SAINT LOUIS UNIVERSITY

BAGUIO CITY
SCHOOL OF MEDICINE

DUMAYAS, HAZEL ANNE I.

GRP 1 MED 3A
ORAL EXAMINATION OUTPUT

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.

Chief Complaint: Jaw pain

History of Present Illness:

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.

No associated popping or clicking, Lockjaw, Headaches, Ear aches.

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.

Past Medical History:

The patient had no history of measles but had mumps and chickenpox when he was in grade school.
Ast year the patient had consultation in the school clinic due to colds and consultation in BGH due to
headache and colds and was given cetirizine. No allergies to dust, pollen, foods and drugs.

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.

Social and Environmental History:

The patient is a 4th year Architecture student in SLU. Attend class for average of 8 hrs per day and
usual activities only involves doing projects and staying late at night finishing school requirements. Patient is
doesn’t do exercise nor engage self in sports and just stay in school or house. He lives in a concrete 3 storey-
building, composed of 2 rooms and currently living with his mother and sister. He is a non-smoker and alcohol
drinker.
Review of Systems:

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

Head and Neck:

a. Hair: Hair is black and evenly distributed. No sign of lice infestations.
b. Head: Symmetric facial structures with no unusual facies or deformities.
c. Eyes: Patient has anicteric sclera and pinkish palpebral conjunctiva, pupils are symmetrical,
no redness, no excessive tearing, no discharges, positive red orange reflex, no periorbital
edema, eyes not sunken
d. Ears:
There are equally in-set ears, both canals with moderate cerumen, cone of light is seen, no
discharges, non-tender
e. Nose and Paranasal sinuses: Septum is at the midline, no discharges noted, no nasal
congestion, with reddish nasal turbinate
f. Mouth and throat: Lips and buccal mucosa are pinkish and moist, no ulcerations or lesions
noted, no dental caries, tongue and uvula midline, tonsils not inflamed, no dental carries,
lower wisdom tooth not completely errupted
g. Neck: Trachea is midline. There was no lymphadenophaties palpated.

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

Abdomen: globular, normoactive bowel sounds, tympanitic, non-tender, no organomegaly, no CVA

tenderness

Extremities: no gross deformities, no joint swelling, no bipedal edema, right shoulder tenderness, ++ dorsalis
pedis pulses bilaterally

NEUROLOGIC EXAM:

I. Cerebral: alert, awake, conscious, and oriented

II. Cerebellar: can reach for objects with no associated clumsiness or incoordination, no tremors, no nystagmus
III. Cranial Nerves
a. I: not assessed
b. II: Pupils equally reactive to light and accomodation
c. III, IV, VI: Extraocular muscles are intact. Patient was able to follow thru six cardinal fields of
gaze.
d. V: blinks spontaneously
e. VII: no facial asymmetry
f. VIII: responds to sound stimulus
g. IX, X: no hoarseness of voice, tongue and uvula midline
h. XI: can shrug shoulders, can move head side to side

MOTOR STRENGTH SENSORY FUNCTION DEEP TENDON REFLEXES

 SAINT LOUIS UNIVERSITY
BAGUIO CITY
SCHOOL OF MEDICINE

5/5 5/5 5/5 5/5 ++ ++

5/5 5/5 5/5 5/5 ++ ++

No atrophy, fasciculation, No sensory deficit Triceps and patellar reflexes intact

tenderness, unable to move
against resistance on left lower
extremity

PROBLEM LIST:
#1: Jaw pain

PROBLEM NO. 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

 Avoid strenuous activities

 Protect strained from further injury
 Comply with medications and follow-up