Case 25: Ruby Chan

INSTRUCTIONS FOR THE DOCTOR

This is a short case.

Please take a history, conduct a focused examination and outline your diagnosis and management plan to the patient.

The following information is on Ruby’s summary sheet:

• Past medical history

• Two children

• One termination of pregnancy aged 16

• Medication

• Nil

• Allergies

• Nil known

• Immunisations

• Nil known

• Pap smear

• Up-to-date

• Social history

• Works at the Memo Club

• Non-smoker

• Alcohol intake—special occasions only.

INSTRUCTIONS FOR THE PATIENT, RUBY CHAN

You are a 40-year-old woman who has had facial pain for a few days. It is getting worse and it kept you awake last night. You have had a cold and are overdue for a check-up at the dentist. The nearest dentist is over 50 km away. The pain is worse when you chew food. You have a slight headache but this does not get worse on bending forwards or sneezing. Your sense of smell is undisturbed.

Your father died of cancer of the tongue. You have never been sure exactly what this is, but it does mean that you are more concerned than normal about your pain being something serious. You would like the doctor to find this out but will not reveal this unless asked appropriately.

Instructions for the facilitator

The candidate should perform a focused oral examination.

Clinical examination findings

Tapping of one of your molars gives you significant pain.

The following information is on your medical record:

• Past medical history

• Two children

• One termination of pregnancy aged 16

• Medication

• Nil

• Allergies

• Nil known

• Immunisations

• Nil known

• Pap smear

• Up-to-date

• Social history

• Works at the Memo Club

• Non-smoker

• Alcohol intake—special occasions only.

SUGGESTED APPROACH TO THE CASE

Establish rapport

Open-ended questions to explore Ruby’s ideas, concerns and expectations.

Specific questions

Ask about the pain, e.g. using OLD CARTS acronym

• — Onset

• — Location

• — Duration, diurnal variation

• — Characteristics—worse on chewing

• — Associated symptoms

• — Relieving factors

• — Treatment tried so far

• — Severity

Exclude systemic symptoms—weight changes, energy level, sleep disturbance

Request permission to examine.

Examination

Temperature

Inspect and/or palpate head and neck

Check teeth, lymph nodes, skin, eyes, salivary glands, temporomandibular joint, cervical ...