Overview
Mr X, a 68 year old gentleman.
Past medical history: Angina, bronchiectasis with recurrent infections, previous PE on anticoagulation with warfarin, chronic joint pain.
Presenting complaint: Sudden severe headache at 11:30hrs. Tried to take regular analgesia for joints but didn’t make that much difference so went to GP the next morning as the headache persisted. GP referred to the Emergency Department for further assessment.
Admission care
Triage nurse 14:30 (day 2): He denies any nausea, vomiting, photophobia
but says it hasn’t changed at all with analgesia.
FY1 14:39: No fever, neck stiffness, or previous migraines. Started suddenly
at 09:30hrs, was initially an 8/10 but now localised to the occipital region and is a 5/10.
No other symptoms and never had pain like this before.
O/e: Clinically no neck stiffness, Kernig’s negative.
Full neurology examination unremarkable, gait intact, walking normally.
Impression: given sudden onset may need to exclude bleed however no other
symptoms which makes it unlikely.
Needs senior review, although most likely tension headache.
Registrar review 16:10:
As per history above, denies head trauma. Pain level onset to peak at hours.
GCS 15, PEARL. No neurology (cranial nerves, peripheral neurology examined), no tenderness in temporal region, no neck stiffness or rash.
Pain has now settled with simple analgesia. Patient has been sleep deprived
recently with work stress.
Discharge letter 16:25:
Diagnosis: likely tension headache or migraine, very low probability of
subarachnoid haemorrhage. Advised to take paracetamol and ibuprofen as needed. Explanation given as doesn’t indicate a CT or a Lumbar puncture at present but to return if feels concerned: particularly vomiting, weakness, new
neurology. (He will need to stop warfarin pre LP).
Follow up arranged by CUH and requested for GP. Patient and partner happy
with the plan.
Subsequent events
Day 3: Patient sleeps through most of the night prior and following day,
waking up to take regular paracetamol and ibuprofen as instructed. Asks wife
call work to let them know he will not be back in just yet.
Day 4 10:00: Attends Gp surgery for review, headache has resolved but now
has a slight cough and runny nose. Given advice for likely viral illness, and
that it will pass in due course. To return if symptoms worsening.
Day 7: returns to work, well.
Questions
How would you describe the level of care that the patient received during his admission assessment?