A 48 year-old male with hypertension and hyperlipidemia presents with headache. Notes onset of symptoms 8 hours prior to presentation, reaching maximal severity within seconds. Headache improved with over-the-counter analgesics. On examination, there are no neurological deficits, neck is supple. A CT head non-contrast is obtained:

ED Course:

A lumbar puncture is performed, CSF sampling reveals xanthochromia – neurosurgery is consulted and the patient is admitted for angiography and possible intervention.

An Algorithm for the Evaluation of Headache

High-Risk Historical Features

• Sudden onset (seconds/minutes), patient recalls activity at onset
• Worst in life or change in character from established headache
• Fever, neck pain/stiffness
• Altered mental status
• Malignancy
• Coagulopathy: iatrogenic, hepatopathy, dialysis
• Immunocompromised
• Rare: CO exposure, jaw claudication, PCKD

Location of Pain

1. Unilateral: migraine
2. Periorbital: glaucoma, CVT, optic neuritis, cluster
3. Facial/maxillary: trigeminal neuralgia, sinusitis
4. Temporal: GCA
5. Occipital: cerebellar stroke
6. Nuchal: meningitis

Characteristics of Primary Headaches

Physical Examination Findings

Vital Signs

Fever: present in 95% of patients with meningitis

Head

Trauma: signs of basilar skull fracture

Temporal artery tenderness/induration: GCA

Pericranial muscle tenderness: tension headache

Trigger point, Tinnel sign: occipital neuralgia

Eyes

Pupillary defects: aneurysm with CN III compression

Papilledema, absence of spontaneous venous pulsations: elevated intracranial pressure

EOM abnormalities: ICH, mass lesion, neuropathy (DM, Lyme)

Horner syndrome (ptosis, miosis, anhidrosis): carotid dissection

Visual field defect: stroke, atypical migraine

Conjunctival injection: glaucoma (fixed, mid-size pupil, elevated intraocular pressure), cluster headache

Mouth

Thrush: immunocompromise

Sinuses

Tenderness to palpation, abnormal transillumination: sinusitis

Neck

Resistance to supine neck flexion: meningitis

Kernig: supine position, hip flexed, knee flexed, resistance to knee extension

Brudzinski: supine position, neck flexion results in knee flexion

Jolt accentuation: patient rotates head side-to-side, 2-3 times/sec exacerbates headache

References:

1. Russi, C. (2013). Headache. In Rosen’s Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 170-175). Elsevier Health Sciences.
2. Godwin SA, Villa J. “Acute headache in the ED: Evidence-Based Evaluation and Treatment Options.” Emerg Med Pract 2001; 3(6): 1-32.
3. Edlow, J. A., Panagos, P. D., Godwin, S. A., Thomas, T. L., & Decker, W. W. (2008). Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients Presenting to the Emergency Department With Acute Headache. Annals of emergency medicine, 52(4), 407–436. doi:10.1016/j.annemergmed.2008.07.001
4. WikEM: Headache

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Key Historical Findings

Onset

Acute onset with associated activity suggests mechanical process

Acute onset without trigger, particularly if severe pain may suggest vascular process

Progressive onset without trigger suggests non-mechanical process (i.e. malignancy)

Aggravating/Alleviating Factors

Worsening with cough/valsalva suggests herniated disk

Relief with flexion associated with spinal stenosis

Location/Radiation

Radicular pain typically extends below knee, associated with nerve root involvement

Radiation to/from chest or abdomen suggests visceral source

Flank location suggests retroperitoneal source

History/Associated Symptoms

Fever

Medications (particularly anti-coagulants)

Hematuria

Malignancy

IVDA

Vascular disease

Key Physical Findings

• Abnormal vital signs
  • Fever: abscess, osteomyelitis, discitis
  • Hypertension: dissection
  • Shock: AAA
• Localize point of greatest tenderness
• Examine abdomen for pulsatile mass
• Perform thorough neurological examination including rectal tone and perianal sensation
• Positive straight leg raise associated with sciatic nerve root irritation and is sensitive (but not specific) for disk disease.

References

1. Mahoney, B. (2013). Back Pain. In Rosen’s Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 278-284). Elsevier Health Sciences.
2. WikEM: Lower back pain

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Key Historical Findings

Location

Lateralized: suggests process related to tube or ovary, consider unilateral urinary tract process. On right, add appendicitis to differential; on left, add diverticulitis (particularly if age >40.

Central: suggests process involving uterus, bladder or bilateral adnexa

Diffuse: suggests PID

Radiation

Radiation to rectum suggests pooling of fluid or blood in cul-de-sac

Onset

Abrupt: suggests acute intrapelvic hemorrhage (from ruptured ectopic or ovarian cyst), ovarian torsion, urolithiasis

Gradual: inflammatory process such as PID

Chronic/recurrent: suggests endometriosis, recurrent ovarian cyst, ovarian mass

Associated Symptoms

Fevers/chills: suggests infectious process

Nausea/vomiting: suggests process involving gastrointestinal tract, though may accompany pregnancy or severe pain associated with ovarian torsion, urolithiasis.

Dysuria: suggests process involving urinary tract, though may be associated with local vulvar/vaginal process

Urinary urgency: more specific for bladder or urethral irritation

Obstetric History

History of recurrent spontaneous abortions or prior ectopic pregnancy increases likelihood of recurrence.

Ongoing fertility treatments increase likelihood for ectopic/heterotopic (occurs in 1:100 with assisted reproduction compared to 1:8000 in general population)

Vaginal Bleeding

In non-pregnant: suggests PID, DUB, cervical or uterine cancer

In early pregnancy: may be associated with ectopic pregnancy, non-viable IUP, or subchorionic hemorrhage

In late pregnancy: may be associated with placental pathology (previa, abruption)

Key Physical Findings

• Pelvic examination: assists with localization of lateralized process. Should be preceded by ultrasound if >20 weeks.
• Abnormal vaginal discharge: suggests vaginitis, cervicitis, PID, or retained foreign body.
• Cervical motion tenderness: suggests reproductive tract inflammation or irritation of adjacent structures (appendicitis, cystitis)
• Unilateral adnexal mass/tenderness: associated with ovarian cyst/mass, TOA, ectopic, or ovarian torsion.

References:

1. Hart, D., & Lipsky, A. (2013). Acute Pelvic Pain in Women. In Rosen's Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 266-272). Elsevier Health Sciences.
2. WikEM: Pelvic pain

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Key Historical Features

Quantity

Patient’s estimate

Symptoms suggestive of anemia/volume depletion: (pre)syncope, dyspnea

Appearance/Location

Distinguish upper from lower GI bleding

PMH

Prior episodes and source

History of aortic aneurysm graft

Comorbidities: presence of CAD, CHF, liver disease or diabetes increases mortality

Medications/substance use

Gastrotoxic, anti-coagulants, anti-platelet agents

Alcohol abuse

Key Physical Findings

Vital signs

Tachycardia or hypotension

Eyes

Conjuntival pallor suggests anemia

Scleral icterus suggests liver disease

Abdomen

Hyperactive bowel sounds may be present in UGIB (blood is cathartic)

Epigastric tenderness to palpation suggests PUD

Diffuse tenderness suggests bowel ischemia, obstruction/ileus, or perforation

Rectal (digital, anoscopy)

May reveal fissures, hemorrhoids or polyps

Labs/Diagnostic Tests

• CBC: consider transfusion for Hb <8-10g/dL particularly in elderly or those with CAD
• BMP: BUN:creatinine > 36 in the absence of renal failure suggests UGIB
• PT/PTT/INR: coagulopathy
• Lactate: elevated in bowel ischemia or systemic hypoperfusion
• T&S or T&C
• ECG: screen for myocardial ischemia

Blatchford Scoring System

References:

1. Goralnick, E., & Meguerdichian, D. (2013). Gastrointestinal Bleeding. In Rosen's Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 248-253). Elsevier Health Sciences.

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Complications of Nausea and Vomiting

• Hypovolemia: activates RAAS
• Metabolic alkalosis: loss of hydrogen ions in vomitus
• Hypokalemia: RAAS promotes sodium retention and potassium excretion
• Esophageal injury: Mallory-Weiss tear, Boerhaave syndrome
• Aspiration

Key Historical Findings

Duration of vomiting

Acute: Episodic and occurring for <1 week. Suggestive of obstructive, toxic/metabolic, infectious, ischemic or neurologic process.

Chronic: Episodic and occurring for >1 month. Suggestive of partial obstruction, motility disorder or neurologic process.

Onset

Acute onset: suggests pancreatitis, gastroenteritis, or cholecystitis.

Timing

Post prandial: delayed >1 hour suggests gastric outlet obstruction or gastroparesis.

Contents

Bile: presence of bile suggests patent connection between duodenum and stomach (no GOO)

Undigested food: suggests upper GI tract process (achalasia, esophageal stricture, Zenker)

Feculent: suggests distal bowel obstruction

Associated symptoms

Headache: suggests elevated ICP

Causes of Nausea and Vomiting

References

1. Zun, L. (2013). Nausea and Vomiting. In Rosen’s Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 238-247). Elsevier Health Sciences.

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1. Visceral: distension of hollow organs or capsular stretch of solid organs.
2. Somatic: parietal peritoneal irritation
3. Referred
   • Extra-abdominopelvic
     • Epigastric: inferior MI
     • Pelvic: hip
     • Abdominal: lower lobe pneumonia/infarction
   • Abdominopelvic
     • Shoulder: diaphragmatic irritation (ex. perforated duodenal ulcer, splenic pathology)
     • Mid-back: aortopathy, pancreatitis
     • Flank: renal pathology
     • Low back: uterus, rectum

Concerning Historical Features

• Elderly: increased probability for severe disease with poor clinical diagnostic accuracy
• Immunocompromised: HIV/AIDS, uncontrolled diabetes, chronic liver disease, chemotherapy, other immunosuppression
• Pain preceding nausea/vomiting: increased likelihood of surgical process
• Abrupt onset, duration <48h, constant timing
• Prior abdominal surgical history: consider bowel obstruction
• No prior episodes of similar pain
• Recent antibiotic or steroid use: may mask signs of infection
• Cardiac risk factors (HTN, vascular disease, atrial fibrillation: increased risk for mesenteric ischemia or aortic aneurysm
• Heavy NSAID use or anticoagulation: increase concern for gastrointestinal bleeding

Imaging

• Plain film reserved for those who would otherwise not undergo CT. XR abdomen for bowel obstruction or radiopaque foreign body.
• CT abdomen/pelvis with IV contrast, particularly if elderly or immunocompromised.
• Ultrasound preferred for hepatobiliary pathology
• Bedside ultrasound for identification of IUP, free intraperitoneal fluid, cholecystitis, CBD dilation, ascites, hydronephrosis, aortopathy, volume status.

Causes of Abdominal Pain

References

1. Budhram, G., & Bengiamin, R. (2013). Abdominal Pain. In Rosen’s Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 223-231). Elsevier Health Sciences.

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Guided Lecture

Watch “Chest Pain: It’s Giving Me Angina” from EM Ed. In this lecture Dr. Celedon reviews the critical differential diagnosis for chest pain and how to safely and effectively work up patient’s with this challenging chief complaint.

References

1. Brown, J. (2013). Chest Pain. In Rosen’s Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 214-222). Elsevier Health Sciences.

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Findings in Selected Causes of Dyspnea

References

1. Braithwaite, S., & Perina, D. (2013). Dyspnea. In Rosen’s Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 206-213). Elsevier Health Sciences.

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Physical Examination:

Neck

Stiffness, limitation of extension suggestive of retropharyngeal abscess.

Jaw

Trismus associated with peritonsillar cellulitis or abscess.

Oral Cavity

Dry mucous membranes suggest dehydration (from odynophagia) and indicates severity of symptoms.

Tongue elevation, sublingual/submental induration, poor dentition (particularly of mandibular molars) associated with Ludwig Angina.

Unilateral tonsillar enlargement with contralateral uvular deviation suggests peritonisllar abscess. Fluctuance may be palpated.

Tonsilar exudates suggest infectious pharyngitis (non-specific).

Palatal petechiae suggest bacterial pharyngitis.

Ulcerations of the anterior oral cavity are associated with herpes infection, lesions on the soft palate are suggestive of coxsackievirus infection.

Rarely, a grey membrane in the posterior pharynx will suggest diphtheria.

Lymphadenopathy

Tender anterior cervical lymphadenopathy may suggest bacterial pharyngitis.

Posterior cervical lymphadenopathy is associated with infectious mononucleosis.

Large, firm, non-mobile lymph nodes may suggest malignancy.

Eyes

Presence of conjunctivitis (also rhinorrhea, exanthema) associated with viral pharyngitis.

Skin

Ulcers involving the hands, feet, in addition to pharyngeal lesions suggest coxsackievirus infection.

Scarlatiniform rash associated with pharyngitis (particularly in school-age children) suggests streptococcal pharyngitis.

Abdomen

Splenomegaly is associated with infectious mononucleosis.

Centor Criteria (Modified)

• +1: Fever
• +1: Tonsillar Exudate
• +1: Tender anterior cervical lymphadenopathy
• +1: Absence of cough
• -1: Age >45yo

Incidence of GABHS by Centor Criteria

• 0, -1: 1%
• 1: 10%
• 2: 17%
• 3: 35%
• 4: 51%

References:

1. Newman, D., & Shreves, A. (2013). Sore Throat. In Rosen’s Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 198-202). Elsevier Health Sciences.
2. King, B. R., & Charles, R. A. (2004). Pharyngitis In The ED Diagnostic Challenges And Management Dilemmas. Emergency medicine practice, 6(5), 1–24.

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Distinguishing Central vs. Peripheral Vertigo

Causes of Vertigo

Characteristics of common causes of vertigo

History

• Onset, duration, timing, severity, exacerbating factors
• Vascular risk factors: age, male, HTN, CAD, DM, atrial fibrillation
• Vestibulotoxic medications: aminoglycosides, AED

Key Physical Examination Findings

• VS: Presence of hypotension suggests presyncope
• Head: Examine for evidence of trauma
• Neck: Auscultate for carotid bruit
• Ear: Effusion or perforation suggests peripheral process (possible perilymphatic fistula)
• Eye: Examine for pupillary defects (CNIII), papilledema, extraoccular muscles
• Neuro: Cerebellar testing

Positional Testing

Dix-Hallpike

Turn head 45°

Upright sitting → supine (head overhanging bed)

Positive: nystagmus + symptoms on one side

Roll

Supine

Turn head 90°

Positive: nystagmus + symptoms on both sides, more severe on affected

HINTS¹

Normal head impulse, direction-changing nystagmus, or skew deviation suggests stroke.

Head impulse

Focus on examiner’s nose

Rapidly turn head 10° in horizontal plan

Presence of corrective saccade suggests defect of peripheral vestibular nerve

Nystagmus

Peripheral: Horizontal, unidirectional. Increases on gaze in direction of fast phase (decreases or resolves opposite)

Central: Direction changing

Skew deviation

Cross cover

Presence of vertical disconjugate gaze suggests brainstem dysfunction

HINTS Gallery

Labs

• Glucose
• CBC/Chemistry
• ECG

Imaging

• Warranted if findings concerning for central process
• MRI preferred

Management

Specific etiologies

Vestibular neuronitis: steroids

Meniere: dietary changes

BPPV: canalith repositioning

Symptomatic relief

Promethazine (Phenergan) 12.5-25mg PO

Ondansetron (Zofran) 4mg IV

Lorazepam (Ativan) 1-2mg PO/IV

Meclizine (Antivert) 25mg PO q6-8h PRN

References

1. Kattah, J. C., Talkad, A. V., Wang, D. Z., Hsieh, Y.-H., & Newman-Toker, D. E. (2009). HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke; a journal of cerebral circulation, 40(11), 3504–3510. doi:10.1161/STROKEAHA.109.551234
2. Chang, A., & Olshaker, J. (2013). Dizziness and Vertigo. In Rosen’s Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 162-169). Elsevier Health Sciences.

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