The most important task of the emergency physician is to distinguish chronic pain from an exacerbation that heralds a life- or limb-threatening condition. A complete history and physical examination should either confirm the chronic condition or point to the need for further evaluation when unexpected signs or symptoms are elicited. An electrocardiogram (ECG) may be needed in some cases of chronic myofascial chest pain to help differentiate it from acute ischemic chest pain. Because chronic pain patients may be frequent visitors to the ED, the entire staff may prejudge their complaint as chronic or factitious. Physicians should insist that routine procedures be followed, including a full triage assessment and a complete set of vital signs.
Rarely is a provisional diagnosis of a chronic pain condition made for the first time in the ED. The exception is a form of post-nerve-injury pain, complex regional pain. The sharp pain from acute injuries, including fractures, rarely continues beyond 2 weeks' duration. Pain in an injured body part beyond this period should alert the clinician to the possibility of nerve injury, and proper treatment, discussed below, should be instituted.
Definitive diagnostic testing of chronic pain conditions is difficult, requires expert opinion, and often expensive procedures such as magnetic resonance imaging (MRI), computed tomography (CT), and thermography. Therefore, referral back to the primary source of care and eventual specialist referral are warranted to confirm the diagnosis.
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