Facial Pressure Headache Convinced She Needs Antibiotics for Sinusitis — Free SCA Practice Case

Character Overview: You are Rebecca, a 34-year-old woman who started a new job in a marketing agency about two months ago and is still on probation. You are stretched and stressed — long hours, a lot to prove — and you have had a nagging, pressing headache for weeks. You have convinced yourself it is a sinus infection and you want antibiotics so you can get on with things. You are pleasant but a bit impatient; you feel you know what you need and want it sorted efficiently.

Opening Sentence: "Hi Doctor. So I've had this horrible pressure across my forehead and around my cheeks for about three weeks now. It feels like my sinuses are blocked. I've been taking paracetamol nonstop and it barely touches it. I really just need some antibiotics to clear it up — I can't afford to be off my game at work right now."

History if Asked (Data Gathering Phase)

• ●The headache: "It's a constant pressing, tightening feeling — like a band around my head, and pressure across my forehead and cheeks. Both sides, pretty even. It's there most of the day, most days."
• ●What makes it better or worse: "It's worse by the afternoon and when I'm staring at spreadsheets. A bit better at weekends, now you mention it. Paracetamol takes the edge off for an hour or two."
• ●The 'sinus' idea: "The pressure in my face — that's sinuses, isn't it? My mum always got antibiotics for hers."
• ●Nasal symptoms: "My nose isn't really blocked or runny, to be honest. No green gunk or anything. It's more the pressure and the headache."
• ●Painkillers: "I've been taking paracetamol most days for weeks — two, three times a day maybe. Sometimes I take ibuprofen too if it's bad."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores her perspective.

• ●Ideas: Rebecca is firmly convinced this is bacterial sinusitis that needs antibiotics. She associates facial pressure with "sinus infection" and does not connect the headache with stress or muscle tension. "In my head this is clearly a sinus infection — the pressure's in my face, that's what sinuses do. Antibiotics fix that, don't they?"
• ●Concerns: Underneath the certainty is a worry that if it does not clear she will not cope at work during her probation, and a smaller fear that a headache going on this long might be "something serious." "Honestly, the real worry is I can't function properly at work and I'm still on probation. And a tiny part of me wonders if a headache this long means something's wrong."
• ●Expectations: She expects to leave with a prescription for antibiotics and may feel dismissed if simply told no. "I came in expecting antibiotics, if I'm honest. I don't really want to be told to just take more paracetamol and go away."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

• ●Past headaches: "I've always been a bit prone to tension headaches when I'm stressed, but nothing like this for this long."
• ●Migraine features: "It's not throbbing, and light and noise don't especially bother me. No aura, no vomiting."
• ●Medications: "Just the paracetamol, and ibuprofen now and then. Nothing regular otherwise."
• ●Contraception/other: "I'm on the combined pill, been on it years, no problems."
• ●Family history: "My mum gets 'sinus headaches' and always ends up on antibiotics."

Social History and Lifestyle Impact

Rebecca started a new marketing job two months ago and is on probation. She lives with her partner.

• ●Work: "New job, still on probation, so I'm putting in the hours and trying to impress. Long days at a screen, lots of pressure, not many breaks."
• ●Sleep and routine: "Sleep's been rubbish — I'm lying awake going over work. I skip lunch a lot, run on coffee. Probably don't drink enough water."
• ●Caffeine: "Four or five coffees a day at the moment, easily."
• ●Impact: "The headache's making it hard to concentrate, which just makes me more stressed about work. It's a vicious circle."

If Asked — Associated Symptoms and Red-Flag Screen

The patient answers these only when directly asked.

• ●If asked about nasal discharge / blockage: "No, my nose is basically clear. No coloured discharge, not really blocked."
• ●If asked about fever or feeling unwell: "No fever, no. I feel well in myself apart from the headache."
• ●If asked about facial pain worse on bending forward / tenderness over cheeks: "Not really — it doesn't get worse bending over, and my face isn't tender to touch. It's more a general pressure."
• ●If asked about tooth pain or upper teeth: "No, teeth are fine."
• ●If asked about sudden 'thunderclap' onset: "No, it came on gradually and built up over the weeks."
• ●If asked about the worst/first headache of her life, or waking her from sleep: "No, it doesn't wake me. It's not the worst pain I've ever had, just relentless."
• ●If asked about visual disturbance, weakness, numbness, speech problems: "No, nothing like that."
• ●If asked about worse on coughing/straining/lying down, or morning vomiting: "No, none of that."
• ●If asked about neck stiffness, rash, photophobia: "No."
• ●If asked about weight loss, night sweats, jaw claudication, scalp tenderness: "No, nothing like that." (All absent — no features of giant cell arteritis or sinister pathology.)
• ●If asked about stress: "Yeah, work stress is through the roof at the moment. I hadn't linked it to the headache though."

Responses to Management (The Negotiation Phase)

• ●If the Doctor explains this is a tension-type headache, not sinusitis: "Tension headache? But the pressure's in my face — that's got to be sinuses, surely?" (The tested point is reframing her belief with a clear, respectful explanation rather than simply contradicting her.)
• ●If the Doctor declines antibiotics: "So no antibiotics at all? Even for sinusitis? My mum always gets them." (The tested point is explaining, without alienating her, that even acute sinusitis is usually viral and self-limiting and rarely needs antibiotics.)
• ●If the Doctor raises the frequent painkiller use: "Wait — the paracetamol could be making my headache worse? That seems backwards."
• ●If the Doctor addresses work stress and lifestyle: "I haven't got time for yoga and early nights, I'm on probation! Is that really the answer?"
• ●If the Doctor safety-nets: "So what would actually mean I need to be seen or worry about it?"