“That Hurts!”
A 53-year-old woman is evaluated in the emergency department for a lumbar compression fracture after a fall. She describes severe pain over the lumbar spine. She has stage G4 chronic kidney disease due to type 2 diabetes mellitus; she also has hypertension and depression. Medications are amlodipine, hydrochlorothiazide, finerenone, dapagliflozin, atorvastatin, sertraline, and acetaminophen.
On physical examination, vital signs are normal. There is point tenderness on the lumbar spine.
Creatinine
2.1 mg/dL (185.6 µmol/L)
H
Estimated glomerular filtration rate
28 mL/min/1.73 m2
Which of the following is the most appropriate for pain management?
A. Hydromorphone
B. Ketorolac
C. Morphine
D. Tramadol
The most appropriate pain management option for this patient with advanced chronic kidney disease (CKD) and acute, severe pain is hydromorphone (Option A). Pain management in patients with CKD should consider the pharmacology and risk profile of the proposed medication as well as the nature and severity of the patient's pain. Options for treating moderate to severe pain in patients with CKD include oxycodone, tramadol, and hydromorphone; longer-acting medications such as fentanyl, methadone, and buprenorphine can also be considered but may be more appropriate for patients with chronic pain. Of these, hydromorphone, which is primarily metabolized by the liver, is often preferred, as it is short acting and relatively well tolerated. It should be started at a low dose and titrated slowly; the lowest possible dosage that controls symptoms should be used.
A 51-year-old woman is evaluated for a 10-year history of chronic pain that she describes as head-to-toe aching, twisting, and sometimes burning that involves several large muscle groups. The pain is constant, and she rates the severity as 6 out of 10. She continues to work but is constantly fatigued. She takes oxycodone, which provides minimal relief. She has tried three other opioid medications, gabapentin, and milnacipran; all provided only minimal improvement in her pain. Medical history is also significant for generalized anxiety disorder treated with sertraline.
On physical examination, tenderness is noted in multiple large muscle groups.
In addition to slowly tapering oxycodone, which of the following is the most appropriate next step in treatment?
A. Lorazepam
B. Physical therapy
C. Transcutaneous electrical nerve stimulation
D. Transdermal fentanyl
Patients with chronic pain should be referred to a structured physical therapy program (Option B) for evaluation and treatment aimed at improving functional status. This patient has a long-standing history of chronic pain that is consistent with fibromyalgia. Physical therapy teaches patients safe, self-guided exercises to improve functional status, and evidence clearly supports its use in all patients with chronic pain. Guided/progressive physical therapy programs are associated with pain reduction and, perhaps most importantly, functional improvement. No evidence suggests that any specific type of physical therapy is preferred, and programs should be tailored to patient ability and adherence.
A 28-year-old woman is hospitalized with a 2-day history of acute pain affecting her legs, low back, and shoulders. Medical history is significant for hemoglobin SS sickle cell disease with frequent vaso-occlusive pain events requiring hospitalization at least twice annually. She reports that her current pain is consistent with previous pain events. She has no other medical problems. Medications are hydroxyurea and folic acid.
On physical examination, the patient appears uncomfortable. Temperature is 37.8 °C (100 °F), blood pressure is 108/68 mm Hg, pulse rate is 107/min, and respiration rate is 18/min. Oxygen saturation is 98% breathing ambient air. The remainder of the examination is normal.
Laboratory studies:
Hemoglobin
8.0 g/dL (80 g/L)
L
Baseline
8.5 g/dL (85 g/L)
L
Leukocyte count
11,000/µL (11 × 109/L)
H
Platelet count
410,000/µL (410 × 109/L)
Reticulocyte count
8% of erythrocytes
H
Bilirubin
Total
1.8 mg/dL (30.8 µmol/L)
H
Direct
0.3 mg/dL (5.1 µmol/L)
Creatinine
0.9 mg/dL (79.6 µmol/L)
Lactate dehydrogenase
250 U/L
H
A chest radiograph is clear.
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In addition to pain control, which of the following is the most appropriate management?
A. Crizanlizumab
B. Incentive spirometry
C. L-glutamine
D. Packed red blood cell transfusion
Incentive spirometry (Option B) is the most appropriate next step in management for this patient with sickle cell disease (SCD) who is hospitalized for an acute vaso-occlusive pain event. Painful vaso-occlusive events are common complications in SCD. Although infection, dehydration, or abrupt changes in weather can trigger pain, a provoking factor is often not identified. Painful events should be recognized and treated immediately, preferably with an opioid, because patients are often undertreated. Acute chest syndrome (ACS) is the most common serious complication in patients with SCD and is characterized by fever, chest pain, hypoxemia, and new consolidation on chest imaging. The cause of ACS is multifactorial, and atelectasis often plays a role in its development; incentive spirometry may be effective in decreasing the risk of ACS by reducing atelectasis. This patient is experiencing an acute vaso-occlusive pain event, but she has no evidence of ACS, with a clear chest radiograph and normal oxygenation. Incentive spirometry should be initiated to help prevent ACS.
A 45-year-old man is evaluated during a follow-up visit for low back pain. The pain began suddenly 8 weeks ago after swinging a baseball bat. The initial pain was sharp and shot down the back of his left leg to the foot. Initial evaluation revealed no neurologic deficits, and he was prescribed NSAIDs and counseled on activity modification. In follow-up 4 weeks ago and again now, his pain is unchanged despite adherence to activity modification and participation in physical therapy. He reports no weakness, sensory symptoms, or bowel or bladder dysfunction. He has hypertension, and his only medication is losartan.
On physical examination, the patient appears uncomfortable. Vital signs are normal. Contralateral straight leg raise test is positive on the left. Mild weakness in plantar flexion is noted on the left with a diminished Achilles reflex. Mild numbness in the left great toe web space is noted. Perineal sensation and rectal tone are normal.
Which of the following is the most appropriate management?
A. Emergent surgical referral
B. Epidural glucocorticoid injection
C. Methocarbamol
D. MRI of the lumbar spine
The most appropriate management in this patient with likely lumbar disk herniation with persistent symptoms is MRI of the lumbar spine (Option D). In suspected lumbar disk herniation, immediate imaging is not necessary in the absence of a severe neurologic deficit, neurologic findings suggesting cord compression or cauda equina syndrome, or concern for a serious underlying cause such as spinal infection or cancer. The initial management strategy for acute lumbar disk herniation involves counselling about avoidance of exacerbating activities (e.g., lifting and bending), NSAIDs for pain management, and consideration of referral to physical therapy. Most patients will improve with time. Nonurgent imaging may subsequently be considered in patients with symptoms persisting for longer than 6 weeks and those with progressive neurologic symptoms. This patient's symptoms, including lower back pain radiating into the foot, a positive straight leg raise test, and weakness and sensory changes, strongly suggest lumbar disk herniation compressing the S1 nerve root. His symptoms have not responded to 8 weeks of conservative therapy, and he has developed minor but progressive neurologic deficits. MRI of the spine is indicated.
A 55-year-old woman with diabetes presents with burning pain in her feet, worse at night. Exam shows decreased sensation in a stocking distribution.
Which is the best initial therapy?
A. Acetaminophen
B. Ibuprofen
C. Oxycodone
D. Duloxetine
E. Prednisone
Answer: D. Duloxetine
Explanation:
This is diabetic neuropathy. First-line agents include SNRIs (duloxetine), gabapentinoids, or TCAs. Opioids are not first-line.
A 49-year-old woman is evaluated for a 1-month history of left hip pain. The pain is localized to the lateral hip and does not radiate. She runs 12 miles weekly, and her pain is exacerbated by running, standing for long periods, and lying on her left side. She has no difficulty putting on shoes and socks. Her medical history is otherwise unremarkable, and she takes no medications.
On physical examination, vital signs are normal. BMI is 29. Significant pain is elicited with palpation over the left lateral hip region. Standing on the affected leg reproduces her pain. Lower extremity strength and sensation are normal.
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Which of the following is the most appropriate next step in management?
A. Avoidance of tight-fitting clothing
B. Left hip radiography
C MRI of the lumbar spine
D. Naproxen
The most appropriate next step for this patient with greater trochanteric pain syndrome (GTPS) is therapy with an NSAID, such as naproxen (Option D). Pain due to GTPS, formerly called trochanteric bursitis, is caused by inflammation of tendons connecting the gluteus muscle group to the hip and femur, sometimes with involvement of the trochanteric bursa. Compression of these tendons and bursa causes lateral hip pain that is worsened by lying on the affected side and by overuse. The pain may radiate to the buttock or knee if the iliotibial band is also affected. The examination maneuvers with the highest positive predictive value for GTPS, which are most useful in combination, are direct palpation of the greater trochanter and the 30-second single-leg stand. GTPS is very likely if a patient has both significant tenderness with palpation of the greater trochanter and pain provoked by standing on the affected leg for 30 seconds. First-line treatment for GTPS is activity modification and NSAIDs. If pain persists, physical therapy can be used to strengthen the gluteal muscle group hip adductors and improve postural control. This patient has risk factors for and features of GTPS; treatment with an NSAID such as naproxen is indicated.
A 28-year-old man is evaluated for follow-up of systemic lupus erythematosus diagnosed 3 years ago. At diagnosis, he presented with oral ulcerations, a photosensitive malar rash, and pericarditis as well as positive antinuclear antibody and anti–double-stranded DNA antibody titers and low complement levels. During the past 4 months, he reports increasing fatigue, generalized achiness, and nonrestorative sleep. He has no other medical conditions. His only medication is hydroxychloroquine.
On physical examination, vital signs and other findings are normal.
Laboratory studies:
Erythrocyte sedimentation rate
Normal
C3 complement
Normal
C4 complement
Normal
C-reactive protein
Normal
Anti–double-stranded DNA antibody titer
Normal
Urinalysis
Normal
Complete blood count and comprehensive metabolic panel are also normal.
Which of the following is the most appropriate next step in management?
A. Add azathioprine
B. Increase hydroxychloroquine
C. Recommend aerobic exercise
D. Recommend massage
The most appropriate management for this patient with symptoms of fibromyalgia is aerobic exercise (Option C). Patients with systemic lupus erythematosus (SLE) or other rheumatologic conditions have a higher risk for comorbid fibromyalgia compared with the general population. Nonpharmacologic interventions, including exercise, are the cornerstone of fibromyalgia management. Aerobic exercise has been shown to improve the clinical symptoms of fibromyalgia, including reduction in pain, increased range of motion, and improved strength and stamina. Low-impact exercises, such as aquatherapy and tai-chi, may be helpful. Patients should be encouraged to introduce exercise gradually because initial postexercise pain may occur. Other nonpharmacologic interventions that are effective include mind-body modalities, stress management, and sleep hygiene. This patient is presenting with symptoms of fibromyalgia without evidence of an SLE flare. Aerobic exercise can improve well-being and functioning as well as reduce pain.
66-year-old man is evaluated for worsening dyspnea and hypoxemia 24 hours after undergoing open cholecystectomy. He has a productive cough and abdominal pain at the incision site, which is aggravated by the cough. He has a 24-pack-year history of smoking. Medications are subcutaneous heparin and morphine sulfate as needed for pain.
On physical examination, respiration rate is 24/min; other vital signs are normal. Oxygen saturation is 90% with the patient breathing supplemental oxygen, 4 L/min by nasal cannula. BMI is 37. Mildly increased work of breathing and shallow breath sounds are noted. Pulmonary examination reveals decreased breath sounds in both lung bases with bibasilar crackles. Abdominal examination reveals moderate tenderness in the right upper quadrant over the incision without rebound tenderness, and the surgical wound is without erythema or discharge. The remainder of the examination is normal.
Chest radiograph shows small lung volumes with bibasilar atelectasis.
A patient-controlled analgesia pump is started.
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Which of the following is the most appropriate management?
A. Bronchoscopy
B. Naloxone
C. Piperacillin-tazobactam
D. Respiratory physiotherapy
The most appropriate management of this patient with postoperative atelectasis, in addition to more effective pain control, is respiratory physiotherapy (Option D). In patients with postoperative hypoxemia, a careful clinical approach is needed to identify the underlying cause. Common causes include the following:
Postoperative atelectasis is very common after upper abdominal surgery. Risk factors include smoking, obesity, and older age. Shallow breathing and weak cough due to pain, diaphragmatic dysfunction, and anesthesia-induced impairment of the mucociliary escalator predispose patients to accumulation of respiratory secretions and reduction in functional residual capacity (FRC). Atelectasis is observed when FRC drops below closing volume (the lung volume at which dependent airways start to close) during tidal breaths. Management of postoperative atelectasis includes pain control, early mobility, secretion management, and respiratory physiotherapy. Inspiratory muscle training, deep breathing exercise, mobility programs, or percussion and vibration therapy help prevent and treat atelectasis as respiratory physiotherapy. In this patient with postoperative hypoxemia, the reduced breath sounds in both lung bases, bilateral crackles, and chest radiograph findings strongly point toward atelectasis as the most likely cause. Chest physiotherapy should be initiated together with improved control of pain.
A 79-year-old woman is evaluated in the emergency department for right hip pain after she tripped on a rug and fell at home. She has not had chest pain, shortness of breath, or decreased exercise tolerance. Medical conditions include osteopenia, hypertension, stage G3a chronic kidney disease, heart failure with preserved ejection fraction, dyslipidemia, and hypothyroidism. Medications are lisinopril, metoprolol, furosemide, atorvastatin, levothyroxine, and a vitamin D supplement.
On physical examination, blood pressure is 156/90 mm Hg and pulse rate is 106/min. She is unable to bear weight on the right leg, which is externally rotated and shortened. The remainder of the examination is normal.
Laboratory studies:
Creatinine
1.3 mg/dL (115 µmol/L)
Complete blood count, the remainder of the basic metabolic panel, and thyroid-stimulating hormone level are normal.
ECG shows sinus tachycardia.
Plain radiographs reveal an intertrochanteric hip fracture.
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Which of the following is the most appropriate management strategy?
A. Cardiology consultation before operative management
B. Nonoperative management
C. Operative management within 24 hours
D. Transthoracic echocardiography before operative management
The most appropriate management strategy is operative management within 24 hours (Option C). The incidence of hip fracture in the geriatric population is increasing, with 300,000 fractures occurring annually in the United States. Because this population has many comorbid conditions, including cardiac disease, the use of an evidence-based protocol for management and preoperative optimization is essential. Orthopedic consultation for early surgery should occur even for patients with multiple comorbid conditions. Early operative management (ideally within 24 hours) results in improved outcomes, including reduced pain, shorter length of stay, and decreased mortality. Waiting longer than 24 hours before surgery is associated with increased complications, and hip fracture surgery delays longer than 48 hours are associated with increased 30-day and 1-year mortality. Therefore, time between admission and surgery for this patient should be minimized.
A 72-year-old woman with metastatic breast cancer is on a stable regimen of extended-release oxycodone but reports intermittent severe pain spikes.
What is the best management?
A. Increase long-acting opioid dose
B. Add NSAIDs only
C. Prescribe short-acting opioid for breakthrough pain
D. Switch to methadone
E. Add benzodiazepine
C. Prescribe short-acting opioid for breakthrough pain
Explanation:
Breakthrough pain is treated with short-acting opioids (typically 10–15% of total daily opioid dose) in addition to baseline therapy.
A 53-year-old woman is evaluated for neck pain. The pain began yesterday, originates in the mid-neck, and radiates down the left lateral arm. She reports no weakness but has noticed intermittent paresthesias in her lateral fingertips of the left hand. She reports no weight loss, fever, gait instability, change in bowel or bladder function, or trauma. Medical history is remarkable only for recently diagnosed type 2 diabetes mellitus, with a hemoglobin A1c of 10.1%. She does not use injection drugs. She has been taking ibuprofen with some benefit; her only other medication is insulin glargine.
On physical examination, the patient appears mildly uncomfortable. Vital signs are normal. Neck range of motion is normal. No weakness of the upper and lower extremities is noted. There is slightly decreased sensation to light touch along the lateral left arm. Left biceps reflexes are 1+, with 2+ reflexes of the right upper extremity and bilateral lower extremities.
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Which of the following is the most appropriate management?
A. Cervical collar
B. MRI of the cervical spine
C. Neck exercises
D. Prednisone taper
The most appropriate management in this patient with a left-sided cervical radiculopathy is conservative treatment, which includes neck exercises (Option C). Cervical radiculopathy is caused by spinal nerve root compression, often resulting from degenerative spinal changes or disk herniation. Symptoms include neck pain accompanied by radiating arm pain and paresthesias as well as pain limited to the upper extremity without neck pain. Physical examination may demonstrate diminished strength in the affected extremity with decreased deep tendon reflexes. Red flag findings suggesting other causes (such as malignancy, infection, or fracture) include fever, weight loss, unrelenting headache, injection drug use, risk factors for osteoporosis, and age older than 70 years. Similarly, the presence of gait disturbance, upper or lower extremity weakness, or bowel and/or bladder dysfunction should prompt consideration of myelopathy. In the absence of red flag findings, most patients can be treated with a multimodal approach tailored to the individual patient, potentially including range-of-motion exercises, physical therapy, ice or heat applications, and analgesic agents for 6 to 12 weeks. The presence of red flag findings at presentation, significant neurologic dysfunction, or progressive pain despite conservative management should prompt MRI imaging. This patient has neck pain with paresthesias and pain radiating down the arm consistent with cervical radiculopathy. She has no red flag findings and should be treated conservatively for 6 to 12 weeks, including range-of-motion neck exercises.
A 27-year-old woman is evaluated for a 4-month history of bilateral breast pain that occurs just before the onset of menses. She has no other breast symptoms, and the pain typically resolves with menstruation. She has tried wearing more supportive bras without improvement. Menses have been regular, and her last menstrual period was 2 weeks ago. She has no family history of breast cancer.
On physical examination, vital signs are normal. Bilateral breast examination reveals no tenderness, masses, skin changes, or axillary adenopathy.
A pregnancy test result is negative.
Which of the following is the most appropriate management?
A. Breast MRI
B. Breast ultrasonography
C. Tamoxifen
D. Topical diclofenac
This patient has cyclic breast pain with a negative clinical breast examination and should be treated with topical diclofenac (Option D). Cyclic breast pain is typically bilateral and diffuse. It is most common in women aged 20 to 39 years, is often seen in the premenstrual phase of the menstrual cycle, and usually resolves with the onset of menstruation. Over the long term, episodes of cyclic pain typically dissipate spontaneously. Conservative management is first-line therapy and includes education, reassurance regarding the absence of malignancy, advice to wear a supportive and well-fitting bra, and topical NSAID therapy. This patient presents with symptoms consistent with cyclic breast pain and has a normal clinical breast examination; she requires no further diagnostic evaluation and can be reassured that her symptoms are benign.
A 78-year-old woman is evaluated for 10 years of worsening left knee pain due to osteoarthritis. Her ability to ambulate is limited, and she is now experiencing pain at rest and at night. Symptoms substantially interfere with daily activities. Physical therapy, yoga, and tai chi have provided minimal benefit. Her symptoms are partially relieved with NSAIDs; however, acetaminophen and duloxetine were ineffective. Intra-articular glucocorticoid injections no longer provide substantial or sustained benefit.
On physical examination, vital signs are normal. Range of motion testing of the knee elicits crepitus. There is medial joint line pain. No meniscal or ligamentous abnormalities are noted.
Radiographs reveal marked narrowing of the medial compartment of the left knee joint and moderate narrowing of the patellofemoral joint. Osteophytes at the joint margin with subchondral sclerosis are present.
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Which of the following is the most appropriate next step in management?
A. Arthroscopic debridement
B. Hydrocodone
C. Intra-articular hyaluronanic acid injection
D. Total knee replacement
The most appropriate next step in management is total knee replacement (Option D). Surgery for osteoarthritis (OA) may be considered when nonpharmacologic and pharmacologic approaches fail to control pain or improve functional limitation. Typical indications for total knee replacement (knee arthroplasty) are debilitating pain and major limitations in fundamental activities of daily living, such as walking, working, and sleeping. The 2023 American College of Rheumatology (ACR) and American Association of Hip and Knee Surgeons clinical practice guideline for the optimal timing of elective hip or knee arthroplasty for patients with symptomatic moderate to severe OA conditionally recommends against delaying total joint arthroplasty to pursue additional nonoperative treatments in patients who have symptomatic and radiographic moderate to severe OA for whom nonoperative therapy was ineffective. Total knee replacement relieves pain and improves function, with excellent long-term outcomes. This patient's symptoms and functional impairments are refractory to recommended nonpharmacologic and pharmacologic interventions. Therefore, proceeding with total knee replacement is appropriat
A 35-year-old man is evaluated for 2 months of worsening pain in the shoulders, arms, lower back, hips, and knees. He has not had any trauma or physical injury, fever, weight loss, or weakness. He was diagnosed with fibromyalgia 6 years ago, which was well managed with a regular exercise program until the current worsening of symptoms. He also has a history of migraines. His only medication is as-needed sumatriptan.
On physical examination, vital signs are normal. He is diffusely tender to palpation across his back, shoulders, and thighs. He has full strength in all extremities. The remainder of the examination is normal.
Which of the following is the most appropriate next step in management?
A. Administer PHQ-9
B. Initiate acetaminophen
C. Initiate duloxetine
D. Measure erythrocyte sedimentation rate
The most appropriate next step for this patient with an acute flare of a chronic pain syndrome is to evaluate for underlying symptoms of a psychiatric disorder, including administering a PHQ-9 (Option A). Pain may be acute or chronic, and it can be further categorized as neuropathic, nociceptive, or nociplastic. Nociplastic pain, which includes fibromyalgia, exists in the absence of tissue or nerve damage, and is often diffuse and nonanatomic, and may be associated with concomitant sensory deficits. Nonpharmacologic strategies (e.g., cognitive behavioral therapy, physical and occupational therapy, biofeedback, complementary and integrative therapies) are the cornerstone of chronic pain management and are associated with improvements in pain and overall function. In addition and regardless of pain type, patients with chronic pain are up to four times more likely to have concomitant depression than patients without a pain syndrome. Because psychological comorbidities and chronic pain experiences mutually influence one another, it is also important to evaluate patients for mental health disorders and psychosocial stressors during the assessment of a new or changing pain syndrome. This patient presents with widespread pain and tenderness in the absence of injury, consistent with a flare of fibromyalgia, and the most appropriate next step is an evaluation for concurrent mood disorder, including a PHQ-9.
A 70-year-old man with ESRD on dialysis requires opioid therapy for severe pain.
Which opioid is safest?
A. Morphine
B. Codeine
C. Meperidine
D. Fentanyl
E. Hydrocodone
Answer: D. Fentanyl
Explanation:
Fentanyl has no active renally cleared metabolites, making it safest in renal failure. Morphine and meperidine accumulate toxic metabolites.
A 37-year-old woman is evaluated for acute low back pain that radiates down the right leg into her foot. It began after lifting her 2-year-old son above her head 2 days ago. She describes the pain as sharp and shooting with associated numbness and weakness in the right foot. She is having difficulty sleeping at night because of the pain. She reports no bowel or bladder incontinence. She has a history of well-controlled diabetes mellitus and takes metformin.
On physical examination, she appears uncomfortable. Vital signs are normal. Mild paraspinal tenderness is noted to palpation in the lumbar region. Straight leg raise tests to 30 degrees reproduce the right leg pain that radiates into the foot. Strength in hip flexion, knee extension, foot dorsiflexion and plantar flexion, and right great toe dorsiflexion is intact. Sensation is intact throughout the lower extremities, and lower extremity reflexes are symmetric and intact.
Ibuprofen is started for pain control, and she is referred for physical therapy.
Which of the following is the most appropriate additional management?
A. Bed rest for 48 hours
B. MRI of the lumbar spine
C. Prednisone for 5 days
D. No additional management
The most appropriate management for this patient who likely has sciatica due to acute lumbar disk herniation is NSAIDs for pain management without additional immediate measures (Option D). Treatment for patients with low back pain is dictated by the underlying cause and may include nonpharmacologic and pharmacologic therapies and, rarely, surgery. The initial management strategy for acute lumbar disk herniation involves counselling about avoidance of exacerbating activities (e.g., lifting and bending) and pain management with NSAIDs. Referral to physical therapy may also be considered. Patients should be counseled about the expected course of back pain and encouraged to engage in physical activity as tolerated. Most patients will respond to conservative therapy over a period of weeks and avoid the need for invasive treatment. Surgery is usually not required but may be indicated in the event of intractable pain or significant or progressive neurologic deficit. This patient's presentation of lower back pain radiating down the right leg into the foot and positive straight leg raise test strongly suggests sciatica due to acute lumbar disk herniation. Her symptoms should be managed with pain control, physical therapy, and gradual return to physical activity.
A 41-year-old man is evaluated for chronic low back pain. The pain began 6 months ago after lifting a heavy load, at which time he was diagnosed with lumbar strain. He was prescribed naproxen, which provided some initial relief, but he eventually discontinued it because of stomach upset and waning effectiveness. After several months of symptoms, an MRI was unremarkable. He completed a course of physical therapy and had trials of topical diclofenac and topical capsaicin, none of which has helped his pain. He misses approximately 4 days of work per month because of pain and is distressed that his pain has not improved. He has had no weight loss, fever, or neurologic symptoms. His medical history is otherwise notable for major depressive disorder treated with escitalopram. He takes no other medications.
On physical examination, vital signs are normal. Diffuse tenderness to palpation is present across both sides of his low back. The remainder of the examination is normal.
Which of the following is the most appropriate management?
A. Celecoxib
B. Cognitive behavioral therapy
C. Epidural spinal injection
D. Oxycodone
The most appropriate management for this patient with a chronic pain syndrome is a nonpharmacologic pain management program, including cognitive behavioral therapy (Option B). Pain can be categorized based on timeline (acute or chronic) and cause (neuropathic, nociceptive, or nociplastic). Nociplastic pain is associated with increased sensitization and diminished inhibitory pathways resulting from maladaptive changes to nociceptive processing and modulation. It often exists in the absence of clear physical damage or may become the predominant pain type following an acute injury after tissue healing has occurred. Nociplastic pain is often diffuse and nonanatomic, and may be associated with sensory deficits. A nonpharmacologic approach is the foundation of all chronic pain management and results in decreased pain and improved overall function. Nonpharmacologic strategies include cognitive behavioral therapy, physical and occupational therapy, biofeedback, and complementary and integrative therapies. Cognitive behavioral therapy can address depression (which is more common in patients with chronic pain) and can help patients restructure maladaptive beliefs about their pain, thereby increasing function and decreasing distress. This patient has developed chronic nociplastic pain following his lumbar strain, and he should be offered first-line nonpharmacologic treatment, which includes cognitive behavioral therapy.
A 39-year-old woman is evaluated during a follow-up visit for fibromyalgia. She has persistent pain in her neck, shoulders, low back, and hips. The pain is aching in quality and is associated with sensitivity to light touch; she specifically notes discomfort when wearing rough fabrics. She participates in cognitive behavioral therapy and a low-impact aerobic exercise program, which have been partially helpful for symptom relief; however, she has not been able to reach her functional goal of consistent work attendance. She has no other medical conditions and takes no medications.
On physical examination, vital signs are normal. She is exquisitely tender across her back, shoulders, and lower extremities. No synovitis or joint deformities are present. The remainder of the examination is normal.
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Which of the following is the most appropriate management?
A. Duloxetine
B. Naproxen
C. Oxycodone
D. Prednisone
The most appropriate management for this patient with chronic nociplastic pain is duloxetine (Option A). Pain can be acute or chronic, and it can be further categorized as neuropathic, nociceptive, or nociplastic. Nociplastic pain exists in the absence of tissue or nerve damage and may become the predominant pain type following an acute injury after tissue healing has occurred. It is thought to result from maladaptive physiologic changes to nociceptive processing and modulation, leading to increased sensitization and diminished inhibitory pathways. Nociplastic pain is often diffuse and nonanatomic, and may include sensory deficits. It manifests as diffuse sensitization (fibromyalgia), functional visceral pain (irritable bowel syndrome, bladder pain syndrome), or regional somatic sensitization (complex regional pain syndrome, temporomandibular disorder). First-line treatment for nociplastic pain is a multimodal nonpharmacologic approach, including cognitive behavioral therapy and a physical exercise program. Patients should also be supported in setting functional goals and restructuring maladaptive beliefs about their pain. When nonpharmacologic approaches have not achieved their desired effect, pharmacologic therapy may be effective. Antiseizure medications, such as the gabapentinoids (gabapentin and pregabalin), as well as analgesic antidepressants (serotonin-norepinephrine reuptake inhibitors, such as milnacipran and duloxetine, and tricyclic antidepressants) have the best evidence as adjunctive therapies for nociplastic pain syndromes. Adverse effects of duloxetine include nausea, dry mouth, headache, weight loss, and constipation or diarrhea. After discussion of risks and benefits, this patient with diffuse sensitization (fibromyalgia) who has not responded completely to nonpharmacologic treatment should be offered a first-line analgesic, such as duloxetine, for nociplastic pain.
A 55-year-old man is evaluated for a 2-week history of neck pain. The pain is centered in the upper posterior neck and does not radiate. He has no weakness, sensory changes, difficulty walking, or bowel or bladder changes. He reports no trauma, fever, or chills. Medical history is significant for rheumatoid arthritis. He has no history of injection drug use. Medications are methotrexate and folic acid.
On physical examination, vital signs are normal. Range of motion of the neck is normal. He has no spinal tenderness on palpation. Strength is 5/5 in the upper and lower extremities. Deep tendon reflexes are 2+ throughout. The proximal interphalangeal and metacarpophalangeal joints are enlarged with minimal tenderness.
Which of the following is the most appropriate management?
A. Epidural glucocorticoid injection
B. Neck radiography
C. Physical therapy
D. Prednisone taper
The most appropriate management in this patient with rheumatoid arthritis (RA) and neck pain is neck radiography (Option B) to assess for atlantoaxial instability. Cervical spine disease is most often caused by degenerative spine and disk disease (spondylosis), especially in older patients. Certain underlying conditions, however, are also associated with a predisposition to cervical spine disease, including Down syndrome, ankylosing spondylitis, and RA. Although RA often spares the axial skeleton, it may affect cervical discovertebral joints, increasing the risk of subluxation of the atlantoaxial apparatus as well as the rest of the cervical spine. Patients may have Lhermitte sign (shock-like sensation shooting down the spine with neck flexion), evidence of cervical myelopathy (weakness, loss of bowel and/or bladder control, paresthesias), and findings of vertebrobasilar insufficiency (drop attacks, bulbar weakness, respiratory dysfunction, nystagmus, and vertigo). A high degree of suspicion is needed to make the diagnosis because pain is not always present. Imaging should be pursued if cervical spine disease is suspected. If cord compromise is not immediately suspected, plain radiographs should be obtained, including anteroposterior, lateral, extension, flexion, and open mouth views to determine the presence and the degree of subluxation. MRI should be obtained if neurologic symptoms or signs are present. If subluxation is present, surgical consultation is necessary. This patient has RA and new-onset neck pain concerning for cervical spine subluxation. Imaging of the neck with plain radiography should be obtained immediately.
A 64-year-old man with osteoarthritis asks for pain control. His history includes CKD stage 4 and heart failure.
Which is the best option?
A. Ibuprofen
B. Naproxen
C. Celecoxib
D. Acetaminophen
E. Indomethacin
D. Acetaminophen
Explanation:
NSAIDs worsen renal function and heart failure. Acetaminophen is safest for mild-to-moderate pain in this setting.
A 78-year-old man with metastatic prostate cancer is evaluated for worsening bone pain that is no longer responsive to nonpharmacologic and nonopioid therapy. He was recently admitted to hospice care. He also has stage G4 chronic kidney disease, hypertension, and depression. Medications are acetaminophen, amlodipine, and escitalopram.
On physical examination, the patient appears chronically ill. Vital signs are normal. There is tenderness over the midthoracic vertebrae, right humerus, and left femur.
Laboratory studies:
Creatinine, serum
2.5 mg/dL (221 µmol/L)
H
Estimated glomerular filtration rate
26 mL/min/1.73 m2
Which of the following is the most appropriate treatment for pain?
A. Extended-release oxycodone
B. Immediate-release hydromorphone
C. Immediate-release morphine
D. Immediate-release tramadol
The most appropriate treatment for cancer-related bone pain in this patient with chronic kidney disease is immediate-release hydromorphone (Option B). Up to 90% of patients with advanced cancer have pain. However, cancer pain is often undertreated, with about one third of patients with cancer receiving inadequate analgesia. Nonpharmacologic interventions that benefit patients with cancer pain include cognitive behavioral therapy to enhance coping techniques, physical therapy to improve function, acupuncture and related therapies, or radiation therapy directed to the underlying lesions. Pharmacologic pain management often requires a multimodal strategy that uses both opioids and nonopioid analgesics. Opioids may be appropriate in patients in whom nonopioid treatment is ineffective, not tolerated, or contraindicated, with careful attention to dosing, frequency, side effect profile, and comorbid conditions. In a palliative care setting,
A 28-year-old woman is evaluated for fibromyalgia, which was diagnosed last year. Nonpharmacologic measures have mildly improved her symptoms. However, daily generalized pain continues to limit the patient's ability to work and function, despite the use of over-the-counter acetaminophen and naproxen. Her only other medication is an oral contraceptive.
On physical examination, vital signs are normal. Tenderness to palpation is present throughout the neck muscles, shoulder girdle, lumbar paraspinal muscles, and lateral hips. Range of motion is normal throughout, and there is no joint swelling.
Which of the following is the most appropriate treatment?
A. Celecoxib
B. Milnacipran
C. Prednisone
D. Sertraline
E. Tramadol
The most appropriate management is milnacipran (Option B). Characteristic features of fibromyalgia are widespread chronic pain, fatigue, and sleep disorders. Mood disorders are often concomitant. First-line therapy is nonpharmacologic and includes patient education, exercise therapy or physical therapy, behavioral therapy, and other interventions guided by the patient's individual needs. Choice of pharmacologic therapy is based on symptom profile, patient comorbidities, and medication adverse effects because no trials have directly compared the efficacy of medications. Serotonin-norepinephrine reuptake inhibitors (SNRIs), such as duloxetine and milnacipran, are FDA approved for fibromyalgia and provide modest pain relief. Other treatment options for fibromyalgia include tricyclic antidepressants and gabapentinoids.
A 52-year-old woman is evaluated for a 5-week history of left lateral hip pain. She describes the pain as an ache that intermittently radiates down the lateral aspect of the leg. It began insidiously and has gradually worsened. The pain worsens when she climbs stairs or lies on her side. She reports no trauma. She has no leg weakness or swelling.
On physical examination, tenderness to palpation is noted over the greater trochanter. Painless full range of motion is present with abduction, flexion, and external rotation of the left hip. The remainder of the examination is normal.
Top of Form
In addition to activity modification and physical therapy, which of the following is the most appropriate management?
A. Glucocorticoid injection
B. Hydrocodone-acetaminophen
C. Ibuprofen
D. Plain radiography of the left hip
This patient's clinical presentation is consistent with greater trochanteric pain syndrome (GTPS; formerly trochanteric bursitis), and first-line therapy is pain relief with an oral NSAID, such as ibuprofen (Option C); activity modification and physical therapy are also recommended. Patients with GTPS typically have pain localized to the greater trochanter that may radiate down the lateral leg to the knee. The pain is often exacerbated by lying on the affected side and climbing stairs. Pain onset is usually insidious. GTPS can be differentiated from hip joint pain in that GTPS does not usually radiate to the groin or limit hip range of motion. Diagnosis is made by history and by eliciting pain with palpation over the greater trochanter or reproduction of the pain when the patient takes a step up.
A 68-year-old man with metastatic lung cancer has worsening pain despite taking oral morphine 120 mg every 8 hours. He has increasing confusion and myoclonus. Renal function is normal.
What is the best next step?
A. Increase morphine dose
B. Add gabapentin
C. Switch to IV morphine
D. Rotate to a different opioid
E. Add haloperidol
: D. Rotate to a different opioid
Explanation:
This patient has opioid-induced neurotoxicity (confusion, myoclonus), often due to morphine metabolites. The best management is opioid rotation (e.g., to hydromorphone or fentanyl), which may reduce neurotoxic effects
A 60-year-old woman on chronic opioids for cancer pain has severe constipation despite docusate and senna.
What is the best next step?
A. Increase fiber intake
B. Add polyethylene glycol
C. Discontinue opioids
D. Start methylnaltrexone
E. Add loperamide
Answer: D. Start methylnaltrexone
Explanation:
This is refractory opioid-induced constipation. Peripheral opioid antagonists (methylnaltrexone) are indicated when standard laxatives fail.