You are an FY2 in general practice
Personal Details:
Name: Chloe Williams
Age: 23
Medical Record:
Past medical history: None.
Regular medication: None.
Allergies: None known.
Notes:
Chloe presents with a 5-day history of a frontal headache. She is concerned it might be something serious.
Task:
1. Take a focused history of her headache.
2. Address her concerns and discuss the likely diagnosis.
3. Explain the management plan.
Opening Sentence: “Doctor, I’ve had this awful headache for five days now, and I’m starting to get really worried.”
Open History (to give freely): “It’s this dull pain right at the front of my head. It feels worse when I bend over. I’ve tried taking paracetamol, but it doesn’t really touch it. My nose feels a bit blocked up, too.”
Cues to give: “I googled my symptoms… it was a bad idea.”
ICE (Ideas, Concerns, Expectations):
Ideas: “I read online that a persistent headache can be a sign of a brain tumour.”
Concerns: “Is this a brain tumour? I’m terrified. I saw that on the internet.”
Expectation: “Can I have a scan to check? And can you give me some antibiotics? I think it might be an infection.”
How to Act: You are very anxious, almost to the point of being tearful. You are convinced you have something serious.
More History (only if asked): The pain is a pressure-like feeling over your forehead and around your nose. You’ve noticed you can’t smell things as well as you used to. There’s no fever, no neck stiffness, no problem with lights, and no weakness in your arms or legs. You haven’t had any head trauma. You have a bit of a runny nose with some thick, greenish discharge.
Social History: You are a university student. You have been smoking a pack of cigarettes a day for the last 2 years, especially recently, due to exam stress.
Questions to ask:
“But are you sure it’s not a brain tumour?”
“Why won’t antibiotics help? It feels like an infection.”
Opening & Establishing Rapport:
Hello, I understand you’ve come in today because of a headache. I’m sorry to hear you’ve been in pain. Let’s try to figure out what’s going on.
History of Presenting Complaint (SOCRATES): “Site: Where exactly is the pain? Can you point to it?” “Onset: When did it start? Did it come on suddenly or gradually?” “Character: What does the pain feel like? Is it sharp, dull, throbbing, or more like a pressure?” “Radiation: Does the pain travel anywhere else, like your neck or shoulders?” “Associated Symptoms: Have you noticed anything else along with the headache, like any changes to your vision, any nausea or vomiting, or any sensitivity to light or sound?” “Timing: Is the headache there all the time, or does it come and go? How long does it last?” “Exacerbating/Relieving factors: Is there anything that makes it better or worse?” “Severity: On a scale of 1-10, with being the worst pain imaginable, how bad is it?”
Red Flag Screening:
Have you had any fever, neck stiffness, or a rash?
Have you had any weakness or numbness in your arms or legs, or any problems with your speech or balance?
Is the headache so severe that it wakes you from sleep?
Have you had any recent head injuries?
Past Medical & Medication History:
Do you have any medical conditions?
Are you taking any regular medications, including the contraceptive pill?
ICE (Ideas, Concerns, Expectations):
What are your own thoughts about what could be causing this headache?
You mentioned your friend had a brain tumour. Is that what you’re worried about?
What were you hoping I could do for you today? Were you thinking about getting a scan?
Explain the situation, the likely diagnosis:
Thanks for coming in and telling me about this, Chloe. I can see you’re very worried. Based on what you’ve described – the location of the pain, it being worse when you bend forward, the blocked nose, and the loss of smell – all the signs are pointing towards acute sinusitis. This is a very common condition where the small air-filled spaces behind your cheekbones and forehead get inflamed, usually after a cold.”
Addressing and answering the patient’s ICE:
You’ve mentioned being terrified about a brain tumour, and it’s completely understandable to feel that way, especially after looking things up online. However, the specific collection of symptoms you have doesn’t fit with that picture. The features we worry about with headaches, like weakness in the limbs, changes in vision, or being woken up by the headache at night, are all absent in your case. This is very reassuring.
Next Steps:
You asked about antibiotics. Sinusitis is almost always caused by a virus, just like a common cold. Antibiotics only work against bacteria, so they wouldn’t be effective here and could cause unnecessary side effects. The good news is that sinusitis usually gets better on its own within a couple of weeks. I would not recommend a scan at this stage, as the diagnosis is quite clear, and it would involve an unnecessary scan.
Lifestyle Modifications:
You can continue to use painkillers like paracetamol or ibuprofen. Sometimes holding a warm flannel to your face can help with the pain. Saline nasal sprays, which you can get from the pharmacy, can also help to clear the congestion. It’s also important to rest and drink plenty of fluids.
Special case management:
I know you’re smoking more due to stress, but smoking can irritate the lining of your nose and sinuses and make this condition worse. We can definitely talk about support to help you cut down or quit when you feel ready. If the headache is not getting better in about 10 days, or if you develop a high fever or feel very unwell, then you should come back to see us, and at that point, we might reconsider antibiotics.
Addressing ideas, concerns, and expectations: Directly and emphatically address her fear of a brain tumour. Explain why sinusitis is the likely diagnosis and why a scan and antibiotics are not appropriate.
Provide strong reassurance and clear self-care advice. Give clear safety netting instructions.
What is the scenario testing: This case tests the candidate’s ability to differentiate a common, self-limiting condition from a serious one, and to manage patient anxiety driven by “Dr Google.” It requires confident clinical reasoning, clear explanation, and the ability to say “no” to inappropriate patient requests for investigations and treatments, while maintaining a supportive and empathetic rapport.