OK, Gang. Here is my clinical note from a patient that I saw today. I am truly stumped by some weird symptoms, and I'd love to have some ideas from anyone who finds interest. Namely, I'm confused about what feet have to do with throbbing toothaches! Thanks for your help in advance....

Kevin

SUBJECTIVE: Patient, an ambulatory 50-year-old woman who states that she was "very healthy" until October 10, 2016, was referred by Dr. X to evaluate complaints of atypical facial pain and to rule out trigeminal neuralgia. Consulted with Dr. X prior to patient's appointment via telephone and received copy of his clinical findings.

CC: "I have constant pain in my left and right jaws, a machine noise in both ears, and tingliness in my feet. I also get random dizziness and severe left side ear aches. I feel like I'm being shocked 24/7."

Questionnaires: On a scale of 1-10, patient reports her jaw function on average as a "2" per rdc/tmd questionnaire. Patient completed a GAD-7 anxiety questionnaire with a score of 9, suggesting significant likelihood of anxiety. Pain diagram completed by patient included

Med Hx: Heart murmur, recurrent herpes labialis, previous chicken pox (no zoster vaccine), "sinus trouble," acid reflux. Medications: allergy to morphine, has been taking various antibiotics, which seem to make her pain "better." Allergy to peanuts that seems to have begun around the onset of present illness.

Hx of Present Illness: Patient can pinpoint the exact date when her symptoms began: October 10, 2016, when she experienced what was diagnosed as a severe "anxiety attack" where she felt "a crushing chest." On September 16, 2016 a "machine noise" began in both ears with excruciating left ear paroxysms, which have continued to present. "Random dizziness" is experienced. Patient reports that she has "severe" daily headaches that create a band-type, dull, aching pain bilaterally and extending occipitally. Patient reports that her ear pain is worsened by "any medication that is taken for more than a couple of doses except antibiotics." Specifically, a course of prednisone exacerbated her pain. Patient describes her lateral neck and jaw pain as dull, aching, and moderate in intensity that is made worse by chewing hard or tough food. Patient denies pain in the jaw joints, but she reports that she occasionally has had "some clicking once in a great while" in her left TMJ.

Patient sought care from Dr. VH as a new patient for a toothache on January 8, 2018 (previous dentist was L DDS, who she had not seen for several years). Dr. VH extracted molar root tips in the upper left quadrant and then removed at least 3 more teeth at patient's request because she insisted that her pain was due to a problem with her teeth. She also experiences some rhinitis after the first extraction; upon referral to ENT by Dr. VH, patient was evaluated by an ENT (she did not recall the physician's name today) who ruled out sinus infection. She reported that when she has pain in her teeth, it was "pulsing," and when her teeth hurt, she had tingling pain in her feet. When first given an inferior alveolar block by Dr. VH on the left side, the symptoms in the feet was temporarily relieved for the duration of anesthesia. (Reviewed Dr. F's clinical note; confirmed his findings except patient declines any history of tooth pain on the right side.)

Patient has seen multiple specialists who have done many tests, including a Lyme Disease expert in Pennsylvania, a rheumatologist, an infectious disease specialist, and a neurology visit is scheduled with Dr. S for next week. Patient reports that Lyme titer and Rheumatoid factors are negative in recent blood tests.

Patient reports that she also has developed "lumps around her ribs since this all began" and reports bilateral dermatomal pain around her ribs. Patient describes her pain in her jaws and abdominal area as "tugging pain, not sharp shooting." She reports that the paroxysmal pain her in left ear lasts in attack so seconds to minutes.

Social history: Non-smoker. Married. Minimal alcohol use.

Hobbies: Avid camper and kayaker; Enjoys watching dirt track racing.

Imaging history: 2 CBCT exams by Dr. VH (not available for review today), one hospital CT of the sinuses the report "TMJs intact."

Patient states that she is "resistant to medication use." However, she wants to know why she is having pain. She is willing to consult with a psychiatrist; referred to Dr. SB and discussed neuropathic pain process.

Patient requested new CBCT to rule out dental infection; discussed risks of radiation and option of panoramic.

OBJECTIVE:

CN exam unremarkable; PERLLA.

Mallampati: IV

Intra/Extra oral mucosa: multiple nevi and freckles external; normal skin temperature; symmetrical appearance; intraoral soft tissues unremarkable. Recent crestal incisions left quadrants appear to be healing within normal limits.

Muscles of Mastication unremarkable except:

Left masseter origin +++ tenderness to palpation with jump sign

Left sternocleidomastoid bifurcation +++ tenderness to palpation with jump sign and referral upward retroauricularly (positive response to triggerpoint injection with immediate pain relief)

Left sternocleidomastoid anterior belly ++ tenderness to palpation with no referral (positive response to triggerpoint injection with immediate pain relief

No resistance to bimanual guidance

TMJs: bilateral crepitus; negative vertical load test; no pain to palpation around joints or over lateral poles; occasional click on the left side without pain reported by patient but not reproduced today.

Range of Motion: Pain free opening 45mm, maximum unassisted opening 57mm, maximum assisted opening 58mm; protrusion 13mm, right excursion 9mm, left excursion 11mm; corrected deviation on opening

Occlusion: Angle's Class II, Div. 2 with left anterior crossbite and bilateral group function with anterior coupling; inadequate posterior support.

Dentition: Multiple intracoronal restorations with multiple visible cracks, especially on maxillary right molars (2 and 3).

Radiographic findings (pending radiologist's review): recent extraction sites unremarkable, widened PDL mesial buccal cusp #2; bifid condyles with left subchondral cyst formation; mucosal thickening right and left maxillary sinus floor, thickened mucosa over inferior concha with apparent contact with nasal floor.

Dental testing: Teeth #2 tests vital with normal response to cold, percussion, and selective occlusal pressure

ASSESSMENT:

Differential diagnosis of present condition:

Toothache of Cardiac Origin

Ramsey-Hunt Syndrome with Post-herpetic neuralgia

Acoustic Neuroma or other neoplasm

Neuralgia of the Nervus Intermedius

Fibromyalgia with Myofascial Pain Syndrome

Chronic Tension-Type Headache

Lyme Disease

Somatoform Pain Disorder

Preliminary Diagnosis: 1. Toothache of Cardiac Origin 2. Fibromyalgia with Myofascial Pain Syndrome 3. Ramsey-Hunt Syndrome with post-herpetic neuralgia

Rationale for preliminary diagnosis: Lyme Disease was ruled out by unremarkable Lyme titer. Definitive onset correlating with acute anginal event and generalized presentation is consistent with toothache of cardiac origin. Paroxysmal pain of left ear, tinnitis, and generalized abdominal superficial symptoms are consistent with Ramsey-Hunt Syndrome and post-herpetic neuralgia. Palpable trigger points with referral of the SCM that significantly reduces pain in the left jaw and neck is consistent with myofascial pain; generalized symptoms are consistent with fibromyalgia. Symptoms are consistent with centralization of pain; somatoform pain disorder and neoplasm must be ruled out.

Recommendations: EKG and MRI of brain and extracranial areas, including the TMJ region and Meckel's cave region. Trial with gabapentin or pregabalin and/or SNRI; consider CBT and/or acupuncture therapy (patient states that she is resistant to medication).

Referrals: Maintain appointment for evaluation by neurologist; schedule evaluation with a psychiatrist.

PROCEDURES:

Intra/extraoral clinical head/neck examination. CBCT of the maxilla, base of skull, and mandible taken and sent to Dr. Dale Miles (oral/maxillofacial radiologist) for review. Pulp testing completed maxillary right quadrant. Diagnostic injections of left SCM bifurcation and clavicular belly and left masseter origin triggerpoints with .3ml Mepivocaine 3%: twitch response confirmed triggerpoint injection; immediate relief of jaw pain reported, and patient believed that her neuropathic symptoms in her feet were relieved as well. Advised gentle stretching of injected muscles.

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