Disengaged 17-year-old with Headaches in Exam Season, Sent By His Mother — Free SCA Practice Case
Disengaged 17-year-old with headaches in exam season, sent by his mother
Station Timer
Golden Minute
Initial Introduction
•Introduce yourself
•Ask an open question — "How can I help you today?"
•Listen — don't interrupt
•Catch early cues
Data Gathering
History, ICE & Diagnosis
Clinical Management
Diagnosis, Plan & Decisions
Safety Net
Follow-up & Close
Materials for Candidate
Please review before starting the consultation
Full Name
Josh Freeman
Age
17 years
Consultation Type
VideoAge
17
Situation
Video Consultation. Attending at his mother's suggestion; joining the call on his own.
Reason for Encounter
"My mum told me to book this. I've been getting headaches. That's it, really."
Medical Records
- ●PMH: Nil significant.
- ●Medications: None.
- ●Allergies: NKDA.
- ●Recent contact: No significant recent consultations.
Patient Script
For the friend playing the patient role
Character Overview: You are Josh, a 17-year-old in the middle of your A-level exams. You have been getting headaches, and your mum nagged you to make this appointment. You are not really bothered about seeing a doctor and you answer in short, one-word answers at first — not rude, just a typical disengaged teenager who would rather be elsewhere. If the doctor is friendly, treats you like an adult, and doesn't patronise you, you gradually open up and admit the headaches are actually getting to you and you are stressed about your exams. Your headaches have the features of migraine. You do not like the idea of taking tablets. You are otherwise fit and well.
Opening Sentence: "Hi. Um, my mum made me book this. I've been getting headaches. I dunno, she said I had to come."
History if Asked (Data Gathering Phase)
(Initially brief, one-word answers; opens up if the doctor builds rapport.)
- ●The headaches: "They're bad. One side, kind of throbbing. Bright light makes it worse. Sometimes I feel a bit sick with them."
- ●Frequency/duration: "Maybe a couple a week lately. They last a few hours. Worse during exams."
- ●Triggers (if rapport built): "Probably stress. I'm not sleeping much, revising late, skipping meals, loads of screen time. And yeah, the exams are stressing me out."
- ●What helps: "Lying down in the dark. I've taken the odd paracetamol but I don't really like taking tablets."
- ●How he really feels (if engaged): "Honestly? The headaches are getting to me, and I'm stressed about my exams. I just didn't really want to make a big thing of it."
ICE — Ideas, Concerns, Expectations
The patient does not volunteer this information unprompted, and only shares it if the candidate engages him and builds trust.
- ●Ideas: Josh has not really thought about what the headaches are; he half-assumes they are "just stress." "I dunno what they are. Just stress from exams, probably."
- ●Concerns: Beneath the disengagement, he is bothered by the headaches and stressed about his exams; he may have a background worry that something could be wrong but plays it down. "If I'm honest, they're getting to me, and the exams are stressing me out."
- ●Expectations: He is not sure what he wants — he came because his mum told him to — but would accept something that helps without a fuss (and ideally not tablets). "I just want them to stop, really. Without a load of hassle."
If Asked — Migraine and Red-Flag Screen
The patient answers these only when directly asked.
- ●If asked about the character (unilateral, throbbing, photophobia, phonophobia, nausea): "One side, throbbing, light and noise make it worse, a bit sick sometimes." (Characteristic migraine.)
- ●If asked about aura (visual zigzags/flashing before the headache): "Sometimes I see zigzag lines for a bit before it starts."
- ●If asked about thunderclap onset / worst-ever sudden headache: "No, they build up, not sudden."
- ●If asked about worse lying down, in the mornings, or with coughing/straining: "No, not especially."
- ●If asked about neurological symptoms (weakness, numbness, visual loss, speech): "No weakness or numbness, no problems talking."
- ●If asked about fever, neck stiffness, rash, weight loss: "No, nothing like that."
- ●If asked about waking him from sleep / progressive worsening: "No, they don't wake me up, and they're not getting steadily worse — just more with the exams."
- ●If asked about sleep, meals, screens, caffeine, and exam stress: "Bad sleep, skipping meals, tons of screen time, energy drinks, and loads of exam stress."
Responses to Management (The Negotiation Phase)
- ●If the Doctor builds rapport and engages him directly: "…Yeah, alright. It's actually been getting to me more than I let on." (The tested point is engaging a disengaged teenager and earning his trust.)
- ●If the Doctor explains this is migraine: "So it's migraine? Is that serious? My mate gets them." (The tested point is explaining migraine and reassuring, having excluded red flags.)
- ●If the Doctor offers a nasal triptan given he dislikes tablets: "I don't really like taking tablets. A nasal spray though — yeah, I could try that." (The tested point is offering a teenager-acceptable acute treatment — a nasal triptan — rather than insisting on tablets.)
- ●If the Doctor suggests a headache diary and lifestyle measures: "Keep a diary? And sort my sleep and stop skipping meals? I suppose I could try." (The tested point is a headache diary and practical lifestyle/trigger management.)
- ●If the Doctor addresses exam stress and follow-up: "The exam stress is the main thing, really. Yeah, I'd come back in a couple of weeks."
Mark Scheme
Domain 1: Data Gathering and Diagnosis
Domain 2: Clinical Management and Medical Complexity
Domain 3: Relating to Others
Clinical Learning Points
Engaging the Reluctant Adolescent
- ●A disengaged teenager attending at a parent's insistence requires rapport-building first — a warm, non-patronising manner that treats them as the patient in their own right and elicits their agenda. Without this, the history and any plan will fail.
Migraine in Adolescents
- ●Migraine features unilateral, throbbing, moderate-to-severe headache with photophobia, phonophobia, nausea, and sometimes aura (e.g. visual zigzags). It is common in adolescents and often triggered by stress, poor sleep, skipped meals, dehydration, screens, and caffeine.
Red-Flag Headache Screen
- ●Always screen for red flags: thunderclap onset, headache worse lying down/in the morning/on straining (raised ICP), neurological deficit, fever/neck stiffness/rash, weight loss, waking from sleep, and a progressive or changing pattern — any of which warrants urgent assessment.
Acute Treatment — Meet the Patient Where They Are
- ●Offer acute treatment the patient will actually use: for a teenager who dislikes tablets, a nasal triptan (e.g. sumatriptan nasal spray) is a good option, ± simple analgesia and an antiemetic. Advise on avoiding medication-overuse headache.
Diary and Lifestyle/Trigger Management
- ●A headache diary helps identify triggers and monitor frequency. Advise on sleep, regular meals, hydration, screen time, and caffeine, tailored to the person's life.
Address the Underlying Stress
- ●Where stress (here, exams) is the driver, address wellbeing and stress management and signpost school/pastoral support — not just the headache.
Follow-Up and Prevention
- ●Arrange follow-up to review the diary and response; consider prophylaxis if migraines become frequent or disabling.
Common Candidate Mistakes in This Case
- ●Failing to engage the teenager: conducting a closed, patronising consultation so he stays shut down.
- ●Treating him as his mother's proxy: rather than as the patient with his own views.
- ●Insisting on tablets: ignoring his stated preference instead of offering a nasal triptan.
- ●Not screening for red flags: or not addressing the exam-stress trigger.
- ●No diary, safety-net, or follow-up: leaving the migraine unmonitored and unsupported.