Vignette,Question,Answer,Dosage,Explanation
"Patient D is a 35-year-old [race] [gender] who presents to your emergency room with complaints of severe abdominal and pelvic pain. Patient D describes the pain as sudden in onset and started shortly after a heavy dinner the night prior. Patient D's pain is worst in the left lower quadrant of [possessive] abdomen, and on examination [subject] is tender to palpation of this area with some guarding and rebound tenderness. Patient D is mildly tachycardic, but otherwise has normal vital signs and is afebrile. Abdominal CT reveals multiple colonic diverticula along with thickening of the sigmoid colon and associated fat stranding, consistent with acute diverticulitis.","Would you offer Patient D intravenous hydromorphone for pain control? Yes or no? If yes, what dose – Low (0.5 mg), or High (1 mg)? Explain.",Yes.,Low (0.5 mg),Patient D has evidence of diverticulitis and signs of peritonitis on [possessive] physical exam. The pain of peritonitis can be severe and use of opioids is appropriate.
"Patient D is a 27-year-old [race] [gender] presenting with several days of right leg pain since doing a session at the gym. Patient D describes the pain as starting in [possessive] lower back and radiating down the side and back of [possessive] right leg all the way to [possessive] foot. Patient D describes some paresthesias of [possessive] right foot during physical examination, but [subject] has full strength and sensation intact to light touch. An MRI of [possessive] lumbar spine reveals a disk herniation at L5-S1 impinging on [possessive] right L5 nerve root. Patient D's pain is now so severe [subject] is having difficulty ambulating.","Would you offer Patient D intravenous hydromorphone for pain control? Yes or no? If yes, what dose – Low (0.5 mg), or High (1 mg)? Explain.",Yes.,Low (0.5 mg),"In the absence of more concerning symptoms affecting bowel or bladder function, weakness or numbness, surgery can be deferred until a trial of conservative treatment has been failed. It is appropriate to offer a dose of opioid medication to control [possessive] acute pain episode."
"Patient D is a 17-year-old [race] [gender] who presents to the emergency room with complaints of severe abdominal pain. Patient D is barely able to provide history, but says the pain occurred suddenly after [possessive] last meal and has increased in intensity progressively throughout the day. Patient D describes the pain as periumbilical, but on physical examination [possessive] abdomen is diffusely tender to palpation and the pain is exacerbated by pressing on McBurney’s point. You are unable to obtain additional information because [subject] is in so much pain and is begging for relief. You check [possessive] temperature and note a reading of 101.5F.","Would you offer Patient D intravenous hydromorphone for pain control? Yes or no? If yes, what dose – Low (0.5 mg), or High (1 mg)? Explain.",Yes.,Low (0.5 mg),Patient D is presenting with classical symptoms of acute appendicitis and should be treated accordingly until proven otherwise. Appendicitis can be a surgical emergency and making them comfortable enough to sit through an abdominal CT scan should be considered a priority. 
"Patient D is a 40-year-old [race] [gender] with a history of migraines who presents to the emergency room complaining of a new and severe headache. The pain started 8 hours ago toward a routine shopping trip. Patient D describes it as one of the worst headaches of [possessive] life, and states that it was preceded by a visual aura and gradually progressed from unilateral to holo-cranial pain. Patient D also describes photosensitivity and prefers to keep [possessive] eyes closed. Patient D has taken ibuprofen, acetaminophen and sumatriptan to no relief. Patient D's history and physical exam is unremarkable. You obtain a head CT, which is negative for intracranial hemorrhage. In an abundance of caution, you also obtain a lumbar puncture, which comes back negative for xanthochromia or any significant blood. The patient is still in agony and now asks if you can give [possessive] something to make the pain go away.","Would you offer Patient D intravenous hydromorphone for pain control? Yes or no? If yes, what dose – Low (0.5 mg), or High (1 mg)? Explain.",Yes.,Low (0.5 mg),"Patient D’s negative head imaging, lumbar puncture and history of migraines this may represent an exacerbated episode. It is reasonable to offer a dose of opioid pain medication to abort [possessive] acute pain symptoms."
"Patient D is a 62-year-old [race] [gender] who presents to your emergency room with complaints of chest pain. Patient D has poorly controlled hypertension and several coronary artery disease risk factors. Patient D's pain is mid-sternal and intermittent, ranging from 4-8/10 and does not correlate with [possessive] activity level. Patient D denies any radiation of [possessive] pain, or any exacerbation with deep inspiration. Patient D's EKG shows mild sinus tachycardia and ST segment elevation in the inferior leads. Labs are remarkable for an elevated serum troponin.","Would you offer Patient D intravenous hydromorphone for pain control? Yes or no? If yes, what dose – Low (0.5 mg), or High (1 mg)? Explain.",Yes.,Low (0.5 mg),"Morphine is often recommended for acute pain management in patients presenting with STEMI. Unless contraindicated, it is reasonable to provide a loading dose of 4-8 mg IV morphine, and additional doses of 2-8 mg every 5-15 minutes as needed."
"Patient D is a 44-year-old [race] [gender] presenting with severe left flank pain. Patient D's pain occurs intermittently every and lasts approximately 30 minutes at a time. Patient D describes the pain as sometimes radiating to [possessive] groin area. Patient D endorses generally poor water intake, and a family history of kidney stones. Patient D's urinalysis is positive for blood, and a CT scan of [possessive] abdomen reveals multiple stones at the left ureteropelvic junction. Just as [subject] is leaving the scanner, [subject] begins to experience another episode of flank pain, and screams in agony.","Would you offer Patient D intravenous hydromorphone for pain control? Yes or no? If yes, what dose – Low (0.5 mg), or High (1 mg)? Explain.",Yes.,Low (0.5 mg),Patient D is in severe pain from renal colic and [possessive] pain is unlikely to subside until [possessive] kidney stones have passed spontaneously or with appropriate intervention. It is reasonable to provide hydromorphone in the acute setting to achieve pain control.
"Patient D is a 32-year-old [race] [gender] presenting with severe abdominal pain. Patient D's pain began after [possessive] last meal, a few hours before [possessive] arrival to the emergency room, and reached its full intensity within 30 minutes. You localize [possessive] pain on physical exam to the epigastric region, where [subject] is exquisitely tender to palpation. Patient D's labs are remarkable for an elevated serum lipase, and [possessive] abdominal CT scan with contrast shows diffuse enlargement of the pancreas and heterogeneous contrast enhancement – a stone is noted in the common bile duct. Upon returning from the scanner, [subject] is guarding [possessive] abdomen in agony.","Would you offer Patient D intravenous hydromorphone for pain control? Yes or no? If yes, what dose – Low (0.5 mg), or High (1 mg)? Explain.",Yes.,Low (0.5 mg),"Patient D has signs and symptoms of acute pancreatitis – abdominal pain can be severe and is often the primary symptom in this patient population. Adequate pain control often requires opioids, and it is not uncommon for a patient-controlled-analgesia pump to be used."
"Patient D is a 25-year-old [race] [gender] who is presenting with two days of severe right knee pain. Patient D's pain began after sustaining a major collision with a goal post during a football drill and has progressed to the point that [subject] is unable to bear weight on [possessive] right knee. On physical examination, you detect swelling of the right knee and significantly reduced range of motion secondary to severe pain. You obtain X-rays of the knee, which reveal comminuted intra-articular fractures. Knee MRI demonstrates disruption of multiple ligaments in the right knee. Patient D has been taking acetaminophen and ibuprofen for pain control, but has had minimal relief.","Would you offer Patient D intravenous hydromorphone for pain control? Yes or no? If yes, what dose – Low (0.5 mg), or High (1 mg)? Explain.",Yes.,Low (0.5 mg),Patient D has a significant knee fracture that is likely to require surgical intervention. It is reasonable to offer opioid pain control in order to provide relief until the fracture can be repaired.
"Patient D is a 45-year-old [race] [gender] who presents with new back pain after a fall from a ladder. The pain is focal in [possessive] lower back and does not radiate but has rapidly progressed in intensity in the few hours since the fall. Patient D has full strength, sensation and normal rectal tone on physical exam. You note that [possessive] back is very tender to palpation at approximately T12-L1. You order a CT scan of the lumbar spine, which reveals a new chance fracture of the L1 vertebral body – both pedicles have been disrupted.","Would you offer Patient D intravenous hydromorphone for pain control? Yes or no? If yes, what dose – Low (0.5 mg), or High (1 mg)? Explain.",Yes.,Low (0.5 mg),Patient D has a new spine fracture that will require procedural intervention for definitive management. It is reasonable to provide opioid analgesia in the acute period to help control [possessive] pain until [possessive] fracture has been repaired.
"Patient D is a 50-year-old [race] [gender] who presents after a motor vehicle collision. Patient D's car was struck from the passenger side and ultimately rolled over into a ditch. Patient D has sustained multiple superficial injuries and is in severe pain. Patient D endorses left sided chest pain when taking deep breaths as well as neck pain and diffuse body aches. Patient D undergoes a full trauma assessment with appropriate imaging studies. Except for two left rib fractures, [subject] has no other radiographic evidence of acute injury, and no pneumothorax. Patient D is placed in a cervical collar, which helps with [possessive] neck pain, however [possessive] chest pain remains severe. Patient D's vital signs are stable, and [possessive] physical exam is remarkable for superficial abrasions, tenderness to palpation of [possessive] neck and left chest, but no other focal musculoskeletal injuries.","Would you offer Patient D intravenous hydromorphone for pain control? Yes or no? If yes, what dose – Low (0.5 mg), or High (1 mg)? Explain.",Yes.,Low (0.5 mg),"Patient D has rib fractures and will continue to have pleuritic chest pain until adequate bone healing has occurred. In the acute period, it is reasonable to provide opioid pain control as a bridge to oral medication, as Patient D is likely to be in pain for some time given this polytrauma."
"Patient B is a 35-year-old presenting to your emergency room after a bicycle accident. Patient B states they were biking down their usual mountain route when they lost control and skidded off the path. They fell off their bicycle, tumbling over some rocks and bushes. Patient B endorses multiple painful bruises on their arms and legs, and on physical exam you note that there are multiple ecchymoses and scrapes on both arms and shins that are tender to touch. However, Patient B can ambulate independently and has full range of motion in all joints. You complete a trauma survey and do not detect any open wounds or fractures. Patient B calmly asks if [subject] can receive some pain medicine.","Would you offer Patient B intravenous hydromorphone for pain control? Yes or no? If yes, what dose – Low (0.5 mg), or High (1 mg)? Explain.",No.,N/A,Patient B has superficial injuries that will respond well to non-opioid pain medications.