Respond to the 2 following discussion posts separately with separate reference lists. References to be no older than 5 years.
1. [Natalie Belvin] Based on the patient’s abrupt onset of severe pain and the ruling out of dental complications, the differential diagnosis to be considered is Trigeminal Neuralgia (TN) Temporal Mandibular joint pain, and Migraine Headache.
Primary trigeminal neuralgia (PTN) is the leading differential diagnosis. It is common neuralgia caused by the compression of an aberrant tissue associated with the trigeminal nerve. The latest classification system identifies TN as either classical or idiopathic TN based on the degree of neurovascular contact or secondary TN caused by pathology other than neurovascular contact. It is severe, unilateral, paroxysmal, and recurring pain that can severely impact the quality of life (Hollier, 2021). TN usually occurs in middle-aged and elderly people (Hollier, 2021)
The therapeutic plan includes Carbamazepine 100 mg PO twice a day in increments of 100 mg PO q 12 hours. Max: 1200 mg PO/24 hours (Hollier, 2021) Non-pharmacological management includes avoiding extreme temperatures such as cold, heat, or even soft touch to the facial areas, as this can aggravate the pain (Hollier, 2021). Surgical decompression, nerve ablation, and nerve block of the fifth cranial nerve are recommended (Hollier, 2021). Acupuncture has also a recommended treatment option (Hollier, 2021)
Migraine is a complex disorder characterized by recurrent episodes of headache, most often unilateral and in some cases associated with visual or sensory symptoms (Medscape, 2021) Migraine is most common in women and has a strong genetic component (Medscape, 2022) Physical findings during a migraine headache may include the following Cranial/cervical muscle tenderness (Medscape, 2021)
Pharmacologic agents used for the treatment of migraine can be classified as abortive or alleviating or prophylactic. Acute treatment aims to reverse, or at least stop the progression of, a headache. It is most effective when given within 15 minutes of pain onset and when pain is mild. (Medscape, 2021).
Zomig 2.5 mg PO q46 hours PRN pain is often used to treat migraines. Selective serotonin receptors, agonists (triptans), and Serotonin 5-HT1F agonists. Reduction of migraine triggers such as a lack of sleep, fatigue, stress, and certain foods. Nonpharmacologic therapy includes biofeedback, cognitive-behavioral therapy, and Integrative medicine such as riboflavin, magnesium, and coenzyme Q10)
TMJ disorder includes chronic facial pain and mandibular dysfunction. It appears to be multifactorial in origin. Et al, 2011. Studies suggest that TMJ disorders increase with age with and are seen most often in females. Clinical symptoms may include self-reported facial
The temporal mandibular joint (TMJ) is the synovial joint that connects the jaw to the skull. These two joints are located just in front of each ear. Pain and functional disturbances related to the TMJ are common (Medscape, 2022).
Signs and symptoms of temporomandibular joint (TMJ) disorders improve over time with or without treatment for most patients (Medscape, 2022). As many as 50% of the patients have a symptomatic improvement in 1 year and 85% in 3 years (Medscape, 2022). Therapeutic treatment for TMJ syndrome includes, attempting conservative measures before invasive therapies, such as a mouth guard, orthodontics, or surgery, are recommended, Analgesics – Nonsteroidal anti-inflammatory drugs, such Motrin 800 mg PO q 4 hours PRN pain, Muscle relaxants – Benzodiazepines, moist heat, and massage of masticatory muscles (Medscape, 2022). A thorough intake assessment and physical assessment are necessary to accurately diagnose this patient.
References
Amelie Hollier, DNP, FNP-BC, FAANP. (2021). Clinical guidelines in primary care, 4th edition (4th ed.). Advanced Practice Education Associates, Inc.
Ding, L., Chen, R., Liu, J., Wang, Y., Chang, Q., & Ren, L. (2022). The effect of functional mandibular advancement for adolescent patients with skeletal class ii malocclusion on the tmj: A systematic review and meta-analysis. BMC Oral Health, 22(1). https://doi.org/10.1186/s12903-022-02075-8
Migraine headache: Practice essentials, background, pathophysiology. (n.d.). Retrieved 2022, from https://emedicine.medscape.com/article/1142556-overview
Montinaro, F., Nucci, L., d’Apuzzo, F., Perillo, L., Chiarenza, M., & Grassia, V. (2022). Oral nonsteroidal anti-inflammatory drugs as treatment of joint and muscle pain in temporomandibular disorders: A systematic review. CRANIO®, 1–10. https://doi.org/10.1080/08869634.2022.2031688
2. [Crystal Loveland-Davis] This scenario is multifactorial, but the factors are cyclical. The whole backstory is not presented, but we know the patient was suffering from depression and was supposed to be taking medication to assist with her symptoms. Unfortunately, this patient was unable to afford her medicine. Following the nursing process, the nurse practitioner should first assess how the patient is currently. The PHQ-9 is a reliable depression screening tool for primary care; nurse practitioners can use the patient-provided questionnaire feedback to guide the conversation and determine a treatment plan (Costantini et al., 2021). The patient’s feelings of not being able to go on should be addressed and suicidal thoughts should either be ruled out or treated immediately if identified. Once the patient’s current mental status is addressed, historical factors, including the patient’s choice not to take her medication, can be addressed, and the financial burden can be explored. Abell highlights that if a patient cannot afford their medications, it is highly likely that they are also struggling with other living essentials like rent, utilities, transportation, and food (2020). If the patient in this scenario is struggling with all of these items, providing her with support could help alleviate her hopelessness.
The nurse practitioner needs to find a way to support this patient and help her meet her needs, to not only treat the depression but also to improve her overall quality of life. Primary care clinicians should have a firm grasp on what community resources are available to help their patients, like state assistance food stamps and community food gardens (Abell, 2020). Personally, clinicians can write for generic medication, call the pharmacy or instruct the patient to call the pharmacy to ask for the medication cash price, provide coupon cards or manufacturer discount program information, and look for medication price if the patient were to change pharmacies (Abell, 2020). Nurse practitioners must be the bridge of knowledge connecting their patients to supportive resources to ensure medication compliance and improve overall health and quality of life.
References
Abell, A. (2020). Medication adherence suffers because of high drug costs. Pharmacy Today, 26(4), 29–30. https://doi.org/10.1016/j.ptdy.2020.03.011
Costantini, L., Pasquarella, C., Odone, A., Colucci, M., Costanza, A., Serafini, G., Aguglia, A., Belvederi Murri, M., Brakoulias, V., Amore, M., Ghaemi, S., & Amerio, A. (2021). Screening for depression in primary care with patient health questionnaire-9 (PHQ-9): A systematic review. Journal of Affective Disorders, 279, 473–483. https://doi.org/10.1016/j.jad.2020.09.131
