The most popular differential diagnosis to our mystery case was temporal arteritis. Dr. Steinbach of Pittsburgh wrote: "Read your article in Dynamic Chiropractic. Thoughts: Age not stated, would assume to be 42 to 50; while incidence at that age level is low, under the "look out" factor mentioned I would consider temporal arteritis as a possible etiology and would consider an arteriogram/ophthalmic exam/arterial biopsy if indicated. Interesting!"
So, let's wrap this up by first including the questions we developed after taking the history and then present the relevant findings of the physical exam.
Contemplations Following the History
Is the temple pain the cause of her post-nasal drip? What is the cause of the temple pain? Is there anything in the history that stands out and says "Look out!"? In other words, is it safe to assume her vital signs will be normal? Why?
The patient is a well-developed and well-nourished Afro-American female in apparent mild emotional distress. Blood pressure, left arm sitting, 156-93 mmHg; right arm sitting, 141/80 mmHg. Pulse, 130 per minute and regular. Temperature, 99.5oF (oral).
Here we discover that her vital signs are abnormal. Our suspicions that her vital signs may not be normal were confirmed ... volatile emotions combined with head complaints create suspicion for metabolic or CNS problems.
Mental Status
Cooperative, oriented, alert, and attentive. Responded with clarity to questions.
Head
Physical examination of the head revealed the patient to be normocephalic. Inspection of the temple area did not reveal any lesions or scarring. There were no other palpable or visible abnormalities.
Eyes
The pupils were equal, round and reactive to light and accommodation. The sclera and conjuctiva were clear.
Neck
No obvious thyromegaly is noted. There does appear to be some minor nodular changes, however this may be a normal variation. There is no lymphadenopathy or other signs of swelling or temperature change.
Hands
No joint swelling, deformity, or nail pitting noted.
Oral Cavity
The examination of the oral cavity is otherwise unremarkable. The uvual elevated symmetrically at elicitation of the gag reflex. The tongue reacted normally to sensation and motor function. No signs of tongue hypertrophy are present.
Respiratory Pattern
Examination revealed normal breathing using the nasal airway.
Muscle Palpation -- Head
Palpation of the extraoral structures reveals a Grade I response in the right anterior temporalis. The anterior temporalis palpates as well defined and focal trigger zone.
Muscle Palpation -- Neck
Palpation of the structures in the neck area did not reproduce any of the face, ear or jaw complaints.
Temporomandibular Joints
No joint sounds nor evidence of dysfunction is detected on the right or left joints during auscultation or palpation. No sounds are detected as the mandible approached full opening. No joint pain is detected during palpation on the left or right joint from either the lateral or posterior approach. Distraction or compression of the joint does not produce pain.
Differential Diagnoses
The historical and clinical examination information indicates that Ms. Arial may be experiencing a number of disorders which will require further investigation.
Due to the discovery of potentially ominous clinical findings (tachycardia, elevated blood pressure, elevated temperature) further investigation (MRI) into Ms. Arial's head pain complaints was warranted.
Is the temple pain the cause of her post-nasal drip? No. Ms. Arial's "post-nasal drip" was due to chronic low grade cerebrospinal fluid rhinorrhea. Secondary to this leak of CSF at the cribbiform plate, Ms. Arial developed chronic low-grade encephalitis. Ms. Arial's abnormal vital signs are consistent with these conditions.
What is the cause of the temple pain? Despite Ms. Arial's insistence that the temple pain is linked to her nasal drip it turns out that they are, in fact, unrelated. The pertinent historical findings leading to the diagnosis: right temple burning or stinging pain which, according to the patient, finally produced a scalp lesion in the same area where she now complains of focal temple pain. She reports that this scalp lesion persisted for a short period of time and this lesion healed but the pain persisted. These findings, plus the physical examination findings, are consistent with post-herpetic neuralgia affecting the site of a prior herpes lesion.
Darryl Curl, D.D.S., D.C.
Norco, California
Editor's Note:
Dr. Darryl Curl will be teaching a Temporomandibular Joint Systems seminar November 14-15 in Chicago, Illinois. You may register for the seminar by dialing 1-800-359-2289.
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