Owen has been suffering from low back pain for several years. His pain has been relatively well controlled up until recently when he's had some problems with his pain and his treatments. Take some time to learn more about Owen, his pain syndrome, and the safe use of opioid analgesics.
Name: Owen Jones
Age: 47
Address: 846 Heavenly Ln
St. Louis, MO 63114
All: NKDA Ins: BC/BS of MO
HPI
Mr. Jones presents for followup of low back pain with intermittent radicular symptoms and numbness which started ~ 2 years ago following a lifting related injury. He describes the pain as, "Sharp, pinching, and sore."
He reports greater disability from the localized lumbar pain versus the radicular pain. He rates his pain now as a 4-5/10 with the worse pain in the AM with gradual reduction throughout the day depending on activity.
He has trialed chiropractic, physical therapy, and injections with varying efficacy. Currently he is medically managed with an NSAID and opioids.
PMHx
- Hypertension
- Obstructive sleep apnea treated with CPAP
- GERD
- Chronic low back pain with intermittent radiculopathy
Meds
- Lisinopril 10mg PO QAM
- Escitalopram 20mg PO QHS
- CR oxycodone 40mg PO Q12 hours
- IR oxycodone 5mg PO Q6 hours PRN
- Celexocib 200mg PO Q12 hours
- Lansoprazole 30mg PO QAM
- Sennosides 8.6mg /docusate 50mg QAM
Review of Systems
Denies acute visual changes, dizziness, confusion, memory loss, loss of consciousness; denies chest pain, shortness of breath, or heart palpitations.
Denies nausea & vomiting, does endorse mild constipation which he self-treats; denies suicidal or homicidal ideation.
Denies urinary or fecal incontinence or urinary retention. Does endorse problems achieving and maintaining and erection. Denies saddle anesthesia.
Objective
- Vitals: BP 132/84; HR 98; RR 16; Temp 98° Ht 71in; Wt 114.5kg
- Physical Exam: A & O X 3, affect & speech appropriate; NAD PERLLA; Mildly fatigued, no impairment of speech, cognition, or memory; no sweating, chills, or flushing; no edema or cyanosis; lungs CTA; decreased bowel sounds X 4 quadrants
- Labs: Hgb 12; Hct 34; RBC 5.2; WBC 12; Plt 225; Na 139; K 4.7; Cl 101; CO2 21; BUN 12; SCr 1.0; Blu 189
- Test / Imaging: L-spine MRI (~ 16 months ago) significant for mild neuroforaminal narrowing bilaterally at L5/S1 secondary to broad based posterior disc buldge; mild multi-level facet arthropathy; PHQ9: 18
Interview Owen
The video covers the following about Owen's pain: site, duration, timing, characterstics, severity, alleviating factors, aggravating factors, current meds, nonmed treatments, med adherence, med use, social history, family history, physical therapy, use of injections, counseling, impact on relationships, impact on sleep, impact on mood, impact on activity, missing work, and med storage.
Assess Owen's Risk
Question: using the Opioid Risk Tool (ORT), can you identify Owen's risk of future opioid use?
Does he have:
Low risk for opioid abuse (score of less than or equal to 3)?
Moderate risk for opioid abuse (score of 4 to 7)?
High risk for opioid abuse (score of greater than 8)?
