Clinical Case 129: A SMACC in the Head (ache)


I need a little help with writing my talk for SMACC in Dublin this June – it is all about diagnosis in the ED.

So I want to present a simple case to you here…  and I want you to answer it honestly, without referring to any papers – I am after your “gut instinct” you “Gestalt” for lack of a better English word!  So please have a read of the scenario below and tell me the answer to the simple question by completing the poll

 Karen is a 45 year old accounts manager. She is usually well aside from occasional asthma and long-standing, mild depression.  Takes salbutamol and citalopram.

She presented to her GP this morning with a history of a bi-frontal headache which came on over a period of 15 minutes whilst at work at her computer.  The headache increased rapidly in intensity to “9/10” pain.  It is the “worst headache she has ever had”.  She felt nauseous after it peaked and nearly vomited.  She has had no syncope or light headedness.  She described some neck stiffness to her GP, but here are no objective findings of meningism on examination.

Her Neuro exam is normal with no changes on fundoscopy.

Her BP is 143/82 and she is in sinus rhythm at 80/min.  ECG Normal.

Her GP was worried about a possible subarachnoid haemorrhage (SAH) and sent her into your ED by ambulance.

By the time you have seen her the headache has been present for 3 hours. It has improved a little with paracetamol and a dose of ketorolac en route…

So that is all the data you will get.. now onto he poll:

[Please try and be as instinctual as possible, answer as if you were in your ED and had to guesstimate the answers to these questions]


I promise that I will get back to you with some poll results and data once I have mined your minds!  See you in Dublin!

OK – after a week and about 250 responses to the questions above I am posting the results:

Q1:  What is the pre-test probability based on the history given above?

pretest SAH

InterestingPOst test risk results with a wide spread of risk assessments and a double Bell curve emerging.

Two peaks around 8%  and one at about 33%.

OK – so that is the patient’s risk, but how risk averse are the Docs?  What were the responses to the question: “What post-testing risk level would you cease further investigation?”

This is a bit of a clearer Bell curve based around the 1% level – although there are a handful of very risk tolerant folk out there who would accept a 1/5 risk – I think that this may represent misunderstanding / a poorly worded question?

So – that is what we found…

comments welcome



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