EM Forum Case #159 "I Don’t Want to
Stay."
by Charlene Babcock Irvin, MD, FACEP
A 41 year old male presents to the
hospital for evaluation of a headache that
he had last week. The headache is gone, but
he followed up with his doctor, and he
ordered an MRI, which revealed a possible
aneurysm. So he sent him to the ED for
evaluation.
He is completely normal
now, and has no complaints. The headache
that prompted the MRI occurred eight days
ago. He works at a toy store, and was
stocking some items on the top shelf. As he
looked up, he developed a sharp pain in the
back of his neck and head area. It was so
severe; he had to get down off the ladder.
It made him very sweaty, and he almost threw
up. He thought he strained his neck, and
left early to go home. The headache and neck
pain persisted all that day, and he called
his doctor who couldn’t fit him in for two
days. When he saw his doctor, his headache
was gone, but his doctor ordered an MRI,
which was then done four days later. His
doctor called him today with the report, and
told him to go to the ED.
ROS:
Negative
PMH: Hypertension
SH: Smoker
(1PPDx 15yrs)
FH: No history of aneurysm
PE: BP=132/78, HR=78, RR=20, Temp=98,
Sat(RA)=98%
Exam: Normal
Questions:
1. What are the grading
scales to clinically grade SAH?
2.
When does Xanthochromia of the CSF appear?
When does it disappear?
3. Does he
need to be admitted if he is completely
asymptomatic? Or can he see the Neurosurgeon
as an outpatient?
4. What important
questions should you ask the neurosurgeon
when you call him?
5. Are there any
decision rules to help predict the risk of
SAH in patients with headaches?
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