"Triaging potential post-trauma vesicular issues"

Quickie Consult 1151
Clinical Information 277 CI

From the Desk of Dr. Mark Studin
Academy of Chiropractic

Preamble: Many of the issues I bring to you are very small, yet each issue is just that, an issue. If you take care of the small issues, then you will be able to build and more importantly, focus on the bigger issues...a larger practice and more family time. -Mark Studin 2006

 

Dr Studin: I’m with Dr. Scott Ferguson from Dayton, Ohio, who's our newest fellow graduate. So you had a patient come in yesterday, could you please explain what happened with your patient?

Guest Doctor: A patient was referred from an attorney; he was at a stoplight. He rear ended by a work van, we're doing an exam.

Dr Studin: a 29-year-old male.

Guest Doctor: He couldn't stand, eventually got to be uncomfortable. So, as we're going through the exam, I did the student Perkins protocol for stroke. We did a couple of VVI aneurisms and he failed them.

Dr Studin: Give the name of the tests.

Guest Doctor: We did a Dockland’s and we did decline. And the other one's escaping me right now.

Dr Studin: The mains test main.

Guest Doctor: Yup. So, he failed both of those and that really irritated his symptoms. So even though he's 29, he was diabetic, which is another count against him as far as should we refer or not refer for additional testing.

Dr Studin: It was another risk factor in this history?

Guest Doctor: Yes. So, we decided we need to shift them.

Dr Studin: What'd you find that in your clinic? what are the clinical evaluation really set you off?

Guest Doctor: when we performed the maneuvers, he had some of the stagnates and he got dizzy and that was a symptom that he had after the accident. And he was really disturbed after the test, we had to keep him in a dark room, give him a water until they calm down. He wasn't driving. I wouldn't let them try at home because his grandmother had driven him.

Dr Studin: So the issue is in this particular case that we spoke about is he has no health insurance. Then he's got a lawyer, this is important, Then it's on a letter of protection. So the only money from this is going to be through the letter of protection with the lawyer. Now from what you explained to me earlier the challenge is he needs at least three MRI's made before.

Guest Doctor: Correct.

Dr Studin: The cervical, lumbar, but definitely an MRI and an MRA. So the question is it's all expensive. So the clinical decision you made was?

Guest Doctor: we're going to have to order it and they're just going to have to sort it out later.

Dr Studin: Because the person's life obviously comes first.

Guest Doctor: Yes, Do you want to try to be judicious and not just order just test out the Wazoo just to get them, he lost his health insurance. He lost everything. You're just in a bad situation. So of course that weighs in your mind, but you can't let that affect your clinical judgment.

Dr Studin: what you considered for what you explained to me before is to do an MRI. which checks the integrity of the vertebral artery and the carotid artery of the neck and an MRI of the brain. Does the temperature check out the circle of Willis to see if there's any posttraumatic vascular insufficiencies going to the brain, which could positively cause stroke? Because when you extended the head, he immediate got staginess, Dizziness, sweating, it’s super positive. And the cervical, he also had radicular pain when you extended his neck. So you ordered an MRI of the cervical spine also to see what the heck's going on in there.

Guest Doctor: I did.

Dr Studin: And then the lumbar spine is going to wait,

Guest Doctor: that's going wait cause that's not as urgent.

Dr Studin: Now did you send them to the emergency room?

Guest Doctor: yes.

Dr Studin: Did you call the emergency room to let them know?

Guest Doctor: I just got in here today. I think Michelle sent our notes over for that, but I haven't followed up with her on them.

Dr Studin: You have to call the emergency room and speak to them and focus on the fact that you simply extended his head in a simple mainstay test and he had immediate Nystagmus and all these other things to focus them on what's needed or they're just going to do a cat scan of his brain and let them go.

Guest Doctor: That's what I'm afraid of.

Dr Studin: But you got to talk to the ER doctor. And that's the case and you've got to call the lawyer to keep them in the loop and let them know, listen, this might eat up a chunk of money, but you know his life comes before the case.

Guest Doctor: I already did that part. I let it go with this paralegal. 

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