Identifying Data:

Name: Mrs. M

Sex: Female

Address: Hicksville, New York

Date of Birth: 52 Years Old

Date & Time: 2/22/21, 6:00 PM

Location: Statcare Urgent Care, Hicksville, NY

Marital Status: Married

Race: Indian

Religion: Muslim

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

Mode of Transport: Car

Chief Complaint: “I have a left-sided migraine and left ear pain” x 3 weeks

History of Present Illness:

52 year old married female with significant medical history of emphysema and Migraines presents to Statcare Urgent Care in Hicksville complaining of a left-sided migraine and ear pain for the past 3 weeks. She states that at that point, she suddenly began feeling a popping sensation in her ears a few times an hour, which causes a sharp ear pain that radiates up the left side of her face and down to her left jaw. It also caused migraine symptoms, which include left-sided severe headache, photophobia, and blurry vision. She states that she does not feel the pain regularly, but it only comes on when she feels the ear popping, at which point the pain is 9/10. She states that her face feels heavy on the left side, she feels a lot of pressure, and she “feels like there is something in my ear.” She states nothing makes the pain better, and bending down makes it worse. She admits to seeing her neurologist 3 weeks ago when the pain began, who prescribed her migraine medication which helped with the migraine, and ondansetron which helped with the nausea. She also admits to taking motrin which is not helping. She states that she has never felt this sensation before. She admits to dizziness, especially when she shakes her head or gets up from sitting, as well as lightheadedness, tinnitus, vertigo, fatigue, and ear itchiness. She denies fever, vomiting, body aches, trouble hearing, cough, nasal/facial congestion, or sore throat.  

Past Medical History:

Present medical illnesses – Emphysema, Migraines

Past Illnesses- none

Childhood illnesses – none

Immunizations – Up to date

Screening Tests- none

Blood Transfusions- none

Past Surgical History:

C-Section-04/1996, no complications

C-Section-06/2000, no complications

Medications:

Migraine Medication PRN, name unknown, PO, last dose yesterday

Albuterol Inhaler, 150 mcg, 1ce a day, last dose yesterday

Ondansetron 4 mg PRN, PO, last dose yesterday

Allergies:

Penicillin, gets a rash

Family History:

Mother – 90, Alive and Well

Father – Deceased at age 97 from Lung Cancer

Daughter- 24, Alive and Well

Son- 20, Alive and Well

Maternal/paternal grandparents – Deceased at unknown age and unknown reasons

Social History:

Mrs. L is a married woman who lives at home with her husband and children. She recently quit her job as an assistant teacher, due to concerns about catching COVID.  

Habits- Patient drinks 3 cups of coffee and 8 cups of tea a day. She smokes 30 pk/yr. Denies past and present use of alcohol, e-cigarettes, illicit drug use, and history of substance abuse.

Travel- Denies any recent travel.

Safety- Admits to wearing seat belt.

Sleep – Admits to not sleeping well, usually less than 6 hours a night

Exercise – States that she exercises while doing housework

Diet- States that she does not eat much, as she never has an appetite.

Sexual History: Heterosexual, monogamous. Currently sexually active. Admits to using contraception. Denies history of sexually transmitted infections.

Review of Systems:

General –Admits to nausea, fatigue, loss of appetite, generalized weakness, and diaphoresis. Denies recent weight loss or gain, fever, chills, or night sweats.

Skin, hair, nails –Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Admits to headache, dizziness, and vertigo. Denies head trauma, unconsciousness, head fracture or coma.

Eyes –Admits to use of glasses, photophobia, and visual disturbances. Denies use of contacts, fatigue, lacrimation, and pruritus. Last eye exam one week ago.

Ears –Admits to ear pain and tinnitus. Denies deafness, discharge, or use of hearing aids.

Nose/sinuses – Denies discharge, obstruction or epistaxis.

Mouth/throat –Denies dentures, bleeding gums, sore throat, sore tongue, mouth ulcers, voice changes.

Neck – Denies localized swelling/lumps or stiffness/decreased range of motion

Breast- Denies lumps, nipple discharge, and pain.

Pulmonary system – Admits to dyspnea on exertion. Denies SOB, cough, wheezing, orthopnea, paroxysmal nocturnal dyspnea, cyanosis or hemoptysis.

Cardiovascular system –Denies hypertension, palpitations, chest pain, edema/ swelling of the ankles/feet, irregular heartbeat, syncope or known heart murmur.

Gastrointestinal system –Admits to constipation. Denies intolerance to foods, abdominal pain, diarrhea, nausea and vomiting, dysphagia, pyrosis, flatulence, eructation, jaundice, hemorrhoids, rectal bleeding, or blood in stool.

Genitourinary system –Denies urinary frequency, urgency, polyuria oliguria, nocturia, incontinence, dysuria, hesitancy, dribbling, or flank pain.

Musculoskeletal system – Denies muscle/joint pain, deformity or swelling, redness or arthritis.

Nervous System– Admits to sensory disturbances such as numbness and parasthesias on left side of her face. Denies seizures, loss of consciousness, ataxia, loss of strength, change in cognition / mental status / memory, or asymmetric weakness.

Peripheral vascular system –  Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema or color changes.

Hematological system –Denies anemia, easy bruising or bleeding, lymph node enlargement, or history of DVT/PE.

Endocrine system –Denies polyuria, polyphagia, polydipsia, heat or cold intolerance, excessive sweating, hirsutism, or goiter.

Psychiatric –Admits to increased stress and anxiety due to COVID. Denies depression/sadness, OCD or ever seeing a mental health professional.

Physical Exam

General: 53 year old female, alert and oriented to person, place and time. Patient has good posture, is well dressed, well groomed, and has good hygiene. Patient appears in no apparent distress.

Vital Signs:      BP: 109/69

R: 16 breaths/minute, unlabored

P: 98 beats/ minute, regular 

T: 98.4, oral                

O2 Sat: 97% on room air

Height: 5’3”    Weight: 121 pounds     BMI: 21.43

Skin- Warm and moist, smooth, good turgor, nonicteric, no lesions, masses, scars, tattoos, thicknesses or opacities.

Head- Tender to palpation over left side.Atraumatic, normocephalic. No deformities or specific faces noted.

Eyes-Symmetrical OU. Eyebrows and eyelashes even distribution, eyelids have no discharge or swelling, lacrimal glands have no excessive tearing, dryness, enlargement or erythema, lacrimal sac not inflamed or swollen. No evidence strabismus, exophthalmos or ptosis. Sclera white, conjunctiva and cornea clear. 

Visual acuity corrected – 20/25 OS, 20/20 OD, 20/20 OU

Ears- Symmetrical and normal size. No lesions, masses or trauma on external ears. No discharge/foreign bodies in external auditory canals AU. Tympanic membrane pearly white/intact with cone of light in normal position AU. Auditory acuity intact to whispered voice AU

Nose-Symmetrical, no masses lesions or deformities, trauma or discharge. Nares patent bilaterally, nasal mucosa pink & well hydrated.

Sinuses- Non-tender to palpation and percussion over bilateral frontal and maxillary sinuses. 

Mouth

Lips – Pink, moist; no cyanosis or lesions.

Mucosa – Pink; well hydrated. No masses; lesions noted. No leukoplakia.

Palate – Pink, well hydrated. Palate intact with no lesions; masses; scars.

Teeth – Good dentition and no obvious dental caries noted.

Gingivae – Pink; moist. No hyperplasia; masses; lesions; erythema or discharge.

Tongue – Pink; well papillated; no masses, lesions or deviation noted. Non-tender to palpation.

Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies. Tonsils present with no injection or exudate. Uvula pink, no edema, lesions.  

Heart-Sinus tachycardia, normal rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

Lungs – Clear to auscultation and percussion bilaterally. Chest expansion and diaphragmatic excursion symmetrical. Tactile fremitus intact throughout. No adventitious sounds. 

Abdomen-Abdomen flat and symmetric, and 2 scars from previous C-sections. No pulsations noted. Bowel sounds hyperactive in all four quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation throughout the right and left lower quadrants, tympanic throughout, no guarding or rebound noted. No hepatosplenomegaly to palpation, no CVA tenderness appreciated. 

Motor/Cerebellar- Romberg positive, pronator drift noted. Gait unsteady with ataxia. Tandem walking and hopping show balance not intact. Full active/passive ROM of all extremities without rigidity or spasticity. Symmetric muscle bulk with good tone. No atrophy, tics, tremors or fasciculation. Strength 5/5 throughout. Coordination by rapid alternating movement and point to point intact bilaterally, no asterixis

Sensory-Intact to light touch, sharp/dull, and vibratory sense throughout.   Proprioception, point localization, extinction, stereognosis, and graphesthesia intact bilaterally

Musculoskeletal- Tender over Temporomandibular joint

Assessment:

Mrs. M is a 53 year old female presenting with left-sided migraine headache and ear pain for the past 3 weeks. She complains of a popping sensation in her ear which causes severe radiating pain throughout that entire side of her face.

Plan:

1. Migraine, Ear Popping/Pain-continue taking migraine medication PRN, refer to neurologist for further workup
2. Nausea-continue taking ondansetron PRN
3. Dizziness, Vertigo, Imbalance- try Epley maneuver, refer to neurologist/audiologist for further testing to determine cause
4. Fatigue, Tiredness- Educate patient on decreasing caffeine intake, especially close to bedtime.
5. Dyspnea on Exertion, Emphysema-consider increasing or changing medication, refer to pulmonologist
6. Tenderness over Temporomandibular joint- educate patient on not chewing gum and not taking large bites, as well as stress management, and taking NSAID’s if the pain gets very bad.
7. Smoker- Educate patient on harms of smoking and offer helpful alternatives/ support to help with quitting

Differential Diagnoses:

1. Migraine- admits to severe one sided headache, as well as ear pain/popping, photophobia, changes in vision, dizziness, lightheadedness, fatigue, scalp tenderness, and nausea. She also has a history of migraines.
2. Eustachian Tube Dysfunction- admits to ear pain, fullness, tinnitus, and popping sounds.
3. Temperomandibular Joint Dysfunction-admits to headache and tenderness over TMJ. However, denies difficulty chewing, mouth or tooth pain, or joint locking.
4. Meniere’s Disease- admits to dizziness, vertigo, tinnitus, ear fullness, and nausea. However, denies hearing loss.
5. BPPV- admits to dizziness, lightheadedness, vertigo, especially when moving head in specific directions, and nausea.
6. Labyrinthitis/Vestibural Neuronitis- admits to dizziness, unsteadiness, vertigo, nausea, and tinnitus. However, denies hearing loss.
7. Vestibular Schwanomma- admits to tinnitus, dizziness, unsteadiness, and numbness and pasrasthesias over face and head. However, denies hearing loss