What’s Your Diagnosis? Pain Management: Beyond Opioids
November 1, 2019


Posted by Andy Jagoda, MD in: What's Your Diagnosis , trackback

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Case Presentation: A 73-year-old woman in the ED after ?twisting? her ankle

A 73-year-old woman with a history of peptic ulcer disease and stage 3 chronic kidney disease presents to the ED after ?twisting? her ankle. She tried acetaminophen at home, but it didn?t adequately alleviate her pain. Currently, she complains of 6/10 pain at rest. She has mild swelling and tenderness at the posterior edge of her lateral malleolus. You order an ankle x-ray to evaluate for fracture and consider giving her oxycodone…

You wonder whether there is a better and safer alternative?

Case Conclusion

You concluded that your first patient likely had either an ankle sprain or a malleolar fracture, and that icing the area and immobilization was likely to improve her pain. With her comorbidities, you were concerned about using systemic NSAIDs, and you were concerned about giving her an opioid because of the association with adverse outcomes in older patients. You decided to apply ice, elevate the extremity, and order topical diclofenac. The radiograph was normal, and the patient?s pain improved with icing, immobilization with an air cast, and topical diclofenac. You discharged the patient with a prescription for topical diclofenac, a walker, and orthopedic follow-up.

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Comments »

1. Briana - November 2, 2019

Topical lidocaine or diclofenac gel topically
Tylenol 1000 mg if she hasnt had any in 4 hrs rest, ice, elevate
Splint if fractured
Consider ankle nerve block with modifications if she will be weight bearing as tolerated

2. David Grounds - November 2, 2019

Limit exercise, compression, and use a cane if needed.

3. Nafeeza Ali - November 3, 2019

Hematoma block or sciatic nerve block

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