Zeina al-saddar
Rama mawajdeh
Teeba al- shammari
Manar qarqash
Pain never
killed any one.
True or False?
Pain
An unpleasant
sensory and
emotional experience
associated with actual
or potential tissue
damage.
Whatever the
patient says it is!
Nociception
Stimulation
In acute pain, free nerve endings (nocicep-tors) are
stimulated in response to noxious stimuli
Transmission
And then the sensation is transmitted through the
nerve fibers of the primary afferent system.
When the transmission is through A-delta (A)
nerve fibers, the pain is generally sharp and localized, whereas when it is transmitted through Cafferent fibers, the pain can be described as dull
and aching.
Perception
The pain is then perceived by the brain
Modulation
finally the sensation is modulated through
various processes that affect how the body
responds to the pain and medications used to
treat the pain.
Acute pain
Useful physiologic process warning individuals of
disease states and potentially harmful situations.
Acute pain usually nociceptive, but it can be
neuropathic in nature.
Common causes : post surgery , acute illness,
trauma, labor, medical procedures.
Chronic pain
Continuous , episodic pain that persists more than 6
months to years it serves no biologic protective
purpose and can cause stress and suffering/
Can be nociceptive, neuropathic or both.
Chronic pain
Subtypes include :
Pain related to chronic disease ( pain
secondary to osteoarthritis ).
pain that persists beyond normal healing time
for acute injury (e.g., complex regional pain
syndrome).
pain without identifiable organic cause (e.g.,
fibromyalgia).
pain associated with cancer.
Pain
Level
Typical
Corresponding
Numerical
Rating (0 to 10
Scale)
WHO Therapeutic
Recommendations
Comments
Mild
pain
1-3
Nonopioid analgesic:
taken on a regular
schedule, not as
needed (prn)
Acetaminophen 650 mg
every 4 hr
Acetaminophen 1,000 mg
every 6 hr
Ibuprofen 600 mg every 6
hr
Modera
te pain
4-6
Acetaminophen 325
mg/codeine 60 mg every 4
hr
Acetaminophen 325
mg/Oxycodone 5 mg every
4 hr
Tramadol 50 mg every 6 hr
Severe
pain
7-10
Switch to a high
potency (strong)
opioid; administer on
a regular schedule
Morphine 15 mg every 4
hr
Hydromorphone 4 mg
every 4 hr
Morphine controlled
release 60 mg every 8 hr
Pharmacologic :
Non opioids
Opioids
Nonopioids
Acetaminophen
NSAIDS (Nonsteroidal antiinflammatory
drugs)
Corticosteroids
Chief Complaint
My belly hurts, and I cant 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 double sized cheeseburger, french fries, and a chocolate of
milkshake at a local fast food 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 made worse
after meals. The pain is now dull, and achy in nature. 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
FH
Father deceased (CVA), age 76; mother
deceased (MI), age 83; brother alive and well,
age 65; sister with breast cancer and gallbladder
disease, age 58
SH
Is a retired bar owner. He lives with his wife
(married for45years) on a 10-acre farm. He
has two dogs and a cat. He has a 50 pack-year
history of smoking and a history of binge
drinking.
ROS
As per HPI; otherwise negative
Meds
Atorvastatin 20 mg po once daily
Hydrochlorothiazide 25 mg po once daily
Lisinopril 20mg po once daily
Glibizide 10 mcg po BID
Metformin 500 mg po BID
Aspirin 81 mg po once daily
Insulin glargine 10 units subQ at bedtime
Maalox TC 30 ml po. PRN heartburn
MVI 1 po once daily
All
Erythromycinabdominal pain(1997)
Morphinehives and mild wheezing(1987)
Physical Examination
Gen
A pleasant, ealderly white man in mild-to-moderate acute
distress; appears his stated age
VS
BP 145/95 mm Hg (sitting), P 84 bpm, RR 20, T 37.8C; pain
4/10, dull, somewthat achy; Wt 78 kg, Ht 510
HEENT
PERRLA, fundi with mild AV nicking; TMs WNL; mucous
membranes moist
Chest
Clear to A & P
Heart
Normal S1 and S2; without murmur, rub, or gallop
Abd
Normal bowel sounds, without organomegaly,
moderate RUQ pain with deep palpation with mild
guarding
Genit/Rect
normal prostates; guaiac () stool
Ext
Good strength throughout, reflexes intact, mild
decreased pinprick sensation to both lower
extremities; no CCE
Lab results :
Na 138 mEq/L (135-152)
(12-16)
AST 78 units/L
(13-35)
K 3.3 mEq/L
(3.5-5.3)
Hct 36%
(37-47%)
ALT 67 units/L
(10-35)
Cl 97 mEq/L
(97-110)
(140-440)
CO2 23 mEq/L
(up to 1.1)
Neutros 76%
(up to 0.3)
Bands 4%
Eos 2%
(1-6%)
Lymphs 18%
(26-45%)
Crcl 60
(40-75%)
Assessment
Acute RUQ abdominal pain; R/O cholelithiasis,
acute cholecystitis, ascending cholangitis, acute
pancreatitis.
Problem Identification
1.a. Create a list of the patients drug therapy problems.
Hepatic disease (elevated liver function tests) >>alcohol abuse.
Hypertension inadequately controlled diuretic and
angiotensin II receptor blocker (acute pain may elevate blood pressure); further
evaluation
Type 2 diabetes inadequately controlled >>(glipizide and metformin)
and basal insulin
Dyslipidemia managed with atorvastatin that requires further
evaluation to assess adequacy of treatment regimen.
Hypertriglyceridemia may precipitate acute pancreatitis
Potential problem:
Metformin >>lactic acidosis>abdominal discomfort
hydrochlorothiazide>> Hypokalemia secondary
>>acute abdominal discomfort.
Desired Outcome
Therapeutic Alternative
1. Nonopioid agents
Acetaminophen (APAP)
analgesic and antipyretic prop.
minor pain.
comparable effectiveness to aspirin
no peripheral anti-inflammatory activity or effects on platelet
function.
fewer GI and renal adverse effects than NSAIDs.
The max.daily dose (adult) is 4 g.
Hepatic toxicity >> 1.acute acetaminophen overdose
2. usual doses in certain high-risk conditions (e.g., alcohol ingestion, cachexia or
malnutrition, and concomitant drugs that induce hepatic enzymes)
NSAIDs
2.Opioids
Meperidine
Fentanyl
. Oxymorphone
Methadone
Levorphanol
3.Central analgesics
Tramadol relieves pain by two mechanisms of action.
1. It is a weak -opioid receptor agonist
2. inhibits the reuptake of the neurotransmitters serotonin and
norepinephrine.
The most common side effects are nausea, dizziness, drowsiness,
and constipation.
Optimal Plan
Outcome Evaluation
What clinical and laboratory parameters are necessary
to evaluate the therapy for achievement of the
desired therapeutic outcome and to detect or
prevent adverse effects?