Working with Headaches Part I: Musculoskeletal Headaches (Myofascial Techniques)
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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.
➤ 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!!
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
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
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
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
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
➤ 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
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
➤ 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
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