Sanju onset of pain, location of pain, duration

Sanju Eswaran

Blue 8- Year 6 Internal Medicine

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Joel Appel, D.O.?Director Ambulatory and Subinternship Programs Wayne State
University School of Medicine

Specific Learning Objectives

Knowledge: Consider pathophysiology in the
etiology of pain?Describe nociceptive
versus neuropathic pain syndromes Understand WHO analgesic ladder for use of
opioid therapy Use adjuvant (non-opiate) therapy when indicated?Manage or prevent complications of pain medications Skills: Perform a history and physical
directed at manifestations of pain Utilize pain assessment tools?Calculate equianalgesic doses of opiates Psychosocial: Use of empathy and compassion
in dialogue with patient in pain Understand impact of pain on patient as a



Case 1:


A 55-year-old female is
admitted directly to the hospital from her primary care physician’s office with
a history of progressive onset of pain. The chart review indicates a history of
invasive ductal cancer of the right breast 3 years earlier. A lumpectomy was
performed. She had received adjuvant chemotherapy for 16 weeks after the
diagnosis. She then received chest irradiation. She had no other active medical


What would be essential
information you would need to elicit in the history?

Information that would be important to elicit in the history would
include be the onset of pain, location of pain, duration of pain, timing of
pain (i.e. time of day), characteristics of pain, alleviating and aggravating
factors of pain, other associated symptoms (review of symptoms), radiation of
pain, and severity of pain. Other factors that are important to address if any
medications were taken for the pain, if she had this pain before, how the pain
has changed over time, and how the pain affects her daily living.


What would be essential
information you would need to elicit on physical examination? Since cancer can be a
complicated and complex diagnosis and can present in numerous ways, it is
important and vital to do a full and complete head-to-toe physical exam. For
example, beginning by inspecting the skin and body for obvious deformities or
visible masses can be a good initial step. Then palpating for masses or
tenderness can be important, whether in the lymph nodes or thoracic/abdominal
cavities. Since several cancers can metastasize to boney structures, it is
important to evaluate the extremities and spine as well for tenderness. As
cancer can commonly metastasize to the lungs, it is imperative to do a full and
comprehensive lung exam. Another common location for cancers to metastasize is
the neurologic system, both centrally and peripherally; assessing cranial
nerves as well as peripheral nerves/extremities is important. Lastly, it is
important to look at vitals including blood pressure, heart rate, temperature,
and respiratory rate as pain associated with cancer can impact all of these
readings.  Your MS III has accompanied you at the bedside. You initiate a
parenteral short acting analgesic, and the patient appears at least transiently
more comfortable and can elaborate further. She had noted discomfort in her
back and hips that began 5- 6 weeks earlier. She initially thought that she may
have been overactive with her exercise regimen. She took non-steroidal
anti-inflammatory medication with initial relief, but the pain became
progressively worse. On this day, she describes it as 9 on a 0-10 scale. It is
present in the mid-back and both hips, the right greater than the left. She
describes it as a deep, boring ache that is worse with activity and alleviated
somewhat by rest. It is continuous. You would like your student to ask further
questions to assess the psychosocial implications of this pain. What features
would you expect her to cover?Psychosocial implications of pain are important to address, especially in
the setting of cancer. Some examples of items to address to cover psychosocial
associations include the following: understanding what the patient thinks her
cause of pain is and how the pain is produced in her case, assessing what the patient
believes will help her pain, how the pain is dealing with pain now, and how the
pain is affecting her wellbeing, mood, activities of daily living, work, and
family/social life. In the context of psychosocial implications, it is also
important to assess the patient’s cultural understanding of pain and causes of
pain/illness, evaluate for depression and anxiety (using SIGECAPS and GAD-7
scoring systems), the patient’s fears, patient’s priorities, approaching death,
support system, and family history. Lastly, it is important to appraise the
patient’s access to resources such as housing, insurance, financial issues, spiritual
resources, the ability to get medications and access facilities, hospitals, and
the healthcare system.


Your student asks you
about the clinical manifestations of nociceptive pain versus neuropathic pain.
How would you contrast these two syndromes? Neuropathic pain and nociceptive pain are the two important
pathophysiologic classifications of pain. Neuropathic pain results from the
injury of nerves, whether it be in the central or peripheral nervous system.
The pain that results from nerve injury can be described as stabbing, sharp, or
burning in nature; it can additionally be described as pulsatile or “shock-like”.
On the other hand, nociceptive pain is pain that results from noxious stimuli,
including thermal, mechanical, and chemical insults, which can include both
somatic and visceral pain. The pain is typically described as dull and achy in
nature if it is visceral and sharp and cramping if it is somatic in nature. Additionally,
the location the pain originates from differs in visceral and somatic pain as
visceral pain originates from abdominal and thoracic organs versus somatic pain
that originates from skin, muscle, and bones.


What would be the most likely etiology of her pain syndrome? In this patient, the most likely cause of her pain is nociceptive somatic
pain as a result of metastases to the bone.  Given the above information, how would you approach this patient

Pharmacologically, I would approach the
patient’s moderate to severe pain initially with short-acting opiates morphine,
hydromorphone/hydrocodone, oxycodone, or fentanyl. Since the patient’s pain has
become more severe and is unresponsive to NSAIDs, I think the use of narcotic
agents can be warranted, whether it may be alone or in combination with
non-narcotic analgesics, such as Tylenol, aspirin, or NSAIDs.


You initiate therapy with Morphine Sulfate at 10 mg IV q 3 hours
as needed. Your patient has requested this 6 times over the next 24 hours. What
would be an appropriate oral dose to convert this patient to?  10 mg IV * 6 times= 60 mg IV/day à   180 mg/day ORAL Morphine Sulfate  


She is discharged on the above dose. An outpatient PET/CT scan was
highly suggestive of bone metastases. One week later, when you happen to be on
an ambulatory block in this physician’s office, she states that while she was
doing well, in the last few days, she was requiring the medication at an
increased frequency, now averaging 30mg MSIR q 3 hours. What would be
pharmacologic opiate options in this setting? Scheduled fentanyl patches (Duragesic patches), sustained/controlled
release preparations of both morphine and oxycodone be used including, or methadone
can be used to treat the increasingly severe pain this patient has. This can be
supplemented with short-acting agents (for breakthrough pain).  What additional non-opiate strategies might you employ? There are several non-opiate strategies that can be employed to help
relieve this patient’s pain including non-narcotic analgesics, such as NSAIDs,
Tylenol, aspirin, or lidocaine patches. Other treatments for this patient’s
bone metastases includes chemotherapy or radiation therapy. Additionally, since
this patient is on an intense opiate/narcotic regimen, it is important to
implement a bowel regimen, such as daily Miralax.  What additional psychosocial support might be useful?

Psychosocial support is very
important to use for patients with pain, especially in the setting of
metastases or poor prognoses. Grief counseling or meeting with a psychiatrist
or psychologist can be helpful as the rate of psychiatric comorbidities is very
high in patients with cancer. Support groups or family meetings can also be
helpful for patients with cancer. Some adjuvant types of support include social
worker/financial support to get access to medications and healthcare,
transportation services, and spiritual/religious support.