Course Projects:

PATIENT PRESENTATION For Class  02/25

Ruth Geide

Patient Description:  40 year old white female

Chief Complaint/ History of Chief Complaint:  Reports new onset of headaches that started two week ago. She describes the pain as starting in her posterior neck, radiating up to the left side of her head, and then radiating down to the left shoulder.  She rates the pain as 6/10.  She has been to a chiropractor for adjustments and therapeutic massages that have provided mild and temporary relief.  She was prescribed Fiorcet daily and reports, “it does nothing for me anymore”.

Review of Systems:

• Neurological:  Denies any visual deficits, tinnitus, parasthesias, or weakness to extremities. Denies any previous trauma or injury to head or neck.
• Musculoskeletal:  Reports mild episodic left -sided mid-back pain/stiffness that increases with movement and with standing or sitting for prolonged periods of time. Does not feel this is relevant to her current condition as “I’ve been like that for years.” Denies any previous trauma or injury to spine or shoulder.

PMH, Social & Family History:  

Current medication: Atenolol, HCTZ, & Lisinopril for HTN; Estrogens conjugated for menopausal symptoms; Omeprazole for GERD; Trazodone HCL for depression; Ocuvite Preser-Vision daily for vitamin supplement.

She is a retired army nurse, mother of two adult children, grandmother of four grandchildren.  She is divorced and lives with an elderly mother.  She currently teaches kindergarten for physically disabled children in a public school.

Physical Exam:

• V/S:  98.3 – 60 – 18- 136/90 
• Neurological:  All cranial nerves grossly intact.   
• Musculoskeletal: Elicited pain when abducting left shoulder to 90°. Full ROM to all extremities without report of pain.  Noted stiffness to lower extremities when rising after being seated during interview. Noted mild spinal misalignment to mid-back.  Hips and knees look to be parallel with each other. 

 

Labs & Test Results: 

Stat X-ray C-spine showed mild C3 & C4 compression and obvious spinal curvature.  Chest x-ray: negative.  Cardiac enzymes (-).

Diagnostic Differentials:

1) Metastatic disease from brain, breast, or lung.

2) Injury to cervical and thoracic spine due to lifting and underlying scoliosis.

3) Degenerative disc disease to cervical spine.




Final Diagnosis:  Headaches due to cervical degenerative disc disease.

 

Plan of Care:

• CT of head to r/o other pathological reasons for headaches.
• CT of spine to assess DDD and to grade scoliosis.
• Reviewed current mammogram with patient and found diagnosis of benign fibrotic cysts.
• Mobic 7.5 mg PO Daily for skeletal pain.
• Moist heating pad daily for muscle pain.
• Encouraged rest and stretching exercises daily.
• Recommended patient sleep on side or back for proper alignment of spine.
• Patient teaching on proper lifting techniques.

 




PATIENT PRESENTATION For Class  04/01

Ruth Geide

Patient Description:  60 year old white male

Chief Complaint/ History of Chief Complaint: Reports new onset of numbness in the fingers of both hands. This numbness causes him to have difficulty holding utensils. The symptoms started about a week ago. He stretches, exercises and applies a “deep heating rub” to his hands and fingers, but the numbness has not worsened or resolved.  He denies pain.  

Review of Systems:

• Neurological: Denies any visual deficits, tinnitus, speech difficulties, or headaches. Denies any recent trauma or injury to head or neck. Reports paresthesia as described above. Reports occasional flush after taking Niacin. 
• Musculoskeletal: Denies any recent trauma or injury to neck, arms, or hands. Denies any recent strains from lifting or moving heavy objects. 

PMH, Social & Family History:

• PMH: Hypothyroidism, Hyperlipidemia, Cervical Radiculopathy.
• PSH: Anterior discectomies with disc fusion at the C4-6 levels and insertion of metallic fixation device.
• SH/FH: Married, retired school teacher. Denies tobacco, alcohol or illegal drug use.
• Medication: Synthroid for hypothyroidism, Zocor & Niacin for hyperlipidemia, NKA.

Physical Exam: 

• V/S: 98°F- 82- 14; 114/72; Ht: 68 inches; Wt: 200 lbs
• HEENT:  Eyes clear, red reflex noted. TMs gray & shiney. Anterior nose clear. Oral cavity and pharynx unremarkable. No lymphadenopathy noted, thyroid palpable. Neck supple, trachea midline, no JVD noted.
• Neurological: All cranial nerves grossly intact. Denies pain.
• Musculoskeletal: Neck without full ROM due to fixation device in cervical spine. Full ROM to all extremities. Equal and bilateral strength against resistance to shoulders and arms. Noted equal weakness of hands and fingers during grasp of examiner hands.  Equal and bilateral strength to all lower extremities against resistance.
• Vascular:  No carotid bruits noted. Palpable pulses 2+ to all extremities. All extremities warm, dry and of flesh tone.

Labs & Test Results:

• Labs:  CBC WNL; CMP WNL; LFTs WNL; B-12/Folate levels WNL; TSH, T3, T4 levels WNL 

• MRI, C-spine w/wo contrast: Degenerative stenosis at C3-C7 levels.  No other abnormalities seen to the cervical spinal cord. Incidental finding: 1.8 cm nodule seen in right lobe of thyroid. Unable to differentiate benign vs. malignancy nodules. 

Diagnostic Differentials:

1)      Metastatic disease from brain, lung, or prostate.

2)      CVA due to history of hyperlipidemia.

3)      Degenerative changes to cervical spine.

Final Diagnosis:  Paresthesis due to degenerative disc disease.

Plan of Care:

• Continue Synthroid & Niacin at current dosages due to normal labs. Add ASA to be taken with Niacin to relieve flushing.
• Reviewed findings of MRI with patient. Agreed to further testing and to an otolaryngology consultation.
• Ordered thyroid scan and ultra-sound of thyroid. Send results to otolaryngology.
• Otolaryngology consult for possible fine needle biopsy and recommendations for surgery if indicated.
• Recommended NSAIDs for anti-inflammatory effect on degenerative changes to cervical spine.
• Physical therapy consult for recommendations on relieving paresthesia.
• F/U: 3-4 weeks to review effectiveness of NSAIDs and to review Otolaryngologist’s recommendations.