Subarachnoid haemorrhage

  • Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are a junior doctor in accident and emergency

Patient: A 45 year old female patient has come in with a headache


– Take a focused history from the patient

– After 6 minutes you will be asked a series of questions by the examiner.

– Answer any questions that the patient may have

Note to actor: Try to restrain yourself from volunteering too much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested. The aim of the exercise is to take a focused history; short answers are required.

You are a 45 year old women who has presented to A&E, with the worst headache ever. You were out shopping today with a friend who is currently parking their car.

You were at the supermarket and you had the worst headache you have ever experienced, you thought you had been hit over the head with a bat. The headache came on instantly. The pain is all over your head, it is a sharp / pressure type pain. There is no radiation anywhere else. You have taken your sumatriptan but this has not helped as it usually does. You are very nauseous and have vomited once.

You admit to the doctor that you do usually suffer with migraines but this one feels different to what you usually get – it is much more intense and usually you only get migraines on the right side of your head but this one is all over. Usually when you have migraines you see “funny lines in my vision” but this time that did not happen.


  • Migranes with aura
  • High blood pressure
  • Autosomal dominant polycystic kidney disease
  • No previous operations


  • Sumatriptan
  • Amlodipine
  • No known drug allergies


  • You are a non-smoker
  • You drink about 2 glasses of white wine a week
  • You live with your partner
  • You are a part-time admin staff at a local school
  • No recreational drug use


You are embarrassed about coming into hospital as your friend thinks this is probably a bad migraine and you want the doctor to tell you that you are acting silly so you can go home.

If the candidate appears to have finished early remind them how long is left at the station and enquire if there is anything else they would like to ask, or whether they have finished. If they have finished, please remain silent and allow the candidate that time for reflection.

Category Question
Introduction Candidate appropriately introduced themselves with:
Full name
Medical school / year / grade
Clarifies who they are talking to
Asks patient for preferred name

PC Presenting complaint
Site of pain
Length of duration of headache

Presenting complaint continued
Relieving factors
Exacerbating factors

Associated features
Visual symptoms
Nausea and vomiting

Red flags
Neck stiffness / rash
Decreased level of consciousness
Sudden onset, worst headache ever / ‘clapping headache’
Seizure or neurological deficit
Reduced visual acuity
Headache worse when laying down with early morning nausea

Constitutional symptoms
Weight loss
Night sweats +/- fever
Loss of appetite

PMH Past medical history
Medical history
No previous operations

DH Drug history
Sumatriptan / Amlodipine
No known drug allergies
No recreational drug use

SH Social History
Living situation

FH Family history
Family history appropriately asked about

Explores ideas, concerns, expectations, feelings

Question Given your history, what is your most likely diagnosis
Subarachnoid haemorrhage

Question What examination/s would you like to do?
Blood pressure
Observation for rash
Neck stiffness
Palpation of temporal region
Upper limb neurological examination
Lower limb neurological examination
Visual examination including - fundi, visual acuity, gait

Question What is the most important investigation to do in this patient given the history
CT head

Question What other investigations would you like to do?
Bloods = FBC, U&Es, LFTs, CRP

Review the CT scan report, what is your management now?

Neurosurgical referral
Coagulopathy correction if required

Question What are the main causes of Subarachnoid haemorrhage?
Rupture of an arterial aneurysm. Allow ‘berry aneurysm’
Arteriovenous malformations
Other appropriate answer