Transcript

Doctor: Hi, good morning. I'm Dr. Helen, I'll be your doctor today. May I know your name?

Patient: You can call me Emma.

Doctor: Okay, Emma. Can you tell me why you are here today?

Patient: I have a terrible headache.

Doctor: That seems really bad, so can you tell me a bit more about this?

Patient: Yeah, it started about three days ago. It seems nothing has helped to relieve it. I had to lie down and I have not been able to go to work. Plus the light is bothering me a lot, Dr.

Doctor: Sorry. Unfortunately, I cannot dim the lights in this room but don’t worry I will try to go quickly. Anything unusual happened, maybe three days ago?

Patient: Nothing actually.

Doctor: Can you tell me anything that makes it better?

Patient: Well...nothing made it feel better. I took some paracetamol, but the headache is still there. I just try not to move too much.

Doctor: If you had to rate the pain, score 0 being no pain and 10 being the worst pain, what would you like to score the pain?

Patient: I would say 7-8.

Doctor: That sounds really bad. As for radiation, does the pain move elsewhere?

Patient: It's kind of all over but it also I got this shooting pain down my neck and my neck is very stiff.

Doctor: Oh! It’s the entire head.

Patient: Yeah..

Doctor: The pain started three days ago. And you said it is constant yeah, it started gradually but once it got there it has not resided, it does not get any better, it does not get worse, it’s just the same, what do you think is going on?

Patient: I just could hardly think it's so painful because it's so bad I was afraid my neighbour had a headache and he ignored it last year and when he had seizure, he was investigated and it turns out he had a brain tumour.

Doctor: Hmm. I can understand your concern. How is it impacting your daily life?

Patient: I can't go to work.. I can't do anything.

Doctor: So, it sounds like it’s really impacting your life. I would like to talk a little bit about your medical history. Alright, can you tell me your medical history. Have you had any medical conditions?

Patient: I was diagnosed with high blood pressure about three years ago, I’ve been addressing it with diet changes and monitoring yearly and it's been well controlled. I haven't been on medications for that. Besides that I don't have any medical problem.

Doctor: I see. Did you have any surgical history or hospitalization?

(patient is shaking her head)

Doctor: Do you have any drug allergies?

Patient: None of I known of.

Doctor: What about family history...Do you have any medical history of headaches?

Patient: Ohh, you know.. my mom said used to have migraines when she was in her 20s and 30s. I can't remember her say anything else. My sister.. she is healthy. My dad uh.. he has high blood pressure otherwise he is healthy and that's about it.

Doctor: I would like to as you some social history questions that would just be for our records. Do you smoke?

Patient: Yeah. I do.

Doctor: How much do you smoke per day?

Patient: About a half a pack a day.

Doctor: What about alcohol consumption?

Patient: I don't drink.

Doctor: Are you married?

Patient: Yeah, I'm married but have no children.

Doctor: Ok, just some additional questions about your gynecology history. When was your last menstrual period?

Patient: I'm in menopause.

Doctor: Okay. Going back to the familial history again. apart from the headache, have you been nauseous?

Patient: Yeah, I've been nauseous in fact I threw up twice earlier because when I move it makes me nauseous.

Doctor: Nothing has been out of ordinary over the past couple of weeks, yeah. Have you been on any trips or anything?

Patient: No. I don't go anywhere else past few weeks except my workplace.

Doctor: Okay, let me just summarize to make sure I've got everything straight. You started onset of headache about three days ago and it worsened with movement and light. It's a 7/8 out of 10 pain score. and you’re also complaining of a stiff neck with that. it's associated with nauseous as well. It came on gradually also it's been a constant pain. Apart from this you have hypertension that is controlled with your diet. Your concern is that your neighbor had headache and seizure but when he went for check, he had brain tumor.

Patient: Yeah. I kinda worried that.

Doctor: I understand your worry. We're pretty done over your history and what I'd like you to do now is follow through to complete a physical examination and do some testing, alright..

Patient: Okay, that sounds good.

Doctor: Okay, great.