Diagnosing and Managing Pain: Consider Horses and Zebras—and Even Unicorns

Pain is one of the most common concerns among the patients you see each day, with more Americans affected by pain than by diabetes, heart disease, and cancer combined. 

Because pain can’t be measured objectively in the clinic like blood pressure, it can’t be auscultated like heart sounds or lung sounds, and it doesn’t show up on a histology slide, a radiograph, or a computed tomography scan, accurately assessing, diagnosing, and managing patients’ pain is one of the biggest challenges for you and your primary care colleagues. (Correspondingly, pain also presents a challenge to us at Consultant, a journal that has distinguished itself with its historic focus on practical articles based largely on photographs, radiology scans, and other images.)

And because pain is the ultimate shape-shifter, it can be a dangerous pitfall to attribute a patient’s pain to an “obvious” mundane etiology without digging deeper to rule out more serious causes, from infection to traumatic injury to cancer.

In this special pain management supplement to Consultant, we’ve assembled a series of case reports that illustrate the need for a detailed history and a comprehensive physical examination to explore the source of a patient’s pain, which may involve much more than initially meets the eye. In most cases, a sprain would be a good bet as the source of an adolescent jogger’s knee pain, pneumonia would be a logical diagnosis for a feverish woman’s pleuritic pain, and colitis would represent a likely explanation for a man’s diarrhea and abdominal pain. But in the cases described in this supplement, the patients’ painful presentations were the result of a much more serious pathology requiring immediate intervention.

While the adage about thinking of horses, not zebras, when you hear hoofbeats remains good advice, it’s important to remember that zebras exist, and you must consider less common reasons for a patient’s pain. In other words, when you hear hoofbeats, it’s best to think horses and zebras—and, occasionally, unicorns, too.

For much more of the latest news and information about pain management from Consultant, including peer-reviewed quizzes, case reports, and review articles, visit the Pain 360 specialty area at Consultant360.com. And share your personal clinical experiences in pain management with Consultant by sending a note to Editor@Consultant360.com or by calling me directly at (800) 237-7285, ext. 4396. Thanks for reading.


Michael Gerchufsky, ELS, CMPP
Managing Editor, Consultant