46 Year Old Male with Headache

46 Year Old Type 1 Diabetic Male With New Onset Persistent Headache

Patient presents to the urgent care near closing time. I am working with a resident who goes to eval the patient. Resident presents a case to me of a 46 yo type diabetic male that’s fairly well controlled with a new onset headache starting about 5-6 days ago. The headache is at the crown of the head and persistent. Not severe but he is tired of it. This evening the headache was slightly worse. Resident reports nothing else and reports a perfectly normal neurovascular exam.

No history of trauma.
No history of brain tumors, no history of brain bleeds.
No blurred vision.
No localized neurologic complaints.
Drinks coffee.
Minimal alcohol consumption.
No new medications. No blood thinners.
No recent travel.

Current Meds: Benazepril, Insulin

Vitals unremarkable. BP 138/84
Resident’s exam from head to toe completely normal except for mild neuropathy that’s at baseline.

I got to speak to the patient because I want to confirm the cranial nerve exam. I introduce myself and patient is flustered, he is tired of waiting, he really doesn’t want to repeat the entire story to me and wants to go home. I do a brief rushed cranial nerve exam and ask him more questions. I pause, give him time to think, allow me time to think. He then says “The only weird thing is that when I go to lift my Kayak the headache worsens every single time”. Based on that I told him he needed a head CT which nearly made him blow his top (he needed to go to the nearby ER to get this done). He basically said that if I wasn’t going to get him pain relief he would leave. The whole time he actually was very courteous but flustered. I leave the room to get the AMA form (after contemplating of at least trying a ketorolac injection for his pain) and the resident convinces him to get the CT.

Diagnosis: Subarachnoid Hemorrhage
Confirmed: By CT, non-contrast.
Outcome: Neurosurgical intervention, successful surgery, admitted to ICU. Discharged after 7 days.