Educational Case #51: Adolescent Pain presented by Dr Cara Lewis, Dr Kylie Edwards and Dr Rory Maguire

Sarah’s notes were requested and letters from each of the previous specialties involved reviewed, to include investigations, possible diagnoses and management. 

Sarah and her mother were invited to attend a multidisciplinary assessment at the Paediatric Pain clinic. She was reviewed by a pain physician, clinical nurse specialist (CNS), physiotherapist and psychologist.

Sarah described widespread dull abdominal pain which would migrate around her abdomen. The location and severity of the pain wasn’t related to her menstrual cycle. At her best she was able to attend a shortened day at school but would come home and sit on the sofa or go to bed for the rest of the day. At worst, the pain would make her stay in bed and could be 10/10 in severity.

Sarah had tried simple analgesia like Paracetamol and Ibuprofen but didn’t find they helped. She had also tried Amitriptyline in the past and found it made her very drowsy but had little effect on pain and so she stopped taking it. Sarah found her sleep was disturbed and would wake up in the night at least once. She didn’t think she was awoken by the pain, but it was present when she woke up.

The pain was worse when she was feeling anxious or stressed, and she felt she had become more socially isolated as she was afraid of developing the pain when out with friends. Sarah felt that her friends were getting sick of her dropping out of engagements, and when she went to school, she was worried they were talking about her behind her back. Sarah described herself as being anxious, and although she didn’t feel depressed, she did worry about her future if she couldn’t study and maintain friendships.

Sarah hoped to complete her education and attend university although she wasn’t sure yet what she wanted to study. She enjoyed English at school and was an avid reader.

Sarah lived at home with her mother and younger brother (age 10). Her parents were divorced, and she spent weekends with her father who lived nearby. She described her relationships with all her family as ‘good’. She attended a nearby comprehensive school, and the staff there had been mainly supportive of her. However, Sarah’s mum was under increasing pressure from the local authority to explain Sarah’s low attendance rate, and this was a cause of tension between Sarah and her mother. Sarah felt pressure to go to school when she was feeling unwell, and was worried about the stress her pain was causing to the wider family.

Sarah walked into the assessment room independently. She was appropriately dressed and communicative. At times she was shy but once rapport was built, she made eye contact and answered questions unprompted. She was examined by the pain physician and had widespread abdominal pain to light touch. She described the pain as dull and achy. She was also tender on palpation at multiple spots over her body. Her Beighton score was 2/9, and she was found to have low truncal strength.

• With the information above, how would you want to manage Sarah’s pain?