.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. X’s 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,