The patient suffered from persistent headaches and a sudden loss of consciousness during the examination, for reasons no one could have imagined.

01 The 48-year-old patient came to see a headache and was admitted to the emergency room eleven years ago, in March, in a cold spring
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The emergency room was full of patients, and just after Zhao Dadan finished nursing Uncle Wang in bed 1, he was called over by the patient in bed 5
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"Nurse, I still have a headache.
Does this potion have any effect?" The patient looked a little sad and a little irritable
.

Zhao Dan thought to himself, "Half of this bottle of mannitol has just been lost.
Maybe it's not time to show the effect yet?" But she didn't say that, but helped the patient again and explained: "Don't worry, I'll ask the doctor again for you
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" The headache patient is a 48-year-old male patient with a history of high blood pressure.
He took medication regularly on weekdays.
He came to the hospital because the headache persisted for three days without relief
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After arriving at the hospital, the triage office found that the patient's blood pressure was as high as 210/120mmHg, and the headache was obvious, so the patient was sent to the emergency room
.

When he first came to the emergency room, the patient still had some resistance, just like other patients, he thought: "I have no big deal, I just have a headache and high blood pressure, so there is no need to mobilize people to see the emergency room
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" He didn't interrupt him, but listened patiently, waiting for him to finish his doubts and dissatisfaction
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Not only because patients have the right to express their opinions, but also because if you want to win the trust and cooperation of patients, the first step you need to do is to listen, just like an old friend
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Faced with this situation, the most important thing to remember is not to play temper tantrums and engage in emotional confrontation like the patient
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When the patient finished speaking, I told him: "Your blood pressure is as high as 210/120mmHg, it's not as simple as a little higher
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With such a high blood pressure and persistent headaches, don't you worry about what's going on in your head? The patient didn't speak, but still felt a little dissatisfied
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I continued to chase after the victory and explained to him: "There is no problem with people assigning you to the emergency room.
In your case, it is almost a hypertensive emergency
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The blood pressure suddenly rises above 180/120mmHg, and there may be damage to important organs such as the heart, brain, and kidneys
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"Speaking of this, the patient seemed to suddenly remember something: "You said no, I take medicine for high blood pressure, and there was no problem with the blood pressure test last week, that is, it started to rise in the past two days
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"After a short communication, the patient gradually calmed down, and changed from not understanding to starting to cooperate, and even took the initiative to ask for an examination: "You can do a CT examination for me, I am also worried about whether there will be a cerebral hemorrhage
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"The patient sat in front of me and told me some stories about cerebral hemorrhage that I had heard
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Listening to him, I was still wondering: "Since you yourself understand that high blood pressure can bring these terrible consequences , and why did you come to the hospital after a sudden increase in blood pressure and a headache that lasted for three days? "The patient smiled a little embarrassedly: "Don't you think you are young!" "Many young and middle-aged patients have such a fluke mentality.
They always feel that their physical strength will not be a big problem, and even if they have some symptoms, they are reluctant to come to the hospital easily
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The second reason is that they are psychologically unwilling to accept the fact that they are ill
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Why, most of the sudden death patients encountered in the emergency room are young and middle-aged men, although there are many other reasons, but the physical condition The blind self-confidence of the patient is also an important reason
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After opening the examination list, I called Zhao Dandan and asked her to find someone to accompany the patient to do the examination.

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I've always suspected that there was something wrong, such as the most common type of cerebral hemorrhage, in this middle-aged patient, who was at ease and responsive, because the patient not only had high blood pressure, persistent headaches, but also frequent vomiting
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Although no typical projectile vomiting was seen, it cannot be ruled out that it is a manifestation of cerebral edema and increased cranial pressure
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For a patient who has suffered from high blood pressure for many years: sudden increase in blood pressure + headache + vomiting, it may completely mean that there is a god of death hidden in the shadows waiting for the opportunity to harvest the patient's life
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Zhao Dandan found a master nurse and asked him to personally take the patient for a head CT, and instructed: "If there is any problem, just call and I will push the car over there
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" The nurse grinned and said: "There won't be any problem, you can see that the corners of his mouth are not crooked, and his hands and feet are not paralyzed.
.
.
" After a while, the patient's head CT examination was completed.
Just as the nurse had predicted, nothing was found.
problem
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First of all, there must be no cerebral hemorrhage.
If it is cerebral hemorrhage, head CT can detect it immediately
.

Second, no obvious infarction was found.
If the patient has acute cerebral infarction, it has been three days, and at least some clues such as ischemic penumbra can be seen on head CT
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However, the current head CT did not show any abnormality
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"I'm relieved if there is no problem
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" The patient also began to relax after learning that there was no problem with the head CT
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Although no problem was found in the examination results, I did not relax my vigilance, because the patient's blood pressure remained at about 190/100mmHg for an hour after taking oral blood pressure-lowering drugs, and the symptoms of nausea and vomiting were not relieved
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If there is no obvious abnormality in the head CT, does it necessarily mean that the patient has no problem? The answer is no
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It is possible that some problems have not yet manifested, or that there is a problem with the diagnostic idea
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After all, there are many causes of headaches in patients, and high blood pressure is only the most conspicuous of them
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02 The examination found no problem, but I took the patient into the emergency room.
I took the patient into the emergency room, arranged for him to lower blood pressure and symptomatic treatment, and arranged some other examinations
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The blood test found some clues, but it didn't seem to be specific
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In a large number of examination reports, only the white blood cell count, platelet count and erythrocyte sedimentation rate were slightly elevated
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The patient was lying on the No.
5 hospital bed and was infused with sodium nitroprusside and mannitol, but there was no obvious effect
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Zhao Bold found me: "Go and explain it to him, it looks very painful, and the mental state is a little bad
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" I was dealing with the doctor's orders of other patients.
See if there are any missing questions
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Now that Zhao Dadan found me, I came to the patient's bed again
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"Isn't it better?" The patient's blood pressure has dropped to 165/105mmHg, and other vital signs are within safe limits
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As a rule of thumb, the patient's headache symptoms should be relieved a little
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However, the fact is that the 48-year-old male patient's headache symptoms did not ease
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"Isn't the root cause of the patient's persistent headaches not high blood pressure? Is high blood pressure just a coincidence?" As I performed the neurological physical examination for the patient again, I quickly thought about what else I missed
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Headache refers to pain above the baseline of the orbital orifice, and this patient is indeed a headache
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Common causes of headaches are migraine, tension headache, cluster headache, trigeminal neuralgia, traumatic headache, infectious headache, mental headache, withdrawal headache, headache due to intracranial disease, and poisoning.
headache
etc.

In the face of a headache sufferer, these are all things to consider
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But what kind of disease is hidden in this patient's body? Vital signs were almost unremarkable except for elevated blood pressure
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Pupils were normal and no pathological signs were elicited
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Traumatic headaches are the first to be ruled out because at a glance there is no trauma or scarring left after trauma
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Could it be the headache caused by acute intracranial infection, but the patient reported that he had never had a fever in the past two years
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Headache caused by increased intracranial pressure cannot be completely ruled out, but the patient has no symptoms such as vision loss and visual field defect
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Could it be the cause of increased intraocular pressure? An ophthalmological consultation has completely ruled out the possibility of increased intraocular pressure and headache due to acute glaucoma
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Trigeminal neuralgia, acute herpes zoster, TOLOsa-Hunt also seems unlikely
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For a time, the diagnosis was deadlocked
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"Another CT scan?" Although the CT scan two hours ago did not reveal any obvious problems, after all, two hours have passed.
Maybe there will be new changes? I have no opinion on the examination of the patient, but I am considering whether to ask the neurology department or cardiovascular medicine department for consultation after the reexamination, or to go to the reexamination after the consultation? "If there is no problem in the re-examination, will you do a lumbar puncture for him?" Zhao Dandan was a little worried that the head CT might still have no positive results in the re-examination
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Then wait for the consultation before making a further decision.
Although the patient still has a headache, fortunately, the vital signs are still stable
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While waiting for the consultation, I asked Zhao Dandan to ask the patient for some medical history information again
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Although I myself have asked for relevant information many times, I am worried that there will be omissions in the patient's answers, sometimes inadvertently, and sometimes even concealed
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Therefore, it is very necessary to collect medical history information for the same patient multiple times
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Sure enough, Zhao Dandan got two important pieces of information: First, the patient not only took antihypertensive drugs orally, but also took a certain brand of isosorbide mononitrate orally for three days
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Second, the patient traveled frequently in the past six months, with irregular diet and poor sleep
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Could the patient's persistent headaches be caused by isosorbide mononitrate? Some patients do experience headaches after using isosorbide mononitrate, and the half-life of this drug is 4-6 hours, and it takes longer to clear from the body after stopping the drug
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However, Lao Zhang, who came to the Department of Cardiovascular Medicine for consultation, denied this possibility
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Lao Zhang said that some patients may experience vasodilatory headaches caused by nitrates in the early stages of medication, as well as facial flushing, dizziness, orthostatic hypotension and reflex tachycardia
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The main cause of the drug's headache is the dilation of blood vessels, and the patient started taking this drug as early as six months ago
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He said it well.
If it was caused by this drug, then the patient should have had headache symptoms as early as six months ago, and the blood pressure will not be so high now
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After Lao Zhang wrote the consultation opinion, he patted his butt and left
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I was still puzzled, so I had to urge the neurologist to come to the consultation again
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The neurology consultation doctor is Dr.
Li, a deputy chief physician with rich clinical experience
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He first performed a detailed physical examination of the patient, and then read the patient's head CT again, and finally came to the conclusion that infectious headache and acute stroke are not very similar
.

"But the patient's blood pressure has dropped significantly, but the headache has not eased.
Do you have any constructive suggestions for the next step?" Brain tumors and primary headaches are just the most common causes, and many are rarer or even never seen before
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"Let's check again
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" Dr.
Li said
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"Is it a review of head CT, or MRI? Or CTA+CTP?" I have to listen to Dr.
Li's opinion on which examination to take priority, after all, she has more experience
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Dr.
Li thought for a while and replied, "Let's do an MRI, and also have the blood vessels done, and the patient can tolerate it
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If the MRI still doesn't find any problems, he will be admitted to the ward for further examination
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If any problems are found , solve any problem if there is any problem
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"The patient has no opinion on this arrangement, let alone the dissatisfaction when he first came to the emergency department
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03 The patient just finished the MRI, but suddenly lost consciousness.
Although the patient agreed to further improve the head MRI, the list in the MRI room The queue is already full.
If the queue is left, there will be no space until nine o'clock at night
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I can wait, but the patient can't
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After several communication, I finally won the first place for the patient by sacrificing the time for my colleagues to eat lunch.
The opportunity to improve the MRI for a while
.

On the way to send the patient for MRI, I continued to ask: "What exactly do you do? Why do you always travel? "The patient didn't think much about it, thinking that I was just chatting with him: "If you do sales, you have to run all over the country
.
"
I can't eat well, I can't sleep well
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"His words suddenly made me realize a little: "Have you ever been to the South?" "Go often!" "Have you ever eaten raw meat?" Raw pork? Raw fish? and so on
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The patient patted his head, thought for a while, and replied, "Should he have eaten it?" Often have BBQ there
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I got so angry that I got several pimples on my face! ""Probably so
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But don't you think it's a little strange to have pimples at 48? Waiting for the MRI results to come back
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"I helped the patient into the MRI room and waited outside with his belt key
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Just after the MRI, the patient's condition, who had been relatively stable, suddenly took a turn for the worse
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Staring up, foaming at the mouth, twitching! "No, I'm having a seizure! "Zhao Dandan and I hurriedly held the patient down to protect his respiratory tract, and then called for help.

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After a period of stabilizing the veins, the patient's epilepsy symptoms were relieved
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"Isn't it still fine just now? Why did it suddenly happen? Did he have epilepsy before?" Zhao Dan, who was sweating profusely, began to wonder
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"He didn't have epilepsy before, but I already knew the answer!" Although the MRI results have not come out yet, I have vaguely guessed the answer
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Sure enough, MRI found that the patient's intracranial venous sinus flow space disappeared, and the direct sign of MRV was the absence of high blood flow signal in the normally developed venous sinus, suggesting venous sinus thrombosis! So far, the patient has had headaches for three days, and the root cause of the sudden seizure during the examination has finally been found: cavernous sinus thrombosis! The cause of cavernous sinus thrombosis has nothing to do with high blood pressure, but has a great relationship with the patient's so-called "getting on with acne"
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04 The culprit is not high blood pressure at all, but an inconspicuous "pimple".
In fact, the patient's face some time ago was not pimples at all, but boils
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Cavernous sinus thrombosis is a serious and life-threatening disease.
Typical patients with cavernous sinus thrombosis can present with external ophthalmoplegia, mydriasis, blurred vision, frontal pain, proptosis, and conjunctival hyperemia
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However, what needs to be more vigilant is the cavernous sinus thrombosis without typical symptoms like this patient
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After the diagnosis was made, the patient was eventually saved
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Thinking back to this case again, I still have some lingering fears
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At that time, it was only considered that the patient had no trauma, but the scab that had just healed on the patient's face was not considered
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When I first saw the patient, I was confused by the patient's high blood pressure, but did not expect that the symptoms of persistent headache had nothing to do with high blood pressure
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But this story, which happened many years ago, tells us three things: first, don’t underestimate those boils and swellings that occur on the face; Causes other than common diseases such as primary headaches
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The third is that if something goes wrong, there must be a monster.
How can a 48-year-old man develop acne? I hope this patient's story can be helpful to you
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After Dopamine, a licensed physician records his life with words, and pays tribute to his work with his life.
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Copyright, cooperation WeChat: dba0604 Author: dopamine Submission email: last-dopamine@foxmail.
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