1

What further observations can I

consider to determine pain
without self-reporting scores?
Anonymity number: 0451

Patient history and assessment

In the format suggested by Bickley (2007)

On arrival:

On arrival in the early hours of the evening, my crew mate and I were escorted
into the patient’s flat by a warden on site. The property is part of a sheltered
accommodation with wardens present during the day and each flat has a
personal alert system installed. The wardens had called 999 due to their
concerns for the patient.

The patient, a white English male of 56 years was sitting, slumped in a soft chair:
he was alert to our presence but quiet in his response (it was apparent he had
just woken up); his respiratory effort was untroubled, but noisy due to his
slumped posture; his pulse was regular and easily palpated at each radial. His
verbal response was slow, with possible minor confusion.

The patient was dressed with a padded support on his left foot. Beside him was a
side table with a clean ashtray, smoking materials, a cup of tea made by the
warden and some biscuits which were untouched. Upon a small dining table was
a stock of dressings, a pharmacy prepared weekly dosset box, a box of Tramadol
and a long out of date box of Flucloxacillin. There was also a sealed ¼ bottle of
brandy. Within reach of the patient was a walking stick. The kitchen was clean
with very little evidence of recent use.

Presenting complaint:

The patient made a specific statement which was; “An indescribable feeling of
being unwell.”

History of presenting complaint:

Over the last 4 days the patient has suffered an acute loss of appetite. He has
eaten next to nothing in this period. Today he is feeling extremely tired and
without energy to even move from his chair. He has noticed that currently he is
pain free which is unusual as there is normally chronic pain in his legs due to
vascular disease. He was unable to be descriptive, just repeating that he felt
dreadful. He has had no cough, nausea or dizziness.
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Past medical history:

The patient suffers from vascular disease, which has caused severe, painful
ulceration to his left foot (A nurse visits regularly to redress the site). He has
been told he has a heart murmur. He also suffered bowel cancer.

He was unable to describe further conditions when asked, but his medication
suggests hypertension and hypercholesterolemia.

Past surgical history:

In 2005 he had a colectomy to address the bowel cancer, subsequently utilizing

a colostomy. This is suggestive of rectal cancer rather than a location higher
within the bowel.

Drug history:

Amlodipine 10mg mane. (Compliant)

Aspirin 75mg mane. (Compliant)

Atorvastatin 40mg nocte. (Tabs still present in this week’s dosset box)

Ramipril 10mg mane. (Compliant)

Tramadol 50-100mg Qds. (Compliant/ None taken today as he has been

immobile)

No known drug allergy.

Social history:

The patient lives alone in a well supported accommodation. He has regular visits
from the district nurse and the wardens on site were prudent enough to call for
an ambulance when they noticed such a visible decline in their tenant. The
patient states he does not have social visitors but he does utilise a motorised
scooter to get out and about when feeling well.

Family history:

The patient did not talk about his family or their medical complaints. The
wardens supplied contact details for his brother.

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On examination:

The patient appears uncomfortable at rest, his posture indicating a favoured

right side for support. Evident kyphosis and scoliosis has made it difficult to
support his head at a suitable angle causing upper airway noise (dull stridor). He
has good dexterity and use of both hands evident in holding a mug of tea in his
right hand and placing it on the table with his left. The patient’s skin was of a
normal temperature and dry to the touch

Initial observations:

Alert. RR16. Radial pulse 84++regular. Perfused in appearance. SpO2 99%. His
BP (seated) was 138/64 though during an episode of pain in his legs following
exertion, his BP raised to 172/103 alongside a pulse of 95. BM 6.2. Temperature
36.3oC. Pearl @4. FAST 0. GCS 14 (4/4/6). The 12 lead ECG showed normal sinus
rhythm.

JACCOL

Hands: Both hands are stained with nicotine. The nail beds of both hands are
pink. The nails are smooth. There is no clubbing and no asterixis.

Eyes: There is no corneal arcus, cataracts or xanthelasma. There is no

discolouration to the conjunctiva or sclera.

Mouth: The mucosa is pink and moist, the tongue is normal. No visual or
olfactory evidence of infection.

Lymph: There are no tender or hard nodes present.

Sacral and Pedal: Both sites are free of oedema.

Skin: No major turgor is apparent.

Review of systems

• CVS

On inspection; no obvious surgical scars or implanted devices, no medical

patches or alert jewellery. I was unable to determine the JVP.

On palpation; regular bilateral radial pulses without a delay. No collapse in

the pulse. The brachials and carotids were palpable without any vibration.
Blood pressure was normal and bilaterally equal at rest though became
hypertensive during a bout of pain. His capillary refill was about 2 seconds
both centrally and peripherally. I was unable to locate the apical pulse. No
heaves or thrills.

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On auscultation; S1 and S2 heard at all four valves. Systolic murmur heard

at the mitral. No carotid bruits heard.

A 12 lead ECG performed showed no abnormalities with a normal sinus

rhythm.

• RS

On inspection; the patient was able to breathe easily, though the chest
expansion was right predominant due to spinal curvature and the AP ratio
was visibly abnormal by a small margin. The patient could speak without
effort though at the end of sentences his voice became quieter. The
trachea was medial and the crico-sternal distance was 3cm.

On palpation; the patient’s chest rose slightly more on the right but
reduced posterior left. There were no sites of tenderness and TVF was
equal left and right.

On percussion: no abnormalities detected.

On auscultation: Bronchial breath sound noisy on deep inspiration.

Vesicular clear and equal left and right.

• GI/GU

On inspection the abdomen is rounded with a colostomy pouch on the

anterior left. There is no discoloration, local distension or mass visible.

On auscultation I noted bowel sounds as normal and was unable to hear

aortic, renal or iliac noise.

On percussion. The abdomen was hyper-resonant barring the lower left

quadrant which I omitted due to the colostomy. No other findings.

Palpation was light only, finding no abnormalities or tenderness.

The patient has no urinary complaint.

• MSS

Thoracic scoliosis (left), with minor kyphosis. Patient walks slowly requiring
a walking stick. He utilises a mobility scooter as he cannot walk beyond
the confines of his flat. The patient has motion and power in all four limbs.
The patient became unsteady visiting the toilet after only 4 paces. He
required assistance to remain stable.

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• Neu

The patient at rest appears slow and fatigued. He had to ‘search’ for
answers but did not need questions repeated. Certain questions regarding
his medical history he could not answer and there was possible difficulty
‘word-finding’ (Expressive dysphasia).

Following exertion and walking to the toilet, the patient suffered leg pain
due to his ulceration. His conversation whilst so pained became confused
and repetitive. He exchanged short words, such as ‘pain’, ’bed’ and ‘legs’
repeatedly without realisation. He was unable to qualify the pain in any
way which could be assessed. He did not acknowledge offers of pain relief.

Impression

This patient is fatigued and tired near exhaustion, alongside the sudden change
in appetite I believe the patient requires hospitalization for further assessment
and monitoring.

Plan

Initially whilst the patient had capacity and refused to go to hospital, I made
arrangements for a GP to visit. Following the patient’s exertion mobilising to visit
the toilet, the pain he suffered appeared to have caused great confusion in the
patient which led me to determine he no longer had capacity utilising an LA5
capacity tool.

• He could not communicate a decision.

• He did not appear to understand the principal risks or benefits of the

proposed transport to hospital.

• The patient could not retain information long enough to make an effective
decision.

The patient’s confusion remained even after 20 minutes at rest. He was taken to
the nearest A & E where he was triaged into the Majors department.

Differential diagnoses
This patient’s presentation of severe fatigue, loss of appetite and confusion with
the underlying vascular disease and history of cancer, leads me to consider the
following diagnoses:

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Depression and anxiety. Due to the patient’s chronic pain it is worth

considering the psychological effects upon this patient who has also suffered
cancer and has had to come to terms with the severity of such an illness. It is a
considerable psychological strain to deal with constant pain; sleep becomes
difficult whilst behavioural and emotional symptoms become pronounced (Glover
et al. 1995). This is further reinforced due to the interaction of depression and
pain following the same biological and neurological pathway; the most recent
review of potential pharmacological interactions by Saarto et al. (2010)
evaluates the therapeutic effects of certain anti-depressants on various
neuropathic pains

The patient’s reticence to leave his flat for any reason is indicative of these
behavioural changes; the marked decline in appetite and sociability noted by the
wardens gives indication that this change is acute; the patient appears to have
distanced himself from interest and concern to his condition. All of which are
listed by Fellows et al. as diagnostic features of depression (2008, 37.15).
Ultimately the confusion that verges on mild delirium, provoked by the
exacerbation of pain to deny capacity, suggests a level of pain in excess of the
patient’s ability to cope.

Vascular disease. It is possible that the patient’s history has aggravated the
symptoms already present due to the ulceration in the left foot. This chronic pain
might be the primary for the acute secondary symptoms suffered. The greater
underlying risk is that of dementia. The presentation of confusion, apathy and
potential depression are all early stage symptoms of dementia. It is known that
the history of smoking, drinking, lifestyle and mid-life disorders of the vascular
system all increase the risk of dementia including Alzheimer’s disease (Kalaria et
al. 2008).

It is worth noting the current non-compliance in the night-time statin could be a

longer term problem. As noted by Cramer et al. (2008) the majority of studies
suggest that the management of cardiovascular disease may be improved by
improving patient compliance.

Metastasized or recurrent cancer. It is quite possible that even with the

successful surgery in 2005 the patient could have a new onset of cancer. Butt et
al. confirm that fatigue, tiredness, anorexia and mild confusion are among the
most frequently observed cancer symptoms (2008). Despite a lack of
lymphadenitis and no stigmata relating to liver complaint, the chance of
recurrence or metastasis is significant: Even where the gold standard of Total
Mesorectal Excision has been the surgical intervention, there is still a mean
18.5% chance that cancer reappears (Ridgeway et al. 2003); the most frequent
sites of distant metastasis are the liver via the mesenteric lymphatics and portal
venous system and also the lungs via the inferior vena cava, right ventricle and
pulmonary artery (McCance et al. 2006, 384-385).

There is also the possibility of a space occupying lesion within the brain, causing
some of the neurological symptoms; dysphasia, confusion but a slower onset

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than a CVA. Without history of any loss of consciousness or how rapid or slow the
onset was, this is difficult to determine.

Infection. Of course, my patient could have succumbed to infection. Whether

via the ulceration in his foot, via the colostomy, by respiratory, digestive or
urinary routes, the four day history of anorexia is unsupported by other abnormal
observations at rest barring confusion (UTI). However, looking at the patient
holistically and considering that the anorexia of infection is part of the host’s
acute phase response, in a patient who could have a low host resistance, I feel
this differential is valid.

CVA. The patient has multiple risk factors; non compliance with his statin,
Hypertension, smoker, heart murmur and known vascular disease. Despite the
FAST negative result which was achieved pain free, I don’t believe it should be
excluded from the differential.

[656 words]

Reflective assessment
Utilising the Driscoll model of reflection (2000).

What? Returning to the situation.

In the case presented, I do not believe there is a definitive diagnosis I can arrive
at without detailed medical and psychiatric investigation beyond the scope of
this essay. What is prevalent in my mind is witnessing the sudden failing in the
patient’s capacity due to pain. The apparent reappearance of this pain following
minor exertion, caused such a change in mental status I attributed it to a
resurgence of chronic pain rather than an acute attack. The psychological factors
presented could not be qualified effectively by my current pain assessment skills
and upon asking my self what I can consolidate from this situation I believe I am
best served by reflecting on the patient’s chronic pain and the overreaching
effects of it.

So what? Understanding the context.

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Pain is a personal and subjective experience. MacCaffery defines it thus:

“Pain is whatever the experiencing person says it is, existing whenever he

says it does.” (1968).

However, to have been able to assess pain in the patient in his non-verbal state,
we must consider alternate methodology. Buffum et al. (2007) reviewed this
challenge in their work with the U.S. Department of Veterans Affairs: A
cognitively impaired patient will likely have compromised self-reporting for pain
ratings. One must understand the question, be able to recount the events in
good time, give a personal value to the pain and be able to tolerate the pain for
a short time. Behavioural observation scales are suggested as best practice. For
example common signs in patients with dementia include facial expressions,
verbalisations/vocalisations and body movements, changes in interpersonal
interactions and mental status changes. Of course the potential signs could
present as indications for other conditions, including depression. Those common
signs were all present in one form or another: grimacing and frowning; verbal
repetition; writhing to find a comfortable posture; denial of our duty of care;
mental withdrawal.

As acute somatic pain is regularly self-reported well, I felt that the patient’s
ability to cope and communicate was eroded by the chronic nature of the pain.
According to Malinen et al (2010), introducing their MRI research on chronic pain;
where acute pain has an associated protective functionality, supported by the
network comprising the insular, anterior cingulate, primary and secondary
somatosensory cortexes and thalamus, chronic pain loses the physiological
protective function. Pain, in a chronic manifestation reduces the quality of life
and alters cognitive, affective and physical functioning. They go on to indicate
that despite the prevalence of chronic pain in the Western world (1 in 5) the
underlying neurology is not fully mapped.

The patient’s major change in mental status is further defined by the

examination of the pathophysiologies of various syndromes, such as phantom
pain, fibromyalgia, migraine and tension type headaches. These are better
understood from structural neuroimaging as discussed by Rodriguez-Raecke et
al. (2009); an altered morphology is reported in areas dealing with pain,
including a potential reduction in pain-transmitting grey matter. The findings
suggest that this intracortical remodeling is not permanent and that the pain is
the cause, not the symptom. It is quite possible that my patient’s deterioration
is solely as a result of his pain.

Noting the lifestyle and psychological issues described by Marcus (2009, Chapter
18) having found the patient asleep during the early evening could be an
indication of insomnia. This can increase depression and disability due to pain.
Alongside smoking, insomnia has also been linked to an increase in pain
occurrence and severity. Both can also reduce the analgesic effect of pain
medications. The patient’s social isolation further aggravates his situation
alongside any other psychological stress present. Marcus goes on to say that

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mental stress is one of the most common stimuli for chronic medical symptoms
affecting a third of patients with chronic pain.

Due to the severity of pain, it is quite possible that depression is pre-existing in

this case and has gone undiagnosed. The patient, even when pain-free had signs
and symptoms associated with depression. They became far more prevalent
when the patient was pained by his leg. This comorbidity is well documented, in
2003 there was an extremely thorough review undertaken by Bair et al. They
reviewed 56 studies of subjects presenting with depression then assessed for
pain and vice versa. They found that the prevalence of pain in depressed
subjects (65%) and of depression in a pain sample (5%-85%) was higher that
when the conditions are investigated in isolation. The comorbidity of pain and
depression is shown to result in poorer clinical outcomes.

This comorbidity has also been a useful pathway when considering drug
therapies for chronic pain. There is definite scope in this case to see if
addressing both depression and chronic pain alongside treatment for the
vascular ulceration would be beneficial. Antidepressant drugs have been used as
a first choice for neuropathic pain for some time. The utilization of tricyclic
antidepressants or venlafaxine is effective at providing moderate relief to
neuropathic pain in a third of cases (Saarto et al. 2010). At this time however, it
is unclear whether pre-emptive use retards the occurrence of neuropathic pain.
It is difficult to identify the type of pain in this case; if neuropathic, it is quite
possible this patient could benefit from treatment that addresses depression in
the form of a tricyclic which could potentially alleviate the pain as well. Obviously
with the current prescription of Tramadol for this patient, a full review of
medication would be required due to interactions and increased risk of
convulsions (Peters 2009, 412-413).

Now What? Modifying future outcomes.

It is apparent that chronic pain is a difficult burden for anyone. There are times
when pain and subsequent despair prevent a sufferer from performing his
activities of daily life. To have arrived at a situation where you cannot describe
your complaints to a health care professional must be frustrating and ultimately
terrible. I find myself considering this fact and wanting to change it.

For me to properly assess patients presenting in this manner, I need to be able

to recognize the signs where the history is not forthcoming and this requires a
focused approach. In this case I found myself trying to obtain verbal reporting to
no avail; from now on I will be refocusing my attentions on the signs which don’t
require the patient to self report. Obviously the verbal pain scale and visual
linear scale are useful tools in the majority of cases and my first line of
investigation, but it will definitely benefit those who cannot give their answers
effectively if I broaden my pain assessment criteria. Somatic symptoms, anxiety
and insomnia, social dysfunction and severe depression; it’s far broader, but I
believe it allows me an insight to the patient’s condition so I can plan my
treatment and care far more effectively.

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It is important to note that depression is so prevalent in cases of chronic pain; I

feel it suitable to consider assessment for depression as a standard in all such
cases I encounter. It follows that I should also investigate pain as diligently for
those suffering from depression. The comorbidity demands it; I can recall
multiple jobs where this information would have directed my thinking and
allowed me to provide more appropriate care to the patient.

With this in mind, when I encounter a patient who exhibits these ‘Pain and
Depression Flags’ I am assured that if it has been overlooked previously, I have a
very good chance of interpreting those signs and incorporating it as part of a
holistic approach to my healthcare. Armed with such knowledge of the complaint
will allow me to provide empathy and compassion; and that can only be a good
thing.

[1284 words]

Postscript.

Before I finished writing this reflective essay, I encountered a patient who had
collapsed. Though she had reduced consciousness, I noticed her rapidly blinking
eyes. I subsequently found out the patient had chronic lower back pain,
insomnia and a great deal of stress in her life. She is considering talking to her
GP about depression.

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