Reference no: EM133844597
Case Study
Chronic Pain Chief Complaint: "I have a constant pain in my lower back with occasional tingling in my left leg. Can I take more Percodan?" HPI: Mary Miller is a 78-year-old woman who has had a history of lower back pain since an automobile accident 10 years ago. Details regarding the accident are limited but the patient reported that she had an operation (laminectomy) to relieve the pain shortly after the accident. Records were unclear as to whether she had a herniated or ruptured disc. She has tried numerous pain therapies including local anesthesia injections and a TENS unit without relief. PMH: Type 2 DM x 8 years; HTN x 15 yrs., Lymph edema of left arm, Sciatica on the left side x 20 years, Insomnia, Depression, History of "heart attack" per patient report (no records available.) FH: Non-contributory SH: Lives at home with her husband. She is very sedentary, remaining in bed or a chair for most of the day. She does not smoke and denies alcohol use. Medications: Lanoxin 0.125 mg po once daily Atenolol 25 mg po every other day Aspirin 325 mg po once daily Maxzide 25/50 po once daily OsCal 500 mg po bid Humulin 70/30 q am & 40 units q pm (previously on glyburide) Zoloft 75 mg po at bedtime Percodan 2 tablets q 6 hr Halcion 0.25 mg po at bedtime Allergies Meperidine (bronchospasm, hives); PCN allergy as a child; flurbinprofen (GI intolerance) Labs Na 144, K 3.9, Cl 103, CO2 31, BUN 16, Cr 1.6, Glu 53 (fasting), AST 30, ALT 15, HbA1c 9.1% MRI spine: Slight degenerative disc disease; no evidence of spinal stenosis or herniated disc DEXA Scan: Lumbar spine T score -3.75, Left hip T score -3.57 Problem List:(1) Chronic moderate to severe lower back pain related to a past automobile accident with increasing requests for pain control. (2) Poorly controlled diabetes (3) Osteoporosis (4) Lymph edema of the arms and thighs (5) HX HTN, insomnia, depression, and questionable MI . Questions: Problem Identification:
1. ?Create a list of the patient's drug therapy problems.
2. ?Which information indicates the presence or severity of chronic non-malignant pain?
3. ?Could any of the patient's problems have been caused by drug therapy? If so, describe.
4. ?What additional information is needed to satisfactorily assess this patient's pain?
5. ?Desired Outcomes: What are the goals of pharmacotherapy in this case?
6.? Therapeutic Alternatives: What non drug therapies might be useful for this patient?
7. ?Compare the pharmacotherapeutic alternatives available for treatment of this patient's pain? State the clinical practice guidelines used to support your answer.
8. ?Optimal Plan: What drug dosage form, schedule, and duration of therapy are best for treating this patient's pain? *State clinical practice guidelines used to support your answer.
9. ?What alternatives would be appropriate if the initial therapy fails or cannot be used?
10. Outcome Evaluation & Follow up Questions: What clinical and laboratory parameters are necessary to evaluate the therapy for achievement of the desired therapeutic outcome and to detect or prevent adverse effects? *State clinical practice guidelines used to support your answer.
11. Patient Education: What information should be provided to the patient to enhance adherence, ensure successful therapy, and minimize adverse effects? Clinical Course/Follow Up The physician accepted your initial plan of care. At her 2 week follow up appointment the patient complained of minimal pain relief and worsening of her edema. She describes her pain as a 7 on scale of 1 to 10. She was also very resistant to reducing the dose of Percodan. She stated that she was sleeping better since starting the antidepressant. She complained of headache since starting the alendronate and expressed concerns about the continuing this treatment.
11. How would you alter your treatment plan for this patient? *Provide your rationale to support your answer.
12. If this patient requires a surgical procedure, what would be your general recommendation for postoperative pain management? *Provide rationale to support your answer