Synopsis
Recognise pain as a multidimensional clinical presentation, identify emergencies and reversible causes, formulate nociceptive, neuropathic and contextual mechanisms, and measure treatment against function and goals rather than intensity alone.
- Pain is whatever the patient reports, but assessment must also identify mechanism, cause, emergency features, functional effect and safe treatment options.
- First-line history uses site, onset, quality, radiation, severity, timing, triggers, associated features, previous response and impact on sleep, movement and roles.
- Classify each pain as somatic, visceral, neuropathic or mixed; one person may need a separate formulation for several concurrent pains.
Key red flags
Back pain with new weakness, sensory change, gait deterioration or bladder or bowel dysfunction requires emergency metastatic spinal cord compression assessment.
Myoclonus, hallucinations, allodynia, diffuse pain and sedation during escalating opioid exposure should prompt toxicity review.
Investigation priorities
Define each pain's site, time course, quality, severity, triggers, associated features, response, meaning and functional impact.
Management branches
A patient reports new, changed or inadequately controlled pain.
- Identify immediate red flags, give proportionate relief and describe each pain's timing, quality, triggers, functional effect and associated features.
- Examine the relevant systems, reconcile all medicines and organ function and use targeted tests only where results could change management.