Background:

This case is designed for Allied Health professions students in the 2nd or 3rd year of their program (dentistry, nursing, medicine).

Key Objectives:

By the end of this iPBL activity of Facial Pain, learners will be able to stepwise manage the patient with the following clinical objectives:

1. List and interpret the important clinical findings, including history and physical examination with emphasis on the following:
2. Review of the pain history (including past treatments), psychosocial and other functional impairment.
3. Identify signs of neurological impairment and other differential causes of pain or numbness for e.g. vascular insufficiency;
4. List and interpret possible appropriate investigations which may include:
5. Screening investigations for underlying medical conditions (e.g., fasting glucose, chest X-ray);
6. Nerve conduction studies;
7. Vascular studies;
8. Construct an effective initial management plan, including:
9. Discussing possible drug options;
10. Counselling, including prevention of progression (e.g., chronicity of symptoms, exercise, activity modification);
11. Optimal treatment of any underlying medical conditions (e.g., diabetic management);
12. Determining whether the patient needs a referral to a pain clinic or pain specialist.

Interprofessional Teamwork Objectives:

During this iPBL activity of Facial Pain, learners will develop knowledge, skills, attitudes and behaviours for effective interprofessional collaborative practice including:

4.1 Role Clarification

1. Describe the student’s professional role.
2. Describe the role of other professionals.
3. Identify professionals who could contribute to the care of the patient.
4. Access others’ skills and knowledge appropriately through consultation.

4.2 Team Functioning

1. Identify the principles of team dynamics and group processes that enable effective Interprofessional team collaboration.
2. Demonstrate skills of effective team membership.
3. Respect team ethics including confidentiality and professionalism.

4.3 Interprofessional Communication

1. Communicate with each other in a collaborative, respectful and responsible manner.

4.4 Collaborative Leadership

1. Investigate resources, including community resources, social service agencies and government programs, and articulate how they may contribute to quality care.
2. Participate in a shared leadership role within the iPBL group.
3. Demonstrate leadership and decision-making behaviours that are likely to contribute to group effectiveness.

4.5 Patient/Client/Family/Community-Centered Care

1. Seek out, integrate and value, as a partner, the input and engagement of patient/client/family/community in designing and implementing care/services.

4.6 Interprofessional Conflict Resolution

1. Identify common situations that are likely to lead to conflict, including role ambiguity, power gradients and differences in goals.
2. Set guidelines for addressing disagreements.
3. Establish a safe environment in which to express diverse opinions.

A note on the role of the facilitator:

“The teacher (facilitator) serves as both a monitor and stimulus to the process by asking leading questions, challenging thinking and raising issues or points that need to be considered. The teacher (facilitator) attempts to help students help themselves in the educational process” (Barrows & Tamblyn, 1980)

Day 1, Part 1:

Case Info:

Tutor Probes:

1. What are the possible causes of Jane’s pain?
2. What do you think of her statement that the pain “felt like an electric shock”?
3. How is the pain affecting Jane’s ability to function?
4. Would this pain keep Jane from working?
5. What is the mechanism of action of ibuprofen?
6. Are there other modalities besides pharmaceuticals for treating pain?
7. Why did Dr. Tong prescribe Ciprodex? Do you agree with this?
8. How soon after treatment with antibiotics would a patient usually experience resolution of their symptoms?
9. What is the appropriate treatment for otitis media?
10. Is this a usual presentation of an ear infection? What other symptoms might Jane have? What symptoms are atypical of otitis media?
11. What challenges do medical offices face when booking emergency patients?
12. Do you think Jane is correct in seeking a second medical opinion?
13. What barriers do patients face in seeking second opinions in their medical care?

Day 1, Part 2:

Case Info:

Tutor Probes:

1. What do you conclude from Jane’s vitals?
2. Why might Jane’s blood pressure be elevated?
3. How do you balance a patient’s pain with the responsibility to complete a proper physical examination?
4. What do you think of Dr. Patterson’s statement: “not sure what Dr. Tong was thinking”? Is this appropriate from a professionalism perspective?
5. What is the difference between Tylenol #3 and regular Tylenol?
6. Is it appropriate to prescribe opioids in this situation?
7. What challenges do patients, prescribers, and society face re: opioid prescribing?
8. What information should Dr. Patterson provide when making a referral to the neurologist?
9. What information should Dr. Patterson provide when making a referral to the oral maxillofacial surgeon?
10. If you were referring a patient urgently, how would you communicate with the specialist?
11. If you were the specialist, how would you like your colleague to communicate with you?
12. How important is person-to-person communication (i.e. telephone conversation) between medical professionals?
13. Are there other questions Dr Patterson could have asked Jane?
14. Apart from examining the ear, what other examination do you think Dr Patterson should have done?
15. Are there investigations Dr Patterson could have ordered to tailor the diagnosis or exclude differentials while awaiting specialist consult?

Wrap-up Questions:

1. What is the differential diagnosis of a patient complaining of facial pain?
2. What are the important investigations required to narrow down the diagnosis?
3. Why is it important to quickly reach a decision, what are the most serious complications?

Day 2, Part 1:

Case Info:

Tutor Probes:

1. How do you think Jane’s pain is affecting other parts of her life, including her work?
2. How do you measure the severity of pain?
3. Did Jane experience a temporary remission of pain? How can the pattern of her pain help us diagnose her condition?
4. What should Jane be aware of when she is researching her medical conditions online?
5. What are the benefits of patients accessing medical information online?
6. What are the drawbacks of patients accessing medical information online?
7. What other avenues do you think Jane should be considering to help diagnose or manage her pain?
8. What could be a possible psychological effect of Jane isolating herself?
9. What aspects of Jane’s case might lead you to rule in/out the differential diagnoses she has suggested (i.e. migraine, cluster, sinusitis)?
10. What diagnosis do you think Jane is most concerned about? What are different ways to ask patients about their concerns/ideas about a diagnosis? How does uncovering a patient’s concerns improve the therapeutic relationship?
11. Is it appropriate to mention worst case scenarios? How do you balance this with not creating fear or anxiety in a patient? How much information is enough?

Day 2, Part 2:

The following week, Jane visited Dr. Sara, an Oral Surgeon, who made her comfortable and listened carefully to what she had to say about her ordeal with the pain and the multiple visits to the GP. Dr. Sara performed an intraoral exam, a Temporomandibular Joint (TMJ) exam, and obtained a panoramic radiograph. Jane had one very small Class 1 cavity which was painless on probing and percussion and her TMJ was slightly stiff with tenderness in the masseter and angle of the mandible.  The panoramic radiograph showed no abnormalities.

Dr. Sara also conducted an extraoral examination of the face and found trigger zones that elicited the sharpshooting, stabbing pain Jane had described. The trigger zones were on the right cheek, right nostril, and upper lip. She then advised an MRI scan to rule out MS and prescribed Carbamazepine 50 mg four times a day till the MRI scan results were available.

A few weeks later, Jane had a follow-up appointment with Dr. Patterson to review the MRI results, which showed no evidence of intracranial lesions but noted a suspected vascular compression of the superior cerebellar artery. Dr. Patterson diagnosed Jane with Trigeminal Neuralgia, suspecting the etiology was related to the vascular compression noted on the MRI. Dr. Patterson contacted the neurologist’s office to make an urgent referral for Jane and adjusted the dosage of Carbamazepine to 100 mg twice a day, pending further treatment advice.

Tutor Probes:

1. How does Dr. Sara making Jane feel “comfortable” affect her ability to treat her as a patient?
2. How do you think Jane feels about having an MRI to rule out MS?
3. How does having to wait for test results affect patient’s psychological health?
4. In some provinces, electronic health systems allow patients to access their test results as soon as they are available on the EMR system (i.e. MySaskHealthRecord). What impact do you think this will have on patients’ health? What impact will this have on the patient’s relationship with the health care system?
5. When should Jane follow-up with Dr. Sara?
6. Are there non-medical options to help treat Jane’s pain?
7. What obstacles prevent patients from being able to take medications as prescribed?
8. Why do you think Jane’s medication was changed from 50 mg QID to 100 mg BID?
9. What other treatment options (including medications) can be used to treat trigeminal neuralgia?
10. What structures does the superior cerebellar artery supply? Can you explain the pathophysiology of Jane’s symptoms?
11. Are there surgical options to treat a vascular compression?

Wrap-up Questions:

1. How should Jane be counseled so that she can avoid possible progression of her illness?
2. How do you determine whether a patient needs a referral to a pain clinic or pain specialist?
3. How does Jane’s case demonstrate the importance of working together as an interprofessional healthcare team?

References

Barrows, H. & Tamblyn, R. (1976) An evaluation of problem-based learning in small groups utilising a simulated patient. Journal of Medical Education, 51., pp. 52- 54.

Cassidy, J. (2018). HIV/AIDS iPBL Case. University of Saskatchewan.

Davis, M., Harden, R. (1999). Problem-based learning: A practical guide. Medical Teacher, 21(2), 130-140.

Kedarnath, N., & Shruthi, S. (2015). MRI as an Essential Diagnostic Approach for Trigeminal Neuralgia. Journal of Maxillofacial and Oral Surgery, 14(Supplement 1), 462-464.