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CSA course case CSA prep 2011

CSA course cases CANDIDATES BRIEF

Patient medical records

Name: Michelle Carter (17 year old)

Past medical history: Nil

Drug history: TriNovum






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CSA course cases Migraine ACTORS BRIEF

Background: You are Michelle Carter a 17 year old A-Level student, in a full-time education studying
English and Law
Approach: You are casually dressed, well mannered person but keen to get to the bottom of your
medical problem and will not accept a poorly thought out explanation
Opening statement: Hi doctor. Ive got a real headache!

History
Open history:
You are experiencing a nasty headache over the front of your head but cannot really put your finger on
it. It is more on the right than the left
It is intensely painful almost like an electric drill into my head
It is not throbbing exactly but does comes and goes and can last 2-4 hours at a time and occurs once
a week
You have tried taking paracetamol, ibuprofen and even aspirins but nothing touches it. When the
headaches are bad you can sometimes take so many aspirins tablets at once that you loose count.
Only then it comes close to reducing the headache
CUE: You can feel sick with them especially when you miss meals
CUE: The exams are piling up and you have been putting extra effort in studying for your exams

Reveal history if asked:
The symptoms have been going on for the last 6 weeks
You have been under a lot of pressure at college for the last 6 months since your mock A-levels have
not been up to scratch and you need to improve your grades from Cs to As quickly
You are keen to emulate your dad and become a lawyer
You sleep only 5 hours a day as you have been revising more and study very late. You have redbull
drinks to keep you up and alert, and take 2 coffees in morning so that you are ready in the morning for
your school shift
Your dad is keen that you perform well in your exams and go to oxford university like he did
The headaches get better after sleeping them off but this is affecting your revision timetable
The headaches do not wake you up from sleep and do not occur when you cough or sneeze
There is no fever, diarrhoea, flu like symptoms
You have had an eye test already last month and told you do not need spectacles

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Your periods are normal and the headaches are not related to your periods
You do not experience any blurring of vision, flashing lights or weakness or numbness in your head

Ideas: Your dad asked you to see the doctor as he wants to know why you are having so many
headaches. You are not sure why you are having these headaches either
Concerns: Your dad is worried about a brain tumour explaining why you have had it for so long. You
share his concerns
Concerns: You think you have taken at least 10 aspirin tablets and worried you are regularly
overdosing on them, you know that your dad takes them for his heart and he only takes one a day.
Expectations: You would like to referred to a neurologist or have an MRI scan to put your mind at rest

Medical history
You have no medical problems

Drug history
You take an oral contraceptive pill with no problems. You have been taking them for the last 6 months.
You have put your relationship on the back burner at the moment and not been intimate for a while due
to the pressures you are under

Social history
You do not smoke or drink alcohol
You are in a stable relationship and take your tablets regularly
You do not have any problems at school in terms of bullying
Your relationship with your dad is slightly strained. You hardly see him as he is at work all the time but
keen to emulate his achievements and make him proud
Diet: You are missing meals and now are snacking on chocolates to keep your sugars up for studying

Family history
You are not aware of any medical problems in your family including migraines. You know your dad has
a heart problem and takes aspirin for it but not sure what it is

If the doctor suggests stress or migraines, ask why are you having the headaches now and not
6months ago when youre mock A-level results came out which werent very good
If the doctor refuses to offer an MRI scan or neurological exam, enquire why
Accept disgruntlely a clear explanation of the headache and steps to address it i.e. analgesia
(sumatriptans, sleep hygiene, etc)

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Act surprised if the doctor suggests that the contraceptive tablets can make migraines worse

Migraines EXAMINER

DATA GATHERING
Positive indicators:
Gathers information regarding presenting complaint. i.e. nature of headache
Attempts to excludes other pathology i.e. brain cancer (worse on coughing, sneezing, walking)
Makes likely diagnosis of migraines
Request to perform a targeted examination i.e. focused cranial examination / neurological

Negative indicators:
Fails to identify based on probabilities a likely diagnosis of migraines / stress
Fails to take a history of precipitants diet, sleep, stress

INTERPERSONAL SKILLS
Positive indicators:
Develops good rapport with the patient for patient to feel comfortable to discuss health beliefs
Explores ICE (worried about cancer, exams, od on aspirin)

Negative indicators:
Fails to explore the social context of the symptoms i.e. exam pressures, expectations of dad to
succeed in exams
Adopts a confrontational approach regarding further investigations


CLINICAL MANAGEMENT SKILLS:
Positive indicators:
Offers lifestyle advice re: dietary (cut down chocolates, caffeine), advise about sleep hygiene and link
of diet and sleep in making headaches worse
Recommend relaxation techniques / talking therapies to the patient
Stress importance of regular meals and link with migraines with missing meals
Consider starting sumatriptans for the headaches or beta blockers as prophylaxis
Suggest to consider stopping the OCP or changing to alternative

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PLAYED BY MRCGP TRAINED CSA ACTORS. FOR ONLY 599

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CSA course case CSA prep 2011
Offer good explanation of why the patient symptoms are consistent with a migraine and also no
neurological symptoms or signs to suggest a brain tumour and that an MRI scan or referral not
currently recommended at this moment in time

Negative indicators:
Fails to offer adequate lifestyle advice
Fails to consider mediation to treat migraines
Fails to offer suitable explanation to the patient regarding their migraine
Organises inappropriate investigations or referral for the patient despite plausible explanation of his
symptoms

CARDS


Vitals
BP 110 / 73
Pulse 65 bpm
BMI 18



Examination
Cranial examination normal
Neurological and cerebellar exam
normal