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.
Mrs. Johnson’s chief complaint is low back pain that she has had for a year.
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
The first person Mrs. Johnson meets with is the nurse manager, who obtains further information about her pain.
Weight and Exercise
After meeting with the nurse manager about pain assessment, Mrs. Johnson is interviewed by the pharmacist about her medication usage.
- 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
- 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
- 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