Pain Since Beginning Treatment
Christine says her pain has gotten much better after the injections.
Eating Changes
Christine said she started to eat pizza again, which was delicious. She said the pain came back after eating it.
Psychiatric Diagnosis
Christine says she recently went to her psychiatrist, who diagnosed her with a compulsive disorder.
Adherence to Prescriptions
Christine says she's not taking any of her medications on orders from her psychiatrist.
Christine's Second Follow Up Exam
Maximal Inter-incisal Opening
TMJ Exam
Muscles of Mastication
Second Assessment
- Myalgia of right masseter muscle: no improvement
- Myofascial pain associated with right anterior temporalis muscle: some improvement
- Tension-type headache
- Parafunctional habit (e.g. grinding/clenching)
- Anxiety with possible depression: diagnosed with a compulsive disorder
Second Updated Treatment Plan
- OTC NSAIDS PRN
- Repeat trigger point injections to Masseter Muscle/Masseter Muscle origin
- Continue with gentle passive jaw stretches
- Maintain soft diet/advance as tolerated
- Return to office in 3 weeks
