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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
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Asks about onset, duration, and progression of headaches
1 ptsIdentifies chronicity and evolution of symptoms, which are crucial for distinguishing between acute and chronic intracranial pathologies.
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Explores headache characteristics (location, quality, severity, timing, frequency)
1 ptsObtains detailed information to differentiate between primary and secondary headache types and assess impact on daily life.
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Inquires specifically about worsening with Valsalva or in the morning
1 ptsElicits red flag symptoms suggestive of raised intracranial pressure.
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Asks about associated visual symptoms (transient visual obscurations, blurred vision, progression)
1 ptsIdentifies features highly suggestive of papilledema and increased intracranial pressure.
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Inquires about other associated symptoms (nausea, vomiting, photophobia, phonophobia, focal neurological deficits)
1 ptsHelps rule out primary headache syndromes, meningitis, or space-occupying lesions.
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Clarifies response to analgesia and use of over-the-counter medications
1 ptsAssesses for medication overuse headache and the adequacy of symptom control.
Past Medical, Social, and Family History
6 pts available
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Asks about previous similar episodes or migraine history
1 ptsDistinguishes new-onset symptoms from pre-existing conditions.
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Screens for risk factors: BMI/weight, sedentary lifestyle, recent weight gain
1 ptsIdentifies modifiable risk factors relevant to idiopathic intracranial hypertension.
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Inquires about hormonal status (e.g., recent contraceptive use, menstrual changes)
1 ptsAssesses for risk factors associated with IIH and other secondary causes.
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Asks about recent infections, trauma, or systemic symptoms (fever, weight loss)
1 ptsScreens for secondary causes of headache (e.g., infection, malignancy).
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Clarifies medication history including over-the-counter and recent new medications
1 ptsChecks for medication-induced or secondary causes of symptoms.
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Asks about family history of neurological or ophthalmological diseases
1 ptsAssesses for hereditary risk factors.
Focused Neurological and Ophthalmological Examination
6 pts available
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Assesses visual acuity in both eyes
1 ptsScreens for objective evidence of visual impairment.
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Performs confrontation visual field testing
1 ptsDetects visual field deficits such as enlarged blind spot or peripheral loss, suggestive of papilledema.
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Performs fundoscopy to assess for papilledema
1 ptsDirectly evaluates for signs of raised intracranial pressure.
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Examines extraocular movements and cranial nerves II, III, IV, VI
1 ptsIdentifies cranial nerve palsies, especially abducens, which can occur with increased ICP.
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Screens for focal neurological deficits (motor, sensory, coordination)
1 ptsRules out focal brain lesions or stroke.
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Assesses for meningeal signs (neck stiffness, photophobia)
1 ptsScreens for signs of meningitis or subarachnoid hemorrhage.
Red Flag and Risk Factor Assessment
4 pts available
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Identifies red flag features (progressive headache, visual loss, morning worsening, Valsalva aggravation)
1 ptsRecognizes features necessitating urgent evaluation for secondary headache.
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Assesses for features of raised intracranial pressure
1 ptsSynthesizes historical and exam findings to identify increased ICP.
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Screens for symptoms of mass lesion or malignancy (e.g., seizures, focal deficits, personality change)
1 ptsEnsures comprehensive assessment for space-occupying lesions.
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Assesses for medication overuse contributing to headache
1 ptsDetects secondary headache due to excessive analgesic use.
Differential Diagnoses and Clinical Reasoning
4 pts available
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Identifies idiopathic intracranial hypertension as leading diagnosis
1 ptsCorrectly prioritizes IIH given demographic and symptom profile.
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Considers and justifies exclusion of primary headache syndromes (migraine, tension-type)
1 ptsDemonstrates critical reasoning in the context of non-classic primary headache features.
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Considers secondary causes: mass lesion, cerebral venous thrombosis, meningitis
1 ptsEnsures broad, safe approach to diagnosis.
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Appropriately rules out medication overuse headache
1 ptsConsiders impact of frequent acetaminophen use.
Initial Investigations and Management Plan
5 pts available
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Recommends urgent neuroimaging (MRI/CT) prior to lumbar puncture
1 ptsPrioritizes safety to exclude mass effect before LP in suspected raised ICP.
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Suggests lumbar puncture for opening pressure and CSF analysis if imaging is normal
1 ptsEssential for diagnosis of IIH and exclusion of other pathologies.
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Advises early referral to neurology and ophthalmology
1 ptsEnsures multidisciplinary care for vision preservation and definitive diagnosis.
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Discusses lifestyle modification and weight reduction strategies
1 ptsAddresses modifiable risk factors in IIH.
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Mentions potential medical therapy (e.g., acetazolamide) if IIH confirmed
1 ptsDemonstrates knowledge of next steps in IIH management.
Communication and Patient-Centered Skills
4 pts available
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Explains likely diagnosis and need for urgent assessment in clear, non-alarming terms
1 ptsEnsures patient understands the seriousness but is not unduly frightened.
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Describes rationale for investigations and referrals
1 ptsPromotes patient engagement and compliance with further testing.
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Addresses patient concerns, anxieties, and expectations
1 ptsProvides reassurance and answers questions appropriately.
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Uses appropriate non-verbal cues and demonstrates empathy
1 ptsEstablishes rapport and comfort throughout the encounter.