Trigeminal Neuralgia

Casebank History
1

Where you are:
You are FY2 in GP surgery

Who the patient is:
Peter Pearson, a 66-year old man who has presented with some concerns.

Other information you have about the patient
None

What you must do:
Talk to the patient and address his concerns

Patient Information:

  • Your name is Peter Pearson.
  • You are a 66-year-old man. You have facial pain on the right side of the jaw and radiates up the face.
  • The pain is sharp and started suddenly while shaving yesterday.
  • You took Paracetamol and Ibuprofen without any improvement.
  • The pain is constant and it is worse when touching the area, on opening the mouth, and eating.
  • Otherwise you are generally fit and well.

Questions:

  • What is wrong with me doctor?
  • Why did the painkillers not work?
  • What type of analgesia should I use?
  • If the candidate say ‘’it could be a problem in your teeth’’ tell them ‘’I went to the dentist and he said everything is normal’’
  • Is there any side effect to the new medication?

Examiner’s prompt:

  • Observations: normal
  • Facial nerve examination: normal
  • Face sensations: normal
  • Cranial nerves examination: normal

Data Gathering

  • SOCRATES (for Facial pain)
  • Differential Diagnosis
    1. Trauma - Have you sustained any injury to your face?
    2. Teeth issues - Have you had any problems in your teeth?
    3. Shingles - Have you noticed any rash? Have you had chickenpox before?
    4. Trigeminal Neuralgia - Does the pain get worse on touching the area? - Does the pain get worse on opening the mouth or chewing? - Has this affected you in any way?
    5. Tempromandibular disorder - Did it occur while yawning?
    6. Giant Cell arteritis - Is it worse on chewing or combing hair?
    7. Is there any weakness of any part of your body?
  • PMAFTOSA
  • ICE
    • I – Ideas: - Is there anything you feel could be the cause of your symptoms?
    • C – Concerns: - Is there anything you are worried about?
    • E – Expectation: at the end of consultation examine the nerves of your face.
  • Let me go through everything you have told me so far, to make sure I have understood correctly. So, you have told me that … You mentioned that … You also mentioned that … Is there anything I missed?

Examination

  • Observations - As a part of examination, I’d like to check your vitals; your BP – Pulse – Oxygen – RR – Temp
  • Specific Examinations - Head to toe examination I’d like to perform a quick general examination of your whole body.
  • Cranial nerves examination I’d also like to perform

Management

  • From what you have told me and after examining you, it seems that you most likely have what we call trigeminal neuralgia.
  • DEFINE: This is a sudden severe facial pain, comes like a sharp shooting pain or electric shock in the jaw, teeth or gums due to irritation of the nerves in the face and the cause is not always known. But it could be triggered by touching the face, talking, vibration, or cleaning teeth.
  • Routine investigations: We need to run some blood tests FBC – U&E – LFT – Blood sugar – Inflammatory markers to make sure that nothing else is going on and we might need to arrange an X-ray of the face if needed.
  • Treatment/Decision
    1. It is a nerve pain that’s why it didn’t respond to Paracetamol or Ibuprofen. It needs a special type of medication, so I’ll start you on Carbamazepine 100mg up to twice daily which could be increased in steps every 2 weeks until pain is relieved.
      (Carbamazepine may lead to some side effects as nausea, vomiting, sedation, dizziness and ataxia, so please inform us if you experience any of these symptoms).
    2. There is also some general advice that I’d like to give you:
      • Try to eat soft food
      • Drink with a straw to avoid any pain when opening your mouth
      • Avoid too much chewing.
      • We might need to consider referral to the neurologist if the pain is not controlled by carbamazepine despite increasing the dose. But at the moment we don’t need a referral.
      • Please come back if you experience any side effects of carbamazepine as nausea, vomiting, sedation, dizziness or ataxia.
  • Follow up
  • I’d like to see you again after 2 weeks to review your symptoms and assess your improvement.
  • Leaflets - Before you go, we’ll bring you a leaflet about trigeminal neuralgia.
  • Summarize - Let us recap what we have discussed…
  • Expectations - Is there anything else I can do for you?