Headache OSCE - Subarachnoid Hemorrhage | Free OSCE Practice

Case Overview

Age/Sex: 57-year-old male
Occupation: Office manager (sedentary job)
Setting: Emergency Department, brought by wife
Chief complaint: "Headache"

Patient Script

Who I Am

I am a 57-year-old office manager who mostly sits at a desk and smokes about a pack a day.

What Brings Me In

"I suddenly got the worst headache of my life about an hour ago and I felt sick and dizzy, so my wife brought me in."

My Story

I was sitting on the couch watching TV when, about one hour ago, I had a sudden, very severe headache that came on in seconds — it felt like someone hit the top of my head. It was the worst headache I’ve ever had and it reached full strength immediately. I vomited twice within the first 30 minutes and felt light-headed; I think I blacked out for a few seconds. I now have a stiff neck and bright lights bother me. The pain hasn’t really eased despite taking an over-the-counter pain tablet an hour ago. I sometimes get headaches at the end of a long week, but they are never like this — those were more like tension headaches and came on gradually.

My Medical Background

Past medical history: no diagnosed high blood pressure, no known diabetes, occasional tension headaches in past years
Medications: none prescribed regularly; took one paracetamol at home (500 mg)
Allergies: none known
Social history: current smoker ~1 pack/day for 35 years (~35 pack-years); drinks 2–3 units alcohol on weekends; sedentary job
Family history: father died of a heart attack at 68

What I Think & Worry About

I’m afraid I might be having a stroke or something serious in my brain.
I’m worried I might collapse or die suddenly — this pain felt very different from my usual headaches.
I hope you can find out quickly what’s wrong and stop the pain.

If You Ask Me About Other Symptoms...

"I feel a bit queasy and have vomited twice since it started."
"My neck feels really stiff when I try to bend it forward."
"Lights hurt my eyes a little — I’m bothered by the overhead lights in the ED."
"I didn’t have any fever before this, and I haven’t had any recent infections except a mild cold last month."
"I do get tension headaches sometimes after long days at work, but never one this bad."
"I haven’t hit my head or had any recent accidents."
"I sometimes take ibuprofen for back pain, but I didn’t take any today before this started."

Clinical Summary

Examination

General: alert but distressed by pain, GCS 15/15
Vital signs: BP 168/102 mmHg, HR 102 bpm, RR 18/min, SpO2 97% on room air, Temp 37.0°C
HEENT: pupils equal and reactive to light, no papilledema on fundoscopic exam noted by examiner
Neck: marked neck stiffness; positive passive neck flexion with discomfort; mild photophobia
Neurology: no focal limb weakness, cranial nerves grossly intact, sensation preserved, speech normal
Cardiovascular/chest/abdomen: unremarkable on exam

Investigations

Non-contrast CT head (performed within 1 hour of arrival): hyperdense signal in the basal cisterns and along the Sylvian fissures consistent with acute subarachnoid hemorrhage (acute SAH)
CT angiography head: 6 mm saccular aneurysm at the anterior communicating artery (AComm) with contrast extravasation not seen (ruptured aneurysm suspected based on SAH distribution)
Lumbar puncture: not performed (not required after positive CT within early window)
ECG: sinus tachycardia 102 bpm with diffuse T-wave inversions and QTc mildly prolonged (likely neurogenic change)
Bloods: Hb 14.2 g/dL, WCC 8.6 x10^9/L, Platelets 220 x10^9/L
Coagulation: INR 1.0, PT and APTT within normal limits
Serum electrolytes and creatinine: within normal limits
Troponin I: mildly elevated 0.09 ng/mL (local lab cutoff 0.04) — consider neurogenic myocardial injury

Diagnosis

Primary diagnosis:

Acute subarachnoid hemorrhage due to a ruptured saccular aneurysm (probable anterior communicating artery aneurysm)
- Evidence: sudden thunderclap headache with immediate maximal intensity, vomiting, meningism/neck stiffness, CT head showing hyperdense blood in basal cisterns/Sylvian fissures, and CT angiography demonstrating a 6 mm AComm aneurysm.

Differential diagnoses (with reasoning):

Primary thunderclap headache (e.g., reversible cerebral vasoconstriction syndrome): less likely given CT evidence of SAH
Meningitis: considered because of neck stiffness and photophobia, but absence of fever, normal WCC and positive CT for blood make meningitis unlikely as the primary cause
Intracerebral hemorrhage (parenchymal bleed): CT pattern is subarachnoid rather than focal parenchymal hematoma
Migraine or tension headache: patient’s description of immediate maximal pain and associated vomiting + CT positive exclude these benign causes
Cervical artery dissection: would typically present with neck pain/radicular symptoms and ischemic deficits; CT shows SAH pattern here

Management

Immediate priorities: airway, breathing, circulation; patient monitored continuously and placed on spine precautions as needed
Analgesia: caution with NSAIDs/antiplatelets; provide paracetamol and consider small opioid aliquots if severe pain (avoid excessive sedation)
Blood pressure management: treat acute severe hypertension aiming for systolic BP <160 mmHg (e.g., intravenous labetalol boluses or titrated infusion) while avoiding hypotension that could reduce cerebral perfusion
Neurosurgical/neuroradiology referral: urgent discussion and transfer to neurosurgical center for definitive aneurysm treatment (endovascular coiling preferred if available; surgical clipping if indicated)
Nimodipine: start oral nimodipine as soon as SAH is diagnosed (60 mg every 4 hours for up to 21 days) to reduce risk of delayed cerebral ischemia
Seizure precautions: monitor; do not give prophylactic anticonvulsants routinely unless seizures occur or high risk
Reverse anticoagulation if present (not applicable here — INR normal and no anticoagulant use)
Monitor for complications: close observation for decreased consciousness, rebleeding, hydrocephalus (consider repeat CT if deterioration), electrolyte abnormalities, and cardiac complications
Arrange ICU/high-dependency monitoring during transfer and prepare for possible external ventricular drain if hydrocephalus develops

Key Learning Points

A sudden, severe "thunderclap" headache reaching maximal intensity within seconds is a red flag for subarachnoid hemorrhage and warrants immediate non-contrast CT head.
Non-contrast CT is highly sensitive for SAH in the first 6 hours; if CT is negative but suspicion remains high, lumbar puncture for xanthochromia is indicated. Early neurosurgical or neurointerventional input is essential once SAH is identified.
Manage blood pressure carefully to reduce risk of rebleeding, start nimodipine to reduce delayed cerebral ischemia, and avoid anticoagulants/NSAIDs until the diagnosis and bleeding source are addressed.