Chris Pasero, MS, RN-BC

Disclosures

July 26, 2012

Case Presentation: Breast Cancer Pain

A 42-year-old woman with breast cancer has undergone chemotherapy and bilateral mastectomies with reconstruction over the past 2 years. She works full-time as a nursing technician at a busy ambulatory surgery center and is a single mother with 3 teenaged sons. Her pain has been mild to moderate in intensity and well controlled with around-the-clock long-acting analgesics and supplemental doses of short-acting agents to relieve breakthrough pain, which occurs once or twice daily. During the past month, she has experienced an increase in the incidence of breakthrough pain, which prompted her to make an appointment with the nurse practitioner (NP).

Her current pain treatment plan is as follows:

  • Ibuprofen 400 mg every 8 hours;

  • Sustained-release oral morphine 30 mg every 12 hours; and

  • Short-acting oral morphine 5-10 mg every 2 hours as needed for breakthrough pain.

Office Visit: History and Physical Examination

History. When seen by the NP, the patient described the same bilateral dull and aching baseline chest muscle pain that she has experienced since her bilateral mastectomies. She rated the current intensity of her baseline pain as 3 on the 0-10 numerical rating scale and states that it is usually no higher than 5.

Until now, the patient has had predictable breakthrough pain, which occurs most often as a result of activity, such as upper-body weight training exercises. She prevents this pain by taking a supplemental dose of short-acting morphine before exercising. Over the past month, however, the patient has experienced an increase in the frequency of breakthrough pain episodes.

The patient's daily pain diary revealed that the new breakthrough episodes occur most often during the 2-hour period before the next dose of sustained-release morphine is due. A major source of distress for the patient is that the new breakthrough pain sometimes occurs without warning. She has been having trouble sleeping and often awakens with pain, and she scheduled this appointment because the frequent breakthrough pain episodes are interfering with her ability to work and participate fully in her sons' school and recreational activities.

Physical examination. On examination, the following are noted:

  • Vital signs:

    • Tympanic temperature: 98.2°F

    • Heart rate: 86 beats/min

    • Respirations: 20 breaths/min; regular and deep; clear and equal breath sounds

    • Blood pressure: 128/60 mm Hg

    • Oxygen saturation on room air (using pulse oximetry): 99%

  • Skin: pink and warm

  • Height, 5' 7"; weight, 112 lb. The patient has lost 3 lb since the last office visit 3 months ago.

  • The patient has dark shadows under her eyes and appears exhausted and sad.

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