Diagnosis of Traumatic Brain Injury

• 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
  >>

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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.

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Source: Differential Diagnosis in Primary Care, 2007

DYSARTHRIA AND SPEECH DISORDERS: Approach to the Diagnosis
(Differential Diagnosis in Primary Care)

Dysarthria without other symptoms or signs requires that myasthenia gravis be ruled out with a Tensilon test and psychometrics be done to rule out hysteria. In the presence of other neurologic signs, speech disorders require a thorough neurologic workup with an EEG, skull x-ray, and CT scan or MRI of the brain; a spinal tap or arteriogram may be indicated. The clinician should remember that dysarthria may be only the first sign of a serious neurologic disease such as multiple sclerosis, Wilson disease, lupus erythematosus, or chronic alcoholism; therefore, close follow-up is important.

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Source: Differential Diagnosis in Primary Care, 2007

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

Perform a complete neurologic examination. Begin with the history. Ask the patient about recent trauma to the head. Did he sustain a severe blow to the head? Was he involved in a motor vehicle accident? Note the patient's level of consciousness as he responds. Does he respond quickly or slowly? Are his answers appropriate, or does he appear confused?

Check the patient's vital signs; be alert for widening pulse pressure and bradycardia, signs of increased intracranial pressure. Assess cranial nerve function in nerves II, III, IV, VI, VII, and VIII. Evaluate pupillary size and response to light as well as motor and verbal responses. Relate these data to the Glasgow Coma Scale. Also, note cerebrospinal fluid (CSF) leakage from the nose or ears. Ask about postnasal drip, which may reflect CSF drainage down the throat. Look for the halo sign — a bloodstain encircled by a yellowish ring — on bed linens or dressings. To confirm that drainage is CSF, test it with a Dextrostix; CSF is positive for glucose, whereas mucus isn't. Follow up the neurologic examination with a complete physical examination to detect other injuries associated with basilar skull fracture.

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

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

Explore dysarthria completely. When did it begin? Has it gotten better? Speech improves with resolution of a transient ischemic attack, but not in a completed stroke. Ask if dysarthria worsens during the day. Then obtain a drug and alcohol history. Also, ask about a history of seizures. Check dentures for a proper fit.

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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.

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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

Blunt chest injuries: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

A history of trauma with dyspnea, chest pain, and other typical clinical features suggest a blunt chest injury. To determine its extent, a physical examination and diagnostic tests are needed.

❑ In hemothorax, percussion reveals dullness. In tension pneumothorax, it reveals tympany. Auscultation may reveal a change in position of the loudest heart sound.

❑ Chest X-rays may confirm rib and sternal fractures, pneumothorax, flail chest, pulmonary contusions, lacerated or ruptured aorta, tension pneumothorax, diaphragmatic rupture, lung compression, or atelectasis with hemothorax.

❑ With cardiac damage, the ECG may show abnormalities, including unexplained tachycardias, atrial fibrillation, bundle-branch block (usually right), ST-segment changes, and ventricular arrhythmias such as multiple premature ventricular contractions.

❑ Serial aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, creatine kinase (CK), and CK-MB levels are elevated. However, cardiac enzymes fail to detect up to 50% of patients with myocardial damage.

❑ Retrograde aortography and transesophageal echocardiography reveal aortic laceration or rupture.

❑ Contrast studies and liver and spleen scans detect diaphragmatic rupture.

❑ Echocardiography, computed tomography scans, and cardiac and lung scans show the injury’s extent.

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

Blunt and penetrating abdominal injuries: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

CONFIRMING DIAGNOSIS A history of abdominal trauma, clinical features, and laboratory test results confirm the diagnosis of blunt or penetrating abdominal injury and determine organ damage.

Consider any upper abdominal injury a thoracicoabdominal injury until proven otherwise. Laboratory studies vary with the patient’s condition but usually include:

❑ chest X-rays (preferably done with the patient upright to show free air)

❑ abdominal X-rays

❑ examination of stools and stomach aspirate for blood

❑ blood studies (decreased hematocrit and hemoglobin levels point to blood loss; coagulation studies evaluate hemostasis; white blood cell count is usually elevated but doesn’t necessarily point to infection; type and crossmatch to prepare for a blood transfusion)

❑ arterial blood gas analysis to evaluate respiratory status

❑ serum amylase levels, which may be elevated in pancreatic injury

❑ aspartate aminotransferase and alanine aminotransferase levels, which increase with tissue injury and cell death

❑ excretory urography and cystourethrography to detect renal and urinary tract damage

❑ radioisotope scanning and ultrasound to detect liver, kidney, or spleen injury

❑ angiography to detect specific injuries, especially to the kidneys

❑ computed tomography scan to detect abdominal, head, or other injuries

❑ exploratory laparotomy to detect specific injuries when other clinical evidence is incomplete

❑ other laboratory studies to rule out associated injuries

❑ peritoneal lavage with insertion of a lavage catheter to check for blood, GI content, vegetable fibers, and bile. In blunt trauma with equivocal abdominal findings, this procedure helps establish the need for exploratory surgery.

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

Battle's sign: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Perform a complete neurologic examination, beginning with the history. Ask the patient about recent trauma to the head. Did he sustain a severe blow to the head? Was he involved in a motor vehicle accident? Note the patient’s level of consciousness as he responds. Does he respond quickly or slowly? Are his answers appropriate, or does he appear confused?

Check the patient’s vital signs; be alert for widening pulse pressure and bradycardia, signs of increased intracranial pressure. Assess cranial nerve function in nerves II, III, IV, VI, VII, and VIII. Evaluate pupillary size and response to light as well as motor and verbal responses. Relate these data to the Glasgow Coma Scale. Also, note cerebrospinal fluid (CSF) leakage from the nose or ears. Ask about postnasal drip, which may reflect CSF drainage down the throat. Look for the halo sign—a bloodstain encircled by a yellowish ring—on bed linens or dressings. To confirm that drainage is CSF, test it with a Dextrostix; CSF is positive for glucose, whereas mucus isn’t. Follow up the neurologic examination with a complete physical examination to detect other injuries associated with a basilar skull fracture.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Dysarthria: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

Explore dysarthria completely. When did it begin? Has it gotten better? Speech improves with resolution of a transient ischemic attack, but not in a completed stroke. Ask if dysarthria worsens during the day. Then obtain a drug and alcohol history. Also, ask about a history of seizures. Observe dentures for a proper fit.

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Headache: History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))

If the patient reports a headache, ask him to describe its characteristics and location. How often does he get a headache? How long does a typical headache last? Try to identify precipitating factors, such as eating certain foods or exposure to bright lights. Ask what helps to relieve the headache. Is the patient under stress? Has he had trouble sleeping?

Take a drug and alcohol history, and ask about head trauma within the last 4 weeks. Has the patient recently experienced nausea, vomiting, photophobia, or visual changes? Does he feel drowsy, confused, or dizzy? Has he recently developed seizures, or does he have a history of seizures?

Begin the physical examination by evaluating the patient’s level of consciousness (LOC). Then check his vital signs. Be alert for signs of increased ICP—widened pulse pressure, bradycardia, altered respiratory pattern, and increased blood pressure. Check pupil size and response to light, and note any neck stiffness. (See Differential diagnosis: Headache, pages 392 and 393.)

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Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006

Headache: History
(The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter)

A. Characteristics of the headache. What is the type of pain, its location, its duration, and its intensity? What symptoms precede or accompany the pain? Does anything trigger the headache or make the pain better or worse? Tell about a typical headache from beginning to end.

 1. Migraine food triggers include alcohol, aged cheese, chocolate, and aspartame.

 2. Approximately 20% to 30% of migraineurs will report an aura, typically visual in nature.

3. Patients with cluster headache report unilateral temporal headache, occurring generally once daily, usually in the evening and associated with ipsilateral nasal stuffiness and conjunctival injection.

4. Chronic daily headache (CDH) patients will describe headaches at least 10 to 15 days/month and usually report heavy use of relief drugs.

 5. Red flags that might suggest intracranial pathology (section I.B) include a loss of consciousness, persistent visual loss, seizures, staggering, or hearing loss.

 B. Chronology of the headache. Most primary headaches recur periodically for years, with only subtle changes over time. If the headache is getting worse, the cause might be psychosocial stressors, medication overuse, or evolving intracranial pathology (Table 2.5). Ask women whether the headache seems related to the menses. Past and current medication use and how they affect the headache can be important clues to headache severity and how the patient may respond to treatment.

 C. Family history. Migraine headaches often exhibit a familial pattern; the causes of secondary headaches generally do not. Tension headache can represent a family pattern of reacting to stress.

D. Psychosocial aspects of the headache. What does the patient believe is the cause of the headache? What life events might be playing a role? How does the patient’s family react to the headache? Ask: “If you did not have the headache, how would your life be different?” The key to management of recurrent primary headaches often lies in the responses to these questions, which can reveal unanticipated stressors, secondary gain, or family discord.

E. Other information. Important data include use of tobacco, alcohol, or coffee; response to exercise; a history of head trauma; or exposure to toxic fumes or chemicals. Have there been symptoms of fever, or fatigue? Ask about depression, which is often seen in migraineurs.

Physical examination

 A. Focused physical examination (PE). This should include vital signs (notably blood pressure) and an examination of the scalp; eyes, including funduscopic examination; ears; nose; paranasal sinuses; throat; and neck. A screening neurologic examination, including cranial nerves, coordination (finger-to-nose test), and deep tendon reflexes, is sufficient in most instances. In the migraineur, the examination findings should be all normal in the absence of a current headache; a positive finding warrants further testing (section IV).

B. Additional PE. Other PE maneuvers are appropriate if the medical history suggests specific secondary headache causes: palpation of the superficial temporal arteries (temporal arteritis), audiometry (acoustic neuroma), transillumination of the paranasal sinuses (“sinus headache”), or checking for nuchal rigidity plus Kernig’s and Brudzinski’s signs (meningeal irritation).

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Source: The 10-Minute Diagnosis Manual: Symptoms and Signs in the Time-Limited Encounter, 2000

Headache: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Migraine

❑ Tension

❑ Acute sinusitis

❑ Acute glaucoma

❑ Postconcussive

❑ Cluster

❑ Meningitis

❑ Drugs

❑ Hypoglycemia

❑ Benign exertional headache

❑ Temporomandibular joint inflammation

❑ Subdural hematoma

❑ Subarachnoid hemorrhage

❑ Acute epidural hematoma

❑ Lumbar puncture

❑ Brain tumor

❑ Headache in HIV

❑ Pseudotumor cerebri

❑ Hypertensive encephalopathy

❑ Carbon monoxide intoxication

❑ Giant cell arteritis

❑ Psychogenic

❑ Brain abscess

❑ Encephalitis

❑ Arteriovenous malformations

❑ Cavernous sinus thrombosis

❑ Pituitary apoplexy

❑ Carotid artery dissection

Diagnostic Approach

Red flags to serious causes include: Sudden onset of “the worst headache of my life,” especially in a non—headache-prone person; headache different from previous headaches; headache precipitated by position change, cough, or exertion; a history of trauma or fever; abnormal mental status or other neurological findings; a headache that disturbs sleep or is present immediately on awakening; immune deficiency such as HIV.

The time course helps in diagnosing headache. A “thunderclap” headache of a ruptured aneurysm peaks instantly. Cluster headache peaks over 3 to
5 minutes, remains at maximum for 45 minutes, and then gradually recedes. Migraine builds over hours, lasts hours to days, and is improved with sleep.

In evaluating patients with recurrent migraine, it is critical to ascertain whether the present headache differs from prior migraines and whether fever is present or spontaneous retinal venous pulsations are abnormally absent. These should prompt a search for alternative causes. If fever is present with headache, rule out meningitis.

Raised intracranial pressure should be suspected with blurred vision upon bending the head forward, headache upon awakening that improves with sitting up, double vision, loss of coordination and balance, or daily
progressive headache with nausea. Pain originating above the tentorium is referred to the frontal, temporal, or parietal region. Pain from the posterior fossa and below is referred to the occiput. Pain from the posterior sagittal and transverse sinuses may be referred to the eye or forehead.

Lumbar puncture, subdural hematoma, or benign intracranial hypertension can cause orthostatic headache. Occipital headache radiating to the vertex and forehead is usually a result of cervical spondylosis but can also be caused by basal subarachnoid hemorrhage, posterior fossa tumor, or meningitis.

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Source: Field Guide to Bedside Diagnosis, 2007

Aphasia/Dysarthria: Differential Overview
(Field Guide to Bedside Diagnosis)

Aphasia (Central)

❑ Broca

❑ Wernicke

❑ Conduction

❑ Anomic

❑ Global

❑ Motor aphasia

❑ Pure word deafness

❑ Alexia without agraphia

❑ Alexia with agraphia

Dysarthria (Peripheral)

❑ Bulbar

❑ Parkinson

❑ Multiple sclerosis

❑ Tongue infiltration

Diagnostic Approach

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Source: Field Guide to Bedside Diagnosis, 2007

Headache: Diagnosis
(Handbook of Diseases)

An accurate diagnosis requires a history of recurrent headaches and physical examination of the head and neck. Such examination includes percussion, auscultation for bruits, inspection for signs of infection, and palpation for defects, crepitus, and tender spots (especially after trauma).

A firm diagnosis also requires a complete neurologic examination, assessment for other systemic diseases (such as hypertension), and a psychosocial evaluation (when such factors are suspected).

Most patients may be diagnosed by a thorough history and physical examination. Magnetic resonance imaging, computed tomography scans, lumbar puncture, and serology may be beneficial. Neurologic deficits, such as stroke or brain tumors; metabolic processes, such as thyroid disease or diabetes; and an aneurysm must be ruled out if the headache is explosive and “the worst” in their lives.

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Source: Handbook of Diseases, 2003

Chest injuries, blunt: Diagnosis
(Handbook of Diseases)

A history of trauma with dyspnea, chest pain, and other typical symptoms suggest a blunt chest injury. A physical examination and diagnostic tests determine the extent of injury.

❑ Percussion reveals dullness in hemothorax and tympany in tension pneumothorax.

❑ Auscultation may reveal a change in position of the loudest heart sound in tension pneumothorax or muffled heart tones in cardiac tamponade.

❑ Chest X-rays may be used to confirm rib and sternal fractures, pneumothorax, flail chest, pulmonary contusions, lacerated or ruptured aorta, tension pneumothorax, diaphragmatic rupture, lung compression, or atelectasis with hemothorax.

❑ ECG may show abnormalities with cardiac damage, including multiple premature ventricular contractions, unexplained tachycardias, atrial fibrillation, bundle-branch heart block (usually right), and ST-segment changes.

❑ Serial aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, creatine kinase (CK), and CK-MB levels are elevated.

❑ Retrograde aortography and transesophageal echocardiography reveal aortic laceration or rupture.

❑ Contrast studies and liver and spleen scans help detect diaphragmatic rupture.

❑ Echocardiography, computed tomography scans, and cardiac and lung scans show the extent of the injury.

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Source: Handbook of Diseases, 2003

Amputation, traumatic: Diagnosis
(Handbook of Diseases)

Any patient with a traumatic amputation requires careful monitoring of vital signs as well as assessment for other traumatic injuries. If amputation involves more than just a finger or a toe, assessment of airway, breathing, and circulation is also required. Because profuse bleeding is likely, watch for signs of hypovolemic shock, and draw blood for hemoglobin level, hematocrit, and typing and crossmatching. If the patient has a partial amputation, check for pulses distal to the amputation.

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Source: Handbook of Diseases, 2003

Abdominal injuries: Diagnosis
(Handbook of Diseases)

A history of abdominal trauma, signs and symptoms, and laboratory results confirm the diagnosis and help determine organ damage. Consider any upper abdominal injury a thoracicoabdominal injury until proven otherwise. Diagnostic studies vary with the patient’s condition but usually include:

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Source: Handbook of Diseases, 2003

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

Obtain the patient’s history, noting recent trauma to the head such as involvement in a motor vehicle accident. Assess his level of consciousness and the appropriateness of his responses to your questions.

Physical examination

Perform a complete neurologic assessment. Check the patient’s vital signs; stay alert for widening pulse pressure and bradycardia — these are signs of increased intracranial pressure. Assess cranial nerve (CN) function in CN II, III, IV, VI, VII, and VIII. Evaluate pupillary size and response to light as well as motor and verbal responses. Relate these data to the Glasgow Coma Scale. Assess for cerebrospinal fluid (CSF) leakage from the nose or ears. Ask about postnasal drip, which may reflect CSF drainage down the throat. Look for the halo sign — a bloodstain encircled by a yellowish ring — on bed linens or dressings. Test drainage to determine the presence of CSF. Follow the neurologic examination with a complete physical examination to detect other injuries associated with a basilar skull fracture.

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

Dysarthria: History
(Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)

Obtain a history of the condition. When did it begin? Has it gotten better? Ask if dysarthria worsens during the day. Then obtain a drug and alcohol history. Also, ask about a history of seizures.

Physical examination

Explore dysarthria completely. Speech improves with resolution of a transient ischemic attack, but not in a completed stroke. Observe dentures for a proper fit. Ask the patient to produce a few simple sounds and words. Compare muscle strength and tone in the limbs on one side of the body with the other. Assess the patient’s tactile sense, DTRs, and note gait ataxia. Assess cerebellar function, test visual fields, and ask about the presence of double vision. Check for signs of facial weakness. Evaluate LOC and mental status.

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

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

Ask the patient about recent trauma to the head. Did he sustain a severe blow to the head? Was he involved in a motor vehicle accident? Note the patient’s level of consciousness (LOC) as he responds. Does he respond quickly or slowly? Are his answers appropriate, or does he appear confused?

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Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007

Dysarthria: History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Explore dysarthria completely. When did it begin? Has it gotten better? Speech improves with resolution of a transient ischemic attack, but not in a completed stroke. Ask if dysarthria worsens during the day. Then obtain a drug and alcohol history. Also, ask about a history of seizures. While taking the patient’s history, pay attention to his speech. Dysarthria is usually evident in ordinary conversation. Observe dentures for a proper fit.

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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?

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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