A 44-year-old male presents to the emergency room with the worst ...

[fox]

A 44-year-old male presents to the emergency room with the worst headache of his life. He is holding his head and appears severely distressed. This is a patient symptom that should prompt a clinician to look for signs of a:
 
  A. Migraine headache
  B. Subdural hematoma
  C. Subarachnoid haemorrhage
  D. Brain tumor

Question 2

When examining the carotid arteries, the clinician should:
 
  A. Ask the patient to hold his/her breath while auscultating the carotid arteries
  B. Use the bell of the stethoscope to listen over the carotid arteries
  C. Palpate one carotid artery at a time
  D. All of the above

[atrochim]

Answer to Question 1

ANS: C
The pain associated with subarachnoid hemorrhage is generally described as severe and acute in onset. The onset is often described as a thunderbolt or lightning. The severity is described as the worst headache of my life. It is generally made worse by lying down. There is often associated nausea and/or vomiting and possible rapid deterioration in neurological function. Typical migraine pain begins unilaterally but may become generalized and may lateralize to the opposite side and/or radiate to the face or neck. The pain ranges from a dull ache to a throbbing or pulsatile pain. The pain is often severe and/or incapacitating and is often aggravated by movement, light, and noise. The headache associated with subdural hematoma is generally dull and aching in nature and may be transient. The history often includes a blow to the head, fall, or other injury, which preceded the pain. The pain will gradually worsen over days to weeks. Headache due to a brain tumor is difficult to diagnose. A headache that awakens a patient from sleep is often a brain tumor. Headache with neurological deficits should also raise suspicion of brain tumor.

Answer to Question 2

ANS: D
Auscultation of the carotid arteries is an important portion of the neurological examination, particularly for elderly patients. The patient should be asked to hold his or her breath during auscultation. The bell of the stethoscope is used to auscultate for bruits. One carotid artery at a time is palpated. A bruit in the carotid artery may be an indicator of potential stroke or carotid artery stenosis and should be followed by further tests, such as carotid duplex and carotid ultrasound.

[fox]

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