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Pain Case - SOAP Note (2011)

1) A 51-year-old female librarian presents with uncontrolled neuropathic pain in her right arm following a workplace injury 9 weeks prior. She is currently taking high doses of Tylenol #1 with minimal relief and acknowledges overuse. 2) She also reports depressed mood, fatigue, and suicidal thoughts since the injury. Her current antidepressant shows minimal effectiveness. 3) The clinical pharmacist recommends optimizing her pain management by switching medications, tapering her codeine use, and increasing her antidepressant dose. Close monitoring of her pain levels, mood, and side effects is planned at follow-up appointments.

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2K views2 pages

Pain Case - SOAP Note (2011)

1) A 51-year-old female librarian presents with uncontrolled neuropathic pain in her right arm following a workplace injury 9 weeks prior. She is currently taking high doses of Tylenol #1 with minimal relief and acknowledges overuse. 2) She also reports depressed mood, fatigue, and suicidal thoughts since the injury. Her current antidepressant shows minimal effectiveness. 3) The clinical pharmacist recommends optimizing her pain management by switching medications, tapering her codeine use, and increasing her antidepressant dose. Close monitoring of her pain levels, mood, and side effects is planned at follow-up appointments.

Uploaded by

Alfie Lee
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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PHAR 401 Pain Case (Tutorial #4)

Nov 14/11 @0945HRS ID Clinical Pharmacist Note MK is a 51-year-old previously healthy female librarian presenting to pain clinic for the first time with uncontrolled pain following a workplace injury after a metal shelving unit fell on her right arm 9 weeks ago. 1) Pain - c/o of shooting and stabbing pain which radiates up/down right arm; pulsates periodically; feels occasional numbness in right arm. Pain worsens when someone brushes up against arm. Pain limits patients ability to perform daily activities (e.g. putting clothes on, eating, perform job duties). - Has tried tramadol, ibuprofen, and naproxen with no improvement; denies current use of these medications. - Currently uses Tylenol #1 for pain; takes 8-9 tablets/dose and uses approximately 100 tablets every 3-4 days. Rates pain as 10/10 prior to and 9/10 after taking Tylenol #1. Patient acknowledges minimal relief with current regimen, but believes there are no other alternatives. - Patient denies any history of chemical dependency. 2) Mood - c/o depressed mood and fatigue. Has loss of interest in interacting with friends and family since the injury occurred. Patient reports suicidal thoughts, but does not have a plan. - Patient denies previous history of depression or psychiatric illness O - Patient is tearful with a sad facial expression; appears frustrated and defeated. - Patient guarding right arm/hand during interview. - Chart note from physical therapist indicates limited range of motion in right arm/hand. - Chart note from case manager indicates patient will not be able to return to work due to injury and will require re-training - All lab results and vitals WNL - Current meds are: 1) Escitalopram 10 mg daily (started 6 weeks ago) 2) Tylenol #1 (see dose as per patient above; started 4 weeks ago) - PharmaNet shows recent prescriptions filled for tramadol, ibuprofen and naproxen.

1) Neuropathic pain control - Patients symptoms consistent with neuropathic pain, and she has inadequate pain control on current regimen - Requires reassessment of current drug therapy in order to reduce pain to a tolerable level and improve function - 1st line options for neuropathic pain = pregabalin, gabapentin, tricyclic antidepressants (e.g. amitriptyline) - Pregabalin has official indication for neuropathic pain, convenient dosing regimen, no significant drug interactions, WorkSafe BC coverage; will need to monitor for sedation, weight gain, edema, dry mouth - Pregabalin side effects can be minimized by titrating dose slowly (q 3 days) 2) Tylenol #1 overuse - Opioid narcotics are not drug of choice for neuropathic pain and patient overusing Tylenol #1 (exceeding daily 4 g maximum for acetaminophen) - Currently uses ~30 Tylenol #1 tablets/day ( 240 mg codeine phosphate/day) - Need to slowly taper codeine dose to prevent withdrawal (i.e. reduce total daily codeine dose by 10-15% every 3-7 days), with eventual goal to discontinue codeine - Taper by switching from Tylenol #1 to an equivalent codeine dose given as longacting (i.e. Codeine Contin) + short-acting (i.e. codeine phosphate) combination to provide baseline + breakthrough pain control - Acetaminophen may have opioid-sparing effects, but total daily dose needs to be lowered to within safe range 3) Depression - Patients depressed mood and suicidal thoughts suggest that current antidepressant regimen is ineffective - Requires reassessment of drug therapy to achieve remission, restore patient optimal functioning, and prevent suicide - Escitalopram is an appropriate 1st line drug choice, however current dose (10 mg/day) is subtherapeutic, and there is room to increase dose - Patient denies any side effects from escitalopram, therefore reasonable to continue for now (and not switch to another drug) 1) Discontinue Tylenol #1 2) Start new pain medication regimen today: - Tylenol Arthritis 650 mg ii PO Q8H at 7am, 3pm, 11pm - Codeine Contin 50 mg PO Q8H at 7am, 3pm, 11pm - Codeine phosphate 15 mg PO BID PRN breakthrough pain 3) Increase escitalopram to 20 mg PO OD 4) Give patient a 7-day supply of all medications; patient to return to clinic in 7 days for follow-up appointment 5) At next follow-up appointment, will plan to start pregabalin 25 mg PO OD x 3 days (with plan to titrate dose up by 25 mg/day every 3 days) 6) Will monitor for efficacy (reduced pain, improved mood, reduced fatigue, improved ability to participate in rehabilitation) and toxicity (drowsiness, constipation, GI upset, reduced sexual interest) 7) Will continue to re-assess pain management and codeine use at each follow-up, with eventual goal to discontinue codeine use

K.Seto
K. Seto, PharmD Pager #: 604-555-5555

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