Clinical Pathological Case Sparrow Hospital/MSU

1. Clinical Pathological CaseSparrow Hospital/MSU Richard Maier, DO

2. Case • 19 year old male • Chief complaint: forehead swelling • HPI: • Has been treated multiple times while traveling as a student over the last several weeks for sinusitis • Has been on 3 rounds of oral antibiotics • Last antibiotics were 3 weeks ago - levofloxacin. • After his last round of antibiotics he noted some swelling of his foreheadand pain • Denied any visual changes, or neurologic changes other than an occasional frontal headache

3. Review of Systems General: Positive for fever, denies chills or fatigue. HEENT: Positive for forehead swelling, sinus congestion, sinus discharge and sore throat Neurologic: Positive for headaches; denies seizure, numbness, tingling, weakness, seizures, visual changes or loss of consciousness. Respiratory, Cardiovascular, GI, GU, Endocrine, Musculoskeletal, Psychological: negative

4. History Past medical history: Migraines, gastroesophageal reflux. Surgical History: Esophagogastroduodenoscopy Social History: The patient denied using alcohol, tobacco or illicit drug use. The patient is a single college student. Family history: pertinent for cancer of unknown type in his mother Allergies: NKDA Home medications: None

5. Physical Examination • Vitals: • BP 113/71 • HR 81 • Respiratory Rate 16 • SpO2 97% on room air • Temperature 97.6 degrees Fahrenheit • Weight 164 pounds. • General: Patient is oriented to person, place, and time, and appears well-developed and well-nourished.

6. Physical Examination • HEENT: • Large area, approximately 6 cm by 10 cm of boggy swelling with fluctuance and tenderness present on the midline of the forehead. No erythema present, not warm to the touch. • Maxillary and ethmoid sinuses are not tender to palpation. • PERRLA, Visual fields intact to confrontation. • Nares are patent, no purulent drainage bilaterally however yellow drainage is noted on the posterior oropharynx. • External auditory canals are patent bilaterally, TMs intact bilaterally without erythema and with normal landmarks. • Moist oral mucosal membranes, no tonsillar erythema or exudates • Uvula midline, phonation is normal and palate elevates symmetrically. There is no evidence of facial asymmetry with voluntary or involuntary movement, and sensation is intact in all dermatomes.

7. Physical Examination Neck, Cardiovascular, Lungs, Abdomen, Musculoskeletal: Normal Neuro: Normal. Skin: forehead swelling as noted in HEENT. Otherwise normal.

8. Initial Emergency Department Evaluation Complete Blood Count Basic Metabolic Panel Erythrocyte sedimentation rate Computed Tomography of the head with and without contrast

9. Labs • BMP • Sodium 142 • Potassium 3.6 • Chloride 104 • CO2 31 • Anion gap 7 • BUN 13 • Creatinine 1.08 • Glucose 84 • ESR 37 • CBC • WBC 9 • RBC 4.69 • Hemoglobin 14.2 • Hematocrit 41.5 • MCV 88.5 • MCHC 34.2 • Platelets 242 • Differential: • Neutrophils 71%, Lymphocytes 19%, Monocytes 7%, Eosinophils 0%, basophils 0%

10. Computed Tomography

11. Computed Tomography