Confirming diagnosis Serum ascorbic acid levels less than 0.2 mg/dl and white blood cell ascorbic acid levels less than 30 mg/dl help confirm the diagnosis.
Dietary history revealing an inadequate intake of ascorbic acid suggests vitamin C deficiency. A capillary fragility test may be performed on the patient’s forearm with a blood pressure cuff; it’s positive if more than 10 petechiae form after 5 minutes of pressure.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
West Nile encephalitis:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
The immunoglobulin (Ig) M antibody capture enzyme-linked immunosorbent assay (MAC-ELISA) is the test of choice for rapid definitive diagnosis. The major advantage of MAC-ELISA laboratory analysis is the high probability of accurate diagnosis of WNV infection when performed with acute serum or cerebrospinal fluid specimens obtained while the patient is still hospitalized.
A new diagnostic test, the WNV MAC-ELISA, was recently approved by the Food and Drug Administration. This test detects levels of IgM antibodies in a patient's ser-um and is intended for use in patients with clinical symptoms consistent with viral encephalitis.
Other conditions to consider include St. Louis encephalitis, which is symptomatically similar.
Encephalitis can be caused by numerous viral and bacterial infections; all data must be examined to determine a definitive diagnosis.
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Source: Professional Guide to Diseases (Eighth Edition), 2005
Brudzinski's sign:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Continue your neurologic examination by evaluating the patient’s cranial nerve function and noting any motor or sensory deficits. Be sure to look for Kernig’s sign (resistance to knee extension after flexion of the hip), a further indication of meningeal irritation. Also look for signs of central nervous system infection, such as fever and nuchal rigidity.
Ask the patient—or his family if necessary—about a history of hypertension, spinal arthritis, or recent head trauma. Also ask about dental work and abscessed teeth (a possible cause of meningitis), open-head injury, endocarditis, and I.V. drug abuse. Ask about the sudden onset of headaches, which may be associated with subarachnoid hemorrhage.
» READ BOOK EXCERPT ONLINE »
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.)
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Nuchal rigidity:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
Obtain a patient history, relying on family members if altered LOC prevents the patient from responding. Ask about the onset and duration of neck stiffness. Were there any precipitating factors? Also ask about associated signs and symptoms, such as headache, fever, nausea and vomiting, and motor and sensory changes. Check for a history of hypertension, head trauma, cerebral aneurysm or arteriovenous malformation, endocarditis, recent infection (such as sinusitis or pneumonia), or recent dental work. Then, obtain a complete drug history.
If the patient has no other signs of meningeal irritation, ask about a history of arthritis or neck trauma. Can the patient recall pulling a muscle in his neck? Inspect the patient’s hands for swollen, tender joints, and palpate the neck for pain or tenderness.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Photophobia:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If your patient reports photophobia, find out when it began and how severe it is. Did it follow eye trauma, a chemical splash, or exposure to the rays of a sun lamp? If photophobia results from trauma, avoid manipulating the eyes. Ask the patient about eye pain and have him describe its location, duration, and intensity. Does he have a sensation of a foreign body in his eye? Does he have any other signs and symptoms, such as increased tearing and vision changes?
Next, take the patient’s vital signs and assess neurologic status. Assess visual activity, unless the cause is a chemical burn. Follow this with a careful eye examination, inspecting the eyes’external structures for abnormalities. Examine the conjunctiva and sclera, noting their color. Characterize the amount and consistency of any discharge. Check pupillary reaction to light. Evaluate extraocular muscle function by testing the six cardinal fields of gaze, and test visual acuity in both eyes.
During your assessment, keep in mind that although photophobia can accompany life-threatening meningitis, it isn’t a cardinal sign of meningeal irritation.
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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
Encephalitis:
Diagnosis
(Handbook of Diseases)
During an encephalitis epidemic, diagnosis is easily based on clinical findings and patient history. Sporadic cases are difficult to distinguish from other febrile illnesses, such as gastroenteritis and meningitis. When possible, identification of the virus in cerebrospinal fluid (CSF) or blood confirms the diagnosis.
The common viruses that also cause herpes, measles, and mumps are easier to identify than arboviruses. Arboviruses and herpesviruses can be isolated by inoculating young mice with specimens taken from patients. In herpes encephalitis, serologic studies may show rising titers of complement-fixing antibodies. Virus-specific indirect fluorescent antibody assays have improved diagnosis.
In all forms of encephalitis, CSF pressure is elevated, and despite inflammation, the fluid is clear in many cases. White blood cell and protein levels in CSF are slightly elevated, but the glucose level remains normal. An EEG reveals abnormalities. Occasionally, a computed tomography scan may be ordered to rule out cerebral hematoma.
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Source: Handbook of Diseases, 2003
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.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
West Nile encephalitis:
Diagnosis
(Handbook of Diseases)
The immunoglobulin M antibody capture–enzyme-linked immunosorbent assay is the test of choice for rapid definitive diagnosis. It has a high probability of accurate diagnosis of WNV infection when performed with acute serum or cerebrospinal fluid specimens obtained while the patient is hospitalized.
Encephalitis can also be caused by numerous viral and bacterial infections, so data must be carefully examined to determine a definitive diagnosis. St. Louis encephalitis, which is symptomatically similar to West Nile encephalitis, should be considered.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Brudzinski's sign:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Ask the patient or his family, if necessary, about a history of hypertension, spinal arthritis, or recent head trauma. Also ask about dental work and abscessed teeth (a possible cause of meningitis), open-head injury, endocarditis, and I.V. drug abuse. Ask about sudden onset of headaches, which may be associated with subarachnoid hemorrhage.
» 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
Nuchal rigidity:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Obtain a patient history, relying on family members if altered LOC prevents the patient from responding. Ask about the onset and duration of neck stiffness. Were there any precipitating factors? Also ask about associated signs and symptoms, such as headache, fever, nausea and vomiting, and motor and sensory changes. Check for a history of hypertension, head trauma, cerebral aneurysm or arteriovenous malformation, endocarditis, recent infection (such as sinusitis or pneumonia), or recent dental work. Then obtain a complete drug history.
If the patient has no other signs of meningeal irritation, ask about a history of arthritis or neck trauma. Can the patient recall pulling a muscle in his neck?
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Photophobia:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
If your patient reports photophobia, find out when it began and how severe it is. Did it follow eye trauma, a chemical splash, or exposure to the rays of a sun lamp? If photophobia results from trauma, avoid manipulating the eyes. Ask the patient about eye pain, and have him describe its location, duration, and intensity. Does he have a sensation of a foreign body in his eye? Does he have any other signs and symptoms, such as increased tearing and vision changes?
» 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
Brudzinski's sign:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Continue your neurologic examination by evaluating the patient's cranial nerve function, noting motor or sensory deficits. Be sure to look for Kernig's sign (resistance to knee extension after flexion of the hip), which is a further indication of meningeal irritation. Look for signs of central nervous system infection, such as fever and nuchal rigidity.
Ask the patient or his family, if necessary, about a history of hypertension, spinal arthritis, or recent head trauma. Ask about dental work and abscessed teeth (a possible cause of meningitis), open-head injury, endocarditis, and I.V. drug abuse. Ask about sudden onset of headaches, which may be associated with subarachnoid hemorrhage.
» 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
Nuchal rigidity:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Obtain a patient history, relying on family members if an altered LOC prevents the patient from responding. Ask about the onset and duration of neck stiffness. Were there precipitating factors? Also ask about associated signs and symptoms, such as headache, fever, nausea and vomiting, and motor and sensory changes. Check for a history of hypertension, head trauma, cerebral aneurysm or arteriovenous malformation, endocarditis, recent infection (such as sinusitis or pneumonia), or recent dental work. Then, obtain a complete drug history.
If the patient has no other signs of meningeal irritation, ask about a history of arthritis or neck trauma. Can the patient recall pulling a muscle in his neck? Inspect the patient's hands for swollen, tender joints, and palpate the neck for pain or tenderness.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
Photophobia:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
If the patient reports photophobia, find out when it began and how severe it is. Did it follow eye trauma, a chemical splash, or exposure to the rays of a sun lamp? If photophobia results from trauma, avoid manipulating the eyes. Ask the patient about eye pain and have him describe its location, duration, and intensity. Does he have a sensation of a foreign body in his eye? Does he have other signs and symptoms, such as increased tearing and vision changes? Does he have nuchal rigidity and severe headache?
Next, take the patient's vital signs and assess his neurologic status. Assess visual activity, unless the cause is a chemical burn. Follow this with a careful eye examination, inspecting the eyes'external structures for abnormalities. Examine the conjunctiva and sclera, noting their color. Characterize the amount and consistency of any discharge. Then check pupillary reaction to light. Evaluate extraocular muscle function by testing the six cardinal fields of gaze, and test visual acuity in both eyes.
During your assessment, keep in mind that although photophobia can accompany life-threatening meningitis, it isn't a cardinal sign of meningeal irritation.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
NUCHAL RIGIDITY:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The workup of nuchal rigidity requires a good history, but if one is
unobtainable, no spinal tap should be performed until the cervical spine is
x-rayed and the eyegrounds are examined. Even with a good history, a spinal
tap should be withheld if there is papilledema: A neurosurgeon should be
consulted immediately under these circumstances. In a patient with fever,
nuchal rigidity, no papilledema, and no focal neurologic signs (particularly
a dilated pupil), a spinal tap can be performed for diagnosis and immediate
therapy. It is preferable, however, to have CT scan results in hand first.
Meningitis or a subarachnoid hemorrhage is frequently found in these
circumstances. CT scans and x-rays of the cervical spine and skull will
still be indicated in cases where the diagnosis remains obscure.
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Source: Differential Diagnosis in Primary Care, 2007
PHOTOPHOBIA:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The approach to the diagnosis of photophobia is the same as that of
blurred vision .
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Meningitis:
Diagnosis
(Pediatric Infectious Disease)
The major reported risk in obtaining a sample of CSF is that a preexisting
intracranial mass will cause a brainstem herniation following lumbar puncture.
There are also concerns that lumbar puncture could cause herniation in a child
who has increased intracranial pressure secondary to severe meningitis. Many
clinicians obtain a computed tomography (CT) scan of the head before obtaining
a lumbar puncture, although this may delay diagnosis and optimal therapy.
Although herniation remains a possibility in the setting of bacterial
meningitis, it remains an uncommon occurrence, with most estimates reporting an
incidence of
less than 5%. Although an increase in intracranial pressure is thought to be
present in virtually all cases of pediatric bacterial meningitis, it is also
known that CT of the brain is normal in most cases of bacterial meningitis,
including cases that had subsequent herniation following lumbar puncture. Most
specialists stress the need for an accurate history and physical examination
when deciding whether to obtain imaging before lumbar puncture. It is noted
that a patient with a mass lesion such as an abscess or brain tumor will
usually report symptoms over the preceding weeks, whereas in bacterial
meningitis, there is a history ranging from hours to days. The diagnosis of
impending cerebral herniation can often be made clinically from abnormalities
of the neurological exam, including sixth nerve palsy, dilated or fixed pupils,
and decerebrate posturing. In patients who have the clinical features of
impending herniation, lumbar puncture should be deferred and diagnostic testing
limited to blood cultures. Aggressive measures to reduce intracranial pressure
are mandatory in such a patient.
Cerebrospinal Fluid Examination
Examination of the CSF is critical. Typically, bacterial meningitis presents
with a CSF white blood cell count of several thousand white cells, most being
segmented neutrophils. The mean CSF white cell count in bacterial meningitis,
regardless of whether patients have been pretreated, is greater than 4,000/m
3. In bacterial meningitis, the protein concentration of the CSF will be high and
glucose concentration low. The probability of a positive Gram stain is
dependent on the number of bacteria present in the CSF, which may be related to
the timing of lumbar puncture in relation to the onset of symptoms. A positive
Gram stain of the CSF in bacterial meningitis is also related to the organism
causing the meningitis.
Streptococcus pneumoniae has the highest rate of having a positive Gram stain (about 90%), with Neisseria meningitidis having a positive Gram stain in about 75% of cases. CSF cultures are more likely
to be positive in patients who had lumbar puncture before the administration of
antibiotics.
» READ BOOK EXCERPT ONLINE »
Source: Pediatric Infectious Disease, 2004
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