Neurology 8 Minutes David Patel, 41 yo (Emergency Department)

Thunderclap Headache & Red Flags History

Candidate Instructions: Mr. David Patel presents with a sudden, agonizing headache that reached maximum intensity within 20 seconds. Take a focused neurological history, evaluate red flags, and determine urgent investigations.

Examiner Marking Checklist

Headache Timing & Characteristics

✓ Time to peak: reached 10/10 within seconds ("hit by a baseball bat")
✓ Activity at onset (straining, exertion, sexual intercourse)
✓ Associated neck stiffness, photophobia, vomiting, syncope

Red Flag Screening

✓ Screen for focal neurological deficits (limb weakness, speech, vision)
✓ Fever, rash, immunocompromise (meningitis / encephalitis)
✓ Personal or family history of cerebral aneurysms or PKD

Critical Red Flags

⚠ Thunderclap onset reaching maximum severity within 1 minute
⚠ Meningism (neck stiffness, positive Kernig/Brudzinski)
⚠ Depressed Glasgow Coma Scale or focal neurological signs

Post-Station Examiner Questions

Examiner: "What is the diagnostic pathway for suspected subarachnoid haemorrhage?"

Model Answer: Non-contrast CT head within 6 hours of onset (sensitivity > 99%). If CT is negative or done > 6 hours after onset, lumbar puncture after 12 hours from symptom onset to test for xanthochromia via spectrophotometry.

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