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INTRODUCTION

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CASE LEARNING OBJECTIVES

  • Recognize components of a comprehensive pain assessment

  • Recommend an appropriate choice of analgesic, dose, and monitoring plan for a patient on the basis of type and severity of pain and other patient-specific parameters

  • Identify the goals of therapy for the management of acute pain

  • Properly educate patients when opioid analgesia is initiated

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PATIENT PRESENTATION

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Chief Complaint

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"This is the worst pain I have ever had. It is like a 10 out of 10."

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History of Present Illness

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Jose Garcia is a 44-year-old man who is admitted to the hospital after a motorcycle collision. He lost control of his motorcycle and hit a parked vehicle when traveling at approximately 40 mph (64 km/h). He was wearing a helmet at the time of the collision. This occurred at 2 am today after he left a local bar to go home. According to the paramedics, he did not have any loss of consciousness, was unable to move his right leg, and had a definite odor of alcohol. In the emergency department, he was given 100 mcg of IV fentanyl for pain and 2 L of IV NS. He was subsequently taken to the operating room for an open reduction internal fixation (ORIF) of his right lower extremity fracture. Soon after surgery he was transferred to a general surgical ward for postoperative care.

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Past Medical History

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PUD × 2 years (had a GI bleed 6 months ago)

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Seizure disorder × 10 years

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Chronic shoulder pain × 5 years (from previous motorcycle collision)

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Family History

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His father died at age 60 from alcoholic cirrhosis and mother died at age 50 from a motor vehicle collision. He has no siblings.

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Social History

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He is single, has no children, and works at a construction company.

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Tobacco/Alcohol/Substance Use

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Drinks six beers daily; smokes one ppd; (−) illicit drug use

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Allergies/Intolerances/Adverse Drug Events

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Morphine (itching); oxycodone (constipation)

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Medications (Current)

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Famotidine 40 mg PO q h (home medication)

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Promethazine 25 mg IV q 4–6 h PRN

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Tramadol 100 mg PO q 4–6 h PRN

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Meperidine 50 mg PO q 2–4 h PRN

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Phenytoin 100 mg PO q 8 h (home medication)

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Ibuprofen 400 mg PO q 6 h PRN (home medication)

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Aspirin 325 mg PO q 24 h (home medication)

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Docusate 100 mg PO q 12 h

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Heparin 5,000 units SC q 24 h

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Review of Systems

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He has severe leg pain ...

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