Headache and serious headache
A middle aged male presented with a GP referral for further evaluation and management of severe hypertension with an office blood pressure of 220/110 mm Hg. On presentation to our ED triage, his blood pressure was 126/85. His presenting complaint to his GP was headaches. It was around midnight and the department was on ""skeletal staffing"" for the night and attending to several critically ill patients (requiring intubation and mechanical ventilation). As he was alert, ambulant and did not exhibit any focal neurological signs on a brief screening examination, he was moved quickly into an observation bed for review later. Several hours later (with cessation of the surge of critically ill patients), a more detailed history and physical examination could be performed. In order to get an idea of the progression of his presentation, I persuaded him to trace out the temporal relationship of his pain score and time. What started out as a gradual onset of headache was punctuated by an abrupt steep worsening which gave me sufficient conviction to get our radiologist and radiographers to get him a CT of his brain after hours. CT brain showed an acute subdural hematoma (spontaneous as there was no reported injury). He was admitted and managed conversatively with good outcome.
This is the first occasion where I have asked a cooperative and cognitively intact patient to describe the temporal characteristic of their pain (headache. This experience reinforced the importance of eliciting the characteristics of the onset of symptom of pain. Often, patients presenting to the ED will describe their pain as acute, sudden, severe etc. The use of visual representation provides an invaluable opportunity for the physician and the patient to clarify on the severity and importantly the onset.
Since then, I have used this technique more often, in appropriate patients, to obtain vital information in my bid to rule out life threathening causes.
The image presented is the original hand drawn graph depicting and temporal relationship of pain. This image and lesson have been shared in many of my teaching sessions in particular with medical students and junior doctors to reinforce the age old adage of a good narrative history can help determine more than 80% of diagnosis (clinical problems).
