A 59-year-old man was referred to the pain clinic by his family doctor. A year previously, he had sustained a stroke following a period of uncontrolled, undiagnosed atrial fibrillation. This had left him with an expressive dysphasia and a dense left sided hemiplegia. Over the ensuing months despite intensive rehabilitation, he remained very disabled and was showing signs of significant distress when his left side of his body in particular the upper limb was passively moved or touched. His left shoulder was dropping and sleep was becoming very problematic. He was becoming increasingly withdrawn.
His family doctor had started the patient on a combination of Codeine 30mg/Paracetamol 500mg tablets of which he was taking eight tablets per day in four divided dosages. He had also been taking Gabapentin 100mg three times a day for a few weeks without any perceived benefit. Of note the patient had been anticoagulated with Warfarin since sustaining the stroke and had also been commenced on Atorvastatin 40mg once daily as well as Bisoprolol 5mg once daily.
- Is there any other information you would like to know?
- What would you look for during examination?
- Are there further investigations that would be helpful?
- Would this patient benefit from evaluation by another speciality?
Differential Diagnosis:
1. Post Stroke Pain
2. Neuropathic upper limb pain secondary to cervical spine disc prolapse
3. Complex Regional Pain Syndrome
4. Intrinsic shoulder abnormality
