Causes of Brain conditions

• 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

» READ BOOK EXCERPT ONLINE »

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

Battle's sign: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

❑ Basilar skull fracture. Battle's sign may be the only outward sign of basilar skull fracture, or it may be accompanied by periorbital ecchymosis (raccoon eyes), conjunctival hemorrhage, nystagmus, ocular deviation, epistaxis, anosmia, a bulging tympanic membrane (from CSF or blood accumulation), visible fracture lines on the external auditory canal, tinnitus, difficulty hearing, facial paralysis, or vertigo.

» READ BOOK EXCERPT ONLINE »

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

Dysarthria: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Alcoholic cerebellar degeneration

Amyotrophic lateral sclerosis (ALS)

Basilar artery insufficiency.

Botulism.

Mercury poisoning

Multiple sclerosis

Myasthenia gravis

Olivopontocerebellar degeneration

Parkinson's disease

Shy-Drager syndrome

Stroke (brain stem).

Stroke (cerebral).

Other causes

Drugs

» READ BOOK EXCERPT ONLINE »

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

Headache: Medical causes
(Handbook of Signs & Symptoms (Third Edition))

Anthrax (cutaneous)

Along with a macular papular lesion that develops into a vesicle and finally a painless ulcer, headache, lymphadenopathy, fever, and malaise may occur.

Arteriovenous malformations

Less common than cerebral aneurysms, vascular malformations usually result from developmental defects of the cerebral veins and arteries

Although many are present from birth, they manifest in adulthood with a triad of symptoms: headache, hemorrhage, and seizures.

Brain abscess

With brain abscess, the headache is localized to the abscess site

Usually, it intensifies over a few days and is aggravated by straining. Accompanying the headache may be nausea, vomiting, and focal or generalized seizures. The patient’s LOC varies from drowsiness to deep stupor. Depending on the abscess site, associated signs and symptoms may include aphasia, impaired visual acuity, hemiparesis, ataxia, tremors, and personality changes. Signs of infection, such as fever and pallor, usually develop late; however, if the abscess remains encapsulated, these signs may not appear.

Brain tumor

Initially, a tumor causes a localized headache near the tumor site; as the tumor grows, the headache  becomes generalized

The pain is usually intermittent, deep seated, dull, and most intense in the morning. It’s aggravated by coughing, stooping, Valsalva’s maneuver, and changes in head position and relieved by sitting and rest. Associated signs and symptoms include personality changes, an altered LOC, motor and sensory dysfunction and, eventually, signs of increased ICP, such as vomiting, increased systolic blood pressure, and a widened pulse pressure.

Cerebral aneurysm (ruptured)

The patient may lose consciousness immediately or display a variably altered LOC. Depending on the severity and location of the bleeding, he may also exhibit nausea and vomiting; signs and symptoms of meningeal irritation, such as nuchal rigidity and blurred vision; hemiparesis; and other features.

Ebolavirus

A headache is usually abrupt in onset, commonly occurring on the fifth day of illness

Additionally, the patient has a history of malaise, myalgia, a high fever, diarrhea, abdominal pain, dehydration, and lethargy. A maculopapular skin rash develops between the fifth and seventh days of the illness. Other possible findings include pleuritic chest pain; a dry, hacking cough; pronounced pharyngitis; hematemesis; melena; and bleeding from the nose, gums, and vagina. Death usually occurs in the second week of the illness, preceded by severe blood loss and shock.

Encephalitis

A severe, generalized headache is characteristic with encephalitis

Within 48 hours, the patient’s LOC typically deteriorates — perhaps from lethargy to coma. Associated signs and symptoms include a fever, nuchal rigidity, irritability, seizures, nausea and vomiting, photophobia, cranial nerve palsies such as ptosis, and focal neurologic deficits, such as hemiparesis and hemiplegia.

Epidural hemorrhage (acute)

Head trauma and a sudden, brief loss of consciousness usually precede acute epidural hemorrhage, which causes a progressively severe headache that’s accompanied by nausea and vomiting, bladder distention, confusion, and then a rapid decrease in the patient’s LOC Other signs and symptoms include unilateral seizures, hemiparesis, hemiplegia, a high fever, a decreased pulse rate and bounding pulse, a widened pulse pressure, increased blood pressure, a positive Babinski’s reflex, and decerebrate posture.

If the patient slips into a coma, his respirations deepen and become stertorous, then shallow and irregular, and eventually they cease

Pupil dilation may occur on the same side as the hemorrhage.

Glaucoma (acute angle-closure)

Glaucoma is an ophthalmic emergency that may cause an excruciating headache as well as acute eye pain, blurred vision, halo vision, nausea, and vomiting Assessment reveals conjunctival injection, a cloudy cornea, and a moderately dilated, fixed pupil.

Hantavirus pulmonary syndrome

Noncardiogenic pulmonary edema distinguishes hantavirus pulmonary syndrome, a viral disease, which was first reported in the United States in 1993 Common reasons for seeking treatment include flulike signs and symptoms — headache, myalgia, fever, nausea, vomiting, and a cough — followed by respiratory distress

Fever, hypoxia, and (in some patients) serious hypotension typify the hospital course. Other signs and symptoms include a rising respiratory rate (28 breaths/minute or more) and an increased heart rate (120 beats/minute or more).

Hypertension

Hypertension may cause a slightly throbbing occipital headache on awakening that decreases in severity during the day However, if the patient’s diastolic blood pressure exceeds 120 mm Hg, the headache remains constant. Associated signs and symptoms include an atrial gallop, restlessness, confusion, nausea and vomiting, blurred vision, seizures, and an altered LOC.

Influenza

A severe generalized or frontal headache usually begins suddenly with the flu. Accompanying signs and symptoms may last for 3 to 5 days and include stabbing retro-orbital pain, weakness, diffuse myalgia, fever, chills, coughing, rhinorrhea and, occasionally, hoarseness.

Listeriosis

Signs and symptoms of listeriosis include fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea If the infection spreads to the nervous system, meningitis may develop

These signs and symptoms include headache, nuchal rigidity, fever, and a change in the patient’s LOC.

Gender cue

Infections during pregnancy may lead to premature delivery, infection of the neonate, or stillbirth.

Meningitis

Meningitis is marked by the sudden onset of a severe, constant, generalized headache that worsens with movement Associated signs include nuchal rigidity, positive Kernig’s and Brudzinski’s signs, hyperreflexia and, possibly, opisthotonos

A fever occurs early with meningitis and may be accompanied by chills. As ICP increases, vomiting and, occasionally, papilledema develop. Other features include an altered LOC, seizures, ocular palsies, facial weakness, and hearing loss.

Plague (Yersinia pestis)

 The pneumonic form of the plague causes a sudden onset of a headache, chills, fever, myalgia, a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, respiratory distress, and cardiopulmonary insufficiency.

Postconcussional syndrome

A generalized or localized headache may develop 1 to 30 days after head trauma and last for 2 to 3 weeks

This characteristic symptom may be described as an aching, pounding, pressing, stabbing, or throbbing pain The patient’s neurologic examination is normal, but he may experience giddiness or dizziness, blurred vision, fatigue, insomnia, an inability to concentrate, and noise and alcohol intolerance.

Signs and symptoms of this disease include a severe headache, fever, chills, malaise, chest pain, nausea, vomiting, and diarrhea

The fever may last for up to 2 weeks, and in severe cases, the patient may develop hepatitis or pneumonia.

Q Fever

Signs and symptoms of Q fever include severe headaches, fever, chills, malaise, chest pain, nausea, vomiting, and diarrhea Fever may last for up to 2 weeks, and in severe cases, the patient may develop hepatitis or pneumonia.

Severe acute respiratory syndrome (SARS)

SARS is an acute infectious disease of unknown etiology; however, a novel coronavirus has been implicated as a possible cause

Although most cases have been reported in Asia (China, Vietnam, Singapore, Thailand), cases have been documented in Europe and North America The incubation period is 2 to 7 days, and the illness generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include a headache; malaise; a dry, nonproductive cough; and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.

Smallpox (variola major)

Initial signs and symptoms of smallpox include a severe headache, backache, abdominal pain, a high fever, malaise, prostration, and a maculopapular rash on the mucosa of the mouth, pharynx, face, and forearms, and then the trunk and legs The rash becomes vesicular, then pustular, and finally crusts and scabs, leaving a pitted scar

In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Subarachnoid hemorrhage

Subarachnoid hemorrhage commonly produces a sudden, violent headache along with nuchal rigidity, nausea and vomiting, seizures, dizziness, ipsilateral pupil dilation, and an altered LOC that may rapidly progress to coma The patient also exhibits positive Kernig’s and Brudzinski’s signs, photophobia, blurred vision and, possibly, a fever

Focal signs and symptoms (such as hemiparesis, hemiplegia, sensory or vision disturbances, and aphasia) and signs of elevated ICP (such as bradycardia and increased blood pressure) may also occur.

Subdural hematoma

Typically associated with head trauma, acute and chronic subdural hematomas may cause a headache and decreased LOC With acute subdural hematoma, head trauma also produces drowsiness, confusion, and agitation that may progress to coma. Later findings include signs of increased ICP and focal neurologic deficits such as hemiparesis.

Chronic subdural hematoma produces a dull, pounding headache that fluctuates in severity and is located over the hematoma

Weeks or months after the initial head trauma, the patient may experience giddiness, personality changes, confusion, seizures, and a progressively worsening LOC. Late signs may include unilateral pupil dilation, sluggish pupil reaction to light, and ptosis.

Tularemia

Signs and symptoms following inhalation of the bacterium Francisella tularensis include an abrupt onset of a headache, a fever, chills, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Typhus

Initial symptoms of typhus include a headache, myalgia, arthralgia, and malaise followed by an abrupt onset of chills, a fever, nausea, and vomiting A maculopapular rash may be present in some cases.

West Nile encephalitis

West Nile encephalitis is a brain infection that’s caused by West Nile virus, a mosquito-borne flavivirus commonly found in Africa, West Asia, the Middle East and, rarely, North America

Mild infection is common; signs and symptoms include a fever, a headache, and body aches, commonly with a skin rash and swollen lymph glands More severe infection is marked by a high fever, a headache, neck stiffness, stupor, disorientation, coma, tremors, occasional seizures, paralysis and, rarely, death.

Other causes

Diagnostic tests

A lumbar puncture or myelogram may produce a throbbing frontal headache that worsens on standing.

Drugs

Many drugs can cause headaches For example, indomethacin produces headaches — usually in the morning — in many patients

Vasodilators and drugs with a vasodilating effect, such as nitrates, typically cause a throbbing headache. Headaches may also follow withdrawal from vasopressors, such as caffeine, ergotamine, and sympathomimetics.

Herb alert

Herbal remedies — such as St

John’s wort and ginseng — can cause various adverse reactions, including headaches.

Traction

Cervical traction with pins commonly causes a headache, which may be generalized or localized to pin insertion sites.

» READ BOOK EXCERPT ONLINE »

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

Headache: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

Most chronic headaches result from tension (muscle contraction), which may be caused by emotional stress, fatigue, menstruation, or environmental stimuli (noise, crowds, or bright lights). Other possible causes include glaucoma; inflammation of the eyes or mucosa of the nasal or paranasal sinuses; diseases of the scalp, teeth, extracranial arteries, or external or middle ear; muscle spasms of the face, neck, or shoulders; and cervical arthritis. In addition, headaches may be caused by vasodilators (nitrates, alcohol, and histamine), systemic disease, hypoxia, hypertension, head trauma and tumor, intracranial bleeding, abscess, or aneurysm.

The cause of migraine headache is unknown, but it’s associated with constriction and dilation of intracranial and extracranial arteries. Certain biochemical abnormalities are thought to occur during a migraine attack. These include local leakage of a vasodilator polypeptide called neurokinin through the dilated arteries and a decrease in the plasma level of serotonin.

Headache pain may emanate from the pain-sensitive structures of the skin, scalp, muscles, arteries, and veins; cranial nerves V, VII, IX, and X; or cervical nerves 1, 2, and 3. Intracranial mechanisms of headaches include traction or displacement of arteries, venous sinuses, or venous tributaries and inflammation or direct pressure on the cranial nerves with afferent pain fibers.

Affecting up to 10% of Americans, headaches are more common in females and have a strong familial incidence.

» READ BOOK EXCERPT ONLINE »

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

Malignant brain tumors: Causes and incidence
(Professional Guide to Diseases (Eighth Edition))

The cause of most brain tumors is unknown, but exposure to ionizing radiation is a known environmental risk. Additionally, most malignant tumors of the brain are of metastatic origin; 20% to 40% of patients with cancer develop brain metastasis.

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

Battle's sign: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Basilar skull fracture

Battle’s sign may be the only outward sign of a basilar skull fracture, or it may be accompanied by periorbital ecchymosis (raccoon eyes), conjunctival hemorrhage, nystagmus, ocular deviation, epistaxis, anosmia, a bulging tympanic membrane (from CSF or blood accumulation), visible fracture lines on the external auditory canal, tinnitus, difficulty hearing, facial paralysis, or vertigo.

» READ BOOK EXCERPT ONLINE »

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

Dysarthria: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Alcoholic cerebellar degeneration

This disorder commonly causes chronic, progressive dysarthria along with ataxia, diplopia, ophthalmoplegia, hypotension, and altered mental status.

Amyotrophic lateral sclerosis

Dysarthria occurs when this disorder affects the bulbar nuclei; it may worsen as the disease progresses. Other signs and symptoms include dysphagia; difficulty breathing; muscle atrophy and weakness, especially of the hands and feet; fasciculations; spasticity; hyperactive DTRs in the legs; and occasionally excessive drooling. Progressive bulbar palsy may cause crying spells or inappropriate laughter.

Basilar artery insufficiency

This disorder causes random, brief episodes of bilateral brain stem dysfunction, resulting in dysarthria. Accompanying it are diplopia, vertigo, facial numbness, ataxia, paresis, and visual field loss, all of which can last from minutes to hours.

Botulism

The hallmark of this disorder is acute cranial nerve dysfunction that causes dysarthria, dysphagia, diplopia, and ptosis. Early findings include dry mouth, sore throat, weakness, vomiting, and diarrhea. Later, descending weakness or paralysis of muscles in the extremities and trunk causes hyporeflexia and dyspnea.

Multiple sclerosis

When demyelination affects the brain stem and cerebellum, the patient displays dysarthria accompanied by nystagmus, blurred or double vision, dysphagia, ataxia, and intention tremor. Exacerbations and remissions of these signs and symptoms are common. Other findings include paresthesia, spasticity, intention tremor, hyperreflexia, muscle weakness or paralysis, constipation, emotional lability, and urinary frequency, urgency, and incontinence.

Myasthenia gravis

This neuromuscular disorder causes dysarthria associated with a nasal voice tone. Typically, the dysarthria worsens during the day and may temporarily improve with short rest periods. Other findings include dysphagia, drooling, facial weakness, diplopia, ptosis, dyspnea, and muscle weakness.

Olivopontocerebellar degeneration

Dysarthria, a cardinal sign of this disorder, accompanies cerebellar ataxia and spasticity.

Parkinson’s disease

This disorder produces dysarthria and a monotone voice. It also produces muscle rigidity, bradykinesia, an involuntary tremor that usually begins in the fingers, difficulty walking, muscle weakness, and stooped posture. Other findings include masklike facies, dysphagia and, occasionally, drooling.

Shy-Drager syndrome

Marked by chronic orthostatic hypotension, this syndrome eventually causes dysarthria as well as cerebellar ataxia, bradykinesia, masklike facies, dementia, impotence and, possibly, stooped posture and incontinence.

Stroke (brain stem)

This type of stroke is characterized by bulbar palsy, resulting in the triad of dysarthria, dysphonia, and dysphagia. The dysarthria is most severe at the onset of the stroke; it may lessen or disappear with rehabilitation and training. Other findings include facial weakness, diplopia, hemiparesis, spasticity, drooling, dyspnea, and decreased LOC.

Stroke (cerebral)

A massive bilateral stroke causes pseudobulbar palsy. Bilateral weakness produces dysarthria that’s most severe at the stroke’s onset. This sign is accompanied by dysphagia, drooling, dysphonia, bilateral hemianopsia, and aphasia. Sensory loss, spasticity, and hyperreflexia may also occur.

Other causes

Drugs

Dysarthria can occur when anticonvulsant dosage is too high. Ingestion of large doses of barbiturates may also cause dysarthria.

Manganese poisoning

Chronic manganese poisoning causes progressive dysarthria accompanied by weakness, fatigue, confusion, hallucinations, drooling, hand tremors, limb stiffness, spasticity, gross rhythmic movements of the trunk and head, and a propulsive gait.

Mercury poisoning

Chronic mercury poisoning causes progressive dysarthria accompanied by weakness, fatigue, depression, lethargy, irritability, confusion, ataxia, and tremors.

» READ BOOK EXCERPT ONLINE »

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

Headache: Medical causes
(Professional Guide to Signs & Symptoms (Fifth Edition))

Anthrax, cutaneous

Along with a macular or papular lesion that develops into a vesicle and finally a painless ulcer, this disorder may produce a headache, lymphadenopathy, fever, and malaise.

Brain abscess

In this disorder, the headache is localized to the abscess site; it usually intensifies over a few days and is aggravated by straining. Accompanying the headache may be nausea, vomiting, and focal or generalized seizures. The patient’s LOC varies from drowsiness to deep stupor. Depending on the abscess site, associated signs and symptoms may include aphasia, impaired visual acuity, hemiparesis, ataxia, tremors, and personality changes. Signs of infection, such as fever and pallor, usually develop late; however, if the abscess remains encapsulated, these signs may not appear.

Brain tumor

Initially, a tumor causes a localized headache near the tumor site; as the tumor grows, the headache eventually becomes generalized. The pain is usually intermittent, deep seated, and dull and is most intense in the morning. It’s aggravated by coughing, stooping, Valsalva’s maneuver, and changes in head position, and it’s relieved by sitting and rest. Associated signs and symptoms include personality changes, altered LOC, motor and sensory dysfunction, and eventually signs of increased ICP, such as vomiting, increased systolic blood pressure, and widened pulse pressure.

Cerebral aneurysm (ruptured)

Cerebral aneurysm is a life-threatening disorder that’s characterized by a sudden excruciating headache, which may be unilateral and usually peaks within minutes of the rupture. The patient may lose consciousness immediately or display a variably altered LOC. Depending on the severity and location of the bleeding, he may also exhibit nausea and vomiting; signs and symptoms of meningeal irritation, such as nuchal rigidity and blurred vision; hemiparesis; and other features.

Ebola Virus

A sudden headache commonly occurs on the 5th day of this deadly illness. Additionally, the patient has a history of malaise, myalgia, high fever, diarrhea, abdominal pain, dehydration, and lethargy. A maculopapular rash develops between the 5th and 7th days of the illness. Other possible findings include pleuritic chest pain; a dry, hacking cough; pronounced pharyngitis; hematemesis; melena; and bleeding from the nose, gums, and vagina. Death usually occurs in the 2nd week of the illness, preceded by massive blood loss and shock.

Encephalitis

A severe, generalized headache is characteristic with this disorder. Within 48 hours, the patient’s LOC typically deteriorates—perhaps from lethargy to coma. Associated signs and symptoms include fever, nuchal rigidity, irritability, seizures, nausea and vomiting, photophobia, cranial nerve palsies such as ptosis, and focal neurologic deficits, such as hemiparesis and hemiplegia.

Epidural hemorrhage (acute)

Head trauma and a sudden, brief loss of consciousness usually precede this hemorrhage, which causes a progressively severe headache that’s accompanied by nausea and vomiting, bladder distention, confusion, and then a rapid decrease in LOC. Other signs and symptoms include unilateral seizures, hemiparesis, hemiplegia, high fever, decreased pulse rate and bounding pulse, widened pulse pressure, increased blood pressure, a positive Babinski’s reflex, and decerebrate posture.

If the patient slips into a coma, his respirations deepen and become stertorous, then shallow and irregular, and eventually cease. Pupil dilation may occur on the same side as the hemorrhage.

Glaucoma, acute angle-closure

This type of glaucoma is an ophthalmic emergency that may cause an excruciating headache as well as acute eye pain, blurred vision, halo vision, nausea, and vomiting. Assessment reveals conjunctival injection, a cloudy cornea, and a moderately dilated, fixed pupil.

Hantavirus pulmonary syndrome

Noncardiogenic pulmonary edema distinguishes this viral disease, which was first reported in the United States in 1993. Common reasons for seeking treatment include flulike signs and symptoms—headache, myalgia, fever, nausea, vomiting, and a cough—followed by respiratory distress. Fever, hypoxia, and (in some patients) serious hypotension typify the hospital course. Other signs and symptoms include a rising respiratory rate (28 breaths/minute or more) and an increased heart rate (120 beats/minute or more).

Hypertension

This disorder may cause a slightly throbbing occipital headache on awakening that decreases in severity during the day. However, if the patient’s diastolic blood pressure exceeds 120 mm Hg, the headache remains constant. Associated signs and symptoms include an atrial gallop, restlessness, confusion, nausea and vomiting, blurred vision, seizures, and altered LOC.

Influenza

A severe generalized or frontal headache usually begins suddenly with the flu. Accompanying signs and symptoms may last for 3 to 5 days and include stabbing retro-orbital pain, weakness, diffuse myalgia, fever, chills, coughing, rhinorrhea and, occasionally, hoarseness.

Intracerebral hemorrhage

In some patients, this hemorrhage produces a severe generalized headache. Other signs and symptoms vary with the size and location of the hemorrhage. A large hemorrhage may produce a rapid, steady decrease in LOC, perhaps resulting in a coma. Other common findings include hemiplegia, hemiparesis, abnormal pupil size and response, aphasia, dizziness, nausea, vomiting, seizures, decreased sensation, irregular respirations, positive Babinski’s reflex, decorticate or decerebrate posture, and increased blood pressure.

Listeriosis

If this infection spreads to the nervous system, it may cause meningitis, whose signs and symptoms include headache, nuchal rigidity, fever, and change in LOC. Earlier signs and symptoms of listeriosis include fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea.

Gender Cue: Listeriosis during pregnancy may lead to premature delivery, infection of the neonate, or stillbirth.

Meningitis

This disorder is marked by the sudden onset of a severe, constant, generalized headache that worsens with movement. Fever and chills are other early signs. As meningitis progresses, it also causes nuchal rigidity, positive Kernig’s and Brudzinski’s signs, hyperreflexia, altered LOC, seizures, ocular palsies, facial weakness, hearing loss, vomiting and, possibly, opisthotonos and papilledema.

Plague

The pneumonic form of this lethal bacterial infection causes a sudden onset of headache, chills, fever, and myalgia. Pulmonary findings include a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, respiratory distress, and cardiopulmonary insufficiency.

Postconcussion syndrome

A generalized or localized headache may develop 1 to 30 days after head trauma and last for 2 to 3 weeks. This characteristic symptom may be described as an aching, pounding, pressing, stabbing, or throbbing pain. The patient’s neurologic examination is normal, but he may experience giddiness or dizziness, blurred vision, fatigue, insomnia, inability to concentrate, and noise and alcohol intolerance.

Q fever

Signs and symptoms of this disease include severe headaches, fever, chills, malaise, chest pain, nausea, vomiting, and diarrhea. The fever may last for up to 2 weeks, and in severe cases, the patient may develop hepatitis or pneumonia.

Severe acute respiratory syndrome (SARS)

SARS is an acute infectious disease of unknown etiology; however, a novel coronavirus has been implicated as a possible cause. Although most cases have been reported in Asia (China, Vietnam, Singapore, Thailand), cases have cropped up in Europe and North America. After an incubation period of 2 to 7 days, the illness generally begins with a fever (usually greater than 100.4° F [38° C]).  Other symptoms include headache, malaise, a nonproductive cough, and dyspnea. SARS may produce only mild symptoms, or it may progress to pneumonia and, in some cases, even respiratory failure and death.

Sinusitis (acute)

This disorder is usually marked by a dull periorbital headache that’s usually aggravated by bending over or touching the face and is relieved by sinus drainage. Fever, sinus tenderness, nasal turbinate edema, sore throat, malaise, cough, and nasal discharge may accompany the headache.

Smallpox (variola major)

Initial signs and symptoms of this virus include a severe headache, backache, abdominal pain, high fever, malaise, prostration, and a maculopapular rash on the mucosa of the mouth, pharynx, face, and forearms and then on the trunk and legs. The rash becomes vesicular, then pustular. After 8 or 9 days, the pustules form a crust, which later separates from the skin, leaving a pitted scar. Death may result from encephalitis, extensive bleeding, or secondary infection.

Subarachnoid hemorrhage

This hemorrhage commonly produces a sudden, violent headache along with nuchal rigidity, nausea and vomiting, seizures, dizziness, ipsilateral pupil dilation, and altered LOC that may rapidly progress to coma. The patient also exhibits positive Kernig’s and Brudzinski’s signs, photophobia, blurred vision and, possibly, a fever. Focal signs and symptoms (such as hemiparesis, hemiplegia, sensory or vision disturbances, and aphasia) and signs of elevated ICP (such as bradycardia and increased blood pressure) may also occur.

Subdural hematoma

Typically associated with head trauma, both acute and chronic subdural hematomas may cause headache and decreased LOC. An acute subdural hematoma also produces drowsiness, confusion, and agitation that may progress to coma. Later findings include signs of increased ICP and focal neurologic deficits such as hemiparesis.

A chronic subdural hematoma produces a dull, pounding headache that fluctuates in severity and is located over the hematoma. Weeks or months after the initial head trauma, the patient may experience giddiness, personality changes, confusion, seizures, and progressively worsening LOC. Late signs may include unilateral pupil dilation, sluggish pupil reaction to light, and ptosis.

Temporal arteritis

A throbbing unilateral headache in the temporal or frontotemporal region may be accompanied by vision loss, hearing loss, confusion, and fever. The temporal arteries are tender, swollen, nodular, and sometimes erythematous.

Tularemia

Signs and symptoms following inhalation of the bacterium Francisella tularensis include abrupt onset of headache, fever, chills, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Typhus

In typhus, initial symptoms of headache, myalgia, arthralgia, and malaise are followed by an abrupt onset of chills, fever, nausea, and vomiting. A maculopapular rash may also occur.

West Nile encephalitis

This brain infection is caused by West Nile virus, a mosquito-borne flavivirus commonly found in Africa, West Asia, the Middle East and, rarely, in North America. Most patients have mild signs and symptoms, including fever, headache, body aches, rash, and swollen lymph glands. More severe infection is marked by high fever, headache, neck stiffness, stupor, disorientation, coma, tremors, and paralysis.

Other causes

Diagnostic tests

A lumbar puncture or myelogram may produce a throbbing frontal headache that worsens on standing.

Drugs

A wide variety of drugs can cause headaches. For example, indomethacin produces headaches—usually in the morning—in many patients. Vasodilators and drugs with a vasodilating effect, such as nitrates, typically cause a throbbing headache. Headaches may also follow withdrawal from vasopressors, such as caffeine, ergotamine, and sympathomimetics.

Herb Alert

Traction

Cervical traction with pins commonly causes a headache, which may be generalized or localized to pin insertion sites.

» READ BOOK EXCERPT ONLINE »

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

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

» READ BOOK EXCERPT ONLINE »

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

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Headache: Causes
(Handbook of Diseases)

Most chronic headaches result from tension — muscle contraction — that may be caused by emotional stress, fatigue, menstruation, or environmental stimuli (such as noise, crowds, and bright lights).

Other possible causes include glaucoma; inflammation of the eyes or mucosa of the nasal or paranasal sinuses; diseases of the scalp, teeth, extracranial arteries, or external or middle ear; and muscle spasms of the face, neck, or shoulders.

In addition, headaches may be caused by vasodilators (such as nitrates, alcohol, and histamines), systemic disease, hypoxia, hypertension, head trauma and tumor, intracranial bleeding, abscess, and aneurysm.

Migraine headache

The cause of migraine headache is unknown, but a genetic link has been identified. These headaches are associated with constriction and dilation of intracranial and extracranial arteries initiated by neurons in the brainstem. Certain biochemical abnormalities are thought to occur during a migraine attack. They include local leakage of a vasodilator polypeptide called neurokinin through the dilated arteries as an inflammatory response and a decrease in the plasma level of serotonin.

Foods associated with migraine headache include aged or processed cheese and meats, alcoholic beverages (particularly red wine), food additives (such as monosodium glutamate), chocolate- and caffeine-containing foods, and nuts. Changes in the weather pattern, menstrual cycle fluctuations, sleep pattern changes, and too much or too little exercise as well as glaring lights and fatigue can also trigger a migraine headache. In addition, one of the more common causes of a recurring headache is the rebound effect that occurs when the original treatment used to get rid of the headache triggers the next episode (as with narcotics).

Headache pain

Pain may emanate from the pain-sensitive structures of the skin, scalp, muscles, arteries, and veins; cranial nerves V, VII, IX, and X; and cervical nerves 1, 2, and 3. Intracranial mechanisms of headache include traction or displacement of arteries, venous sinuses, or venous tributaries and inflammation or direct pressure on the cranial nerves with afferent pain fibers.

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Source: Handbook of Diseases, 2003

Brain tumors, malignant: Causes
(Handbook of Diseases)

Some tumors are congenital, whereas others are hereditary. The cause of most brain tumors is unknown.

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Source: Handbook of Diseases, 2003

Brain abscess: Causes
(Handbook of Diseases)

A brain abscess usually occurs secondary to some other infection, especially otitis media, sinusitis, dental abscess, and mastoiditis. Other causes include subdural empyema; bacterial endocarditis; human immunodeficiency virus infection; bacteremia; pulmonary or pleural infection; pelvic, abdominal, and skin infections; and cranial trauma, such as a penetrating head wound or compound skull fracture.

This condition also occurs in about 2% of children with congenital heart disease, possibly because the hypoxic brain is a good culture medium for bacteria. Common infecting organisms are pyogenic bacteria, such as Staphylococcus aureus and Streptococcus viridans. Penetrating head trauma or bacteremia usually leads to staphylococcal infection; pulmonary disease, to streptococcal infection. In up to 25% of patients, an original source isn’t discovered.

Pathophysiology

A brain abscess usually begins with localized inflammatory necrosis and edema, septic thrombosis of vessels, and suppurative encephalitis. This is followed by thick encapsulation of accumulated pus, and adjacent meningeal infiltration by neutrophils, lymphocytes, and plasma cells. Increasing pressure in the brain results in more damage.

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Source: Handbook of Diseases, 2003

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

Basilar skull fracture

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

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

See Dysarthria: Causes and associated findings, pages 114 and 115.

Alcoholic cerebellar degeneration

Alcoholic cerebellar degeneration commonly causes chronic, progressive dysarthria along with ataxia, diplopia, ophthalmoplegia, hypotension, and altered mental status.

Amyotrophic lateral sclerosis (ALS)

Dysarthria occurs when ALS affects the bulbar nuclei; it may worsen as the disease progresses. Other signs and symptoms include dysphagia; difficulty breathing; muscle atrophy and weakness, especially of the hands and feet; fasciculations; spasticity; hyperactive DTRs in the legs; and occasionally excessive drooling. Progressive bulbar palsy may cause crying spells or inappropriate laughter.

Basilar artery insufficiency.

Botulism

Manganese poisoning

Chronic manganese poisoning causes progressive dysarthria accompanied by weakness, fatigue, confusion, hallucinations, drooling, hand tremors, limb stiffness, spasticity, gross rhythmic movements of the trunk and head, and propulsive gait.

Mercury poisoning

Chronic mercury poisoning also causes progressive dysarthria accompanied by weakness, fatigue, depression, lethargy, irritability, confusion, ataxia, and tremors.

Multiple sclerosis

When demyelination affects the brain stem and cerebellum, the patient displays dysarthria accompanied by nystagmus, blurred or double vision, dysphagia, ataxia, and intention tremor. Exacerbations and remissions of these signs and symptoms are common. Other findings include paresthesia, spasticity, intention tremor, hyperreflexia, muscle weakness or paralysis, constipation, emotional lability, and urinary frequency, urgency, and incontinence.

Myasthenia gravis.

Olivopontocerebellar degeneration

Dysarthria, a major sign, accompanies cerebellar ataxia and spasticity.

Parkinson’s disease

Parkinson’s disease produces dysarthria and a monotone voice. It also produces muscle rigidity, bradykinesia, involuntary tremor usually beginning in the fingers, difficulty in walking, muscle weakness, and stooped posture. Other findings include masklike facies, dysphagia, and occasionally drooling.

Shy-Drager syndrome

Marked by chronic orthostatic hypotension, Shy-Drager syndrome eventually causes dysarthria as well as cerebellar ataxia, bradykinesia, masklike facies, dementia, impotence and, possibly, stooped posture and incontinence.

Stroke (brain stem)

Brain stem stroke is characterized by bulbar palsy, resulting in the triad of dysarthria, dysphonia, and dysphagia. The dysarthria is most severe at onset; it may lessen or disappear with rehabilitation and training. Other findings include facial weakness, diplopia, hemiparesis, spasticity, drooling, dyspnea, and decreased LOC.

Stroke (cerebral)

A massive bilateral stroke causes pseudobulbar palsy. Bilateral weakness produces dysarthria that’s most severe at onset. This sign is accompanied by dysphagia, drooling, dysphonia, bilateral hemianopsia, and aphasia. Sensory loss, spasticity, and hyperreflexia may also occur.

Other causes

Drugs

Dysarthria can occur when anticonvulsant dosage is too high. Ingestion of large doses of barbiturates may also cause dysarthria.

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

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

Basilar skull fracture

Battle’s sign may be the only outward sign of a basilar skull fracture, or it may be accompanied by periorbital ecchymosis (raccoon eyes), conjunctival hemorrhage, nystagmus, ocular deviation, epistaxis, anosmia, a bulging tympanic membrane (from CSF or blood accumulation), visible fracture lines on the external auditory canal, tinnitus, difficulty hearing, facial paralysis, or vertigo.

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

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

Alcoholic cerebellar degeneration

Alcoholic cerebellar degeneration commonly causes chronic, progressive dysarthria along with ataxia, diplopia, ophthalmoplegia, hypotension, and altered mental status.

Amyotrophic lateral sclerosis

Dysarthria occurs when amyotrophic lateral sclerosis (ALS), also known as Lou Gehrig disease, affects the bulbar nuclei; it may worsen as the disease progresses. Other signs and symptoms of ALS include dysphagia; difficulty breathing; muscle atrophy and weakness, especially of the hands and feet; fasciculations; spasticity; hyperactive DTRs in the legs; and occasionally excessive drooling. Progressive bulbar palsy may cause crying spells or inappropriate laughter.

Basilar artery insufficiency

Basilar artery insufficiency causes random, brief episodes of bilateral brain stem dysfunction, resulting in dysarthria. Accompanying it are diplopia, vertigo, facial numbness, ataxia, paresis, and visual field loss, all of which last for minutes to hours.

Botulism

The hallmark of botulism is acute cranial nerve dysfunction causing dysarthria, dysphagia, diplopia, and ptosis. Early findings include dry mouth, sore throat, weakness, vomiting, and diarrhea. Later, descending weakness or paralysis of muscles in the extremities and trunk causes hyporeflexia and dyspnea.

Manganese poisoning

Chronic manganese poisoning causes progressive dysarthria accompanied by weakness, fatigue, confusion, hallucinations, drooling, hand tremors, limb stiffness, spasticity, gross rhythmic movements of the trunk and head, and propulsive gait.

Mercury poisoning

Chronic mercury poisoning also causes progressive dysarthria accompanied by weakness, fatigue, depression, lethargy, irritability, confusion, ataxia, and tremors. Changes in vision, hearing, and memory may also occur.

Multiple sclerosis

When demyelination affects the brain stem and cerebellum, the patient displays dysarthria accompanied by nystagmus, blurred or double vision, dysphagia, ataxia, and intention tremor. Exacerbations and remissions of these signs and symptoms are common. Other findings of multiple sclerosis include paresthesia, spasticity, intention tremor, hyperreflexia, muscle weakness or paralysis, constipation, emotional lability, and urinary frequency, urgency, and incontinence.

Myasthenia gravis

Myasthenia gravis is a neuromuscular disorder that causes dysarthria associated with a nasal voice tone. Typically, the dysarthria worsens during the day and may temporarily improve with short rest periods. Other findings include dysphagia, drooling, facial weakness, diplopia, ptosis, dyspnea, and muscle weakness.

Olivopontocerebellar degeneration

Dysarthria, a major sign of olivopontocerebellar degeneration, accompanies cerebellar ataxia and spasticity. The patient may also have abnormal eye movement, sexual dysfunction, bowel and bladder problems, and difficulty swallowing.

Parkinson’s disease

Parkinson’s disease produces dysarthria and a monotone voice. It also produces muscle rigidity, bradykinesia, involuntary tremor usually beginning in the fingers, difficulty in walking, muscle weakness, and stooped posture. Other findings include masklike facies, dysphagia, and occasionally drooling.

Stroke (brain stem)

Brain stem stroke is characterized by bulbar palsy, resulting in the triad of dysarthria, dysphonia, and dysphagia. The dysarthria is most severe at onset; it may lessen or disappear with rehabilitation and training. Other findings include facial weakness, diplopia, hemiparesis, spasticity, drooling, dyspnea, and decreased LOC.

Stroke (cerebral)

A massive bilateral cerebral stroke causes pseudobulbar palsy. Bilateral weakness produces dysarthria that’s most severe at onset. This sign is accompanied by dysphagia, drooling, dysphonia, bilateral hemianopsia, and aphasia. Sensory loss, spasticity, and hyperreflexia may also occur.

Other causes

Drugs

Dysarthria can occur when anticonvulsant dosage is too high. Ingestion of large doses of barbiturates may also cause dysarthria.

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

Headache: Medical causes
(Signs & Symptoms: A 2-in-1 Reference for Nurses)

Brain abscess

With brain abscess, the headache is localized to the abscess site. Usually, it intensifies over a few days and is aggravated by straining. Accompanying the headache may be nausea, vomiting, and focal or generalized seizures. The patient’s LOC varies from drowsiness to deep stupor. Depending on the abscess site, associated signs and symptoms may include aphasia, impaired visual acuity, hemiparesis, ataxia, tremors, and personality changes. Signs of infection, such as fever and pallor, usually develop late; however, if the abscess remains encapsulated, these signs may not appear.

Brain tumor

Initially, a brain tumor causes a localized headache near the tumor site; as the tumor grows, the headache eventually becomes generalized. The pain is usually intermittent, deep-seated, and dull, and most intense in the morning. It’s aggravated by coughing, stooping, Valsalva’s maneuver, and changes in head position, and it’s relieved by sitting and rest. Associated signs and symptoms include personality changes, altered LOC, motor and sensory dysfunction, and eventually signs of increased ICP, such as vomiting, increased systolic blood pressure, and widened pulse pressure.

Cerebral aneurysm (ruptured)

Ruptured cerebral aneurysm is a life-threatening disorder that’s characterized by a sudden, excruciating headache, which may be unilateral and usually peaks within minutes of the rupture. The patient may lose consciousness immediately or display a variably altered LOC. Depending on the severity and location of the bleeding, he may also exhibit nausea and vomiting; signs and symptoms of meningeal irritation, such as nuchal rigidity and blurred vision; hemiparesis; and other features.

Encephalitis

A severe, generalized headache is characteristic of encephalitis. Within 48 hours, the patient’s LOC typically deteriorates — perhaps from lethargy to coma. Associated signs and symptoms include fever, nuchal rigidity, irritability, seizures, nausea and vomiting, photophobia, cranial nerve palsies such as ptosis, and focal neurologic deficits, such as hemiparesis and hemiplegia.

Epidural hemorrhage (acute)

Head trauma and a sudden, brief loss of consciousness usually precede acute epidural hemorrhage, which causes a progressively severe headache that’s accompanied by nausea and vomiting, bladder distention, confusion, and then a rapid decrease in LOC. Other signs and symptoms include unilateral seizures, hemiparesis, hemiplegia, high fever, decreased pulse rate and bounding pulse, widened pulse pressure, increased blood pressure, a positive Babinski’s reflex, and decerebrate posture.

If the patient slips into coma, his respirations deepen and become stertorous, then shallow and irregular, and eventually they cease. Pupil dilation may occur on the same side as the hemorrhage.

Glaucoma (acute angle-closure)

Acute angle-closure glaucoma is an ophthalmic emergency that may cause an excruciating headache as well as acute eye pain, blurred vision, halo vision, nausea, and vomiting. Assessment reveals conjunctival injection, a cloudy cornea, and a moderately dilated, fixed pupil.

Hypertension

Hypertension may cause a slightly throbbing occipital headache on awakening that decreases in severity during the day. However, if the patient’s diastolic blood pressure exceeds 120 mm Hg, the headache remains constant. Associated signs and symptoms include an atrial gallop, restlessness, confusion, nausea and vomiting, blurred vision, seizures, and altered LOC.

Influenza

A severe generalized or frontal headache usually begins suddenly with the flu. Accompanying signs and symptoms may last for 3 to 5 days and include stabbing retro-orbital pain, weakness, diffuse myalgia, fever, chills, coughing, rhinorrhea and, occasionally, hoarseness.

Intracerebral hemorrhage

In some patients, intracerebral hemorrhage produces a severe generalized headache. Signs and symptoms vary with the size and location of the hemorrhage. A large hemorrhage may produce a rapid, steady decrease in LOC, perhaps resulting in coma. Other common findings include hemiplegia, hemiparesis, abnormal pupil size and response, aphasia, dizziness, nausea, vomiting, seizures, decreased sensation, irregular respirations, positive Babinski’s reflex, decorticate or decerebrate posture, and increased blood pressure.

Meningitis

Meningitis is marked by the sudden onset of a severe, constant, generalized headache that worsens with movement. Associated signs include nuchal rigidity, positive Kernig’s and Brudzinski’s signs, hyperreflexia and, possibly, opisthotonos. Fever occurs early with meningitis and may be accompanied by chills. As ICP increases, vomiting and, occasionally, papilledema develop. Other features include altered LOC, seizures, ocular palsies, facial weakness, and hearing loss.

Plague

The pneumonic form of plague, caused by the bacterium Yersinia pestis, causes a sudden onset of headache, chills, fever, myalgias, productive cough, chest pain, tachypnea, dyspnea, hemoptysis, respiratory distress, and cardiopulmonary insufficiency.

Postconcussional syndrome

With postconcussional syndrome, a generalized or localized headache may develop 1 to 30 days after head trauma and last for 2 to 3 weeks. This characteristic symptom may be described as an aching, pounding, pressing, stabbing, or throbbing pain. The patient’s neurologic examination is normal, but he may experience giddiness or dizziness, blurred vision, fatigue, insomnia, inability to concentrate, and noise and alcohol intolerance.

Signs and symptoms of this disease include severe headache, fever, chills, malaise, chest pain, nausea, vomiting, and diarrhea. The fever may last for up to 2 weeks, and in severe cases, the patient may develop hepatitis or pneumonia.

Severe acute respiratory syndrome

Severe acute respiratory syndrome (SARS) is an acute infectious disease of unknown etiology that generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms of SARS include headache, malaise, a dry nonproductive cough, and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.

Sinusitis (acute)

Acute sinusitis is usually marked by a dull periorbital headache that’s usually aggravated by bending over or touching the face and is relieved by sinus drainage. Fever, sinus tenderness, nasal turbinate edema, sore throat, malaise, cough, and nasal discharge may accompany the headache.

Smallpox

Initial signs and symptoms of smallpox (variola major) include severe headache, backache, abdominal pain, high fever, malaise, prostration, and a maculopapular rash on the mucosa of the mouth, pharynx, face, and forearms, and then the trunk and legs. The rash becomes vesicular, then pustular and finally forms a crust and scab, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Subarachnoid hemorrhage

Subarachnoid hemorrhage commonly produces a sudden, violent headache along with nuchal rigidity, nausea and vomiting, seizures, dizziness, ipsilateral pupil dilation, and altered LOC that may rapidly progress to coma. The patient also exhibits positive Kernig’s and Brudzinski’s signs, photophobia, blurred vision and, possibly, fever. Focal signs and symptoms (such as hemiparesis, hemiplegia, sensory or vision disturbances, and aphasia) and signs of elevated ICP (such as bradycardia and increased blood pressure) may also occur.

Subdural hematoma

Typically associated with head trauma, both acute and chronic subdural hematomas may cause headache and decreased LOC. With acute subdural hematoma, head trauma also produces drowsiness, confusion, and agitation that may progress to coma. Later findings include signs of increased ICP and focal neurologic deficits such as hemiparesis.

Chronic subdural hematoma produces a dull, pounding headache that fluctuates in severity and is located over the hematoma. Weeks or months after the initial head trauma, the patient may experience giddiness, personality changes, confusion, seizures, and progressively worsening LOC. Late signs may include unilateral pupil dilation, sluggish pupil reaction to light, and ptosis.

Temporal arteritis

A throbbing unilateral headache in the temporal or frontotemporal region may be accompanied by vision loss, hearing loss, confusion, and fever. The temporal arteries are tender, swollen, nodular, and sometimes erythematous.

Tularemia

Signs and symptoms of tularemia (caused by inhalation of the bacterium Francisella tularensis) include abrupt onset of headache, fever, chills, generalized myalgias, nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Other causes

Diagnostic tests

A lumbar puncture or myelogram may produce a throbbing frontal headache that worsens on standing.

Drugs

A wide variety of drugs can cause headaches. For example, indomethacin produces headaches — usually in the morning — in many patients. Vasodilators and drugs with a vasodilating effect, such as nitrates, typically cause a throbbing headache. Headaches may also follow withdrawal from vasopressors, such as caffeine, ergotamine, and sympathomimetics.

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

Headache: Principal Causes of Headache
(The Diagnostic Approach to Symptoms and Signs in Pediatrics)

1. Tension-typeheadache
2. Vascular headache
   1. Migraineheadache
      1. Migrainewith aura (classic migraine)
      2. Migraine without aura (common migraine)
      3. Complicated migraine
         1. Hemiplegicmigraine
         2. Ophthalmoplegic migraine
         3. Basilar artery migraine
         4. Confusional migraine
      4. Migraine variants
   2. Cluster headache
   3. Systemic infection
   4. Hypoxia
   5. Systemic hypertension
   6. Connective tissue diseases
3. Head trauma
4. Headache due to disorders of head andneck structures
   1. Head and neck disorders
   2. Ear, eye, and sinus disorders
   3. Mouth and jaw disorders
5. Intracranial infections
   1. Meningitis
   2. Encephalitis
   3. Brain abscess
6. Traction headache
   1. Braintumor
   2. Intracranial hemorrhage
   3. Disorders of cerebrospinal fluid pressure
7. Psychogenic

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Source: The Diagnostic Approach to Symptoms and Signs in Pediatrics, 2006

Battle's sign: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Basilar skull fracture.Battle's sign may be the only outward sign of basilar skull fracture, or it may be accompanied by periorbital ecchymosis (raccoon eyes), conjunctival hemorrhage, nystagmus, ocular deviation, epistaxis, anosmia, a bulging tympanic membrane (from CSF or blood accumulation), visible fracture lines on the external auditory canal, tinnitus, difficulty hearing, facial paralysis, or vertigo.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Dysarthria: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Alcoholic cerebellar degeneration.Alcoholic cerebellar degeneration commonly causes chronic, progressive dysarthria along with ataxia, diplopia, ophthalmoplegia, hypotension, and an altered mental status.

Amyotrophic lateral sclerosis (ALS).Dysarthria occurs when ALS affects the bulbar nuclei; it may worsen as the disease progresses. Other signs and symptoms include dysphagia; difficulty breathing; muscle atrophy and weakness, especially of the hands and feet; fasciculations; spasticity; hyperactive DTRs in the legs; and, occasionally, excessive drooling. Progressive bulbar palsy may cause crying spells or inappropriate laughter.

Basilar artery insufficiency.Basilar artery insufficiency causes random, brief episodes of bilateral brain stem dysfunction, resulting in dysarthria. Accompanying it are diplopia, vertigo, facial numbness, ataxia, paresis, and visual field loss, all of which last for minutes to hours.

Botulism.The hallmark of botulism is acute cranial nerve dysfunction causing dysarthria, dysphagia, diplopia, and ptosis. Early findings include a dry mouth, a sore throat, weakness, vomiting, and diarrhea. Later, descending weakness or paralysis of muscles in the extremities and trunk causes hyporeflexia and dyspnea.

Mercury poisoning.Chronic mercury poisoning causes progressive dysarthria accompanied by weakness, fatigue, depression, lethargy, irritability, confusion, ataxia, and tremors.

Multiple sclerosis (MS).When demyelination affects the brain stem and cerebellum as with MS, the patient displays dysarthria accompanied by nystagmus, blurred or double vision, dysphagia, ataxia, and intention tremor. Exacerbations and remissions of these signs and symptoms are common. Other findings include paresthesia, spasticity, intention tremor, hyperreflexia, muscle weakness or paralysis, constipation, emotional lability, and urinary frequency, urgency, and incontinence.

Myasthenia gravis.Myasthenia gravis causes dysarthria associated with a nasal voice tone. Typically, the dysarthria worsens during the day and may temporarily improve with short rest periods. Other findings include dysphagia, drooling, facial weakness, diplopia, ptosis, dyspnea, and muscle weakness.

Olivopontocerebellar degeneration.Dysarthria, a major sign of olivopontocerebellar degeneration, accompanies cerebellar ataxia and spasticity.

Parkinson's disease.Parkinson's disease produces dysarthria and a monotone voice. It also produces muscle rigidity, bradykinesia, involuntary tremor usually beginning in the fingers, difficulty walking, muscle weakness, and a stooped posture. Other findings include masklike facies, dysphagia, and occasionally drooling.

Shy-Drager syndrome.Marked by chronic orthostatic hypotension, Shy-Drager syndrome eventually causes dysarthria as well as cerebellar ataxia, bradykinesia, masklike facies, dementia, impotence and, possibly, a stooped posture and incontinence.

Stroke (brain stem).A brain stem stroke is characterized by bulbar palsy, resulting in the triad of dysarthria, dysphonia, and dysphagia. Dysarthria is most severe at its onset; it may lessen or disappear with rehabilitation and training. Other findings include facial weakness, diplopia, hemiparesis, spasticity, drooling, dyspnea, and a decreased LOC.

Stroke (cerebral).A massive bilateral stroke causes pseudobulbar palsy. Bilateral weakness produces dysarthria that's most severe at onset. This sign is accompanied by dysphagia, drooling, dysphonia, bilateral hemianopsia, and aphasia. Sensory loss, spasticity, and hyperreflexia may also occur.

Other causes

Drugs.Dysarthria can occur when the anticonvulsant dosage is too high. Ingestion of large doses of barbiturates may also cause dysarthria.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

Headache: Medical causes
(Nursing: Interpreting Signs and Symptoms)

Anthrax (cutaneous).Along with a macular papular lesion that develops into a vesicle and finally a painless ulcer with anthrax, headache, lymphadenopathy, fever, and malaise may also occur.

Arteriovenous malformations.Less common than cerebral aneurysms, vascular malformations usually result from developmental defects of the cerebral veins and arteries. Although many are present from birth, they manifest in adulthood with a triad of symptoms: headache, hemorrhage, and seizures.

Brain abscess.With brain abscess, the headache is localized to the abscess site. Usually, it intensifies over a few days and is aggravated by straining. Accompanying the headache may be nausea, vomiting, and focal or generalized seizures. The patient's LOC varies from drowsiness to deep stupor. Depending on the abscess site, associated signs and symptoms may include aphasia, impaired visual acuity, hemiparesis, ataxia, tremors, and personality changes. Signs of infection, such as fever and pallor, usually develop late; however, if the abscess remains encapsulated, these signs may not appear.

Brain tumor.Initially, a tumor causes a localized headache near the tumor site; as the tumor grows, the headache becomes generalized. The pain is usually intermittent, deep seated, dull, and most intense in the morning. It's aggravated by coughing, stooping, Valsalva's maneuver, and changes in head position and relieved by sitting and rest. Associated signs and symptoms include personality changes, an altered LOC, motor and sensory dysfunction and, eventually, signs of increased ICP, such as vomiting, increased systolic blood pressure, and a widened pulse pressure.

Cerebral aneurysm (ruptured).Ruptured cerebral aneurysm is a life-threatening disorder that's characterized by a sudden, excruciating headache, which may be unilateral and usually peaks within minutes of the rupture. The patient may lose consciousness immediately or display a variably altered LOC. Depending on the severity and location of the bleeding, he may also exhibit nausea and vomiting; signs and symptoms of meningeal irritation, such as nuchal rigidity and blurred vision; hemiparesis; seizure activity; and other features.

Ebola virus.With ebola virus, headache is usually abrupt in onset, commonly occurring on the fifth day of illness. Additionally, the patient has a history of malaise, myalgia, a high fever, diarrhea, abdominal pain, dehydration, and lethargy. A maculopapular skin rash develops between the fifth and seventh days of the illness. Other possible findings include pleuritic chest pain; a dry, hacking cough; pronounced pharyngitis; hematemesis; melena; and bleeding from the nose, gums, and vagina. Death usually occurs in the second week of the illness, preceded by severe blood loss and shock.

Encephalitis.A severe, generalized headache is characteristic with encephalitis. Within 48 hours, the patient's LOC typically deteriorates—perhaps from lethargy to coma. Associated signs and symptoms include a fever, nuchal rigidity, irritability, seizures, nausea and vomiting, photophobia, cranial nerve palsies such as ptosis, and focal neurologic deficits, such as hemiparesis and hemiplegia.

Epidural hemorrhage (acute).Head trauma and a sudden, brief loss of consciousness usually precede acute epidural hemorrhage, which causes a progressively severe headache that's accompanied by nausea and vomiting, bladder distention, confusion, and then a rapid decrease in the patient's LOC. Other signs and symptoms include unilateral seizures, hemiparesis, hemiplegia, a high fever, a decreased pulse rate and bounding pulse, a widened pulse pressure, increased blood pressure, a positive Babinski's reflex, and decerebrate posture.

If the patient slips into a coma, his respirations deepen and become stertorous, then shallow and irregular, and eventually they cease. Pupil dilation may occur on the same side as the hemorrhage.

Glaucoma (acute angle-closure).Glaucoma is an ophthalmic emergency that may cause an excruciating headache as well as acute eye pain, blurred vision, halo vision, nausea, and vomiting. Assessment reveals conjunctival injection, a cloudy cornea, and a moderately dilated, fixed pupil.

Hantavirus pulmonary syndrome.Noncardiogenic pulmonary edema distinguishes hantavirus pulmonary syndrome. Common reasons for seeking treatment include flulike signs and symptoms—headache, myalgia, fever, nausea, vomiting, and a cough—followed by respiratory distress. Fever, hypoxia, and (in some patients) serious hypotension typify the hospital course. Other signs and symptoms include a rising respiratory rate (28 breaths/minute or more) and an increased heart rate (120 beats/minute or more).

Hypertension.Hypertension may cause a slightly throbbing occipital headache on awakening that decreases in severity during the day. However, if the patient's diastolic blood pressure exceeds 120 mm Hg, the headache remains constant. Associated signs and symptoms include an atrial gallop, restlessness, confusion, nausea and vomiting, blurred vision, seizures, and an altered LOC.

Influenza.A severe generalized or frontal headache usually begins suddenly with the flu. Accompanying signs and symptoms may last for 3 to 5 days and include stabbing retro-orbital pain, weakness, diffuse myalgia, fever, chills, coughing, rhinorrhea and, occasionally, hoarseness.

Listeriosis.Signs and symptoms of listeriosis include fever, myalgia, abdominal pain, nausea, vomiting, and diarrhea. If the infection spreads to the nervous system, meningitis may develop. These signs and symptoms include headache, nuchal rigidity, fever, and a change in the patient's LOC.

Meningitis.Meningitis is marked by the sudden onset of a severe, constant, generalized headache that worsens with movement. Associated signs include nuchal rigidity, positive Kernig's and Brudzinski's signs, hyperreflexia and, possibly, opisthotonos. A fever occurs early with meningitis and may be accompanied by chills. As ICP increases, vomiting and, occasionally, papilledema develop. Other features include an altered LOC, seizures, ocular palsies, facial weakness, and hearing loss.

Plague (Yersinia pestis).The pneumonic form of the plague causes a sudden onset of a headache, chills, fever, myalgia, a productive cough, chest pain, tachypnea, dyspnea, hemoptysis, respiratory distress, and cardiopulmonary insufficiency.

Postconcussional syndrome.A generalized or localized headache may develop 1 to 30 days after head trauma and last for 2 to 3 weeks. This characteristic symptom may be described as an aching, pounding, pressing, stabbing, or throbbing pain. The patient's neurologic examination is normal, but he may experience giddiness or dizziness, blurred vision, fatigue, insomnia, an inability to concentrate, and noise and alcohol intolerance.

Q Fever.Signs and symptoms of Q fever include severe headaches, fever, chills, malaise, chest pain, nausea, vomiting, and diarrhea. Fever may last for up to 2 weeks, and in severe cases, the patient may develop hepatitis or pneumonia.

Severe acute respiratory syndrome (SARS).SARS generally begins with a fever (usually greater than 100.4° F [38° C]). Other symptoms include headache; malaise; a dry, nonproductive cough; and dyspnea. The severity of the illness is highly variable, ranging from mild illness to pneumonia and, in some cases, progressing to respiratory failure and death.

Smallpox (variola major).Initial signs and symptoms of smallpox include a severe headache, backache, abdominal pain, a high fever, malaise, prostration, and a maculopapular rash on the mucosa of the mouth, pharynx, face, and forearms, and then the trunk and legs. The rash becomes vesicular, then pustular, and finally crusts and scabs, leaving a pitted scar. In fatal cases, death results from encephalitis, extensive bleeding, or secondary infection.

Subarachnoid hemorrhage.Subarachnoid hemorrhage commonly produces a sudden, severe headache along with nuchal rigidity, nausea and vomiting, seizures, dizziness, ipsilateral pupil dilation, and an altered LOC that may rapidly progress to coma. The patient also exhibits positive Kernig's and Brudzinski's signs, photophobia, blurred vision and, possibly, a fever. Focal signs and symptoms (such as hemiparesis, hemiplegia, sensory or vision disturbances, and aphasia) and signs of elevated ICP (such as bradycardia and increased blood pressure) may also occur.

Subdural hematoma.Typically associated with head trauma, acute and chronic subdural hematomas may cause a headache and decreased LOC. With acute subdural hematoma, head trauma also produces drowsiness, confusion, and agitation that may progress to coma. Later findings include signs of increased ICP and focal neurologic deficits such as hemiparesis.

Chronic subdural hematoma produces a dull, pounding headache that fluctuates in severity and is located over the hematoma. Weeks or months after the initial head trauma, the patient may experience giddiness, personality changes, confusion, seizures, and a progressively worsening LOC. Late signs may include unilateral pupil dilation, sluggish pupil reaction to light, and ptosis.

Tularemia.Signs and symptoms following inhalation of the bacterium Francisella tularensis include an abrupt onset of a headache, a fever, chills, generalized myalgia, a nonproductive cough, dyspnea, pleuritic chest pain, and empyema.

Typhus.Initial symptoms of typhus include a headache, myalgia, arthralgia, and malaise followed by an abrupt onset of chills, a fever, nausea, and vomiting. A maculopapular rash may be present in some cases.

West Nile encephalitis.Signs and symptoms of West Nile encephalitis include a fever, a headache, and body aches, commonly with a skin rash and swollen lymph glands. More severe infection is marked by a high fever, a headache, neck stiffness, stupor, disorientation, coma, tremors, occasional seizures, paralysis and, rarely, death.

Other causes

Diagnostic tests.A lumbar puncture, myelogram, or epidural or spinal procedure may produce a throbbing frontal headache that worsens on standing.

Drugs.Many drugs can cause headaches. For example, indomethacin produces headaches—usually in the morning—in many patients. Vasodilators and drugs with a vasodilating effect, such as nitrates, typically cause a throbbing headache. Headaches may also follow withdrawal from vasopressors, such as caffeine, ergotamine, and sympathomimetics.

Traction.Cervical traction with pins commonly causes a headache, which may be generalized or localized to pin insertion sites.

» READ BOOK EXCERPT ONLINE »

Source: Nursing: Interpreting Signs and Symptoms, 2007

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