Case 16: The Nightmare (headache) before Christmas

Mr Nicholas is a 1713 year old north-Norwegian unemployed male that presents to your GP clinic with recurrent headache. He has been getting these headaches for the past 100 years that tend to come on in the afternoon, last 6 hours and causes severe pain bilaterally around the frontal region. Only sitting in the dark makes the pain better and Christmas lights (which he hates) makes them much worse.

Mr Nicholas says he is otherwise well but claims to see ‘little people’ that work for him at home.fatherxmas


  • COPD due to soot inhalation –  diagnosed 2003
  • Lyme disease from reindeer tick – treated 2008
  • Black death – cured 1349
  • Frost bite – several episodes
  • High cholesterol
  • Gout


Currently taking – Simvastatin 20mg, Salmeterol 2 puffs BD, Ipratropium Bromide 1 puff TDS, Beclometasone, Allopurinol 100mg OD.


Mr Nicholas says he lives in a large bungalow with hundreds of ‘elves’ and eight reindeer. He copes well at home with help from his elves and has good mobility although his back does get stiff after sitting down to read the large number of letters he receives. He has never married (‘married to the job’), has no children and no close family.

Mr Nicholas does drink alcohol but only one night a year where he drinks around 1 billion glasses of sherry (1 billion units). He describes having a well balanced diet of minced pies and the odd carrot when the reindeers are full.


Uncle had Christmas disease.

O/E – BMI: 54, looks well and in good spirits. .

HR 70bpm regular & normal in character and volume. O2 saturations 93% on air. Temperature 37.2°C. RR 16pm

  • Heart sounds 1 & 2 present, no added sounds. No peripheral oedema.
  • Bibasal coarse crepitations and wheeze. Normal chest expansion, resonant to percussion.
  • Poor dentition (he has a sweet tooth), palmar erythema, gynaecomastia and central adiposity. Abdomen soft non-tender.

Neurological examination normal.

Question 1:Mr Nicholas says his previous Doctor diagnosed him with a humor problem. What is Mr Nicholas talking about and which of his humors is out of kilter?

Discuss now on Twitter, using the hashtag #quclms. Follow @quclms for updates. Further information and follow-up questions will appear on Twitter throughout the week.

Question setter: Harry Costello, Final Year Medical Student, UCL Medical School

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