Case 9
CASE 9: DESCRIPTION
A 52-year-old left-handed male presents to urgent care for 8 days of head pain. The pain occurs primarily in the evening when he is having a beer and tends to last on average for around 30 minutes. Some days it happens multiple times. He describes the pain as “like being stabbed in and around my left eye repeatedly” and he tends to pace around the room. He is currently experiencing an attack. He feels like his eyelid is swollen and sometimes droopy but denies nausea, vomiting, or sensitivity to light or sound. Denies any warning signs. It is not triggered by wind, touch, eating.
PMH: One prior similar episode about one year ago, lasting 2 weeks around Wintertime.
SHx: Tobacco dependence. Symptoms worse with EtOH. Identifies as Filipino.
Vitals: T 37.2, BP 140/85, HR 100 and regular, RR 12, O2 sat 99% RA.
General Exam: mildly agitated, appears stated age
HEENT: Unilateral scleral injection and lacrimation of left eye, pain is unaffected by facial palpation
Neurologic Exam:
Mental status: Alert, answers questions appropriately with fluent language. Distracted by head pain, stands up and paces back and forth while giving history.
CN: Anisocoria noted with miotic left pupil, mild ptosis on left, left eyelid swelling, there is no proptosis, no scalp bruit, denies diplopia but reports pain with EOM, EOMI, face is otherwise symmetric in strength and sensation
Motor: normal bulk and tone. Full strength throughout extremities.
Sensory: Intact to light touch throughout extremities
Reflexes: 2+ and symmetric in limbs, toes down
Coordination: Finger-to-nose testing without dysmetria