Subjective:

HPI: Patient comes in today complaining of a headache which he states he has had for 22 years.
Recently the pain has started in the back of his throat and moves into his left ear. He states that the
pain is pretty constant but is worse with movement of the jaw such as talking, eating, chewing tough
foods, brushing his teeth, coughing, or yawning. He has been taking ASA for the pain which helps better
than prescription pain relievers but states that he has to take upwards of 20 ASA a day to deal with the
pain. The pain is making it difficult for him to lead a productive life. When the pain is at its worst he
cannot work or carry on daily activities. He states that he has seen numerous physicians for this and has
had surgery to clip the trigeminal nerve due to one physician diagnosing him with trigeminal neuralgia.
He also has had injections along the nerve route to help dull the pain. He has also had numerous x-rays,
nerve studies, labs, gone through acupuncture and hyponosis with minimal to no relief in symptoms.
Past Medical History: Appendectomy at the age of nine. Neurosurgery at trigeminal nerve route for
pain. No other medical history noted.
Social History: Lives with his wife of 14 years. Two living children, boy of 10 and girl of 9. He states that
he has a happy home life. Works as a real estate agent and deals with people all day. The pain is
making his job very difficult.
Allergies: No known drug allergies.
Family History: None.
Current Meds: ASA, up to 20 a day to relieve pain.
ROS:

Constitutional: Denies fever, fatigue, chills, unintentional weight loss/gain.

Eyes: Patient denies any visual changes, eye drainage, redness, or pain.
ENT: Denies any dizziness, ear drainage. Denies any nose bleeds or other nasal discharge.
Denies sore throat, swelling/pain of the tongue, or bleeding of the gums. Complains of headache
for the past 22 years which has worsened recently to include severe pain when chewing food or
otherwise moving his jaw. He states that when the pain is at its worst it moves into his left ear.
He states that the pain is a dull and constant pain that is so severe it affects his daily life.
Respiratory System: Denies any wheezing, cough, shortness of breath, or mucous production.
Cardiovascular: Denies any palpitations, chest pain, swelling of extremities, coldness in
extremities, or exertional dyspnea.
Gastrointestinal system: Denies any pain of the abdomen, nausea, vomiting, change in appetite,
indigestions, constipation, or diarrhea. Denies any blood in his stools.

Genitourinary system: Denies nocturia, urinary frequency/urgency, incontinence, or urinary

retention.
Skin: Denies any rash, dryness, scaling, changes of moles, or easy bruising.
Endocrine: Denies any heat or cold intolerance. Denies any hair changes. Denies any dry skin
or excessive thrist.
Musculoskeletal System: Denies any swelling or stiffness of joints. Denies any difficulty
walking, muscle pain, or cramps. Complains of jaw pain with movement such as eating, talking,
yawning, or coughing.
Neurologic System: Denies any change in mental status, increase forgetfulness, or nervousness.
Pscyh: Denies anxiety or depression.
Hematologic/Lymphatic: He denies any bleeding or easy bruising. He denies any lymph node
swelling or pain.
Allergic/Immunologic: He denies taking allergy shots or cortisone shots. He denies HIV.

Objective:
Physical Exam:
BP: 120/80

P: 74

R: 16

Temp: 98.6

HT: 57 Wt: 142

Physical Examination.
General: Caucasian male who is well developed and well nourished in appearance. No distress
or anxiety noted.
Head: Normocephalic.. Negative TMJ. No lymphadenopathy or sinus tenderness noted.
Tenderness of left tonsillar pillars with decreased sensation to palpation of the posterior 1/3 of
tongue on left. No pain over glossopharyngeal nerve on right. Palpation over the
glossopharyngeal nerve on left produces a sharp pain on left. Mass noted on left border of
tongue just medial to the tonsillar pillars at the junction of the mid and posterior 1/3 of tongue.
Submucosal, rounded, well circumscribed mass noted of 1 - 1.5 cm. No induration. Touching the
mnass reproduces pain. Protruded tongue deviates to the left.
Eyes: PERRLA.
Ears: Tympanic membranes intact and pearly gray in color. No fluid or irritation noted. No
masses or lesions.

Nose: Septum midline. Nasal turbinates not swollen and nasal passages are clear. Mucosa pink
and moist. No polyps noted
Mouth: Several missing teeth noted. Numerous fillings noted. Mucosa pink and moist. Tongue
midlines with no lesions or swelling noted. Gums pink with no disease or bleeding noted.
Neck: No lymphadenopathy noted. Thyroid reveals no enlargement or masses. Trachea midline.
Symmetrical and supple.
Skin: No lesions, bruising, abnormal moles, excessive dryness, peeling, cracking, or rashes noted.
Respiratory: Chest rise and fall is symmetrical. Respirations are unlabored. Breath sounds are
clear.
Cardiovascular: S1 and S2 heard. No murmurs, rubs, or gallops noted. Rhythm regular.
GI: Abdomen reveals no distention. No pulsations noted. Bowel sounds noted in all 4 quadrants.
No tenderness to palpation.
Lymphatic: No lymphadenopathy or tenderness noted.
Musculoskeletal: Normal gait. Full range of motion and denies pain with movement. No crepitus
noted.
Neuro: Decreased pinpoint sensation around the angle of the jaw and below the ear. Some pain
noted inthe face where the trigeminal nerve is supplied. Decreased sensation to touch of cotton
on the left side of the face. Patient alert and oriented. Full strength noted in upper and lower
body.
Labs/studies: Normal TSH at 2.9. Normal CBC. CT and MRI not available. Normal mouth biospy.
Normal laryngoscopy. X-ray unremarkable.
Assessment:
Primary diagnosis:
Tongue cancer/mass.
Differential Diagnosis:
Trigeminal neuralgia.
TMJ.
Rheumatoid arthritis.
Cervical disc disease.
Plan:

The patient's primary diagnosis is tongue cancer/mass which we cannot verify by MRI, PET, or CT
due to these tests being unavailable. The patient's mouth biopsy and larynggoscopy were
unremarkable but this does not rule out CA. We will refer the patient to general surgery for
evaluation and possible surgery/chemo/radiation. The patient has no restrictions on exercise or
diet. Diet will be tolerated as the pain allows. The patient is to discontinue the use of ASA since
he is currently overusing it. We will begin the patient on Percocet 5/325 to take q 4 hours prn
pain. The patient is to continue to monitor his vital signs and he is to return to us following his
appointment with surgery for repeat blood work and to manage his symptoms.