Test your pain management skills with this case.

A 66-year old man with metastatic prostate cancer develops slowly progressive right-sided pelvic pain in the region of known pelvic metastases. He describes dull-aching pain rated at 8/10 in the lateral pelvis and sharp shooting pain that radiates down the left leg. The pain limits mobility and awakens the patient from sleep. He has no focal motor or sensory deficits. An x-ray shows blastic metastases in the lateral pelvis. He is undergoing a course of palliative radiation therapy. Morphine immediate release 30mg ever 4 hours controlled his pain until the past several days. The dose currently decreases his pain from 8/10 to 6/10 for 1-2 hours at best.

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Value: 1
This patient has somatic pain.
 
 
  

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The patient has neuropathic pain.
 
 
  

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Changing his drug regimen to 2 tablets of hydrocodone/acetaminophen 10/325 every 4 hours would likely provide better analgesia.
 
 
  

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Training in relaxation techniques or imagery could be integrated into the pain management strategy.
 
 
  

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Stopping morphine and substituting nortriptyline would provide better analgesia.
 
 
  

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Starting extended release morphine 30mg every 6 hours with morphine 60mg every 1-2 hours for breakthrough pain is an appropriate strategy to provide better analgesia
 
 
  

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A strategy to improve analgesia would be to increase the current dose of immediate release morphine to 45mg q 4 hours plus breakthrough dosing.
 
 
  

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To provide better analgesia, one could begin transdermal fentanyl with breakthrough morphine once his pain is better controlled with immediate relief morphine.
 
 
  

 


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