03 October 2009

Dodged one


Saw a nine-year old with a headache today.  His dad brought him in, and explained that all the men in his family get migraines; he figured this was his son's first one.  The kid seemed perfectly well, with a positive Cheetos sign and my gut instinct was that I would discharge him with no work-up.  But when I flexed his neck fully, he winced.

Just a tiny bit, for a fleeting moment.  I almost missed it.  I asked him, "Did that hurt?"  He said no, without hesitation.  Flexed it again.  No resistance, not a shred, but again the minuscule flicker of discomfort across his face.  "That hurt, didn't it?"  He assured me that it did not.

I decided to tap him. 

Very satisfying tap: first poke, as it should be, and almost painless for the lad.  Positive white cells on the tap, and a non-reassuring differential (almost all neutrophils, indicating possible bacterial meningitis).  Weird -- he looked great, still eating Cheetos when I got the tap results.  Not even a fever.

I'm hoping it's viral, for his sake.  But still: I came that close to just sending him home.

I should buy myself a lottery ticket.

His dad should buy one, too.


  1. I'd hug you if it was my kid.

    But wait you mean you didn't send him for a head CT first? What gives?

    (I think I've been told 5 or 6 times this year "remember that kid you did a CT and cxr on 2 hours ago, yeah they have meningitis--you want a dose of cipro?")

  2. This is how you tell the good EM practitioners: they find the answer despite what the patient is saying out loud. Nice catch.

  3. What was the gram stain and Cx?

  4. Love the + cheetos sign, read the link. Will remember that one.


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