Question: HPI: A 72-year-old woman with a tumor of the right fallopian tube is to undergo surgery to remove the tumor. PMH: Hypothyroidism for 40 years; hypertension for 20 years;

Part 1:
HPI: A 72-year-old woman with a tumor of the right fallopian tube is to undergo surgery to remove the tumor.
PMH: Hypothyroidism for 40 years; hypertension for 20 years; atrial fibrillation for 5 years; depression for 2 years.
FH: Mother had osteoporosis; father had diabetes
SH: Lives with husband; has four grown children
Meds: Metoprolol succinate ER 50 mg daily; rivaroxaban 20 mg daily; levothyroxine 150 mcg daily; polyethylene glycol 3350 17 g daily; lisinopril 2.5 mg daily; amiodarone 200 mg daily; sertraline 50 mg daily
Pain Assessment: Patient rates pain as 4 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, she was placed on morphine patient-controlled analgesia (PCA). She has been using 27 mg of morphine/24 hours with adequate pain control; however, she has developed redness and itching on her neck that is believed to be due to the morphine.
Current Meds: Morphine PCA; metoprolol succinate ER 50 mg daily; rivaroxaban 20 mg daily; levothyroxine 150 mcg daily; polyethylene glycol 3350 17 g daily; lisinopril 2.5 mg daily; amiodarone 200 mg daily; sertraline 50 mg daily. She will be discharged to a skilled nursing facility for rehabilitation therapy.
You would like to convert her to a combination preparation of hydrocodone and APAP.
• 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:
She was discharged to a skilled nursing facility and is receiving physical therapy and occupational therapy 6 days each week.
Current Meds: Metoprolol succinate ER 50 mg daily; rivaroxaban 20 mg daily; levothyroxine 150 mcg daily; polyethylene glycol 3350 17 g daily; lisinopril 2.5 mg daily; amiodarone 200 mg daily; sertraline 50 mg daily, hydrocodone/acetaminophen 10/325 mg every 6 hours as needed for pain.
Pain Assessment: Patient reports pain of 7 out of 10; worse with movement. She complains of pain “everywhere, but my shoulder is really bothering me.” Physical therapy notes indicate patient is unable to complete therapy goals due to complaints of pain in her shoulder.
• 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 2 weeks and is making progress toward rehabilitation goals; however, during a follow-up appointment to her surgeon, she learned that she has metastatic ovarian cancer.
She states that she has not been sleeping well and has lost 7 lb (3.2 kg) since admission. She also states that she hates waiting for her pain pills and requests something longer acting.
Pain Assessment: 8 out of 10
Current Meds: Metoprolol succinate ER 50 mg daily; rivaroxaban 20 mg daily; levothyroxine 150 mcg daily; polyethylene glycol 3350 17 g daily; lisinopril 2.5 mg daily; amiodarone 200 mg daily; sertraline 50 mg daily; diclofenac transdermal gel 1% to neck and left shoulder four times daily; hydrocodone/acetaminophen 10/325 mg every 4 hours as needed for pain (uses 6 doses per day).
• What additional recommendations would you have at this time regarding pain management?
• Are there any other therapeutic issues that should be addressed?

Part 5:
The patient was discharged to her home, but 3 months after discharge was admitted to hospice service. She is no longer able to swallow her tablets and requires them to be crushed. The hospice nurse requests your advice on an equivalent regimen using transdermal fentanyl and oxycodone for breakthrough pain.
Pain Assessment: 8 out of 10
Current Meds: Metoprolol succinate ER 50 mg daily; rivaroxaban 20 mg daily; levothyroxine 150 mcg daily; polyethylene glycol 3350 17 g daily; lisinopril 2.5 mg daily; amiodarone 200 mg daily; diclofenac transdermal gel 1% to neck and left shoulder four times daily; morphine sulfate ER 30 mg twice daily; mirtazapine 15 mg at bedtime.
• What additional recommendations would you have at this time regarding pain management?
• Are there any other therapeutic issues that should be addressed?


Requirements:
- Minimum of 250 words.
- 2 scholarly sources within the last five years (one MUST be your textbook).
- APA 7th edition Student Format
- Use DOIs whenever possible. The use of .com’s is not acceptable as they are not
considered scholarly sources.
- Insert hyperlinks in your reference page
- All discussion posts must be submitted through Turnitin. Any post with more than a 20% similarity score will have one opportunity to revise and resubmit their work.
- If this week’s discussion post consists of a case study, you may mention the case studies in your answer to the question(s), but do not write them verbatim. It will not count toward your word count.

Other resources you may use to address the case scenario:

Dynamed:

• Dynamed – Opioids for chronic pain: https://wilkes.idm.oclc.org/login?url=https://www-dynamed-com.wilkes.idm.oclc.org/management/opioids-for-chronic-noncancer-pain

• Dynamed- Chronic low back pain: https://wilkes.idm.oclc.org/login?url=https://www-dynamed-com.wilkes.idm.oclc.org/condition/chronic-low-back-pain

• Dynamed- Osteoarthritis of the hip: https://wilkes.idm.oclc.org/login?url=https://www-dynamed-com.wilkes.idm.oclc.org/condition/osteoarthritis-oa-of-the-hip

• Dynamed – Osteoarthritis of the knee: https://wilkes.idm.oclc.org/login?url=https://www-dynamed-com.wilkes.idm.oclc.org/condition/osteoarthritis-oa-of-the-knee

• Dynamed – Peripheral neuropathy: https://wilkes.idm.oclc.org/login?url=https://www-dynamed-com.wilkes.idm.oclc.org/condition/peripheral-neuropathy

• Dynamed – Opioid abuse and dependence: https://wilkes.idm.oclc.org/login?url=https://www-dynamed-com.wilkes.idm.oclc.org/condition/opioid-abuse-and-dependence

• Nociceptive and neuropathic pain: https://www-proquest-com.wilkes.idm.oclc.org/docview/2000726586?pq-origsite=360link

• SUBOXONE® (buprenorphine and naloxone) Prescribing information: https://www.suboxone.com/pdfs/prescribing-information.pdf

Evidence Based Practice Guidelines:

• Chou, R., et al. (2009). American Pain Society: Clinical Guidelines for the Use of Chronic Opioid Therapy in Chronic Noncancer Pain. The Journal of Pain, Vol 10, No 2 (February), 2009: pp 113-130. https://www.jpain.org/article/S1526-5900(08)00831-6/pdf

• Dowell, D., Haegerich, T. M., Chou, R. (2016). CDC: Guideline for Prescribing Opioids for Chronic Pain. Recommendations and Reports. Morbidity and Mortality Weekly Reports. March 18, 2016 / 65(1);1–49. https://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1.htm?s_cid=rr6501e1_w

• VA/DoD: Clinical Practice Guideline for Opioid Therapy for Chronic Pain (2017). https://www.healthquality.va.gov/guidelines/Pain/cot/VADoDOTCPG022717.pdf

• Manchikanti, L., et al. (2017) ASIPP: Responsible, Safe, and Effective Prescription of Opioids for Chronic Non-Cancer Pain. Pain Physician. 2017 Feb;20(2S):S3-S92. http://www.painphysicianjournal.com/current/pdf?article=NDIwMg%3D%3D&journal=103

• Ferrell, B., et.al. (2009) American Geriatric Society: Guideline on pharmacological management of persistent pain in older persons. Journal of American Geriatric Society, 2009 Aug;57(8):1331-46. http://pubmed.ncbi.nlm.nih.gov/19573219?dopt=Abstract