AN A&E APPROACH TO HEADACHES

DR Y MAHOMED 4/11/2016

THE UNWRITTEN

PROTOCOL OF MADADENI?!HEADACHE=LUMBAR

PUNCTURE

A VERY DANGEROUS PRACTICEBUT I’M NOT HERE TO TELL YOU NOT TO DO LUMBAR PUNCTURES. IN

FACT THEY ARE VERY USEFUL, BUT THE POTENTIAL FOR FATAL COMPLICATIONS IS HIGH!!!

WHAT IS A HEADACHE?➤ THERE ARE MANY REASONS FOR

THE PAIN

➤ CHANGES IN INTRACRANIAL PRESSURE MAY COMPRESS OR PUT TRACTION ON PAIN SENSITIVE STRUCTURES IN THE MENINGES AND SKULL

➤ THERE IS THE NEWER NEUROLOGICAL THEORY THAT SUGGESTS A COMPLEX INTERPLAY OF VASCULAR,INFLAMMATORY AND NEUROLOGICAL CHANGES

➤ OCCIPITAL NERVE IRRITATION MAY CAUSE OCCIPITAL NEURALGIA

➤ BUT FOR MOST HEADACHES THE PATHOPHYSIOLOGY IN UNCLEAR

THERE ARE MANY DIFFERENT TYPES OF HEADACHES

➤ IF WE HAD AT LEAST A WEEK I WOULD DISCUSS EACH IN DETAIL

➤ MORE IMPORTANTLY WE NEED TO KNOW HOW TO DIFFERENTIATE A SERIOUS/ LIFE-THREATENING HEADACHE FROM A BENIGN ONE

➤ ALSO WHEN DO WE SUBJECT OUR PATIENTS TO A LUMBAR PUNCTURE

➤ AND WHEN IS A CT SCAN MORE APPROPRIATE

HISTORY

➤ PATIENT AGE

➤ OLDER PTS > 50 YRS WITH NEW OR WORSENING HEADACHES ARE A HIGH RISK GROUP

➤ THEY ARE LESS LIKELY TO DEVELOP THE BENIGN CAUSES AT THIS AGE

➤ ONSET OF SYMPTOMS

➤ SUDDEN OR PROTRACTED

➤ WAS IT A THUNDERCLAP TYPE HEADACHE

➤ IS THERE ASSOCIATED NAUSEA, SEIZURES, LOSS OF CONSCIOUSNESS ETC.

CAUSES OF ‘THUNDERCLAP’HEADACHE

ALSO, TECHNICALLY, A ‘THUNDERCLAP’ HEADACHE

➤ WE ALSO NEED TO PAY ATTENTION TO CHANGES IN THE QUALITY AND FREQUENCY OF THE HEADACHE

➤ FEVER RAISES THE CONCERN OF AN UNDERLYING INFECTIVE PROCESS

➤ MEDICATIONS

➤ ANTI-COAGULANTS (BLEEDING)

➤ STEROIDS (IMMUNOSUPPRESSION)

➤ ANTIBIOTICS (MAY MASK AN INFECTIVE CAUSE)

➤ CHRONIC ANALGESIC USE (REBOUND HEADACHES)

➤ A PRIOR HISTORY OF PARTICULAR TYPES OF HEADACHES

➤ SUBSTANCE ABUSE (ESPECIALLY COCAINE AND AMPHETAMINES)

➤ A FAMILY HISTORY OF ANEURYSM

EXAMINATION

➤ YOUR VITALS WILL GIVE YOU A GOOD GUIDE AS TO POTENTIAL CAUSES

➤ PYREXIA: POSSIBLE MENINGITIS

➤ BP: INCREASES MAY SIGNAL RAISED ICP OR HPT URGENCY/EMERGENCY

➤ HEART RATE: DECREASE COMBINED WITH RAISED BP IS HIGHLY SUSPICIOUS OF RAISED ICP

➤ HYPERGLYCAEMIA CAN LEAD TO SIGNIFICANT HEADACHE

NECK STIFFNESS

➤ NOT A PAINFUL NECK!!!!!

➤ CHECK FOR RIGIDITY

➤ CHECK FOR MUSCLE FASCICULATIONS

➤ CHECK FOR A POSITIVE BRUDZINSKIS AND KERNIGS SIGN

➤ REMEMBER TO CHECK THE UPPER AIRWAY TO LOOK FOR POSSIBLE SOURCES OF AN INFECTION THAT COULD CAUSE MENINGITIS

DO A NEUROLOGICAL EXAM

➤ I DON’T MEAN LOOK A THE PUPILS, AND SEE IF THERE IS FACIAL ASYMMETRY ONLY!!!

➤ DO A FULL NEUROLOGICAL EXAMINATION

➤ THIS INCLUDES CHECKING CRANIAL NERVES

➤ MOTOR EXAMINATION

➤ SENSATION CHECK

➤ REFLEX EXAMINATION

➤ AND GAIT AND CO-ORDINATION!!!

DON’T FORGET THE EYE

➤ CLOSE ANGLE GLAUCOMA CAN CAUSE VERY SEVERE HEADACHES

➤ CHECK THE VISUAL FIELDS

➤ CHECK VISUAL ACUITY

➤ IF YOU FEEL COMFORTABLE, DO A FUNDOSCOPY

➤ A RED EYE WITH HEADACHE WARRANTS FURTHER INVESTIGATION

FEATURES OF A MIGRAINE2% OF ALL ED VISITS IN THE US ARE FOR BENIGN

HEADACHES

MY PERSONAL FAVOURITE,

IT ALWAYS JUSTIFIES AN LP!!

FEATURES OF A CLUSTER HEADACHEAT OUR HOSPITAL THIS PT WOULD GET 2 LP’s

NO ONE WOULD BELIEVE THE FIRST ONE WAS CLEAR!!

SOME OTHER COMMON HEADACHES

MYOPIA HEADACHES

➤ OFTEN OVERLOOKED

➤ COMMON IN YOUNGER/ SCHOOL-GOING CHILDREN

➤ MANIFESTS AT THE END OF THE SCHOOL DAY

➤ IN ADULTS AND CHILDREN AFTER READING OR WATCHING TV

➤ CAUSED BY THE EXCESSIVE STRAIN OF THE EYE MUSCLES TRYING TO ALTER GLOBE SHAPE

FEATURES OF TEMPORAL ARTERITIS

THESE PTS HAVE JAW CLAUDICATION

IF YOU SAW THE HIGH

ESR , WOULD YOU HAVE

ADMITTED

THIS PT AS TBM?

SAH CT SCANS AND GRADING SCALE

NB!! SAH CAN BE PRESENT WITH MINIMAL PAIN AND NEURO DEFICIT

DIFFUSE SAH SCATTERED SAH

YOU’VE TAUGHT US NOTHING DR MAHOMED!!

➤ YOU’VE SHOWN US THAT BOTH BENIGN AND SERIOUS HEADACHES CAN PRESENT WITH BOTH MILD AND SEVERE SYMPTOMS!!

➤ THIS IS WHY NO ONE WANTS TO WORK IN THE A&E!!

➤ AT THIS POINT OUR WAY OF JUST DOING AN LP SEEMS JUSTIFIED

AND WORST OF ALL I’VE GIVEN YOU TOO MUCH TO REMEMBER!!

LETS SIMPLIFY

CLINICAL RED FLAGS

➤ NOTE THE DIFFERENCES BETWEEN THESE DANGER SIGNS AND SOME OF THE BENIGN CAUSES

➤ NOTE THAT UNILATERAL THROBBING HEADACHES ARE USUALLY BENIGN

➤ NOTE HOW IMPORTANT A NEUROLOGICAL AND OPHTHALMIC EXAMINATION IS IN THE EVALUATION OF A HEADACHE

AND NOW THE BIG QUESTION!!!

SO WHEN SHOULD I DO AN LP? NEVER?!!!!

ALWAYS?!!!!

PATIENT NAME: HOSPITAL NUMBER : DATE: DRS NAME& SPEED DIAL:

YES NO Task ADDITIONAL NOTES

ON HISTORY

HX OF PREVIOUS INTRACRANIAL BLEED

HX OF PREVIOUS INTRACRANIAL LESION

FAMILY OR PT HX OF ANEURYSM

SEIZURES

PHOTOPHOBIA

RVD STATUS CHECKED INDICATE STATUS ON NOTES NOT ON CHECKLIST

DO WE KNOW THE CD4 COUNT INDICATE LEVEL ON NOTES NOT ON CHECKLIST

DOES PT HAVE A BLEEDING DISORDER IF YES,HAVE WE DONE AN INR

PTS PLATELET COUNT

IS MY PT OVER 60 YEARS OF AGE

ON EXAMINATION

ARE THERE SIGNS OF RAISED ICP BP= VOMITING + - PAPILLOEDEMA + -

IS THERE HIGH BP AND BRADYCARDIA CUSHINGS REFLEX , DEFINITE RAISED ICP!!

VITALS NORMAL

GCS E= M= V= TOTAL=

NECK STIFFNESS BRUDZINSKIS + - KERNIGS + -

MUSCLE FASCICULATIONS

PUPILS EQUAL AND REACTIVE TO LIGHT

EYE MOVEMENTS CHECKED IF ABNORMAL, WHICH MOVEMENT IS ABNORMAL

FUNDOSCOPY DONE IF NOT, STATE WHY NOT

CRANIAL NERVES CHECKED IF ABNORMAL THEN STATE WHICH

COORDINATION AND GAIT CHECKED IF ABNORMAL THEN STATE WHICH

POWER IN LIMBS RUL= LUL= RLL= LLL=

TONE IN LIMBS RUL= LUL= RLL= LLL=

REFLEXES RUL= LUL= RLL= LLL= BABINSKI + -

SENSATION RUL= LUL= RLL= LLL=

IS THERE LOCALISED SEPSIS AT SITE

IS THERE ACUTE SPINAL TRAUMA

INVESTIGATIONS

ABG DONE

BASELINE BLOODS TAKEN AND NORMAL

SERUM CLAT SCREEN + -

IS THE PT KNOWN PTB

CONCLUSIONS

BASED ON THESE FACTORS AND OBSERVATIONS DO I CONSIDER IT SAFE TO PERFORM AN LP

CT SCAN INDICATED PRIOR TO LP INDICATE REASONS IN NOTES

LUMBAR PUNCTURE

�1

TOUGH QUESTION

➤ THIS LP CHECKLIST IS PRESENT IN A&E

➤ IT WILL GUIDE YOU AS TO WHEN AN LP IS APPROPRIATE

➤ IF YOU HAVE A PT WITH A HEADACHE AND YOU FIND NO DANGER SIGNS, AN LP CAN ASSIST YOUR DIAGNOSIS

➤ LP’S ARE NOT EVIL

➤ BUT DR’S WHO OVERUSE THEM ARE

WHEN SHOULD I CT A PT WITH A HEADACHE?

➤ ITS NOT THAT DIFFICULT REALLY

➤ MY OVER-ARCHING MESSAGE IS THAT THERE ARE MANY CAUSES OF A HEADACHE

➤ DON’T LIMIT YOURSELF TO SIMPLE DIAGNOSIS

➤ ENJOY YOUR WORK

➤ PLAY DETECTIVE, AND LOOK FOR WIERD AND WONDERFUL DIAGNOSIS

CASE SCENARIO 1JUST TO GET THOSE BRAINS WORKING

ON HISTORY

➤ 57 YR OLD MALE PT, RVD -VE, PRESENTS WITH A SUDDEN ONSET HEADACHE SINCE EARLIER THIS MORNING

➤ HE WAS AT THE GYM WHEN HE FELT A SHARP PAIN AT THE BACK OF HIS HEAD AND ITS NOT GOING AWAY WITH ANY PILLS

➤ ITS ABOUT A 4/10 ON THE PAIN SCALE

➤ HE WAS TOLD BY HIS GP THAT HE HAS CLUSTER HEADACHES, BUT THIS DOESN’T FEEL THE SAME

➤ HE HAS NOT BEEN VOMITING BUT IS FEELING NAUSEOUS ➤ HE HAS NO KNOWN ALLERGIES ➤ HE IS NOT ON ANY CHRONIC MEDICATIONS

➤ THERE IS NO SIGNIFICANT FAMILY, MEDICAL OR SURGICAL HX

➤ HE HAS SOBER HABITS EXCEPT FOR THE OCCASIONAL SOCIAL ALCOHOL USE

ON EXAMINATION

➤ HE HAS ISOLATED SYSTOLIC HYPERTENSION OF 146/79

➤ HIS GCS 15/15; PEARL; NO CRANIAL NERVE ABNORMALITIES; NORMAL GAIT AND CO-ORDINATION; EQUAL POWER,TONE AND REFLEXES AND SENSATION BILATERALLY

➤ THERE IS HOWEVER STIFFNESS OF THE NECK WITHOUT MUSCLE FASCICULATIONS

➤ THERE ARE NO VISUAL ABNORMALITIES

➤ BRUDZINSKIS AND KERNIGS SIGNS ARE NEGATIVE

➤ THE REST OF HIS PHYSICAL EXAMINATION IS NORMAL

SO WHAT NEXT?URGENT CT?

LP? TELL HIM TO TAKE TWO PANADO AND CALL US IN THE MORNING?

DOES HE HAVE RED

FLAGSLP OR CT?

PATIENT NAME: HOSPITAL NUMBER : DATE: DRS NAME& SPEED DIAL:

YES NO Task ADDITIONAL NOTES

ON HISTORY

HX OF PREVIOUS INTRACRANIAL BLEED

HX OF PREVIOUS INTRACRANIAL LESION

FAMILY OR PT HX OF ANEURYSM

SEIZURES

PHOTOPHOBIA

RVD STATUS CHECKED INDICATE STATUS ON NOTES NOT ON CHECKLIST

DO WE KNOW THE CD4 COUNT INDICATE LEVEL ON NOTES NOT ON CHECKLIST

DOES PT HAVE A BLEEDING DISORDER IF YES,HAVE WE DONE AN INR

PTS PLATELET COUNT

IS MY PT OVER 60 YEARS OF AGE

ON EXAMINATION

ARE THERE SIGNS OF RAISED ICP BP= VOMITING + - PAPILLOEDEMA + -

IS THERE HIGH BP AND BRADYCARDIA CUSHINGS REFLEX , DEFINITE RAISED ICP!!

VITALS NORMAL

GCS E= M= V= TOTAL=

NECK STIFFNESS BRUDZINSKIS + - KERNIGS + -

MUSCLE FASCICULATIONS

PUPILS EQUAL AND REACTIVE TO LIGHT

EYE MOVEMENTS CHECKED IF ABNORMAL, WHICH MOVEMENT IS ABNORMAL

FUNDOSCOPY DONE IF NOT, STATE WHY NOT

CRANIAL NERVES CHECKED IF ABNORMAL THEN STATE WHICH

COORDINATION AND GAIT CHECKED IF ABNORMAL THEN STATE WHICH

POWER IN LIMBS RUL= LUL= RLL= LLL=

TONE IN LIMBS RUL= LUL= RLL= LLL=

REFLEXES RUL= LUL= RLL= LLL= BABINSKI + -

SENSATION RUL= LUL= RLL= LLL=

IS THERE LOCALISED SEPSIS AT SITE

IS THERE ACUTE SPINAL TRAUMA

INVESTIGATIONS

ABG DONE

BASELINE BLOODS TAKEN AND NORMAL

SERUM CLAT SCREEN + -

IS THE PT KNOWN PTB

CONCLUSIONS

BASED ON THESE FACTORS AND OBSERVATIONS DO I CONSIDER IT SAFE TO PERFORM AN LP

CT SCAN INDICATED PRIOR TO LP INDICATE REASONS IN NOTES

LUMBAR PUNCTURE

�1

DOES HE HAVE CONTRA-

INDICATIONS TO AN LP

( WE WILL ASSUME HIS BLOOD WORK IS NORMAL)AS I HAD MENTIONED, THE POINT

OF MY PRESENTATION IS NOT THAT LP’S ARE EVIL

ISOLATED SYSTOLIC BP INCREASE

SO MOST LIKELY A SUBARACHNOID

HAEMMORHAGE

➤ OF COURSE IT COULD BE A TRAUMATIC TAP

➤ IF YOU GET A YELLOWISH DISCOLOURATION THIS IS XANTOCHROMIA, WHICH SUGGESTS AN SAH

➤ ALTERNATIVELY YOU CAN COVER THE SAMPLE AND ASK FOR BILIRUBIN LEVELS

➤ BILLIRUBIN PRESENT=SAH

➤ WE SHOULD ALSO NOW DO A CT

➤ GIVEN THIS PTS HISTORY, AN SAH IS MOST LIKELY

➤ ONLY 1% OF EMERGENCY DEPARTMENT VISITS WORLDWIDE FOR HEADACHE SHOW A SERIOUS UNDERLYING CAUSE

➤ FROM THIS 1%, ABOUT 60% TURN OUT TO BE SAH

➤ UNFORTUNATELY MOST EARLY SAH ARE MISSED, APPROXIMATELY 25-35%

➤ AND THESE HAVE THE BEST OUTCOMES

➤ I WILL SAY IT AGAIN, LP’s ARE NOT A BAD THING, JUST HAVE A GOOD APPROACH TO HEADACHES AND THEY CAN BE OF GREAT BENEFIT

CASE SCENARIO 2ONLY 6 MORE CASE SCENARIOS AND WE’RE DONE

JUST KIDDING

ON HISTORY

➤ 32 YEAR OLD FEMALE, RVD -VE, PRESENTS WITH A 1 WEEK HISTORY OF SEVERE OCCIPITAL PAIN

➤ PAIN IS MAINLY ON THE RIGHT SIDE, CAUSING NAUSEA AND VOMITING , BUT SHE ALSO HAS INTERMITTENT PARAESTHESIA OF THAT SIDE OF THE HEAD AND NECK

➤ SHE IS A FINANCIAL ADVISOR AND SPENDS MOST DAYS ON THE COMPUTER

➤ SHE IS A KNOWN HYPERTENSIVE ON TREATMENT

➤ SHE HAD SEEN HER GP ABOUT THIS 2 DAYS BEFORE AND HE HAD STARTED HER ON TRIPTANS FOR A MIGRAINE

➤ SHE HAS HAD NO RELIEF

➤ THE PAIN IS 5/10 ON THE PAIN SCALE

ON EXAMINATION

➤ BP= 160/87, REST OF VITALS NORMAL

➤ SHE IS GCS 15/15, PEARL, SOME PHOTOPHOBIA BUT NOT SEVERE, PTOSIS OF R EYELID DUE TO PAIN

➤ NO FOCAL NEUROLOGICAL SIGNS

➤ TENDERNESS OVER OCCIPUT

➤ EXACERBATED BY MOVEMENT BUT NO NECK STIFFNESS OR SIGNS OF ACUTE MENINGITIS

➤ REST OF EXAMINATION NORMAL

IF IT LOOKS LIKE A DUCK AND

QUACKS LIKE A DUCK THEN IT

MUST BE ……..BUT WE KNOW TRIPTANS

ARE NOT HELPING!!

SIGNS OF A MIGRAINE

A DIAGNOSIS OF OCCIPITAL LANCINATING HEADACHE WAS MADE

THE PT WAS GIVEN A GREATER OCCIPITAL NERVE BLOCK AND REPORTED IMMEDIATE RELIEF

UNFORTUNATELY SHE RETURNS 2 DAYS LATER

THIS TIME THE PAIN IS WORSE AND SHE IS EXPERIENCING DIPLOPIA AND VISUAL FIELD ABNORMALITIES

IS THIS WORRYING

➤ SHE DOES HAVE SOME WORRYING SIGNS, THATS FOR SURE

➤ WE WENT THROUGH OUR LP CHECKLIST AND DECIDED TO DO AN URGENT CT SCAN

PATIENT NAME: HOSPITAL NUMBER : DATE: DRS NAME& SPEED DIAL:

YES NO Task ADDITIONAL NOTES

ON HISTORY

HX OF PREVIOUS INTRACRANIAL BLEED

HX OF PREVIOUS INTRACRANIAL LESION

FAMILY OR PT HX OF ANEURYSM

SEIZURES

PHOTOPHOBIA

RVD STATUS CHECKED INDICATE STATUS ON NOTES NOT ON CHECKLIST

DO WE KNOW THE CD4 COUNT INDICATE LEVEL ON NOTES NOT ON CHECKLIST

DOES PT HAVE A BLEEDING DISORDER IF YES,HAVE WE DONE AN INR

PTS PLATELET COUNT

IS MY PT OVER 60 YEARS OF AGE

ON EXAMINATION

ARE THERE SIGNS OF RAISED ICP BP= VOMITING + - PAPILLOEDEMA + -

IS THERE HIGH BP AND BRADYCARDIA CUSHINGS REFLEX , DEFINITE RAISED ICP!!

VITALS NORMAL

GCS E= M= V= TOTAL=

NECK STIFFNESS BRUDZINSKIS + - KERNIGS + -

MUSCLE FASCICULATIONS

PUPILS EQUAL AND REACTIVE TO LIGHT

EYE MOVEMENTS CHECKED IF ABNORMAL, WHICH MOVEMENT IS ABNORMAL

FUNDOSCOPY DONE IF NOT, STATE WHY NOT

CRANIAL NERVES CHECKED IF ABNORMAL THEN STATE WHICH

COORDINATION AND GAIT CHECKED IF ABNORMAL THEN STATE WHICH

POWER IN LIMBS RUL= LUL= RLL= LLL=

TONE IN LIMBS RUL= LUL= RLL= LLL=

REFLEXES RUL= LUL= RLL= LLL= BABINSKI + -

SENSATION RUL= LUL= RLL= LLL=

IS THERE LOCALISED SEPSIS AT SITE

IS THERE ACUTE SPINAL TRAUMA

INVESTIGATIONS

ABG DONE

BASELINE BLOODS TAKEN AND NORMAL

SERUM CLAT SCREEN + -

IS THE PT KNOWN PTB

CONCLUSIONS

BASED ON THESE FACTORS AND OBSERVATIONS DO I CONSIDER IT SAFE TO PERFORM AN LP

CT SCAN INDICATED PRIOR TO LP INDICATE REASONS IN NOTES

LUMBAR PUNCTURE

�1

CT IS COMPLETELY NORMALEXCEPT FOR PROPTOSIS OF THE RIGHT EYE WITH

NO DEFINITIVE CAUSE SEEN ON CT

➤ CLINICALLY THERE IS A SUGGESTION THAT THERE MAY BE RAISED INTRA-OCULAR PRESSURE

➤ COULD THIS BE A GLAUCOMA

➤ PT GOES TO THE OPHTHALMOLOGISTS

➤ NOPE, IOP IS COMPLETELY

➤ NOT EVEN A SMALL SUGGESTION OF OCULAR ABNORMALITIES

➤ HECK, SHE MAY EVEN HAVE X-RAY VISION

GIVE UP? NEVER?

➤ WITH THE NORMAL CT SCAN BEHIND US, A DECISION WAS MADE TO DO AN LP

➤ ON THE CHECKLIST ALL THE POSSIBLE CONTRA-INDICATIONS HAD BEEN EXCLUDED

➤ IT WAS EITHER AN LP OR REMOVE HER BRAIN AND HAVE A LOOK AT IT DIRECTLY

➤ LP WAS DONE WITH NO COMPLICATIONS

➤ AN HOUR LATER WE GET A CRYPTOCOCCAL TEST (CLAT) POSITIVE RESULT

➤ PT HAD SEROCONVERTED SINCE LAST TEST 6 MONTHS PRIOR

➤ WAS GIVEN APPROPRIATE TREATMENT AND IS NOW BACK ON THE STREETS GIVING FINANCIAL ADVICE

LIKE I SAID LP’S ARE NOT EVIL

JUST BE SURE BEFORE YOU DO ONE

CASE SCENARIO 3AND THEN WE ARE DONE I PROMISE

ON HISTORY

➤ 24 YEAR OLD MALE PT, RVD-VE, DEVELOPS SUDDEN ONSET SEVERE HEADACHE ON HIS WAY HOME FROM WORK

➤ THIS IS ACCOMPANIED BY PROJECTILE VOMITING

➤ APPROX 14 EPISODES IN 2HRS

➤ PAIN 10/10 ON PAIN SCALE

➤ PATIENT IS UNABLE TO GIVE A GOOD HISTORY, HIS WIFE HAS TO EXPLAIN WHAT IS GOING ON

➤ HE CAN ONLY BE DESCRIBED AS ‘SOMNOLENT’

➤ NO KNOWN ALLERGIES, OR SIGNIFICANT FAMILY OR PAST HISTORY

➤ VERY SOBER HABITS

➤ NO PRECEDING TRAUMA OR EXERCISE

ON EXAMINATION

➤ BP =156/104, HR=66, HGT=4.3, TEMP=36.5, RR=12

➤ GCS E=3,M=6,V=5=14/15; PUPILS EQUAL BUT SLUGGISHLY REACTIVE TO LIGHT; CRANIAL NERVES CLINICALLY INTACT; PT UNABLE TO STAND TO ASESS GAIT; GLOBAL DECREASE IS POWER AND TONE, BUT REFLEXES INTACT

➤ HE HAS SIGNIFICANT PHOTOPHOBIA AND DIPLOPIA

➤ NO NECK STIFFNESS

➤ REST OF PHYSICAL EXAMINATION UNREMARKABLE

SEEMS QUITE SIMPLE HEY!

HE HAS SIGNS OF A SERIOUS CAUSE OF A HEADACHE!

HE NEEDS AN URGENT CT AND FURTHER WORK-UP

THIS WAS MY NEPHEW, AND LET ME TELL YOU WHAT REALLY HAPPENED

➤ HE PRESENTED TO HIS GP AT 18:30 WITH THESE SYMPTOMS

➤ HIS GP IS A VETERAN, IN PRACTICE FOR TWENTY YEARS

➤ TOLD THE FAMILY IT WAS A SEVERE MIGRAINE AND GAVE HIM TRIPTANS, ENTI-EMETICS, SYNTHETIC OPIATES(TRAMADOL) AND A VOLTAREN INJECTION

➤ AS YOU CAN IMAGINE HE DID NOT IMPROVE

➤ HIS WIFE CONTACTED MYSELF AND ANOTHER FAMILY DOCTOR TO GET ADVICE

➤ WE BOTH ADVISED THAT HE BE RUSHED TO THE NEAREST EMERGENCY ROOM

➤ THEY STRUGGLED THROUGH THE NIGHT USING THE MEDS, IN THE HOPE HE WOULD BE OKAY, BUT WHEN HE DIDN’T IMPROVE THEY WERE FORCED TO TAKE HIM TO HOSPITAL

➤ ON ARRIVAL AT THE ER OF THE LOCAL PRIVATE HOSPITAL HE WAS STARTED ON MORPHINE FOR PAIN CONTROL

➤ THE ER DR WHO WAS ALSO A LOCAL GP CALLED THE PHYSICIAN ON CALL TO COME AND ASSESS AS HE FELT THERE WAS SOMETHING SERIOUSLY WRONG

➤ THE PHYSICIAN SUGGESTED AN LP BEFORE HIS ARRIVAL

➤ THE ER DOCTOR DID NOT ARGUE ,BUT LUCKILY THOUGHT THIS WAS A BAD IDEA AND JUST DIDN’T DO IT

➤ INSTEAD HE BOOKED MY NEPHEW IN FOR AN EMERGENCY CT

HE HAD ACUTE HYDROCEPHALUS

DUE TO A COLLOID CYST AT THE BASE OF THE

3RD VENTRICLE AN EMERGENCY BILATERAL

VP SHUNT WAS DONE

➤ UNFORTUNATELY HE DIED THREE WEEKS LATER DUE TO COMPLICATIONS IN THEATRE WHEN THE CYST WAS TO BE REMOVED

➤ NOW IMAGINE IF THE ER DR HAD DONE THAT LP, GRANTED IT WOULDN’T HAVE CHANGED THE EVENTUAL OUTCOME

➤ BUT AT LEAST BY THINKING HE GAVE MY NEPHEW A CHANCE

➤ AS FOR THE GP AND PHYSICIAN, SHOWS YOU WE CAN ALL GET A BIT JADED SOMETIMES

PLEASE BE CAREFUL WHEN ASSESSING A HEADACHE

YOU NEVER KNOW WHOSE NEPHEW,NIECE,CHILD OR PARENT YOU MAY BE SEEING