What is The Diagnosis?
12 May 2012
How would you like to save a life this week? After all, it’s not only doctors who are involved in life or death situations. So all you have to do is remember this column.
A report in the Canadian Medical Protective Association (CMPA) bulletin shows that one of the best ways to diagnose a problem is to think about its possibility. One of the best ways to miss the diagnosis is to ignore it. This sounds like a simple rule, but doctors are not robots. They can and do miss important diagnoses that may result in either severe disability or death.
For instance, a 61 year old male, a smoker with a history of high blood pressure, was punched on the left side of the head during an assault. There was no loss of consciousness and all the patient complained of was a mild left-sided headache and tenderness of the scalp.
But 12 hours after the incident he experienced onset of severe left-sided headache along with numbness of the right arm, right leg and vomiting. Thirty-six hours after the onset of the headache he was finally admitted to a small community hospital.
Examination showed that his heart rate and breathing were normal as was a neurological examination. He was given medication to control the vomiting and was discharged with the diagnosis of concussion.
The following day he returned to the emergency department with the same symptoms. His neurological examination again proved normal. He was given intravenous medication for nausea and discharged again with the same diagnosis.
The next evening due to the persistent headache he returned to emergency and was seen by a neurologist. A CT scan showed a subarachnoid hemorrhage and he was transferred to the care of a neurosurgeon at a larger hospital. Angiography showed three small aneurysms that required surgery. Three days later he became confused and a CT scan showed marked spasm of the brain’s arteries. Ultimately, he was left with significant mental and motor problems.
Subarachnoid hemorrhage means bleeding between the brain and the thin tissues covering it. Sometimes this cerebral aneurysm will spontaneously rupture or is the result of trauma in young people following a car accident or from a fall in the elderly. It’s more common in women and high blood pressure can be a factor. In some cases there is a family history of subarachnoid hemorrhage.
Usually, if there’s been no trauma, the main symptom is a severe headache that starts suddenly and is often worse at the back of the head. Always be on the alert if a patient says, “It’s the worst headache ever.” This is exactly what I told the doctor when I awakened one morning in my final year at the Harvard Medical School. In my case the headache to end all headaches was due to poliomyelitis.
Diagnosis of subarachnoid hemorrhage is made by CT scans, MRIs and angiography. But even if a CT scan is done, the diagnosis can still be missed if there has been only a small amount of bleeding. But the sooner the diagnosis has been made and the bleeding stopped the greater the chance of recovery. Of course none of these diagnostic tests will be done if doctors are not thinking about the possibility of subarachnoid hemorrhage as happened in this case.
Don’t forget that during our lifetime many have been hit on the head and developed a headache without getting a subarachnoid hemorrhage. But you can help to save a life if , following a blow to the head, there’s also neck pain, vomiting, a seizure, numbness in any part of the body, mood changes, confusion, increased irritability and decreased consciousness. Or, be on high alert it there’s no history of injury and suddenly someone says, “I have a headache to end all headaches, unlike any other headache”. This is the time to call 911. Today, the medical consumer, by becoming better educated, doesn’t always have to be a doctor to save a life.
