comes with the headache 

  • Develops hot flushes and sweating, intermittent 

• Timing : Persistent, last for a maximum of 5 minutes  

• Exacerbating : None (symptoms suddenly occur) 

• Alleviating factors : Pain relieved with OTC paracetamol. Temporary relief. 

• Severity : 7/10

• Red flag symptoms :

  • No fever, neck stiffness, nausea, vomiting (▲meningitis) 

  • No thunderclap headache, worst headache of his life (▲TIA)

  • TRO other secondary causes of hypertension 

• Otherwise, NO fever, lost of weight, loss of appetite (constitutional symptoms) 

• No signs suggestive of Hyperaldosteronism, Hyperthyroidism, and Cushing's Syndrome

  • Hyperaldosteronism : Muscle weakness (d/t hypokalemia) 

  • Hyperthyroidism : Sweaty, tremors, anxiety, sensitive to heat, exophthalmos,
    weight loss

  • Cushing syndrome : Weight gain, buffalo neck, central obesity, moon face,
    abdominal striae

• Previous episodes: Never experienced this before.

• Ideas: “I don’t know!”

• Expectations: “Please help me doctor?”

• Concerns: “Do I have something serious?”

• NO chest pain

• NO vomiting, diarrhea, abdominal pain

• NO weakness of upper limbs and lower limbs.

• Normal urinary flow and bowel habits.

Previous hospital admissions: None

Previous surgeries: None

Medical conditions: None

Medications:

• None

Over the counters:

• Paracetamol for the headache. Only temporary relief.

Allergies:

• None.

Everyone in the family is healthy and well.

• Smoking: Does not smoke

• Alcohol: Does not drink alcohol

• Recreational drugs: Never

• Diet: Always eat takeaway food

• Exercise: Sometimes jogging 

• Ill contacts: No one around me was recently ill

• Home: Lives in the college dorm

• Active Daily Living: Study and attend lectures

• Occupation: College Student. Finds it stressful but manageable. No abnormal sleep changes.