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Hollie Harrison

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Hollie Harrison, 27-year-old female, presents with persistent headaches and blurred vision.

Case details

Patient Demographics

Name: Hollie Harrison
Age: 27 years
Gender: Female
Occupation: Receptionist for insurance company
Relevant Details: Overweight (BMI 28), sedentary job

History of Presenting Complaint

Hollie Harrison presents with a 2-month history of persistent, diffuse throbbing headaches, worst in mornings and with straining (Valsalva). Headaches are sometimes accompanied by nausea but no vomiting. Reports transient visual obscurations (lasting seconds) when changing positions or bending over. Blurred vision has progressively worsened. No photophobia/phonophobia. No prior migraine history. OTC acetaminophen provides minimal relief.

Past Medical History

No significant medical history
No head trauma
No prior hospitalizations/surgeries

Medications

Acetaminophen PRN (500mg, 1-2 tablets daily)
No regular medications
Good compliance with OTC analgesics

Allergies

No known drug allergies
No other allergies reported

Social History

Non-smoker
Occasional alcohol (2-3 units/week)
Works long hours at computer
Moderate caffeine intake (2 coffees/day)
Lives alone in apartment

Family History

No family history of:
- Migraines
- Neurological disorders
- IIH/pseudotumor cerebri

Examination Findings

General: Mild distress from headache, otherwise well
Vitals: BP 130/80, HR 72, RR 16, Temp 98.6°F
HEENT: No papilledema (fundoscopy normal), no bruits
Neuro: CN II-XII intact, normal visual fields, no focal deficits, reflexes 2+ symmetric

Investigation Results

CBC/CMP: Normal
Brain MRI: No masses/structural abnormalities
LP: Opening pressure 260 mm H₂O (elevated), normal CSF analysis

Actor Instructions

1. Rub temples frequently during interview
2. Squint occasionally when describing vision changes
3. Speak slowly when describing headache characteristics
4. Appear frustrated by persistent symptoms
5. Lean forward slightly when seated (as if avoiding pain)
6. Ask about weight implications if not addressed

Red Flags

1. Morning headaches with nausea
2. Positional visual changes
3. Elevated ICP on LP
4. Progressive symptoms
5. Obesity as risk factor

Expected Approach

1. Thorough headache characterization (timing, triggers, associated symptoms)
2. Vision change details (transient vs persistent, positional nature)
3. Medication history (especially OCPs, vitamin A derivatives)
4. Weight/BMI assessment
5. Fundoscopy request
6. IIH diagnostic criteria consideration

Common Pitfalls

1. Missing papilledema absence doesn't rule out IIH
2. Overlooking BMI as modifiable risk factor
3. Not asking about medications that increase IIH risk
4. Failing to connect visual symptoms with headache pattern
5. Premature migraine diagnosis without excluding IIH

Marksheet

Hollie Harrison Marksheet

35 pts available

History of Presenting Complaint

6 pts available

Asks about onset, duration, and progression of headaches
1 pts

Identifies chronicity and evolution of symptoms, which are crucial for distinguishing between acute and chronic intracranial pathologies.
Explores headache characteristics (location, quality, severity, timing, frequency)
1 pts

Obtains detailed information to differentiate between primary and secondary headache types and assess impact on daily life.
Inquires specifically about worsening with Valsalva or in the morning
1 pts

Elicits red flag symptoms suggestive of raised intracranial pressure.
Asks about associated visual symptoms (transient visual obscurations, blurred vision, progression)
1 pts

Identifies features highly suggestive of papilledema and increased intracranial pressure.
Inquires about other associated symptoms (nausea, vomiting, photophobia, phonophobia, focal neurological deficits)
1 pts

Helps rule out primary headache syndromes, meningitis, or space-occupying lesions.
Clarifies response to analgesia and use of over-the-counter medications
1 pts

Assesses for medication overuse headache and the adequacy of symptom control.

Past Medical, Social, and Family History

6 pts available

Asks about previous similar episodes or migraine history
1 pts

Distinguishes new-onset symptoms from pre-existing conditions.
Screens for risk factors: BMI/weight, sedentary lifestyle, recent weight gain
1 pts

Identifies modifiable risk factors relevant to idiopathic intracranial hypertension.
Inquires about hormonal status (e.g., recent contraceptive use, menstrual changes)
1 pts

Assesses for risk factors associated with IIH and other secondary causes.
Asks about recent infections, trauma, or systemic symptoms (fever, weight loss)
1 pts

Screens for secondary causes of headache (e.g., infection, malignancy).
Clarifies medication history including over-the-counter and recent new medications
1 pts

Checks for medication-induced or secondary causes of symptoms.
Asks about family history of neurological or ophthalmological diseases
1 pts

Assesses for hereditary risk factors.

Focused Neurological and Ophthalmological Examination

6 pts available

Assesses visual acuity in both eyes
1 pts

Screens for objective evidence of visual impairment.
Performs confrontation visual field testing
1 pts

Detects visual field deficits such as enlarged blind spot or peripheral loss, suggestive of papilledema.
Performs fundoscopy to assess for papilledema
1 pts

Directly evaluates for signs of raised intracranial pressure.
Examines extraocular movements and cranial nerves II, III, IV, VI
1 pts

Identifies cranial nerve palsies, especially abducens, which can occur with increased ICP.
Screens for focal neurological deficits (motor, sensory, coordination)
1 pts

Rules out focal brain lesions or stroke.
Assesses for meningeal signs (neck stiffness, photophobia)
1 pts

Screens for signs of meningitis or subarachnoid hemorrhage.

Red Flag and Risk Factor Assessment

4 pts available

Identifies red flag features (progressive headache, visual loss, morning worsening, Valsalva aggravation)
1 pts

Recognizes features necessitating urgent evaluation for secondary headache.
Assesses for features of raised intracranial pressure
1 pts

Synthesizes historical and exam findings to identify increased ICP.
Screens for symptoms of mass lesion or malignancy (e.g., seizures, focal deficits, personality change)
1 pts

Ensures comprehensive assessment for space-occupying lesions.
Assesses for medication overuse contributing to headache
1 pts

Detects secondary headache due to excessive analgesic use.

Differential Diagnoses and Clinical Reasoning

4 pts available

Identifies idiopathic intracranial hypertension as leading diagnosis
1 pts

Correctly prioritizes IIH given demographic and symptom profile.
Considers and justifies exclusion of primary headache syndromes (migraine, tension-type)
1 pts

Demonstrates critical reasoning in the context of non-classic primary headache features.
Considers secondary causes: mass lesion, cerebral venous thrombosis, meningitis
1 pts

Ensures broad, safe approach to diagnosis.
Appropriately rules out medication overuse headache
1 pts

Considers impact of frequent acetaminophen use.

Initial Investigations and Management Plan

5 pts available

Recommends urgent neuroimaging (MRI/CT) prior to lumbar puncture
1 pts

Prioritizes safety to exclude mass effect before LP in suspected raised ICP.
Suggests lumbar puncture for opening pressure and CSF analysis if imaging is normal
1 pts

Essential for diagnosis of IIH and exclusion of other pathologies.
Advises early referral to neurology and ophthalmology
1 pts

Ensures multidisciplinary care for vision preservation and definitive diagnosis.
Discusses lifestyle modification and weight reduction strategies
1 pts

Addresses modifiable risk factors in IIH.
Mentions potential medical therapy (e.g., acetazolamide) if IIH confirmed
1 pts

Demonstrates knowledge of next steps in IIH management.

Communication and Patient-Centered Skills

4 pts available

Explains likely diagnosis and need for urgent assessment in clear, non-alarming terms
1 pts

Ensures patient understands the seriousness but is not unduly frightened.
Describes rationale for investigations and referrals
1 pts

Promotes patient engagement and compliance with further testing.
Addresses patient concerns, anxieties, and expectations
1 pts

Provides reassurance and answers questions appropriately.
Uses appropriate non-verbal cues and demonstrates empathy
1 pts

Establishes rapport and comfort throughout the encounter.