USMLE PRACTICE QUESTION #67
TOPIC: Pain management.
Today’s question will test your understanding of pain management.
I’m Paul Ciurysek, MD, and this is The USMLE Times: An independent, subscriber-supported newsletter designed to help you survive medical school, pass your USMLE exams, and match into your dream residency program. This question and all others are free for 48 hours; after that, it’s available to Premium subscribers only.
A 55-year-old female with a history of type 2 diabetes and obesity undergoes a total abdominal hysterectomy for endometrial cancer. The surgery is uneventful, and she is transferred to the postoperative care unit. On postoperative day 1, she complains of moderate-to-severe pain at the incision site. Her pain is rated 7 out of 10 on the numeric scale. Her vital signs are stable, with blood pressure 135/80 mmHg, heart rate 78 beats per minute, respiratory rate 16 breaths per minute, and oxygen saturation 98% on room air. Physical examination reveals a well-approximated incision without erythema, drainage, or induration. The patient's medical history includes a contraindication to the use of NSAIDs. What is the most appropriate next step in pain management for this patient?
A. Intravenous acetaminophen
B. Intravenous morphine
C. Transdermal fentanyl patch
D. Oral ibuprofen
E. Oral oxycodone
Detailed Breakdown of Answers + Correct Answer Below ⏬
ANSWER + QUESTION BREAKDOWN
The mental model used to answer this question comes from our detailed test-taking skills masterclass. Here’s how to think through this question:
Step 1. Read the last line to determine the actual question: “What is the most appropriate next step in pain management for this patient?”
Step 2: Is this a first-, second-, or third-order question?
Answer: 3rd order. 1st: Determine her pain level and find any contraindications to specific treatment(s); 2nd: Look to see if/what has been done for pain thus far; 3rd: Identify the most appropriate pain management.
Step 3: Ask yourself: “What is the most appropriate way to manage this patient’s pain?”
Step 4. Look at the answer choices and select the option most closely resembling your thoughts from “Step 3” above.
GENERAL ANALYSIS
In this scenario, the patient is experiencing moderate-to-severe postoperative pain following a total abdominal hysterectomy. Her vital signs are stable, and she has a contraindication to the use of NSAIDs. The task is to determine the most appropriate next step in pain management.
ANSWER CHOICES:
CHOICE A: Intravenous acetaminophen
Explanation: Acetaminophen can be administered intravenously for pain management, especially when oral administration is not feasible or when rapid onset of action is desired. While this can be effective, it may not be sufficient alone for moderate-to-severe postoperative pain.
CHOICE B: Intravenous morphine
Explanation: Morphine can be administered intravenously to manage moderate-to-severe pain. Given the patient's pain severity and contraindication to NSAIDs, IV morphine provides effective pain relief and is commonly used for acute postoperative pain management.
CHOICE C: Transdermal fentanyl patch
Explanation: Fentanyl patches are used for chronic pain management and are not typically recommended for acute postoperative pain due to their delayed onset. The transdermal route is not suitable for immediate postoperative pain relief.
CHOICE D: Oral ibuprofen
Explanation: Ibuprofen is an NSAID, which should be avoided because this patient has contraindications.
CHOICE E: Oral oxycodone
Explanation: Oxycodone can be used for moderate-to-severe pain, and while effective, oral administration may not provide rapid relief compared to intravenous options in the immediate postoperative setting.
FINAL VERDICT…
For a patient experiencing moderate-to-severe postoperative pain with a contraindication to NSAIDs, intravenous morphine is an appropriate choice. It provides effective and rapid pain relief, which is crucial in the immediate postoperative period. The use of IV opioids like morphine allows for better control of acute pain and helps facilitate recovery by enabling the patient to participate in necessary postoperative activities such as mobilization and deep breathing exercises.
CORRECT ANSWER: B) Intravenous morphine
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