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Diagnosis of Pneumococcal meningitis

Pneumococcal meningitis Diagnosis: Book Excerpts

Diagnostic Tests for Pneumococcal meningitis: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Pneumococcal meningitis.


HEADACHE: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is there a history of drug, caffeine, or alcohol ingestion? The hangover headache is well known and should not present a problem in diagnosis. Caffeine withdrawal headaches are also common because of the large amount of caffeine consumed in coffee, various soft drinks, and chocolate. Drugs that may induce headache include the nonsteroidal anti-inflammatory drugs such as indomethacin (Indocin®) and the anti-hypertensives such as clonidine, aspirin, quinidine, and bromides.
  2. Is there a history of trauma? Trauma may cause concussion and postconcussion headaches, intracranial neoplasms such as subdural hematoma, and cervical sprain, all of which can induce headaches.
  3. Is the headache acute or chronic? An acute onset of a headache can be a serious problem. It should be taken seriously because it may mean a subarachnoid hemorrhage or meningitis. This can be easily confirmed by checking for nuchal rigidity. Whenever there is an acute onset of a headache this must be done. Chronic headaches, on the other hand, are most likely due either to migraine if they occur in exacerbations or remissions, or to tension headaches if they are fairly constant, mild, and chronic. The headache of a brain tumor is rarely severe and is rarely the presenting symptom of a brain tumor. Headaches that occur in clusters almost daily for 6 to 8 weeks with interruptions of several months must make one consider cluster headaches. Unilateral headaches in the elderly with acute onset should make one think of temporal arteritis.
  4. Is there nuchal rigidity? The presence of nuchal rigidity should make one think of a subarachnoid hemorrhage or meningitis, but it may also be due to cerebral hemorrhage or cerebral abscess.
  5. Is there fever? If the headache is associated with fever, the possibility of acute sinusitis should be considered, and the sinuses should be transilluminated. Other sources for the fever should be looked for, and meningitis or encephalitis should be considered.
  6. Is there papilledema or are there focal neurologic signs? With acute headache and focal neurologic signs and/or papilledema, one should consider cerebral abscess or cerebral hemorrhage. With a chronic headache and papilledema or focal neurologic signs, one should consider a space-occupying lesion such as a primary brain tumor or metastatic neoplasm.
  7. Do the sinuses transilluminate well? A sinus transilluminator should be in the armamentarium of every physician who expects to diagnose headache. If the sinuses fail to transilluminate, one should consider acute sinusitis as the diagnosis.
  8. Is there tenderness of the superficial temporal artery? The presence of a tender superficial temporal artery should make one think of temporal arteritis, particularly in the elderly, but it may also be related to a long-standing migraine attack.
  9. Is the headache relieved by superficial temporal artery compression? Relief of the headache on superficial temporal artery compression should suggest classical or common migraine. If one can relieve the headache by compression of the occipital artery, occipital migraine should be considered. When there is no relief on compression of the superficial temporal artery, one should consider tension headaches, occipital neuralgia, cervical spondylosis, and cluster headaches as the cause.

DIAGNOSTIC WORKUP

Routine diagnostic tests include a CBC to rule out severe anemia, a sedimentation rate to rule out temporal arteritis, a chemistry panel to rule out liver and kidney disease, a VDRL test to rule out central nervous system syphilis, an x-ray of the sinuses to rule out sinusitis, and an x-ray of the cervical spine to exclude cervical spondylosis. A chest x-ray should also be done to rule out the possibility of metastatic neoplasm. A tonometry study may be done if glaucoma is suspected.

If there are focal neurologic signs, referral should be made to a neurologist or neurosurgeon as soon as possible. If one is not readily available, a CT scan or MRI may be done, the CT scan being the preferred procedure if the expense is a consideration.

If there is nuchal rigidity, a CT scan should be done to rule out a space-occupying lesion before proceeding with a spinal tap. If the CT scan is negative, a spinal tap can be done, and this will ascertain whether there is intracranial bleeding or meningitis. It is usually best to refer the patient to a neurologist or neurosurgeon if there is nuchal rigidity.

If the headaches are chronic and episodic, and there are no focal neurologic signs, papilledema, or nuchal rigidity, an imaging study can be postponed for a while until the response to treatment is evaluated. However, if the response to treatment is poor, one should not hesitate to order a CT scan or MRI.

Difficult cases of headache should also be studied with 24-hr blood pressure monitoring, a 24-hr urine for catecholamines, and lumbar puncture to diagnose central nervous system lues. Histamine phosphate 0.5 cc subcutaneously may help diagnose cluster headaches. Response to beta-blockers may help diagnose migraine. Cerebral angiography may be necessary to diagnose aneurysms and arteriovenous malformations. Patients with chronic headache unresponsive to therapy should be referred to a psychiatrist.

 

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Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

PHOTOPHOBIA: Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)

  1. Is there a history of exposure to drugs or toxins? Quinine, cocaine, atropine, and Apresoline® are just a few of the drugs that may cause photophobia.
  2. Are there abnormalities on the eye examination? Almost any condition of the eye may cause photophobia, including conjunctivitis, blepharitis, keratitis, iritis, corneal ulcers, and retinitis.
  3. Are there abnormal tonometry readings? The eye may appear normal, but the tonometry may disclose glaucoma.
  4. Is there nuchal rigidity? The presence of nuchal rigidity, especially with fever, would suggest meningitis. Without fever or with only a low-grade fever, the presence of nuchal rigidity should suggest subarachnoid hemorrhage.

DIAGNOSTIC WORKUP

A careful eye examination including tonometry and slit lamp examination should be done. A referral to an ophthalmologist may be necessary to accomplish this. If there is nuchal rigidity, a CT scan followed by a spinal tap should be done in conjunction with a neurologic consultation. If there is fever without nuchal rigidity, the workup can proceed as outlined on page 168 . A histamine test may be helpful in diagnosing migraine.

 

» READ BOOK EXCERPT ONLINE »

Source: Algorithmic Diagnosis of Symptoms and Signs, 2003

Headache: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Tension-type headache
    –Most common cause of headache
    –Diffuse, bilateral, band-like pain
    –Lasts for hours to days
    –May occur on a fairly regular basis
  • Migraine headache
    –Throbbing unilateral or bilateral pain
    –May last for days
    –May have preceding aura (flashing light)
    –Triggers include foods, drugs, or stress
  • Meningitis
    –May present with fever, photophobia, neck stiffness, nausea/vomiting, papilledema
    –Brudzinski's sign: Neck pain upon passive flexion of neck
    –Kernig's sign: Neck pain and involuntary flexion upon passive extension of knee with hips flexed
  • Head trauma
  • Medications
  • Carbon monoxide exposure
  • Sinusitis
  • Temporomandibular joint syndrome or dental pain
  • Withdrawal from alcohol, barbiturates, caffeine, or other substance
  • Temporal arteritis
    –Pain/tenderness over temporal area/jaw
    –Occurs uniquely in patients over 50
    –Blindness may occur
  • Mass lesions (e.g., tumor, hematoma)
    –Daily, progressive headache
    –May awaken from sleep
    –Focal neurologic signs
  • Subarachnoid hemorrhage
    –Sudden onset of “worst headache of my life”
    –Neck stiffness
    –Loss of consciousness
  • Cluster headache
    –Severe, unilateral pain
    –Lasts minutes to hours
    –Occurs daily for months, then remits for months or even years
  • Glaucoma
    –Retro-orbital pain
  • Chronic daily headache or rebound headache (e.g., secondary to chronic analgesic use)
  • Benign intracranial hypertension

Workup and Diagnosis

  • History and physical exam often make the diagnosis
    –History should focus on onset, duration, frequency, possible triggers, severity, quality (e.g., throbbing, band-like), accompanying symptoms (e.g., aura, photophobia, visual changes, nausea/vomiting, lacrimation, nasal congestion), constitutional symptoms (e.g., weight loss, fever), medications, and dietary history
    –Is this first and/or worst headache of life?
    –Exam should include a complete neurologic exam, visual/retinal exam, head/neck, and gait exam
  • Possible serious etiologies and need for further workup are suggested by the following red flags: Constitutional symptoms, new headache in a patient over 50, sudden onset, awakening from sleep, mental status changes, focal neurologic signs, visual/motor/balance disturbance, papilledema
  • CT will identify hemorrhage and mass lesions and rule out increased intracranial pressure
  • MRI will identify posterior fossa tumors
  • Lumbar puncture is indicated if CT is normal but still suspect hemorrhage, infection, or tumor
  • Serologies for bacterial, viral, and other causes of meningitis or encephalitis
  • Elevated ESR suggests temporal arteritis or infection
  • Carboxyhemoglobin measurement if history suggests carbon monoxide poisoning

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Source: In a Page: Signs and Symptoms, 2004

Photophobia: Differential Diagnosis
(In a Page: Signs and Symptoms)

  • Corneal abrasion
  • Conjunctivitis
    –Viral: Watery discharge; adenovirus most common, also herpes simplex
    –Allergic: Usually bilateral
    –Chemical: History of exposure
    –Bacterial (rare): Purulent discharge
  • Migraine headache: Normal eye and neurologic exam, headache, phonophobia
  • Idiopathic anterior uveitis/iritis (often associated with a triad of pain, photophobia, and blurred vision)
    –Ankylosing spondylitis
    –Reiter's syndrome
    –Inflammatory bowel disease
    –Psoriatic arthritis
    –Sarcoidosis
    –Infections (e.g., Lyme disease, herpes simplex/zoster, tuberculosis, syphilis)
    –Postoperative reactions
    • Meningitis/encephalitis
    • SAH
    • Influenza
    • Lightly pigmented eye
    • Mydriatic use
    • Keratoconjunctivitis sicca, or dry eye syndrome
    • Less common etiologies (“zebras”) include albinism, total color blindness, vitamin A deficiency, measles, posterior uveitis, congenital glaucoma, sinusitis, mononucleosis, influenza, Colorado tick fever, babesiosis, botulism, and acute viral hepatitis (A, B, or E)

    Workup and Diagnosis

    • History and physical examination
      –Focused history for exposure to foreign bodies (e.g., woodworking or other flying debris), allergens, exposure to others with URI and/or conjunctivitis, systemic symptoms (e.g., arthritis)
      –Physical exam should include a detailed neurologic exam, ocular exam (including dilated fundoscopic and slit-lamp exam if possible), eyelid eversion to rule out foreign bodies, fluorescein staining of the cornea to rule out abrasion, and intraocular pressure measurement
    • Head CT scan without contrast if subarachnoid hemorrhage is suspected
    • Lumbar puncture if subarachnoid hemorrhage or meningitis is suspected
    • CBC and/or blood cultures if suspect meningitis
    • Further workup is based on examination
      –If anterior uveitis is suspected, targeted testing may include CBC, ESR, ANA, ACE level (sarcoidosis), RPR (syphilis), PPD, chest X-ray (TB/sarcoidosis), Lyme titers, Chlamydia cultures (Reiter's syndrome), HLA-B27 assay, sacroiliac spine films (ankylosing spondylitis), and colonoscopy (inflammatory bowel disease)
      –If optic neuritis is diagnosed, an MRI of the brain and orbits is indicated to evaluate for multiple sclerosis

» READ BOOK EXCERPT ONLINE »

Source: In a Page: Signs and Symptoms, 2004

Headache: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

  • Migraine
    –Recurring headache with throbbing, pulsating pain; nausea and vomiting; photophobia, phonophobia
    –Family history of migraine
    –Improvement with rest/sleep
    –Without aura (common migraine) 85%
    –With aura (classic migraine) 15%
    –Frequently bilateral pain in children
    –Aura usually develops over 5 minutes and is most commonly visual
    –Migraine is an episodic disorder
    –Chronic daily headache is not migraine
    • Tension headache
      • Pseudotumor cerebri
        –Elevated ICP with no masses or abnormalities in CSF or labs
      • Cluster headache
        –Unilateral nonthrobbing, periorbital pain
        –May have ipsilateral conjectival injection, lacrimation, rhinorrhea
    • Subarachnoid hemorrhage
      –Sudden paroxysmal headache
      –Meningeal signs
      –An emergency requiring CT and LP
    • Increased intracranial pressure
      –Tumor, abscess, hydrocephalus, hemorrhage
    • Sinusitis, otitis
    • Dental disease
    • Systemic infection
    • TMJ disease
    • Postconcussive syndrome
    • Trigeminal neuralgia
    • Mitochondrial disorders
    • Venous sinus thrombosis
    • Meningitis/encephalitis
    • CSF leak, post-lumbar puncture
    • Hypertensive crisis
    • Trauma
    • Arteriovenous malformation
    • Stroke
    • Toxins and medication
      –Nitrites, cocaine, interferon, CO
    • Fever
    • Anemia

    Workup and Diagnosis

      • History
        –Duration (recurrent, progressive), frequency
        –Time of onset and duration
        –Location and nature of pain, warning (aura)
        –Factors that alleviate or exacerbate symptoms (e.g., stress)
        –Nausea, vomiting, photophobia, phonophobia
        –Family history, response to treatment
    • Physical exam
      –Vital signs (temperature, blood pressure)
      –Height, weight, head circumference
      –Funduscopy (to rule out papilledema)
    • Neuroimaging (CT, MRI) is required for certain symptoms
      –Short history of headache (<6 months) or age <5–6 years
      –Worsening headaches, no response to treatment
      –Deterioration in cognitive or motor function
      –Short stature, macrocephaly
      –Awakening at night or early morning
      –Repeated morning vomiting
      –Exacerbation by position change or cough
      –Focal neurologic symptoms during headache
      –Cluster headache in prepubertal children and adolescent girls
      –Systemic symptoms: Fatigue, weight loss
      –Abnormal neurological exam
      • Lumbar puncture with opening pressure
        –Subarachnoid hemorrhage, pseudotumor, or meningitis
      >>

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    Nuchal Rigidity: Differential Diagnosis
    (In A Page: Pediatric Signs and Symptoms)

    • Stress
      –Causing muscles to tighten and stiffen
    • Injury/whiplash secondary to trauma
    • Cervical adenitis
      • Meningitis
        –Presence of nuchal rigidity has 30% sensitivity, 95% specificity
    • Encephalitis
    • Subarachnoid hemorrhage
    • Retropharyngeal abscess
      –Associated with fever, sore throat (84%)
    • Epiglottitis
    • Focal dystonia
    • Torticollis, congenital or acquired
      • Tetanus
        –Associated with trismus, risus sardonicus, opisthotonus, muscle spasms
    • Dental abscess
    • Pharynx/larynx spasms
    • Chemical meningitis
      –After spinal anesthesia or lumbar puncture
    • Parameningeal infection
      –Lesion on MRI/CT
    • Posterior fossa tumor
    • Thyroiditis
    • Rheumatoid arthritis
    • Cervical arthritis
    • Pneumonia
    • Cervical spine osteomyelitis
    • Poliomyelitis
    • Trichinosis
    • Chagas disease
    • Infantile Gaucher disease
    • Maple syrup urine disease
    • Kernicterus
    • Toxins
      –Phenothiazines
      –Strychnine
      –Lead poisoning
      –Methanol poisoning
      –Hypervitaminosis A

    Workup and Diagnosis

    • History
      –Duration
      –Age of onset
      –Presence and location of pain
      –Trauma
      –Vomiting, headache, fever
      –History of blood clots, aneurysm
      –Decreased sensation or movement in other areas
      –Recent infection or recent dental work
      –Visual changes
      –Seizures
    • Physical exam
      –Vital signs, blood pressure, pulse, temperature
      –Head circumference in infants to evaluate for progressive increase in intracranial pressure
      –Head and neck should be palpated
      –Sinus tenderness, thyromegaly, and focal lymph nodes
      –Kernig sign: Flex hip and knee, then extend knee, assess for resistance to knee straightening
      –Brudzinski sign: Flex neck/chin to chest, observe if hip and knees flex
      –Careful mental status examination
      • Evaluation
        –Lumbar puncture to identify bacterial or viral meningitis, particularly in the febrile patient
        –MRI scan if focal neurologic abnormality, seizure, mental status changes

    » READ BOOK EXCERPT ONLINE »

    Source: In A Page: Pediatric Signs and Symptoms, 2007

    HEADACHE: Approach to the Diagnosis
    (Differential Diagnosis in Primary Care)

    The patient presenting with a history of headaches is an exciting diagnostic challenge. If one approaches the challenge simply on the basis of what is common, the patient most likely has migraine or muscle traction headache. But, wait a minute! Shouldn’t we look for serious conditions such as brain tumor, meningitis, or subarachnoid hemorrhage to avoid a serious mistake and a malpractice suit? First, check for nuchal rigidity to rule out meningitis and subarachnoid headache. Next, do a careful neurologic examination to rule out a brain tumor or other space-occupying lesion. These steps are particularly important in a patient is experiencing his or her first serious headache. If there is nuchal rigidity or focal neurologic signs, it is wise to immediately refer the patient to a neurologist or neurosurgeon for further workup and possible hospitalization. The specialist will probably order a CT scan of the brain and follow that with a spinal tap if a subarachnoid hemorrhage or meningitis is suspected. It is clear that a CT scan should be done prior to a spinal tap if there are focal neurologic signs or papilledema. One other condition that must be considered in acute headache particularly in the elderly is temporal arteritis. A sedimentation rate will usually be positive but a neurology consult is axiomatic so that steroids can be started immediately.

    In the patient with chronic or recurring headaches and no neurologic findings, it is wise to see the patient during the attack. Migraine and histamine headaches can be diagnosed by the response to sumatriptan by mouth or injection. If the headaches are due to chronic allergic or infectious rhinitis, relief can be had by spraying the turbinates with phenylephrine. Muscle traction headaches will often be relieved by occipital nerve blocks supporting the diagnosis. Compression of the superficial temporal artery will often relieve migraine temporarily supporting that diagnosis. Compression of the jugular veins will often give relief to post spinal tap headaches.

    If the patient is seen between headaches, certain prophylactic measures may help establish the diagnosis. For migraine, β-blockers may be prescribed and if the headaches are prevented, there is good support for the diagnosis. A course of corticosteroids may be initiated in patients with histamine (cluster) headaches to help establish the diagnosis. Muscle relaxants and/or tricyclic drugs may be given to help diagnose muscle contraction headaches.

    The diagnostic workup of chronic headaches might include a CT scan of the brain, x-rays of the sinuses, x-rays of the cervical spine and routine blood work. Certainly if headache persists after careful follow up, these need to be done.

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 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 for blurred vision (see page 83).

    » READ BOOK EXCERPT ONLINE »

    Source: Differential Diagnosis in Primary Care, 2007

    Brudzinski's sign: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    Continue your neurologic examination by evaluating the patient's cranial nerve function, noting motor or sensory def-icits. 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. 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 sudden onset of headaches, which may be associated with subarachnoid hemorrhage.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Headache: History and physical examination
    (Handbook of Signs & Symptoms (Third 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 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 past 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 — 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: Handbook of Signs & Symptoms (Third Edition), 2006

    Kernig's sign: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    If you elicit a positive Kernig’s sign and suspect life-threatening meningitis or subarachnoid hemorrhage, immediately prepare for emergency intervention. (See When Kernig’s sign signals CNS crisis, page 370.)

    If you don’t suspect meningeal irritation, ask the patient if he feels back pain that radiates down one or both legs. Does he also feel leg numbness, tingling, or weakness? Ask about other signs and symptoms, and find out if he has a history of cancer or back injury. Then perform a physical examination, concentrating on motor and sensory function.

    » READ BOOK EXCERPT ONLINE »

    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Nuchal rigidity: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    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 a headache, a 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: Handbook of Signs & Symptoms (Third Edition), 2006

    Photophobia: History and physical examination
    (Handbook of Signs & Symptoms (Third Edition))

    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?

    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.

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    Source: Handbook of Signs & Symptoms (Third Edition), 2006

    Headache: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    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, or tender spots (especially after trauma). 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.

    Diagnostic tests include cervical spine and sinus X-rays, EEG, computed tomography scan — performed before lumbar puncture to rule out increased intracranial pressure (ICP) — or magnetic resonance imaging. A lumbar puncture isn’t done if there’s evidence of increased ICP or if a brain tumor is suspected because rapidly reducing pressure by removing spinal fluid can cause brain herniation.

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    Source: Professional Guide to Diseases (Eighth Edition), 2005

    Meningococcal infections: Diagnosis
    (Professional Guide to Diseases (Eighth Edition))

    CONFIRMING DIAGNOSIS Gram-negative diplococci, on blood or cerebrospinal fluid (CSF) Gram stain, are highly suspicious for N. meningitidis. Isolation of N. meningitidis through a positive blood culture, CSF culture, or lesion scraping confirms the diagnosis, except in nasopharyngeal infections because N. meningitidis is part of the normal nasopharyngeal flora.

    Tests that support the diagnosis include counterimmunoelectrophoresis of CSF or blood, low white blood cell count and, in patients with skin or adrenal hemorrhages, decreased platelet and clotting levels. Diagnostic evaluation must rule out Rocky Mountain spotted fever and vascular purpuras.

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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.

    » READ BOOK EXCERPT ONLINE »

    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.

    » READ BOOK EXCERPT ONLINE »

    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).

    » READ BOOK EXCERPT ONLINE »

    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.

    » READ BOOK EXCERPT ONLINE »

    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.

    » READ BOOK EXCERPT ONLINE »

    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

    Kernig's sign: History
    (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

    If you suspect meningitis, ask the patient about recent infections, especially tooth abscesses. Ask about exposure to infected persons or places where meningitis is endemic. Meningitis is usually a complication of another bacterial infection, so blood cultures are needed to determine the causative organism. If subarachnoid hemorrhage is the suspected diagnosis, ask about a history of hypertension, cerebral aneurysm, head trauma, or arteriovenous malformation. Check the patient’s pupils for dilation, and assess him for signs of increasing intracranial pressure, such as bradycardia, increased systolic blood pressure, and widening pulse pressure.

    If you don’t suspect meningeal irritation, ask the patient if he feels any back pain that radiates down one or both legs. Does he also feel leg numbness, tingling, or weakness? Ask about other signs and symptoms, and find out if he has a history of cancer or back injury.

    Physical examination

    Perform a physical examination, concentrating on motor and sensory function. Assess motor function by inspecting the muscles and testing muscle tone and strength. Perform cerebellar testing. Cerebellar deficits affect the patient’s voluntary movements, equilibrium, integration of sensations, and sense of position. Assess sensory function by checking the patient’s sensitivity to pain, light touch, vibration, position, and discrimination.

    » READ BOOK EXCERPT ONLINE »

    Source: Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series, 2007

    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

    Kernig's sign: History
    (Signs & Symptoms: A 2-in-1 Reference for Nurses)

    If you elicit a positive Kernig’s sign and suspect life-threatening meningitis or subarachnoid hemorrhage, immediately prepare for emergency intervention. (See When Kernig’s sign signals CNS crisis, page 392.)

    If you don’t suspect meningeal irritation, ask the patient if he feels back pain that radiates down one or both legs. Does he also feel leg numbness, tingling, or weakness? Ask about other signs and symptoms, and find out if he has a history of cancer or back injury.

    » 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.

    • » READ BOOK EXCERPT ONLINE »

    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

    Kernig's sign: History and physical examination
    (Nursing: Interpreting Signs and Symptoms)

    If you elicit Kernig's sign and suspect life-threatening meningitis or subarachnoid hemorrhage, immediately prepare for emergency intervention. (See When Kernig's sign signals CNS crisis.)

    If you don't suspect meningeal irritation, ask the patient if he feels back pain that radiates down one or both legs. Does he also feel leg numbness, tingling, or weakness? Ask about other signs and symptoms, and find out if he has a history of cancer or back injury. Then perform a physical examination, concentrating on motor and sensory function.

    » 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.

    » READ BOOK EXCERPT ONLINE »

    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


     » Next page: Signs of Pneumococcal meningitis

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