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Case history

image A 69-year-old man presented with shortness of breath on exertion and weight loss. He had a history of hypertension and ischaemic heart disease. He was a miner and ex-smoker for over 50 pack-years. A staging CT scan demonstrated appearances consistent with lung cancer and bone metastases in the right chest wall. The diagnosis of metastatic small cell lung cancer was confirmed after biopsy, and a plan was made to commence carboplatin and etoposide chemotherapy. At a subsequent oncology outpatient appointment, he complained of moderate-intensity pain in the right subscapular area. Despite taking regular paracetamol and ibuprofen his chest wall pain persisted.

How would you take a pain history from this patient?

What approach is used for initiating pain management and what plan would you suggest for this patient?

What specific treatment options may be considered when managing pain secondary to bone metastases?

If strong opioid analgesia were required how should it be initiated?

What side effects of strong opioids should the patient be warned about?

What other information is important to provide to the patient when initiating strong opioids?

How would you take a pain history from this patient?

A thorough clinical assessment of pain includes gathering information on its site, character, radiation, exacerbating or relieving factors, timing and severity (Table 37.1). Cancer patients often experience two distinct pains; therefore, this assessment may need to be repeated for each separate pain.1

Table 37.1SOCRATES, a common mnemonic for investigating pain.

A full medication history including over-the-counter or complementary therapies should be taken. 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. It is also important for clinicians to understand the impact of pain on patients.

What approach is used for initiating pain management and what plan would you suggest for this patient?

The WHO pain relief ladder provides the basis for initiating and titrating analgesia (Figure 37.1).2 It 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 ...

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