International Journal of Clinical & Medical Images

Clinical Image

Getting to the ‘source’ of a patient’s pain is the essence of good practice, but this can be very challenging when a patient is semi-conscious. A female patient, mid-fifties, diagnosis of Sheehan’s Syndrome, was referred to Specialist Palliative Care by the Nephrology team. She had multi-organ failure and was in obvious distress with restlessness requiring symptom control at End-of-Life (EoL). Aetiology of this distress was explored, cardiac source, pain, air-hunger and/or nausea. A continuous sub-cutaneous infusion for 24 hours with low dose opioid and a centrally acting anti-emetic was commenced and breakthrough opioid to assess if her symptoms improved. Minimal relief was observed. The history was re-explored and the potential for an osteoporotic spinal collapse secondary to her longstanding endocrine failure was key. Her husband’s collateral history confirmed that a bone density scan was scheduled prior to this acute care episode. It transpired that weeks prior her decline she had been ‘pinching’ her posterior chest wall and he took a photograph to show her that she was deeply bruising herself in an area not visual to her. The bruise was now cleared. The photograph immediately clenched the source of her distress. It showed a dramatic area of bruising on her left chest wall, corresponding to the Thoracic dermatome levels of T5 and T6. The clear ‘source’ of her pain was therefore neuropathic pain. Neuropathic pain does not tend to respond to opioids but responds well to the membrane stabiliser class of drugs, i.e., antiepileptics. This patient could not swallow and effective anti-epileptics for pain were not available in an intravenous and/or sub-cutaneous format for delivery. Carbamazepine, 250 mg twice daily suppositories were therefore commenced. Within hours her distress resolved, and she remained comfortable at EoL. Sheehan’s syndrome, pituitary failure from infarction, commonly secondary to postpartum haemorrhage, is a known cause of osteoporosis from somatotropin and gonadotropic failure, predisposes to spontaneous osteoporotic/fragility fractures. 30% of compression fractures occur acutely in bed-bound patients, pain is localized to fracture site and radicular in nature due to neural compression. A diagnosis of the ‘source’ of pain is vital for safe, effective management of a patient’s pain. Perseverance is vital!