Physician's Assistant

Patient Details

Refined clerking (13 weeks ago 22:04)

Refined clerking Mon 05 January 2026 22:04

Last Modified: 90 days ago

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Content:

Medical ST5 Miller Clerking

Presenting Complaint:
Headache and visual disturbance

History of Presenting Complaint:
28-year-old woman presents with 3-week history of intermittent severe headaches following flu-like illness before Christmas. Initially developed sinus infection which resolved with pharmacy treatments including saline rinses. On Boxing Day developed upper jaw pain which she attributed to sinus pressure, but symptoms progressively worsened and spread.

Describes intense pressure sensation in forehead "like magnets pulling" radiating to back of neck, ears, and behind eyes. Episodes last approximately 2 hours during which she is unable to function normally. Pain particularly affects upper jaw and teeth, worsened by tilting head forward.

Developed visual disturbance over past week - intermittent blurring especially with bright lights. Denies complete visual loss but notes strain sensation in eyes during episodes.

Past Medical History:
• F+W

Drug History:
• No regular medications

Allergy History:
• NKDA

Social History:
Lives with partner and two children (ages 4 and 7)

On Examination:
General Appearance: Alert, well, cooperative
Neurological: Full cranial nerve examination normal including visual fields, eye movements, facial sensation and movement. Upper and lower limb power, reflexes, coordination and sensation all normal. Gait normal.
Tender sinuses

Investigations:
• FBC: WCC 10.6, Neutrophils 7.51, Platelets 416, Hb 124
• ALT: 43 (prev 23)

Impression:
Ongoing sinusitis most likely
To exclude Cerebral venous sinus thrombosis or other intracranial cause

Management Plan:
1. CT venogram to exclude cerebral venous sinus thrombosis
- Sinusitis only
2. Home with antibiotics PenV 5 days

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Patient Details

Refined clerking Mon 05 January 2026 22:04

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