Dreaded Dizzy answer

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The pretending wanted to admit the patient for syncope.  The attending wanted to scan the patient’s head.  The med student wasn’t sure what to do.  The chief was 5&2’ing somebody in Trauma 3 so he wasn’t involved at all.

The patient has bilateral subacute sdh.

First of all, anyone who saw the patient would agree that getting a head CT was not an obvious decision.  The guy was fine.  He had a normal neuro exam, he wasn’t in any discomfort, and he’s walking around in the ED.  When the case was presented last week at follow-up, everyone wants to get a head CT because it’s a conference case.

There are two main teaching points here.  (1) Headache + vertigo is a concerning combination.  However, patients cc this combination all the time, and the trick is to figure out who has tension HA + peripheral vertigo (or nada), and who has something more serious (see point #2).  (2) The way to decide whether to scan a patient for a headache is to look at the patient and decide whether he has a genuine headache.  I don’t go the “first, worst, different” route because it’s non-specific because 99% of ED HA patients say yes to “first, worst, different”, and you can’t scan everyone.  I get 100 patients cc HA a day, but it’s extremely rare that I ever think that the patient has a genuine HA.  Some of the things that I use to read a patient are: (a) they only cc headache and nothing else, (b) they look like the HA is bothering them, (c ) the headache does not seem like a migraine in character, (d) the patient is someone who wouldn’t come to the ED for a minor problem.

When I talked to this guy, I just could not get away from his HA cc.  However, I did not put “rule out bilateral sdh” on his ct request.

In general, bilateral chronic sdh are a disease of older patients.  They are generally very asymptomatic.  They never have focal findings.  They rarely have a headache.  The common deficit that I see is that they may not be able to walk, or they walk poorly, but it’s not an ataxic gait.

The resident was upset he missed this case.  It’s ok.  If you miss a case because you were flippant, then it’s not ok.  He had never seen a bilateral sdh before, so it’s an understandable miss.  The patient had a normal neuro exam, a generally reassuring finding.  If we sent the patient home, he would have been fine.  Nothing terrible would happen to the patient, but he would likely bounce back in a few days – weeks.
The patient was admitted.  There’s very little work-up for these chronic / acute-on-chronic bilateral subdurals.  Generally, there’s no medical reason for getting the bilateral sdh, and there’s no underlying problem (e.g. coagulopathy) to fix.  They are followed by neurosurgery and electively operated on or observed.



The patient was observed for a couple of days, then went to neurosurgery clinic.  A few weeks later, the sdhs were drained because the pt was persistently symptomatic, and the collections got a little bit bigger.  He did fine.

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