Family medicine
Facial Pain
Facial pain is an unpleasant sensory experience localized to the face, arising from neurological, vascular, musculoskeletal, or sinus-related etiologies such as trigeminal neuralgia, temporomandibular disorders, or sinusitis.
Murtagh Diagnostic Strategy
| Category | Diagnosis | Key Discriminator | Cantonese Question / Finding |
|---|---|---|---|
| Probability Diagnosis | Acute rhinosinusitis | Facial pressure ↑ bending forward + nasal congestion/purulent discharge [3] | 「彎低身有冇痛啲？有冇鼻塞同黃綠色鼻涕？」 |
| Dental pathology (abscess, caries) | Localised to jaw/tooth, throbbing, ↑ hot/cold, swelling | 「有冇牙痛？食凍嘢熱嘢有冇痛啲？」 | |
| TMJ dysfunction | Dull ache at jaw joint, clicking, bruxism, stress | 「開口合口有冇聲或者卡住？訓覺有冇咬牙？」 | |
| Serious Not To Miss | Nasopharyngeal carcinoma (NPC) | Blood in postnasal drip, unilateral nasal obstruction, neck mass, CN palsies; endemic in southern Chinese [5] | 「痰有冇帶血？頸有冇粒嘢？面有冇痺？」 |
| Giant cell arteritis (GCA) | Age > 50, new temporal headache, jaw claudication, raised ESR, visual loss risk [4] | 「你幾多歲呀？太陽穴痛唔痛？食嘢顎骨會唔會攰到痛？」 | |
| Intracranial lesion (tumour, abscess) | Progressive headache, focal neuro deficits, ↑ICP signs | 「有冇嘔、朝早頭痛、或者手腳冇力？」 | |
| Acute glaucoma | Severe periorbital pain, red eye, haloes, ↓vision, hard globe | 「個眼有冇紅痛？睇燈有冇彩虹圈？」 | |
| Pitfalls | Trigeminal neuralgia | Paroxysmal electric shock seconds in V2/V3, triggered by touch [1] | 「個痛係咪好似電到咁，掂到塊面就發作？每次幾秒？」 |
| Herpes zoster / post-herpetic neuralgia | Vesicular rash in dermatome; burning pain persisting after rash | 「塊面有冇出過水泡或者紅疹？」 | |
| Cluster headache | Severe periorbital pain 15–180 min + ipsilateral tearing/congestion, agitation [2] | 「個痛係咪圍住隻眼？有冇流眼水同鼻塞埋同一邊？」 | |
| Chronic rhinosinusitis ± polyps | Symptoms > 12 weeks, nasal blockage, ↓smell [3] | 「呢啲症狀有冇超過三個月？聞嘢聞唔聞到？」 | |
| Masquerades | Depression / somatisation | Vague facial pain + low mood, sleep disturbance, multiple somatic complaints | 「心情點呀？有冇周身唔舒服但搵唔到原因？」 |
| Diabetes → mononeuropathy | Known DM, sudden CN V pain/numbness [6] | 「你有冇糖尿病呀？」 | |
| Medication overuse headache | Chronic daily analgesic use | 「你有冇日日食止痛藥？食咗幾耐？」 | |
| Trying to Tell Me Something? | Fear of NPC (very common in HK) | HK endemic; family member with NPC; blood in sputum | 「你有冇擔心係咩大病呀？屋企人有冇試過鼻咽癌？」 |
| Work/social stress → TMJ/bruxism | Stress, jaw clenching, sleep disturbance | 「最近壓力大唔大？有冇咬緊牙關？」 |
6-Minute Consultation Structure
| Time | Task | Cantonese Key Phrases | Why It Scores Marks |
|---|---|---|---|
| 0:00–0:30 | Friendly opening, build rapport, set agenda | 「你好呀！我係今日幫你睇症嘅醫生。你點稱呼呀？今日有咩唔舒服呀？」(Hello, I'm the doctor seeing you today. How should I address you? What's bothering you today?) | Interpersonal marks: greeting, name, open question |
| 0:30–2:00 | HPI – characterise facial pain (SOCRATES) | 「呢個痛幾時開始㗎？邊度痛呀？」「痛係點樣痛呀？好似電到咁定係脹脹哋？」「有冇嘢會令到佢痛啲或者好啲？」 | Core symptom analysis – drives diagnosis |
| 2:00–3:00 | Red flags + targeted systems review | 「有冇發燒、流鼻涕、或者鼻塞呀？」「有冇嘢睇唔到、或者對光好敏感呀？」「面有冇痺痺哋或者冇力嘅感覺？」 | Rules out sinusitis, GCA, intracranial pathology |
| 3:00–3:30 | PMHx, DHx, allergy, FHx, SHx | 「你以前有冇咩病呀？食緊咩藥？有冇藥物敏感？屋企人有冇類似嘅問題？你做邊行㗎？」 | Completeness marks on CRF |
| 3:30–4:30 | ICE – Ideas, Concerns, Expectations | 「你自己覺得呢個痛可能係咩嚟㗎？」(Ideas) 「你最擔心啲咩呀？」(Concerns) 「你今日嚟想我幫到你啲咩呀？」(Expectations) | Marks-rich section – uncovers hidden agenda and RFC |
| 4:30–5:00 | Functional impact + psychosocial | 「呢個痛有冇影響到你瞓覺、返工、或者食嘢呀？」「最近壓力大唔大呀？心情點呀？」 | Biopsychosocial completeness |
| 5:00–5:30 | Summarise and check understanding | 「等我總結吓你講嘅嘢，睇吓有冇遺漏…」「我有冇講漏咗啲咩？」 | Signposting + summarising = interpersonal marks |
| 5:30–6:00 | Explain plan, safety-net, close | 「我初步覺得你可能係…我想幫你檢查吓同埋安排…如果痛得好犀利、突然間睇唔到嘢、或者發高燒，你一定要即刻返嚟或者去急症。」 | Safe closure, safety-net for red flags |
Uncovering the hidden agenda: The RFC (reason for consultation) is often NOT the pain itself. Ask 「點解揀咗今日嚟睇呀？」 (Why did you decide to come today?) — the patient may fear cancer (NPC worry in HK), fear stroke, or be unable to eat/work. This single question often reveals the real reason.
| Domain | English Question | Cantonese Question | Why It Matters | If Positive Think Of |
|---|---|---|---|---|
| Site | Where exactly is the pain? Point to it. | 「可唔可以指畀我睇邊度痛呀？」 | Localises to sinus/dental/CN V territory | Sinusitis (cheek/forehead), TN (V2/V3), dental (jaw) |
| Onset | When did it start? Sudden or gradual? | 「幾時開始痛㗎？突然定慢慢嚟？」 | Acute vs chronic narrows DDx | Sudden → TN paroxysm, SAH; gradual → sinusitis, TMJ |
| Character | What does it feel like? Stabbing/throbbing/pressure? | 「痛係點樣㗎？好似㩒住、電到、定係跳住咁痛？」 | Sharp, electric shock-like = TN [1]; pressure = sinusitis; throbbing = vascular | TN, cluster HA, sinusitis |
| Radiation | Does the pain go anywhere else? | 「個痛有冇去到其他地方？」 | Radiation to teeth → maxillary sinusitis; to ear → TMJ/NPC | Sinusitis, NPC, TMJ |
| Timing/Duration | How long does each episode last? | 「每次痛幾耐呀？幾秒定係成日？」 | Seconds = TN; 15–180 min = cluster; hours-days = sinusitis/migraine [1][2] | Key temporal discriminator |
| Triggers | Anything that brings it on? Touching face, chewing, bending forward? | 「有冇嘢會引發到佢痛？例如掂塊面、刷牙、食嘢、或者彎低身？」 | TN: triggered by touch/chewing/brushing teeth [1]; Sinusitis: worse bending forward [3] | TN vs sinusitis |
| Severity | How bad is it on 0–10? | 「由零到十分，有幾痛呀？」 | Documents severity; TN = excruciating | |
| Nasal Sx | Any blocked nose, runny nose, coloured discharge, loss of smell? | 「有冇鼻塞、流鼻水、黃綠色鼻涕、或者聞唔到嘢呀？」 | ≥2 symptoms (including ≥1 nasal) = rhinosinusitis diagnostic criteria [3] | Acute/chronic rhinosinusitis |
| Fever | Any fever or feeling unwell? | 「有冇發燒或者周身唔舒服呀？」 | Infection (sinusitis, dental abscess); GCA constitutional Sx | Bacterial sinusitis, dental abscess, GCA |
| Visual Sx | Any change in vision, double vision? | 「睇嘢有冇矇咗、重影、或者望唔到某一邊？」 | GCA → amaurosis fugax (sight-threatening) [4]; NPC → CN involvement | GCA, NPC, orbital complication |
| Jaw claudication | Pain in jaw when chewing that eases when you stop? | 「食嘢嗰陣個顎骨有冇痛，停咗就好返？」 | Jaw claudication = highly specific for GCA [4] | GCA |
| Temporal headache/scalp tenderness | Any headache at the temples? Sore scalp? | 「太陽穴嗰度有冇痛？梳頭有冇痛？」 | GCA features | GCA |
| Ear Sx | Any ear pain, discharge, hearing change? | 「有冇耳仔痛、流膿、或者聽力差咗？」 | Otitis media with referred pain; NPC with Eustachian tube involvement [5] | OM, NPC |
| Epistaxis/blood in postnasal drip | Any nosebleed or blood when clearing your throat? | 「有冇流鼻血或者痰入面有血呀？」 | Blood in postnasal drip significant for early NPC [5] | NPC |
| Neck lump | Any lump in the neck? | 「頸有冇摸到有粒嘢呀？」 | NPC most commonly presents with upper neck mass [5] | NPC |
| Numbness/weakness of face | Any numbness or weakness of the face? | 「面有冇痺痺哋或者冇力？」 | Neurological deficit → secondary TN, NPC invasion, stroke | NPC, secondary TN, MS |
| PMHx | Past medical history? DM, cancer, autoimmune? | 「你以前有冇咩病？糖尿、高血壓？」 | DM → mononeuropathy [6]; autoimmune → GCA/SLE | Diabetic CN V neuropathy |
| Drug Hx | What medications are you taking? | 「食緊咩藥呀？」 | Drug-related (e.g. overuse headache); anticoagulants relevant for procedures | |
| Smoking/alcohol | Do you smoke or drink? | 「有冇食煙飲酒呀？」 | NPC risk (smoking, salted fish – HK relevant) | NPC |
| Family Hx | Any family history of cancer or similar problems? | 「屋企人有冇人試過類似或者有癌症呀？」 | NPC familial clustering in southern Chinese | NPC |
| Occupation/stress | What do you do? Under stress? | 「你做邊行呀？最近壓力大唔大？」 | TMJ dysfunction a/w bruxism and stress; psychosocial assessment | TMD, psychogenic pain |
| Impact | Can you eat, sleep, work normally? | 「食到嘢瞓到覺返到工嗎？」 | Functional impairment → biopsychosocial | |
| Mood | Any low mood, worry, poor sleep? | 「心情點呀？有冇好擔心或者瞓唔著？」 | Depression as masquerade; anxiety about cancer | Depression, health anxiety |
Case Report Form Answer Builder
Write: "Facial pain for [duration]." Then document SOCRATES with:
- Site (which part of face; unilateral vs bilateral)
- Onset, character (sharp/pressure/throbbing), duration of each episode
- Triggers (touch, chewing, bending forward)
- Associated Sx: nasal (congestion, discharge, anosmia), visual, fever, numbness
- Previous episodes and treatments tried
- Impact on eating, sleeping, working
| Likely RFC | How to phrase |
|---|---|
| Worried about the cause (esp NPC in HK) | "Patient is concerned about the cause of the facial pain, particularly worried it may be cancer." |
| Pain is interfering with eating/work | "Patient is unable to eat or work due to severe facial pain and seeks relief." |
| Symptoms worsening/not improving | "Patient presents because symptoms have persisted/worsened despite OTC analgesics." |
Pick the ONE answer that matches why the patient came today. Phrase it as: "The main reason for consultation is [patient's own reason], not merely the symptom itself."
| Component | Likely Content | Example Written Answer |
|---|---|---|
| Ideas | "I think it might be sinus infection" / "I'm worried it could be cancer" | "Patient thinks the pain may be from sinusitis." |
| Concerns | Fear of NPC (HK-specific!), fear of stroke, fear of losing vision | "Patient is worried the facial pain could be a sign of nasopharyngeal cancer, as a relative had NPC." |
| Expectations | Wants investigation (X-ray/CT), wants referral to ENT, wants pain relief | "Patient expects imaging to rule out serious causes and wants effective pain relief." |
Choose based on the clinical stem. The two most testable scenarios:
| Scenario Clue | Most Likely Diagnosis | Minimum Supporting Evidence |
|---|---|---|
| Facial pressure + nasal congestion + purulent discharge ± fever, ↑ bending forward | Acute rhinosinusitis | ≥2 of: nasal blockage, discharge, facial pain/pressure, ↓smell (≥1 nasal symptom required) [3] |
| Paroxysmal electric-shock pain seconds in V2/V3, triggered by touch/chewing, no neuro deficit | Trigeminal neuralgia [1] | Unilateral, V2/V3, seconds duration, triggered by innocuous stimuli, no neurological deficit |
| DDx | One Key Discriminator |
|---|---|
| Trigeminal neuralgia (if rhinosinusitis is primary) / Acute rhinosinusitis (if TN is primary) | Electric shock seconds vs pressure with nasal Sx |
| Dental abscess | Localised tooth tenderness, swelling, ↑ percussion, hot/cold sensitivity |
| TMJ dysfunction | Jaw clicking/locking, ↑ with chewing/stress, tenderness over TMJ |
Other strong alternatives depending on stem: cluster headache, GCA (age > 50), NPC (HK endemic), herpes zoster.
| Domain | Example Problem |
|---|---|
| Biological | Facial pain limiting oral intake → weight loss / dehydration risk |
| Psychological | Anxiety about serious cause (NPC/cancer fear); sleep disturbance from pain |
| Social/Functional | Unable to work / attend school due to severe pain; social withdrawal |
| Diagnosis/DDx | Best Supporting Physical Sign | How to Elicit | Why It Supports This Diagnosis |
|---|---|---|---|
| Acute rhinosinusitis | Tenderness on palpation over maxillary/frontal sinus + purulent discharge on anterior rhinoscopy | Press firmly over cheek (maxillary) and above eyebrow (frontal); inspect nasal cavity with otoscope/speculum | Localised sinus tenderness + visible purulent discharge confirms inflamed sinus [3] |
| Trigeminal neuralgia | Trigger zone elicitation — light touch to cheek/nasolabial fold reproduces paroxysmal pain; neurological examination of CN V is otherwise NORMAL [1] | Light touch with cotton wool to V2/V3 territory; test corneal reflex, jaw clench, pinprick in all 3 divisions | TN = pain triggered by innocuous touch BUT no sensory deficit; any deficit → secondary TN, needs MRI |
| Dental abscess | Localised dental tenderness on percussion + facial/gingival swelling | Tap suspected tooth with tongue depressor; inspect gums for swelling/erythema | Percussion tenderness localises infected tooth |
| TMJ dysfunction | Tenderness + crepitus/clicking on palpation of TMJ during mouth opening | Palpate pre-auricular area while patient opens/closes mouth; note click or deviation of jaw | TMJ tenderness + click during motion is characteristic |
| GCA | Thickened, tender, non-pulsatile temporal artery | Palpate temporal artery anterior to ear; assess for tenderness, nodularity, absent pulsation | Temporal artery abnormality highly specific; urgent ESR + temporal artery biopsy if suspected [4] |
| NPC | Firm, non-tender, upper cervical lymphadenopathy (level II) + possible CN palsy | Palpate neck systematically; test CN III–VI, V (facial sensation), IX–XII | Upper neck mass is most common initial presenting symptom of NPC [5] |
| Cluster headache | Ipsilateral conjunctival injection + lacrimation + partial ptosis during attack | Observe during attack; look for Horner's syndrome features | Autonomic features ipsilateral to pain are diagnostic criteria [2] |
| Herpes zoster | Vesicular rash in dermatomal distribution (V1/V2/V3) | Inspect face for grouped vesicles on erythematous base; check if respects midline | Rash in CN V dermatome with pain = herpes zoster; absent rash with pain = consider post-herpetic neuralgia or zoster sine herpete |
Exam Discriminators and Traps
Top Traps That Lose Marks
- Forgetting to ask about NPC red flags in a HK patient — blood in postnasal drip, unilateral nasal obstruction, neck lump, cranial nerve palsies. NPC is endemic in southern Chinese and examiners expect you to screen for it.
- Confusing TN with sinusitis — TN = seconds, electric, triggered by touch; sinusitis = hours-days, pressure, nasal symptoms, ↑ bending forward.
- Missing GCA in a patient aged > 50 — jaw claudication, temporal headache, scalp tenderness, visual symptoms. This is sight-threatening; failure to ask = dangerous miss.
- Not eliciting ICE — simply describing pain without asking "What do you think it is? What worries you? What do you want me to do?" loses multiple marks.
- Writing the symptom as the RFC — "Facial pain" is the complaint, NOT the reason for consultation. The RFC is WHY they came TODAY (e.g. fear of cancer, pain not responding to treatment).
- Forgetting to ask about triggers in suspected TN — touching face, shaving, brushing teeth, chewing are classic triggers [1].
| Red Flag | Suspect | Action |
|---|---|---|
| Visual loss / amaurosis fugax + age > 50 | GCA | Urgent ESR/CRP + same-day high-dose steroids BEFORE biopsy [4] |
| Neurological deficit (facial numbness, diplopia, CN palsy) | NPC / intracranial lesion / secondary TN | Urgent MRI + ENT/neurology referral |
| Blood in postnasal drip + neck mass | NPC | Urgent ENT referral for nasopharyngoscopy + biopsy [5] |
| Severe unilateral eye pain + red eye + ↓vision | Acute angle-closure glaucoma | Same-day ophthalmology referral |
| Signs of orbital/intracranial complication of sinusitis (periorbital swelling, high fever, altered consciousness) | Complicated sinusitis | Emergency admission |
「如果個痛突然間好犀利、睇嘢矇咗、面痺咗、或者發高燒，你一定要即刻去急症室。」 (If the pain suddenly gets much worse, your vision blurs, your face goes numb, or you get a high fever, go to A&E immediately.)
High Yield Summary
What to ASK: SOCRATES for facial pain, nasal symptoms (congestion/discharge/anosmia), triggers (touch/chewing/bending), visual symptoms, jaw claudication, blood in postnasal drip, neck lump, fever, mood, and ICE.
What to WRITE: Chief complaint with duration → HPI in SOCRATES → RFC (why today, not the symptom) → ICE (fear of NPC is very HK-specific) → Most likely Dx with supporting criteria → 3 DDx with discriminators → 3 biopsychosocial problems → 1 physical sign.
What NOT to MISS: GCA in age > 50 (sight-threatening), NPC red flags (HK endemic), neurological deficit suggesting secondary cause, and always ask ICE and RFC separately from the presenting complaint.
Active Recall - Family Medicine Clinical Test
[1] GC 082. Severe headache_headache and neuralgia; neuro-imaging I.pdf (Trigeminal Neuralgia slide) [2] Senior notes: Ryan Ho Neurology.pdf (p. 64–66, Cluster headache and Trigeminal Neuralgia sections) [3] Senior notes: Ryan Ho Respiratory.pdf (p. 54–55, Rhinosinusitis section) [4] Senior notes: Block A - Rheumatology Interactive Tutorial.pdf (p. 1, PMR and GCA case) [5] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai).pdf (p. 251, NPC clinical manifestation) [6] Senior notes: Ryan Ho Endocrine.pdf (p. 97, Diabetic mononeuropathy - CN V involvement)
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