Hazeem Jabbal is a 47-year-old construction worker who comes to his family medicine doctor complaining of hoarse voice and trouble eating. 5 days ago, while working to move bags of cement from the floor to above his head, he suddenly had pain in his left jaw and teeth that spread to his left ear. A few minutes later, he also felt dizzy and unsteady and his vision was suddenly blurry in both eyes. He had to sit down and call his wife to come get him because he wasn’t sure if he could drive. She arrived 20 minutes later, and he wasn’t dizzy any more but was still in a lot of pain so they drove both cars home. He took some ibuprofen and a migraine medicine of his wife’s, and the pain in his jaw and ear resolved over the next hour or so.
He then awoke from sleep at 3 am with a headache in the back of his neck on the right and on the right side of his head that was pretty bad and took some more ibuprofen as well as icing up his neck muscles. He stayed home from work in the morning and the headache resolved, so he went back to work in the afternoon. That night his wife noticed his voice was hoarse, he felt like his tongue was swollen, and he choked several times while trying to eat dinner with his family. He thought he was maybe having an allergic reaction to something, but he hasn’t gotten better with ibuprofen and diphenhydramine over the last few days and his wife was worried, so she made him come to the doctor.
He takes HCTZ and lisinopril for hypertension and takes atorvastatin for cholesterol.
He completed high school in Iran and started working full-time to support his mother and 3 sisters upon seeking asylum to the US in the 1990’s with a humanitarian refugee program that allowed his family to obtain green cards and then full citizenship. He wants to go to college but thinks that won’t be possible for him, as he has 3 kids to put through college first. He smokes a pack a day and has since he was 13. He has been married for 20 years and has 3 children He works as a foreman in his construction job for a large construction firm that is currently renovating the medical school and also takes on side work and home renovations through his networking with the Iranian community locally. He pays for his own health insurance and the health insurance for his family and is able to buy at a reduced group rate through his company. He lives in the East End of Louisville and they own their own home. He is an observant Muslim, attends mosque, prays (at home only since 9/11 when praying at set times in the workplace became dangerous), and does not eat pork or shellfish.
His father was killed as a political prisoner in Iran in the 1990’s. His mother and sisters are all well and have no chronic medical problems.
Vitals: T 98.1 F, HR 79, BP 158/98, RR 12, SpO2 99% on room air. BMI 30.
Gen: well nourished, muscular build
HEENT: Eyes as shown below, both constrict with direct and indirect light. Left side of face more ruddy than right. Both pupils are round. Fundus normal with sharp optic disks. Gag reflex decreased on left, uvula pulls to the right when saying “aaaaah.” Tongue deviates to left, left side of tongue is swollen. Left neck is tender to palpation. No carotid bruit.
CV: regular rate and rhythm, no murmurs. Pulses are 2+ and equal in both upper extremities.
Pulm: clear to auscultation in all lung fields.
Abd: Soft, nontender, no organomegaly, normal bowel sounds
LN: no enlarged nodes in the cervical, axillary, or inguinal regions
Skin: no bruising or erythema, no skin breakdown
Neurologic: Sensation (fine touch, pain, temperature, proprioception) preserved over all areas of face and body. Muscle weakness seen in turning the head to the left compared to right and in shrugging the shoulders on the left compared to right.
The family medicine physician sends Mr. Jabbal to the ER and calls ahead to explain his concern for this patient. The ER physician sees him and orders a CT head without contrast, which is normal. A CT angiogram is then ordered, with the abnormalities seen below as denoted with the arrow by the radiologist.
Mr. Jabbal is then seen in the ER by a neurologist, who consults an interventional radiologist to discuss options in his care. They talk in Mr. Jabbal’s ER room for about 30 minutes, but he is unable to tell them after the discussion if he wants to have a procedure or just take medicine to fix the problem and says he needs to talk to his family, who is not there. He then calls his wife from the ER and asks her to come listen to the physicians and make sure he is asking the necessary questions. All he really understood from the discussion the two doctors had in front of him is that he needs to take blood thinners for sure, probably for life, and won’t be able to work construction for a while, possibly ever. He also tells his wife that he is getting admitted to the hospital for that night and is expected to stay a few nights.