A Short discussion on headaches as seen at our a&e at madadeni. Presented at our weekly cpd meeting

1. AN A&E APPROACH TO
HEADACHES
DR Y MAHOMED
4/11/2016

2. THE
UNWRITTEN
PROTOCOL OF
MADADENI?!
HEADACHE=LUMBAR
PUNCTURE

3. A VERY DANGEROUS PRACTICE
BUT 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!!!

4. 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

5. 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

6. 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.

7. CAUSES OF ‘THUNDERCLAP’HEADACHE

8. ALSO, TECHNICALLY, A ‘THUNDERCLAP’ HEADACHE

9. ➤ 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

10. 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

11. 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

12. 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!!!

13. 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

14. FEATURES OF A MIGRAINE
2% OF ALL ED VISITS IN THE US ARE FOR BENIGN
HEADACHES
MY PERSONAL FAVOURITE,
IT ALWAYS JUSTIFIES AN LP!!

15. FEATURES OF A CLUSTER HEADACHE
AT OUR HOSPITAL THIS PT WOULD GET 2 LP’s
NO ONE WOULD BELIEVE THE FIRST ONE WAS CLEAR!!

16. SOME OTHER COMMON HEADACHES

19. 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

21. FEATURES OF
TEMPORAL
ARTERITIS
THESE PTS HAVE JAW
CLAUDICATION
IF YOU SAW THE HIGH
ESR , WOULD YOU HAVE
ADMITTED
THIS PT AS TBM?

23. SAH CT SCANS AND GRADING SCALE
NB!! SAH CAN BE PRESENT WITH MINIMAL PAIN AND NEURO DEFICIT
DIFFUSE SAH SCATTERED SAH

24. 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

25. AND WORST OF ALL I’VE GIVEN YOU
TOO MUCH TO REMEMBER!!
LETS SIMPLIFY

26. 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

27. AND NOW THE BIG
QUESTION!!!
SO WHEN SHOULD I DO AN LP?
NEVER?!!!!
ALWAYS?!!!!

28. 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
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

29. 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

30. CASE SCENARIO 1
JUST TO GET THOSE BRAINS WORKING

31. 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

32. 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

33. SO WHAT NEXT?
URGENT CT?
LP?
TELL HIM TO TAKE TWO PANADO AND CALL US IN THE MORNING?

34. DOES HE
HAVE RED
FLAGS
LP OR CT?

35. 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
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

36. SO MOST LIKELY A SUBARACHNOID
HAEMMORHAGE

37. ➤ 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

39. ➤ 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

40. CASE SCENARIO 2
ONLY 6 MORE CASE SCENARIOS AND WE’RE DONE
JUST KIDDING

41. 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

42. 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

43. 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

44. A DIAGNOSIS OF OCCIPITAL
LANCINATING HEADACHE WAS MADE
THE PT WAS GIVEN A GREATER OCCIPITAL NERVE
BLOCK AND REPORTED IMMEDIATE RELIEF

45. UNFORTUNATELY SHE RETURNS 2
DAYS LATER
THIS TIME THE PAIN IS WORSE AND SHE IS EXPERIENCING
DIPLOPIA AND VISUAL FIELD ABNORMALITIES

46. 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

47. CT IS COMPLETELY NORMAL
EXCEPT FOR PROPTOSIS OF THE RIGHT EYE WITH
NO DEFINITIVE CAUSE SEEN ON CT

48. ➤ 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

50. 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

51. LIKE I SAID
LP’S ARE
NOT EVIL
JUST BE SURE BEFORE
YOU DO ONE

52. CASE SCENARIO 3
AND THEN WE ARE DONE I PROMISE

53. 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

54. 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

55. SEEMS QUITE
SIMPLE HEY!HE HAS SIGNS OF A SERIOUS CAUSE OF A
HEADACHE!
HE NEEDS AN URGENT CT AND FURTHER
WORK-UP

56. 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

57. ➤ 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

58. HE HAD ACUTE
HYDROCEPHALUS
DUE TO A
COLLOID CYST AT
THE BASE OF THE
3RD VENTRICLE
AN EMERGENCY BILATERAL
VP SHUNT WAS DONE

59. ➤ 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

60. PLEASE BE CAREFUL WHEN
ASSESSING A HEADACHE
YOU NEVER KNOW WHOSE NEPHEW,NIECE,CHILD
OR PARENT YOU MAY BE SEEING