Case Study: Prescribed Drugs with CAMs
Mr. X, a 42-year-old male presents to your primary care practice today complaining of low back pain.
History Mr. X states that he has had chronic low back pain since he had a skiing accident about 10 years ago. Three days ago, he felt a pulling sensation in his lower back after moving some boxes. The pain intensity increased over the subsequent 24 hours and is now steady, aching in nature, at 3-4 out of 10. Mr. X also has Type2 diabetes, which is well controlled on metformin with a HGA1c of 5.6. He has a history of DVT 4 months ago for which he takes Coumadin, INR is WNL. He is followed by a specialist for this problem. He recently started taking two OTC products; kava kava for what he describes as anxiety and CoEnzyme Q10 on the advice of a friend.
Social - Mr. X is a smoker, 1 pack per week for 15 years. No alcohol or drug use. He is employed as an accountant and has medical insurance. He is divorced.
PE/ROS - Complains of low back stiffness and pain on movement with occasional spasms related to moving in certain directions. You note he has mild difficulty getting onto the exam table but gait is normal. He denies weakness/numbness/tingling of legs, no radiation, no change in bowel or bladder habits. BMI 27. All range of motion of the back is decreased by 25%. Straight leg lift is negative bilaterally, DTR intact. All other systems WNL.
Medications:
Metformin 1000mg ER one tab daily - Type II Diabetes controlled
Coumadin 5 mg. daily - Hx of DVT - Controlled
Kava Kava 50 mg. tid Self-medication for anxiety
CoQ10 - 200 mg. daily. Self-medication for unknown reason
Provide a diagnosis for the patient and your rationale for the diagnosis
Provide a treatment plan specifically for this patient, pharmacologic and non-pharmacologic.
Comment on the use of OTC products in relation to Mr. Xs current chronic and acute disease diagnoses and medications. Include drug-drug interactions and side effect profiles.
Provide an education plan for Mr. X
Present this Assignment as a PowerPoint presentation with between 12 and 16 slides (not including opening slide and resource slide).
You will use the Narrative notes section of the presentation to include the majority of your evidentiary support of your treatment choices and education of family complete with in-text citations using APA formatting.
PowerPoint Presentation: Case Study Analysis of Mr. X
Slide 1: Title Slide
- Title: Case Study Analysis of Mr. X
- Subtitle: Management of Chronic Low Back Pain with CAM Considerations
- Presented by: [Your Name]
- Date: [Current Date]
Slide 2: Patient Overview
- Content:- Age/Gender: 42-year-old male
- Chief Complaint: Chronic low back pain exacerbated by recent activity
- Medical History: Type II diabetes, history of DVT, well-controlled on medications
- Narrative: Mr. X presents with complaints of chronic low back pain, which has worsened following a recent injury. His medical history includes well-controlled Type II diabetes and a previous DVT for which he is taking Coumadin.
Slide 3: History of Present Illness
- Content:- Chronic low back pain for 10 years post-skiing accident
- Recent exacerbation after moving boxes
- Pain intensity: steady aching at 3-4 out of 10
- Narrative: Mr. X reports a long-standing issue with low back pain, which has intensified due to physical strain. The pain is described as steady and aching but remains manageable.
Slide 4: Physical Examination Findings
- Content:- Mild difficulty getting onto the exam table
- Normal gait, decreased range of motion (25%)
- Negative straight leg raise, intact DTRs
- Narrative: The physical examination reveals stiffness and pain on movement, with no neurological deficits. This suggests a musculoskeletal issue rather than a neurological complication.
Slide 5: Diagnosis
- Content:- Primary Diagnosis: Acute exacerbation of chronic low back pain (musculoskeletal)
- Rationale: The increase in pain intensity following a physical activity suggests a musculoskeletal strain or sprain, exacerbating his chronic condition.
Slide 6: Treatment Plan Overview
- Content:- Pharmacologic Treatments- NSAIDs (Ibuprofen) for pain management
- Consider muscle relaxants if spasms persist
- Non-Pharmacologic Treatments- Physical therapy for strengthening and flexibility
- Heat/ice application to relieve pain
- Lifestyle modifications (ergonomics, posture)
- Narrative: A comprehensive treatment plan should address pain relief while considering Mr. X’s existing conditions and medications.
Slide 7: Pharmacologic Treatment Details
- Content:- Ibuprofen: 400 mg every 6 hours as needed for pain.
- Muscle relaxants (e.g., Cyclobenzaprine) as needed.
- Narrative: Ibuprofen is chosen for its anti-inflammatory properties and effectiveness in managing acute pain. Muscle relaxants may be considered if muscle spasms occur frequently.
Slide 8: Non-Pharmacologic Treatment Details
- Content:- Physical therapy sessions (2-3 times a week)
- Application of heat or cold packs as needed
- Education on proper lifting techniques and ergonomics
- Narrative: Physical therapy can help restore mobility and strength, while heat or cold applications provide immediate relief from muscle discomfort.
Slide 9: OTC Products Consideration
- Content:- Kava Kava (50 mg tid): Used for anxiety.- Potential risks: Liver toxicity, sedation.
- Drug interactions with Coumadin.
- Coenzyme Q10 (200 mg daily): Unknown reason for use.- Generally safe but may have limited evidence for certain benefits.
- Narrative: Both OTC products should be examined closely due to possible interactions and side effects, especially Kava Kava's potential to affect liver function in conjunction with Coumadin.
Slide 10: Drug Interactions and Side Effects
- Content:- Kava Kava + Coumadin = Increased risk of bleeding.
- Ibuprofen may increase bleeding risk when taken with Coumadin.
- Narrative: It is crucial to monitor Mr. X for signs of increased bleeding due to these interactions, necessitating careful management of all medications.
Slide 11: Education Plan for Mr. X
- Content:- Importance of medication adherence and regular follow-up appointments.
- Educate on potential side effects and interactions of current medications.
- Discuss lifestyle modifications to manage both back pain and diabetes effectively.
- Narrative: Educating Mr. X on his medications and their interactions is vital for safe management. Encouraging lifestyle changes can also enhance his overall health.
Slide 12: Follow-Up Plan
- Content:- Schedule follow-up appointment in 4-6 weeks to assess progress.
- Re-evaluate pain management strategy.
- Monitor blood glucose levels regularly due to medications.
- Narrative: A follow-up plan is essential to ensure that Mr. X's treatment is effective and that he is managing both his back pain and diabetes effectively.
Slide 13: Conclusion
- Narrative: In summary, Mr. X's case highlights the importance of a comprehensive approach to managing chronic low back pain while considering his existing conditions and medications. Ongoing education and monitoring will be critical in optimizing his treatment outcomes.
Slide 14: References
1. American Academy of Family Physicians. (2021). Diagnosis and Management of Low Back Pain.
2. National Center for Complementary and Integrative Health (NCCIH). (2020). Kava.
3. UpToDate. (2021). Treatment of Chronic Low Back Pain.
4. MedlinePlus. (2021). Coumadin (warfarin) Information.
Note:
When creating your PowerPoint presentation, remember to use the narrative notes section to elaborate on the content presented on each slide, including in-text citations in APA format where appropriate. Ensure that your delivery is clear and engaging to effectively educate your audience about Mr. X's case and the considerations surrounding his treatment plan.