CS: Workup for headache always includes imaging?!!

[funshine]

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Hey,

I am looking at First Aid for CS, and find the workup for headache kind of ridiculous. For every single headache, they include CT +/- MRI, whereas I'm taught to only get imaging if I suspect an intracranial mass...they also suggest getting an LP on almost everyone. Of course, this is also because they are listing intracranial neoplasm and pseudotumor cerebri on the differential even when it's really really unlikely. I guess if we put something down on the differential, even if it's the last possibility, we are required to order the testing for that?
So basically, a thorough exam on headache would automatically include LP/imaging.

Thoughts? I think if I were the physician grading this case, I'd get really annoyed at people ordering unnecessary tests and take points off, but maybe they're not allowed to deduct for excessive testing?

 

[Medstudentquest]

Hey,

I am looking at First Aid for CS, and find the workup for headache kind of ridiculous. For every single headache, they include CT +/- MRI, whereas I'm taught to only get imaging if I suspect an intracranial mass...they also suggest getting an LP on almost everyone. Of course, this is also because they are listing intracranial neoplasm and pseudotumor cerebri on the differential even when it's really really unlikely. I guess if we put something down on the differential, even if it's the last possibility, we are required to order the testing for that?
So basically, a thorough exam on headache would automatically include LP/imaging.

Thoughts? I think if I were the physician grading this case, I'd get really annoyed at people ordering unnecessary tests and take points off, but maybe they're not allowed to deduct for excessive testing?

I am freaking out as well about this! i wonder how they will grade this section in particular. Especially because there is no grading criteria, it concerns me.

 

[lord_jeebus]

use common sense

 

[Law2Doc]

Hey,

I am looking at First Aid for CS, and find the workup for headache kind of ridiculous. For every single headache, they include CT +/- MRI, whereas I'm taught to only get imaging if I suspect an intracranial mass...they also suggest getting an LP on almost everyone. Of course, this is also because they are listing intracranial neoplasm and pseudotumor cerebri on the differential even when it's really really unlikely. I guess if we put something down on the differential, even if it's the last possibility, we are required to order the testing for that?
So basically, a thorough exam on headache would automatically include LP/imaging.

Thoughts? I think if I were the physician grading this case, I'd get really annoyed at people ordering unnecessary tests and take points off, but maybe they're not allowed to deduct for excessive testing?

HA can certainly be caused by masses as well as bleeds/strokes/ICP, so in someone without a headcold, sinus issues or a history of migraines or cluster headaches, some form of imaging isn't unreasonable. Certainly in an ED they would use the CT liberally because the downside of missing a reversible pathological cause of HA far exceeds the negative of a high hospital bill. Welcome to the era of defensive medicine. As for an LP -- if you are going down that route, you need to do a CT first, to r/o pressure before pushing in a needle and causing a herniation. I probably would only go the LP route on this test if the patient also reported fever, change of mental status, sore/stiff neck, or had some predisposing condition like HIV.

You don't want to order unwarranted tests, but you don't want to send a dude with SAH home on Advil either.

 

[jake2]

For the purposes of CS, I'd guess you'll be safe putting CT/MRI and I would unless you can think of five more pressing studies to order. Clearly not the case in real life, but this test is a long, long way from the real world.

 

[ROBINHO]

Headache can be a sympton of a Mass in there