Cancer pain case - worked example

The patient descibes pain which is poorly localised and dull over his liver. Abdominal examination reveals a large tender liver but is otherwise unremakable.

On closer questioning, he also reports pain over his lumbar spine which is severe, 'like a knife', and associated with shooting pain down his right leg. This pain is worse on movement. Neurological examination does not identify any abnormal neurology.

1. What is the cause of the pain?
• Liver capsule pain? Vertebral bone metastases?
• Is the patient well enough to require imaging e.g. MRI spine? Would they be well enough for any treatment such as radiotherapy? Prognosis?
• Remember, for example, lung metastases are not painful unless the pleura/chest wall is involved
• Pain in patients with cancer always has an underlying mechanism - for example, compression? infiltration? perforation? mass effect? neuropathic/pathological pain?
2. Severity
• May be moderate/severe
• May be a different severity at rest or on movement (incident pain)
• Use VAS or Faces pain scale if appropriate
3. Classify the pain - pain is likely to be complicated
• May be acute/chronic/acute on chronic
• Nociceptive? Neuropathic? Or mixed?
• This patient has chronic, cancer, mixed nociceptive and neuropathic pain
4. Other factors contributing to the pain?
• Physical - symptoms due to primary tumour or metastases? other diseases/co-morbidities? Neurological symptoms due to spinal cord/cauda equina involvement?
• Psychological - fear of dying? anxiety? depression? Grief? Loss of independence?
5. Use SOCRATES??

SOCRATES assesment

• Site
• Onset
• Character ….. Dull, sharp, ache, burning, pins and needles, shooting
• Radiation
• Associations
• Time course
• Exacerbating/relieving factors
• Severity …. Mild, moderate, severe…….”out of 10”