Level 3: Headache – Contrasting Case #3: Patient Information

Given these changes from the original case, what is your diagnosis?

What is your diagnostic explanation?

As compared to the long case, this patient is a 35 year old male who presents to his primary care doctor with reports of a headache for one month.

HPI: The patient describes his headache as a dull ache and it usually feels like a tight band has been placed around his head. He denies any specific timing to his headaches, except he does notice that they occur more frequently when he is stressed at work. He denies any photophobia or phonophobia with his headaches. He denies any throbbing or sharp, stabbing pain. He reports rest and relaxation as a relieving factor. He denies any muscle weakness or paresthesias. He denies any dizziness or lightheadedness. He also denies any nausea, vomiting, fever, chills, or recent illness. He denies any changes in bowel or bladder habits.

PMH: Illnesses – Hyperlipidemia; Medications – Simvastatin 40mg qd

FMH: Mother, age 56, has HTN, HLD, and DM. Father, age 60, has HTN and DM. Brother, age 37, has HTN and HLD. Sister, age 32, has HTN.

SH: Alcohol – 2-3 beers per night

ROS: Noncontributory

General: Male patient appearance consistent with age. Patient is cooperative and in no acute distress.
Vital Signs: BP:145/95, P:70, RR:18, BMI:33, T:100.9
Fundoscopic: Optic disc visual bilaterally. No papilledema present. No signs of A/V nicking present.
Neck: Non-tender to palpation. No lymphadenopathy. Full ROM.
Respiratory: Normal respirations present, no accessory muscle use. Normal, vesicular breath sounds present bilaterally. No wheezes, rales, or rhonchi.
Neurologic: Cranial nerves II – XII grossly intact bilaterally. Muscle strength 5/5 on the upper and lower extremities bilaterally. DTRs are 2/4 on the upper and lower extremities bilaterally. Proprioception is intact bilaterally. Coordination testing is considered normal with no dysmetria upon performing the finger-to-nose and heel-to-shin tests.

Special Instructions:
– Repeat BP at follow up visit: 148/95
– Renin:Aldosterone ratio: normal