My head hurts SAQ by Luke Phillips

 

This SAQ is worth 20 marks

A 57yo Female has presented to your emergency with a severe headache.  She is GCS 15, has no focal neurology.  BP is 148/72 and HR 90. 

Question 1.
Outline 8 differential diagnoses for this presentation and 3 features of history/ examination that may help in identifying the cause of this patients headache.
 (12 marks)

Differential Clinical Features                
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 



Question 2.
You suspect a subarachnoid haemorrhage in this patient. List 5 clinical features would make this patient high risk for a Subarachnoid haemorrhage?
 (2.5 marks)

1.

2.

3.

4.

5.

 



Question 3.
List 3 Investigations that you would order to exclude a Subarachnoid haemorrhage and justify your reasoning for this.
 (3 marks)

Investigation Justification                   
   
   
   



Question 4.
List 5 circumstances where you would not perform a lumbar puncture in this patient. (2.5 marks)

1.

2.

3.

4.

5.



 

This SAQ is worth 20 marks

A 57yo Female has presented to your emergency with a severe headache.  She is GCS 15, has no focal neurology.  BP is 148/72 and HR 90. 

Question 1.
Outline 8 differential diagnoses for this presentation and 3 features of history/ examination that may help in identifying the cause of this patients headache.
 (12 marks)

 

Differential

Clinical Features

Subarachnoid haemorrhage

Sudden onset, maximal intensity within 1 hour Neck pain
Onset with exertion

Family history of aneurysm or previous aneurysm Hypertension

Primary Headache(Migraine)

Unilateral, photophobia/phonophobia, usually slower onset 4-72 hours, aura

Menigitis

Fever, neck stiffness, rash, photophobia

Brain tumour

Worse in AM, with change in position, assoc nausea & vomiting, Hx of Malignancy

ICH (spont/ traumatic)

Trauma, anticoagulant use, hypertension, focal neuro signs, vomiting, ETOH use

Stroke

Limb/Face weakness/parasthesia, dysphasia, apraxia, visual distrubance

Temporal arteritis

Severe throbbing headache - fronto temporal. Pain with chewing, loss of vision, shoulder pains, non-palpable temporal artery

Ophthalmic disorders (eg. Gluacoma)

Red eye, visual loss, pupil unequal



Question 2.
You suspect a subarachnoid haemorrhage in this patient. List 5 clinical features would make this patient high risk for a Subarachnoid haemorrhage?
 (2.5 marks)

Perry 2010 

- Age >45
- Neck pain

- Headache maximal intensity with first hour - Hypertension
- Witnessed syncope
- Onset with exertion
- Brought in by ambulance.

Question 3.
List 3 Investigations that you would order to exclude a Subarachnoid haemorrhage and justify your reasoning for this.
 (3 marks)

   

CT Brain C-

Identifies acute bleeds, large aneurysms, other pathology.

Lumbar puncture and CSF analysis

If <12 hours looking for Red blood cells (>5x10^6/L, some people quote 0 RBC)
If >12 hours looking for Xanthchromia

 

   

CT Angiogram Circle of Willis

Unable to perform LP but suspicious, -ve LP but high suspicion
+ve LP (RBC or Xanthochromia).



Question 4.
List 5 circumstances where you would not perform a lumbar puncture in this patient. (2.5 marks)

- Pt refusal
- Anticoagulant use/Elevated INR
- Within 6hrs of headache onset/Reported CT (experienced radiologist)/Multislice CT/No other
hight risk features (Perry/Stiehl, BMJ 2011)
- Raised intracranial pressure on CT or papilloedema
- Platlets low
- Infected skin over entry site.


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