Event 1: Meet Mrs. Johnson

Mrs. Johnson is being seen for the first time In a primary care office that follows the Medical Home Model and provides biopsychosocial care.

This practice has a full-time nurse manager and part-time pharmacist and psychologist on site.

Chief Complaint

Mrs. Johnson’s chief complaint is low back pain that she has had for a year.

Medical History

Mrs. Johnson has completed a series of questionnaires about her medical history that includes:

  • Body drawing
  • Body Perception Index
  • Questionnaire containing multiple details regarding pain (OLD CART-P)
  • Past Med Hx, Family Hx, Social Hx, and Review of Systems
  • Patient Health Questionnaire-9

Patient Health Questionnaire

Image shows chart of patient health questionnaire. Mrs. Johnson notes her pain started about a year ago, but was not related to an accidental injury. The pain is usually present, and has increased over the last six months. She rates her pain right now as a 6 out of 0 being no pain and 10 being very severe pain, a 6 for the average intensity of her pain this week, a 9 for the worst pain she felt in the last week, and a 7 for the pain at its least in the last week. She notes pain in her lower back and legs.
Patient health questionnaire
Image shows patient health questionnaire, continued. Mrs. Johnson notes a dull, aching, throbbing, pressure, soreness, and tightness in her back, while she feels burning, shooting, stabbing, lightning shock, radiating and tingling pain in her legs. Aggravating factors included walking, standing, bending, lifting, twisting, stairs, changes in weather, use of legs, and exercise. Alleviating factors include sitting, lying, medications (some, not all), heat (but the heating pad burned her)
Patient health questionnaire, continued page 2
Image shows another page of the patient health questionnaire where Mrs. Johnson notes diabetes, hypertension/high blood pressure in her previous medical history, and a family history of cardiovascular (heart or blood vessel) disease (mother), and alcohol use (past or present) (dad and brother)
Patient health questionnaire, continued page 3
Image shows page 4 of the patient health questionnaire. Mrs. Johnson notes that she currently does not work, is not on disability, is not involved in legal action regarding her pain, and is not attempting to return to the work force. She has smoked for 60 years, currently 5 cigarettes per day, does not drink alcohol but has used alcohol in the past, does not use recreational drugs, has not used drugs in the past, and does not engage in hazardous activities.
Patient health questionnaire, continued page 4
Image shows page 5 of the patient health questionnaire. Mrs. Johnson notes she has cataracts, chronic wheezing, asthma, joint pain, stiffness or swelling, limitation of motion, difficulty walking, chronic back pain, and chronic depression.
Patient health questionnaire, continued page 5

Nurse Manager

The first person Mrs. Johnson meets with is the nurse manager, who obtains further information about her pain.

Daily Routine

 Sleep

Genitourinary

Weight and Exercise

Diet

Substance Use

Pharmacist Assessment

After meeting with the nurse manager about pain assessment, Mrs. Johnson is interviewed by the pharmacist about her medication usage.

Medications

  • Lisinopril 10 mg daily
  • Amlodipine 10mg orally daily
  • Glipizide XL 10mg daily
  • Sitagliptin 25mg orally daily
  • Tiotropium 18mcg Inhale daily
  • Albuterol 90mcg/puff MDI 1-2 puffs inhale Q4h as needed SOB
  • Citalopram recently increased to 40mg daily 
  • Ibuprofen 600mg TID
  • Zolpidem 10mg QHS as needed (using regularly)
  • Hydrocodone/Acetaminophen 5/325mg as needed pain

Medication Intolerance

  • Our patient reported N/V with previous codeine use
    • Example of a medication intolerance, not an allergy
  • Reasonable for patient to start Hydrocodone/Acetaminophen
    • Codeine and hydrocodone are within the phenanthrene opioid class
  • If nausea develops, consider a trial of a dopamine antagonist until she develops tolerance to the adverse effect

Over the Counter (OTC) Medications

Based on the patient’s history, we discover that she has taken a variety of over the counter (OTC) medications:

  • Camphor 11%, Menthol 8% Cream (Tiger Balm Cream®)
  • Menthol 10%, Methyl Salicylate 30% Cream (Icy Hot Cream®)
  • Glucosamine/Chondroitin 500/400mg caplets, 2 caplets PO BID

Unlikely that patient is experiencing benefit in her osteo- arthritis from glucosamine/chondroitin. Consider discontinuing and not restarting.

An excellent resource about non-conventional preparations is: http://www.mskcc.org/cancer-care/integrative-medicine/about-herbs-botanicals-other-products

Topical Counterirritants

  • Not indicated for chronic pain
  • Unclear if our patient was using topical counterirritants at the same time she experienced a burn from using a heating pad
  • Products containing menthol concentrations >3% and methyl salicylate concentrations >10%
  • Consider discontinuing and not restarting

Next: Event 2: Geriatric Insomnia Management

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