Special Operations Forces Medical Handbook

3-55

13. Evacuate patient to a gynecologist for definitive care. If evacuation not possible, proceed with the
    following steps.


14. Cut a 15cm length of Iodoform gauze and loosely pack the cavity with it. This will keep the incision
    open and allowing continuous drainage over the next few days. Have the patient return in 24 hours
    for reassessment.


15. If the abscess recurs, marsupialize the gland. Open the cyst again as in before, then suture the everted
    edges of the gland to the vaginal mucosa. This allows for continuous drainage and a permanent open
    path (Figure 3-4).

What Not To Do:
Do not open abscess through normal skin. Enter via the vaginal mucosa.
Do not make too large or deep an incision.
Do not attempt marsupialization of the gland unless evacuation is not available to a trained gynecologist.

Symptom: Headache

CDR David Llewellyn, MC, USN

Introduction: There are virtually hundreds of conditions that can cause headaches. Any disease process
affecting anything from the neck up can have headache as a symptom. Pain can be referred from the
eyes, ears, nose, throat, teeth, sinuses, neck, tongue. Therefore a good examination of HEENT, neck, and
the nervous system is crucial. Generalized illness, such as viral syndromes, can also cause secondary
headaches. If the headache has an identiable cause such as cerebral hemorrhage or meningitis, it is
termed a secondary headache. Most headaches, such as migraine, tension-type and cluster headaches,
are not due to any clearly identiable cause and are termed primary headaches-- they are real but have
no identiable cause.

Subjective: Symptoms
Head pain, which can vary in severity, and be accompanied by virtually any symptoms; fever, rash, neck
stiffness; loss of consciousness or altered mental status.
Migraine: Pounding/throbbing pain, usually but not always unilateral, moderate to severe in intensity, often
with nausea/vomiting, often with light or noise sensitivity; routine activities make it worse, patient wants to lie
down in a quiet, dark room; builds up over minutes to hours and lasts hours to days; some patients have an
“aura”, such as ashing lights; women affected more than men.
Tension-type: Global, squeezing headache; less severe than migraine; can last hours to weeks; no nausea
or aversion to light and sound.
Cluster: Less common, but affect young men predominantly; severe, short-lived unilateral headaches, usually
around the eye, lasting at most a few hours; can occur many times in a day and even wake the patient at night;
may want to pace the halls (compare to migraine).
Focused History: Have you had a similar headache before? (This makes a benign headache more likely).
Have you taken headache medications? What have you tried in the past? (use same treatment if effective)
Do you have other symptoms such as nausea, vomiting, fear of light or sound? (typical migraine) Have
you been hit, or been in an accident? Do you have a fever, stiff neck or rash? (afrmative answer
suggests meningitis, stroke, other CNS damage) Do you have any neurologic symptoms such as: trouble
thinking/talking, loss of consciousness, visual blurring, double vision, vertigo, numbness, weakness etc?
(Positive answers suggest an intracranial problem)

Objective: Signs
Using Basic Tools: Possible tachycardia and hypertension; fever in infection or some CNS trauma; neck stiff-
ness in meningitis; neck tenderness in tension-type headache; abnormal neurological examination (including
mental status examination [MMSE is adequate]; see Appendix) suggests signicant CNS or PNS; papilledema
suggests intracranial swelling; neurological exam may change over time, indicating a worsening condition.
Using Advanced Tools: Lab: WBC for infection.