Patient Information
J. D., 20, Male, Native American
Subjective data
CC: a headache
J. D. is a 20-year-old Native American male who was in his usual state of health until about 6 days ago and now presents with complaints of experiencing intermittent headaches. J. D. states that the headaches diffuse all over the head, but the greatest intensity and pressure occur above the eyes and spread through the nose, cheekbones, and jaw. J. D. says that a headache is mild at first, but it reaches its maximal intensity within a few minutes. Due to headaches, J. D. finds it hard to focus and sleep. In order to reduce pain, J. D. takes Ibuprofen, but the medication is ineffective if taken after a long time since a headache started. He does not experience vomiting and says that a headache is accompanied by tension and pain in his jaw and facial muscles. The man noticed that he began to experience headaches after he started working at a new job. J. D. states that the headaches bother him less on weekends when he does not work. 7/10 in pain severity.
Location: head
Onset: 6 days ago
Character: pressing, tightening, pressure above the eyes spreading through the nose, cheekbones, and jaw
Associated signs and symptoms: pain in facial muscles
Timing: after a long day at work
Exacerbating/ relieving factors: long working days trigger headaches
Severity: 7/10 pain scale
Current Medications: Ibuprofen 200 mg oral tab, 200 mg orally every 6 hours as needed for pain; total length of time used – 4 days.
Allergies: The patient reports no known medication, food, or environmental allergies.
PMHx: No significant past medical history, immunizations are up-to-date. Last Tetanus shot was 02/2013.
Soc Hx: J. D. works as an organizational development consultant at a grand financial company. He likes playing table football and chess; his lifestyle is rather sedentary. Single, heterosexual with no current partner, no children; denies smoking and alcohol intake. Reports seat belt use while driving, has no smoke detectors in the house. Does not use a cell phone while driving; reports several cups of coffee daily, up to 4 cups per day.
Fam Hx: Both mother and father are healthy with no known health issues. Paternal grandmother had breast cancer, and maternal grandmother had hypertension.
ROS
- GENERAL: No weight loss, fever, and chills. J.D. states that he suffers from fatigue.
- HEENT: Eyes: No visual loss, blurred vision, double vision or yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion. Pain in joint. Limited ability to open the jaw.
- SKIN: No rash or itching.
- CARDIOVASCULAR: No chest pain, chest pressure or chest discomfort. No palpitations or edema.
- RESPIRATORY: No shortness of breath, cough or sputum.
- GASTROINTESTINAL: No anorexia, nausea, vomiting or diarrhea. No abdominal pain or blood.
- GENITOURINARY: Denies urinary frequency, hesitancy, incontinence.
- NEUROLOGICAL: Intermittent headaches above the eyes radiating to the nose, cheekbones, and jaw.
- MUSCULOSKELETAL: Denies trauma or injury.
- HEMATOLOGIC: No anemia, bleeding or bruising.
- LYMPHATICS: No enlarged nodes. No history of splenectomy.
- PSYCHIATRIC: Depression and anxiety. Report trouble concentrating.
- ENDOCRINOLOGIC: No reports of sweating, cold or heat intolerance.
- ALLERGIES: No history of asthma, hives, eczema or rhinitis.
Physical exam
GENERAL: White male, well-kept and well-mannered. Has a decreased facial mobility.
H: 5’8”
W: 160 lbs
BP 123/78
P 76
HEENT
Skin: Warm and dry, soft to touch, no erythema or color changes.
Head/Neck: Normocephalic. No signs of head trauma, lacerations, contusions. No palpable lymph node enlargement. Neck supple and non-tender. Pain and tenderness on palpation in the muscles of mastication. Muscle tenderness. The patient finds it painful to open the jaw.
Eyes: White sclera. No conjunctival infection.
Nose: Clear nasal discharge, no blood noted.
Throat: Uvula midline, equally rises and falls.
NEUROLOGIC: Alert and person-oriented, cooperative. Slow movement due to pain from a headache. Maintains balance with eyes closed. Reflexes are 2+ and symmetric with plantar reflexes. Increased mechano-sensitivity of the supra-orbital nerve. Tenderness of the scalp muscles.
Diagnostic results
Electromyography to diagnose a tension-type headache (Naderi & Jorjorzadeh, 2015). The diagnosis of the temporomandibular joint disorder is based largely on the patient’s history and physical examination findings (Gauer & Semidey, 2015). Trigeminal neuralgia may be diagnosed based solely on physical and neurological examination. Also, imaging may be used for determining neuropathic pain (Cruccu et al., 2016). Temporal arteritis may be diagnosed using positron emission tomography, computed tomography, and blood tests (Salvarani, Soriano, Muratore, Shoenfeld, & Blockmans, 2017).
Diagnosis: Temporomandibular joint disorder.
Differential diagnoses: Temporomandibular joint disorder, tension-type headache, trigeminal neuralgia, temporal arteritis, sinusitis.
Differential Diagnoses
- Temporomandibular joint disorder. A headache accompanied by pain in jaw and facial muscles may be explained by temporomandibular joint disorder (TJD). This diagnosis is supported by pain and tenderness on palpation in the muscles of mastication and muscle tenderness (Ball, Dains, Flynn, Solomon, & Stewart, 2015). Intermittent headaches as well as pain in facial muscles which J. D. experiences may act as symptoms of TJD.
- A tension-type headache. A tension-type headache occurring in the frontal area has pressing or tightening quality and mild or moderate intensity (Waldie, Buckley, Bull, & Poulton, 2015). A tension-type headache is not aggravated by routine physical activity such as walking. It may be stated that the leading cause of the patient’s tension-type headache is his job that adds to his anxiety and depression. This is in compliance with the information that the most common precipitants of a tension-type headache are stress or mental tension (Waldie et al., 2015). Since the onset of the headaches was only 6 days ago, it is impossible to identify whether a tension-type headache is frequent, infrequent, or chronic. However, a tension-type headache does not explain pressure around jaw that occurs alongside a headache.
- Trigeminal neuralgia. Trigeminal neuralgia may be diagnosed if a person has a shock-like brief pain, which is true for J. D. It may also be suggested that headaches he experiences are exacerbated not by long working day and stress but by talking with people. However, based on the patient’s subjective data, he does not have spontaneous attacks of pain.
- Temporal arteritis. Head pain and tenderness experienced by J. D. may be symptoms of temporal arteritis or giant cell arteritis. Other signs and symptoms common for temporal arteritis and experienced by the patient are jaw pain and fatigue. However, the patient does not have a double vision, unintentional weight loss, and loss of appetite (Ball et al., 2015).
- Sinusitis. J. D. may have sinusitis as he has symptoms such as pain, tenderness, and pressure around eyes, cheeks, nose, and forehead. Other signs and symptoms common for sinusitis and experienced by the patient include a headache, aching in jaw, and fatigue. However, the patient does not have nasal obstruction and congestion that cause difficulty breathing through his nose.
This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
References
Ball, J. W., Dains, J. E., Flynn, J. A., Solomon, B. S., & Stewart, R. W. (2015). Seidel’s guide to physical examination (8th ed.). St. Louis, MO: Elsevier Mosby.
Cruccu, G., Finnerup, N. B., Jensen, T. S., Scholz, J., Sindou, M., Svensson, P.,… Nurmikko, T. (2016). Trigeminal neuralgia: New classification and diagnostic grading for practice and research. Neurology, 87(2), 220-228. Web.
Gauer, R. L., & Semidey, M. J. (2015). Diagnosis and treatment of temporomandibular disorders. Am Fam Physician, 91(6), 378-386.
Naderi, F., & Jorjorzadeh, M. (2015). The effect of biofeedback electromyography (EMG & EEG) training on the tension and migraine headaches of migraine patients. International Journal of Applied Psychology, 5(2), 54-58. Web.
Salvarani, C., Soriano, A., Muratore, F., Shoenfeld, Y., & Blockmans, D. (2017). Is PET/CT essential in the diagnosis and follow-up of temporal arteritis? Autoimmunity Reviews, 16(11), 1125-1130. Web.
Waldie, K. E., Buckley, J., Bull, P. N., & Poulton, R. (2015). Tension-type headache: A life-course review. Journal of Headache & Pain Management, 1(1), 1-9.