Pain Syndromes

Questions

Questions to be asked at the time of initial contact depend on the pain syndrome. Localization will determine the subsequent path of questioning, but certain questions are pertinent to all pain syndromes. The first three questions can be asked over the phone to prepare for the history taking and examination.

• 1.

  Where is the pain?

  Is the pain localized or diffuse? Does it correspond to a particular anatomic pattern or dermatomal distribution? Does it radiate?

• 2.

  When did it begin?

  Did it come on suddenly or worsen over time?

• 3.

  Is there a history of injury, underlying neurologic disease, or other chronic medical condition?

  Acute injury from lifting or from a mechanical task is common for radicular pain. Traumatic injury to a limb may precede CRPS. A variety of underlying medical conditions predispose to painful peripheral neuropathies, including diabetes mellitus, alcoholism, and a variety of medications.

• 4.

  Are there red flags?

  Is there acute and significant weakness or sensory loss? Is there a change in normal bowel or bladder function? Does the patient have a fever or unintentional weight loss? Is there a known history of cancer or other immunocompromised condition?

Orders

No orders should be given over the phone. Although analgesia may be required to obtain an adequate history and perform an adequate physical examination, it is best to evaluate the patient yourself first.

Inform RN

“Will arrive at the bedside as soon as possible.”

Quick-Look Test

Does the patient appear acutely ill?

Tachypnea, diaphoresis, or a decreased level of alertness suggests that the medical illness should be attended to before the pain syndrome is addressed.

How severe does the pain appear to be?

Pain is very subjective, and tolerance can vary; one should ask about severity and observe the patient’s pain behaviors.

Vital Signs

Fever suggests infection. Tachypnea may mean an underling medical condition or hyperventilation in response to pain. Tachycardia and elevated blood pressure often accompany acute pain.

Selective History and Chart Review

• 1.

  Define the character of the pain.

  The questions posed during the phone call should be asked directly (Where is the pain? When did the pain begin?). One strategy is to differentiate between neuropathic and somatic pain. Neuropathic pain is often described as burning, sharp, or shooting. Neuropathic pain may be induced by normally innocuous stimuli such as the touch of a shirt or spray from a shower (dysesthesia, allodynia). Somatic pain is oftentimes described as dull or achy. You should also ask about the presence of radiating pain.

• 2.

  What makes the pain better or worse?

  Ask if certain positions lessen or worsen pain. For example, an acute herniated lumbar disk is often worse with lumbar flexion, whereas peripheral neuropathy can be most bothersome at rest.

• 3.

  What is the patient’s medical history?

  Ask about specific conditions (such as diabetes) and exposures to neurotoxic substances (such as chemotherapy or alcohol) when considering a diagnosis of peripheral neuropathy. Any history of trauma may lead to a diagnosis of nerve or root compression or CRPS. Malignancy may produce neural pain either by compression from a mass or by neural infiltration. A previous stroke, particularly in the thalamus, the lateral medulla, or the parietal lobe, may produce a central pain syndrome.

• 4.

  What medications has the patient tried already?

Selective Physical Examination I