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Case History

Image not available. A 69-year-old man attends the oncology outpatient clinic. He complains of moderate-intensity pain in the right subscapular area, shortness of breath on exertion, and weight loss. He is an ex-miner and an ex-smoker of over 50 pack-years. A staging computed tomography (CT) scan has demonstrated appearances consistent with metastatic lung cancer with bone metastases in his right chest wall. A biopsy confirms small-cell lung cancer and the patient is planned to start carboplatin and etoposide chemotherapy. The patient has been taking regular paracetamol and ibuprofen, but his subscapular chest wall pain persists despite this.

How would you characterize and treat this patient's pain?

How would you advise this patient with regard to pain medication?

How would you manage side effects from pain medication?


How would you characterize and treat this patient's pain?

Image not available. Pain is defined as an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage (IASP 1986).1 The majority of patients with cancer experience pain, therefore it is important for clinicians to understand the impact pain can have on patients, and endeavour to manage symptoms as quickly and effectively as possible.

On average, cancer patients experience two distinct pains. The first step is a thorough clinical assessment; this should include site, character, radiation, exacerbating or relieving factors, timing and severity (see Table 43.1 for further details).

Table 43.1'SOCRATES' - a common mnemonic for investigating pain

A full medication history should be taken, including over the counter or complementary therapies. It is important to establish which medications patients feel have been effective for their symptoms and any side effects experienced, as this may affect compliance.

The World Health Organization (WHO) analgesic ladder provides the basis for initiating and titrating (Figure 43.1). This considers the severity of pain and previous analgesia. For example, strong opioids are indicated if pain is moderate to severe in intensity (with no previous analgesia) or if pain has not responded to weaker analgesia.

Figure 43.1

World Health Organization (WHO) analgesic ladder.

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