USING THE HEAD AND NECK EXAMINATION TO DIAGNOSE FOCAL NEUROLOGIC DEFICITS. D. Fotino 1 , N. Parekh 1 ; 1 Tulane University, New Orleans, LA (Tracking  ID #77089)   LEARNING OBJECTIVES: USE THE EXAM SKILLS TO DIAGNOSE FOCAL  NEUROLOGIC DEFICITS.  CASE INFORMATION: A 41 year-old diabetic man presented with a sudden onset of slurred speech and left-sided weakness. On examination, he had severe dental caries, slurred speech, and a left facial droop. His tongue deviated to left on protrusion, and he had left upper and lower extremity weakness. There was tenderness over the right mastoid process. His WBC was 27,000 with 14% bands. A CT showed subdural fluid collection in the right frontoparietal region. Vancomycin, ceftazidime and metronidzaol were empirically started for a presumptive diagnosis of subdural empyema. Shortly after admission, he deteriorated to persistent and refractory status epilepticus. The CSF protein was 149; WBC 630 (70% neutrophils); the gram stain was negative. A repeat CT showed an area of hypodensity and a midline shift, consistent with subdural empyema. He underwent drainage of the abscess; the cultures grew out pseudomonas aeruginosa. Ciprofloxacin was added to his regimen to double cover the pseudomonas. His seizure activity relented soon thereafter. IMPLICATIONS/DISCUSSION: Sinusitis is the leading cause of subdural empyema, and can present with focal neurological signs if intra-cerebral extension occurs. Diabetic patients are also at risk for malignant external otitis, and empiric coverage for pseudomonas is warranted at even the lowest level of suspicion. Although this patient's symptoms suggested a cerebrovascular accident, the finding of mastoid tenderness directed the diagnosis towards the infected mastoid sinus and the subdural abscess. In diabetic patients, empiric pseudomonas coverage should be initiated early; double coverage should be instituted when a pseudomonas infection is confirmed, as this reduces the mortality of deep tissue infections by 50% when compared to single coverage. A thorough examination of the oro and nasopharyngeal cavities can direct and expedite diagnostic testing and prevent grave sequelae of treatable diseases.