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INTERNSHIP SURVIVAL GUIDE
Focused Examination
General
Does the patient appear ill or distressed?
HEENT
Look for signs of trauma, pupil size, symmetry,
response to light, papilledema, nuchal rigidity, tem-
poral artery tenderness, and sinus tenderness.
Neurologic
Thorough examination is mandatory, including men-
tal status.
Laboratory and Diagnostic Data
•
Consider CBC and erythrocyte sedimentation rate if temporal
arteritis is suspected.
•
Head CT
should be considered for the following:
• A chronic headache pattern that has changed or a new severe
headache occurs
• A new headache in a patient older than 50 years
• Focal findings on neurologic examination
•
If meningitis is suspected, an LP should be performed!
Obtain
a head CT before LP in the following: elderly, immunocom-
promised, in the presence of seizures, those with altered level of
consciousness, and those with focal neurologic abnormalities (see
Chapter 22, Neurology).
Management
•
The initial goal is to exclude the serious life-threatening con-
ditions
mentioned previously. After such conditions have been
excluded, management can focus on symptomatic relief.
•
For suspected bacterial meningitis, start antibiotics immediately
(do not wait for an LP; see Chapter 22, Neurology).
•
For suspected subdural hematoma or subarachnoid hemorrhage,
obtain CT scan. If positive, a neurosurgery consultation should
be obtained.
•
Tension headaches and mild migraines can be treated with acet-
aminophen 650 to 1000mg PO q6h PRN or ibuprofen 200 to
600mg PO q6-8h.
•
Consider sumatriptan 25mg PO for moderate to severe migraine
headaches; can repeat 25 to 100mg q2h for maximum of 200 to
300mg/d. This therapy is most effective when given immediately
after the onset of headache. Avoid use in patients with angina or
uncontrolled HTN.
•
IV ketorolac and prochlorperazine are often used in the hospital for
abortive therapy for headache.