Question

A patient comes to the clinic following discharge from the ED due to colliding with a teammate during soccer practice. The ED work-up was unimpressive and the patient was discharged without incident and told to follow-up with their PCP in the next 3 days. Today the patient reports feeling a bit tired and has begun to have a runny nose. He also complains of tenderness behind his ear where his teammate hit him. On examination the NP notices that the patient has bruising behind his ear and periorbital eccymosis. What does the NP order/test for to rule out basilar skull fracture?

a. Dix-Hallpike test
b. CT scan
c. X-ray
d. Urine dipstick of nasal discharge

Answer 1

To rule out a basilar skull fracture in a patient with head trauma who exhibits bruising behind the ear and periorbital ecchymosis, the nurse practitioner should order a CT scan. Other tests like the Dix-Hallpike test, X-ray, and urine dipstick of nasal discharge are not appropriate for diagnosing this type of fracture.

Step-by-step explanation:

The presence of bruising behind the ear and periorbital ecchymosis (also known as 'raccoon eyes') in a patient who has recently sustained head trauma is concerning for a basilar skull fracture. Such injuries can be subtle and may not manifest immediate symptoms. However, the described tenderness and bruising are significant clinical findings that warrant further investigation. The appropriate next step to rule out a basilar skull fracture would be ordering a CT scan. A CT scan of the head is the diagnostic tool of choice because it provides detailed images of the bone and can quickly identify any fractures. The other options listed - Dix-Hallpike test, X-ray, and urine dipstick of nasal discharge - are not appropriate for diagnosing basilar skull fractures. The Dix-Hallpike test is used for diagnosing benign paroxysmal positional vertigo (BPPV), X-rays lack the necessary detail for detecting subtle skull fractures, and a urine dipstick of nasal discharge might be used to detect the presence of cerebrospinal fluid (CSF) leak, but not fracture.

Given that the patient reports feeling tired and has symptoms of a runny nose post head injury, it is also important to assess for possible CSF leak, which can sometimes accompany basilar skull fractures. This can be done by testing the nasal discharge for the presence of beta-2 transferrin, which is a protein uniquely found in CSF.