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A 71-year-old A 71 year old female patient with controlled hypertension reports to the clinic with fatigue for 1 month, fever, headache present for 3 weeks, and loss of appetite.  She also reports intermittent vision loss in the right eye, pain in the jaw with chewing, and scalp tenderness, She is a smoker and takes clonidine, hctz, and estrogen.  Overall, she is well and fully active

 

 

 

Differential Diagnosis #1

1. Trigeminal Neuralgia ICD G50.0- Patient presents with pain in the jaw while chewing, affecting CN V motor function. No complaints of ipsilateral, episodic, severe facial pain lasting seconds to minutes.

Plan

Diagnostic Labs & Studies

• CMP to monitor baseline renal and hepatic function, and sodium levels prior to initiating treatment. Oxcarbazepine has been shown to cause hepatotoxicity and kidney dysfunction with long term use. It should be used with caution in the elderly and in those with liver disease. Treatment can also include clinically significant hyponatremia and those with conditions predisposing them to hyponatremia such as SIADH or hypothyroidism and should be closely monitored.
  • NA: 135-145 mEq/L
  • Liver function tests: ALT- 7-56 units/L, AST- 10-40 units/L, Albumin- 35-55 g/L, Total bilirubin- 3-20 umol/L, Conjugated bilirubin 0-14 umol/L, Gamma-glutamyl transferase 0-40 IU/L, Alkaline phosphatase 90-300 IU/L
  • Renal function tests: Potassium- 3.5-5.0 mmol/L, Chloride 95-105 mmol/L, Serum creatinine 0.7-1.4 mg/dl, creatinine clearance- 88-128 ml/min, BUN- 14-23 mg/dl, GFR- >90.
• MRI to identify any secondary causes (such as tumors or multiple sclerosis). As well as to detect morphological changes of the trigeminal nerve- inflammation, demyelination, displacement, or degenerative changes (Domino et al., 2022, p. 1018).
• Medication treatment is contraindicated in those with AV block (Maarbjerg et al., 2017).  Anticonvulsants such oxcarbazepine “inhibit voltage- gated sodium channels and reduce membrane excitability in neurons and muscle and can be associated with cardiovascular effects” (Trileptal disease…, n.d., para. 16). Second and third- degree heart blocks have been identified after beginning treatment and thus, are contraindicated.

Treatment

Oxcarbazepine 300 mg oral twice daily for 4-6 weeks, depending on remission of condition (Domino et al., 2022).

Patient teaching

• Avoid stimulation (heat, cold, air) to trigger zones, including the lips, cheeks, and gums (Domino et al., 2022, p. 1018).
• Medication side effects- including diarrhea, constipation, abdominal pain, dizziness, visual disturbance, nystagmus, nervousness, or photosensitivity (Domino et al., 2022).
• Side effects to report to your healthcare provider- Nausea, vomiting, headache, confusion, fatigue, muscle weakness, twitching, cramps, seizures, restlessness, bad temper (Domino et al., 2022).
• Support groups- The Facial Pain Association and Living with Facial Pain (Domino et al., 2022).
• Call 911 or go to the nearest emergency room if they have trouble breathing, develop a rash, or become nauseated and begin to vomit.

Referrals

• For initial treatment failure with oxcarbazepine and carbamazepine, surgical referral can be made.
• Radiotherapy/radiosurgery with Gamma Knife radiation.
• CAM therapy with acupuncture has shown evidence of analgesic effect (Domino et al., 2022).

Follow up

Follow up in four weeks to monitor initial treatment efficacy and symptoms. Afterwards, every three months for the first year to monitor treatment, symptoms, labs- renal, hepatic, sodium levels.

Reference

 

Domino, F.J., Baldor, R.A., Berry, K., Golding, J., & Stephens, M.B. (2022). The 5-minute clinical consult 2022. Lippincott Williams & Wilkins.

ICD10Data. (2021). 2021 ICD-10-CM Diagnosis Code H40.219. Retrieved from

https://www.icd10data.com/ICD10CM/Codes/H00-H59/H40-H42/H40-/H40.219