Medical Fiction Questions Answered: 08/12/09

Okay, gang... the Doctor is IN! More medical fiction questions...

Disclaimer: The information provided in this post is intended for writing purposes only and does not represent medical advice. (Sorry, my lawyer-boy husband makes me say that.)

Hi Heather,

I have character related medical questions (and whoa, very nice to have you as a resource. The QTBlog is awesomesauce!):

Can a school nurse run blood work if requested? What would the nurse check for automatically? Would the nurse screen for drugs? Pregnancy? How would a school verify drug use?

What tests would be run for headaches? MRI? CAT scan? Both? Would the same tests be used for visual hallucinations? Are there different tests for auditory hallucinations--or are all hallucinations covered by say MRI and CAT scans? How else would you diagnose the cause of hallucinations? Could a doctor render a proper diagnosis if information is being withheld, e.g., the character claims headaches, not hallucinations. When might a psychiatrist be called in? If the character admitted seeing things (say, within the context of a therapist visit), what anti-psychotic medications might be prescribed?

Any light you can shed would be greatly appreciated.

Regards,

Ctairo

Wow, Ctairo... that's a lot of questions!

Let's take them one at a time:

Q: Can a school nurse run blood work if requested?

A: Not usually. At least not easily. Most school nurses have very limited resources, and they certainly wouldn't be able to run the blood tests themselves on the premises. So, since any tests would be sent out anyway, what would usually be done is the nurse would simply refer the student to their physician or a clinic or, in an emergency, to a hospital. Also, most lab tests must be ordered by a physician or nurse practitioner, and very few school nurses have that level of training.

Q: What would the nurse check for automatically?

A: I'm not sure what you mean by this, but a school nurse wouldn't typically check for much. She would treat minor illnesses, help students administer their home medications, etc. But diagnostic testing does not typically play a big role in school nursing offices.

Q: Would the nurse screen for drugs? Pregnancy? How would a school verify drug use?

A: Depending on the school facilities, it's possible the school would have the capability to offer pregnancy testing (which is a simple urine test). Drug testing can be done with a simple urine test as well (which usually tests for marijuana, cocaine, opiates, barbiturates, amphetamines, and PCP) and some high schools do perform drug testing, but most require parental consent first and reasonable cause to request them (unless they are required for, say, participating in sports). You would need to research the school district rules in the area your story is set.

(I'm assuming the rest of your questions refer to evaluation in a clinic or emergency room.)


Q: What tests would be run for headaches? MRI? CAT scan? Both?

A: There aren't many tests done for headaches, actually. The first step would be to take a thorough history of the headache. Where it's located, the duration, associated symptoms, aggravating factors, alleviating factors, etc. They would also do a neurological evaluation, including vision. The vast majority of headaches can be diagnosed with just a history and physical.

If the headache was suspicious or unusual in some way, or associated with, say, vision changes or seizures or a head injury, they might do some imaging studies. A CT scan is often done first, since it's quicker and cheaper. A CT is always the best choice for trauma, as it shows blood better than an MRI.

An MRI is better for something like a brain tumor or a stroke.

Neither of these tests would be routinely ordered for someone with just a headache.

If the patient had a fever, or neck stiffness, or mental status changes (or if their retinal exam showed something called papilledema), they might need to do a spinal tap to check for meningitis, encephalitis, or a condition called pseudotumor cerebri.

Q: Would the same tests be used for visual hallucinations? Are there different tests for auditory hallucinations--or are all hallucinations covered by say MRI and CAT scans? How else would you diagnose the cause of hallucinations?

A: Like headaches, hallucinations are first evaluated by a careful history (meaning what the patient can tell you about the problem under questioning) and physical evaluation. There's a nice chart here of some types of hallucinations (by history) and the possible explanations for them.

Q: Could a doctor render a proper diagnosis if information is being withheld, e.g., the character claims headaches, not hallucinations.

A: That would greatly depend on what the diagnosis was. Some problems, like meningitis or a brain tumor, have very specific findings. Many other problems rely on the history for diagnosis. How much influence the patient would have over his or her diagnosis would also depend on their level of function. For example, someone with severe schizophrenia may not be able to appropriately identify or describe their hallucinations, but their behavior might suggest them to the evaluator, as their ability to hide their symptoms would be poor.

Q: When might a psychiatrist be called in?

A: A psychiatrist would be called in if an evaluation for other causes was negative, or if other signs or symptoms suggested a psychiatric diagnosis.

Q: If the character admitted seeing things (say, within the context of a therapist visit), what anti-psychotic medications might be prescribed?

A: That would depend on the diagnosis following a psychiatric evaluation. A chart of some diagnoses and the recommended treatments can be found here.

I hope you find this information helpful. Our resident psychologist, Carolyn, may have some additional helpful suggestions for you, too. ;)

ETA: And, indeed, she does! Here's Carolyn's thoughts:

Great questions, and great answers! All of Dr. Dyer's disclaimers apply to what lies below:

The possible benefits of anti-psychotics (also sometimes called neuroleptics) must be measured against the possible side effects, so the psychiatrist or physician would want to be pretty sure the character is psychotic (ie having hallucinations and/or delusions) before prescribing them. Anti-psychotic medications can have long-term side effects including sedation, weight gain, and the possibility of developing what are called "extrapyramidal side effects" -- small, involuntary movements of the lips and tongue, muscle rigidity, and internal restlessness.

The classic antipsychotics, which you often hear named in movies, are most likely to have these side effects (ie Haldol, Thorazine). Atypical antipsychotics are used much more often, and present a lower risk for extrapyramidals -- Risperdal, Zyprexa, Seroquel, and Geodon. Abilify is also sometimes used -- it has the fewest side effects. (Abilify is kind of a controversial drug right now. The research that says it works seems to be biased. Not unusual, unfortunately.)

Someone who is having hallucinations could have several different diagnoses, including schizophrenia or bipolar disorder, which is also called manic depression (some people hallucinate as part of mania or, even more rarely, as part of a devastating depression).

If the person has bipolar disorder, a clinician is going to notice. People who are manic tend to talk too fast, make bad decisions, feel euphoric or aggressive, and think the whole time that there's nothing wrong with them. People who are devastatingly depressed talk slowly, move slowly, seem sad or angry, and bring a heaviness with them where ever they go. People who have schizophrenia don't just have hallucinations and/or delusions -- they also have strange thought patterns and mannerisms. The disorder is very difficult to hide. Finally, there's something called a brief psychotic disorder that can be triggered by extreme stress. It has to last more than one day but less than a month and can include the symptoms of schizophrenia, but it resolves itself without turning into schizophrenia. All of the links above will take you to more information on the disorders.

It's also possible that hallucinations could be caused by drugs, which would certainly be a consideration in someone who was school-aged.

Hope that's helpful!

Remember, if YOU have a medical fiction question, email me at hldyer at querytracker.net and include "medical question" in the subject title. You'll receive an automatic reply confirming that your question has safely arrived in my email box.