358 Emergency Medicine
such as aphasia, visual disturbances, or hemiparesis. This patient does not
exhibit any of these findings. Migraines (d)tend to be unilateral and pulsating
and associated with nausea, vomiting, photophobia, phonophobia, blurred
vision, and light-headedness. Patients should not exhibit papilledema.
322.The answer is e.(Rosen, pp 1613-1614.)This patient’s clinical picture
is consistent with temporal arteritis (TA).Patients are usually middle-
aged females(age > 50) who present with malaise, fevers, and headache.
A completephysical examination would have revealed temporal artery ten-
derness to palpation. This patient also complains of symptoms consistent
withpolymyalgia rheumatica,a general achiness that may become con-
fused with influenza. Temporal or giant-cell arteritis is a granulomatous
inflammation that involves the large- and medium-sized arteries of the body,
commonly the carotid artery and its branches. Symptoms are produced as a
result of ischemia to the organs fed by the branches of the artery. Visual loss
in one eye, transient diplopia and jaw claudication are common symptoms
when the branches of the internal and external carotid are affected. A temporal
artery biopsyis the diagnostic test of choice and will confirm the diagno-
sis. However, it is important to note that TA is segmental in nature and
false-negatives do occur. Treatment up until the time of biopsy should include
high-doseglucocorticoids,namely prednisone or methylprednisolone. This
does not alter biopsy results and may prevent progression of the disease. Hospi-
talization is warranted in patients with severe debilitation or impending visual
loss and may require high-dose steroids.
(a)Symptoms of influenza closely mimic those of polymyalgia rheumat-
ica, were it not for the specific eye/jaw symptoms. (b) Patients with
Streptococcuspharyngitis may present with profound general malaise, how-
ever, they are typically more febrile and have a history of sick contacts and
dry cough. Tonsillar exudates and anterior cervical adenopathy might be evi-
dent upon physical examination. (c)An ESR between 50 and 100 mm/h is a
good initial test to further the suspicion of TA; however, it is not the diag-
nostic test of choice. An elevated C-reactive protein may also be present.
(d)A CBC may indicate anemia, which results from the arterial inflamma-
tion that furthers the breakdown of red blood cells (RBCs). However, this
and an elevated WBC count are nonspecific findings.
323.The answer is e.(Aminoff et al, Ch 2 Headache and facial pain.)
Tension headachesoften occur daily,and classically cause bilateral occipi-
tal pain that is described as a band tighteningaround the head. In general,