Information Sheet for Candidates:

You are working as the night covering HMO in a suburban

hospital when you are called to see a 30 year old Miss Way,
who had been admitted early that night for observation to
the surgical ward. She presented to the emergency
department with abdominal pains but the surgical and the
ED registrar had felt that her pains were not caused by any
significant underlying organic pathology but more likely
related to psychosomatic problems.
She is rather upset that she has not been taken seriously and
states that the prescribed panadol does not really relieve her
pains. She wants to have a pethidine injection.
Your tasks are to:
Take a history
Perform a physical examination
Counsel the patient regarding her wish to have
analgesia
Explain your diagnosis and management to the
examiner

HOPC:
Five years ago, after the birth of her daughter, the patient started to develop regular
nightly abdominal pains. She consulted several GPs and specialists (surgical and O+G)
but no organic cause was found. However, she used to call locum doctors and they
provided her with on average fortnightly pethidine injections which helped to control her
pains. Unfortunately last night the locum doctor was not available and the service
coordinator asked her to come to this public hospital. She was assessed in the emergency
department by several doctors but she felt that nobody took her pain problem serious.
They prescribed some panadol and admitted her for observation overnight. The pains are
still very, very bad and she would like to have a pethidine injection.
She has no problems with her mood, sleep or appetite.
PHx. + FHx. : unremarkable
SHx.: single unemployed woman on centre link pension with a 5 year old child, living
with her parents who help a lot. The father of her child was a drug addict and left her
when she found out that she was pregnant, although she never used illicit drugs but she
has had a few run-ins with the police for minor offences. Non smoker, no alcohol.
EXAMINATION:
Miss Way looks quite well, normal vital signs, no significant findings on physical
examination, especially her abdominal examination does not reveal any major
pathological findings. She is rather annoyed that you are the third doctor examining her
but nobody has helped her.
WHAT IS THE MOST LIKELY DIAGNOSIS?: DRUG SEEKING BEHAVIOUR
(CHRONIC PAIN MANAGEMENT) !
This patient obviously has a history of opioid abuse with subjective pain perception
(10/10) in contrast to her physical examination findings. However she denies to be a
druggie and she does not believe in counseling and drug and alcohol services etc.
Even monitoring her pain overnight seems to be a waste of time but she reluctantly
agreed to it, so that she can prove how severe her pain is.
She rejects any ideas that her pains might be caused by her emotional or situational
problems.
However, if the candidate is sympathetic to her cause, she will accept alternative pain
management and counseling and she is prepared to talk to a counselor form alcohol and
drug services or a pain management clinic .
MANAGEMENT:
Empathetic approach, understand her feelings, dont criticize or provocate the
patient! Explain relationship between body and mind, her stress might have
resulted from her partner leaving her, presenting as abdominal pain.
Continue with non-opioid analgesia

Do not support the narcotic seeking approach of the patient and dont prescribe
opioid analgesia!
Continue to monitor the patient (incl 0-10 Liekert scale), especially if there is a
chance of withdrawal symptoms!
Develop an alternate plan of pain management which should include consultation
with pain management and A+D services.
Pharmacological short term support with a short term sedative is acceptable
Check patients understanding, e.g. ?do you agree with me?.