AKT – Pain management

James Walker, aged 67, presents with a six-month history of worsening lower back pain, worse at night and not relieved by rest. He has also noticed unintentional weight loss and increasing fatigue.

Review of systems reveals urinary hesitancy and nocturia. He is not on any regular medications and has no known allergies.

Past history includes hypertension. His brother died from prostate cancer at age 72.

On examination, he has tenderness over the lower lumbar spine, reduced range of motion, and no focal neurological deficits. PSA is 48 µg/L and plain lumbar spine x-ray shows sclerotic lesions in the vertebrae.

What is the most appropriate next step?

Samantha Brodie, aged 45, presents with a six-week history of right shoulder pain that started insidiously and is now limiting her ability to work as a hairdresser.

She describes the pain as dull and aching, worse with overhead activity, and notices some stiffness in the morning lasting about 15 minutes. There is no history of trauma.

Examination reveals limited active range of motion, especially abduction and external rotation, but relatively preserved passive movement. Pain is reproduced on Hawkins-Kennedy test.

What is the most appropriate initial management?

Ahmad Khan, aged 52, presents with bilateral foot burning pain, worse at night, ongoing for several months. He describes it as a constant burning sensation with occasional shooting pains.

Past medical history includes poorly controlled type 2 diabetes. Medications include metformin and gliclazide.

Neurological exam shows reduced vibration sense and pinprick to the mid-shins and absent ankle reflexes bilaterally. BSL today is 16.3 mmol/L.

What is the most appropriate pharmacological treatment?

Fiona Nguyen, aged 34, presents with severe dysmenorrhoea and deep dyspareunia. She reports needing time off work each month due to the pain and has tried simple analgesia with minimal benefit.

She is nulliparous and not currently trying to conceive. Menstrual cycles are regular. Pelvic examination reveals mild tenderness in the posterior fornix, but is otherwise unremarkable.

What is the most appropriate next step in management?

Paul Edwards, aged 62, presents with persistent pain in his right hip that worsens after walking more than 50 metres and improves with rest. He denies back pain or numbness. Examination reveals reduced internal rotation of the right hip and pain at the end of range.

There is no neurological deficit and straight leg raise is negative. X-ray shows joint space narrowing and osteophytes at the right hip joint.

What is the most appropriate next step in management?

Rebecca Sloan, aged 29, presents with a 3-month history of daily headaches that are bilateral, pressing in nature, and not associated with nausea or photophobia. They tend to worsen as the day progresses. She has a demanding office job and reports poor sleep and skipping meals.

There are no red flag features on history or examination.

What is the most likely diagnosis?

George Thomas, aged 73, presents with constant, burning right-sided chest pain persisting for 2 months after a shingles outbreak. He describes it as sharp and shooting at times, and it interferes with his sleep.

He is otherwise healthy and is not taking any current medications.

Examination reveals allodynia in the T4 dermatome.

What is the most appropriate pharmacological treatment?

Angela D’Souza, aged 57, presents with a long history of chronic low back pain, now worsening over the past year. She has been using codeine regularly but finds it less effective. She denies red flag symptoms but reports low mood and poor sleep.

She has tried physiotherapy and massage in the past without lasting benefit.

What is the most appropriate next step in management?

Lucia Marino, aged 48, presents with severe pain in her right foot following a minor ankle sprain 4 months ago. The pain is burning in quality, associated with swelling, temperature sensitivity, and skin colour changes. She is unable to bear weight on that side.

Examination reveals allodynia, oedema, and shiny skin on the dorsum of the right foot. Pulses are normal.

What is the most likely diagnosis?

Daniel Norris, aged 19, presents after a rugby injury with severe right knee pain. Examination shows swelling, tenderness over the medial joint line, and a positive McMurray’s test. He cannot fully extend the knee.

There are no signs of neurovascular compromise.

What is the most appropriate next step in management?

Helen Barclay, aged 82, is a resident in a nursing home and has advanced osteoarthritis of the knees. She frequently complains of pain and has difficulty mobilising. She is currently taking regular paracetamol and occasionally uses topical diclofenac. Her renal function is borderline and she has a history of hypertension.

What is the most appropriate next step in management?

Marcus Li, aged 22, presents with severe pain and swelling of the right great toe that started suddenly overnight. He is otherwise well. Examination shows a red, hot, tender and swollen first metatarsophalangeal joint. He has no history of trauma. His father has a history of gout.

What is the most appropriate initial management?

Thomas Grant, aged 41, presents with persistent left-sided jaw pain and clicking that worsens with chewing. He works as a software engineer and reports stress and teeth grinding at night.

Examination reveals tenderness over the left temporomandibular joint (TMJ) with audible clicking during opening and closing of the mouth. There is no trismus or swelling.

What is the most appropriate initial management?

Nerida Smith, aged 38, presents with vulval burning and pain for the past 4 months, worse with prolonged sitting and during intercourse. She reports that routine investigations have been normal and antifungal therapy was ineffective.

Examination is normal, with no signs of infection or dermatological changes. Cotton swab testing reproduces pain at the vulvar vestibule.

What is the most likely diagnosis?

David Ross, aged 56, presents for opioid renewal for chronic shoulder pain following a rotator cuff injury 2 years ago. He has been on oxycodone for 18 months. He now reports low mood, poor motivation and escalating doses with diminishing effect.

He has not engaged in physiotherapy recently and has no red flag symptoms. You suspect opioid-induced hyperalgesia.

What is the most appropriate next step?

Emily Crouch, aged 26, presents with persistent pelvic pain that has lasted over 6 months. She describes the pain as constant, dull, and sometimes cramping. It is not related to her menstrual cycle. She has had normal pelvic ultrasounds and STI screening. She takes regular ibuprofen with partial relief.

She reports a history of sexual assault as a teenager. On examination, there is generalised tenderness without guarding or rebound.

What is the most appropriate next step in management?

Luke Jensen, aged 47, presents with chronic pain in the left lateral elbow that worsens with gripping and lifting. He is a tennis coach and has had symptoms for several months despite rest and NSAIDs.

Examination reveals tenderness over the lateral epicondyle and pain with resisted wrist extension.

What is the most appropriate next step in management?

Joan Miller, aged 80, presents with generalised aching pain, stiffness lasting over an hour in the morning, and fatigue. Symptoms are bilateral and involve her shoulders and hips. She has difficulty getting out of bed and rising from chairs.

There is no joint swelling. ESR is 58 mm/hr and CRP is elevated.

What is the most appropriate next step in management?

Amir Hossain, aged 36, presents with ongoing pain in the right heel for 3 months. It is worst with the first steps in the morning and after prolonged standing. He has recently taken up running. Examination reveals tenderness at the medial calcaneal tuberosity and a tight Achilles tendon.

What is the most appropriate first-line management?

Carla Mendes, aged 61, presents with new onset sharp facial pain, described as electric shocks lasting seconds, triggered by touching her cheek or brushing her teeth. She has no neurological deficits and no history of trauma.

What is the most appropriate initial pharmacological treatment?

David Makenzie, aged 58, presents with poorly controlled type 2 diabetes and painful numbness in both feet. He describes a burning sensation that disrupts his sleep. Examination reveals reduced vibration sense to the knees and absent ankle reflexes. He is currently taking metformin and gliclazide, and his HbA1c is 9.4%.

What is the most appropriate next step in management?

Linda Harrow, aged 44, presents with severe dysmenorrhoea and is suspected to have endometriosis. She has regular menses and is not planning to conceive. Past medical history includes migraines with aura. She has tried NSAIDs with minimal benefit.

What is the most appropriate next step in management?

Anthony Russo, aged 49, presents with dull aching pain in the right upper quadrant for the last 3 months. It is worse after meals and not associated with weight loss or jaundice. Ultrasound shows multiple gallstones but no gallbladder wall thickening or biliary dilatation.

What is the most appropriate next step?

Mark Collins, aged 60, presents with new onset of shoulder and pelvic girdle stiffness and pain, especially in the mornings. Symptoms have developed over a few weeks and he also reports fatigue. On examination, there is reduced active movement but no joint swelling. CRP is 40 mg/L.

What is the most likely diagnosis?

Grace Tran, aged 30, presents with severe epigastric pain radiating to the back, nausea, and vomiting. She drinks alcohol socially but has no history of gallstones. Lipase is 580 U/L and her abdominal ultrasound is normal. She is haemodynamically stable.

What is the most appropriate initial management?

Michael Yan, aged 40, presents with a 2-week history of constant, aching lower back pain radiating down his left leg to the calf. He describes numbness in the foot and difficulty walking due to pain. He has no red flag symptoms.

On examination, straight leg raise is positive on the left, and there is reduced ankle reflex on the same side.

What is the most appropriate next step in management?

Sarah Paterson, aged 25, presents with new onset pain in her right lower jaw. She describes it as throbbing and worse at night. She has no systemic symptoms. On examination, there is tenderness over the lower right third molar area with mild swelling and no trismus.

What is the most appropriate next step in management?

Anna Le, aged 33, presents with generalised musculoskeletal pain, fatigue, and poor sleep for the past 9 months. She feels unrefreshed in the mornings and struggles with concentration. Blood tests including inflammatory markers and thyroid function are normal.

On examination, there are multiple tender points at characteristic locations.

What is the most appropriate initial management?

Joey Miller, aged 16, presents with anterior knee pain that worsens with activity, especially climbing stairs and squatting. There is no history of trauma. He is active in basketball training. Examination reveals pain on patellar compression and tenderness at the patellofemoral joint.

What is the most likely diagnosis?

Monique Russo, aged 71, presents with new-onset persistent headache, scalp tenderness, and jaw discomfort when chewing. She also reports weight loss and general fatigue. ESR is 89 mm/hr. Examination reveals tenderness over the temporal artery.

What is the most appropriate next step?

Naomi Fielding, aged 37, presents with a three-week history of right-sided chest wall pain following a coughing illness. The pain is sharp, worse with deep inspiration and palpation over the costochondral junctions. There are no signs of respiratory compromise.

What is the most likely diagnosis?

Jared Ng, aged 32, presents with sharp perianal pain, particularly during defecation. He notices small amounts of bright red blood on the toilet paper. He has no systemic symptoms. Examination reveals a small tear in the posterior anal canal.

What is the most appropriate initial management?

Pauline Yates, aged 65, presents with persistent aching in her hands, particularly the thumb base and distal interphalangeal joints. Symptoms worsen with activity and are relieved with rest. There is bony enlargement of several DIP joints on examination.

What is the most likely diagnosis?

Brent Holloway, aged 50, presents with worsening mid-thoracic back pain for the past three months. He has a history of prostate cancer. The pain is dull, constant, worse at night, and not relieved by rest. Neurological examination is normal. PSA is elevated.

What is the most appropriate next investigation?

Kylie Lang, aged 34, presents with left foot pain following an inversion injury one week ago. She has continued difficulty bearing weight. Examination reveals tenderness over the base of the fifth metatarsal and swelling. There is no bruising over the malleoli.

What is the most appropriate next step?

Olivia Martin, aged 52, presents with persistent burning pain on the lateral border of her thigh. She describes the sensation as tingling and numbness, especially after prolonged standing or wearing tight jeans. Examination reveals no motor weakness but decreased sensation in the lateral thigh.

What is the most likely diagnosis?

Craig Delaney, aged 61, presents with ongoing knee pain from osteoarthritis. He has previously used regular paracetamol and topical NSAIDs. He has stage 3 chronic kidney disease and a history of gastric ulcer. He is not keen on surgery at this stage.

What is the most appropriate next pharmacological option?

Jessie Pham, aged 17, presents with left lower quadrant abdominal pain that started suddenly during sport. The pain is sharp and worsens with movement. Her last menstrual period was 2 weeks ago. She has no fever, nausea, or urinary symptoms. On examination, there is localised tenderness but no rebound or guarding.

What is the most likely diagnosis?

Victor Barrett, aged 68, presents with sudden onset of excruciating back pain while lifting boxes. He has a history of osteoporosis and has not had recent bone density monitoring. On examination, there is midline tenderness at T12 but no neurological deficits.

What is the most appropriate next step in management?

Belinda Snow, aged 31, presents with right wrist pain following a fall onto her outstretched hand. There is tenderness in the anatomical snuffbox and reduced grip strength. Plain wrist x-rays are reported as normal.

What is the most appropriate next step?

Harriet Keane, aged 45, presents with persistent burning pain and sensitivity to light touch in her right hand three months after a Colles fracture. Examination reveals glossy skin, mild swelling, and increased sweating of the right hand.

What is the most likely diagnosis?

Barry Lawson, aged 72, presents with severe lower back pain radiating to both legs. He describes numbness in the perineum and difficulty initiating urination. On examination, there is decreased anal tone and reduced sensation in the sacral dermatomes.

What is the most appropriate next step?

Michelle Tong, aged 36, presents with frequent migraine attacks occurring 6–8 times per month. She uses sumatriptan during attacks with good effect. She is otherwise well and has no aura or neurological symptoms. She does not wish to use hormonal contraception.

What is the most appropriate next step in management?

Leah Morrison, aged 22, presents with right-sided abdominal pain and shoulder tip pain after a syncopal episode. She reports light vaginal bleeding. Her last menstrual period was 7 weeks ago. On examination, her blood pressure is 92/60 mmHg and she is tachycardic.

What is the most likely diagnosis?

Nicholas Brandt, aged 68, presents with ongoing cancer-related pain despite regular oxycodone. He reports breakthrough pain several times per day, particularly before dressing changes. He is receiving palliative care support at home.

What is the most appropriate adjustment to his analgesic regimen?

Kelly Atkinson, aged 31, presents at 28 weeks’ gestation with worsening lower back and pelvic pain, particularly when walking or rolling in bed. There is no urinary or neurological involvement. She has a normal pregnancy and no history of trauma.

On examination, there is tenderness over the pubic symphysis and sacroiliac joints. Neurological exam is normal.

What is the most appropriate management?

Nathaniel Lewis, aged 29, presents with gradually worsening right elbow pain after increasing his gym workouts. The pain is aggravated by gripping and lifting. On exam, there is tenderness over the lateral epicondyle and pain with resisted wrist extension.

What is the best initial management?

Alice Chen, aged 56, has a history of breast cancer with known bony metastases. She presents with new mid-back pain and increasing difficulty walking. On examination, there is weakness in both legs and brisk lower limb reflexes.

What is the most appropriate immediate action?

Jeremy O’Connor, aged 48, presents with chronic neck pain following a whiplash injury 12 months ago. He has difficulty sleeping and reduced work productivity. He has been using over-the-counter analgesia with limited benefit. Examination is normal.

What is the most appropriate management approach?

Fatima Noor, aged 24, presents with frequent episodes of severe lower abdominal pain associated with bloating and altered bowel habits. Symptoms improve after defecation. She is otherwise well and has no red flag features.

What is the most appropriate next step in management?