Date: April 9, 2010 Chief Complaint/Reason for referral/patient goals: - Left pelvic pain/referral for lidocaine infusion by Dr.William Craig (specialist in
o Wants to learn about lidocaine for pain treatment o To be pain free o To be able to sleep through the night o To be able to work and be active
History of Present Illness: - Niomi has left groin pain near her pubic bone. The pain began after her
hysterectomy in 1995 where she had some post operative damage to her pudendal nerve. She describes the pain as “tolerable” for the first five years. It has progressively worsened over the last 7 years due to scar tissue formation around the nerve. The severity of her pain fluctuates as some weeks she will be confined to her bed most of the time and other times she is able to go to work and the gym regularly. She previously worked five days and a week and has gradually cut back on her hours to three half days a week.
- She has been on oxycodone CR for the past three years and the dose was recently
increased from 10 mg PO BID to 15 PO BID. For breakthrough pain she uses oxycodone 5 mg PO q4h prn. On a typical day, she uses about 5 breakthrough doses.
- About nine months ago, she was started on duloxetine for pain and depression. The
duloxetine has helped with her pain but has not had any benefit on her mood.
- In addition to a referral to the Pain Clinic for lidocaine infusion, Dr. Craig has also put
in a referral to Dr Mark Conway in New Hampshire and Dr Stanley Antolak, a urologist in Minnesota, who specializes in pudendal nerve release.
Medical Assessment/Impression - Niomi has myofascial and neuropathic pain secondary to injury to the pudendal
nerve and development of scar tissue. The pain is interfering with her ability to work full-time, her activity level and her sleep. It is increased with strenuous activity, bowel movements, a full bladder and sexual intercourse.
Summary of Medication Recommendations (see explanation at the end) Suggest a trial of celecoxib starting at 100 mg PO daily. Possibility of lidocaine trial to be discussed with pain clinic medical director. Present Medications
Schedule Duration Indication Adverse Drug reactions: - She develops a rash when she takes morphine. Compliance/Adherence - Niomi goes to Forbes Pharmacy Langford in Langford and gets her medications
filled in vials. She has Manulife for third party coverage through her husband’s insurance.
1. Opioids: She has tried hydromorphone, morphine and acetaminophen with codeine
2. NSAIDS: She has tried naproxen and ketoralac with no benefit. She has not tried
3. Amitriptyline: There is a record that she has tried amitriptyline in her chart but patient
4. Anticonvulsants: Topiramate made her gain weight. Gabapentin was not effective.
There is a record in her chart that she also tried carbamazepine but she does not remember taking it. Dr Craig notes that she became drowsy and irritable when she took amitriptyline, topiramate, gabapentin and carbamazepine.
5. Various herbal products: She does not remember the names of the products but
6. Cyclobenzaprine: This was prescribed after her car accident in July 2009 but she no
7. CT blocks (2008): She had 5 days with no pain and pain gradually came back. We
are unsure what drug(s) were used for this intervention.
8. Trigger point injections with lidocaine 2%: She did not have any pain relief, however
Dr. Craig reports that there was 1 hour of pain relief.
9. Acupuncture, swimming and yoga: She did not find these beneficial. 10. Massage: Caused her pain to flare up.
Social History Niomi is a former smoker. She quit in 2004. She drinks alcohol socially, about 5-6 drinks per month. She works as a self-employed house cleaner. She is married. She has 2 children, one daughter (age 20) and one son (age 13). Medical Problem List: - Chronic pain in left groin - Depression Surgical History: - Tubal ligation - Hysterectomy and left oophrectomy (2001) - 12 gynecologic surgeries over the past 11 years to remove scar tissue as well as for Pain Evaluation
Left groin around pubic bone Description: Dull pain that never goes away like “tying a shoe on my nerve”. The only time she gets a sharp pain is when her pain is aggravated. Radiation: Pain is localized to the left groin. Severity: On a good day, she rates her pain as 3-4/10. On a bad day, she rates her pain as 6 -7/10 Temporal: Pain is worse in the mid-afternoon up until nighttime. She attributes this due to her activity level during the day. What makes pain worse?: Sitting or standing for long periods (> 1 hour), going to the gym (treadmill, bicycle, stepper), bowel movements or full bladder, sexual intercourse What makes pain better?: Ice packs, heating pads, relaxation, cutting back on work hours Functional Review: - Niomi is able to do all her activities of daily living. She is able to cook and clean but
depending on her activity level during the day, sometimes these activities cause some pain.
Niomi goes to the gym regularly. Over the past six months, her ability to go to the gym has declined. She used to go to the gym 5 times a week and now can only go 2 times a week.
Systems Reviews Neurology - Niomi gets migraine headaches 2 to 3 times per month. These are relieved by taking
- Sleep: She goes to bed at 10pm each night and wakes up multiple times through the
night. When she wakes up in the morning she feels exhausted. She has tried sleep medications in the past but made her feel “hungover” the next day.
- Memory: Her long term memory is affected. She also has to write a lot of tasks down
- Concentration: She finds it hard to focus on one thing and says her “mind races”. Psychiatry - Her moods are labile. She cries one minute and is laughing the next. Often times,
she feels angry and claims her husband has noticed changes in her anger over the past few years. She has not seen a mental health professional.
EENT - She has reading glasses and is deaf in one ear due to a birth defect. Chest/Pulmonary - She had intramuscular stimulation after her car accident which unfortunately
punctured her lung and she had to have a chest tube inserted.
Gastroenterology - Her appetite is good except when she has pain, sometimes she does not feel like
- In 2005, she lost approximately 70 pounds because she thought it might alleviate
- Her bowel movements alternate between constipation (one bowel movement every 5
days) and normal (two bowel movements per day). Bowel movements also sometimes worsen her pelvic pain.
GU - When she has a full bladder, her pelvic pain worsens. Musculoskeletal - In July 2009, she was in a car accident where she sustained a whiplash injury. She
claims to not have any long term effects from the accident.
Other systems were unremarkable. Drug-related Issues 1. Niomi has demonstrated declining activity and function due to pain and has required increasing narcotic doses. S/O: Patient’s pain is rated 3-4/10. On a bad day, is it a 6 -7/10. Over the past six months, her ability to go to the gym has declined. She used to go to the gym 5 times a week and now can only go 2 times a week. She has also had to cut her work days from 5 days a week to 3 half days per week. Her pain has also affected her ability to have
sexual intercourse and her ability to sleep through the night. She has been taking oxycodone CR for the past 3 years and the dose was recently increased from 10 mg PO BID to 15 mg PO BID. For breakthrough pain, she uses oxycodone IR 5 mg and on an average day, she uses about 5 doses. Nine months ago she was started on duloxetine for pain and depression. Her current dose is 90 mg PO daily. Duloxetine has helped with her pain but not for her mood. She has tried multiple neuropathic medications in the past (see above) which were ineffective and/or she had intolerable adverse effects. A: Niomi has pelvic pain that has required increasing doses of oxycodone CR and multiple breakthrough doses through the day. Trials of other medications have been effective or not tolerated. Options including:
1. Add celecoxib: may have anti-inflammatory effect on myofascial tissue around
2. Trial lidocaine infusion test dose: if positive could trial oral mexilitine or initiate
intermittent subcutaneous lidocaine infusions on an on-going basis
3. Increase oxycodone dose: the dose was recently increased and she thinks the
oxycodone is affecting her cognition/concentration.
4. Add Tramadol: she is already on a narcotic and tramadol is equipotent to
codeine. It will not likely be beneficial.
5. Adding pregabalin: she did not respond to gabapentin and therefore this probably
P/Recommendation: Patient’s case discussed with inter-disciplinary team at rounds. It is difficult to know whether it is worth repeating trials of the medications. Suggest a trial of celecoxib 100 mg PO daily and increase to 100 mg twice daily if she has partial response. We will discuss the possibility of giving the patient a test dose of lidocaine with Dr. William Davis, medical director of the VIHA Pain Program. To help us with the discussion making, Dr Saffrey is invited to attend complex case rounds at the Victoria Pain Clinic, where we can review Niomi’s case with the team. Please contact Carolyn DeGirolamo, clinical nurse leader, at 250-519-1836 if you interested. In addition, we will discuss the possibility of connecting Niomi with another patient in the Pain Clinic program who has also had pudendal nerve pain. This patient went for pudendal nerve release surgery in France and achieved complete pain relief. This surgery may also be an option for Niomi. _______________________
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