Identifying Data:
Full Name: Ms. JK
Address: Forest Hill, NY
Date of Birth: June 23rd, 1970
Date & Time: July 10th, 2020
Location: South Shore Family Medical, NY
Religion: Catholic
Source of Information: Self
Source of Referral: Self
Mode of Transport: Self
Chief Complaint: “I keep having severe headaches” x 4 days.
Ms. JK is 50-year-old woman with a PMH of paroxysmal atrial fibrillation, and HTN/HLD, presents today with complains of severe headaches. Patient states that during her lunch break as she was getting lunch from a nearby Deli she suddenly started getting headaches. She describes the headaches as sharp, especially on her right side of her head with no radiation. Patient states the headaches last about 10 mins and is not constant pain. Patient rates the pain a 7/10 and has tried Advil which has helped with the headaches for the first few hours but the pain resumes again and was getting worse day by day that’s why she decided to come in today. Patient also stated that her jaw muscles gets sore and stiff after meals (especially after chewing gum or bread) 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.
Past Medical History:
Present illnesses – HTN/Hyperlipidemia x 4 years; paroxysmal A.fib x 3 years.
Past medical illnesses – Appendicitis at the age of 26 years old.
Hospitalizations: A few days after her appendectomy. No complications.
Immunizations- Up to date.
Screening tests and results- pap smear 3 years ago, benign.
Childhood illnesses –Denies childhood illnesses.
Past Surgical History:
Appendectomy at age 26, done at NYPQ, does not remember the name of the surgeon. No complications.
Medications:
Atorvastatin, 10 mg PO QHS for hyperlipidemia, last dose yesterday.
Eliquis, 2.5 mg PO, 1-tab q12h, to prevent clot formation due to Afib, last dose was last night
Diltiazem 240 mg, PO q12h, rate control for Afib, last dose last night.
Multivitamins PO daily supplement for overall health.
Allergies:
Denies drug, environmental or food allergies.
Family History:
Denies family history of cardiovascular diseases, cancer, strokes.
Father- deceased at age 88- MI
Mother-deceased at age 73- Pulmonary complications (doesn’t know exactly)
Social History:
Ms. JK lives with her husband and her son in an apartment in Forest Hills. She works as a dental assistance at a private clinic for about 15 years now.
Habits- Ms. JK denies use of alcohol. Denies use tobacco and illicit drug use.
Travel- Has not recently traveled anywhere.
Diet- She doesn’t follow a specific diet. However, she tries to eat healthy by cutting down on her carbs and reducing her fatty food consumption due to her hyperlipidemia.
Exercise- Tries to walk to work which is about 2 miles away from her house.
Sexual Hx- Not sexually active. No past history of STD’s or HIV.
Review of Systems:
General: denies loss of appetite, fever, recent weight loss or gain, generalized weakness/fatigue, or night sweats.
Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus, or changes in hair distribution.
Head – Patient states she has sharp and painful headaches mostly on the right side of her head. Denies vertigo or head trauma.
Eyes – Denies lacrimation, pruritis, visual disturbances, or photophobia. Last eye exam 2017 – does not know her visual acuity, normal pressure.
Ears – Denies deafness, pain, discharge, tinnitus or use of hearing aids.
Nose/sinuses – Denies discharge, obstruction, or epistaxis.
Mouth/throat – Patient states she experiences jaw soreness when chewing gum for too long or when eating bread. Denies bleeding gums, sore tongue, sore throat, mouth ulcers, voice changes. Last dental exam 2019.
Neck– Denies localized swelling/lumps or stiffness/decreased range of motion.
Breast – Denies lumps, nipple discharge, or pain.
Pulmonary system – Denies dyspnea, dyspnea on exertion, cough, wheezing, hemoptysis, cyanosis, orthopnea, or paroxysmal nocturnal dyspnea (PND).
Cardiovascular system – Patient states she has A.fib but ever since she’s been on medication she has not experienced any symptoms of a.fib. Denies chest pain, palpitations, edema/swelling of ankles/feet, syncope, known heart murmur.
Gastrointestinal system – Has regular bowel movements daily. Denies change in appetite, intolerance to specific foods, nausea, vomiting, dysphagia, pyrosis, unusual flatulence or eructations, abdominal pain, diarrhea, jaundice, hemorrhoids, constipation, rectal bleeding, or blood in stool.
Genitourinary system –Denies urinary frequency or urgency, oliguria, polyuria, dysuria, incontinence.
Nervous – Patient states she has sharp and painful headaches mostly on the right side of her head. Denies seizures, loss of consciousness, sensory disturbances, ataxia, loss of strength, change in cognition / mental status.
Musculoskeletal system – Patient states she experiences jaw soreness when chewing for too long such as when eating bread. Denies other muscle/joint pain, deformity or swelling, redness or arthritis.
Peripheral vascular system – Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.
Hematological system – Denies anemia, easy bruising or bleeding, lymph node enlargement, blood transfusions, or history of DVT/PE.
Endocrine system – Denies polyuria, polydipsia, polyphagia, heat or cold intolerance, excessive sweating, hirsutism, or goiter
Psychiatric – Denies mood changes, depression. Denies sadness, OCD.
Physical exam:
General: Pt is alert and oriented x3, neatly dressed, slightly distressed due to her pain but is responsive to verbal commands.
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)
Skin: warm to the touch & moist, good turgor. Nonicteric, no lesions noted, no scars, tattoos.
Hair: Normal hair pattern.
Nails: no clubbing, capillary refill <2 seconds throughout.
Head: Patient reports pain on palpation to her right 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 acuity (uncorrected – 20/40 OS, 20/40 OD, 20/40 OU).
Visual fields full OU. PERRL, no accommodation, EOMs full with no nystagmus
Fundoscopy – Red reflex intact OU. Cup: Disk < 0.5 OU/no evidence of A-V nicking, papilledema, hemorrhage, exudate, cotton wool spots, or neovascularization OU.
Ears: Symmetrical and normal size. No evidence of lesions/masses / trauma on external ears. No discharge / foreign bodies in external auditory canals AU. TM’s pearly white / intact with light reflex in normal position AU. Auditory acuity hardly intact to whispered voice AU. Weber midline / Rinne, BC<AC AU.
Nose – Symmetrical / no obvious masses / lesions / deformities / trauma / discharge. Left nostril congestion due to mucus. Nasal mucosa pink & appears dehydrated. No discharge noted on anterior rhinoscopy. Septum midline without lesions / deformities / injection / perforation. No evidence of foreign bodies.
Sinuses – Non tender to palpation and percussion over bilateral frontal, ethmoid and maxillary sinuses.
Lips – Pink; no evidence of cyanosis or lesions. Non-tender to palpation.
Mucosa – Pink. No masses: lesions noted. Non-tender to palpation. No evidence of leukoplakia.
Palate – Pink. Palate intact with no lesions; masses; scars. Non-tender to palpation; continuity intact.
Teeth –2 dental caries noted.
Gingivae – Pink. No evidence of hyperplasia; masses; lesions; erythema or discharge. Non-tender to palpation.
Tongue – Pink; well papillated; no masses, lesions or deviation noted. Non-tender to palpation.
Oropharynx –no evidence of injection; exudate; masses; lesions; foreign bodies. Tonsils present with no evidence of injection or exudate. Uvula pinkish, no edema, lesions.
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.
Thyroid –Non-tender; no palpable masses; no bruits noted.
Thorax & Lungs:
Chest– symmetrical, no deformities, no evidence of trauma. Respirations unlabored, no paradoxical respirations or use of accessory muscles noted. Lat to AP 2:1, non-tender to palpations.
Lungs– Clear to auscultation and percussion bilaterally. Chest expansions and diaphragmatic excursions symmetrical. Tactile fremitus symmetric throughout. No adventitious sounds.
Heart: No tenderness to palpation. JVP is 2.5 cm above the sternal angle with the head of the bed at 30°. PMI in 5th ICS in mid-clavicular line. Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR); S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs or other extra sounds.
Abdomen: No hernias noted. Flat / symmetrical / no evidence of scars, striae, caput medusae or abnormal pulsations. BS present in all 4 quadrants. No bruits noted over aortic/renal/iliac/femoral arteries. Tympany to percussion throughout. Non-tender to percussion or to light/deep palpation. No evidence of organomegaly. No masses noted. No evidence of guarding or rebound tenderness. No CVAT noted bilaterally.
Peripheral Vascular:
The extremities are normal in color, size and temperature. Pulses are 2+ bilaterally in upper and lower extremities. No bruits noted. No clubbing, cyanosis or edema noted bilaterally (no C/C/E B/L) No stasis changes or ulcerations noted.
|
|
Brachial
|
Ulnar
|
Radial
|
Femoral
|
Popliteal
|
D.P.
|
P.T.
|
| R
|
2+
|
2+
|
2 +
|
2+
|
2+ | 2 +
|
2 +
|
| L
|
2+
|
2+
|
2+
|
2+
|
2+ | 2+
|
2+
|
Upper & Lower Extremities:
No soft tissue swelling / erythema / ecchymosis / atrophy / or deformities in bilateral upper and lower extremities. Non-tender to palpation / no crepitus noted throughout. FROM of all upper and lower extremities bilaterally. No evidence of spinal deformities.
Cranial nerves:
I . Olfactory: intact bilaterally
- Optic: OD OS
visual acuity 20/40 20/40 (uncorrected)
fundoscopic examination: (see eye exam)
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,
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
Motor Systems no evidence of atrophy, fasciculations or abnormal movements
normal muscle bulk, contour and tone
Muscle Strength: Right Left
upper extremities 5/5 5/5
lower extremities 5/5 5/5
rapid alternating movements and point to point movements intact, no asterixis
gait normal, Romberg negative, slight pronator drift
Sensory Systems dull, thermal, and light touch sensation intact upper and lower extremities bilaterally, vibratory sensation intact over great toe bilaterally
proprioception, stereognosis, graphesthesia, two-point discrimination, point localization and extinction intact
Reflexes
Biceps Brach. Triceps Abd Knee Ankle Plantar Response
RT 2+ 2+ 2+ 2+ 2+ 2+ Down-going
LT 2+ 2+ 2+ 2+ 2+ 2+ Down-going
Assessment:
Ms. JK is 50-year-old woman with a PMH of paroxysmal atrial fibrillation, and HTN/HLD, presents today with complains of severe headaches. Patient describes them as sharp pain and unilateral to the right side of her head and also reports jaw soreness and stiffness while chewing (especially when chewing gum or eating bread for a longer time). On exam, patient reported pain when the right side of her head was being palpated. Patient had visual acuity of 20/40 on both eyes and the rest of the physical exam was benign.
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. CT of the head should be ordered to rule out trauma to the head.
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 in our patient. Patient claims this is the first time she’s getting headaches like this one.
Plan:
1) Order CBC, CMP, CT scan to rule out head trauma and head bleeding. Also order ESR/CRP and if the results are still indecisive, order a temporal biopsy doe definite diagnosis of temporal arteritis.
2) Refer to ophthalmologist for her decreased visual acuity and observe for possible blindness.
3) If temporal arteritis confirmed- high dose methylprednisolone 60 mg/day.
4) Continue Atorvastatin, 10 mg PO QHS for hyperlipidemia
5) Continue Eliquis, 2.5 mg PO, 1-tab q12h, to prevent clot formation due to Afib
6) Continue Diltiazem 240 mg, PO q12h, rate control for Afib.
7) Continue Multivitamins PO daily supplement for overall health.
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