Patient rounds involve various disciplines coming together to discuss the patient’s condition and coordinate care. They are used as an educational tool and also help keep everyone on the same page when it comes to the treatment plan. The following case is found in the textbook (Pharmacotherapy: Principles and Practices. Chisholm-Burns et al, eds.  5th edition.  McGraw-Hill.  New York 2019. ISBN-978-1-260-01944-5; Chapter 34. “Patient encounter”).

After reading the assigned chapters in the textbook, resources identified in Dynamed and Evidence based practice guidelines, please present the case to your peers in the form of a discussion. This will be your initial post. Please be sure to address all parts of the case and ensure your responses are well researched [including supporting, evidence based guidelines such those of the WHO, CDC, APS, etc.]. 

Part 1:

HPI:  A 78-year-old man who is to undergo a left above the knee amputation due to a limb abscess

PMH: Peripheral artery disease for 18 years; cardiomyopathy, benign prostatic hypertrophy for 13 years

FH: Mother had osteoporosis; father had diabetes

SH: Lives with wife; has two grown children

Meds: Aspirin 81mg daily; atorvastatin 80 mg at bedtime; multivitamin 1 daily; pantoprazole 40 mg daily; tamsulosin 0.4 mg daily

Pain Assessment: Patient rates pain as 8 on a scale of 0 to 10.

• Based on the type of injury, what type of pain is this patient likely to experience?
• What type of pain management regimen would you suggest in the postoperative period? Explain your answer

Part 2:

Following surgery he was placed on morphine patient-controlled analgesia (PCA). He has been using 55 mg of morphine/24 hours with adequate pain control; however, he developed redness and itching on his neck that is believed to be due to the morphine.

Current Meds:  Morphine PCA; aspirin 81 mg daily; atorvastatin 80 mg at bedtime; multivitamin 1 daily; gabapentin 100 mg three times daily; pantoprazole 40 mg daily, tamsulosin 0.4 mg daily; heparin 5000 units twice daily until discharged home. He will be discharged to a skilled nursing facility for rehabilitation therapy.

You would like to convert him to a combination preparation of hydrocodone and APAP for as-needed pain relief.

• What dosing regimen would you suggest?
• What would your monitoring plan include for this patient?
• How would you assess pain response?
• The patient is concerned about the redness and itching that he developed while on morphine. Would you document this as an allergic reaction?
• What other interventions or education may be necessary at this time?

Part 3:

The patient was discharged to a skilled nursing facility and is receiving physical therapy and occupational therapy 6 days each week.

Current Meds: Aspirin 81 mg daily; atorvastatin 80 mg at bedtime; multivitamin 1 daily; gabapentin 100 mg three times daily; pantoprazole 40 mg daily, tamsulosin 0.4 mg daily, heparin 5000 units twice daily until discharged home, hydrocodone/acetaminophen 5/325 mg every 6 hours as needed for pain.

Pain Assessment: Patient reports pain of 7 out of 10; worse with movement.

Physical therapy notes indicate the patient is unable to complete therapy goals due to complaints of pain.

• Based on this information, what would you recommend to optimize pain control?
• Prescribers play a critical role in prescription drug misuse and abuse prevention. What steps can be taken to identify signs of dependence and abuse and what education can you provide to the patient regarding the negative effects of medication misuse?

Part 4:

The patient has been at the skilled nursing facility for 4 weeks and is making progress toward rehabilitation goals; however, he complains that his leg is throbbing and feels like pins and needles. As a result, he requests to rest several times during her therapy sessions. During unit rounds, his therapist inquires whether her previous pain medication should be reordered.

Pain Assessment: 4 out of 10

Current Meds: Aspirin 81 mg daily; atorvastatin 80 mg at bedtime; multivitamin 1 daily; gabapentin 100 mg three times daily; pantoprazole 40 mg daily, tamsulosin 0.4 mg daily, heparin 5000 units twice daily until discharged home,

• What additional recommendations would you have at this time regarding pain management?
• Are there any other therapeutic issues that should be addressed?