Pain can be complex to assess and influenced by multiple factors. Total pain is a concept that includes physical, emotional and spiritual pain and is strongly influenced by practical issues and worries about the future.
This is a pragmatic summary for assessing a patient in the community. Please see the references below for further reading.
Red flags
Remember to consider bowel obstruction and spinal cord compression as causes of acute pain
Key clinical features to assess
- Review underlying diagnosis (e.g. known site of tumours) and prexisting co-morbidities - ischaemic heart disease, osteoarthritis etc
- Medication review. What analgesics are they currently taking? Are the medicines giving 24 hour pain relief and what helps most?
- Examination of the painful area to try and elucidate the cause
- Remember referred pain.
- Remember shingles which is common in people with advanced disease or on steroids
- Assessment of mood and other key concerns
An initial approach to treatment
- Treat according to likely cause (see table)
- If cause of pain unknown investigate if appropriate and follow the WHO ladder
- Remember antiemetics and laxatives if prescribing opioids
- Review response to initial treatment
Common causes of pain and initial treatments:
| Type of pain | Possible cause | An initial approach to treatment |
|---|---|---|
| Burning, shooting, tingling, altered sensation, dermatomal distribution | Nerve pain (due to nerve compression, for example) | See Neuropathic pain |
| Headache associated with nausea, worse on lying down, especially in the mornings | Increased intracranial pressure from brain metastases | Start on 6-8mgs Dexamethasone and discuss with oncologist |
| Pain worse on weight bearing or tender areas of bone | Bone pain (e.g. due to metastasis or fracture) | See Bone pain |
|
|
Dyspepsia Liver metastases Peritoneal metastases (e.g bowel or gynaecological) Renal colic Biliary colic |
See Abdominal pain |
| Chest pain |
Consider pre-existing cardiac and respiratory causes |
See Bone pain |