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December 6, 1943 At: Saint Louis University Baguio City School of Medicine
December 6, 1943 At: Saint Louis University Baguio City School of Medicine
December 6, 1943 At: Saint Louis University Baguio City School of Medicine
BAGUIO CITY
SCHOOL OF MEDICINE
GENERAL DATA:
N.M., a 19-year old, male, 4th year Architecture student, Filipino, Born again Christian, born on
December 6, 1943 at Agoo, La Union, presently residing in Green valley, Baguio City. On second consultation
in this institution. Informant is the patient with 95 % reliability.
Three days PTC, the patient started to experienced unilateral jaw pain upon walking up. The pain was
described as stretching, non-radiating, graded as 4-5/10, lasting for a second and was precipitated by
chewing foods. There is no previous history of trauma. No associated fever, colds, headache and dizziness.
Two days PTC, the pain persist every time the patient will open his mouth and move jaw side by side.
Patient was awaken at night due to sudden manifestation of pain and with sensation of involuntary grinding of
the teeth and clenching of the jaw.
One day PTC, the jaw pain become bilateral. No medications were taken.
Family History:
Patient has family history of DM on maternal side. No history of HTN, cancer and asthma. Patient’s
father is a 48 y/o glass decorator in Saudi and mother is a 52 y/o housewife. He has a 17 y/0 sister. All are well
and doesn’t have known diagnosed disease.
GENERAL: (-) weakness, (-) weight loss, (-) dizziness, (-)fever, (-)headache
INTEGUMENTARY: (-) pallor, (-) dryness, (-) rashes/lesions
HEAD & NECK: (-) trauma, (-) stiffness
EYES: (-) tearing, (-) itching, (-) redness, (-)blurring of vision
EARS: (-) discharges, (-) pain, (-) vertigo
NOSE: (-) colds, (-) congestion, (-) sneezing
MOUTH & (-) hoarseness, (-) dryness, (-) difficulty swallowing
THROAT:
RESPIRATORY: (-) cough, (-) dyspnea
CARDIOVASCULAR: (-) easy fatiguability, (-) chest pain, (-) edema, (-)orthopnea, (-) palpitations
GASTROINTESTINAL: (-) diarrhea, (-) vomiting, (-) constipation, (-)abdominal pain
GENITOURINARY: (-) hematuria, (-) frequency, (-)dysuria
MUSCULOSKELETAL: (-) muscle pain, (-) joint, (-) weakness
Endocrine (-) polyphagia, (-) polyuria, (-) polydipsia, (-) heat and cold intolerance,
Nervous (-) convulsions, (-) tremors, (-) fainting
PHYSICAL EXAMINATION
SAINT LOUIS UNIVERSITY
BAGUIO CITY
SCHOOL OF MEDICINE
General: Conscious, coherent, ambulatory, oriented to time, place and person, not in cardiopulmonary
distress
Vital Signs:
• Temperature: 37 0C • Weight: 57.5
• RR: 12 cpm • Height: 5’6
• CR: 80 bpm • BMI: 20.46 kg/m2 (normal)
• BP: 120/80 mmHg
Skin: brown skin color, acyanotic, warm to touch with good skin turgor, no rashes/lesions
Chest and Lungs: symmetrical chest wall expansion, no retractions, resonant, vesicular breath sounds, no
crackles or wheezes
Heart: Adynamic precordium, PMI at the 5th LICS, MCL, heart with regular rhythm, S1 louder at the apex, S2
louder at the base, no S3 or S4, no murmurs, no heaves or thrills
Extremities: no gross deformities, no joint swelling, no bipedal edema, right shoulder tenderness, ++ dorsalis
pedis pulses bilaterally
NEUROLOGIC EXAM:
PROBLEM LIST:
#1: Jaw pain
SUBJECTIVE OBJECTIVE
ASSESSMENT:
Differentials:
Myofascial pain syndrome - (previously known as myofascial pain and dysfunction syndrome [MFPDS])
can occur in patients with a normal temporomandibular joint. It is caused by tension, fatigue, or
spasm in the masticatory muscles (medial or internal and lateral or external pterygoids, temporalis,
and masseter). Symptoms include bruxism, pain and tenderness in and around the masticatory
apparatus or referred to other locations in the head and neck, and, often, abnormalities of jaw
mobility. Diagnosis is based on history and physical examination. Conservative treatment, including
analgesics, muscle relaxation, habit modification, and bite splinting, usually is effective.
Bruxism
Impacted wisdom tooth – jaw pain, difficulty opening mouth
Red or swollen gums
Tender or bleeding gums
Jaw pain
Swelling around the jaw
Bad breath
An unpleasant taste in your mouth
Difficulty opening your mouth
PLAN:
Diagnostics:
Dental X-ray To reveal the presence of impacted teeth, as well as signs of damage to teeth or bone.
Treatment
General measures
Bed rest
Avoidance of aggravating factors at work or with recreational activities
Specific
Eperisone (Myonal) 50 mg 1 tab three times a day
Celecoxib 200 mg once a day for the pain as needed
Acupuncture and manual therapy may help reduce pain early after injury or presentation
Proprioceptive neuromuscular facilitation or muscle energy techniques may be employed in a
structured program with physical therapy or in a home program with the goal to improve motion.
Patient education
Take drug with food or meals if GI upset occurs
Rest the restraint muscle.
SAINT LOUIS UNIVERSITY
BAGUIO CITY
SCHOOL OF MEDICINE