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LEARNING OBJECTIVES

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

  • 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.

PATIENT PRESENTATION

Chief Complaint

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

HPI

Charles Porter is a 68-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 extra hot chicken wings with cheese fries and gravy 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 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.

PMH

HTN × 20 years; poorly controlled

Type 2 DM × 23 years; under fair control

History of gout; last attack 15 years ago

Dyslipidemia × 23 years

Alcoholic fatty liver disease without cirrhosis × 10 years

FH

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 58

SH

He is a retired bar owner and lives with his wife (married for 35 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.

ROS

As per HPI; otherwise negative

Meds

Atorvastatin 20 mg PO once daily

Hydrochlorothiazide 25 mg PO once daily

Losartan 100 mg PO once daily

Exenatide ER 2 mg subcutenously weekly

Metformin 1000 mg PO BID

Aspirin 81 mg PO once daily

Insulin glargine ...

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