Presenting Complaint

Recurrent headache
Mild photophobia

History of Presenting Complaint

Patient presents with headache for the last two months, occurring two or three times a week.
Normally triggered when sitting at the computer.
When it happens she experiences photophobia and pain in light, has to stay in a dark room.
Headache lasts for a couple of hours.
Associated with a bit of nausea, no vomiting.
No problems with sounds.
Patient has taken paracetamol with mild improvement but not complete resolution.
No other symptoms, no weakness in arms and legs, no facial droop, no slurring of speech.
No fever, no cough, no sore throat, no flu like symptoms.

Observations

Patient alert.
Temp 37.2
RR 18
O2 98%
HR 80
BP 139/70

On Examination

Pupils equal and reactive.
Facial nerve preserved, motor and sensory function intact.
No papilledema.
Grossly normal power in upper and lower limbs.
Grossly normal sensation.

Plan

Prescription for sumatriptan 50 milligrams, one at onset of headache. Can take another 50 milligrams if there is improvement, otherwise stop.
Metoclopramide for nausea, maximum three times a day as required.
Continue paracetamol one gram, up to maximum four times a day.
Follow up in seven days.

Safety Netting

If deteriorates, contact 111 or 999.

Audit

Presenting Complaint

Recurrent headache [1]
Mild photophobia [1]

History of Presenting Complaint

Patient presents with headache for the last two months, occurring two or three times a week. [1][2]
Normally triggered when sitting at the computer. [2][3]
When it happens she experiences photophobia and pain in light, has to stay in a dark room. [3][4]
Headache lasts for a couple of hours. [4]
Associated with a bit of nausea, no vomiting. [4]
No problems with sounds. [4]
Patient has taken paracetamol with mild improvement but not complete resolution. [5]
No other symptoms, no weakness in arms and legs, no facial droop, no slurring of speech. [5][6]
No fever, no cough, no sore throat, no flu like symptoms. [6][7]

Observations

Patient alert. [7]
Temp 37.2 [7]
RR 18 [7]
O2 98% [8]
HR 80 [8]
BP 139/70 [8]

On Examination

Pupils equal and reactive. [9]
Facial nerve preserved, motor and sensory function intact. [9]
No papilledema. [10]
Grossly normal power in upper and lower limbs. [10]
Grossly normal sensation. [10]

Plan

Prescription for sumatriptan 50 milligrams, one at onset of headache. Can take another 50 milligrams if there is improvement, otherwise stop. [11][12]
Metoclopramide for nausea, maximum three times a day as required. [12][13]
Continue paracetamol one gram, up to maximum four times a day. [13][14]
Follow up in seven days. [14]

Safety Netting

If deteriorates, contact 111 or 999. [14]

References

[1] Headache, mild photophobia. Patient presents with headache for the last

[2] two months, occurs two or three times a week, normally triggered when she's sitting at the

[3] computer. When it happens she feels a bit of photophobia or pain in light, has to stay in

[4] a dark room headache lasts for a couple of hours a bit of nausea no vomiting no problems listening

[5] to sounds um patient has taken paracetamol mild improvement not completely no other symptoms no

[6] weakness in arms and legs no facial droop no slurring of speech no fever no cough no sore

[7] throat no flu-like symptoms or examination patient alert temperature is 37.2 respiratory for 18

[8] oxygen of 98 um heart rate of 80 blood pressure 139 over 70.

[9] pupils equal and reactive facial nerve preserve motor and sensory function

[10] no papilledema uh grossly normal power up and lower limbs and grossly normal sensation

[11] uh so much time prescribed prescription for sumatriptan 50 milligrams um one onset of headache

[12] and then can take another 50 milligrams if there is improvement otherwise stop cyclobenzaprine 50

[13] milligrams with nausea maximum three times a day as required uh continue pressing metoclopramide one gram

[14] up to maximum four times a day follow up in seven days 15 and if deteriorates contact 111-1999