Common OSCE Presentations

Question 1

A patient presents with an ACUTE headache.

How might you explore this patient’s headache?

Answer 1

Site: where is it?

Onset:
- what were you doing at the time?
- did it come on slowly or suddenly?

Character: what type of pain is it?

Radiation: does the pain go anywhere? (ask about neck)

Associated symptoms/red flags: N&V, seizures, LOC, worse on coughing/bearing down, changes in sensation, weakness, fever/neck stiffness/photophobia, vision changes, positional

Timing:
- how has it changed over time?
- how long did it take to reach max intensity?

Exacerbating/relieving factors

Severity: rate 1-10

History of head trauma?

Previous episodes?

Question 2

Potential clinical exams to perform in acute headache?

Answer 2

• Cranial nerve exam
• UL & LL neuro exam
• GCS
• Fundoscopy
• GI exam (if vomiting)

Question 3

What special tests can be used to test meningism?

Answer 3

1) Nuchal rigidity (neck stiffness and restricted movement, not just painful movement)

2) Kernig’s sign (resisted extension of the knee when knee and thigh held at 90 degrees)

3) Brudzinski’s sign (flexion of the neck causing flexion of the hips whilst laying supine)

Question 4

Most appropriate initial investigation in severe acute headache?

Answer 4

Plain CT head

Question 5

If a plain CT head does not show any abnormalities in an acute headache, what is next investigation?

Answer 5

Lumbar puncture: for microscopy, culture, and sensitivity (MC+S), protein, glucose, and xanthochromia testing.

Question 6

Possible differentials for acute headache & vomiting?

Answer 6

• SAH
• Intracerebral haemorrhage
• CNS infection e.g. meningitis, abscess, encephalitis
• CNS tumour (1ary or metastatic)
• Acute angle-closure glaucoma
• 1ary headache disorder e.g. migraine, cluster
• Temporal arteritis
• Traumatic brain injury
• Hypertensive crisis

Question 7

What are the 2 most common causes of SAH?

Answer 7

1) Trauma
2) Aneurysm rupture

Others: vasculitis, bleeding from arteriovenous malformations

Question 8

What medications are recommended for the initial management of SAH?

Answer 8

1) Nimodipine (a CCB that has shown benefit in reducing the risk of vasospasm in subarachnoid haemorrhage)

2) Aspirin (sometimes)

Question 9

What CCB is indicated in the mangement of SAH?

Answer 9

Nimodipine

Question 10

What are the possible surgical or interventional measures for SAH?

Answer 10

Depending on the type, location and size of the aneurysm, options include interventional neuroradiological procedures such as coiling and surgical procedures such as clipping of the aneurysm.

Other surgical procedures may be required, such as inserting an external ventricular drain (EVD) to manage hydrocephalus.

Question 11

What complications may occur following SAH?

Answer 11

Hydrocephalus
Vasospasm
Hyponatraemia
Re-bleeding
Seizures
Neurological deficit