Case 46 – History


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Case 46

Pacemaker and chronic back pain


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Brief Past Medical History

The patient was a middle-aged Caucasian man with a history of borderline hypertension and borderline high cholesterol who had a pacemaker placed within the past couple to several years.

The indication for pacemaker placement, per the family, was that the patient was tired or dizzy upon standing or exertion; and was found to be unable to raise his heart rate.

The pacemaker seemed to help some, but the patient still had, at least at times, some symptoms.

He also had chronic back pain.


Recent events

Approximately 1 week prior to death, he had the sudden onset of a “new back” pain in a “different” location.

He received medical attention at least two times and with consideration for musculoskeletal back pain.

The patient himself thought the pain was some type of musculoskeletal pain.

During the two days prior to death, the patient “decompensated.”


Day of Death

On the day of death, the family received a call from the pacemaker service asking them to bring the patient into the emergency room because they noticed a problem with the device.

The patient presented to the emergency room and underwent cardiopulmonary arrest.

Resuscitative measures were undertaken, but the patient died.

The history is obtained from the family.

Next: External exam

Discussion Questions

1. What is your assessment of the history?
2. What treatment issues does the case illustrate?
3. Do you think the patient had musculoskeletal pain?
4. In a patient with chronic pain, how will you distinguish an exacerbation of the condition from other, more life threatening clinical developments?
5. What is your opinion of “drug seeking behavior” in patients with chronic pain, for example, patients with sickle cell disease?
6. What is your threshold for narcotic prescription in patients with chronic pain?
7. What is the family’s and patient’s role in the health care system? Do you think the patient was “at fault” here in any manner?