Event 2: Margaret Meets with her Primary Care Physician

Margaret At the Primary Care Office

In this segment, the physician explores potential “catastrophic” diagnoses using the Review of Systems.

Test Your Knowledge

In taking the patient’s history, you have several causes of headache in mind. You ask questions that make a specific diagnosis more or less likely.

Question 1

What is most commonly associated with a tight band across the forehead?

Incorrect

Correct. http://umm.edu/health/medical/reports/articles/headaches-tension

Question 2

What is most commonly associate with photophobia?

Incorrect

Correct. http://www.nlm.nih.gov/medlineplus/ency/article/00709.htm

Incorrect

Question 3

What is most associated with a stiff neck?

Incorrect

Correct. http://www.mayoclinic.com/health/tension-headache/DS00304/DSECTION=symp…

Incorrect

Question 4

What is most often associated with clumsiness, loss of balance?

Correct. http://www.braintumor.org/patients-family friends/about-brain-tumors/symptoms-and-diagnosis.html

Incorrect

Primary Concerns

In the absence of early morning awakening with pain, nausea, or vomiting, significant escalation of pain intensity over time, and focal neurologic signs such a clumsiness or falling, the physician diagnoses Margaret’s pain as most consistent with a tension-type headache.

Test Your Knowledge

At this point, given a tentative diagnosis of tension headache, which of the following medications are you LEAST likely to recommend?

Incorrect

Correct. This is a common second-line drug of choice, but a trial of a simple over-the-counter pain reliever would be reasonable for a short-term trial, even though the headache has not been relieved by them in the past.

Incorrect

Medication Review

The patient’s mother calls in one week as requested. Note that the physician now makes a presumptive diagnosis of temporomandibular joint disorder. She also recommends a three-pronged approach to Margaret’s management.

Phone Follow Up

Test Your Knowledge

Although the physician is acting on a assumption of TMJ Disorder, based on the history, which of the following conditions should she also consider in the differential diagnosis of a 17-year-old girl with jaw pain/temporal headache?

Correct. While all the listed conditions can be associated with pain that mimics temporomandibular disorder, trigeminal neuralgia typically occurs after age 40 and giant cell arteritis typically occurs after age 50.

Incorrect

Suspicion of TMJ

Based on the nurse practitioner’s evaluation there is a high suspicion of temporomandibular joint disorder and a panoramic radiograph is taken to evaluate the right and left condyles
The panoramic radiograph is additionally useful in the evaluation of teeth (erupted and unerupted), bone structure, and maxillary sinuses

Test Your Knowledge

Based on the history, which two of the following are least likely to be considered in the differential diagnosis of a 17-year-old girl with jaw pain/headache?

Incorrect

Correct. Trigeminal Neuralgia and Giant Cell Arteritis are the correct answers. Typically, these disorders do not manifest until later in life and would be rare in a patient this young. Facial pain from Pulpitis, Pericor0nitis, and Otitis media would be more likely in a 17 year old patient.

Correct. While all the listed conditions can be associated with pain in the temporal region that mimics temporomandibular disorder, giant cell arteritis primarily manifests in individuals over 50 years of age.

Margaret’s Panoramic Radiograph Revealed

No overt dental caries or pulpal pathology
No periodontal disease
No suggestion of maxillary sinusitis
Normally developing third molars (‘wisdom teeth’) in all four mouth quadrants, with no suggestion of pericoronitis or other pathology

However:

Differences between the right and left temporomandicular joints were noted