Headache (acute)

For suspected subarachnoid haemorrhage, meningitis (viral/bacteria)

Px Hx:

Can you tell me more about it? Woke up at 5am by this terrible headache,
worst headache ever, all over the head.
Were you fine before going to bed last night? Sort of feverish.
My son got fever last week.
Any warnings or an signs before your Idea: got it from him
headache starts?
Do you have any other complaints like No
blurred vision? Numbness, weakness?
Rash, nausea or vomiting? Diarrhoea? Son has rash
swollen joints?
You look pretty uncomfortable, we are going
to get an IV in and give you some blood if
that’s okay.
Do you ever have any problems with No
headache?
Any other medical problems? Any Asthma. Family history of migraines.
medications? Any allergies?
Immunosuppressed? Hypertension?

Summarise
Have you take anything to relieve the pain? Not relieved by Tylenol.
Any recent travel? No

Exam:

GCS 1. Can you open your eyes for me? (E3)

2. Can you please tell me your name? Where do you think you are at the
moment? Do you know what time of the day it is? (V4 if confused)
3. Can you shake my hand with your right hand? Apply pain then patient
localised (M5)

Fundoscopy 1. Is the light bothering you? (I will dim the lights and give the patient’s
some analgesia as he is having photophobia)
2. Look straight up at the celling for me

Meningism 1. Can you touch your chin on your chest please?

2. Brudzinski – flex patient’s neck (Both hands hold on the pillow or
occiput) – px lifted and flex the leg
 3. Kernig – I am going to lift your leg to 90 degrees and straighten it okay?

Pronator 1.
drift
CNS 2. I am going to look at couple of nerves at your face okay?
3. Can you sit up for me?

ll: Keep your head still, just follow my fingers with your eyes
V: Clench your teeth real tight for me like this (feel for temporalis and
masseter)
Vll: Raise your eyebrows like this, close your eyes real tight like this, show me
your teeth
Vlll: Assess hearing (whisper test), open your mouth for me.
Xl: Can you strug your shoulder for me? Push your head against my hand,
that’s really sore, sorry about that.
Xll: Can you stick your tongue out?

Tone
Reflexes Triceps, biceps, supinator, knee, ankle, plantar

Power 1. Shoulder abduction

2. Elbow flexion
3. Elbow extension (push against my hand)
4. Wrist extension
5. Thumb abduction
6. Finger abduction
7. Finger flexion (squeeze my finger, don’t let me pull them out)
8. Knee extension

Verbalise what not done

Pulse and BP for sepsis, arrange a CT scan to exclude raised ICP, go for a lumbar puncture.

Child presenting with fever (9-year-old)

- check CVS
- Respi – pneumonia
- ENT – otitis media

Encephalitis
Wet bed – change in behaviour
Meningitis
Headache, vomit, neck pain

Treatment: cefotaxime + acyclovir + clarithromycin (mycoplasma pneumonia)

Differentials: brain abscess,

Investigation: FBC (WBC), U&Es, CRP,