FIRST AID AMC

CLINICAL
NEUROLOGY
HEADACHE CLUSTER
 HEADACHE D/D

❑Tension headache
❑Trauma
❑Tumor
❑Temporal arteritis
❑Migraine
❑Meningitis
❑Cluster headache
History:
❑Hemodynamic stability
❑Painkiller( I got to know from the notes that you are having headache. I am really sorry to hear
that. Would you please tell me how severe is your pain in a scale of 1-10? Do you have any allergy
to painkiller? Okay, I am going to arrange a strong painkiller for you right now, hopefully you will
feel comfortable.)
❑How are you feeling now? Are you okay to answer few of my questions please?
❑History of presenting complaints: PAIN QUES
Since when? Where exactly you are having the pain? Is it for the 1st time? If prev
episodes then ask – how many episodes so far? Any change in severity/ character of the
pain? Does it come suddenly or gradually? How long does it last? Can you describe the
pain for me? Does the pain go to anywhere? Anything makes it better?(like taking rest or
avoiding light or noise)Anything makes it worse like bright light/noise/strong odor/ any
foods like coffee , chocolate , cheese, red wine?
❑Associated : nausea/ vomiting?
❑D/D:
❑Migraine: any strange sensation before the headache starts like flashing lights/ zigzag lines?
Does the light hurt your eyes? Any FHx of migraine?
❑Meningitis: any fever/ rash/ neck pain or stiffness?
❑Trauma: any injury to the head?
❑Tumor: is the headache worse in the morning? any early morning nausea/ vomiting?
❑Temporal arteritis: any pain while chewing? Any pain/ stiffness in the shoulder or hip? Any
blurring of vision?
❑Cluster headache: any runny nose /red eyes ?
❑Sinusitis: any pain in the face? Does the headache become worse when you lean forward?
❑Stroke: any weakness in any part? Any problem with vision or speech? Any problem with
walking?
❑Refractive error : do you wear glasses?
❑Dental infection : any toothache/ ear pain or discharge? Any flu like illness/
❑Tension headache: Any stress at your home or work? How is your mood these days/
any financial issues? Do you always like to keep things in order/ are
you perfectionist in nature?
❑Somatoform / hypochondriasis : Do you have any specific concern about this
headache?
❑PMHx : How is your general health? Any past medical hx like DM/ HTN/stroke?
❑SADMA (smoking/alcohol/medication)
❑FHx : Cancer? Migraine?
❑For Migraine ask ➔ OCP ( are you taking any pill esp. OCP) / any relation with period?
PEFE :
❑GA
❑VITALS & BMI
❑Neck stiffness
❑Paravertebral muscle stiffness
❑Head : temporal artery tenderness
❑ENT: Nasal discharge /sinus tenderness
❑CNS : complete neurological examination including cranial nerves esp.
EYE : visual acuity, visual filed, pupillary response, eye movement, nystagmus ,
Diplopia, FUNDOSCOPY****
CNS : ITPRCS ( inspection , Tone , power, reflex , co-ordination, sensation)
❑CVS and other system
❑Office test: UDT/BSL
MIGRAINE
QUES: a 35 years old woman comes to your ED with on and off
headache for the last 6 months.
TASK:
❑Take history
❑PEFE
❑DX and DDX
QUES: A lady of 35 years came to your GP with recurrent headache for last 6
years. Sometimes very severe and subsides by taking panadol and rest. She
is very concern regarding this and have visited many doctors but not
relieved. All investigation including CT scan done and were normal
Company secretary/Busy with work and kids at home and have less time for
rest/No Family history of DM, HTN, Epilepsy, cancer etc./Family history of
Migraine present/Social drinker but do not smoke/No financial stress but
have stress in work and she is a perfectionist.

Task:
1.Take focus history
2.Give diagnosis
3.Further Management
POSITIVE POINTS IN HISTORY:
❑Unilateral throbbing type of headache
❑On and off for last 6 months
❑Worsened by bright lights, loud noise, certain foods like cheese, red wine, chocolate ,
coffee , hunger , stress
❑Relieved by taking rest in a quiet dark room
❑Associated nausea /vomiting
❑No aura like features, no photophobia
❑FHx of migraine +ve
❑Was on OCP
❑PEFE normal
EXPLANATION:
❑Most likely you are having a condition called Migraine headache. Do you know what it
is?
❑It’s a very common cause of headache specially in females.
❑The exact cause why this occurs is not known but it has certain triggers like fatigue,
hunger, strong odors, loud noise, hormonal changes and certain kind of foods like
cheese, coffee, chocolates etc.
❑The headache is usually one-sided throbbing in nature and sometimes you can have
nausea or vomiting along with it. Also, you can have some strange sensation like seeing
flashing lights or zigzag lines before the onset of the headache.
❑Don’t worry, its not a serious condition and its quite manageable .
❑When you have this attack try to rest in a quiet, dark room and try to avoid reading,
watching TV etc.
❑You can also take aspirin or paracetamol tablets along with a medication for vomiting
as soon as you suspect you are going to have an attack.
❑If these drugs are not effective, then we will start you with ergotamine /triptan .these
are the drugs which is used for more severe cases of migraine.
❑To prevent further episodes:
❑Try to avoid trigger factors
❑Adopt a healthy life-style
❑Try some relaxation techniques like meditation, yoga etc
❑If you get 3 or more attacks in one month, we will also start you with preventive
medication propranolol to reduce the attack
❑If pt on OCP : Stop it
❑4R
PASSED FEEDBACK:
❑40-year-old male patient comes to your GP. Has had headaches since adolescence.
❑Relevant history
❑Explain most probable diagnosis and other diagnosis to the patient with reasons.
❑Patient gave a TYPICAL textbook history of migraine since adolescence self-medicated
with ibuprofen up to now (it works most of the time), never sought medical help
before. No red flag symptoms present. (Not increased with coughing, sneezing/ not
associated with eye movement, blurred vision, stiff neck, rash, malaise/ no
neurological signs/ no sudden severe) Excluded other DDs but diagnosis of migraine
was quite clear. (When asked if anything about headache changed, to see why he
came this time, said it’s getting worse now. Any other worries? His cousin was
diagnosed with brain cancer recently. (Now started to show anxiety. Do I have cancer
too doctor??? Had to address this showing empathy and explaining his symptoms are
quite different from that of brain tumor.)
❑General health good. No significant past illness/medications. SAD -nothing significant.
He is an accountant had some worries at workplace. Can faintly remember that he had
a family history of migraine too (brother).
❑Explain most probable diagnosis and other diagnosis to the patient with reasons
❑Explained typical pattern of migraine pain. Tried to explain a bit of pathophysiology
about vessel dilatation etc. Explained other diagnosis like cluster headache/ tension
headache/ brain tumor for long standing headache, but said infectious causes
(sinusitis/meningitis) also considered but unlikely. Ran out of time to finish.
❑3/5 key steps covered. PASSED

❑If asked what to do if I have migraine during my period:

https://patient.info/health/migraine-leaflet/migraine-triggered-by-periods
TENSION HEADACHE
QUES: You’re intern in an ED. A 35 years old engineer complained of increase
headaches over the last 5 years. The pain was dull, no aura, no vomiting, no
local signs. Usually appearing when he’s tired. Improving with Panadol. He’s a
very busy man.
❑TASK
1. History
2. Examination finding
3. Investigations if needed
4. Management
POSITIVE POINTS:
❑Band like headache, 4-5 in severity, on and off for 5 years
❑Get worse in the evening
❑No nausea ,vomiting
❑Not related to posture or exercise
❑Happily married
❑Very busy at work
❑Perfectionist in nature
❑ worried about having brain tumor
❑PEFE: paravertebral muscle stiffness +ve
EXPLANATION:
❑Most likely you are having a condition called Tension Headache.
❑It’s a very common cause of headache and it’s related to the stress you are going
through right now.
❑The headache is usually associated with spasm or tightening of your neck muscles.
Please don’t worry, I can assure you this is not brain tumor as you are not having any
early morning worsening of headache , nausea or vomiting ; also, no problem with
vison, speech or walking.
❑There could have other causes of headache as well like➔ give ddx
❑As this headache is associated with stress and there is no underlying organic cause
right now there is no need of any investigation. I would advice you to follow some
lifestyle modifications: Try to avoid stressful situations, I do understand its very
important for you to manage your job, but I would advice you to take few holidays
and spend some time with your friends and family.
❑Try not to bottle up things, try to be easy on yourself.
❑Try some relaxation techniques.
❑Eat healthy balanced diet.
❑Try to do some physical exercise.
❑If you are too much stressed and you feel low, I can refer you to a psychologist for
talk therapy.
❑I will give you some Panadol for your pain as well.
❑If anytime the intensity of the pain increases, or you have difficulty with
vision/speech or weakness in any part come to me immediately
❑I will again review you in one week.
❑Reading materials.
TEMPORAL ARTERITIS
QUES: 55 years old lady comes with headache for 2 weeks.
TASK:
❑Take relevant history
❑PEFE
❑Dx and DDx
❑POSITIVE POINTS IN HISTORY:
❑Unilateral headache
❑Patient was holding her left side of the temple
❑Jaw claudication
❑No vision problem
❑Pain and stiffness in the shoulder and hip
MANAGEMENT:
❑Based on your history and physical examination most likely you are having a condition
called temporal arteritis.
❑Let me draw a picture for you. This is your temporal artery ; one of the blood pipes
supplying the temporal region of your head and also your eye. In your case the lining or
wall of this blood pipes is inflamed and that’s why your are having headache in this site.
This condition sometimes can also be associated with another condition called PMR where
you have pain and stiffness in your shoulder and hip joint.
❑There could be other reasons of headache as well➔ give dd
❑That’s why to confirm my dx and rule out other conditions I would to few blood test like
FBC, ESR /CRP.
❑Mrs. Smith, this is a medical emergency as it can involve your eyes and lead to irreversible
blindness.
❑That’s why, I would urgently like to start you on high does oral steroids like prednisolone for
2-4 weeks, then gradually reduce it according to the ESR/CRP levels. You may have to
continue taking this for at least 2 years.
❑Meanwhile I will refer you to a specialist who will take a tissue sample from that inflamed
blood pipes. I would also like to refer you to a neurologist and ophthalmologist who would
further confirm the condition. If you develop any vision problems or severe headache, or
any pain in joints, please come back immediately.
❑Please don’t worry, its very good that you are here before the eye problem developed and
with appropriate management you will be totally fine.
❑Give reading materials.
Brain Tumor/ Raised ICP
Stem: 10 years old child brought in by father with occasional headache
with vomiting for 3 months.
Task:
1. History
2. PEFE
3. Dx and DDx
Feedback:
• Headache for 3 months.
• Early morning occasional Nausea, vomiting.
• FHx Positive for Migraine (to confuse).
• Headache can be exacerbated with bending forward.
• Diff with walking or keeping balance.

PEFE: Fundoscopy reveals Papilloedema

Explain:
▪ The symptoms that your child is having is most likely due to increased
pressure around his brain known as raised ICP. This can happen due to
multiple conditions such as Brain Tumor, infection called meningitis, head
injury, stroke, accumulation of spinal fluid in brain cavities known as
Hydrocephalus, benign Intra-cranial HTN etc.
▪ But based on his symptoms such as headache, early morning vomiting and
balance problem, I am suspecting it could be due to Brain tumor.
▪ Please don’t get scared, as its just an assumption. We need to do further
investigation to confirm it.
https://www.healthline.com/health/increased-intracranial-
pressure#causes
STROKE
QUES: You are HMO in ED seeing an old man who lost consciousness a few hours
ago with weakness of left side of his body. He has long standing hypertension and on
ACEI and aspirin. There was no HO of fall. CT scan of brain is done which is similar to
following one but in exam it was on rt side. Wife has come to discuss.
Tasks :
❑Explain CT scan findings to wife
❑ Discuss about possible causes
❑Explain about prognosis
EXPLANATION:
❑ Hi Marry, I am Dr ARSHAN. One of the Dr here. I am really sorry to hear about your
husband. Marry, before I explain about your husband condition, I would like to talk with
my examiner first and then come back to you again. Is that alright with you?
❑ Dr, I would like to confirm if the wife has the consent to talk on behalf of his husband?
(Examiner - Dr, Pt has lost consciousness. This is his wife. All the decisions is up to u now.
Then I turned towards role player, she said “Dr, I have authority to discuss about my husband’s
situation” and smiled at me)
❑Ok Marry. I understand your husband has lost consciousness few hours back. We did the CT
scan of his brain, and the results are with me right now. Let’s see it together. If you don’t
understand at anytime pls feel free to ask me again.
❑This is his CT scan of brain. Basically, in CT scan, white things are solid structures and grey
things are soft tissues. This is the head bone. This is the brain. If we compare two sides, u
see there is a large white thing on left side.
❑So, this white thing is not supposed to be there. Considering his clinical history, it could be
a blood clot from bleeding in his brain we call hemorrhagic stroke. There are other possible
causes, like it could be brain abscess which is infection and collection of pus in brain. It
could be nasty growth brain tumor. Or it could be TB infection of brain we call tuberculoma
which is very rare in Australia. But they are very unlikely.
❑This type of bleeding and blood clot can be caused by head injury but according to his
notes, he didn’t have any. So, most likely cause is stroke which is rupture of blood vessels
that supply brain and blood come out from them. He has high BP, and it exerts pressure on
vessel wall to cause it rupture. Moreover, he is taking blood thinner, and it can make more
bleeding. Our brain control the opposite side of the body and blood clot is in rt side, so he
has weakness in left side of arm and leg.
❑So far, are u with me? (Yep Dr)
❑I can’t even imagine how you are feeling right now ,but I want to assure you still there is lots
of things that we can do. Please don’t loose hope, we are trying our best to make him better
as like before.
❑I am going to call my senior and also, we will involve the brain specialist who will come and
review your husband.
❑In terms of outcome, it depends on how much area of his brain has been damaged and how
he recovers from this. Specialist might decide to do surgery to remove blood clot and
hopefully, he can get well. He may have residual weakness when he recovers, for that, we
will get involve physiotherapist who will teach him some exercise regimen to get his muscle
strength back. On the other hand, unfortunately he can get into prolonged unconsciousness
; I am really sorry to say that.
(RP : If it happens, we dun want him to be lying on bed as a useless body. I want him to die
rather than going this way)
❑I really understand ur concern. We will respect your decision.
❑Give lots of reassurance and support
Blurring of Vision
QUES: 54 years old female comes to your GP clinic complaining of blurring
of vision for 4 min which has improved now. He is hypertensive and taking
ACEI.
▪ TASKS:
▪ History
▪ PE from examiner
▪ Investigations, Diagnosis and Management
D/Dx of Blurring of Vision
❑TIA/ Amaurosis Fugax
❑Temporal arteritis
❑Optic neuritis
❑Migraine
❑Glaucoma
❑CRAO/CRVO
❑Retinal Detachment
History:
❑Presenting complaints: Can you tell me more about the blurring of vison you had today?
When did it occur? What were you doing at that time? Was it sudden or gradual? How long
does it last? Is it for the 1st time?
❑Associated symptom: any weakness? Tingling/numbness? Difficulty in speech/swallowing?
Any change in your voice? (TIA ruling out)
❑D/D:
❑Temporal arteritis : same as before
❑Optic neuritis: any associated pain on eye movement?
❑Migraine: any headache? Any strange sensation like flashing lights /zigzag lines? Any hx of
migraine?
❑Glaucoma: any pain or redness of eye? Any nausea/vomiting?
❑Retinal Detachment: any trauma to the eye? Any flashes or floaters ?
❑PMHx: DM/HTN/ high cholesterol? Any hx of heart disease like valvular heart disease
or rhythm disorders like AF? Any prev hx of TIA/stroke?
❑FHx
❑SADMA

Physical examination:
❑GA: any facial asymmetry?
❑Vitals: BP, Pulse( regular/irregular)
❑BMI
❑Neck: carotid bruit
❑EYE: PEARL( is the pupil equal and reactive to light?) , visual acuity, visual filed, eye
movement, light reflex and accommodation reflex, FUNDOSCOPY
❑CNS: ITPRCS
❑CVS
❑Office test: BSL, ECG

EXPLANATION:
❑The blurring of vision that you had is most likely due to a condition called amaurosis fugax
which is due to temporary lack of blood flow to the back of your eye called retina.
We also call it TIA or mini stroke.
❑Let me draw a picture for you. In your case one of the blood pipes supplying the back of
your eye got blocked by some clot , but as the clot was small it has dislodged by itself, and
your symptoms resolved spontaneously. This clot can be formed in your neck blood pipes
and then travel to the retinal blood pipes, or it can come from your heart as well.
❑But It can be risky as you might develop a major stroke later on. That’s why It is a medical
emergency.
❑I would like to send you to the hospital where you will be admitted and seen by the
neurologist and a cardiologist and further investigations will be done like FBE, ESR/CRP, UEC,
LFT, BSL, coagulation profile, lipid profile, ECG, carotid Doppler, and brain imaging
❑If the investigations confirm TIA, they will monitor you and start you on a blood thinning
medication called Aspirin. Also, they may start you with cholesterol lowering drugs called
statin.
❑Depending on the carotid doppler further definitive treatment will be done. If the level of
blockage of your neck blood pipes is severe the specialist might consider surgery to remove
the fatty deposition and restore normal blood flow.
❑There are certain risk factors for this condition like smoking, alcohol, Diabetes,
Hypertension, but sometimes it can happen spontaneously
❑That’s why It is very important to adopt healthy lifestyle.
❑Once you are discharged from the hospital, I will follow you up regularly, and we can further
discuss in detail about the risk factors.
QUES: A 60 years old female came to the GP clinic with weakness of her right
leg that get resolved after 30 minutes. She is a diabetic patient and in on
metformin for last 10 years.
TASK:
1.Take hx
2.PEFE
3.Dx and DDX
 D/Dx OF ONE-SIDED WEAKNESS:
❑Stroke
❑TIA
❑Space occupying lesion/Tumor
❑Subdural hematoma
❑Epidural hematoma
❑Subarachnoid hemorrhage (aneurysmal bleed)
❑Complex migraine
❑Epilepsy
❑Meningitis
❑Encephalitis
❑Trauma: Head injury
❑Psychogenic
History:
❑Presenting complaints
❑D/Dx
❑CVS risk QUES: ABCDEFS
❑PMHX
❑FHX
❑SADMA
Ques: 72 years old lady presents with left sided weakness of her arms
and legs. PEFE shows left sided spastic paralysis, hypertonia and
Hyperreflexia.
Task:
History
Dx and DDx with reasons
History suggests patient had a recent head trauma and she is on
warfarin for multiple DVT.
DELIRIUM
 D/Dx of DELIRIUM:
❑D - drugs, depression, alcohol, ❑ T - trauma or tumor
dementia
❑ I - infections (meningitis,
❑E - electrolyte imbalance
pneumonia, gastroenteritis,
UTI)
❑M - metabolic (hypo or hyperglycemia,
hypo or hyperthyroidism), liver failure
❑ A - arteriovascular (ACS,
❑E - eyes and ears (difficulty hearing) arrythmia)

❑N - neurological (stroke, TIA, epilepsy)

 EASY WAY TO REMEMBER:
❑INFECTION-----Meningitis, UTI, Pneumonia, GE
❑CNS------Stroke/TIA, Trauma, Tumor , Epilepsy
❑CVS---- MI, arrythmia, CCF
❑ELECTROLYTE----
❑ENDOCRINE-----DM , Thyroid
❑EYES & EARS
❑MEDICATION
❑MOOD
HISTORY:
❑History of presenting complaints:
❑DDx:
❑Infection: any fever , rash? Cough , SOB ? How about your water works and bowel
habit? Any pain or burning sensation during passing urine?
❑CNS: any difficulty with vision or speech? Any weakness in any part of the body?
Any injury to head? Any early morning headache/nausea/vomiting?
❑CVS: any chest pain, racing of heart?
❑ELECTROLYTE : any vomiting , diarrhea? Any dizziness or blackouts?
❑ENDOCRINE: Any hx of DM? any weather preference?
❑EYES and EARS
❑MOOD
❑PMHx
❑Medication( AMC CASES: ketamine induced/ Digoxin induced/ Indapamide
induced)
❑SADMA
❑Fhx
❑Social hx and support
QUES: GP setting. An elderly man in nursing home, long history of HTN, DM, on medication
imipramine, atenolol and Indapamide (a bit long stem), he has developed tired, confused
and strange behavior for the last couple of days. investigations showed:
Na 120 (low)
Ka (normal)
Cl (normal)
HCO3 (normal)
Urea (normal)
Creatinine (normal)
Tasks:
• Explain the results to the patient's daughter
• Explain the possible cause of the condition of the patient
• Advice your management plan
❑Greet the daughter
❑Show empathy: I am really sorry to hear about your father , but pls don’t worry we will do our
best to manage his condition. Before I discuss with you about his condition I would like to talk
with my examiner for a moment.
❑Check Guardianship
❑Explain the Condition: Based on the symptoms of your father I am suspecting he is having a
condition called delirium or acute brain syndrome. This is a condition characterized by sudden
onset of confusion , fluctuating level of consciousness and sometimes perceptional
disturbances.
❑There are many possible causes of that condition; therefore, we have to order several
investigations. Right now, I am having the test results of his electrolyte level which are minerals
in our blood system .As you can see here, all the levels are in the normal range except the level
of sodium which is low. We call this hyponatremia or low sodium in the blood. This can be the
possible cause of his confusion.
❑This low sodium could be due to many reasons like it could be due to severe vomiting,
diarrhea, excessive sweating, kidney/liver/heart failure or sometimes it could be due
to some medication.
❑Ask few question to find out the cause
❑Apart from this, delirium has many other reasons like infection of brain/urine/lungs,
stroke or head injury, brain tumor, hormonal disturbances like DM/Thyroid etc.
❑That’s why what we need to do at this stage is to arrange transferring your father to
the hospital, there are special units called Delirium unit that deal with such condition
very effectively.
❑In the hospital your father will be managed by a MDT including doctors, nurses and
allied health services. They might do a complete delirium work up including checking
his blood and urine as well as necessary imaging . A CT scan of the brain might be
required to rule out any brain abnormalities.
❑They will review his medication and if needed they will change it accordingly.
❑They will repeat his blood test and replace his electrolytes/ minerals accordingly.
❑Also, they will allow presence of family member with him, cause, it will help him
to be reoriented and more familiar with the environment. They will keep your
father under close monitoring and observation in a calm and quite room with
subdued lighting and ambient temperature.
❑Please don’t worry, its not very uncommon condition in this age group. We will do
everything possible to make him as comfortable as possible. Do you want me to call
anyone to be with you now?
Ques: You are a night intern in a general hospital and your next patient is a 25 years old
male student with 20% partial thickness burn sustained when throwing fuel on fire. The
burns involving all the limbs are being managed conservatively and have been dressed
under IV ketamine. You have been called because the patient is unable to sleep, restless and
distressed and has pulled out the IV line delivering PCA which is morphine 1mg/hr.

TASKS
1. Determine the cause of sleeping problem
2. Explain to the patient the nature of the problem
❑History:
❑May I know a bit more about what happened? When did it happen? How were you
brought to the hospital? Do you know which hospital you are admitted and for how long?
❑I understand you’re unable to sleep. May I know the reason for it? For how long is this
happening to you? Do you hear or see things when nobody else is around? Do you think
somebody is trying to hurt you? By any chance, do you think of harming yourself or others?
❑Do you feel pain at the moment?
❑How is your general health? Do you feel feverish? Any headaches, SOB, racing of heart, or
tummy pain?
❑How’s your appetite? Do you have N/V? What about your waterworks or bowel motions?
Any pain or burning sensation?
❑Are you comfortable in this hospital environment?
• PMHx: Any condition like diabetes, thyroid, liver, kidney, or heart disease, anemia? CVA?
Mental/psychiatric illness ?Previous hospitalization? Previous similar episodes?
• SADMA?
• FHx of psychiatric illnesses?
• How’s your home situation?

EXPLAIN:
❑Most likely you have a condition called delirium or acute brain syndrome. This is a
common complication of major injuries and their treatment such as your burns. It will get
better along with your recovery. Your visual problems and fears are part of it and do not
mean that you have a mental illness.
❑We need to find out the cause. In your case, pain relief medication (ketamine/morphine)
may be the cause, But there are many other reasons of such condition----give all ddx
❑That’s why we need to arrange a complete delirium work up:
BLOOD==FBC, ESR/CRP, LFT, RFT, TFT
URINE== Urine MCU , Urine Na and osmolarity
IMAGING= CXR, ECG, CT SCAN of brain
❑I will let the nursing staff know about your concern so that they will take extra care for you
and explain what they are doing (assign same staff each shift to care for the patient).
❑ Environmental disturbances like lighting and noise will be addressed for your benefit. If you
want your family/friends to be here, I can help with that.
❑You will also be seen by a physician registrar to give some medication to help with your
sleep and arrange other painkillers if required.
Facial pain
• Case:
Question: middle aged lady presented with right sided facial pain for
some weeks.
Task:
• history
• pefe
• diagnosis and dd to patient
D/D of Facial Pain:

• Dental pathology
▪ Parotid gland: Infection
• Eye disorders
▪ Temporal Arteritis
• EAR infection
▪ Chronic paroxysmal hemicrania
• Nose: Rhinitis, sinusitis
▪ Cervical spinal dysfunction
• Mouth: Ulcer/ Cancer/ Tonsillitis
• TMJ dysfuction
• Erysipelas
• Herpes zoster
• Trigeminal neuralgia (tic douloureux
• Glossopharyngeal neuralgia
• Migrainous neuralgia (cluster
headache
History:
▪ Greet and introduce.
▪ Offer analgesia.
▪ Pain Questions:
▪ D/D Ques
▪ PMHX
▪ SADMA
▪ FHX
Trigeminal Neuralgia:
▪ Patient over the age of 50.
▪ Quality: excruciating, searing jabs of pain like a burning knife or electric shock
▪ Frequency: variable and no regular pattern
▪ Duration: seconds to 1–2 minutes (up to 15 minutes)
▪ Onset: spontaneous or trigger point stimulus
▪ Offset: spontaneous
▪ Precipitating factors: talking, chewing, touching trigger areas on face (e.g. washing,
shaving, eating), cold weather or wind, turning onto pillow)
▪ Relieving factors: nil
▪ Associated features: rarely occurs at night; spontaneous remissions for months or
years
Explain:
▪ Most likely you have got a condition called TN which is the pain arising from the
nerves that supply your face known as Trigeminal nerve.
▪ The exact cause why it occurs is not known but it is thought to be caused by
compression of the nerve by a loop of artery or vein.
▪ In this case, the pain usually comes very suddenly which feels like an electric
shock or sharp stabbing pain lasting for a few sec to minutes. It usually gets
aggravated with talking, chewing, touching trigger areas on face (e.g. washing,
shaving, eating), cold weather or wind, turning onto pillow etc. There is no
investigations to confirm it, usually can be diagnosed by clinical signs and
symptoms.
▪ Please don’t worry, its not a serious condition and the pain can be managed with
effective painkillers.
▪ Give DDx