A 42 year-old woman with a history of migraines and a recent diagnosis of hypertension presented to Emergency Department with a headache.

She awoke with a 9/10 pain located in the occiput and radiating to the forehead. The headache was unlike any she had ever experienced. She had taken paracetamol and codeine OTC with some relief. She had noticed a similar but less severe headache 2 weeks previously.

On Examination

  • The patient is distressed.

  • BP 130/80, HR 105 regular, temperature 36.3°C.

  • There are no neurologic deficits.

  • Kernig's sign is positive.

Questions

Answer one question before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. The first part of teaching will be spent discussing this case:

  1. What features of the headache history would concern you?

  2. Which factors in a medical history are associated with SAH and which high risk behaviours are associated with SAH?

  3. What is Kernig's sign and what does it demonstrate?

  4. The CT is normal, what is your next step and why?

  5. What common complications are associated with a SAH?

    On re-evaluation her GCS is 4, HR - 40, BP 220/112 and on examination her left pupil is fixed and dilated.

  6. How do you explain these physiological observations?

  7. How do you explain her pupillary findings and what are your next steps?

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