Chief Concern: Hoarse voice and trouble eating.
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 at 3 am with a severe left-sided headache, as well as pain in the back of his neck.
The following day he was still having symptoms so he stayed home from work. His headache gradually faded over that day.
That evening at dinner his wife noticed that his voice was hoarse. He felt like his tongue was swollen. He remembers choking several times while trying to eat dinner with his family.
He has resumed working for the past couple days. His wife was concerned that his symptoms are persisting and insisted that he come to the doctor.
PMHx: Otherwise healthy
His father suffered a stroke in Iran 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.
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?”
Gen: Well nourished, muscular build
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 more ruddy 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
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 down 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.