Severe Headache

in a 62-year-old Woman Seen at an

Immediate Care Center

N U R S E P R A C T I T I O N E R S F O R U M

Author: T. Smith, RN, MS, FNP, CEN, Naperville, Ill

Section Editor: Gail Pisarcik Lenehan, RN, EdD, FAAN

T. Smith, Illinois State Council ENA, is employed at MidwestEmergency Associates, Oakbrook, Ill, and Provena Mercy Hospital,Aurora, Ill.

For reprints, write: T. Smith, RN, MS, FNP, CEN, 868 Havenshire Rd,Naperville, IL 60565-6187; E-mail: TSmith421@aol.com.

J Emerg Nurs 2004;30:501-3.

0099-1767/$30.00

Copyright n 2004 by the Emergency Nurses Association.

doi: 10.1016/j.jen.2004.07.081

October 2004 30:5

young-looking, retired, 62-year-old woman,

A along with her daughter, came to the free-

standing Immediate Care Center with a com-

plaint of bsinus headache,Q nausea, vomiting, and diarrhea

for the past 24 hours. The triage registered nurse who

evaluated the woman documented that the patient was

complaining of increasing pressure in her cheeks and

forehead, with pain radiating to her right ear and jaw that

was 10 on a scale of 10. Her headache had started 2 days

earlier and was increasing in intensity and not responding

to her usual over-the-counter medications. She had one

episode of nausea, vomiting, and diarrhea the day before

arrival at the Center. Her vital signs were as follows: blood

pressure, 163/78 mm Hg; heart rate, 99 beats/minute;

respiratory rate, 18 breaths/minute; and oral temperature,

36.28C (97.28F).

What do you think?

The patient and her daughter had walked by the unit

station where I was charting. The patient was holding her

head to the right and cupping her hand over her right eye

and forehead. Her daughter was holding the patient’s arm

as if to be her support or guide. As a nurse practitioner, my

thoughts before entering the patient room were as follows:

Why was the daughter helping to guide this very capable

and healthy-appearing woman? She must be in a great deal

of pain.

What are your differential diagnoses?

My immediate differentials included sinusitis, meningitis,

encephalitis (it was August and West Nile Virus was pre-

valent), and subdural or intracerebral bleed. I omitted

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migraine headache from my list because 62-year-old

women usually do not have migraine headaches.

Initial contact

Upon entering the treatment room, I found the patient

and her daughter sitting in chairs. The patient was still

holding her head to the right and cupping it in her hand.

I introduced myself and put my hand out to shake hers.

She did not respond to my introduction or to my gesture.

Her daughter told me that her mother had been driving

to her house early that morning to baby-sit, as she does

every day. This morning she made it halfway and called

her daughter because her headache was so severe. Her son-

in-law drove to her and brought her back to their house.

The daughter said that when her mother arrived, she

seemed disoriented. She took 2 tablets of acetaminophen,

325 mg, with pseudoephedrine, 60 mg, went to bed,

and slept until noon. Upon awakening, she took another

2 tablets of 325 mg of acetaminophen with 60 mg of

pseudoephedrine and rested until deciding to come to the

Immediate Care Center 2 hours later.

During the initial interview, my patient said very little

and did not remove her hand from her head. My first

thought was that this is a severe headache and yet the

patient was able to sleep. Second, why was she disoriented?

Third, her elevated systolic blood pressure might explain

these symptoms.

Pertinent medical history

The patient had a history of frequent sinus headaches and

multiple mosquito bites in the week before admission.

She had no history of migraine headaches or hyper-

tension. She had no chills or fever and no recent signs or

symptoms of sinusitis in the past month. She had seasonal

allergies and no known drug allergies. Medications she

was taking included cetirizine (Zyrtec), 10 mg daily;

Flonase, 2 sprays to each nostril daily; and acetamino-

phen, two 325 mg tablets with pseudoephedrine, 60 mg,

taken at 8:30 AM and 12:30 PM. There was no family

history of stroke but a positive family history for

cardiovascular disease. She had a brother with heart

disease. The patient baby-sits her grandchildren daily,

502 J

driving 40 miles back and forth in rush-hour traffic

between her home and her daughter’s home.

OUR

Then I asked the binfamousQ question,bIs this the worst headache of yourlife? Q to which she replied, bYes.Q

The patient’s daughter assisted her mother in walking

the 8 feet from the chair to the cart. Her movements were

very slow and deliberate, but she easily maneuvered onto the

cart and into a sitting position. I continued my interview.

bHave you ever had a headache like this with your sinus

infections?Q She replied, bNo.Q Then I asked the binfamousQquestion, bIs this the worst headache of your life?Q to which

she replied, bYes.Q My thought was, bSomething is seriously

wrong! This is more than djust a sinus headacheT.Q

What are your differential diagnoses now?

Now the differentials included subdural hematoma, evolv-

ing stroke, and intracerebral bleed.

Pertinent neurologic assessment data

The patient’s pupils were equal, round, and reactive

to light and accommodation. Extraocular movements

were intact. Cranial nerves II–XII were grossly intact.

The patient was alert and oriented to date, time, place,

and recent events. Her distant memory was intact. She

had good cognition and thought processes. Her affect was

f lat. She had a steady gait and adequate balance.

Symptoms of ICH include a suddenonset of headache, nausea, vomiting,and hypertension, often with a changein level of consciousness that progressesover minutes to hours.

What diagnostics are needed?

I knew that the patient needed a computed tomography

(CT) scan of her brain and that she should be transferred to

NAL OF EMERGENCY NURSING 30:5 October 2004

N U R S E P R A C T I T I O N E R S F O R U M /S m i t h

the emergency department. When I met with my

collaborating physician, I related the information that I

had gleaned from my brief assessment and ended with the

following statement: bShe says this is the worst headache

she has ever had.Q The only response from the physician

was, bGet a CT.QI took the patient to our on-site CT suite. Within

15 minutes, the CT technician requested that the physi-

cian come to the suite immediately to review the prelimi-

nary results. The CT revealed a large, right intracerebral

bleed without ventricle involvement and without a shift.

Upon return to the Immediate Care Center, our patient

admitted that she had been in a minor car crash on her

way to her daughter’s home that day and had been

disoriented and upset when she called her daughter

to come and get her. The physician evaluated her and

we prepared her for transfer to the emergency department.

Outcome

Our patient progressed well and was discharged home with

very few residual neurologic deficits. No surgical inter-

vention was necessary.

Octo

Our patient’s symptoms did not fit thisclassic presentation. She presented withpain to her forehead radiating to herright face, ear, and jaw and had onlyone episode of nausea and vomiting theday prior to admission. The lesson,therefore, is always to keep thedifferential wide!

Discussion

Intracerebral hemorrhage (ICH) is more common than

subarachnoid hemorrhage and usually has a poor out-

come.1 The American Heart Association’s Scientific State-

ment suggests that as many as 50% of patients who

experience an ICH die within 1 month of the event.1

Risk factors for ICH include hypertension, aging, male

sex, vascular malformations, ruptured aneurysm, coagula-

tion disorders, use of anticoagulants, brain tumors, and

ber 2004 30:5

drug abuse. Our patient’s only risk factor was her

increased age, although the pseudoephedrine that was

taken with the acetaminophen may have elevated her

blood pressure.

Symptoms of ICH include a sudden onset of head-

ache, nausea, vomiting, and hypertension, often with a

change in level of consciousness that progresses over

minutes to hours. Focal neurologic signs are dependent

on the anatomic site of the cerebral bleed. Our patient’s

symptoms did not fit this classic presentation. She

presented with pain to her forehead radiating to her right

face, ear, and jaw and had only one episode of nausea and

vomiting the day prior to admission. The lesson, therefore,

is always to keep the differential wide!

REFERENCE

1. Broderick JP, Adams HP, Barsan W, Feinberg W, Feldmann E,Grotta J, et al. AHA Scientif ic Statement: Guidelines for themanagement of spontaneous intracerebral hemorrhage. Stroke1999;30:905-15.

Contributions for this column are welcomed and encouraged.Submissions may be sent to:

Gail Pisarcik Lenehan, RN, EdD, FAANc/o Managing Editor, 77 Rolling Ridge Rd, Amherst, MA 01002

800 900-9659, ext 4044 . awbkelly@comcast.net

JOURNAL OF EMERGENCY NURSING 503