Headache

Name: Linda Ward

Age: 58 Years Old

Date of Birth: 9th June 1966

Location: Accident and Emergency Department

Occupation: Secretary

“My head hurts so much, please do something about it. It feels like it’s about to explode”

• Site: At the back of the head.

• Onset: Started this morning.

• Character:  Extremely severe pain, pain peaked within a minute. If asked to further characterize the pain: “Felt like a huge clap of thunder in my head”.

• Radiation: Goes down the neck.

• Associated Symptoms: Nauseous, however has not vomited

• Time: Has not gone away since it started.

• Exacerbating and Alleviating Factors: Nothing makes it better or worse.

• Severity: Pain rated 10/10. Worst pain ever experienced.

• Precipitating Factors : Cannot think of anything that may have triggered these symptoms.

• Recent illness: None.

• Recent head trauma: None.

• Recent travel: None.

• Ideas: “Do I have brain cancer?”

• Expectations: “I have a feeling I might need some form of surgery, I mentally prepared myself for that as I made my way here.”

• Concerns: “Will I die from this? This feels way too severe to be something mild, please help me!”

• Bowel habits: Slightly constipated recently but otherwise normal.

• Urinary habits: Normal

• Appetite: Same as usual.

• Sleep: Usually sleeps poorly: “I am a very light sleeper.”.

• Weight: Been gaining some weight recently due to binge snacking as a result of stress from work.

• ENT: Normal

• Cardiology: Normal

• Ophthalmology: Vision feels a little blurry ever since headache started but unsure if this is because of the headache or something else at play.

• Previous hospital admissions: 

  1. Complicated chest infection 10 years ago, stayed in hospital for three weeks. Recovered completely after.

  2. Appendicectomy at the age of 24, uncomplicated, stayed in hospital for 2 days.

• Previous surgeries: Appendicectomy

• Medical conditions:

  • Hypertension. “I missed my last GP follow up. I was too busy with work.”

  • Type 2 Diabetes Mellitus

  • Right Knee Osteoarthritis

  • Liver cysts were found during a health check-up decades ago

• Medications:

  • Amlodipine and Ramipril for hypertension. 

  • Metformin for Type 2 Diabetes Mellitus. 

  • “I admit I have not been very disciplined with taking my medication. I have been too busy with work - I keep forgetting to take them.”

• Over the counters:

  • None

• Allergies:

  • Ibuprofen (makes me feel itchy all over)

Grandfather had a brain bleed many years ago. Sister has polycystic kidney disease. All other family members are well.

• Smoking: 10 cigarettes a day for the past 10 years. 

• Alcohol: A glass of whisky every night. Maybe two to three glasses on weekends.

• Recreational drugs: Never

• Diet: I cook at home, so I eat quite healthily.

• Exercise: Does not exercise at all.

• Ill contacts: No one around me were ill recently

• Home: Lives with husband and two daughters.

• Active Daily Living: Good mobility and able to perform daily functions normally.