CONFIRMING DIAGNOSIS A history of abdominal trauma, clinical features, and laboratory test results confirm the diagnosis of blunt or penetrating abdominal injury and determine organ damage.
Consider any upper abdominal injury a thoracicoabdominal injury until proven otherwise. Laboratory studies vary with the patient’s condition but usually include:
❑ chest X-rays (preferably done with the patient upright to show free air)
❑ abdominal X-rays
❑ examination of stools and stomach aspirate for blood
❑ blood studies (decreased hematocrit and hemoglobin levels point to blood loss; coagulation studies evaluate hemostasis; white blood cell count is usually elevated but doesn’t necessarily point to infection; type and crossmatch to prepare for a blood transfusion)
❑ arterial blood gas analysis to evaluate respiratory status
❑ serum amylase levels, which may be elevated in pancreatic injury
❑ aspartate aminotransferase and alanine aminotransferase levels, which increase with tissue injury and cell death
❑ excretory urography and cystourethrography to detect renal and urinary tract damage
❑ radioisotope scanning and ultrasound to detect liver, kidney, or spleen injury
❑ angiography to detect specific injuries, especially to the kidneys
❑ computed tomography scan to detect abdominal, head, or other injuries
❑ exploratory laparotomy to detect specific injuries when other clinical evidence is incomplete
❑ other laboratory studies to rule out associated injuries
❑ peritoneal lavage with insertion of a lavage catheter to check for blood, GI content, vegetable fibers, and bile. In blunt trauma with equivocal abdominal findings, this procedure helps establish the need for exploratory surgery.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Rape trauma syndrome:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Even if the victim wasn’t beaten, the physical examination (including a pelvic examination by a gynecologist) will probably show signs of physical trauma, especially if the attack was prolonged. Depending on specific body areas attacked, a patient may have a sore throat, mouth irritation, difficulty swallowing, ecchymoses, or rectal pain and bleeding.
If additional physical violence accompanied the rape, the victim may have hematomas, lacerations, bleeding, severe internal injuries, and hemorrhage; if the rape occurred outdoors, she may suffer from exposure. X-rays may reveal fractures. If severe injuries require hospitalization, introduce the victim to her primary nurse if possible.
Assist throughout the examination and carefully label all possible evidence. Before the victim’s pelvic area is examined, take vital signs; if she’s wearing a tampon, remove it, wrap it, and label it as evidence. The pelvic examination is typically very distressing for the victim. Reassure her and allow her as much control as possible. During the examination, assist in specimen collection, including those for semen and gonorrhea. Carefully label all specimens with the patient’s name, the physician’s name, and the location from which the specimen was obtained. List all specimens in your notes. If the case comes to trial, specimens will be used for evidence, so accuracy is essential. (See Legal considerations, page 338.) Most emergency departments have “rape kits” that include containers for specimens.
Carefully collect and label fingernail scrapings and foreign material obtained by combing the victim’s pubic hair; these also provide valuable evidence. Note to whom you give these specimens.
For a male victim, be especially alert for injury to the mouth, perineum, and anus. As ordered, obtain a pharyngeal specimen for a gonorrhea culture and rectal aspirate for acid phosphatase or sperm analysis.
Assist in photographing the patient’s injuries (this may be delayed for 1 day or repeated when bruises and ecchymoses are more apparent).
Most states require medical facilities to report rape. The patient may not press charges and not assist the police. If the patient doesn’t go to a facility, she may not report the rape.
If the police interview the patient in the facility, be supportive and encourage her to recall details of the rape. Your kindness and empathy are invaluable.
The patient may also want you to call her family. Help her to verbalize anticipation of her family’s response.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Cold injuries:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
A history of severe and prolonged exposure to cold may make this diagnosis obvious. Nevertheless, hypothermia can be overlooked if outdoor temperatures are above freezing or if the patient is comatose.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Battle's sign:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Perform a complete neurologic examination, beginning with the history. Ask the patient about recent trauma to the head. Did he sustain a severe blow to the head? Was he involved in a motor vehicle accident? Note the patient’s level of consciousness as he responds. Does he respond quickly or slowly? Are his answers appropriate, or does he appear confused?
Check the patient’s vital signs; be alert for widening pulse pressure and bradycardia, signs of increased intracranial pressure. Assess cranial nerve function in nerves II, III, IV, VI, VII, and VIII. Evaluate pupillary size and response to light as well as motor and verbal responses. Relate these data to the Glasgow Coma Scale. Also, note cerebrospinal fluid (CSF) leakage from the nose or ears. Ask about postnasal drip, which may reflect CSF drainage down the throat. Look for the halo sign—a bloodstain encircled by a yellowish ring—on bed linens or dressings. To confirm that drainage is CSF, test it with a Dextrostix; CSF is positive for glucose, whereas mucus isn’t. Follow up the neurologic examination with a complete physical examination to detect other injuries associated with a basilar skull fracture.
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Headache:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If the patient reports a headache, ask him to describe its characteristics and location. How often does he get a headache? How long does a typical headache last? Try to identify precipitating factors, such as eating certain foods or exposure to bright lights. Ask what helps to relieve the headache. Is the patient under stress? Has he had trouble sleeping?
Take a drug and alcohol history, and ask about head trauma within the last 4 weeks. Has the patient recently experienced nausea, vomiting, photophobia, or visual changes? Does he feel drowsy, confused, or dizzy? Has he recently developed seizures, or does he have a history of seizures?
Begin the physical examination by evaluating the patient’s level of consciousness (LOC). Then check his vital signs. Be alert for signs of increased ICP—widened pulse pressure, bradycardia, altered respiratory pattern, and increased blood pressure. Check pupil size and response to light, and note any neck stiffness. (See Differential diagnosis: Headache, pages 392 and 393.)
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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Headache:
History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
A. Characteristics of the headache. What is the type of pain, its location, its duration, and its intensity? What symptoms precede or accompany the pain? Does anything trigger the headache or make the pain better or worse? Tell about a typical headache from beginning to end.
1. Migraine food triggers include alcohol, aged cheese, chocolate, and aspartame.
2. Approximately 20% to 30% of migraineurs will report an aura, typically visual in nature.
3. Patients with cluster headache report unilateral temporal headache, occurring generally once daily, usually in the evening and associated with ipsilateral nasal stuffiness and conjunctival injection.
4. Chronic daily headache (CDH) patients will describe headaches at least 10 to 15 days/month and usually report heavy use of relief drugs.
5. Red flags that might suggest intracranial pathology (section I.B) include a loss of consciousness, persistent visual loss, seizures, staggering, or hearing loss.
B. Chronology of the headache. Most primary headaches recur periodically for years, with only subtle changes over time. If the headache is getting worse, the cause might be psychosocial stressors, medication overuse, or evolving intracranial pathology (Table 2.5). Ask women whether the headache seems related to the menses. Past and current medication use and how they affect the headache can be important clues to headache severity and how the patient may respond to treatment.
C. Family history. Migraine headaches often exhibit a familial pattern; the causes of secondary headaches generally do not. Tension headache can represent a family pattern of reacting to stress.
D. Psychosocial aspects of the headache. What does the patient believe is the cause of the headache? What life events might be playing a role? How does the patient’s family react to the headache? Ask: “If you did not have the headache, how would your life be different?” The key to management of recurrent primary headaches often lies in the responses to these questions, which can reveal unanticipated stressors, secondary gain, or family discord.
E. Other information. Important data include use of tobacco, alcohol, or coffee; response to exercise; a history of head trauma; or exposure to toxic fumes or chemicals. Have there been symptoms of fever, or fatigue? Ask about depression, which is often seen in migraineurs.
Physical examination
A. Focused physical examination (PE). This should include vital signs (notably blood pressure) and an examination of the scalp; eyes, including funduscopic examination; ears; nose; paranasal sinuses; throat; and neck. A screening neurologic examination, including cranial nerves, coordination (finger-to-nose test), and deep tendon reflexes, is sufficient in most instances. In the migraineur, the examination findings should be all normal in the absence of a current headache; a positive finding warrants further testing (section IV).
B. Additional PE. Other PE maneuvers are appropriate if the medical history suggests specific secondary headache causes: palpation of the superficial temporal arteries (temporal arteritis), audiometry (acoustic neuroma), transillumination of the paranasal sinuses (“sinus headache”), or checking for nuchal rigidity plus Kernig’s and Brudzinski’s signs (meningeal irritation).
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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Headache:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Migraine
❑ Tension
❑ Acute sinusitis
❑ Acute glaucoma
❑ Postconcussive
❑ Cluster
❑ Meningitis
❑ Drugs
❑ Hypoglycemia
❑ Benign exertional headache
❑ Temporomandibular joint inflammation
❑ Subdural hematoma
❑ Subarachnoid hemorrhage
❑ Acute epidural hematoma
❑ Lumbar puncture
❑ Brain tumor
❑ Headache in HIV
❑ Pseudotumor cerebri
❑ Hypertensive encephalopathy
❑ Carbon monoxide intoxication
❑ Giant cell arteritis
❑ Psychogenic
❑ Brain abscess
❑ Encephalitis
❑ Arteriovenous malformations
❑ Cavernous sinus thrombosis
❑ Pituitary apoplexy
❑ Carotid artery dissection
Diagnostic Approach
Red flags to serious causes include: Sudden onset of “the worst headache of my life,” especially in a non—headache-prone person; headache different from previous headaches; headache precipitated by position change, cough, or exertion; a history of trauma or fever; abnormal mental status or other neurological findings; a headache that disturbs sleep or is present immediately on awakening; immune deficiency such as HIV.
The time course helps in diagnosing headache. A “thunderclap” headache of a ruptured aneurysm peaks instantly. Cluster headache peaks over 3 to
5 minutes, remains at maximum for 45 minutes, and then gradually recedes. Migraine builds over hours, lasts hours to days, and is improved with sleep.
In evaluating patients with recurrent migraine, it is critical to ascertain whether the present headache differs from prior migraines and whether fever is present or spontaneous retinal venous pulsations are abnormally absent. These should prompt a search for alternative causes. If fever is present with headache, rule out meningitis.
Raised intracranial pressure should be suspected with blurred vision upon bending the head forward, headache upon awakening that improves with sitting up, double vision, loss of coordination and balance, or daily
progressive headache with nausea. Pain originating above the tentorium is referred to the frontal, temporal, or parietal region. Pain from the posterior fossa and below is referred to the occiput. Pain from the posterior sagittal and transverse sinuses may be referred to the eye or forehead.
Lumbar puncture, subdural hematoma, or benign intracranial hypertension can cause orthostatic headache. Occipital headache radiating to the vertex and forehead is usually a result of cervical spondylosis but can also be caused by basal subarachnoid hemorrhage, posterior fossa tumor, or meningitis.
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Source: Field Guide to Bedside Diagnosis, 2007
Headache:
Diagnosis
(Handbook of Diseases)
An accurate diagnosis requires a history of recurrent headaches and physical examination of the head and neck. Such examination includes percussion, auscultation for bruits, inspection for signs of infection, and palpation for defects, crepitus, and tender spots (especially after trauma).
A firm diagnosis also requires a complete neurologic examination, assessment for other systemic diseases (such as hypertension), and a psychosocial evaluation (when such factors are suspected).
Most patients may be diagnosed by a thorough history and physical examination. Magnetic resonance imaging, computed tomography scans, lumbar puncture, and serology may be beneficial. Neurologic deficits, such as stroke or brain tumors; metabolic processes, such as thyroid disease or diabetes; and an aneurysm must be ruled out if the headache is explosive and “the worst” in their lives.
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Source: Handbook of Diseases, 2003
Wounds, open trauma:
Diagnosis
(Handbook of Diseases)
A thorough physical examination of the patient will reveal traumatic wounds. They may be seen during the primary and secondary assessment of the patient.
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Source: Handbook of Diseases, 2003
Chest injuries, blunt:
Diagnosis
(Handbook of Diseases)
A history of trauma with dyspnea, chest pain, and other typical symptoms suggest a blunt chest injury. A physical examination and diagnostic tests determine the extent of injury.
❑ Percussion reveals dullness in hemothorax and tympany in tension pneumothorax.
❑ Auscultation may reveal a change in position of the loudest heart sound in tension pneumothorax or muffled heart tones in cardiac tamponade.
❑ Chest X-rays may be used to confirm rib and sternal fractures, pneumothorax, flail chest, pulmonary contusions, lacerated or ruptured aorta, tension pneumothorax, diaphragmatic rupture, lung compression, or atelectasis with hemothorax.
❑ ECG may show abnormalities with cardiac damage, including multiple premature ventricular contractions, unexplained tachycardias, atrial fibrillation, bundle-branch heart block (usually right), and ST-segment changes.
❑ Serial aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, creatine kinase (CK), and CK-MB levels are elevated.
❑ Retrograde aortography and transesophageal echocardiography reveal aortic laceration or rupture.
❑ Contrast studies and liver and spleen scans help detect diaphragmatic rupture.
❑ Echocardiography, computed tomography scans, and cardiac and lung scans show the extent of the injury.
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Source: Handbook of Diseases, 2003
Abdominal injuries:
Diagnosis
(Handbook of Diseases)
A history of abdominal trauma, signs and symptoms, and laboratory results confirm the diagnosis and help determine organ damage. Consider any upper abdominal injury a thoracicoabdominal injury until proven otherwise. Diagnostic studies vary with the patient’s condition but usually include:
chest X-rays (preferably done with the patient upright) to show free air
examination of stool and stomach aspirate for blood
blood studies (decreased hemoglobin levels and hematocrit point to severe blood loss; coagulation studies evaluate hemostasis; white blood cell count is usually elevated but doesn’t necessarily point to infection; typing and crossmatching help prepare for blood transfusion)
arterial blood gas analysis to evaluate respiratory status
serum amylase levels, which are commonly elevated in those with pancreatic injury
aspartate aminotransferase and alanine aminotransferase levels, which increase with tissue injury and cell death
excretory urography and cystourethrography to detect renal and urinary tract damage
angiography to detect specific injuries, especially to the kidneys
peritoneal lavage with insertion of a lavage catheter, to check for blood, urine, pus, ascitic fluid, bile, and chyle (a milky fluid absorbed by the intestinal lymph vessels during digestion) (In blunt trauma with equivocal abdominal findings, this procedure helps establish the need for exploratory surgery.)
computed tomography scan to detect abdominal, head, chest, or other injuries
exploratory laparotomy to detect specific injuries when other clinical evidence is incomplete
other laboratory studies to rule out associated injuries.
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Source: Handbook of Diseases, 2003
Cold injuries:
Diagnosis
(Handbook of Diseases)
A history of severe and prolonged exposure to cold may make this diagnosis obvious. Nevertheless, hypothermia can be overlooked if outdoor temperatures are above freezing or if the patient is comatose.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Battle's sign:
History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
Obtain the patient’s history, noting recent trauma to the head such as involvement in a motor vehicle accident. Assess his level of consciousness and the appropriateness of his responses to your questions.
Physical examination
Perform a complete neurologic assessment. Check the patient’s vital signs; stay alert for widening pulse pressure and bradycardia — these are signs of increased intracranial pressure. Assess cranial nerve (CN) function in CN II, III, IV, VI, VII, and VIII. Evaluate pupillary size and response to light as well as motor and verbal responses. Relate these data to the Glasgow Coma Scale. Assess for cerebrospinal fluid (CSF) leakage from the nose or ears. Ask about postnasal drip, which may reflect CSF drainage down the throat. Look for the halo sign — a bloodstain encircled by a yellowish ring — on bed linens or dressings. Test drainage to determine the presence of CSF. Follow the neurologic examination with a complete physical examination to detect other injuries associated with a basilar skull fracture.
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Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007
Battle's sign:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Ask the patient about recent trauma to the head. Did he sustain a severe blow to the head? Was he involved in a motor vehicle accident? Note the patient’s level of consciousness (LOC) as he responds. Does he respond quickly or slowly? Are his answers appropriate, or does he appear confused?
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Headache:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If the patient reports a headache, ask him to describe its characteristics and location. How often does he get a headache? How long does a typical headache last? Try to identify precipitating factors, such as certain foods or exposure to bright lights. Ask what helps to relieve the headache. Is the patient under stress? Has he had trouble sleeping?
Take a drug and alcohol history, and ask about head trauma within the last 4 weeks. Has the patient recently experienced nausea, vomiting, photophobia, or visual changes? Does he feel drowsy, confused, or dizzy? Has he recently developed seizures, or does he have a history of seizures?
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Headache:
Clinical Features and Diagnosis
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Tension-Type Headache
Most commontype of headache in adolescence but also occurs in childhood.Usually dull in character, diffuse,and bilateral and may last hours or days.Nausea and vomiting are unusual.Precipitating factors include emotionalstress and fatigue. Vascular Headache
Migraine Headache
Vascularheadaches that are periodic, throbbing, and usually unilateral.Generalized headaches are more commonthan unilateral headaches in children.Positive family history is found inmany cases.Typical clinical features and positivefamily history are diagnostic. Migraine with Aura (Classic Migraine)
Migraineheadaches that occur with aura are called classic migraine.Not only does aura precede headache,but it can persist with headache. May consist of visual (scotomata,flashing lights, blurring), sensory (numbness, paresthesias), ormotor (mild aphasia) phenomena.Headache usually lasts for a few hoursbut can persist for 1–2 days. Interrupts normal activity,and most children wish to lie down in quiet place until it goesaway. Noise, light, and activity make headache worse. Migraine without Aura (Common Migraine)
Migraineheadaches that occur without aura are called common migraines.In childhood they are more common thanclassic migraines.Headache is bifrontal or bitemporaland is often associated with nausea, vomiting, and abdominal pain.Positive family history for migraineis important diagnostic clue. Complicated Migraine
Associationof migraine episode with transient neurologic disturbance.Deficits are usually benign but mustbe distinguished from serious intracranial pathology; thus, headCT or MRI is often necessary. Hemiplegic Migraine
Hemisensoryloss or hemiparesis followed by headache on contralateral side characterizeshemiplegic migraine, which can be familial.Hemiplegia may persist after headacheresolves and lasts hours to days. Can recur and alternate from sideto side. Permanent deficit rarely occurs. Ophthalmoplegic Migraine
Associationof recurrent, unilateral, periorbital headaches associated withthird nerve palsy is known as ophthalmoplegic migraine.Headache may precede, accompany, orfollow ophthalmoplegia. Eyes appear "down and out," withdeficits in elevation and adduction. There also may be ptosis andmydriasis.Headache may last a few hours, butophthalmoplegia can persist for days to weeks. Basilar Artery Migraine
Often beginswith visual disturbance consisting of blurred vision, scotomata,or transient loss of vision. Nausea, vomiting, ataxia, vertigo,paresthesias, hemiparesis, quadraparesis, and impaired consciousnessalso can occur.Occipital headache may precede, accompany,or follow neurologic deficits. Episode lasts usually 10–30mins.Recurrent attacks with absence of residualneurologic deficits is general pattern. Confusional Migraine
Headacheusually precedes episodes of confusion that last a few hours upto 1 day. Impaired memory and restless or combative behavior sometimesoccur.There is often family history of migraineheadache.Diagnosis is usually made retrospectively. Migraine Variants
Migrainevariants refer to transient episodic neurologic dysfunction in individuals withmigraine or who later develop migraine.Cyclic vomiting is episodic occurrenceof unexplained nausea, vomiting, and abdominal pain that may occur ± headache.Paroxysmal torticollis consists ofrecurrent episodes of torticollis, which are associated with nausea,vomiting, and headache that may last from hours to days.Benign paroxysmal vertigo is suddenonset of vertigo, lasting a few minutes, and usually occurring inchildren 2–6 yrs of age. Children are frightened and unableto stand but do not lose consciousness. Cluster Headache
Form ofvascular headache that may be transmitted as autosomal-dominanttrait in some cases.Onset is usually in children >10yrs of age.Headaches are intense, unilateral,and periorbital in location. Occur 2–10 times/day,lasting from 10 mins to a few hours, and never switch sides.Headaches are usually episodic, occurringfor 1–3 mos at a time with remissions that last monthsto years. Systemic Infection
Any systemic infection, usually viral orbacterial, may produce fever and headache. Hypoxia
Can cause vasodilatation of cerebral arteriesand produce headache. Frequent causes include high altitude, carbonmonoxide poisoning, and chronic lung disease (most commonly cysticfibrosis). Systemic Hypertension
When severe, may cause headache, which canbe dull or throbbing. BP should be measured in anyone who complainsof persistent severe headache. Connective Tissue Diseases
Systemic lupus erythematosus may cause cerebralvasculitis and headache. Head Trauma
Minor headtrauma can produce bruising, soft-tissue swelling, and mild headache. Whiplashinjuries produce neck pain, stiffness, and often occipital headache.Concussion-associated headache generallylasts for a few days.Postconcussion syndrome is unusualin childhood but may last for months or years. Besides headache,dizziness, irritability, insomnia, memory loss, and learning difficultiesalso may occur. Headache Due to Disorders of Head and Neck Structures
Headache often occurs with various disordersinvolving head and neck region. History, physical exam, and appropriateradiographs are usually diagnostic. Head and Neck Disorders
Other causesof cranial headache include osteomyelitis of skull and cervicalspine disorders (congenital anomalies, fracture, bone tumor, juvenilerheumatoid arthritis).See section Head Trauma. Ear, Eye, and Sinus Disorders
Acute otitismedia can produce headache, but earache and fever are major manifestations.Hyperopia and astigmatism are occasionallyassociated with sustained contraction of extraocular, frontal, andtemporal muscles, which can cause frontal headache.Acute glaucoma is characterized byincrease in intraocular pressure and steady pain in eye region,which may radiate to forehead.Eye strain is another cause of ocularpain and headache.In young children, headache from sinusdisease is uncommon. In older children, acute and chronic sinusitiscan cause frontal headache along with tenderness over involved sinus.Maxillary and ethmoid sinuses are most commonly involved. Pain isusually dull, aching, and nonthrobbing. Mouth and Jaw Disorders
Dental caries, malocclusion, and temporomandibularjoint dysfunction sometimes cause pain in frontal and temporal areasas well as jaw pain. Intracranial Infections
Headachewith meningitis or encephalitis is usually acute, constant, generalized,and associated with fever.Brain abscess may produce headacheif abscess is large enough to cause traction and displacement ofintracranial structures. Associated findings include fever, vomiting,seizures, papilledema, hemiparesis, and alteration in consciousness.CT and MRI are usually diagnostic.See Chap.3, Alteration in Consciousness. Traction Headache
Pain-sensitive intracranial structures includecerebral and dural arteries and large cerebral veins and venoussinuses. Traction on these structures produces headache. Brain Tumor
Headachesin children with brain tumors may be throbbing or nonthrobbing.Although pain-free intervals sometimesoccur, these headaches are usually persistent and become more intense.Also common for these headaches toawaken children from sleep and to occur upon awakening in morning.Vomiting, lassitude, visual disturbance,ataxia, seizures, personality change, neck stiffness, papilledema,and alteration in consciousness can be manifestations of brain tumor.Response to analgesics is unreliableindicator for presence of tumor.CT or MRI locate and define extentof tumor. Histologic diagnosis is definitive.Table25.1 lists common brain tumors and their locations.
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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006
Battle's sign:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Perform a complete neurologic examination. Begin with the history. Ask the patient about recent trauma to the head. Did he sustain a severe blow to the head? Was he involved in a motor vehicle accident? Note the patient's level of consciousness as he responds. Does he respond quickly or slowly? Are his answers appropriate, or does he appear confused?
Check the patient's vital signs; be alert for widening pulse pressure and bradycardia, signs of increased intracranial pressure. Assess cranial nerve function in nerves II, III, IV, VI, VII, and VIII. Evaluate pupillary size and response to light as well as motor and verbal responses. Relate these data to the Glasgow Coma Scale. Note cerebrospinal fluid (CSF) leakage from the nose or ears. Ask about postnasal drip, which may reflect CSF drainage down the throat. Look for the halo sign—bloodstain encircled by a yellowish ring—on bed linens or dressings. To confirm that drainage is CSF, test it with a Dextrostix; CSF is positive for glucose, whereas mucus isn't. Follow up the neurologic examination with a complete physical examination to detect other injuries associated with basilar skull fracture.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Headache:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient reports a headache, ask him to describe its characteristics and location. How often does he get a headache? How long does a typical headache last? Does he have a history of high blood pressure? Try to identify precipitating factors, such as certain foods or exposure to bright lights. Ask what helps to relieve the headache. Does he experience stress at work or at home? Has he had trouble sleeping?
Take a drug and alcohol history, and ask about head trauma within the past 4 weeks. Has the patient recently experienced nausea, vomiting, photophobia, or vision changes? Does he feel drowsy, confused, or dizzy? Has he recently developed seizures or does he have a history of seizures?
Begin the physical examination by evaluating the patient's level of consciousness (LOC). Then check his vital signs. Be alert for signs of increased ICP—a widened pulse pressure, bradycardia, an altered respiratory pattern, and increased blood pressure. Check pupil size and response to light, and note any neck stiffness.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
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