PAIN MGMT Cases
A 31-year-old woman is brought to the emergency department for a severe throbbing headache, nausea, and photophobia for 3 hours. She has severe occipital pain and chest tightness. Prior to onset of symptoms, she had attended a networking event where she had red wine and, shortly after, a snack consisting of salami and some dried fruits. The patient has recurrent migraine headaches and depression, for which she takes medication daily. She is mildly distressed, diaphoretic, and her face is flushed. Her temperature is 37.0°C (98.6 F), pulse is 90/min, respirations are 20/min, and blood pressure is 195/130 mmHg. She is alert and oriented. Deep-tendon reflexes are 2+ bilaterally. This patient's symptoms are most likely caused by a side effect of which of the following medications?
A) Amitriptyline
B) Ibuprofen
C) Verapamil
D) Sumatriptan
E) Phenelzine
Phenelzine, a monoamine oxidase inhibitor (MAOI), is typically reserved for treatment-resistant or atypical major depressive disorder given its severe side effect profile and numerous drug interactions. Monoamine oxidase breaks down excess tyramine in the body. Since MAOIs block this enzyme, the consumption of tyramine-rich foods (e.g., red wine, certain nuts, aged cheeses or meats, dried fruits) leads to an accumulation of tyramine. This, in turn, leads to a release of norepinephrine that can provoke a hypertensive crisis, as seen in this patient.
Henry's got a lot going on in his life. How can you interview him to see if he's ready to incorporate exercise into his daily activities.
What are the 5 stages of "Patient Readiness to Change"
Pre-Contemplation: Henry would not be ready to change but you can discuss benefits of physical activity
Contemplation: Henry may be receptive to receiving basic guidance on becoming more physically active.
Preparation: You can write physical activity perscription for Henry or refer to exercise professionals
Action: Discuss relapse prevention strategies - plan for challenges. Applaud efforts that Henry has made
Maintenance: Encourage Henry to spend time with people with similar healthy behaviours. Applaud efforts.
A 14-year-old boy is brought to the emergency department after being hit with a baseball bat on the lateral side of his leg immediately below the knee. He is unable to dorsiflex his foot. Which nerve is most likely injured?
Common fibular (peroneal)
A pain that persists beyond the normal tissue healing time. This time interval is often indicated as 3 months, though some experts have identified the window as 6 months
Chronic Pain
A 24-year-old man comes to the physician because of back pain after being severely sunburned on his upper back 3 days ago. He now experiences pain in the affected area when applying cream or putting on a shirt. Physical examination of the upper back shows erythema of the skin and some mild blistering. Sensitization of which of the following structures would best explain this patient's symptoms?
A) Glycinergic receptors of thalamic neurons
B) The nociceptors of the dorsal root are involved in the pathophysiology of dysfunctional perceptions of pain, such as allodynia. Although incompletely understood, allodynia is thought to result from both peripheral and central sensitization. After an injury (e.g., sunburn), cytokines, nerve growth factors, and other chemical mediators are released in the injured area, leading to a constant, increased input to the nociceptors. This causes an up-regulation of the ion channels in the nociceptors, making them more sensitive to chemical mediators and lowering the threshold to stimulus, consequently causing more action potentials to form. This phenomenon is known as peripheral sensitization. The constant increased peripheral output is likely a significant driver to the sensitization of central nociceptive neurons, which likely contributes to the persistence of allodynia long after the initial injury (e.g., in postherpetic neuralgia).
What are 5 categories that are tested in Waddell's Score.
Tenderness: Superficial, and diffuse tenderness and/or non-anatomical tenderness
Simulation: tests based on movements which produce pain, without actually causing that movement i.e.) Axial loading and pain on simulated rotation
Distraction: Positive tests are rechecked when the patient's attention is distracted, such as a straight leg raise test
Regional Disturbance: Regional weakness or sensory changes which deviate from accepted neuroanatomy
Overreaction: Subjective signs regarding the patients demeanour and reaction to testing
These are usually random, have a stabbing/squeezing quality, radiate in the supraorbital/temporal area, a severity of >8 and lasts minutes
Cluster Headaches
A pain that arises from a nerve fibre sensitive to a noxious stimulus or to a stimulus that may become noxious
Nociceptive pain
A 62-year-old woman comes to the physician because of low back pain for 1 week. Menopause occurred 10 years ago. Physical examination shows localized tenderness over the lumbar spine after movement. X-rays of the spine show a compression fracture of L1-2. A DEXA scan shows decreased bone mineral density. Serum calcium and phosphorus concentrations and serum alkaline phosphatase activity are within the reference ranges. A bisphosphonate drug is prescribed. The expected beneficial effect of this drug is most likely due to which of the following actions?
(A)Decreased insulin-like growth factor-1 concentration
(B) Decreased osteoclast activity
(C) Decreased osteoprotegerin production
(D) Increased 1,25-dihydroxycholecalciferol concentration
(E) Increased osteoblast activity
(F) Increased receptor activator of NF-κB ligand (RANKL) production
(B) Decreased osteoclast activity
Explain the difference between Factitious Disorder and Malingering.
Bonus: If you say what I'm thinking you'll get an extra 100 points. Has to do with the DSM-V
Factitious Disorder (aka Munchausen's): Patient is consciously producing symptoms but NOT for secondary gain. Like's to assume the sick role or sick role by proxy (be aware of child abuse)
Malingering: Patient fabricates symptoms of physical disorders for secondary gain or external reward
What I was thinking: Malingering is NOT a mental illness or a psychiatric pathology. Not in the DSM-V
A 73-year-old woman comes to the physician because of a 2-month history of diffuse weakness and tingling of her arms and legs. Neurologic examination shows weakness of the extensor and flexor muscles of the lower extremities. Knee and ankle deep tendon reflexes are exaggerated. Sensation to vibration and position is decreased in all extremities, but the decrease is more prominent in the lower extremities than in the upper extremities. This patient most likely has a deficiency of which vitamin?
Vitamin B12 (cyanocobalamin)
A pain from abnormal neural activity due to disease, injury, or dysfunction of the peripheral nervous system and/or central nervous system
Neuropathic pain
A 61-year-old woman with a history of stage IV pancreatic cancer comes to the emergency department with insomnia due to intractable midepigastric pain. The pain had been constant for months but has worsened over the past few weeks despite the fact that she is already taking hydrocodone 10 mg and ibuprofen 400 mg. She has a past medical history of chronic pain and major depressive disorder. In the past month, she has been taking her pain medications with increasing frequency, going from twice a day to four times a day. Her other medications include venlafaxine and eszopiclone. She describes her mood as low, but states she does not have any suicidal thoughts. She appears fatigued and slightly cachectic. Her temperature is 36°C (96.8°F), pulse is 100/min, and blood pressure is 128/65 mm Hg. Physical examination shows a mass in the midepigastric region. Which of the following is the most appropriate next step in management?
A) Discontinue hydrocodone and ibuprofen, and start IV ketorolac
This patient's current pain medications (hydrocodone and ibuprofen) are not providing her with enough pain relief. Therefore, she needs to be switched to a stronger medication (e.g., hydromorphone) according to the WHO analgesic ladder. When converting between opioids, patients will likely have less tolerance to a new opioid than to their previous opioid (i.e., incomplete cross-tolerance), therefore, it should be given at a 25–50% lower dose, then adjusted according to the patient's pain score. Additionally, this patient should continue taking ibuprofen, as nonopioid analgesics should be used in each step of the ladder for effective and balanced pain relief.
Name 6 of the 11 symptoms that are assessed in the Clinical Opiate Withdrawal Scale (COWS)
Resting Pulse Rate, Sweating, Restlessness, Pupil Size, Bone or Joint Ache, Runny Nose or tearing, GI Upset, Tremor, Yawning, Anxiety or Irritability, Gooseflesh Skin/Goosebumps
A 73-year-old man is brought to the emergency department 30 minutes after the sudden onset of right-sided body weakness. His wife reports that he does not seem to understand simple questions. He has type 2 diabetes mellitus and has smoked 1 pack of cigarettes daily for 45 years. The patient speaks fluently, but he answers questions with nonsensical phrases and cannot repeat single words. What type of aphasia is the most likely diagnosis?
Wernicke aphasia is caused by lesions in the superior temporal gyrus of the dominant (usually left) hemisphere, usually along the left MCA distribution. Patients with Wernicke aphasia typically present with impaired language comprehension and repetition; although they can speak fluently, they produce nonsensical phrases. Furthermore, these patients lack awareness of their impairment, as is the case here. In addition to Wernicke aphasia, signs of an MCA stroke include gaze deviation towards the side of the infarction and contralateral homonymous hemianopia without macular sparing.
Pain initiated or caused by a primary lesion or dysfunction in the peripheral or central nervous system
Neurogenic pain
Explain the WHO Analgesic Ladder for Cancer Pain Relief. Name/explain the 3 steps.
1. Mild Pain 1-3, (non-opioid +/- adjuvant)
2. Moderate Pain 4-6, Opioid for mild to moderate pain (+/- non-opioid, +/- adjuvant)
3. Severe Pain 7-10, Opioid for moderate to severe pain (+/- non-opioid, +/- adjuvant)