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LEARNING OBJECTIVES

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After completing this case study, the reader should be able to:

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  • Differentiate acute pain from chronic pain.

  • Describe the typical clinical findings associated with acute pain.

  • Describe the subjective and objective assessment of pain.

  • Identify appropriate nonopioid and opioid analgesics for selected patients with acute pain.

  • Choose suitable drug and nondrug therapy for the management of common opioid analgesic side effects.

  • Develop an appropriate therapeutic plan (including monitoring parameters) for a patient with acute pain.

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PATIENT PRESENTATION

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Chief Complaint

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“My belly hurts, and I can’t stand the sight of food.”

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HPI

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Charles Porter is a 58-year-old man who presents to the Family Practice Center with a 2-day history of nausea, vomiting, and epigastric and RUQ abdominal pain. The patient states that the pain began several hours after eating a large platter of cheese ravioli with sausage and meatballs at a local restaurant. The pain intensified and was associated with escalating nausea followed by several episodes of vomiting. The vomiting finally ceased but the abdominal pain has persisted and is made worse after meals. The pain is now dull, constant, and “bores” to his back. Lying up in bed or sitting in a chair seems to relieve some of the pain. Since the initial episode, his appetite has decreased and he has been avoiding fried or fatty foods. He denies any change in stool color or consistency.

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PMH

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  • HTN × 18 years; poorly controlled

  • Type 2 DM × 23 years; under fair control

  • History of gout; last attack 15 years ago

  • Dyslipidemia × 23 years

  • Alcoholic hepatitis without cirrhosis × 5 years

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FH

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Father deceased (esophageal varices), age 76; mother deceased (MI), age 83; brother alive and well, age 65; sister with breast cancer and gallbladder disease, age 48

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SH

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Is a retired bar owner. He lives with his wife (married for 25 years) on a 10-acre farm a few miles from town. He has two dogs and a cat. He has a 50 pack-year history of smoking and a history of chronic alcohol abuse.

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ROS

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As per HPI; otherwise negative

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Meds

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  • Atorvastatin 20 mg PO once daily

  • Hydrochlorothiazide 25 mg PO once daily

  • Losartan 100 mg PO once daily

  • Exenatide 10 mcg subQ twice daily

  • Metformin 500 mg PO BID

  • Aspirin 81 mg PO once daily

  • Insulin glargine 10 units subcutaneously at bedtime

  • Pepcid AC 20 mg PO PRN heartburn

  • MVI one PO once daily

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All

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  • Erythromycin—abdominal pain

  • Morphine—hives and mild wheezing

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Physical Examination

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Gen
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A pleasant, middle-aged white man in mild-to-moderate acute distress; appears his stated ...

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