Diagnostic Tests for Pneumococcal meningitis
Pneumococcal meningitis Tests: Book Excerpts
Home Diagnostic Testing
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Pneumococcal meningitis Diagnosis: Book Excerpts
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HEADACHE:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
PHOTOPHOBIA:
DIAGNOSTIC WORKUP
(Algorithmic Diagnosis of Symptoms and Signs)
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
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.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
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:
Physical examination
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)
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).
Testing
A. Clinical laboratory tests. For most recurrent headache patients, no blood, urine, or other clinical laboratory tests are needed. Laboratory tests that might be suggested by the clinical history and PE include erythrocyte sedimentation rate (temporal arteritis), hematocrit or thyroid studies (fatigue), cerebrospinal fluid examination (meningeal irritation), and white blood count with differential (systemic infection).
B. Diagnostic imaging. In most instances, diagnostic imaging is not needed. In one study, 350 patients with a chief complaint of headache, regardless of the presence or absence of neurologic signs, were referred for computed tomography (CT). Only 2% had clinically significant CT findings, and all patients with significant CT findings had abnormal PE findings or unusual clinical symptoms (3).
1. Diagnostic imaging may be indicated in patients with atypical headache patterns, a history of seizures, or focal neurologic signs or symptoms (4). New onset and “worst ever” headaches are significant complaints (i.e., atypical headache patterns).
2. Despite the greater cost, magnetic resonance imaging (MRI) provides the best imaging for the detection of brain tumors and most other chronic pathologic causes of headache that can be detected by imaging. CT is preferred if acute bleeding is suspected.
V. Diagnostic assessment. The key to the diagnosis of headache is the clinical history. A history of an aching, bitemporal headache that is associated with stress and that waxes and wanes is a typical tension headache. Migraine is characteristically a one-sided headache, throbbing in nature, often associated with nausea and vomiting, frequently accompanied by photophobia and sonophobia, and lasting 4 to 12 hours, perhaps longer. It may be “with aura” (classic) or “without aura” (common migraine), with the latter seen in 70% to 80% of migraineurs. Cluster headache is a strictly one-sided, recurring headache that chiefly affects men, and that occurs in “clusters” of 1 to 2 months of episodes. An increasing number of patients have chronic daily headache, often with virtual constant discomfort; many CDHs are the result of “transformed migraine” following daily analgesic use, especially codeine derivatives (5). Because recurrent headache is caused, at least in part, by life stresses and because it also causes personal and family stress, the diagnostic assessment is incomplete until this complex relationship has been adequately explored over a series of visits.
References
1. Stewart WF, Lipton RB, Celentano DD, Reed ML. Prevalence of migraine headache in the United States. JAMA 1992;267:64–69.
2. Becker L, Iverson DC, Reed FM, et al. Patients with new headache in primary care: a report from ASPN. J Fam Pract 1988;27:41–47.
3. Mitchell CS, Osborn RE, Grosskreutz SR. Computed tomography in the headache patient: is routine evaluation really necessary? Headache 1993;33:83–86.
4. The utility of neuroimaging in the evaluation of headache in patients with normal neurologic examinations: summary statement. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 1994;44:
1353–1354.
5. Silberstein SD, Lipton RB, Sliwinski M. Classification of daily and near daily headaches: field trials of revised IHS criteria. Neurology 1997;49:638–639.
» READ BOOK EXCERPT ONLINE »
Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000
Headache:
Diagnostic Approach
(Field Guide to Bedside Diagnosis)
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
Brudzinski's sign:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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), which is a further indication of meningeal irritation. Also, you should look for signs of central nervous system infection, such as fever and nuchal rigidity.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Headache:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Kernig's sign:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Perform a physical examination, concentrating on motor and sensory function. Assessing motor function includes inspecting the muscles and testing muscle tone and strength. Cerebellar testing is also done because the cerebellum plays a role in smooth muscle movements such as tics, tremors, or fasciculations. Sensory system evaluation involves checking the patient’s sensitivity to pain, light touch, vibration, position, and discrimination.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Nuchal rigidity:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Perform a neurologic assessment followed by musculoskeletal and cardiopulmonary assessments. Inspect the patient’s hands for swollen, tender joints, and palpate the neck for pain or tenderness.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Photophobia:
Physical assessment
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
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. Then check pupillary reaction to light. Evaluate extraocular muscle function by testing the six cardinal positions of gaze, and test visual acuity in both eyes. (See Testing the six cardinal positions of gaze, page 464.)
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: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Headache:
Diagnostic Approach
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)
Most commoncauses of headache in otherwise well children are tension-type andmigraine headaches.In ill children, most common causeis viral or bacterial infection.History and physical exam are diagnosticin most cases.In every child with significant headache,careful neurologic exam including funduscopic exam should be performedand BP should be measured.When history and physical exam arenormal, other tests rarely reveal presence of significant organicdisease.Although less common, headaches sometimesare associated with life-threatening illnesses (e.g., meningitis,encephalitis, brain abscess, and brain tumor). Besides history,physical exam, and lumbar puncture for suspected meningitis or encephalitis,CT and MRI are most important diagnostic tools. If increased intracranialpressure is suspected, CT should be performed before lumbar puncture.Cerebral angiography is useful for demonstrating cerebral aneurysmor arteriovenous malformation.
» 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
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