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HPI: (7 parameters): KP, is a 64 -year-old female with a past…
HPI: (7 parameters): KP, is a 64 -year-old female with a past medical history of Osteoarthritis, migraine headache, hypothyroid, DM, HTN, HLD, renal calculi, GERD presents to the ED with her daughter with complaints of blurry vision, left sided headache and left sided temporal area tenderness, characterized by intermittent shooting pain for brief duration radiating from the left side of the head to cheek, and under eyelid with a severity of pain rating of 6-8 on a scale of 1-10 for the past 2 weeks with no improvement on over the counter NSAIDS. Pain is aggravated with touch or pressure on that side of the head. KP complaints of associated leg cramps. KP denies jaw claudication, limb claudication, N/V, vision changes, photophobia, eye pain, noise intolerance, fever, chills, dizziness, fall or injury. KP ‘s PCP from All Care Family Medicine and private ophtho asked her to come to ED for further evaluation on GCA with Temporal artery biopsy and ESR, and prescribed prednisolone but had not taken, as she was worried that it would elevate her blood glucose levels, Moreover, she was also told that she has cataracts and would need corrective surgery. KP and her daughter recalls a similar incident of headache 10 years ago but was told that it was not GCA at that time but does not remember the medical condition that was told to them. She often have occasional migraine headaches, but not of this origin or severity. KP denies of any dental procedure or surgeries in the past. Upon arrival to the ED, pertinent chemistry and CBC revealed Hb/MCV : 11.8/74.5 and normal ESR (23)and CRP (<0.6) levels, CTA head negative. KP continued to endorse left side head and facial pain, worse on palpation even after receiving a course of prednisone 60 mg, Reglan 10 IVPB, 10 Tylenol 1000mg IV and Toradol 15mg. Even with normal ESR levels, Considering the risk factors and presenting symptoms KP is admitted to the inpatient for further testing and monitoring her symptoms for GCA. Need help with coming up with a complete H and P on this case with at least 5 differential diagnoses The pt has more like trigeminal neuralgia, Kp has blurry vision secondary to cataract told by her PCP, KP CT negative, follow up with rheumatology, ophthalmology, and neurology on the progression of worsening of the symptoms. vascular surgery was consulted for temporal artery biopsy but was later canceled due to the low suspicion of GCA. pt TSH was 85 on admission with normal T3. H1ac 7.7. pt currently on synthroid 112 mcg, hydralazine 50 mg , verapamil, losartan 100 mg, januvia 100 mg, metformin 1000mg, meloxicam, simvastatin 20 mg.... MRI and MRA of head and neck revealed no structural abnormalities or tumors or bleed,,, based on the clinical presentation , pt likely to have trigeminal neuralgia...... currently on gabapentin 100 mg BID , tylenol along with her hospital meds but plan to swap the gapapentin to carbamazepine 200 mg BID if pt tolerates after liver and kidney function test and some health education....... if u need the refernces, i can send .. thanks Answer from your tutor: Report this answer UltraRhinocerosMaster824Active 6 minutes ago KP, a 64-year-old female, went to the emergency department with hazy vision, left-sided headache, and left-sided temporal area tenderness. Her Hb/MCV was 11.8/74.5, and her ESR (23) and CRP (0.6) readings were normal. NSAIDs have not been effective in relieving the discomfort. Explanation: Onset: KP, a 64-year-old female, went to the emergency department with her daughter complaining of hazy vision, left-sided headache, and left-sided temporal area pain. KP was also experiencing some left-sided temporal area tenderness. The headache has been persistent for the past two weeks and is characterized by intermittent pain that shoots from the left side of the head to the cheek and under the eyelid. The discomfort lasts for only a few seconds at a time. Location/Radiation: The discomfort is concentrated on the left side of the head and extends to the cheek as well as the area just under the eyelid. Duration: I've been experiencing this discomfort consistently for the past two weeks. Character: The pain is described as being intermittent, shooting, and only lasting for a short period of time. Aggravating Factors: The pain is made worse by any contact or pressure applied to the left side of the head. Relieving Factors: OTC nonsteroidal anti-inflammatory drugs (NSAIDs) have not been effective in relieving the discomfort. Timing: The pain has been present for the past two weeks. Severity: On a scale from one to ten, the level of pain ranges from six to eight. KP also complained of leg cramps connected with the condition. She denied having jaw claudication, limb claudication, nausea, vomiting, changes in vision, photophobia, eye pain, noise intolerance, fever, chills, disorientation, a fall or injury, or any of the other symptoms that were listed. She also stated that she had suffered from headaches on occasion in the past, but they were not of the same origin or severity as the headache that she is currently experiencing. KP insisted that he had never undergone any dental work or surgical procedures in the past. The patient's Hb/MCV was found to be 11.8/74.5 when they arrived at the emergency department, and their ESR (23) and CRP (0.6) readings were found to be normal. CT of the head was likewise negative. After therapy with prednisone 60 mg, Reglan 10 IVPB, 10 Tylenol 1000mg IV, and Toradol 15mg, KP continued to express left side head and face discomfort, worst on palpation. Given the risk factors and presenting symptoms, KP was admitted to the inpatient for additional testing and monitoring of her symptoms for GCA. Need explaination with the assessment plan
