Can you make the diagnosis?

A 45-year-old male patient has had a rough day at the office.  He has very demanding clients, and his secretary has just given her two week notice.

At 4:10 pm, he has the onset of a severe headache, that hits suddenly, like a thunderclap.  He lays his head on his desk, hoping that it will pass. He has never had a headache like this before.

His past medical history is negative for any significant medical problems.  He has never had a problem with headaches.

Should he:

  1. Continue working and wait for it to pass;
  2. Take an Advil and call his doctor for an appointment next week;
  3. Got to an Urgent Care,
  4. Go to the Emergency Department



If you guessed go to the Emergency Department, you are right!


Once at the Emergency Department, the triage nurse checks the patient.  He does not have a fever, but his blood pressure is 150/90 (elevated).  He is alert and is not confused.

The Emergency Physician sees the patient and orders a CT scan, which is negative.

What is the next step?

  1.  The patient should feel good about his negative CT scan, and go home.
  2.   The Emergency Physician should order a blood test.
  3.   The Emergency Physician shoulder perform a lumbar puncture (spinal tap).
  4.   The Emergency Physician should give the patient a prescription for Valium for his stressful job and send him home.



If  you chose 3, perform a lumbar puncture (spinal tap), you are right!  A CT scan will not always show a subarachnoid hemorrhage, which this patient has.

One in every 50 people in the United States has an unruptured cerebral aneurysm.  When these rupture, it can cause a severe headache, “thunderclap headache”.  Forty percent of the time, this is fatal.

But for patients who make it to the Emergency Department, the CT scan will often be normal.  Further testing such as a lumbar puncture or MRI is required.  The aneurysm can then often be treated successfully.



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