A 23-year-old female college student is eating lunch with friends when she suddenly senses that the right side of her tongue doesn’t seem to be working. She mentions it to her friends, who tell her that the whole right side of her face is drooping. Alarmed, she runs to the bathroom, looks in the mirror and thinks, I have had a stroke. She has her friend call 9-1-1 and sits down to wait for the ambulance.
After establishing the patient’s level of consciousness, securing the airway and monitoring circulation, if the patient is able to answer questions, ask the usual OPQRST and SAMPLE history questions.
For trauma patients with injuries like a blow to the head or a fall, ask if the symptoms started before or after the traumatic event. Ask the patient to describe exactly what happened.
If it’s a medical condition, ask whether it has ever happened before. Was onset sudden or gradual, over minutes or days? Note the quality of her voice and whether there is any hoarseness or difficulty speaking.
Specific history questions and findings include:
- Did she lose consciousness? Consider the possibility if the patient is unable to describe the event. Did the loss of consciousness occur before the injury or after? If a blow to the head resulted in unconsciousness and the patient is conscious now, consider the possibility of an epidural bleed. The brief return to consciousness—the “lucid interval”—in an epidural bleed is quickly followed by a diminishing level of consciousness, unconsciousness, seizure activity and death.
- Are hazardous conditions, such as exposure to toxic chemicals, involved?
- Does the patient have a history of seizures; could a seizure be involved?
- Does the patient complain of visual disturbances? “Double vision” (diplopia), flashes of light or tunnel vision may indicate pressure on the optic nerve. Kaleidoscope vision may indicate an optical migraine. Extreme light sensitivity (photophobia) may indicate a migraine or, more ominously, intracranial hemorrhage.
- Has there been nausea or vomiting, particularly projectile vomiting, which is a sign of increasing intracranial pressure?
- Does the patient have a headache? A sudden, severe headache in a patient who has never had one like it before can signal a serious medical problem like a subarachnoid hemorrhage. SAH often presents as a sudden, severe, debilitating headache—the “thunder-clap headache”—followed rapidly by neck stiffness, loss of consciousness and cardiac arrest. Patients who complain of headache should be asked to describe it in terms of location, severity, character (constant, throbbing, aching, dull, sharp, pounding) and duration.
- Has the patient drunk alcohol or taken any recreational drugs?
Nausea or vomiting, changes in vision, pain with bright lights (photophobia), neck pain or stiffness, fever, weakness, dizziness or other symptoms may be signs of increasing intracranial pressure.1
Examining the Head
While still taking the history, begin the physical examination.
Look at the patient’s head. Does it appear to be normally developed with normal features? Note any deviations that could signal a genetic or developmental disorder.
Inspect and palpate the skull. Look for symmetry, bleeding and bruises. Place your hands on the skull and feel for swelling or indentations in all regions. Does palpation produce pain? Look for bruising behind the ear (Battle’s sign) and bruising around the orbits (“raccoon eyes” or “panda eyes”), but keep in mind that these may take a while after injury to develop. If present, they may signal a skull fracture.
Inspect the ears for discharge and note whether it is bloody or clear. Inspect the eyes for pupillary size, shape, reaction to light and movement. (See our article in the May issue on assessment of the eye.)