Event 1: Case Summary


38 year old with history of breast cancer with postmastectomy pain, limited response to opioid pain medications, and negative impact on function.

History of Present Illness

Ms. Jackson is a 38-year-old, African American nurse who completed treatment for triple negative breast cancer 5 months ago. She opted for bilateral mastectomy, radiation, and chemotherapy.

Her treatment history is significant for very poor pain control following her mastectomies and her TRAM flap reconstruction, which were performed 3 months apart. Ms. Jackson describes her post-operative experience as “horrific and isolating.”

She rates her global pain as a 7 on a 0 to 10 scale, and notes that the pain is both constant and “unrelenting.” She has persistent moderate to severe pain that she describes as a tight “band” around her chest.

Additional moderate pain sensations, she states, feel like “burning or tingling” in her hands, suggesting a neuropathic pain component, which have been gradually improving since completion of the chemotherapy. The patient is frustrated that she still experiences pain, states “it’s ruining my life, I don’t think it will get better, and I worry that my family and friends don’t care about me anymore.”


Past Medical History

Intraductal carcinoma of the breast

Past Surgical History

Bilateral mastectomy with TRAM flap reconstruction

Current Medications

  • Hydromorphone 4mg every 4 hours as needed
  • Sustained release oxycodone 60 mg every 12 hours
  • Gabapentin 300 mg every 8 hours
  • Multivitamin
  • Aspirin


None known

Family History

Ms. Jackon’s mother and sister both died of breast cancer before their 45th birthdays. Ms Jackson recalls their illnesses and deaths vividly, and notes that they had excruciating pain. Ms Jackson has one older brother who has both hypertension and diabetes mellitus. He is an alcoholic. There is no other illness in the family.

Social History: 

Mrs. Jackson is divorced, and has an amicable relationship with her ex-husband. She has two adult daughters, who live nearby and are very engaged in her life.

Psychiatric History

Mrs. Jackson states she was probably depressed at the time of her divorce, but did not receive any treatment for depression at that time.

Substance Abuse History

Mrs. Jackson has no history of substance abuse

Review of Systems

As above.

Physical Exam

Vital Signs

Temperature 97.2, Blood Pressure 152/88, Heart Rate 96, oxygen saturation 96% on room air

General Appearance

Well developed woman, no distress

Head, Ears, Eyes, Nose, Throat and Mouth Exam

Normocephalic, sclera anicteric, conjunctivae clear, oral mucosa moist and pink.


Normal range of motion.




Tachycardic, regular rhythm, no murmurs.


Reconstructed breast mounds bilaterally, scars well healed, tenderness to superfical touch bilateral axilla.


Soft, palpable liver tip, no masses, no tenderness to palpation, low horizontal well healed scar from TRAM flap.


No cyanosis, clubbing or edema.


No rashes.


Strength 5/5 upper and lower extremities.


Alert and oriented, normal gait, cranial nerves intact.

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University of Alabama at Birmingham