Case and Honest Question

[jmj11]

I would like to see what you think about this case and I will discuss it later.

 

A 54 year old Hispanic man was struck in his occiput when a metal box containing pipe fittings, weighting about 80 lbs., which fell off a forklift from 10 feet up. He fell and had a brief moment of unconsciousness. He was taken to the ER and had a CT and was normal. He was dazed for about a week with dizziness and memory problems. The later symptoms seems to have resolved.

 

Since the accident, 20 months ago, he has suffered with 5-9/10 throbbing headache, centered in his occiput, which has greatly impacted his quality of life. When it is severe he has nausea, photo-phobia and even vomiting.

 

Past Medical History: HTN otherwise unremarkable. Never had headaches before. No family history of headaches.

 

Objective: Exam is normal except for tenderness around his occiput and some discomfort with the rotation of his neck in both directions.

 

He has had the initial CT of his head, which was normal. He had a subsequent MRI neck and head, which were normal.

 

Tx: He had PT, which did help his neck 50% but then L and I denied further treatments. He was followed by a headache clinic for 12 months where he saw a outstanding headache PA (:wink:) and diagnosed as chronic post traumatic headaches (International Headache Society Criteria: ICHD II 5.2). L and I denied all treatments until the previous two months including medications and occipital nerve blocks. He has had 20% improvement with Depakote ER 500 MG per day.

 

Social Hx: He has worked hard in industry and has never had prolonged absences.

 

He was sent for an "independent" Medical exam by a neurologist. The final impression was:

 

"The gentleman has stress headaches, which are totally unrelated to his injury, which is confirmed by a normal brain MRI."

 

His past and future L and I claims have been denied regarding this event based on the neurologist's findings, which trumps the impression of a PA.

 

So, what's your thoughts?

[gebaldwi]

#1 Is the neurologist implying the "stress" headaches are tension HAs?

#2 Seems odd his stress HAs started immediately after his accident.

[andersenpa]

It would be interesting if his dx was different if he was blinded to your credentials on the notes.

By your quotes are you saying the neurologist is an insurance industry guy?

 

And- by IHS guidelines can you have chronic post traumatic headaches with a nl MRI?