Hattie Harrison: A 77-Year-Old Female With Headache and Jaw Pain

Learning Objectives

  • Learn the common causes of headache.

  • Learn the clinical presentation of temporal arteritis, including the unique symptom of jaw claudication.

  • Learn how to use physical examination to identify physical findings associated with temporal arteritis.

  • Learn to distinguish temporal arteritis from other pathologic processes that may mimic the disease.

  • Learn the complications associated with temporal arteritis.

  • Develop an understanding of the treatment options for temporal arteritis.

Hattie Harrison

“I told Mom that she needed to see the doctor, but as usual, she wouldn’t listen,” complained Hattie’s daughter, Betty. “She only wants to do what Hattie wants to do.” I looked over at Hattie, who gave her daughter a dirty look and rolled her eyes. Hattie had been a patient of mine for several years and always came in for a flu shot, but otherwise I never saw her. Hattie was an original article: always cracking a joke and always ready to talk about Betty. Although she always had some criticism about Betty, it was obvious that she adored her. When she came in last fall for her flu shot, she brought me a copy of her Advanced Directives and Health Care Power of Attorney to put in her file. She became tearful, took my hand, and said, “Doctor, promise me that you will do whatever Betty tells you to do. I trust her to look after me like I looked after her. Nobody ever had a better daughter.” I squeezed her hand and said, “I promise.”

“Doctor, I told Betty I was fine! Just a little headache. You know, everybody gets a headache now and then. I am just fine,” Hattie insisted. “I am a tough old bird.” I took her hand and looked her straight in the eye and said, “Hattie, I know you are tough, but Betty is really worried about you. She says that you are having trouble chewing your food and you’re losing weight. Let’s see what we can do to get you back on your feet!” She gave her daughter a defiant look and said, “I told you I am fine. Go take care of people that actually have something wrong with them!”

Hattie told me that her headache pain began about 2 weeks ago. She said that it just gradually came on. At first it was just an ache, but lately it is more severe. She said, “Doctor, it’s the craziest thing, but it hurts when I try to brush my hair.” Hattie went on to say that over the last week she found it hard to get comfortable because her head hurt all the time. Tylenol and aspirin helped a little, but she finally agreed to come in because her jaw had started hurting whenever she tried to chew her food. “Doctor, it’s kind of like a cramp in my jaw. If I try to keep chewing, the pain keeps getting stronger. If I rest for a minute, the cramping goes away, but if I try to chew again, the pain comes right back. It’s very strange!”

I asked Hattie what made her pain worse and she said, “Chewing.” I asked her what made the pain better, and she, without missing a beat, said, “Being left alone!” I laughed and asked if she had any problem going to the bathroom or was she losing any urine or feces or having any difficulty walking. Hattie shook her head adamantly from side to side. “Doctor, I can take care of myself.” And looking straight at Betty, she said, “Nobody is going to put me in the old folks, home!” I reassured her that she wasn’t going to the nursing home any time soon. I really didn’t know what Betty had on her mind, though, because Betty could be as stubborn as her mother. I told Hattie I was going to take a look at her and see what we could do to get her better.

On physical examination, Hattie was afebrile. Her eye exam revealed dense bilateral cataracts. I really couldn’t adequately visualize her optic discs. Her nose and throat examination, as well as her thyroid examination, were unremarkable. I asked Hattie if she was having any problem seeing or if anything had recently changed with her vision, and she snapped, “I can see better than you can!”

“Hattie, are you still driving?” I asked. Hattie glared at Betty and said, “Not since she took away my car keys!” “Mom,” Betty said, “you know I will take you wherever you want to go.” I made a note to refer Hattie to an ophthalmologist to look at her cataracts before she left the office.

Hattie’s cardiopulmonary examination revealed a grade 2 mitral valve systolic murmur, which I had noted on previous visits. Her abdominal examination was benign, with no abnormal mass or organomegaly. There was a trace of peripheral edema. Hattie’s radial pulses were 1+ bilaterally, but I was unable to identify any posterior tibial or dorsalis pedis pulses. What really concerned me was the finding of an inflamed, erythematous, thickened temporal artery on the left. The artery was easily visible and was so large that I could easily roll it between my fingers. A careful neurologic examination of the upper and lower extremities was unremarkable. No pathologic reflexes or clonus were identified.

Key Clinical Points—What’s Important and What’s Not

The History

  • History of jaw claudication associated with headache

  • No significant history of previous headache

  • Difficulty eating due to persistent jaw claudication

  • Denies any recent decrease in visual acuity

The Physical Examination

  • Patient is afebrile

  • Inflammation and thickening of the left temporal artery

  • Dense cataract formation bilaterally

  • No peripheral pulses in the lower extremities

  • Normal neurologic examination

  • No pathologic reflexes

  • No clonus

Other Findings Of Note

  • Grade 2 mitral valve murmur

What Tests Would You Like to Order?

  • Urgent erythrocyte sedimentation rate (ESR)

  • Urgent ultrasound and color Doppler image of the temporal arteries

  • Urgent temporal artery biopsy

  • Ultrasound of the aorta

Test Results

Mar 21, 2022 | Posted by in PAIN MEDICINE | Comments Off on Hattie Harrison: A 77-Year-Old Female With Headache and Jaw Pain

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