Therapeutics Case Studies

Care Plan Description & Criteria for Assessment

Patient Name: Rachel Hanna Age: 54 years old Gender: Female Height: 5’6’’ (167.64 cm)

Weight (actual): 138 lbs (62.6 kg)

IBW: IBW Female: 45.5 kg for the first 5 feet + 2.3 kg for each 1 inch greater than 5 feet (60”) = 59.3 kg

BMI = ABW in kg/(height in meters)2 = 22.28 m2

Estimated CrCl (round to the nearest whole number if student uses IBW): 93 ml/min (using IBW)

Allergies: NKDA

Problem List Provide a prioritized list of the patient’s problems according to the ASHP Priority Designation.
& 1. Acute Pain due to trauma
Prioritization 2. Fractured Wrist (may include as #2)
3. Seizure Disorder without status epilepticus
3. Essential (primary) hypertension

Subjective & Provide all pertinent subjective and objective data pertaining to the assigned patient problem.
Objective
Subjective data
o CC: New onset severe pain to left wrist s/p fall
o HPI: Fell while walking dog earlier this morning, pain is 8/10 severe, uncontrolled by
Ibuprofen and OTC Acetaminophen
o ROS: unremarkable except noted in CC

Objective data
o PMH:
o HTN x 2 years
o Seizure disorder x 13 years

o Medications:
o Amlodipine 10 mg tab PO Daily
o Ibuprofen 200 mg 2 tabs PO PRN Q4H
o Acetaminophen 500 mg 2 caps PO Q6H PRN
o Chlorthalidone 25 mg tab PO Daily
o Lamotrigine ER 300 mg tab PO Daily

o PE
o BP 138/88 mmHg
o Pain 8/10
o Actual Wt: 138 lbs (62.6 kg)

o Labs
o WNL

o X-Rays
o Left radius: Fracture near base

o Procedures and/or diagnostic tests: N/A

Assessment Goals of Therapy
o Alleviate acute pain associated with fracture using appropriate medication therapy
management
o Return to normal daily activities
o Minimize adverse effects of medications
o Prevent drug-disease interaction

Assessment of Patient Problem(s) & Assessment of Current Therapy (if applicable)

o Assessment of Patient Problems: Patient is experiencing acute pain in left wrist after a
fall. X-ray shows fracture to left radius near base. Blood pressure is currently elevated.
Patient has history of seizure disorder (controlled with lamotrigine)
o Assessment of Current Therapy: Patient’s blood pressure is likely elevated due to acute
pain, therefore no need to adjust therapy at this time. Seizure disorder currently
controlled using Lamotrigine 300 mg ER.
o Patient should not be initiated on Tramadol due seizure history.
o Patient’s pain is not controlled on the current Tylenol and Ibuprofen regimen, Pain score
is 8/10.
o Assessment of Current Therapy:
o Ibuprofen- not providing adequate pain relief
o Acetaminophen- not providing adequate pain relief

Assessment of Drug Treatment Options

o Tramadol: Not indicated for use considering patient’s seizure disorder

o Gabapentin/Pregabalin/Duloxetine: not indicated for the treatment of acute,
musculoskeletal pain. Preferred for neuropathic pain.
o Cyclobenzaprine/Methocarbamol: muscle relaxers are not an appropriate choice for pain
related to bone fracture. Pt is not experiencing muscle spasms.
o Hydrocodone/Acetaminophen: appropriate choice for moderate/severe pain the patient is
experiencing. Should be limited to a short course of therapy and a lower dose given that
the patient is opioid naive
o Oxycodone/Acetaminophen: not the best choice; the pain is moderate/severe but since
the patient is opioid naive, so hydrocodone/acetaminophen would be a better option.
o A student could make a case for choosing this agent without being wrong. Should
be limited to a short course of therapy with a lower dose
o Oxycodone ER: would be inappropriate for acute pain management and in someone who
is opioid naive
o Morphine SA: inappropriate for acute pain in outpatient setting and patient is opioid naive
o Fentanyl Patch: inappropriate for acute pain management and in someone who is opioid
naive, patch formulation would also not be appropriate for pain resulting from a broken
wrist bone. Reserved for chronic pain.

Plan Recommended Drug Therapy

o STOP: Contact Provider to STOP new prescription for Tramadol due to seizure history.
o STOP taking the following:
o Ibuprofen 200 mg 2 tabs PO PRN Q4H
▪ Pt is not receiving benefit from current anti-inflammatory agent

▪ As long as patient is not experiencing adverse effects with NSAID, could

continue and would not be incorrect as long as student justifies to continue
the NSAID - NSAID alone would not be appropriate.
o Acetaminophen 500 mg 2 caps PO Q6H PRN
 ▪ New medication contains Acetaminophen

o START: Hydrocodone/Acetaminophen 5/325 mg 1 tablet PO Q 6H PRN PAIN x 1 week

o Patient is opioid naive, therefore the opioid should be at the lowest effective dose
for the shortest duration possible.
o Extended release and immediate release formulations should be avoided given
that the patient is opioid naive.
o Duration should not exceed 1 week, since the patient is scheduled to follow up
with the physician in 1 week.
o MAX Dose per day: 12 tablets/day of Hydrocodone/Acetaminophen = 3,900 mg of
Acetaminophen {Max total daily dose of Acetaminophen is 4 grams}
o Caution the patient against taking other Acetaminophen containing products
including over-the-counter.

o Opioid Induced Constipation {Prevention}

o Options could include one of the following (below are OTC dosing options)
▪ Dulcolax (Bisacodyl) 5 mg tablets

● Adult Dose: 1 tablet PO at bedtime while taking

Hydrocodone/Acetaminophen
● May increase up to 3 tablets in a single daily dose if constipation
persists.
● Relief in 6 to 12 hours

▪ Senokot (Sennosides) Regular Strength 8.6 mg tablet

● Adult Dose: Take 2 tablets PO once a day while taking

Hydrocodone/Acetaminophen
● Max dose is 4 tablets PO BID

● Relief in 6 to 12 hours

▪ (MiraLAX) Polyethylene Glycol Osmotic Laxative

● 17 grams of powder once daily

● Stir and Dissolve in 4 to 8 ounces of water then drink

● Do not use more than 7 days

● Generally produces a bowel movement in 1 to 3 days

o CONTINUE Medications for Seizures and Hypertension:

o Amlodipine 10 mg tab PO Daily
o Chlorthalidone 25 mg tab PO Daily
o Lamotrigine ER 300 mg tab PO Daily

Recommended monitoring plan

o Follow-up with healthcare provider in 1 week
o Monitor blood pressure at home and recheck at follow-up
o Improvement of symptoms (decrease in pain score)
o Symptoms of opioid induced constipation or other opioid related side effects
o Monitor for sedation while starting Hydrocodone/Acetaminophen
o Monitor for signs of opioid dependence/opioid withdrawal

Additional Monitoring (but not needed if student omits but provides good discussion points to
discuss with the students):

o Prescription Drug Monitoring Program (PDMP):

o Recommended to check prior to initiating opioid
o Urine Drug Screen (UDS)
o Recommended to check prior to initiating opioid
o Offer Naloxone
o While the patient is not on 50 MME/day (dose = 20 MME/day) the CDC
recommends that patients should still be offered Naloxone to prevent accidental
or intentional overdose.
o Narcan 4 mg/0.1 mL Nasal Spray
▪ 4 mg Intranasally at the sign of an overdose
o Kloxxado 8 mg/0.1 mL Nasal Spray
▪ 8 mg/0.1 mL Intranasally at the sign of an overdose

Patient Education

o Constipation - Since the patient is on an opioid, prevent constipation while taking to

return the patient to their normal bowel routine. Instruct patient on the difference between
a stimulant laxative +/- stool softener.
o Sedation - do not drive or operate machinery or equipment while taking
o Do not take more than 4 grams (4,000 mg) of Acetaminophen a day
o Keep medication in an area away from others
o Medication is only for the person it is prescribed. Do not share with anyone else
o Discard any unused medication through drug take back programs or check with the local
pharmacist.
o A long-term nonpharmacologic plan including SMART goals with the patient until the
injury heals.