Ms. D is a 56-year-old female patient with complaint of unbearable headaches x 3 days.
History Elements:
PMHx: paroxysmal atrial fibrillation, and HTN/HLD.
Onset: Headaches started 3 days ago when she was getting ready for sleep.
Location: Left side of her head.
Timing/Duration: Headaches last about 5 mins and is not constant pain.
Characteristics: Headaches are sharp, especially on her left side of her head.
Aggravating/alleviating factors: Advil helps with the headaches for the first few hours but the pain resumes again and was gets worse day by day that’s why she decided to come in today.
Radiation: No radiation
Severity: Patient rates the pain an 8/10
Patient also admits that her jaw muscles gets sore and stiff after meals (especially after chewing meat) and this has been going on for about a week now. After a few minutes of no more chewing, her jaw goes back to normal and does not feel sore anymore.
Patient denies, cough, fever, night sweats, change in appetite, nausea, vomiting, constipation, diarrhea, rectal bleeding, unusual flatulence, SOB, wheezing, pyrosis, chest pain, jaw swelling or deformity, redness, vertigo, head trauma, visual disturbances, sensory disturbances, ataxia, loss of strength, change in cognition / mental status.
No past surgical/medical history; Immunizations- up to date; screening tests and results- pap smear 3 years ago, benign.
No allergies
No family history of cardiovascular diseases, cancer, strokes.
Medications: Atorvastatin, 10 mg PO QHS, Eliquis, 2.5 mg PO, 1-tab q12h, Diltiazem 240 mg, PO q12h.
Denies use of alcohol, tobacco and illicit drug use.
Travel- Has not recently traveled anywhere.
Sexual Hx- Not sexually active. No past history of STD’s, HIV, or any other sexually transmitted diseases.
Physical Exam:
Vital Signs: BP: R L
Seated 135/85 125/80
Supine 130/80 130/70
R: 19/min unlabored P: 89, regular
T: 99.6 degrees F (oral) O2 Sat: 98% Room air
Height 5 feet and 6 inches Weight 160 lbs. BMI: 25.8 (overweight)
Head: Patient reports pain on palpation to her left side of her head (temporal side of the head). Head is normocephalic, atraumatic.
Eyes – symmetrical OU; no evidence of strabismus, exophthalmos, or ptosis; sclera white.
conjunctiva & cornea clear. Visual fields full OU, PERRL, no accommodation
Visual acuity (uncorrected – 20/40 OS, 20/40 OD, 20/40 OU).
Fundoscopy – no abnormalities.
Sinuses – Non tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.
Neck – Trachea midline. No masses; lesions; scars; pulsations noted. Supple; non-tender to palpation. no stridor noted. 2+ Carotid pulses, no thrills; bruits noted bilaterally.
Lungs:
Lungs clear to auscultation and percussion bilaterally. No adventitious breath sounds.
Heart: RRR. S1 & S2 normal. No murmurs, S3, S4 splitting of heart sounds, friction rubs or other abnormal sounds.
Abdomen: BS in all 4 quadrants, no bruits, no evidence of scars, striae, caput medusae or abnormal pulsations, tympany to percussion throughout. Non-tender to percussion or to light/deep palpation, no masses noted. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally.
Cranial nerves:
I . Olfactory: intact bilaterally
- Optic: OD OS
visual acuity 20/40 20/40 (uncorrected)
III. Oculomotor, IV Trochlear, VI Abducens:
extraocular movements (intact), no nystagmus, ptosis.
direct and consensual pupillary light reflex intact bilaterally
accommodation restricted bilaterally
- Trigeminal: masseter/temporalis strength 5/5
corneal reflex intact OU.
VII. Facial: facial movements intact.
VIII. Acoustic: auditory acuity intact bilaterally to whispered voice, Weber: midline, Rinne: AC>BC
- Glossopharyngeal- No abnormalities.
X Vagus: uvula midline, soft palate and pharynx rise symmetrically
- Spinal Accessory: sternocleidomastoid strength 5/5 bilaterally,
trapezius strength 5/5 bilaterally
XII. Hypoglossal: no tongue atrophy, deviation upon protrusion or fasciculations noted.
Differential Diagnosis:
1) Most likely Temporal Arteritis: Patient presents with unilateral headache, unilateral scalp tenderness during palpation and jaw pain when chewing all of which point to temporal arteritis. Temporal arteritis is most commonly seen in females who are over 50 years old, and our patient falls right into that category as well. On exam we also noted some visual changes which further point to temporal arteritis.
2) Direct trauma to the head: Unilateral tenderness when palpating the head could also indicate recent trauma to the head. Although patient does not recall any recent trauma she could’ve accidently banged her head against something and not notice.
3) Cluster Headache: Cluster headaches can present as very painful unilateral headaches and may sometimes effect vision as well. Cluster headaches often occur daily for some weeks then is followed by a period of remission, which is not seen with our patient. Patient claims this is the first time she’s getting headaches like this one.
Lab/Tests:
Elevated ESR- 80 mm/hr
Elevated CRP- 15 mg/L
Elevated platelet count- 450,000/µL
CBC reveals mild normochromic normocytic anemia.
CT-scan of the head- normal
All other labs- normal
Definitive diagnosis- Temporal artery biopsy- positive for GCA.
Treatment:
High dose methylprednisolone 60 mg/day.
Refer to ophthalmologist for her decreased visual acuity and observe for possible blindness.
If no improvement with methylprednisolone, methotrexate, or azathioprine is recommended.
Patient education:
Monthly follow up for the first 6 months of treatment.
Consult pt on watchful symptoms for polymyalgia rheumatica and further visual complications as Temporal arteritis can lead to blindness. If symptoms noted, seek medical attention immediately.
Patient should monitor possible side effects of high dose of glucocorticoids and seek medical attention of severe side effects are noted (Increase BP, triglycerides, cholesterol, or glucose).
Source:
PancePrepPearl
https://www.uptodate.com/contents/diagnosis-of-giant-cell-arteritis
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