History and Physical — Patient 30

History

Present Illness: The patient is a 39 year old right-handed Hispanic male with a previous history of headaches and a recurrence of head pain associated with double vision. Three months prior to admission, the patient developed gradually worsening headaches that were qualitatively similar to those he suffered several years earlier. The pain was described as "generalized" initially, but progressed to become a constant, severe, right retro-orbital and forehead pain. He denied any precipitating factors and denied exacerbation of the pain with coughing, sneezing, Valsalva, or position change. He likewise denied nausea, vomiting, photophobia, phonophobia, fever, chills, weight loss, cough, neck pain, or radiation of pain. He denied any recent trauma or HIV risk factors.

Two weeks prior to admission, he developed binocular diplopia in all directions of gaze, associated with a feeling of dizziness. Initially he could correct the diplopia by turning his head to the left, but the problem quickly progressed to the point where this maneuver was no longer effective. He denied any vertigo, tinnitus, or hearing loss.

The patient's previous headaches occurred on a daily basis in "clusters", lasting six months at a time over a two year period. They were described as pressure-like, generalized in location, and constant. Each headache lasted for several hours at a time. He denied any associated rhinorrhea, lacrimation or ptosis. The headaches were diagnosed as "cluster headaches" and subsided after he stopped drinking caffeine.

Past Medical History: The patient was involved in a motor vehicle accident five years prior to presentation. He did not hit his head.

Family History: There is no family history of headaches.

Physical Exam Physical Exam

General: Well-developed, well-nourished male appearing his stated age, in no apparent distress.

Vital Signs: B.P. 127/60; pulse 60; temperature 97.7 F; respirations 12; weight 150 lbs.

HEENT: NCAT, sclerae anicteric, conjunctivae pink; no exophthalmos or proptosis; oropharynx is clear, moist without lesions; temperomadibular joint exam shows no point tenderness; no temporal tenderness; neck is supple without lymphadenopathy, masses, or bruits.

Chest: Clear to auscultation and percussion bilaterally.

Cardiovascular: RRR without rubs, gallops, murmurs.

Abdomen: Soft, non-tender, non-distended, without masses or bruits.

Extremities: No cyanosis, clubbing, or edema.

Neurological Examination

Cranial Nerves:

Cranial Nerves

Findings

INot tested.
IIVA 20/70 OD, 20/30 OS, corrects with pinhole exam; Pupils 3 mm and reactive to light and accomodation bilaterally; fundi normal; visual fields full; red match test normal.
III / IV / VIWeakness in the right SR, IR, IO, MR, and SO; right LR intact; mild ptosis on right.
VSlight numbness in V1 distribution on the right.
VIISmile is symmetrical.
VIIIHearing intact to finger rub bilaterally; Weber does not lateralize.
IX / XGag intact bilaterally; palate elevates in the midline.
XISCM and trapezius strength 5/5.
XIITongue midline without atrophy or fibrillations.

 

Motor: Tone was normal. Muscle bulk was normal. There was no cogwheel rigidity or tremor. All muscles groups of both the upper and lower extremities were normal (5/5).

Reflexes: 2+/2+ for upper and lower extremities.

Sensation: Intact pinprick, vibration, position sense, temperature, and light touch throughout.

Cerebellar: Intact f-n-f, heel-shin; normal RAMs.

Gait: Normal stance, stride length, arm swing, pivot; normal heel, toe, and tandem walking.

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