# headache x 1 week



## zzyzx (Jun 3, 2012)

Here's a patient I had the other week:

You are greeted at the door by a 35 y/o patient who apologizes for calling 911 but states that last time he went to the ER by private car he waited for hours to be seen.

He c/o of a headache x 1 week. He also c/o of right-sided weakness, but states that it has mostly resolved (grips feel equal when you test them).

Hx of an enlarged heart and kidney transplant due, he says, to uncontrolled hypertension. Takes prednisone, and antihypertensive that he does not remember the name of, and another medication that he also cannot recall.

Vitals: 130/80, pulse 70 strong and regular, RR 14, SpO2 98%, afebrile. The patient is fully alert and oriented. He's pleasant and apologizes but states that he just can't stand waiting for hours again with this headache.


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## abckidsmom (Jun 3, 2012)

zzyzx said:


> Here's a patient I had the other week:
> 
> You are greeted at the door by a 35 y/o patient who apologizes for calling 911 but states that last time he went to the ER by private car he waited for hours to be seen.
> 
> ...



So you load him up and take him to the hospital.  He's got a complicated enough setup that I'd have a bit of sympathy on him.

But why can't he remember the names of his meds?


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## Shishkabob (Jun 3, 2012)

First thing out of my mouth when someone apologizes for calling "The ones who apologize tend to need us the most", which tends to put them at ease.  I've honestly never met an abuser who apologized for calling, but most of the people who've apologized were truly sick.

First thing out of my mouth when someone says they went, got tired of waiting and returned home to call 911:  "Patients are seen on a basis of necessity and are triaged.  If you are deemed to be able to wait, you'll wait in the waiting room with the rest.  Just because you arrive by ambulance doesn't mean you'll be seen faster"


Plus, triage nurses don't take too kindly to stories of "Patient came, didn't want to wait and called 911".  Especially with vitals like that and a complaint a week old and self-resolving.  Even with "one sided weakness" I don't see the patient going anywhere but the waiting room in all the local ERs if they're anywhere near busy.


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## Aidey (Jun 4, 2012)

A kidney transplant and enlarged heart by age 35 for uncontrolled HTN? That is pretty impressive non-compliance with treatment.


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## Veneficus (Jun 4, 2012)

Aidey said:


> A kidney transplant and enlarged heart by age 35 for uncontrolled HTN? That is pretty impressive non-compliance with treatment.



Sounds to me like there is a genetic enzyme deficency somewhere.

If such is the case, the meds may likely not work anyway.


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## Aidey (Jun 4, 2012)

Veneficus said:


> Sounds to me like there is a genetic enzyme deficency somewhere.
> 
> If such is the case, the meds may likely not work anyway.



Don't underestimate the ability of Americans to eat, smoke, and drug their way into very unhealthy places at young ages.


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## zzyzx (Jun 6, 2012)

So are you guys okay with an AMA, or should this get sent BLS, or what?


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## phideux (Jun 7, 2012)

I think I've had this patient before, repeatedly. He probably has been to all the local ERs, repeatedly. I'll bet he has been to a couple of them during the past week while he has been fighting that "headache". I'll also bet that he is allergic to Toradol, and most of the other Non-Narcotic analgesics, and the only thing that cures the headache is a narcotic. :wacko::wacko:
Like Linuss said, just because you come in by ambulance don't mean you get a free pass through triage.


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## DrankTheKoolaid (Jun 7, 2012)

Would actually bring him in ALS on my first encounter with him. Get a line and a blood draw and very specifically ask him when his last brain CT was.  If after a follow up conversation with the MD treating the patient- Read MD and not RN - that the ED doc after a full workup thinks he is drug seeking then future encounters with said patient would not play out the same way. 

Obviously this patient has either intrinsic issues or has extrinsic factors that caused this and the rest of his chronic issues.  Either why he has true pathology and should be approached as such.

Just because a patient is triaged out and back to the waiting room does not always mean it was the appropriate thing to do.  The triage nurse my have a jaded view of anyone complaining of a headache.  And %99.99 of the time it is probably accurate.  But who are we to say that this person isnt that minute fraction of a percent who actually needs the help.

After working with a ED Doc for 10 years and watching him write scripts for narcs and giving them out in the ED to patient we were all sure were drug seeking I asked him one day why he was doing it.  His answer which has changed the way I look at pain in patients and the way I teach patient care to paramedic student and expect out of other paramedics through the QA process is this.  " I may be giving narcotics 9 out of 10 times to drug seekers, but that is far better then not treating that 1 out of 10 patient that truely needed the relief".

The sooner your own personal convictions are removed from patient evaluation and treatment the better.


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## AnthonyM83 (Jun 7, 2012)

Was the right sided weakness x1 week also?
That's a red flag for me. 
Would probably be a red flag for the triage nurse too. Locally, if the hospitals are busy, don't think he'd be sent to the waiting room. He'd be waiting on our gurney in the ER hallway for however long it took (hours?) to get him an ER bed.


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## Veneficus (Jun 7, 2012)

zzyzx said:


> So are you guys okay with an AMA, or should this get sent BLS, or what?



I am ok with ALS ambulance to the hospital

That has a CT scan at least a neuro service and neurosurg would be a nice bonus.


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## zzyzx (Jun 7, 2012)

I don't remember how long his R sided weakness was, but it was resolved when I assessed him.

Anything else you guys want to do?


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## zzyzx (Jun 7, 2012)

Ever since I began working in the hospital, it made me think differently about pain management and drug seekers, though I don't actually have clearly formed opinions because I think this is a very complicated subject.

When I was working up on the floor, it was really a pain in the *** to give pain meds Q 2 hrs to people who clearly where not in pain and just wanted to get high. That said, if I was in the hospital and could get high legally and for free, hey, why not?! At one point I had a shift in my way of thinking and I just accepted that often my role was not as a healthcare provider but more like that of a cocktail waitress. It sucks to be in the hospital and be dealing with chronic medical issues, so can you blame anyone for wanting to get high? That said, is it a good idea that we are allowing patient to treat their psychological issues with narcotics? Anyway, no one can really judge if someone is in pain or just wants to get high or wants to not be depressed or has become addicted to drugs due to dealing with chronic pain or depression---it gets complicated real fast.

In the field we try so hard to figure out who is a drug seeker and who is not. I suppose part of the reason is that there's a lot of ego involved in being a paramedic, and we don't want to get fooled by a drug seeker.

In my hospital, I have seen many patients admitted to the floor who everyone knew (including the doctor) were just drug seekers. However, their story was good enough to get them admitted.

Like I said, I don't have clearly formed opinions on all this, and I'm only scratching the surface on this very complicated subject.

By the way, last night when I worked in the ER, we had a drug seeker come in, a guy who everyone knew because he was here so often, but this time his c/o pain was due to an aortic dissection. The surgeon told him he would die without surgery, but he had only a 10% chance of surviving the surgery due all his other issues.


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## AnthonyM83 (Jun 8, 2012)

zzyzx said:


> I don't remember how long his R sided weakness was, but it was resolved when I assessed him.
> 
> Anything else you guys want to do?



Do you mean as far as assessments? Like recent trauma, 12-lead even, full stroke assessment.

Or options for this patient? I wouldn't be comfortable denying him transport because of that transient right sided weakness. My old partner had a similar call...transported him...hour later came back to ER with a different patient and guy was unconscious stroking out...


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## zzyzx (Jun 8, 2012)

Like checking the patient's pupils.

His pupils are markedly unequal, with the R pupil not only dilated but also oblong shaped.

He tells you that his pupil has been like this for a week.

WTF??!!:unsure:


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## AnthonyM83 (Jun 8, 2012)

Crap, he's an alien!

http://server.myspace-shack.com/d17/normal2.gif


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## exodus (Jun 8, 2012)

AnthonyM83 said:


> Crap, he's an alien!
> 
> http://server.myspace-shack.com/d17/normal2.gif



I want contacts like that. Would be fun with my 5150's


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## AnthonyM83 (Jun 8, 2012)

Saw a fire medic wearing them for Halloween. We had a patient who was spazzing out from some kind of hallucinogen. Freaked the heck out when he saw her...


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## zzyzx (Jun 8, 2012)

AnthonyM83 said:


> Saw a fire medic wearing them for Halloween. We had a patient who was spazzing out from some kind of hallucinogen. Freaked the heck out when he saw her...



Or maybe she was just freaked out to be under the care of an L.A. fire medic.


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## AnthonyM83 (Jun 8, 2012)

zzyzx said:


> Or maybe she was just freaked out to be under the care of an L.A. fire medic.



That's a more likely explanation....


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## Melclin (Jun 9, 2012)

He'd be going with me to hospital.

I wouldn't be at all happy with someone leaving this pt at home. 

I don't know whats wrong with him but I think he needs a CT head in the not too distant future.


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## Handsome Robb (Jun 9, 2012)

Melclin said:


> I don't know whats wrong with him but I think he needs a CT head in the not too distant future.



Agreed.

At first read I'll admit I was leaning towards the "bull:censored::censored::censored::censored:" category but with other findings that popped up I'd be pressing hard to transport him. Also I'd be pushing pretty hard to get him into a room rather than triage. 

I'm sure he'd probably be fine with an ILS transport but ALS would be better.


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## zzyzx (Jun 9, 2012)

What is the most serious emergent condition that would cause his headache with unequal pupils. I did not know this myself, by the way.

Nope, it's not a bleed.


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## Aidey (Jun 9, 2012)

Herniation or acute glaucoma are probably the two that need the most immediate attention.


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## AnthonyTheEmt (Jun 9, 2012)

What about a tumor? That could cause a headache with a slow onset.


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## zzyzx (Jun 10, 2012)

Acute glaucoma is another emergency condition I didn't consider.

Herniation from a bleed is sort of unlikely due to his normal mentation and the fact that the pupil has been dilated for a week, but I suppose it should not be ruled out. 

A tumor is a definite concern, along with a whole bunch of other pathological causes for anisocoria, but it's not as emergent as something else that needs to be ruled out.


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## exodus (Jun 10, 2012)

Something with one of the cranial nerves?


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## Aidey (Jun 10, 2012)

zzyzx said:


> Acute glaucoma is another emergency condition I didn't consider.
> 
> Herniation from a bleed is sort of unlikely due to his normal mentation and the fact that the pupil has been dilated for a week, but I suppose it should not be ruled out.
> 
> A tumor is a definite concern, along with a whole bunch of other pathological causes for anisocoria, but it's not as emergent as something else that needs to be ruled out.



When you look at his history of uncontrolled HTN resulting in hypertrophy and renal failure that makes him a pretty good candidate for intracranial hypertension, which I believe can lead to herniation in severe cases.


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## zzyzx (Jun 14, 2012)

So, like I said I didn't consider this either, but the MD stated his main concern was that the unequal pupil + headache could be due to pressure from an aneurysm.


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## bstone (Jun 15, 2012)

One Dx that is greatly overlooked is CSF leak. As him if his headache is worse while sitting up or standing up but better after laying down. Any orthostatic changes in pulse and BP? Is the pain in the eyes and stabbing, with a dull throb near the occipital lobe? Might be a CSF leak. Pretty rare but usually completely missed.


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## zzyzx (Jun 15, 2012)

By the way, I don't know why this patient's pupil was not only dilated but also so oddly shaped.

I followed up on him and was told that his CT was unremarkable.


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