Immune System


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M44_F1.jpg"}},{"insert":"\n\n"},{"insert":"\u0022... why would you do that?! Did you really think that was the best management? Remind me again why you are still on this case!\u0022\r\n \r\nYou stare blankly at the director\u0027s face and try to defend yourself, but the words don\u0027t seem to form ...\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M44_F2.jpg"}},{"insert":"\n\n"},{"insert":"The thrill of the alarm clock bolts you back to reality and you heave a sigh of relief. \u0022Another bad dream\u0022, you mumble to yourself. \r\n \r\nYou feel a slight bang across your temples which you instinctively massage with little or no relief.\n"}]}


{"ops":[{"insert":"Kicking your feet off the bed, you start off the day with an aspirin pill to ward off the thundering headache from yesterday\u0027s party. Boy, was that a wild night out!\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M44_F4.jpg"}},{"insert":"\n\n"},{"insert":"The hospital is just as you left it: a smooth mix of chaos and order; the latter, only visible to trained eyes, case in point, yours.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M44_F5.jpg"}},{"insert":"\n\n"},{"insert":"You head past the ED to your office and settle behind the desk to offer your own little help in returning order to the rowdy hospital.\r\n \r\nOn cue, the nurse steps in with a couple of folders and hands them over. She calls in the first patient as she steps out.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M44_F6.jpg"}},{"insert":"\n\n"},{"insert":"In comes an elderly female, 64-year-old Martha Walters, as it says on her card.\r\n \r\nShe is a known hypertensive first diagnosed 4 years ago, with good control on 5mg lisinopril and 75mg aspirin daily.\r\n \r\nYou welcome her in, introduce yourself, offer a seat and ask how you may be of help today.\n"}]}


{"ops":[{"insert":"\u0022My head... that\u0027s my problem right now. My head\u0022, she says. You ask her to elaborate further and she begins.\r\n \r\n\u0022The divorce proceedings I believe, are taking a toll on me. I recently moved here about 4 months ago, after deciding to call it quits with my partner\u0022, she starts.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M44_F8.jpg"}},{"insert":"\n\n"},{"insert":"\u0022Well over, let\u0027s call it 2 or 3 months, I\u0027ve been having this nagging headache which doesn\u0027t seem to go. I\u0027ve tried all the common painkillers and I\u0027ve even been given some of the stronger stuff, but it just goes down for a while and the next thing, it\u0027s back again\u0022.\n"}]}


{"ops":[{"insert":"\u0022It\u0027s right here\u0022, she adds, massaging her temples. \u0022Brushing my hair has also become an uphill task because of this headache. It feels painful each time I try, so most times now, I just wear a hat\u0022.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M44_F10.jpg"}},{"insert":"\n\n"},{"insert":"You inquire about the severity of the headaches on a scale of 1 to 10, which she places on 6. She has no knowledge of any aggravating or relieving factors.\r\n \r\n\u0022Oh, before I forget, most times while eating, I have this odd pain in my jaw which chewing, but it tends to disappear after I stop doing so for a while\u0022, she says.\n"}]}


{"ops":[{"insert":"You inquire about disturbances in vision, which she denies. She also replies negatively to any history of weight loss or night sweats.\r\n \r\nOn questioning about early morning stiffness, she says she has not taken note of any. She denies experiencing pain in any of the four limbs.\r\n \r\nShe has a significant 10 pack year history of smoking and drinks occasionally.\n"}]}


{"ops":[{"insert":{"image":"\/storage\/case-images\/cs\/M44_F12.jpg"}},{"insert":"\n\n"},{"insert":"You request to examine Martha, and she gives her consent. Her vital signs are as follows:\r\n \r\nBMI: 28.4 kg\/m2 (height: 1.65 m, weight: 78 kg) \r\nTemperature: 98.8 \u02daF (37.1 \u02daC) \r\nPulse: 92 bpm \r\nBlood pressure: \r\n Left arm: 130\/82 mmHg\r\n Right arm: 126\/76 mmHg\r\nRespiratory rate: 18\/min\n"}]}


{"ops":[{"insert":"General examination reveals mild tenderness over the scalp and temples. The eye examination reveals an unaided visual acuity of 6\/12 m (20\/40 feet).\r\n \r\nVisual field and fundoscopic assessments reveal no abnormalities. Her nervous system exam is unremarkable as well.\n"}]}


{"ops":[{"insert":"During examination of the peripheral pulses, the temporal artery is noted to be tender with reduced pulsation bilaterally.\n"}]}


{"ops":[{"insert":"All other aspects of the systemic examination are essentially normal.\n"}]}


{"ops":[{"insert":"As you return to the desk, you consider the best line of management.\n"}]}