Pain in Primary Care

A Latinx Patient in Severe Pain

Charles P. Vega, MD; Sean Siguenza; Sheila Panez


May 26, 2022

To focus on issues of pain management in primary care, this month I'm presenting a clinical scenario involving a woman with acute pain. I'll tell you what I plan to do, but I'm most interested in crowdsourcing a response from all of you to collectively determine best practice. So please answer the polling question and contribute your thoughts in the comments, whether you agree or disagree.

The Patient

Cristina is a 25-year-old woman who prefers to speak Spanish. She has a history of endometriosis, severe obesity, depression, and irritable bowel syndrome. She presents today with a 5-day history of left flank pain with radiation to her groin. The pain is colicky and has become more severe over the past 3 days, but she avoided coming to the clinic or emergency department (ED) because she lacks health insurance and is also worried about missing work as a caregiver. She now rates the pain as 10/10. She has no history of this type of pain. Ibuprofen 400 mg had no effect on the pain after several attempts.

Cristina is unsure whether the pain is worse with urination, but she did have two episodes of gross hematuria 3 days ago. She denies fever or fatigue. Her bowel habits have been stable, with daily cramping relieved by a soft bowel movement. She denies any new stress, and depression remains well controlled. She has a history of irregular menses, and her last menses was 6 weeks ago. She is sexually active with a male partner and not using any form of family planning. She is nulliparous.

Her medication list currently includes duloxetine, psyllium, progesterone, and peppermint oil.

Physical examination reveals mild tachycardia; other vital signs are normal. She has left costovertebral angle tenderness. Her abdomen is obese with mild tenderness throughout.

A urine dipstick is positive for blood but otherwise negative.


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