becksdad Posted October 19, 2006 Posted October 19, 2006 Forgive my ignorance, but do chem panels include specifics for pituitary, thyroid, and adrenals? Lets look there, and CT of head/neck, as well as others mentioned. You realize I'm grasping at straws here......
Callthemedic Posted October 19, 2006 Posted October 19, 2006 Attention all passengers, the captain has abandoned ship. This is no way to stop the sinking of this one. To try to answer all questions in one reply: No snake bites. House built 3 years ago, electric stove. It never seems to wake her up, but is present when she wakes up. It goes away after she has been headache up for a few hours. The only nightmares she has is the ones of becksdad (man I feel bad for beck, if only he knew what his dad was doing) in her leather. No palpitations, memory seems intact. VS are pretty much the same as they were. So to recap this is a middle-aged woamn with h/o htn dx one year ago who seemed to be well controlled on atenolol who is c/o a right sided headache when she wakes up every morning for the past week. No other headache history. Pain is nonradiating and is usually relieved after she has been up for a few hours. She has some nauseousness, but no vomiting or visual distrubances. The is no neuro deficit on exam and the exam is otherwise unremarkable. You arrive at the ER and the doc says he's too busy for someone that sounds like something so benign. He tells you to write the orders and he'll cosign them. What do you want to order? Just popped in and saw this thread. I would check the bedding before ordering tests for some obscure zebra. Maybe she has severe bedhead (aka tight rows). Maybe the .38 she hides under the pillow is giving her a special type of cranial bed sore. Tests?? How about visual inspection first? Let's not go right to the invasive procrdures on the first date.
Callthemedic Posted October 20, 2006 Posted October 20, 2006 Although Hammer threw the "parasite card" on the table, nobody suggested visual inspection??? ERdoc has you all at the ER and none of you have laid your hands on your patient yet? Are there skill sheets I'm not aware of since I've been out of the loop?? Just saying........first tool out of the bag is your five senses. Use your sixth sense to know when something isn't quite right, but never before the others.
chaser Posted October 20, 2006 Posted October 20, 2006 chem panels are different but I wanted lytes, bun, lft, cardiac enzymes just for a basis...just searching. probably also a red tube for typing (just in case) Most interested in the UA results. Poss add to chem TSH, FSH.
ERDoc Posted October 20, 2006 Author Posted October 20, 2006 I will try to address everything that has been suggested. MRI, not going to happen in the ER, "No paralysis, no analysis." Blood cultures will take 5 days (what is the indication?). CT neck and chest, expensive tests. Please justify these $1000 tests on someone with a headache. ABG, why do such a painful test on someone with goods sats and no c/o resp distress? TSH will not come back in a reasonable time. FSH, not going to happen. ER docs are simple folks and this is too complex for them to understand (I wouldn't know what to do with it if I did order one) and will probably take a while to get back. UA good thought, but negative (I'll even tell you that the HCG is neg). CBC and chem 10 wnl. LFTs, although not indicated, are also normal. Pituitary and adrenal testing not practical in the ER. Cardiac enzymes (again, not indicated) are wnl. From an ER standpoint, the only workup this pt warrants is a head CT, and you could make an arguement for CBC, chem, UA, HCG. Although I am will to argue otherwise. Obviously if you find something in those you may need a further workup.
chaser Posted October 20, 2006 Posted October 20, 2006 Ok ERdoc- I just want to slap you. What already??? You are such a tease......
MrSpykes Posted October 20, 2006 Posted October 20, 2006 What about a pregnancy test? Also, when does she take her Attenolol, morning or at night? If its in the morning, do her headaches feel better after she takes it. She just simply has a headache. She needs to just wake up every morning, take her shower, drink a cup of coffee and if after an hour she still has a headache take a couple Excedrin and get over it!
EMS49393 Posted October 20, 2006 Posted October 20, 2006 Transport of a patient with a chief complaint of a headache. Get a comprehensive history. Do a full assessment. Everything appears to be within normal limits with this patient thus far. Give Oxygen, a few liters by cannula is acceptable. I'd start an IV, and do a blood draw and glucometry. Our system utilizes prehospital blood draws, so I try to save the patient the extra stick. I like to get a BGL because I have the blood, and you never know when you're going to get that strange patient that did not know they had a BGL of 400. I'd give an anti-emetic if they have nausea, preferably Zofran. Dim the lights and transport. This is a headache of unknown etiology. Neuros are intact, and it appears to be somewhat chronic which leads me to believe it's not an acute stroke. We put all our IV starts on the ECG monitor, not that I think she needs it, but because it makes my CQI guy happy. As for being able to order what I want in the ER... I'd order a CBC because I'd like to make sure the blood counts are normal. I'd order a head CT. Let's see what the CT shows before we get all blown away with spending thousands on tests this patient probably doesn't require. I would consider two things in the event of a negative CT. Psychiatric, or sleep apnea. A good clinician can generally get a feel for whether a patient requires psychiatric intervention during their examination and questioning. She may get a psychiatric consult, and if she's not a danger to herself or others, be referred to a psychiatrist for evaluation and treatment. Sleep apnea is an outpatient deal and she'd be referred to follow with her PCP for a consult with a sleep disorders center for a sleep study. I may feel good and write her a script for Toradol if I suspect her headaches are sleep apnea related to get her over the hump until she gets a sleep study. It's very difficult do get a feel for a "patient" without laying eyes or hands on them. I do enjoy these scenarios, I just enjoy my real patients a lot more.
Callthemedic Posted October 20, 2006 Posted October 20, 2006 Ok then, fine ER Doc, what do I see and feel on visual inspection of the side of her head with the pain? What do I feel if the side of the head where the pain is coming from is palpated? Do I smell anything unusual that might indicate infection or poor hygeine? These are basic physical exam questions that have not been addressed. Everybody is ordering lab magic and it could be some old Cracker Jacks tangled in a hard mass.
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