Worst Headache Ever

Voiceover: Every minute someone’s life takes a terrifying detour not down a dark alley, but into the sterile, bright halls of healing. They walk in, seeking care and find themselves plunged into a nightmare. Most malpractice claims in hospitals are related to surgical errors, whereas most claims for outpatient care, which accounts for more than half of the paid malpractice claims, are related to missed or late diagnosis. 

Now, before you raise a pitchfork at every white coat you see, let’s be clear this isn’t an indictment. It’s a revelation. Because the truth is, any provider, any nurse, any human being capable of brilliance is also capable of a mistake. This is about understanding why and using that knowledge to build a safer future for every patient who walks through those doors. 

Welcome to Scrubs and Subpoenas: Tales from the Witness Stand, a podcast where we’ll peel back the sterile sheets and delve into the real stories of medical malpractice. Each episode a cautionary tale, a blueprint for change. A reminder that even in the darkest corners of human error, there’s a light. The light of knowledge. The light of empathy. The light of a future where healthcare becomes not a gamble, but a guarantee. 

So, join us as we dissect the mistakes, illuminate the flaws, and ultimately learn to heal, not just bodies, but the very system itself. 

Jannah Amiel: Hello and welcome to another episode of Scrubs and Subpoenas: Tales from the Witness Stand. You know, doctor, I kind of want to do like, a thunder sound. Every time I see that in the background, it just feels like we should do that. Welcome back. Thunder. Boom. Right. And what do you think?  

Sally Miller: I mean, I always think of the tales from whenever you-whenever I hear you say that, I think of Tales from the Crypt.  

JA: I think we should add it. We should definitely add it.  

SM: That would be awesome.  

JA: Thank you for joining me, Dr. Miller. How are you?  

SM: I’m well, thank you. And you?  

JA: Good, good. Excited to hear these stories. I always really love tuning into these with you and learning. 

I learn something new, personally, every single time we walk away from this. So, that’s a good thing. I think that’s the point. Right? To talk about these stories. Right. To learn from these stories. We are all healthcare providers. I think I’m probably being biased in saying this, but if anybody knows, like mistakes can be made, it’s us. 

It’s us on this side who are working with patients and people in real world scenarios every single day. Sometimes in environments that are so wacky, right, so, so wacky. Because that’s just the nature of the beast in some, in some cases. So, we know mistakes happen and this is the time where we get to really talk about when they do, what can we learn from it? 

What are the takeaways that can help us to just practice better? Just be a little bit better than we were yesterday, right. And for our patients, for everybody that we really are taking care of, including the facilities that we help to support. Anything you want to add to that, Dr. Miller? I also like to set the stage for everybody listening. 

SM: No, I think there is always something to learn and it’s always-it’s easy to Monday morning quarterback and be very critical and I-like this particular case that we’re going to talk about today, I think it’s really, really instructive to look back at it. Not Monday morning quarterbacking, to the extent we can learn from it. 

So, there is that. But it’s also important to remember that, that the idea here isn’t to criticize, knowing what you know, it’s to evaluate it from the perspective of the person at the time that they are providing care and trying to, you know, trying to consider what they were thinking, what that person had to work with. 

And so, as we look at this case, I think there’s-I think there’s just some good things to pull out of it for all of us. So, that’s why I picked it for us today.  

JA: Yeah, I think that’s fair. And I’m excited to listen to it. So, whenever you’re ready. 

SM: Now, I’m always ready. Now what I did-I always like-I take out snippets from my notes so I can read things directly because I really try not to infuse my personal opinion, you know, to some extent when an expert writes a report, of course it’s called your opinion, but it’s still supposed to be- 

I mean, it still should be unbiased and objective. And I guess perspective is the word. Like you’re looking at it through the eyes of the clinician, knowing what they knew or should have known, not what we know now a couple of years later. And that’s how I’m doing this.  

JA: That sounds hard.  

SM: It is.  

JA: I mean, really like it is really hard because that sounds really difficult to be unbiased. 

SM: And I think, well, you know, there’s that whole concept of implicit bias.  

JA: Yeah.  

SM: We all have biases and don’t even realize it. And I mean, listen, we can’t control for everything. But the most important thing is to recognize that we do have implicit biases and to just do the best we can to try to acknowledge that and recognize them and mitigate them as best we can. 

So, the events of this case are really very short-lived. We just have a couple of days. The patient had encounters with the healthcare system on, well, 2 days. And then the third day the patient died. I guess I’m not giving away anything when I say that. Now, so I’m going to read some snippets to you from each day. 

This patient, this gentleman, was in his mid 50s, I want to say 50s. Yeah. 57-year-old man. Excuse me. And to set the stage here, you know, remember I take out bits and pieces to share with our audience. Like the most relevant stuff. But of course, the entire lawsuit, there is a bigger picture here. And one of the things that is very clear about this gentleman is that he’s not a complainer. 

He was a stoic gentleman, stoic, working class man like, worked, you know, with his hands physically and stuff all of his life. Just a hard worker, a doer and so he did not have a regular healthcare provider. One of the examples that his wife gave in her deposition was that a few years back, he had had some sort of acute orthopedic injury. 

I forget exactly what it was now, but something that would-the rest of us would take us out.  

JA: Yeah.  

SM: And he continued to work for 3 full days on his physical job before finally saying, ‘Oh, well, you know, I better go see somebody about this.’ And it turned out to be like an orthopedic surgery, like it was a significant ordeal. 

So, he’s just, he’s a hardworking, stoic man. Not one to complain, not one, you know, to seek out healthcare. And so, that-I think that’s helpful background data. So, what happened was well, first let me just share with you the note. And then there’s like some relevant pieces from the deposition testimony of his wife. 

And, you know, deposition testimony is sworn testimony. And it is taken as true, it is considered as valid of information as anything else. That’s part of the lawsuit. And so I guess my just- 

JA: Yeah.  

SM: Well, so on the 21st of the month, on month X, on the 21st, the patient woke up with a headache. Well, the wife actually-when the wife was deposed, she said, ‘Well he was awake first. 

And then when I got up, he told me he had a headache.’ So, whether he woke up with it or it developed between the time he woke up and she woke up, who cares, you know? Right? Like, still in the morning of the 21st, he had a really bad headache. This man who doesn’t complain, you know, who worked through an orthopedic injury, first thing he tells his wife is that he has a really bad headache. 

He’s not going to work that day. He’s going to stay home. And she said, like, he like-lights out, no noise. And he had a cool washcloth on his head, and- 

JA: That’s heavy. That is bad. 

SM: And she had to go out and she worked part-time. She was out for a few hours. So, that was all that was- 

It was bad. And it was all day on the day of the 21st. All right. So, he continues to have the headache throughout the day and all night. So, the next day on the 22nd his wife takes him to urgent care. So, the urgent care note-so, this is this is the history of present illness, pretty much verbatim: 57-year-old male presents for a complaint of headache that started yesterday morning. 

Patient reports he woke up and had some neck stiffness that turned into a throbbing frontal headache. Since then, patient has developed nausea and vomiting and increasing pain. Patient does not have a history of migraines, but has had sinus headaches and other headaches in the past. Has a history of possible hypertension, but he has never been diagnosed as he does not see doctors frequently. 

Patient’s father has a history of stroke, hypertension, and CAD. The patient has been under significant stress at work as well as emotionally as his father is preparing to pass away. Patient denies any change in vision, slurred speech, numbness, tingling, weakness or loss of consciousness.  

So, it’s a pretty decent H&P as far as H&Ps go, you know? I mean, we could be critical. 

And I mean, I could tear it apart if I wanted to because I teach how to do an H&P. And these are the perfect one. That’s pretty good for urgent care. No diss to urgent care, but urgent care is very specific, complaint-focused, you know, and that’s what we’ve got. The neurologic exam was documented as normal. No numbness, tingling, slurring a speech, facial, whatever. 

Okay, so that’s that. He also was found at this time to have a blood pressure of 194/95.  

JA: Whoa.  

SM: He remainder of his vital signs were normal. He was awake, alert, oriented, etc. He was given clonidine in urgent care, and the blood pressure came down a little bit. I’m sure the numbers are here somewhere. It came down to below 180/120. 

I can tell you that it was still high, but it came down after clonidine. And so he was discharged with a diagnosis of elevated blood pressure without diagnosis of hypertension and which, you know, in your ICD-10 code world, that’s technically correct. I mean, you’re not supposed to diagnose hypertension unless the patient has elevated pressures on two separate occasions. 

JA: Okay. 

SM: Unless they have target organ damage, which, you know, there’s no evidence. So anyway, that’s like neither here nor there. That was his diagnosis. He was discharged with lisinopril and instruction to establish care with a primary care provider. And that’s that. That’s urgent care. And that’s, you know, that’s what urgent care does. Urgent care has to decide, you know, what the disposition is? 

Do you need to escalate it or do you discharge it? And then but everybody should have a primary care provider. And so in the end you’re always advised to go follow up with primary care.  

JA: Yeah.  

SM: So, that’s what happened on that day. So, a patient went home and now his wife-you know again like they’re like simple people. 

You know simple working class kind of people. They were told to keep an eye on the blood pressure. So, man, his wife is checking his blood pressure like, you know, every 15 minutes, taking his blood pressure and writing it down. And they filled the prescription right away. And blood pressure was I mean, it was still in that like 170-180 range but, nothing else changed. 

Now, the wife in her deposition did say that this this was a PA in urgent care. And she said that the PA said on several occasions during this encounter that she did not want to send him to the ER. You know, she talked about the ER, but she didn’t want to send him. The wife said it was almost like she thought it wasn’t a good ER, but nobody said that. 

But he said that that’s just the wife’s impression. But repeatedly. Then she said the PA kept saying, ‘We’re not going to let anything happen to you, big guy.’ Like, ‘Don’t worry, big guy. We’ll take care of you, big guy.’ Just as a side note, it reads really bad. It just sounds bad. You know, patients aren’t ‘big guys.’ 

They’re patients. But anyway, she said she had the impression that, like, ER was on the brain, but she didn’t want to send her there. Okay, so patient goes home. Goes home with this lisinopril, and his headache is no better. And, the next day-but he gets some sleep off and on through the night. The next day he wakes up and his headache is still just as bad. 

No good. So, he’s still sleeping, still lying in bed with a cold cloth on his head and his headache is no better. And in the deposition testimony, the wife testified that when they were in the exam room and that the PA was getting information about the headache that the patient said, ‘It’s not like my sinus headaches that are here.’ 

And he indicated, you know, that like the sphenoid sinuses, it’s more here. Like he was indicating a frontal headache.  

JA: Yeah.  

SM: Versus ethmoid, okay. So, the next day the patient still can’t go to work. He’s still having head pain that is constant. So, the wife calls like she goes to primary care sometimes. So, she has a practice she’s affiliated with and she knows they can get in there that day. 

So, just like they were told to do, they were-she was very much like they told us to do this. And we did what they told us to do. She calls her primary care office and she gets him in for an appointment that day. So, you know how it is in primary care if you want to go in that day, you see who’s available. 

And in this case, it wasn’t the person the wife normally sees. It was a nurse practitioner. So, the patient goes in to see the nurse practitioner complaining of this headache. So, this note, it’s a single page note. It’s harder to read because it’s not electronic. I don’t know why because this wasn’t that long ago. It should have been electronic. 

It like-but it wasn’t. It’s a paper chart. And it’s one of those things that has little blocks. And then the physical is over here. And the paper history up here. There’s this thing here. So, I’m going to share with you as best I can. All right. The blood pressure today is 168/100, temp 98.1, pulse 64. 

Okay. That’s fine. So, under history, here’s what-now this is a new patient. This is a new patient to this practice. And it’s the first time-not just the first time that NP is seeing him, but for the first time he’s ever been there.  

JA: Not new to the wife but new to him.  

SM: Yeah. So, brand new to this patient. He’s brand new to that practice. 

‘Patient to office to establish care. Patient seen in urgent care last night with elevated blood pressure, positive headache, negative visual changes, positive tinnitus, negative edema.’ And then the physical exam. There’s a few circles around. The skin is warm. No acute distress. Pupils reactive, lungs clear. Heart regular. That’s it. That’s the whole physical exam. So, that’s the history and that’s the physical exam. 

And then under diagnosis and plan it says diagnosis number one: hypertension, uncontrolled. Number two: fatigue. Number three: nausea. Those are the diagnoses. Treatment plan number one: EKG. And it showed sinus brady at 56. Number two: decrease salt intake, decrease caffeine intake, and decrease alcohol intake. Number three: hydrate with water. Number four: increase lisinopril to 20mg a day. 

Number five: use Fibercon for constipation. Number six: start amlodipine 2.5 mg a day. Monitor blood pressure at home and then return to office in 1 month to follow-up. Hypertension. Okay, so that’s that. So, the patient-and now the wife said they were there for a long time. She said it wasn’t like an in and out. That there was-that the amp was like went out of the room to consult with the physician and then came back and she said this NP, on more than one occasion during this visit, was sort of thinking out loud like, ‘Why didn’t urgent care send him to the ER’ and then opined that she didn’t want to send it to the ER,  

So, the ER is on everybody’s brain here that for whatever reason, nobody and nobody wrote anything down. Like nobody explained why. And so, the next day, so, like, so the headache started in the 21st. The urgent care was on the 22nd. This visit in primary care is on the 23rd. And then the next note is on the 24th. 

When the patient presents to the emergency room. And so this note says 57-year-old man with a history of hypertension, was suffering with headache, was seen at primary care provider office where per chart review, he had a systolic blood pressure of over 200, which he didn’t. I don’t know where that came from. We started on lisinopril, however headache worsened. 

Urgent care, neck stiffness, progressive nausea and vomiting. Treated for elevated BP again and sent home this morning. He collapsed at home after the worst headache of his life, suffering a code arrest in the field. Pulseless electrical activity. Got four rounds of epi, no shocks. Was brought to the ER where a head CT showed a subarachnoid hemorrhage. 

Angiography revealed a circular aneurysm. You know, blah, blah, blah. And anyway, the patient expired, patient died, and so you can-you know, again, being objective here and thinking about what somebody-what they knew, what they didn’t know, what they thought and what they wrote down. There’s so many things that we can take away from this lecture. 

Because I read the deposition of the wife, I read the deposition of the nurse practitioner, you know, read everybody’s deposition. And I can tell you in summary, the nurse practitioner was thinking migraine.  

JA: Yeah.  

SM: Didn’t write it down. The nurse practitioner was thinking migraine. I actually like-last night I, honest to God, when I was reading the wife’s deposition, I actually got teary eyed, which I don’t often do anyway. 

This is about a dog, but she like she was talking about how they plan to retire when he was 60 and, you know, he was 57. I know, right? 

JA: Oh my God. 

SM: I can feel myself and that like-now she just can’t even think about tomorrow. She doesn’t know what she did. She’s just getting through. The attorney who is deposing her said, ‘You’re just going day-to-day.’ 

And she said, ‘I’m just getting through situation to situation.’ Just, you know, really very, very sad.  

JA: Oh my God.  

SM: So, what do you think? Any questions for you or any questions that you have.  

JA: So, I got to be honest, the minute you said-and this is like the nursing school coming back the minute you said the worst headache of his life. My brain said, that’s an aneurysm. 

That’s gone. Okay. The ER. thing kind of makes me nuts. I got to be honest, because and I think again, I’m being biased. I learned just from myself that, in work right, working as a nurse if it ever comes up-if I ever think like just for an example. Gosh like, I don’t know, I should really call Sally on this one. 

No, no, no, I meant like, I don’t know, maybe I should call Sally. Like if it comes in my brain. I have learned through a lot of different scenarios to just do it, like to just do it better to have like, overdid it. I didn’t need to consult Sally than to not. So, that’s an interesting thing that they didn’t do that and then the other thing and I just don’t know the rules on this. 

If someone has a headache that bad and their blood pressure is that high, is it inappropriate to do a scan of the head, like, is that inappropriate? It’s been-he’s having terrible headaches and really high blood pressure. Is that not a thing that you’re thinking about it.  

SM: So, you know, when you put them together like that, I’m not entirely sure how to answer it. 

Like just the very high blood pressures.  

JA: Yeah. 

SM: Just very high blood pressures, there is no reason to scan the head.  

JA: Yeah.  

SM: High blood pressure with acute target organ damage, then, yes, it would be appropriate. But then-so there would be two schools of thought on this and one school of thought that says that headache didn’t sound like target organ damage, which we would think of as like encephalopathy and mental status change and stuff like that. 

You know, that, like, you know, the one side of the coin would look at it that way, but with a headache and a blood pressure like that, I would-and I’m not just Monday morning quarterbacking here. I would scan that head. But there are those who would say, but his mental status wasn’t changed. You know, his pupils were fine, you know. 

Okay. Yeah. But the thing that really jumps out at me about this is that headache. Because-and like anybody coming out of NP school hopefully remembers that you don’t start getting migraines when you’re 57. See, this is where it’s so easy to fall down a rabbit hole like the NP-she didn’t like the note. Like, listen, we can all learn about documentation, and I’m sure that the NP learned a lot about documentation, a couple things, a couple-many things, you know, are learning curves from that. 

But one of them is that she went from high fever for headache to high blood pressure as a diagnosis, like pulling off the urgent care note. You know, the headache was the problem. That’s the reason the patient was there, not his blood pressure. He didn’t care about his blood pressure. He was there for his headache, headaches should have been the primary target there, you know. 

And it wasn’t. The blood pressure became the target. So, that’s where it’s just good to remember-I think when we were doing documentation and I said the chief complaint should always be in the patient’s words, why the patient is there. Because that keeps us grounded on the number one priority. It’s a classic example of it. 

JA: Yeah.  

SM: This NP went from here to here. And then the other thing is that, maybe a lesser experienced NP team might look at this and say, ‘Uh oh, headache, nausea, photosensitivity?’ Like, this classic migraine phenomenon. And statistically migraine is much more common than a subarachnoid hemorrhage and all of that. But the thing that just really jumps out here, that it’s just so difficult to ignore, is that the guy never had a headache like this before. 

And that’s why it’s so relevant that he’s not a complainer. Yeah, but he’s not. You know, this man went from never seeing anybody for anything to having to stay home from work for days. You know, this thing over his head going to two different providers on 2 days because the pain is so profound and constant and intense that right there, blood pressure or not, that right there goes in a scanner. 

JA: Yeah.  

SM: That is that is not a migraine.  

JA: Yeah.  

SM: And even-you know, I think in the urgent care note, which really, really was pretty good. The urgent care note said he has no history of migraines, would get sinus headaches once in a while and then, you know, one person might say, ‘Well, those things that he called sinus headaches, they probably were really migraine headaches.’ 

But again, it doesn’t-like this is the first time this is happening at 57 years old? 

JA: Right.  

SM: He needed to go in a scanner. It just had to go in a scanner. For like for me, of all the other things that arise from this case, that’s the biggest one. That’s the takeaway. Don’t let yourself get sucked down that rabbit hole of, oh, headache, vomiting or nausea, vomiting, photosensitivity or whatever else I said must be migraine, because that’s most common. 

JA: Yeah.  

SM: Like you don’t want to ignore another very another really important feature of migraine is they virtually always begin in adolescence or young adulthood. And that’s-they just don’t start when you’re 57 years old.  

JA: That’s a really-this is a sad story. That is really sad. But you know what-and I would like to hear your perspective on this. 

Like headaches seem hard as a NP, as any type of provider, headache seem hard because in my mind it’s either nothing, it’s a little nothing like you just actually didn’t eat today and like that’s your problem. You just need to have something for the worst-case scenario. And I imagine that’s something that NP struggles with. 

Is that true that like when someone comes in and is like, ‘My head hurts.’ What’s a protocol for that? Like then what?  

SM: Oh yeah, I know there’s-there is totally a diagnostic evaluation of headache. And in fact, you know, our own Wendy, right?  

JA: Yeah.  

SM: Is, you know, particularly skilled in and knowledgeable about headache. And I think she does a lot of CE about headache assessment. 

And so, for people that are really interested or feel like they need more, more info, that’s definitely one avenue. Not-I sound like a commercial here, right? I mean, just like a commercial. I don’t get kickbacks on, Dr. Wendy’s-but no, but that’s a particular area of expertise for her and for anyone who feels like they need some help with it, whether here or anywhere. 

You know, you do want to brush up on it because there is an approach to the evaluation of the patient with a headache. There’s definitely a diagnostic trajectory there. And it’s true that, you know, in the world of headaches, 99% of them will be what we call a primary headache-tension, migraine, or cluster. So just statistically, out of every 100 patients that walk into your office with a headache, 99 of them, it’s going to be a primary headache that can be safely managed in the primary care setting. 

JA: Yeah.  

SM: One in 100 won’t be. One in 100 statistically will be what we call a secondary headache or due to another condition. And that secondary headache isn’t always an aneurysm. You know, aneurysms are things we see articles about and stuff. Sometimes people have a secondary headache because they have temporal arteritis or a true sinus infection or the flu or COVID or there’s or eye strain or a brain tumor or an aneurysm or a bleed or something like that. 

I mean, a secondary headache can be many things, and statistically, overall it’s only 1 in 100. But there are certain red flags that should call you out to think, ‘Oh, let me rule out the secondary headache.’ And the age of onset is one of them because our primary headaches, tension, migraine, and cluster, virtually always-now every time I say always there’s always someone that says, ‘But I had a patient-’ In 99 parallel worlds, you don’t start getting those headaches when you’re 57 years old. 

And whatever else did or didn’t happen in the past to this man, this is clearly and distinctly so different from anything he’s ever experienced before and has put, you know, is taken down this man who, you know, out of some sort of knee fracture or something didn’t take out before, like, that’s all you need to know. 

That really does need to go in a scanner. Now, if it’s not that bad, if somebody is having a headache and it, you know, and you go through your evaluation and you think, ‘Oh, this doesn’t sound like, you know, tension migraine or cluster, maybe it’s more benign. Maybe. Is it a sinus thing? Is it an eye thing?’ 

You know, but there is a diagnostic pathway. And you know, NPs are taught this in school. And and like I said, if it’s something that pops up in your practice more often, there’s lots of good about there. But there is definitely a way to move through the evaluation trajectory. But the first one is really the age of onset and then the history, like you will have people with migraines that come in like that. 

They’ve been lying all night in bed with a rag over their head, and they can’t stand the light and they feel so sick to their stomach, like in many ways, that does sound like a migraine.  

JA: Yeah.  

SM: And if he were 14, you know- 

JA: Yeah.  

SM: Nineteen or even 20 or if at 57 he was only there for pain management says, ‘Oh my gosh, I’ve been getting these, I’ve been getting these for 30 years. 

You know, this one’s just really bad. And I ran out of my med.’ Then, then you can call it a migraine. But when but when it shows up like that at that age and that intensity, it goes in a scanner. And even if it was 14, 15 or 16, or 20, if it was the first time they had that kind of pain, it still should go in a scanner. 

And then when you know that there’s nothing wrong, and then if it happens again, well, you know, that’s where your migraine diagnoses come.  

JA: Yeah. And really then taking two-because this is a good takeaway I feel like sometimes providers do this-no disrespect to any providers, but like don’t really take into account the importance of what the patient is telling you. 

So ,to your point, this guy who’s not ever complained and complained and complained and like and you know this from the wife and you hear this like, this person is not a complainer. Like he could take the worst of the worst. That is something that we need to consider clinically. I mean, it’s not like a clinical thing, but I need to consider that, like this person could probably take a lot. 

So, if this is something that he’s complaining about, it must be really significant. Like we shouldn’t pooh pooh that. 

SM: And the note like that-the NP note, it didn’t allude to any of that at all. Like it didn’t allude anything about his headache. So, the reader really can’t-you know, just a documents no acute distress. 

JA: Right.  

SM: You know, no, nothing about the headache. Now, it sounds like she was asking questions like that because the wife said he was indicating where it hurts and where it didn’t, it sounds-and she, in her deposition, said she was thinking it was a migraine. So, there’s a whole lot missing in that documentation. 

JA: Yes.  

SM: If her documentation supported a migraine, well, then you’d have a whole different story. Like if she wrote in her note ‘Well, this is the worst headache, but patient has a history of headaches that he describes as, you know, always thought they were-’ Like if there was some documentation to lead you down that path, well then it wouldn’t be such a clear cut- 

A clear cut thing. But there’s just in this case, like, you know, number one is when that kind of headache shows up for the first time of that age, into the scanner you go. Off to the ER you go. And if you don’t like the ER, call them up and say, ‘I’m sending in this patient. He needs a CT of his head.’ 

JA: Right.  

SM: You know, I mean, that helps. For what it’s worth. So, that’s one thing. And then the getting pigeonholed going from headache to hypertension because of the last note. That’s another takeaway message. And it happens all the time. Remember we had a case sometime back about, a young woman that had back pain. And the first doctor visit called it sciatica. 

So, then for the next days, everybody kept thinking, sciatica. Let’s evaluate sciatica. Oh, yeah. It’s like the MRI does not support sciatica. And yet they got pigeonholed into that from the very beginning. We don’t want to get pigeonholed. So, this is just another good example of how that can happen. And then the quality of your documentation, when we talked in, in our episode about documentation, about how the note should from top to bottom, you should be able to draw the conclusion, the chief complaint informs your history, that informs your physical, even a pertinent negative. 

For somebody with this kind of head pain, pertinent negative neurologic findings are important, and they were there and then all of that should lead to the diagnosis.  

JA: You know, and the one thing I don’t think I heard, you may have said it, I could have just missed it. But if this was a migraine, I didn’t hear migraine medications that I know anyway, that I heard. I’d heard blood pressure medications. 

So, like, if you thought it was a migraine, wouldn’t you treat it with migraine drugs? 

SM: And then-we don’t know. And I don’t necessarily mean this in a malicious way, it could very well be that when she looked back at it later, she thought migraine. You know she got sued, was looking back at everything like a migraine. 

But at the time, didn’t- 

JA: Yeah. There’s just there’s a lot of takeaways here for all of us. Wow. So, let me guess, were you on the plaintiff’s side?  

SM: Yes.  

JA: Oh, yeah. Yeah, I can see that. Yeah. Because, I mean, this is a stark contrast to one of our episodes we did on really, really good, you know, charting in that way. 

Wow. Yeah. That’s unfortunate. That’s unfortunate. Dr. Miller, thank you for sharing this. This was this was a good learning opportunity, really. 

SM: Always a pleasure.  

JA: And I think some big things, especially listening to your patient that comes up a lot like that. That means something that really means something. Awesome. Appreciate your time. And thank you all for listening in. 

We hope you enjoyed this story and got some good takeaways from it. And check us out. And next week, every Friday we drop a new release. We hope you will join us for that. And in the meantime, goodbye for now. 

Voiceover: Thank you for listening and learning with Scrubs and Subpoenas: Tales from the Witness Stand presented by Fitzgerald Health Education Associates. Please rate, review, and subscribe to this podcast, and for more NP resources, visit FHEA.com. Join us again next time as we dissect more medical malpractice cases.