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  1. What is your goal of pain therapy?

  2. How are you going to “measure” pain?

  3. Are you treating multiple pain issues or types of pain?

  4. Does this patient have comorbidities that will affect your pain care?

  5. What are the most appropriate and effective pain treatment options available?

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Case 96-1

An 84 year old female with a history of dementia, hypertension, hypercholesterolemia, coronary artery disease, chronic obstructive pulmonary disease, and chronic low back pain suffered a lower extremity fracture. The orthopedic surgery service has surgically repaired her leg and transferred her back to the primary service for management of multiple medical problems. On the postoperative day two pain has limited her movement and she has not been able to work with physical therapy or use the bathroom facilities. Home medications include atorvastatin, metoprolol, ramipril, hydrochlorothiazide, ipratropium, albuterol metereddose inhaler, and oxycodone sustainedrelease 20 mg twice a day. Her vital signs were: heart rate is 120 beats per minute, blood pressure 150/95 mm Hg, SpO2 95% on 2 L of oxygen, and temperature 37.2°C. Laboratory results were notable for a glucose level of 212. Despite an order for 2 mg of intravenous (IV) morphine “as needed” every 2–4 hours, the patient reports “a lot” of pain “not coming down with the morphine.”


Any discussion on the diagnosis and treatment of pain must start with the definition of pain. The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.

Pain can be classified in multiple domains. The first is the classification based on the underlying etiology of the pain. Nociceptive pain refers to the direct tissue injury from a noxious stimulus. Inflammatory pain refers to the release of inflammatory mediators that perpetuate and modulate nociceptive input. Direct injury to nerves results in a third type of pain , neuropathic pain, whereby the nature of sensory transmission is altered and accompanied by pain frequently described as a burning type of pain. Although these are described as discrete types of pain, they more often represent a continuum of the same injury. Surgical incision is a model of nociceptive injury that produces an inflammatory response. Incising the primary nociceptors in the skin with subsequent development of inflammatory neuritis can result in neuropathic pain.

The second domain of classification refers to the anatomic location of pain. In this category, pain can be described as either somatic or visceral. Somatic pain refers to a well-localized sensation related to skin, muscle, and bone, whereby visceral pain is poorly localized and is usually in response to distention of the internal organs such as the colon or small bowel, or compression or inflammatory injury, which occurs in pancreatic cancer or pancreatitis.

The final domain classifies pain based on ...

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