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A 75-year-old, otherwise healthy man undergoes an elective right hemicolectomy for colon cancer. The case was converted from laparoscopic to open due to dense adhesions from a prior laparotomy. Six hours after the operation, you are paged by the patient’s nurse because he is complaining of 8 out of 10 abdominal pain and his next dose of “prn” morphine is not available for another 2 hours.

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When you arrive at the bedside, the patient is alert and answers all questions appropriately. He complains of a sharp pain along the length of his incision that was improved from 10 out of 10 to 6 out of 10 after receiving a dose of morphine 4 hours ago. In the past hour, however, the pain has been gradually increasing and is once again 10 out of 10. He is not nauseated and has not vomited.

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His vital signs are: temperature 37.2°C, heart rate 85, blood pressure 150/90, and respiratory rate 12. His abdomen is soft with localized and appropriate tenderness along the length of the midline incision dressing. He is making 100 mL/h of clear yellow urine and, except for the pain, has been recovering well.

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You review his medications and find he is ordered for “morphine 2 mg IV q6h prn pain.” He has received a single dose since arriving to the surgical ward 4 hours ago.

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1. Why did you have to come see the patient and not simply provide a new order over the phone?

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2. How would you change the order for his pain medications?

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Postoperative Pain Management

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Answers
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  1. When evaluating a patient complaining of an unusual amount of pain, or pain that is persistent despite the administration of medication, your first thought should always be that the pain might be the result of a surgical complication. While the most common cause of pain in the immediate postoperative period is inadequate analgesia, this should always be considered a diagnosis of exclusion. Therefore, patients with refractory pain need to be evaluated in person, and orders to increase the dose of narcotics should never be given over the phone. On your way to evaluate this patient you should be thinking of the possibility that bleeding, an anastomotic leak, or a missed bowel injury is responsible for his pain.

    Your bedside history and physical exam should therefore focus on ruling out these serious complications. The fact that the patient’s pain is localized to his incision, rather than the site of the anastomosis (likely the RUQ or RLQ) or diffusely over the entire abdomen, is reassuring, as is the fact that the pain is partially relieved by medication. The patient’s vital signs are also within normal limits except for mild hypertension. Any fever, tachycardia, hypotension, or tachypnea in the immediate postoperative period is concerning ...

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