Pain Management in Children
CARE STUDY: A CHILD WITH PAIN
Beth is a 14-year-old diagnosed with Crohn's disease who you visit in her home.
CHIEF CONCERN:
“My stomach hurts all the time.”
HISTORY OF PRESENT CONCERN:
Child has had a history of loose bowel movements 4 to 5 times a day plus anorexia for the past 6
months. Has frequent flatulence and sometimes notices blood in stool. Has lost 8 pounds over the
past 6 months.
She had a colonoscopy under conscious sedation 1 month ago and was diagnosed as having
Crohn's disease. Was hospitalized for 5 days with intravenous morphine sulfate for pain relief.
Was discharged home on total parenteral nutrition plus Azulfidine and prednisone to reduce
bowel inflammation.
At first she was cooperative about helping out with household chores and working with a tutor;
she has spent the last week crying about having to stay home and being so tired of constant, but
low-grade, abdominal pain. Refusing to take prednisone because of publicity that steroid use is
bad for athletes.
FAMILY PROFILE:
Father works as the high school football coach at Beth's school. Mother is primary caregiver
(works part time selling cosmetics). Family lives in a single-family home. Siblings are a
10-year-old brother and 8-year-old twin sisters. Finances are described as “not a problem.”
HISTORY OF PAST ILLNESSES:
Roseola at 8 months; no other childhood diseases. Had appendectomy at 7 years. Broke right
ulna at age 10 in soccer game. Immunizations up to date.
HISTORY OF FAMILY ILLNESSES:
Hypertension in maternal grandfather; diabetes mellitus in paternal aunt. A brother of child's
father “always complains of stomach trouble.”
DAY HISTORY:
Nutrition: No oral intake but occasional hard candy. Nutrition supplied by central line
intravenous parenteral nutrition.
Sleep: Sleeps poorly because of low-grade pain. Insists one parent stay awake during night and
sit with her.
Recreation: Was active in sports as a member and captain of the high school varsity soccer and
basketball teams and a coach for a city soccer team of 4-year-olds before illness. Now inactive;
grows tired walking a city block.
, Growth & Development: Always met developmental milestones. Currently is a high school
freshman (age appropriate). She was an A student before becoming ill. Her marks have begun to
fall over the last 6 months as she has missed considerable school (20 days) this semester.
REVIEW OF SYSTEMS:
Neuropsych: Child is "high-strung;" works very hard to be the best at what she does. No history
of seizures.
HEENT: Wears glasses for reading: vision 20/30 and 20/40. Hearing was assessed in school and
rated adequate. No otitis media.
Gastrointestinal: Had an allergy to milk when first born. Formula was changed four times,
finally to soy base which was tolerated. When milk was reintroduced again at 1 year, Beth had
no difficulty digesting it. Has had numerous "canker sores" in mouth during last year. States,
“Don’t touch my stomach. I’ll feel pain all the way down into my legs if you do.”
Extremities: Has paper cut on right index finger from homework assignment last night. Notices
“charley horse” leg cramps on walking.
PHYSICAL EXAMINATION:
Height: 164 cm (50th percentile). Weight: 81 pounds (5th percentile). BMI: 13.5 (underweight).
General Appearance: White, thin-appearing, adolescent female with uncombed hair and still
wearing nightgown although it is 2:00 p.m.
Head: Normocephalic; hair oily; unbrushed.
Eyes: Red reflex. Follows through fields of vision. No erythema of conjunctivae.
Ears: TMs pink and subtle; landmarks and light cone visible.
Nose: Nares patent; midline septum
Mouth and Throat: Midline uvula; intact palate. 30 teeth present; no caries. Mucous membrane
moist; no ulcerations.
Neck: Subtle; No palpable lymph nodes. No thyroid hypertrophy; midline trachea.
Chest: Lungs clear to percussion and auscultation. Respiratory rate: 20 breaths per minute.
Heart: PMI at left 5th intercostal space. Heart rate: 84 beats per minute. No murmurs.
Abdomen: Extreme guarding. Tenderness elicited in all four quadrants on palpation. Bowel
sounds hyperactive in upper quadrants.
Genitourinary: Tanner stage 2. Perineal and rectal area is erythematous with a pinpoint rash.
Back: No curvature of spine; no tenderness of vertebrae.
Extremities: Full range of motion; normal gait. ½ inch laceration on right index finger; no
inflammation at site.
Neurologic: Patellar reflex: 3+; Sensation and gross motor grossly intact. Fully oriented to place
and person.
Beth is diagnosed as having a recent exacerbation of Crohn’s disease.
CARE STUDY: A CHILD WITH PAIN
Beth is a 14-year-old diagnosed with Crohn's disease who you visit in her home.
CHIEF CONCERN:
“My stomach hurts all the time.”
HISTORY OF PRESENT CONCERN:
Child has had a history of loose bowel movements 4 to 5 times a day plus anorexia for the past 6
months. Has frequent flatulence and sometimes notices blood in stool. Has lost 8 pounds over the
past 6 months.
She had a colonoscopy under conscious sedation 1 month ago and was diagnosed as having
Crohn's disease. Was hospitalized for 5 days with intravenous morphine sulfate for pain relief.
Was discharged home on total parenteral nutrition plus Azulfidine and prednisone to reduce
bowel inflammation.
At first she was cooperative about helping out with household chores and working with a tutor;
she has spent the last week crying about having to stay home and being so tired of constant, but
low-grade, abdominal pain. Refusing to take prednisone because of publicity that steroid use is
bad for athletes.
FAMILY PROFILE:
Father works as the high school football coach at Beth's school. Mother is primary caregiver
(works part time selling cosmetics). Family lives in a single-family home. Siblings are a
10-year-old brother and 8-year-old twin sisters. Finances are described as “not a problem.”
HISTORY OF PAST ILLNESSES:
Roseola at 8 months; no other childhood diseases. Had appendectomy at 7 years. Broke right
ulna at age 10 in soccer game. Immunizations up to date.
HISTORY OF FAMILY ILLNESSES:
Hypertension in maternal grandfather; diabetes mellitus in paternal aunt. A brother of child's
father “always complains of stomach trouble.”
DAY HISTORY:
Nutrition: No oral intake but occasional hard candy. Nutrition supplied by central line
intravenous parenteral nutrition.
Sleep: Sleeps poorly because of low-grade pain. Insists one parent stay awake during night and
sit with her.
Recreation: Was active in sports as a member and captain of the high school varsity soccer and
basketball teams and a coach for a city soccer team of 4-year-olds before illness. Now inactive;
grows tired walking a city block.
, Growth & Development: Always met developmental milestones. Currently is a high school
freshman (age appropriate). She was an A student before becoming ill. Her marks have begun to
fall over the last 6 months as she has missed considerable school (20 days) this semester.
REVIEW OF SYSTEMS:
Neuropsych: Child is "high-strung;" works very hard to be the best at what she does. No history
of seizures.
HEENT: Wears glasses for reading: vision 20/30 and 20/40. Hearing was assessed in school and
rated adequate. No otitis media.
Gastrointestinal: Had an allergy to milk when first born. Formula was changed four times,
finally to soy base which was tolerated. When milk was reintroduced again at 1 year, Beth had
no difficulty digesting it. Has had numerous "canker sores" in mouth during last year. States,
“Don’t touch my stomach. I’ll feel pain all the way down into my legs if you do.”
Extremities: Has paper cut on right index finger from homework assignment last night. Notices
“charley horse” leg cramps on walking.
PHYSICAL EXAMINATION:
Height: 164 cm (50th percentile). Weight: 81 pounds (5th percentile). BMI: 13.5 (underweight).
General Appearance: White, thin-appearing, adolescent female with uncombed hair and still
wearing nightgown although it is 2:00 p.m.
Head: Normocephalic; hair oily; unbrushed.
Eyes: Red reflex. Follows through fields of vision. No erythema of conjunctivae.
Ears: TMs pink and subtle; landmarks and light cone visible.
Nose: Nares patent; midline septum
Mouth and Throat: Midline uvula; intact palate. 30 teeth present; no caries. Mucous membrane
moist; no ulcerations.
Neck: Subtle; No palpable lymph nodes. No thyroid hypertrophy; midline trachea.
Chest: Lungs clear to percussion and auscultation. Respiratory rate: 20 breaths per minute.
Heart: PMI at left 5th intercostal space. Heart rate: 84 beats per minute. No murmurs.
Abdomen: Extreme guarding. Tenderness elicited in all four quadrants on palpation. Bowel
sounds hyperactive in upper quadrants.
Genitourinary: Tanner stage 2. Perineal and rectal area is erythematous with a pinpoint rash.
Back: No curvature of spine; no tenderness of vertebrae.
Extremities: Full range of motion; normal gait. ½ inch laceration on right index finger; no
inflammation at site.
Neurologic: Patellar reflex: 3+; Sensation and gross motor grossly intact. Fully oriented to place
and person.
Beth is diagnosed as having a recent exacerbation of Crohn’s disease.
