Society for Pediatric Pain Medicine
Better Care for Children in Pain.

A 13-year-old female is admitted to the hospital for hemoptysis. Her mother reports the patient has a past medical history of anxiety, depression, IBS, Ehlers-Danlos syndrome, POTS, and CRPS Type I in the left lower extremity. Her mother has prevented her from participating in normal activities, kept her home from school, and limited her physical therapy appointments, due to concern for syncope secondary to POTS, debilitating pain, and an inability to bear weight on her left foot. On admission, she was started on 0.05 mg/kg IV morphine q4 hours PRN for her 10/10 left lower extremity pain. The patient winces when her left foot is touched and has not placed a sock or shoe on that extremity for several months. Physical inspection reveals no abnormalities; reflexes are within normal limits, and strength is 4+ throughout. Infectious causes of hemoptysis were ruled out, as were pulmonary and gastrointestinal etiologies with bronchoscopy and EGD, respectively. CT scans of the head, neck, and chest, as well as X-rays of the left foot and ankle, were unremarkable. Vital signs are within normal limits, and she sleeps comfortably at night. She has experienced 3 more episodes of hemoptysis, always occurring at night and never observed by clinical staff. Her mother, who is concerned about her clinical status, asks for further diagnostic testing, such as MR enterography, colonoscopy, nasal endoscopy, MRI of the left foot, and stronger pain medication for her left lower extremity pain, since it remains a 10/10. What is the most important next step in management for this patient’s pain?