RACGP KFP 2016.1.4 Bryan has facial pain

by | Feb 6, 2018

Bryan, a 32 year old man presents to your rural hospital around 6am on a Sunday with an extremely severe stabbing pain in his face on the right side.  It has been present for 45 minutes.  He reports he has now had 7 attacks like this around the same time every day over the past few weeks but usually only last 15 minutes.    He smokes and drinks quite heavily most weekends.   He has no other medical history and takes no regular medications.

What is the single most likely diagnosis? List 1

  1. Cluster headache

GPCC – The intent of this stem is to be pathognomonic for cluster headaches.

What further assessment in history or exam do you want to take that will further support your diagnosis? List 4

  1. Ipsilateral lacrimation
  2. Ipsilateral conjunctival injection
  3. Nasal congestion
  4. Ipsilateral eyelid oedema
  5. Ipsilateral miosis or ptosis
  6. Ipsilateral forehead and facial perspiration

RACGP – Whilst a significant proportion of the candidates gave the diagnosis they could not identify further aspects of the assessment, either history or examination to clarify their diagnosis.  Many candidates offered answers to assess any form of pain and so were not specific and did not gain marks.

GPCC – this is a straight question of the key features of history and examination in cluster headaches. Know your lists.

Other than investigations how would you manage this patients facial pain? List 4

  1. Oxygen (8 L/min for 10 minutes or 100% by mask)
  2. Sumatriptan s/c injection 6mg [OR Sumatriptan 20 mg intranasally]
  3. Bridging therapy prednisolone 50 mg orally, once daily for 5 days, then reduce daily dose by 12.5 mg every 3 days, then stop
  4. Prophylactic Verapamil PO 80mg tds
  5. Reduce/cease alcohol

RACGP – In the management section candidates were asked to provide answers other than investigations.  Despite this, there were many candidates who offered investigations, which whilst appropriate did not answer the questions.  This is a common error in the KFP: Providing answers not relevant to a focussed question such as, ‘other than investigations how would you manage this patients’s facial pain?’  Many answers were nonspecific such as ‘analgesia’ or ‘educate’.  Broad general answers will not gain marks, it is important to be specific: which analgesia/medication, educate about what?  A good answer also focussed on all aspects of management and not simply listing all the possible medications.

GPCC – Again a straight list regurg – “what are the key features of management in cluster headaches”. Know it.

RACGP Feedback

In this case we find a 32 year old male with unilateral severe facial pain.  Candidates are asked for a single diagnosis, given the classic presentation, and the subsequent assessment and management of this presentation.

Whilst a significant proportion of the candidates gave the diagnosis they could not identify further aspects of the assessment, either history or examination to clarify their diagnosis.  Many candidates offered answers to assess any form of pain and so were not specific and did not gain marks.

In the management section candidates were asked to provide answers other than investigations.  Despite this, there were many candidates who offered investigations, which whilst appropriate did not answer the questions.  This is a common error in the KFP: Providing answers not relevant to a focussed question such as, ‘other than investigations how would you manage this patients’s facial pain?’  Many answers were nonspecific such as ‘analgesia’ or ‘educate’.  Broad general answers will not gain marks, it is important to be specific: which analgesia/medication, educate about what?  A good answer also focussed on all aspects of management and not simply listing all the possible medications.

Further reading

 

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