Presenting Complaint

Headache
Cough
Rash on right arm

History of Presenting Complaint

Headache ongoing for the last three months, intermittent, occurring two or three times a week.
Normally triggered by high stress, associated with photophobia.
Normally has to stay in a dark room, some nausea but no vomiting, each episode lasts about four to five hours.
Has taken paracetamol but finds it increasingly ineffective.
Cough ongoing for the last few weeks, worse over the last week.
Dry cough, no phlegm, no hemoptysis.
No SOB, no wheeze, mild sore throat, feels feverish but no recorded temperature.
Yesterday developed a small rash on the right arm, not painful, not tender to touch, not itchy, has not spread any further.
Patient otherwise well, no dizziness, no fainting episodes, no drowsiness, no confusion.
Patient attended today worried about the combination of symptoms and thinks they may be related.
No new medications recently.

Observations

Patient alert, speaking in full sentences.
Temp 37.2
RR 18
O2 95%
HR 80
BP 140/60

On Examination

Pupils equal and reactive.
Facial nerve motor and sensory functions intact.
No photophobia on examination.
On ophthalmoscopy, no papilledema.
No neck stiffness.
Chest is clear, heart sounds normal, throat is normal.
Moving all four limbs normally.
Rash on left arm, small papular rash, mild erythematous blanching, appears more like a viral type of rash.

Plan

Discussed with patient possible migraine headache and possible recent chest infection.
For migraine, advised to continue paracetamol 1g PO QDS.
Prescribed sumatriptan 50mg to take at the onset of headache. Can take another dose after one hour if the initial dose helps with symptoms, otherwise do not continue.
Prescribed amoxicillin 500mg capsules, take one capsule three times a day.
Follow up in two weeks.
Rest and keep hydrated.

Safety Netting

If symptoms are not improving or deteriorate, contact surgery again within the next 48 hours.
If symptoms deteriorate with SOB, worsening cough, chest pain, or any other deterioration, contact 111 or 999.

Recordings

Original (A8) — Play recording

Audit

Presenting Complaint

Headache [1]
Cough [1]
Rash on right arm [1]

History of Presenting Complaint

Headache ongoing for the last three months, intermittent, occurring two or three times a week. [2]
Normally triggered by high stress, associated with photophobia. [3]
Normally has to stay in a dark room, some nausea but no vomiting, each episode lasts about four to five hours. [4]
Has taken paracetamol but finds it increasingly ineffective. [5]
Cough ongoing for the last few weeks, worse over the last week. [6][7]
Dry cough, no phlegm, no hemoptysis. [7]
No SOB, no wheeze, mild sore throat, feels feverish but no recorded temperature. [8]
Yesterday developed a small rash on the right arm, not painful, not tender to touch, not itchy, has not spread any further. [9][10]
Patient otherwise well, no dizziness, no fainting episodes, no drowsiness, no confusion. [10][11]
Patient attended today worried about the combination of symptoms and thinks they may be related. [12][13]
No new medications recently. [14]

Observations

Patient alert, speaking in full sentences. [15]
Temp 37.2 [16]
RR 18 [16]
O2 95% [16][17]
HR 80 [17]
BP 140/60 [17]

On Examination

Pupils equal and reactive. [17]
Facial nerve motor and sensory functions intact. [17][18]
No photophobia on examination. [18]
On ophthalmoscopy, no papilledema. [18]
No neck stiffness. [18][19]
Chest is clear, heart sounds normal, throat is normal. [19]
Moving all four limbs normally. [19]
Rash on left arm, small papular rash, mild erythematous blanching, appears more like a viral type of rash. [20][21]

Plan

Discussed with patient possible migraine headache and possible recent chest infection. [21][22]
For migraine, advised to continue paracetamol 1g PO QDS. [22][23]
Prescribed sumatriptan 50mg to take at the onset of headache. Can take another dose after one hour if the initial dose helps with symptoms, otherwise do not continue. [23][24]
Prescribed amoxicillin 500mg capsules, take one capsule three times a day. [25]
Follow up in two weeks. [26]
Rest and keep hydrated. [27]

Safety Netting

If symptoms are not improving or deteriorate, contact surgery again within the next 48 hours. [26][27]
If symptoms deteriorate with SOB, worsening cough, chest pain, or any other deterioration, contact 111 or 999. [28]

References

[1] Patient has been having headache, also tender with cough and also a rash in the right arm.

[2] Headache has been ongoing for the last three months, intermittent, happens two or three times a week,

[3] normally triggered when he's highly stressed, feels a bit of photophobia with the headache,

[4] normally has to stay in a dark room, a bit of nausea, no vomiting, normally each episode lasts about four or five hours.

[5] has taken paracetamol but finds it increasingly ineffective to treat the headache.

[6] Also having cough, this has been ongoing for the last few weeks,

[7] worse than over the last week. Coughing up, it's a dry cough, no phlegm, no hemoptysis,

[8] no shortness of breath, no wheeze, mild sore throat, feels feverish but no recorded temperature.

[9] yesterday developed rash small rash on the right arm not painful not tender to

[10] touch not itchy has not spread any further patient otherwise well no

[11] dizziness no fainting episodes no drowsiness no confusion has attended

[12] today has worried about symptoms a combination of symptoms things they may

[13] thinks it may be related.

[14] No new medications recently.

[15] On examination patient alert, speaking full sentences.

[16] Temperature 37.2, respiratory rate 18, oxygen 92,

[17] 95 sorry not 92 Heart rate 80 blood pressure 140 over 60 pupils equal and reactive facial nerve motor

[18] and sensory functions intact, no photophobia, on ophthalmoscopy, no papilledema, no neck

[19] stiffness, chest is clear, head sounds normal, throat is normal, moving all four limbs normally,

[20] examine rash on left arm, small papular rash, mild erythematous blanching, rash appears

[21] more like a viral type of rash. Discuss with patient possible migraine, headache, also possible

[22] recent chest infection. For migraine, advise patient to continue paracetamol one gram four

[23] times a day. Also prescribe simutriptan 50 milligrams to take at the onset of heartache.

[24] Can take another one after one hour if the initial dose helps with symptoms, otherwise do not continue

[25] a so-prescribed moxicillin 500 milligram tab the capsules take one capsule three times a day

[26] and then follow up in two weeks time if symptoms are not improving or deteriorates to contact

[27] surgery again in in the next 48 hours otherwise rest keep hydrated

[28] And then if symptoms deteriorate, shortness of breath, worsening cough, chest pain, or any other deterioration, contact 111 or 999.