Neurology -Peer Comment- Marilyn

Peer Responses:

Relate to another journal article

• Marva, a 66-Year-Old female, presents to the office. She has a history of Multiple Sclerosis, hypertension and CVA 2 years ago with no residuals. She explains why she is here today and points at the temporomandibular right side of her face and reports pain that can become intolerable at times. She says that it comes in waves, lasting a couple of moments, and it feels like electric shocks. She says it can be aggravated simply by touching, and that some of her ADL’s including brushing her teeth and eating have been impacted. Provide at least 3 possible differential diagnoses and justify your rationale for each differential. Develop a therapeutic plan from data that is provided from the clinical practice guideline. 
• Among the possible diagnoses for Marva’s case study, there are three possibilities:

The pain Marva described as intermittent and severe, resembling electric shocks on the right side of her face is characteristic of trigeminal neuralgia (TN). Exacerbations with touch and impact on activities of daily living (ADLs), such as brushing teeth and eating, are consistent with TN symptoms. (Charles C Ho, 2023).

Given Marva’s pain, being located in the temporomandibular area, she may suffer from TMJ disorder. As a result of TMJ disorders, facial pain can be experienced, especially when moving one’s jaw (Mehta & Keith, 2024).

A possible cause of postherpetic neuralgia is previous herpes zoster (shingles) infection, given Marva’s age and multiple sclerosis history. Electric shock-like sensations may indicate PHN in the affected dermatome (Ortega, 2021).

The rationale for each differential

The trigeminal nerve distribution is affected by recurrent, sudden-onset, severe stabbing pain in people with trigeminal neuralgia (TN). Symptoms related to touch, for example, are aligned with the trigger factors. In this case, the intermittent nature of the pain is in line with the description (Ho et al., 2023).

In the case of TMJ disorder, facial pain is often experienced during chewing or talking activities. In Marva’s case, pain in the temporomandibular region affects her ability to eat and brush her teeth, suggesting a TMJ disorder. Further, MS patients may be more likely to sustain secondary complications, such as TMD(Mehta & Keith, 2024).

A shingles episode may increase Marva’s susceptibility to complications, including Postherpetic Neuralgia (PHN). Persistent pain and electric shock-like sensations are characteristic of PHN (Ortega, 2021).

Therapeutic Plan

Trigeminal Neuralgia (TN) treatment consists of anticonvulsant medications such as carbamazepine, oxcarbazepine, or a combination of these medications, such as carbamazepine and oxcarbazepine. A referral to a neurologist is recommended for further evaluation (Ho et al., 2023).

For Temporomandibular Joint Disorders (TMJ), suggest conservative treatment measures like jaw exercises, cold or heat therapy, and a soft diet. In the event of persistent symptoms, consult a dentist or oral surgeon for an evaluation and potential splint therapy (Mehta & Keith, 2024).

• In case of active herpes zoster, prescribe antiviral medications to prevent postherpetic neuralgia (PHN). The most effective pain management involves a medication like gabapentin or pregabalin, in conjunction with consultation with a pain specialist for comprehensive pain treatment (Ortega, 2021).

Overall, Marva needs to undergo a comprehensive clinical evaluation. Her specific findings during her examination should inform these differentials and therapeutic suggestions. The patient may referred to a specialist for a more detailed assessment and management plan.

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