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PATIENT PRESENTATION

Chief Complaint

My back, ribs and belly really hurt. We need to do something-I can't take this pain and the electric shock feelings in my legs

History of Present Illness

H.T. is a 56-year-old peri-menopausal woman recently diagnosed with stage IV breast cancer, with metastases to bone (spine and ribs) and liver. She will be starting radiation and targeted chemotherapy later this week, and her oncologist is optimistic about her outcome based on tumor markers. HT grades her back pain as 9/10, rib pain 7/10 and abdominal pain 6/10.

Student Work-Up

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Missing Information?

Evaluate:

Patient Database

Drug Therapy Problems

Care Plan (by Problem)

TARGETED QUESTIONS

  1. What other information would be useful in characterizing, assessing, and treating this patient’s pain?

    Hint: See Clinical Presentation and Diagnosis in PPP

  2. What symptoms of neuropathic pain does the patient describe, and how is this type of pain treated differently than other types of chronic pain?

    Hint: See Clinical Presentation and Diagnosis in PPP

  3. Why are both scheduled and prn pain medications used for chronic pain?

    Hint: See Treatment in PPP

  4. What are the principles behind multimodal pain management?

    Hint: See Clinical Presentation and Diagnosis and Treatment in PPP along with reference 1 below

  5. What nonpharmacologic therapies may be useful for this patient?

    Hint: See Treatment in PPP along with reference 1 below

FOLLOW-UP

The patient returns to see you two weeks later. She has started her cancer treatment, and she says her pain is much improved on the regimen you started. She says her main problem now is constipation, and the docusate she is taking doesn’t seem to help. What treatment for her constipation would you recommend?

Hint: See Treatment in PPP along with reference 1 below

CASE SUMMARY

Global Perspective

Cancer and its associated problems such as pain are global issues, and there are differences in how pain is managed in different countries and regions of the world. These differences may be based in part on cultural, religious, and spiritual factors. Cancer pain is present in about 50% of patients with cancer and in 70% of those with more advanced stages. While evidence-based pain management guidelines have been available for many years, may patients with cancer are not adequately treated particularly in low- and middle-income countries (LMIC) which constitute 85% of the world’s population. About 80% of patients with cancer in LMIC present with advanced disease. The prevalence of undertreated pain in relatively high in Asia (58%) compared to Europe (40%) and the U.S. (39%), and there are wide differences in per capita opioid consumption ...

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