From the Guidelines
I strongly recommend a comprehensive approach for the patient, including prescribing naproxen for back pain, duloxetine 30 mg at bedtime for potential neuropathic pain, scheduling imaging studies for the back, and an ultrasound for the breast mass, given the patient's history and current symptoms. The patient's history of a broken back with current symptoms of back pain and tingling in his right leg suggests possible nerve involvement that requires further investigation. Naproxen, a non-steroidal anti-inflammatory drug, is appropriate as it has previously provided effective pain relief for this patient, as noted in similar cases 1. The addition of duloxetine 30 mg at bedtime will help address potential neuropathic pain components associated with the tingling sensation.
For the right breast mass, which is tender on palpation, an ultrasound is necessary for proper evaluation, especially given the patient's family history of cancer, as recommended by guidelines for screening and diagnosis of breast cancer 1. This comprehensive approach addresses both immediate pain management needs while pursuing diagnostic clarity for the underlying causes of his symptoms. The back imaging will help determine if there are structural issues from the previous injury that may be causing the tingling sensation, which could indicate nerve compression requiring more targeted intervention.
Key considerations in managing the patient's care include:
- The patient's family history of cancer, which increases the importance of thorough evaluation of the breast mass
- The need for a multidisciplinary approach in diagnosing and treating breast cancer, as outlined in guidelines 1
- The importance of patient preferences and quality of life in treatment decisions, as emphasized in guidelines for metastatic breast cancer management 1
- The role of imaging and diagnostic tests in guiding treatment and ensuring timely intervention for potential complications.
Given the most recent and highest quality evidence, the patient should undergo an ultrasound for the breast mass and further imaging for the back to ensure timely diagnosis and intervention, considering the potential for underlying serious conditions such as breast cancer or nerve compression 1.
From the Research
Patient's Condition and Treatment
- The patient is a 26-year-old male with a history of back pain due to a previous injury and is now experiencing tingling sensations in his right leg.
- The patient has requested naproxen for pain management, which has been effective for him in the past.
- The patient has also reported a mass in his right breast, which feels tenderer compared to his left breast, and has a family history of cancer.
Duloxetine Prescription
- Duloxetine has been prescribed to the patient at a dose of 30 mg at bedtime 2, 3, 4.
- Studies have shown that duloxetine is effective in managing chronic pain conditions, including diabetic peripheral neuropathic pain, fibromyalgia, and chronic musculoskeletal pain due to chronic osteoarthritis pain and low back pain 2.
- Duloxetine has also been shown to improve painful chemotherapy-induced peripheral neuropathy by inhibiting the activation of p38 MAPK and NF-κB 3.
Imaging and Further Investigation
- An ultrasound has been suggested to investigate the mass in the patient's right breast further, given his family history of cancer.
- The use of ultrasound as a diagnostic tool for neuropathic pain has been supported by the literature, which highlights its advantages in assessing and guiding therapy for various diseases 5.
- The patient's neuropathic pain may be caused by a lesion or disease of the somatosensory nervous system, and treatment options may include drugs acting on α2δ subunits of calcium channels, sodium channels, and descending modulatory inhibitory pathways 6.