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Would you head CT this?


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nope. an FP clinic can miss anything they can't work up. they can't do cardiac enzymes or CT a head. that's why they say "go to the ER".

you hear stories all the time about pts who saw their doc in clinic the prior day and died and nothing happens. when EM clinicians send folks home and they die and they really should have known better they generally get canned and/or sued. you can get it right 4999 times/yr, but miss it once and you are careless....also, PAs are held to a much higher standard than docs in every setting. "A doc never would have missed this" is how every PA case gone bad starts....

 

 

I was thinking about this discussion last night (while waiting for head CT results to come back as a matter of fact... not on a headache, though).  I had a couple questions I couldn't answer for a variety of reasons.

 

We who work in the ER are held to a different standard as expressed in the comment I quoted.  Get it wrong just that once, no matter how many times we got it right, and we're in for a world of hurt.  Are there ways that we can mitigate our risk?  Or is this really, as I've heard argued before, really just a fact of what we do and the environment in which we work?  A fact that we either agree to when we accept the job or find another specialty in which to work?

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I scanned through the posts, so if someomne mentioned this forgive me.  I dont recall any one here suggesting pseudotumor cerebri though.  Neuro consult is the end result, but this Pt's bio,history, HPI soulnd a lot like PTC as well.

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I scanned through the posts, so if someomne mentioned this forgive me.  I dont recall any one here suggesting pseudotumor cerebri though.  Neuro consult is the end result, but this Pt's bio,history, HPI soulnd a lot like PTC as well.

 

jmj mentioned doing a good fundoscopic exam earlier, and equated to a "poor man's MRI".  It's not doing an LP, but with at least seeing or not seeing papilledema you know if you need to head down the road of pseudotumor

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I've never had a case of pseudotumor without seeing papilledema first.  There may be some cases where papilledema has not occurred yet.  

 

We have a pseudotumor guru in Seattle (neuro-ophthalmologist) who I've sent patients to for a second opinion. For example, a local neurologist dx a lady with pseudotumor based on an ER opening pressure of 30 CM and she had been on acetazolamide. I was doubtful based on the nature of her headaches and perfectly clear optic nerves.  I sent her to this neuro-ophthalmologist and he  gave a confident no to the diagnosis based simply on the presence of SVP (spontaneous venous pulsations).  He is convinced that while very rarely you can have pseudotumor without papilledema that you can never have pseudotumor with SVP.  

 

I usually have no trouble evaluating the optic nerve head with the panoptic for edema. However, I have a very hard time seeing SVP in the undilated eye. If I see it, I'm confident that it is not pseudotumor. But if I don't see SVP, it could be that they are there and I just can see them.

 

Here is a nice video of SVP. I wish it was always this clear.

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“Much worse than any HA she has ever had” = CT with recommendation for an LP. If the patient has a lengthy migraine history that has been worked up by neurology with prior CT/MRI, then I am less inclined so long they are experiencing baseline symptoms (which this patient is not) and no neurological deficits suggesting cerebral fat embolism, meningeal irritation, pseudotumor cerebri etc. 

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  • 1 month later...

CT would be looking for what, exactly, in this patient? A CT for blood this far out from onset is worthless. A CT for a neoplasm is far inferior than MRI. Other headache conditions are also unlikely to be diagnosed with CT at this stage.

 

An MR and/or LP would be much more useful. Not to mention, radiation free.

 

 

Sent from my iPhone using Tapatalk

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  • 4 weeks later...

Eric, we have had a similar case where I work. The FP doc is not off the hook.  Still litigating.

 

This is not an acute onset headache.  Patient meets no criteria I am aware of warranting a CT.  Treat as a migraine, follow-up with neuro.

 

G
 

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