Pain Management Review and Cases

Curtis M. Grenoble, MS, PA-C

Lock Haven University PA Program

PA Days, Summer 2009

The most important part…

• The HISTORY!!• Be sure to obtain the full list of symptom

attributes for pain– LORCATES

• This will help you to identify the pathophysiology and choose proper management

• Be aware of malingerers and drug seekers– Inconsistent history that doesn’t match findings

on physical exam

Types of pain…

• Nociceptive (tissue) pain– Due to tissue damage– Two subcategories

• Somatic– Musculoskeletal pain (muscle, joints, bones, ligaments, skin)– Characteristics: often sharp, well localized, reproducible

• Visceral– Originates in organs (thoracic, abdominal, and pelvic

cavities)– Characteristics: often poorly localized, vague, deep

ache/cramp, may produce referred pain

– Commonly treated with• Anti-inflammatories• opioids

Types of pain…

• Neuropathic (Nerve) Pain– Damage or dysfunction of nerves in the peripheral or

central nervous system• Traumatic injury, burns, nerve degeneration (MS), pressure,

inflammation, infection (shingles)

– Characteristics: burning, electrical sensation, may describe as a shock…but may not describe as pain but rather “going to sleep”

– Referred pain to area innervated by the nerve– Light touch of affected area may elicit severe pain– Anti-inflammatories & opiods usually ineffective– Tx: anticonvulsants (gabapentin), TCAs

(amitriptyline), sodium channel blockers

Types of pain…

• Sympathetic Pain– Complex Regional Pain Syndrome I

• Reflex Sympathetic Dystrophy• Chronic pain with a pattern suggesting overactivity of

the sympathetic nervous system often with a history of injury but may not be able to identify

– Complex Regional Pain Syndrome II• Causalgia• Caused by serious injury to major nerve trunk that

is immediately obvious

– Both respond best to combination treatments including anti-inflammatory/pain and nerve pain

Case 1

• CC: left flank pain over past few weeks• HPI: 45 y.o. male presents to the ED complaining

of “occasional twinges” in the L flank over the past few weeks, occurring once every 2-4 days. Today developed L flank pain that gradually worsened over the past 3 hours. Describes pain as sharp, constant (8/10), with waves of severe intensity (10/10) during which he feels the need to move around. Pain radiates to L groin and he can’t find a comfortable position. Pain is associated with nausea but no emesis. Denies fever, chills, dysuria, hematuria, frequency, hesitancy and abdominal pain.

Case 1

• PMH:– No hospitalizations/surgeries/chronic dz– Meds: None– Allergies: Amoxicillin

• VS: 96.8F, 96, 182/92, 16, 98% on RA• PE:

– General: healthy appearing main writing in pain holding is L side

– HEENT/Heart/Lungs: non-contributory– Abd: soft, non-tender, non-distended, + BS– Back: L flank moderately tender, CVA tenderness on L– GU/rectal: no lesions, non-tender testicles, heme-

negative stool, non-tender prostate

Case 2

• CC: “My joints have been getting more and more stiff and achy over the past 6 months

• HPI: 68 y.o. caucasian female, recently retired store clerk, established pt, presents to your clinic complaining of joint discomfort that has gradually increased over the last 4 years. Describes stiffness and aching in hands, R hip and L knee. 0-1/10 at rest, 6/10 with activity. Stiffness present in AM for ~15 min but improves with warm shower. Walking, standing, and gardening for prolonged periods of time aggrates pain in knee and hip while needlework aggravates pain in the hands. Heating pad helps pain in hip. 1 year ago began to notice bumps on fingers and concerned that they may be tumors.

Case 2

• PMH:– Meds: Premarin 0.625 mg PO daily, Risedronate 35 mg PO

weekly– Allergies: ASA – hx of GI bleed– No chronic illnesses– Denies trauma to the affected joints but did stand for prolonged

periods of time as a store clerk• VS: 98.7F, 88, 12, 135/88, 5’4”, 160#• PE:

– General: moderately overweight, mild discomfort upon sitting and arising

– Heart/Lungs: no pathologic findings– Musculoskeletal: full ROM all joints, no atrophy or asymmetry,

tender DIPs and PIPs b/l with nodes present, discomfort with flexion and int. rotation R hip, + crepitus in knees, ligaments stable

Case 3

• CC: “I’ve had low back pain for 1 week and it just doesn’t get any better”

• HPI: Ms. C is a 42 y.o. African American female employed as a geriatric staff nurse at a large hospital that has recently experienced a reduction in staffing due to the recession. She presents complaining of back pain x 1 wk following an unaided transfer of a pt. Describes a constant aching pain (5/10) across her lower back and down into her buttocks. Pain is always present when sitting, worsens with bending (7/10). Continues to work but came in today because the pain is not improving.

Case 3

• PMH– No hx of major illnesses, surgeries, fx, or previous back problems– NKDA; Meds: none

• PE– VS: 98.6F, 78, 18, 120/76, 5’4”, 190#– General: moderately overweight AA female, uncomfortable sitting,

more comfortable standing– Back: symmetric, no atrophy, erect posture, flexion of

thoracic/lumbar spine causes pain at L4-L5. L-S spine tender at L4-L5 extending bilaterally into paravertebral muscles. No sciatic notch sensitivity.

– LE: Full ROM, no atrophy or weakness– Neuro: DTRs 2/4, cutaneous sensation comparable b/l able to

recognize light touch/sharp/dull, SLR produces pain at L4-L5 and into buttocks, does not radiate down leg no increase with dorsiflexion, able to squat, and walk on heels and toes

Case 4

• CC: RUQ pain x 2 days• HPI: 52 y.o. caucasian male presents with

severe upper abdominal pain. Onset of pain 2 days ago following lunch. Over this period of time, pain his come on in waves often associated with meals and has been associated with nausea and bloating. Pain has become progressively worse (7/10) and is now localized in the RUQ. Felt similar pain a few times in the past however those episodes were brief and resolved without treatment. Denies vomiting, diarrhea, fever, chills, sweats, chest pain, SOB.

Case 4

• PMH:– Hypercholesterolemia, s/p tonsillectomy– Meds: none– Allergies: Penicillin – rash

• SH:– Tobacco 1ppd, 2 beers per day

• PE:– VS: 99.0F, 99, 117/77, 99% on RA– General: appears well, no distress– HEENT: anicteric, moist membranes, no pallor– Abd: soft, non-distended, tender in RUQ with guarding, worse on deep

inspiration, positive Murphy’s sign, no hepatosplenomegaly, heme negative stool

– US – revels multiple gallstones, thickening of GB wall and pericholecystic fluid

• Surgery is consulted, reviews findings and asks to keep NPO and give pain control of your choice…