MR C Gpcs A Courses Cases Over Use Headache

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CSA course case
CANDIDATES BRIEF
Patient medical records Name: Jessica Bentley (54 year old)
Past medical history: Hypertension Drug history: Co-codamol 30/500 2 qds
Last consultation (6months ago) Patient complaining of headaches has tried ibuprofen and paracetamol and has not helped. Denies visual symptoms. Started on cocodamol review 1 month to see if symptoms improving.
DNA medication Review (5 months ago) Doctors note (1 months ago) Patient DNAed medication review. Repeat medication stopped. Patient too book appointment if still needs cocodamol.
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Contact us: csaprep123@gmail.com visit us www.csaprep.co.uk CSA course case - Medication overuse headache - CSA prep 2011
CSA course case Medication overuse headache

You are Jessica Bentley, a 54 year old Headmaster
ACTORS BRIEF
Approach: You are appropriately dressed, well spoken, however, you are initially very upset and angry as your medication was stopped without your knowledge. You are very busy and simply want a repeat prescription to leave and are pushy to get it. You can be very difficult and closed initially. However, if doctor is appears warm, empathic and enquires about the causes of the headaches (i.e. stresses) then you will open up. You do not open up immediately and are a challenge Opening statement: I want to know why my painkillers were stopped without anyone telling me!
History Open history: You are a busy headmaster who is responsible for the whole school affairs. You have had to cancel an important meeting with the school directors to make time to meet the doctor today. You attended last week to pick up your medication and found out to your dismay that they have been stopped. You are acutely annoyed that it was stopped without your knowledge (i.e. no letter), but not interested in an official complaint. You would accept the doctors apology (if the doctor does not apologise you can remain difficult). You say you want the tablets as they simply work and do not want to already waste more time then necessary.
Reveal history if asked: You complain of almost daily headaches for the last 6 months that feels like a pressure on the front of your head. You wake up with the headache first thing and it lasts the whole day. It is a dull ache, not throbbing in nature, moderate intensity 4/10 in severity There are no neurological features with the headache. You have had your eyes test and you do not need glasses. The headache does not wake you up from sleep, you do not vomit. It does not change in nature when you lean forward, and there are no warning signs that they are coming. The headaches get better after taking the medication but after 6 hours come back. You find that taking the medication (2 tablets every 6 hours) helps the headache. You do not think you have a problem with overuse of your medication.
Individualised feedback from course facilitators & CSA actors on your performance You are stressed at work as you are responsible for the whole school. You have a number of staff off work due to maternity leave or long term sickness and have been working long hours to organise cover. You have not had any time off work or been able to have a holiday as it has been so busy. You are unable to take time off work You recently had some relationship problems and do not wish to discuss them (you are persistent not to go into this) You had a miscarriage two years ago and have not really got over it since. You believe that you may have become a workaholic to compensate You feel overburdened buy everything and have low mood but are not suicidal. You sleep late but you believe the tablets help a bit to make you sleep You are surprised if told your headaches can be caused by medication overuse You are keen to continue with the medication and worry that taking ibuprofen or paracetamol will not treat your headaches. You do not want to stop taking the medication immediately as have an important meeting coming up with directors and worry headaches will interfere with it. You are happy to stop them after the meeting if advised to do so. You are open to reducing the medication over a period of time or given an alternative medication (paracetamol, ibuprofen) intermittently to wean you off. You are open to talking therapies Counsellors. Etc, headache diary
Past medical history You are fit and have no other medical problems
Drug history You are only on cocodamol 30/500, 2 tablets four times a day. You do not have any drug allergies.
Social history You do not smoke or drink alcohol.
Family history There is no family history
CSA course case - Medication overuse headache

DATA GATHERING Positive indicators:
EXAMINER
Use open questions to explore the patients problem (stress, miscarriage) and closed questions to clarify possible causes of the symptoms and excluding red flag symptoms i.e. nausea & vomiting, sudden onset, very severe, drowsiness Offers to undertake a targeted examination: BP, cranial nerves Does a brief depression screen
Negative indicators: Doctor adopts a checklist approach and fails to ask open questions Questioning is not sufficiently detailed to exclude red flag symptoms and potential causes i.e. migraine, tension headache Makes immediate assumptions about the illness Is disorganised or unsystematic in gathering information The physical examination is not requested or insufficiently targeted i.e. requests to check blood pressure
INTERPERSONAL SKILLS Positive indicators: Apologises that patient was not given prior notice of medication stoppage i.e. via letter Gives reasons as to why medication was stopped Explores the causes of he headache in an empathic way. Sensitively broaches the subject with the patient about concerns of link between medication overuse and headaches Adopts a non-confrontational approach if patient persists with position. However should not be coerced into simply prescribing a repeat prescription to diffuse the situation Attempts to negotiate an agreed plan to ideally stop medication or reduce dose.
Negative indicators: Fails to acknowledge patient verbal and non-verbal cues Instructs the patient rather than seek common ground
Individualised feedback from course facilitators & CSA actors on your performance CLINICAL MANAGEMENT SKILLS: Positive indicators: Recognises likely diagnosis of medication overuse headache. Considers tension headache as a differential Offer to stop them altogether rather than try to cut down gradually. However alternatively reduce cocodamol over period of time after important meeting if necessary (not best practice but to negotiate with patient) Negotiates and discusses relaxation techniques, time off work, exercise, talking with friends and family Offers headache diary Can offers counselling/talking therapies Performs brief depression screen Adequate follow up is arranged with observation of warning symptoms
Negative indicators: Decision on whether to prescribe are inappropriate Decision on whether to refer is inappropriate. Does not negotiate management plan i.e. insists on stopping medication immediately Unable to enhance patients coping strategies The examination request of the problem is inadequate or poorly targeted Follow up arrangements are inadequate
No examination required
CARDS

FOCUSED HISTORY
APPROACH
Take a brief headache history. Ensure that you start off asking several open questions before asking a select few closed questions such as: Site Severity Onset Character Relieving Aggravating Timing Differentials Migraine Meningitis Raised ICP Tension Sinusitis Eyes Arteritis Red flags Sudden onset of severe pain (thunderclap), blurring of vision, focal neurology, head injury, change in personality, signs of meningitis, drowsiness, scalp tenderness, seizure, wakes up from sleep Medical History Migraines, hypertension, strokes, angina, epilepsy? Medical History Nitrates, calcium channel blockers, codeine (i.e. cocodamol) Family History Migraines, brain tumours Have you had a throbbing headache? Any visual symptoms (flickering lights, spots, zig-zag lines, fortification spectra? Have you had any fever, rash, neck stiffness? Do your headaches wake you up in the morning? Are they worse on sneezing, coughing or standing up? Do you feel sick or nauseous? Have you been under a lot of stress recently? Are the headaches worse when you lean forwards? Have you had your eyes tests? Are your headaches worse on chewing food, combing your hair? Where exactly is the pain? unilateral/bilateral/always same side? How severe is the pain (pain score)? When did you first notice the pain? When did it first start? How would you describe the headache (sharp, dull, throbbing pain)? Does anything make the pain better (standing, lying, posture)? Does anything make the pain worse (stress head movements, coughing)? How long does the pain last for?
Social History Smoke Alcohol Dietary Stress Do you smoke? How many a day and for how long? Do you drink alcohol? How much per day? Do you eat a lot of cheese, chocolate, yoghurts? Do you drink tea/coffee? Have you had any recent increase in stress levels?
PHYSICAL EXAMINATION Vitals Eyes Rheumatology Neurological MSK MANAGEMENT Diary Migraine Headache diary Advise the patient to avoid triggers. Treat with analgesics (paracetamol, ibuprofen, aspirin) +/- antiemetics (i.e. paramax, migraleve). Consider triptans. Prophylaxis (>1 per month beta-blockers i.e. propranolol) Manage stress reassure, talking therapies, relaxation techniques, exercise. Consider paracetamol or NSAIDS, avoid opioids i.e. cocodamol (risk of overuse) Initially 100% oxygen, sc sumatriptan 6mg, nasal lidocaine. Avoid alcohol during headaches. Prophylaxis: verapamil 240-960 mg daily. Attempt to stop medication completely BP Examine eyes : fundi Palpation temporal arteries for tenderness Perform focused cranial nerve examination and neurological assessment Examine the neck for muscle tenderness and stiffness (tension)
Tension Cluster Medication overuse
MX NOTES
Medication overuse headache is often caused by taking simple painkillers too often to treat pain or a headache like a migraine. They can be the cause of daily headaches. The solution is to stop taking the medication as soon as possible. Whilst this may initially worsen your headache for one or two weeks it should later get better. Symptoms & features Common cause of chronic daily headaches affecting more than 15 days in the month Affects 1 in 50 people with female more than men (5:1) Commonest cause codeine or codeine based medication (i.e. co-codamol)
Individualised feedback from course facilitators & CSA actors on your performance Other implicated medication: aspirin, NSAIDS, triptans Often occurs after treatment of migraine / tension headache
Management Triptans and simple analgesia ideally be stopped immediately. However can worsen headache initially (up to 7-10 days but can be week/months). Opioid based analgesia can be gradually weaned off Alternative approach is to give short course of NSAIDS whilst stopping causative medication (if NSAIDS not the cause) Can give antiemetic to treat nausea (withdrawal symptom)

The GMC advice regarding writing reports
MANAGEMENT
You must be honest and trustworthy when writing reports, and when completing or signing forms, reports and other documents. You must do your best to make sure that any documents you write or sign are not false or misleading. This means that you must take reasonable steps to verify the information in the documents, and that you must not deliberately leave out relevant information. If you have agreed to prepare a report, complete or sign a document or provide evidence, you must do so without unreasonable delay.

MR C Gpcs A Courses Cases Over Use Headache

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CSA scenarios with REAL CSA actors AsclosetotheCSAexamaspossible

CSA course case

Patient medical records Name: Jessica Bentley (54 year old)

Past medical history: Hypertension Drug history: Co-codamol 30/500 2 qds

CSA scenarios with REAL CSA actors AsclosetotheCSAexamaspossible

CSA course case Medication overuse headache

CSA scenarios with REAL CSA actors AsclosetotheCSAexamaspossible

Social history You do not smoke or drink alcohol.

Family history There is no family history

CSA scenarios with REAL CSA actors AsclosetotheCSAexamaspossible

CSA course case - Medication overuse headache

CSA scenarios with REAL CSA actors AsclosetotheCSAexamaspossible

CSA scenarios with REAL CSA actors AsclosetotheCSAexamaspossible

CSA course case - Medication overuse headache

CSA scenarios with REAL CSA actors AsclosetotheCSAexamaspossible

CSA course case - Medication overuse headache

CSA scenarios with REAL CSA actors AsclosetotheCSAexamaspossible

Tension Cluster Medication overuse

CSA course case - Medication overuse headache

CSA scenarios with REAL CSA actors AsclosetotheCSAexamaspossible

CSA course case - Medication overuse headache

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