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Kornhauser Health Sciences Library

Hazeem Jabbal: The Case

 

The Case

 

Setting: Outpatient family medicine practice

Chief Concern: Hoarse voice and trouble eating.

HPI:

Hazeem Jabbal is a 47-year-old construction worker who presents complaining of hoarse voice and trouble eating.

He reports that his symptoms began suddenly 5 days ago while at work. He remembers moving bags of cement from the floor to a shelf above his head when he had experienced sudden and severe pain in his left jaw that went into his teeth. The pain then spread to his left ear and head. He felt dizzy and unsteady. His vision was also blurry.

He sat down and called his wife to come get him because he wasn’t sure if he could drive home. His wife arrived 20 minutes later. By then he wasn’t dizzy anymore but the left jaw pain and headache persisted.

Later that night, he awoke from sleep with a severe left-sided headache, as well as pain in the back of his neck. He took acetaminophen and was able to get back to sleep but symptoms persisted so he stayed home from work the following day. His headache gradually faded. That evening at dinner his wife noticed that his voice was hoarse.  He felt like his tongue was swollen.  He remembers having difficulty swallowing several times while trying to eat dinner with his family.

He was able to return to work but his wife was concerned that his symptoms were persisting so insisted that he come to the doctor.

Past Medical History: Otherwise healthy

Medications: None

Family Medical History:

His father suffered a stroke that caused right hemiplegia affecting his face and arm and made him have difficulty speaking.

His mother and sisters are all well and have no chronic medical problems.

His children are healthy.

Social History:

He has been married to his wife for 20 years and they have 3 teenage daughters.  He works as a construction foreman. No smoking or alcohol use.  He is the sole provider for his family.  He has health insurance through his work.

He fearfully asks “Doctor, do you feel like I could be having a stroke like my father?”

PE:

Test

Result

T

98.1

HR

79

BP

158/98

RR

12

SpO2

99%

BMI

24

Gen: Well nourished, muscular build

HEENT:

Eyes as shown below.  Pupils constrict with both direct and indirect light but the left appears smaller than the right. Fundi are normal with sharp optic disks.  The left side of face appears ruddier than the right and while the right side is perspiring, the left side is not.  Gag reflex is decreased on the left and the uvula pulls to the right when saying “aaaaah.” His tongue deviates to the left when protruded. Left neck is tender to palpation. No carotid bruits.

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, and proprioception) preserved over all areas of face and body. Manual muscle testing demonstrates 4/5 strength with head rotation to the left and shoulder shrug on the left side.  All other movements 5/5.  Balance and coordination are largely intact. Hearing is normal to finger rub bilaterally.

The family medicine physician explains to Mr. Jabbal that she feels he needs to be seen in the ER for more testing.  She calls the ER to communicate with the attending about her concerns for Mr. Jabbal.

Mr. Jabbal is seen in the ER, where his exam is unchanged.  The ER physician wants to rule out a stroke and orders a STAT CT head without contrast, which is seen below and interpreted as normal:

A CT angiogram is then ordered and is below.  The radiologist marks the abnormalities with arrows. 

 

Mr. Jabbal is admitted to the hospital and the neurology and interventional radiology teams were consulted to discuss treatment options. After consideration of each, Mr. Jabbal and his wife opted for conservative medical management with aspirin.

The speech-language pathologist was consulted and recommended using a chin tuck and head rotation to help combat dysphagia. After a couple days in the hospital, he is discharged home with instructions to follow up with his primary care physician and neurologist as an outpatient.

 

 

A week later, Mr. Jabbal is seen by his family medicine physician in follow up for his recent symptoms and hospitalization.  He feels like he has only improved minimally since his symptoms began about 10 days ago. 

He has several questions for his physician including how long he should expect symptoms to persist, what measures can be taken to prevent recurrent dissection and what physical restrictions are necessary as he is afraid to perform strenuous activity but needs to return to work to support his family.

 

 

Since his injury began on the job, he also asks the primary care physician if she would fill out his worker’s compensation paperwork so that he can file a claim with his employer. 

Clinical Librarian

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Ansley Stuart
Contact:
Health Science Campus
Kornhauser Library, Rm 204
502-852-8534

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