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Dental Pain

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You are called to the house of a 39y/o male at 4am for dental pain. He tells you that is left upper wisdom tooth has been bothering him for 3 days. It woke him up this morning and while he was using some mouthwash he developed a severe headache which is why he called you. As you walk in the room he has one episode of vomiting.

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Clearly ebola and not herpegonsyphilitis. Run away.


Contents of the vomit? First episode or have there been previous?

Pulse, BP, rr, SpO2, ecg when there's time.

Skin conditions; including an accurate temp.

Look in his mouth; any bleeding, pus, discoloration, abscesses, swelling?

Why does he think it's his wisdom teeth? Previous problem with them?

Any other complaints? Recent illness? Drug use/abuse?

Medical history? Medications?

39 is a bit old for it to be impacted, but I guess that could be the case. Or a dental abscess of one type or another. Or the stereotypical withdrawal from narcotics...in all seriousness that should be on the list of differentials, though you can rule it out relatively easily.

Edited by triemal04

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Contents of the vomit are unremarkable. This was the first episode. He is missing a few teeth. The painful tooth is the left upper wisdom tooth, which is fractured at the gum (not a new finding). There is no gum swelling and mild pain with percussion of the tooth. No bleeding, pus or other abnormalities. He has had episodes of pain with the tooth before, but has never had a headache like this. No sick otherwise, no history of drug use/abuse. Your fancy ambulance has access to hospital records and the state drug database, both of which are unremarkable. No medical problems or medications other than some Motrin he's been taking for the tooth pain.

P88 BP 143/90 RR 18 SpO2 99% on room air, skin is cool to the touch and dry. Tympanic temp is 35.2C. He is pulling the blanket over his head because the light bothers him

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Dental pain especially in the upper left jaw associated with nausea and photophobia, I would say he had a migraine.

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Think outside the box. I have had 2 cases like this. Work him up to rule out AMI with 12 Lead. My cases were both atypical presenting heart attacks.

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Your 12 lead is normal.

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What is his mental status? oto/rhinorrehea? Neuro check? Stroke s/s?

Dental abscess that has "migrated" to the brain. Mouthwash followed the tract and is now in the brain. My $0.02.

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He is A&OX3/4, No -rhea, Normal neuro exam. There have been a few good ideas, but let's develop a full differential.

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The headache and photophobia could certainly be a migraine; history of the same?

Maybe an infection that has spread to the sinus cavity; it's certainly odd that his temp is down, unless that's just due to the environment he's in.

Maybe a nerve has gotten stimulated from the mix of the broken tooth/mouthwash combo.

Chem7, cbc, CT of head/neck.

Any changes with positioning or head movement? Palpation to the face?

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