I recently had a case in the ER that reminded me of another from years ago. Here’s how it went down.*
A man in his late 50s came to the ER where I was working in Queens. He had a headache. He had never had one like this. He didn’t remember when exactly it started, but it had been mild at first. Then, it had slowly gotten worse over several weeks. Now it was really bothering him.
I looked him over and did a neurological exam. He didn’t have any difficulty with coordination. He passed all of the tests we do to assess the major nerves of the brain. His walking was fine. His speech was normal. He remembered no trauma. He took no blood thinners. He hadn’t had any changes in his appetite or weight,
When patients with headaches come into the ER, the big question for me is whether or not I should order any imaging, like a CT scan. Generally, it doesn’t take much to get me to scan older folks. The radiation is low risk and there are many dangerous problems that could have subtle findings on an ER examination in the elderly. On the flip side, I won’t routinely scan young people unless there’s a very compelling reason to do so. Even though the radiation is low, it’s not zero risk. A man in his 50s is probably somewhere in the gray zone. I tend to scan people this age with a headache that differs from any prior ones they’ve had, but even that is not a slam dunk.
I was already leaning towards scanning this guy. Then I asked a simple question.
“What do you do for work?” I said.
His answer led to a whole side conversation that took me aback and sealed the deal. Not only did I want to a CT scan of his brain, I wanted it done right away. Here’s what he said:
Keep reading with a 7-day free trial
Subscribe to Inside Medicine to keep reading this post and get 7 days of free access to the full post archives.