Case 035: Acute Pain Management

PATIENT PRESENTATION

Chief Complaint

“This is the worst stomachache I’ve ever had – nothing makes it better and I can’t even keep any medications down”

History of Present Illness

Jane Clerc is a 28-year-old female who presented to the emergency department yesterday with acute abdominal pain in addition to nausea and vomiting that has progressively worsened over the past 3 days. She reports a dull, aching pain deep in her upper abdomen that radiates to her back. She is admitted to the internal medicine service for acute pancreatitis.

Link to EMR

Student Work-Up

TARGETED QUESTIONS

1. What type of pain is Jane experiencing based on her admission diagnosis and symptoms?

   Hint: See Pathophysiology and Clinical Presentation and Diagnosis in PPP

2. What patient-specific considerations must be considered when developing a pain management regimen?

   Hint: See Clinical Presentation and Diagnosis and Treatment in PPP

3. What is multi-modal analgesia? Discuss examples of this found in Jane’s case.

   Hint: See Treatment in PPP

4. When should opioid rotation be considered and how is it accomplished?

   Hint: See Table 35-3 and Treatment in PPP

5. How should response to treatment of acute pain be monitored? How often?

   Hint: See Outcome Evaluation in PPP

FOLLOW-UP

Six days later, Jane is being discharged with close monitoring. Her nausea has improved, and she is able to tolerate things by mouth. Her pain is still present, and her primary team asks for recommendations for a pain regimen. They are wondering about a long-acting option since she has needed opioid analgesia around the clock while admitted. What regimen do you recommend? What are key counseling points to discuss with Jane if she goes home with opioids?

Hint: See Table 35-3 and Treatment in PPP

CASE SUMMARY

Global Perspective

Pain is a highly personal sensory and emotional experience – it is influenced by an individual’s lived experience, past medical history, and present circumstances. A thorough history is vital to determine the etiology of pain. While acute pain is typically nociceptive, an individual’s experience of acute pain and response to its treatment is influenced by co-existing pain etiologies. Decisions about drug therapy for pain should be guided by etiology (ie, nociceptive, neuropathic, nociplastic, or mixed), patient-specific considerations, including safety, and shared decision making with the patient.

Key References