Australian Family Physician
Australian Family Physician


Volume 42, Issue 3, March 2013

Clinical challenge

Sarah Metcalfe
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Questions for this month’s clinical challenge are based on articles in this issue. The style and scope of questions is in keeping with the multiple choice questions of the RACGP Fellowship exam. The quiz is endorsed by the RACGP Quality Improvement and Continuing Professional Development Program and has been allocated 4 Category 2 points per issue. Answers to this clinical challenge are available immediately following successful completion online at www.gplearning.com.au. Clinical challenge quizzes may be completed at any time throughout the 2011–13 triennium, therefore the previous months answers are not published.

Case 1

Jemima Stewart

Jemima, 36 years of age, suffers with chronic lower back pain following a motor vehicle accident at the age of 32. The pain severely limits her activity and she has not been able to work since the accident. She is also suffering from depression and struggling to care for her 6-year-old son after her partner left 12 months ago. She is very frustrated, doesn’t understand why she still has pain so long after her accident and wants you to ‘give me something to make it go away.’

Question 1

What factors could be negatively influencing Jemima’s pain experience in this case:

  1. depression
  2. hypervigilence and activity avoidance
  3. lack of personal acceptance of pain
  4. unrealistic expectations
  5. all of the above.

Question 2

You explain the concept of mind-body approaches to pain management to Jemima. As part of this explanation, it would be correct to tell her:

  1. any intervention that changes the emotional or mental state, is likely to produce corresponding physical changes
  2. if she practises yoga daily, her back pain will resolve
  3. patients should not take medication when using these techniques
  4. there is no good evidence for the effectiveness of these approaches in chronic pain management
  5. you think her back pain is ‘all in her head’.

Question 3

Jemima expresses fears that her back is ‘stuffed’ and soon she will not be able to walk or look after herself, let alone her son. An appropriate response to expression of these types of thoughts would be:

  1. commiserate with Jemima about her bad luck at being involved in the car accident at such a young age
  2. offer Jemima some less exaggerated beliefs as an alternative
  3. reinforce that Jemima’s pain will go away if she can adhere to recommended treatments
  4. spend time explaining the biomedical details behind her injury and pain
  5. suggest Jemima needs to avoid activities that exacerbate her pain.

Question 4

In reference to the relaxation response and its association with greater pain tolerance, the following are true EXCEPT:

  1. it can enhance the brain’s responsiveness to endorphins
  2. it can reduce inflammation
  3. it causes muscle relaxation
  4. it is the opposite of the fight or flight response
  5. it sensitises central pain pathways.

Case 2

Tanya Jones

Tanya, 47 years of age, has been an intermittent attender at your practice over the past 5 years. She presents complaining of debilitating left shoulder pain for the past 4 months. Your colleague diagnosed subacromial bursitis and she has had two ultrasound guided steroid injections without significant relief. She is on the waiting list for community health physiotherapy and can’t afford private sessions. She asks you for ‘something stronger’ to manage her pain. She is already using regular paracetamol and ibuprofen and you consider the addition of an opiate.

Question 5

As part of your drug and alcohol history, which of the following elements would be important to cover:

  1. ability to work
  2. amount and pattern of substance use
  3. brief pain inventory
  4. signs of intoxication or withdrawal
  5. suicide assessment.

Question 6

You recognise the role of non-pharmacological methods in the management of chronic pain. Which of the following would be considered an active therapy:

  1. acupuncture
  2. heat or cold application
  3. nerve blocks
  4. relaxation training
  5. strapping.

Question 7

Following a full assessment of Tanya, you determine a trial of oxycodone to be appropriate. All of the following could be included as part of an opioid contract EXCEPT:

  1. early repeats only for loss of prescription
  2. escalating or higher doses will trigger a comprehensive review
  3. identification of Tanya’s functional goals
  4. no lending, giving or selling of medications
  5. time-limited trial of the therapy.

Question 8

Tanya starts on oxycodone and following review of use, you are able to control her pain with 10 mg of the slow release version BD. When reviewing Tanya using the 4As of opioid monitoring you would NOT routinely assess:

  1. Aberrant behaviours
  2. Activities of daily living
  3. Adverse reactions
  4. Analgesia
  5. Anxiety symptoms.

Question 9

At Tanya’s third review, 6 weeks after commencing oxycodone, you ask how the treatment is going. Which of the following responses would be considered an aberrant drug related behaviour that may suggest addiction:

  1. haven’t taken them for 3 weeks because I lost my prescription and I knew that I couldn’t get an early repeat
  2. It wasn’t working so now I’m taking four tablets a day – I think I need a higher dose
  3. My pain is much better with the medication. I can get on with my day now
  4. Not great, I’m getting really constipated
  5. They are helping a bit … at least it takes the edge off.

Question 10

Four months down the track, Tanya is taking 30 mg slow release oxycodone BD with twice daily 5 mg immediate release tablets as breakthrough. You complete a comprehensive review and determine that her pain is still 8/10 and the difficulties with constipation and nausea have persisted. The physiotherapy referral has finally come through about 3 weeks ago. What would be an appropriate approach to Tanya’s opiate therapy at this stage:

  1. do not renew her prescription and cease both preparations immediately as they are clearly not working
  2. increase the dose of the long acting oxycodone until she gets symptom relief
  3. refer her to an orthopaedic surgeon for re-review of the cause of the pain
  4. stop the adjuvant paracetamol as that may be causing the nausea
  5. wean her off both preparations slowly over about 10 weeks and focus on alternative management strategies.

Case 3

Maria Rollo

Maria, 58 years of age, is regular patient who presents to the clinic complaining of paroxysms of shooting pain on the right side of her face and jaw that last about 30 seconds. Her symptoms are made worse by chewing and she is finding it difficult to sleep and eat properly. Maria has poorly controlled type 2 diabetes and hypertension.

Question 11

Which of the following would strengthen your suspicion that Maria’s pain was due to trigeminal neuralgia:

  1. a history of migraine
  2. tenderness to palpation over the temporal artery
  3. trigger zones and hyperalgesia along the jawline
  4. vesicular skin lesions on the jawline
  5. visual loss on the affected side.

Question 12

After excluding other possible causes, you determine Maria’s pain is likely due to trigeminal neuralgia. The most common accepted cause of this condition is:

  1. alcohol induced neuropathy
  2. compression of the sensory ganglion of the trigeminal nerve
  3. diabetic neuropathy
  4. idiopathic
  5. postherpetic neuralgia.

Question 13

You decide to try some medication to give Maria some relief and help her sleep. First line pharmacological therapy for trigeminal neuralgia would be:

  1. amitriptyline
  2. baclofen
  3. carbamazepine
  4. duloxetine
  5. lamotrigine.

Case 4

Claudia Rollo

Maria comes back 2 weeks later and her pain is much more manageable with treatment. She has brought her 17-year-old daughter Claudia with her and is concerned that she still has severe pain in her left hand following a wrist fracture 6 months ago. Claudia reports that she is still avoiding using that hand due to pain and that it feels ‘hot’ and weaker than her right side.

Question 14

Which of the following examination features would support a diagnosis of chronic regional pain syndrome (CRPS):

  1. erythema
  2. hyperhidrosis
  3. reduced power
  4. swelling
  5. all of the above.

Question 15

Findings you might expect on imaging include:

  1. bone loss
  2. cortical thickening
  3. decreased third phase peri-articular uptake on bone scan
  4. osteophyte formation
  5. sclerosis.

Question 16

Following specialist assessment, a diagnosis of CRPS is confirmed. Claudia starts intensive physical and psychological therapy with the aim of improving function. Which of the following pharmacological therapies has some evidence of efficacy in this condition:

  1. gabapentin
  2. NSAIDs
  3. opioids
  4. sodium channel blockers
  5. tricyclic antidepressants.

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