First, refer to Pam’s background for reference:
HPI
41-year-old Caucasian female with chief complaint of pain in chest, arm, and shoulder.
PSHx
Bilateral skin sparing mastectomy with axillary node dissection and reconstruction 3 months ago
PMHx
GAD, Depression, Breast Ca (Stage 3C invasive ductal carcinoma)
Meds
Tamoxifen 20mg PO daily
Goserelin 3.6mg subQ every 28 days
Lorazepam 2mg PO QHS
Oxycodone ER 20mg 1 tab Q12 hours
Oxycodone / acetaminophen 5-325mg 1 tab PO Q 4-6 hours PRN (~ 2 doses daily)
Ibuprofen 400mg PRN (~ 2 to 3 doses daily)
Sennosides / docustate 2 caps QAM
SHx
Denies tobacco or recreational drugs, occasional alcohol intake socially
Pain
Stabbing, sharp, aching, and tender over lateral aspect of chest wall, shoulder, and occasionally the arm. It is worse in the morning and with strenuous activity. Burning, tingling, and numbness in hands and feet but improving. Aggravated by light touch, pressure, trigger point (underarm), exposure to cold air, raising arms above 90 degrees. Alleviated by meds, rest, and warm baths. 5/10 now, 6/10 average, 9/10 worst, 5/10 least; 8/10 activity, 6/10 mood, 5/10 sleep, 3/10 work, 10/10 relations, 8/10 enjoyment.
ROS
Fatigued, some depression, mild constipation, musculoskeletal pain over anterior chest.
Vitals
BP 112/74 mmHg; HR 78 bpm; RR 20 bpm; Temp 98; Ht 65’ in; Wt 140 lbs
Physical Exam
Hunched posture, decreased bowel sounds, surgical scars healing well, mild swelling in both arms R > L. Decreased ROM bilaterally and guarding present.
Labs
CBC, BMP, HgBA1c, B12, and TSH within normal limits
Test Your Knowledge: Pam's Current Problems
Test Your Knowledge: Pain Control
With this knowledge in mind, which of the following interventions would you recommend to help Pam’s pain?
Note: While there are no absolute right or wrong answers, we agree that Pam would benefit from initiation of an adjuvant analgesic, such as gabapentin. She would also likely benefit counseling for coping strategies, pacing, and acceptance. A physical therapy referral for Pam would be absolutely warranted. Increasing or decreasing the dose of Pam’s opioid would be a provider specific decision, however, she would be likely benefit from a trial wean, especially once the gabapentin is at therapeutic doses. We would avoid increasing the benzodiazepine dose for Pam, especially if opioids were continued. Ibuprofen will likely have little benefit for Pam’s pain.
Test Your Knowledge: Functional Limitations
Which of the following do you feel should be added to the treatment plan for Pam?
Test Your Knowledge: Psychosocial Distress
Which of the following techniques would you recommend for Pam?
Test Your Knowledge: Drug-Related Problems
Which of the following is a drug-related problem for Pam?
