Headache 2

Name: Benedict Cumberbatch

Age: 60 Years Old

Date of Birth: 1st February 1964

Location: GP Clinic

Occupation: Senior Sales Manager

“I have been having headaches for the past 2 months”.

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

• Onset : 2 months ago, first time

• Character : Throbbing and aching 

• Radiating : Non-radiating 

• Associated symptoms

  • Palpitations, intermittent, comes with the headache 

  • Occasional blurry vision, no obstruction of view, temporary 

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

• Exacerbating : Stress  

• 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, No sudden weakness (▲TIA)

  • TRO secondary causes of hypertension!
    

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

• No signs and symptoms suggesting secondary hypertension

  • Pheochromocytoma : Hot flushes

  • 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: Diabetes and High Cholesterol

Medications:

• Tab Metformin 500g BD, compliant

• Tab Simvastatin 5mg ON, compliant

Over the counters:

• Paracetamol for the headache. Only temporary relief.

Allergies:

• None.

Father and mother have high blood pressure. Diagnosed in their 40s. Compliant with medications. Siblings are otherwise healthy and well. 

Married with one child. Otherwise 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 with wife and children

• Active Daily Living: Work in the city centre

• Occupation: Senior Sales Manager. Finds it stressful to keep up with the younger peers.