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
"This is the worst pain I have ever had. It is like a 10 out of 10."
History of Present Illness
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.
PUD × 2 years (had a GI bleed 6 months ago)
Seizure disorder × 10 years
Chronic shoulder pain × 5 years (from previous motorcycle collision)
His father died at age 60 from alcoholic cirrhosis and mother died at age 50 from a motor vehicle collision. He has no siblings.
He is single, has no children, and works at a construction company.
Drinks six beers daily; smokes one ppd; (−) illicit drug use
Allergies/Intolerances/Adverse Drug Events
Morphine (itching); oxycodone (constipation)
Famotidine 40 mg PO q h (home medication)
Promethazine 25 mg IV q 4–6 h PRN
Tramadol 100 mg PO q 4–6 h PRN
Meperidine 50 mg PO q 2–4 h PRN
Phenytoin 100 mg PO q 8 h (home medication)
Ibuprofen 400 mg PO q 6 h PRN (home medication)
Aspirin 325 mg PO q 24 h (home medication)
Docusate 100 mg PO q 12 h
Heparin 5,000 units SC q 24 h
He has severe leg pain ...