Pain Management

For the past week, a 16-year-old boy has had a progressively worsening dry, irritating cough; dyspnea on exertion; and intermittent fever and chills. During the past 24 hours, he has had no appetite and has vomited greenish material 3 or 4 times.

A 30-year-old woman complains that her headaches no longer respond to triptans; instead, they have increased in frequencyand severity. The pain interferes with her ability to work part-time and to take care of her 16-month-old daughter.

A 46-year-old man presents with right-sided facial paralysis. His symptoms beganthe previous evening when he had difficulty in closing his right eye; by morning,paralysis had developed. He also reports headache and mild photophobia.

Carbamazepine is associatedwith numerousclinically significantdrug interactions.1 Thiswidely used agent ismost commonly prescribed for eitherseizure disorders or adjunctivepain management.

abstract: The keystone of influenza prevention is still vaccination. The 2 available types of influenza vaccine--the inactivated vaccine, which is administered intramuscularly, and the attenuated vaccine, which is delivered via nasal spray--have efficacy rates of 70% to 80%. Unfortunately, only about 65% of persons who should receive the influenza vaccine are, in fact, vaccinated. The neuraminidase inhibitors oseltamivir and zanamivir are 70% to 90% effective in preventing influenza. These antivirals also are effective in reducing the severity of influenza symptoms and the duration of illness when administered within 48 hours of the onset of clinical disease. Some patients have difficulty in self-administering zanamivir because the inhalation process is fairly complicated. Because of the resistance pattern observed in 2005, amantadine and rimantadine are not currently recommended for prophylaxis or therapy. (J Respir Dis. 2007;28(1):21-29)

A 34-year-old man has had bilateralknee pain for the past 16 months andbilateral hip pain for the past 8 months.The pain is exacerbated by running, byweight bearing, and recently even by sittingfor extended periods. Moving froma sitting to a standing position is especiallydifficult. A week earlier, he visitedan urgent care center and was given naproxen and a 7-day course of prednisone,but neither medication alleviatedthe pain; in fact, he now feels worse.

We chose to present this case to readersbecause the patient’s neurologicexamination was normal and her presentationthus appeared benign.

A 12-month-old previously healthy boypresented to the pediatric emergencydepartment (ED) with a 10-day historyof fever, irritability, and anorexia.The patient’s mother had originallynoted the development of 3 erythematouspapules on the patient’s back, leftaxilla, and chest; these were followedby the onset of daily fevers, with temperaturesranging from 38.8°C to41.1°C (102°F to 106°F). The lesionsgrew progressively larger and erythematous,and became ulceratedwith central eschars.

A 23-year-old man presents to the emergency department with fever, headache,and photophobia. His illness began 5 days earlier with malaise, followed byfever, prostration, nausea, and vomiting. After 3 days, a severe headache developed,accompanied by photophobia; the headache did not respond to over-thecounteranalgesics.

A 37-year-old man found unresponsiveat home with erratic respiration andurinary incontinence was brought tothe emergency department (ED). Accordingto his family, the patient hadbeen complaining of headaches, vertigo,and mild neck pain for 2 months.During that time, a CT scan of thesinuses revealed chronic sinusitis; thepatient had completed a course ofprednisone, naproxen, and meclizinewithout symptomatic improvement.The day before he was brought to theED, he had presented to a differenthospital with the same complaints andwas given a prescription for antibioticsfor a presumed sinus infection. He haddiet-controlled hypercholesterolemiaand did not smoke.

For over 25 years, NSAIDs have been used to treat a variety of pain syndromesand inflammatory diseases. More than 50 million Americanstake these drugs. Unfortunately, control of pain and inflammation is notachieved without an associated cost-namely, GI complications and, to a lesserextent, nephrotoxicity.In an attempt to reduce drug-related toxicity, a new class of selectiveNSAIDs-the COX-2 inhibitors-was introduced in 1999. These selectiveNSAIDs are as effective as and pose less risk of gastric toxicity than nonselectiveNSAIDs.1,2The COX-2 inhibitors are thought to reduce end-organ injury, such as GIulceration, by sparing homeostatic or “constitutive” COX-1 enzyme function.1,2 Incontrast, therapeutic effects result from the inhibition of the “inducible” COX-2enzyme.1,2 Such drug effects target the production of proinflammatory prostaglandinsby COX-2 without interrupting normal cell function mediated by COX-1.2,3

In the first case study featured in the article by Drs Jagoda and Riggio, “WhatYou Forgot About the Neurologic Exam, Part 1: History, Mental Status,Cranial Nerves” (CONSULTANT, December 2004, page 1773), a 46-year-oldwoman with a history of migraine presented with a bilateral headache thatradiated to the occiput.

As a physician who specializes in pain management, I read with interest thearticle on chronic nonmalignant pain by Drs Atli and Loeser (CONSULTANT,November 2004, page 1693). Although the article was otherwise extremely informative,I was troubled by the authors’ failure to clarify the meaning of“breakthrough pain” in a nonmalignant setting and by their advocacy of theuse of short-acting opioids to treat such pain.

A 27-year-old woman is hospitalized after laboratory studies revealed extremelyelevated liver enzyme levels. The studies were ordered after the patient soughtmedical attention for severe headaches that began 3 weeks earlier and for thepast several days had been accompanied by malaise, nausea, and vomiting.

A 12-year-old boy complains of severe weekly headaches that last 2 to 3 hours. The pain involves both sides ofthe head and the frontal and occipital areas. Occasionally during a headache, the patient complains of some abdominaldiscomfort and pain. He becomes passive and irritable during the headache; he does not want to be aroundpeople, play, or even watch TV. The patient’s parents note that a few hours before a headache, he becomes somewhatrestless and agitated. The headaches started about 1 year earlier, and the headache pattern (frequency, duration,location of pain, and associated symptoms) has not changed since that time. The patient’s mother and maternalgrandmother suffer from migraine.

A 30-year-old woman complains that her headaches no longer respond to triptans; instead, they have increased in frequencyand severity. The pain interferes with her ability to work part-time and to take care of her 16-month-old daughter.About 12 years earlier, the patient started having migraine headaches. She had no significant medical history, norwas there any obvious precipitating event. Typically, she had 1 or 2 debilitating headaches a month. These were accompaniedby photophobia, nausea, and vomiting-but not by auras. Oral triptans usually relieved the pain and associatedsymptoms within 1 hour.

A 53-year-old woman, who has a remote history of acne, says that facial rednessappears each time she has a migraine. Her migraine medication, fiorinalwith codeine, ameliorates the headache, but the erythema lingers for days.

A painful scalp eruption of 4 days’duration brings an 81-year-old man toyour office. He has taken a lipid-loweringagent and an antihypertensivefor years but has not started any newmedications recently. One week earlier,he had a haircut. He denies recenttrauma to the scalp.

Primary care doctor: Because of the patient’s age and theabsence of a headache history, I first considered such secondarycauses as tumor and temporal arteritis. However,MRI of the brain and erythrocyte sedimentation rate werenormal. I now suspect a sleep-related headache becausethe attacks occur only at night and awaken the patientfrom a sound sleep. How can I determine which type ofsleep-related headache is involved?

Clinician: The patient’s symptom profile is confusing, especiallybecause his test results are normal. Are his amnesicepisodes related to his migraine?

For several weeks, a 29-year-old woman has had worsening left lower backpain that is aggravated by sitting and walking. The pain is most severe aboveher left buttock; it radiates into the buttock and very slightly into the leg. Overthe-counter analgesics have been ineffective. Assuming a supine position providessome relief, but the pain still occasionally awakens her at night. She deniesweakness, other neurologic symptoms, and any symptoms of bowel orbladder dysfunction.

Smallpox, which is caused byinfection with poxvirus variola,may follow variouscourses. An erythematouseruption can precede theappearance of tense, deep-seatedpapules that rapidly transform intovesicles. The lesions may be sparseor so numerous that they becomeconfluent.

A 32-year-old woman is admitted to the hospital because of nausea, vomiting,and mild jaundice. For 4 days, her health has steadily deteriorated: hepatictransaminase and bilirubin levels are elevated, prothrombin time is prolongedand, most recently, obtundation and changes in mentation have developed.Serologic studies for infection with hepatitis A, B, and C viruses are negative,as are tests for Epstein-Barr virus mononucleosis.

An 81-year-old woman is hospitalizedwith localized nonradiating low backpain of 3 weeks’ duration. She has nohistory of trauma, weakness of the legs,or urinary or bowel incontinence.

Which of these scenarios is familiarto you? •A local pharmacist calls to say thatyour patient wants another refill for thecombination analgesic containing aspirin,caffeine, and butalbital that youprescribed last week. Pharmacy recordsindicate that this patient has received250 tablets of this medication inthe last 34 days.

For 2 days, a 45-year-old woman has had a painful rash on her left upper chest,upper back, neck, shoulder, and upper arm; she has also had pain around herleft ear. She describes the pain as burning, needlelike, and so severe that it hasprevented sleep; it is unrelieved by topical emollients. The rash was precededby 24 hours of a similar burning pain in the same area. No neurologic deficitsare associated with the rash. She has no history of rashes; no pain or rashesoccur elsewhere on her body.

A 60-year-old man has had anterior neck discomfort for the pastseveral weeks. He also has right-sided cephalalgia and occasional jaw discomfortwhile eating but no dysphagia or odynophagia. The cephalalgia, which hasbeen present for the past week, is moderately severe and is associated withblurred vision.

A 29-year-old woman is brought to the emergency department after a caraccident. She complains of head pain and has a contusion over the posterioraspect of the right temporal bone and right occipital bone; a small amount ofblood flows from the right external auditory canal. She has only a vague recollectionof the accident. Past medical history-although difficult to ascertain-seems noncontributory.

A 58-year-old man complains ofintermittent headaches that beganabout 2 months earlier and have recentlyincreased in severity. Theheadaches occur at various times ofthe day and improve slightly whenhe sits. He denies trauma, fever, photophobia,and other neurologicsymptoms. He has 1 alcoholic drinka day and has smoked 1 pack of cigarettesa day for the past 20 years.Medical history is noncontributory.

A 36-year-old womanhas had a rash on her hands and feetfor the past week. She denies recentillness, pruritus, fever, chills, sorethroat, and abdominal discomfort.She is currently in a monogamousrelationship with her fiancé.