Patient rounds involve various disciplines coming together to discuss the patient’s condition and coordinate care.

Patient rounds involve various disciplines coming together to discuss the patient’s condition and coordinate care.
Collaborative communication during rounds often leads to a deeper understanding of patient needs and fosters improved care outcomes. They are used as an educational tool and also help keep everyone on the same page when it comes to the treatment plan. Such interdisciplinary teamwork not only enhances clinical decision-making but also supports continuity of care. The following case is found in the textbook (Pharmacotherapy: Principles and Practices, Chisholm-Burns et al., eds., 6th edition, McGraw-Hill, New York, 2022. ISBN: 978-1-260-46027-8; Chapter 35, “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.
Engaging your peers through critical discussion helps integrate theory with clinical practice and encourages reflection on patient-centered care strategies. 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 as those of the WHO, CDC, and APS. Evidence integration is key to justifying treatment choices and improving patient outcomes. It is recommended this be complete between weeks 4–6.

Your response post(s), to at least one peer, shall be based upon your research and references citing circumstances where you may either endorse or refute the information your peer has presented in their case workup.
Meaningful feedback allows for diverse clinical perspectives to be shared and validated. The response post(s) must be completed by week 12, allowing sufficient time for reflective engagement and academic growth among peers.

Part 3

She was discharged to a skilled nursing facility and is receiving physical therapy and occupational therapy six days each week.
Her progress through rehabilitation demonstrates both the benefits and challenges of multidisciplinary care.

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 six 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 the patient is unable to complete therapy goals due to complaints of shoulder pain. Chronic pain can significantly impede recovery and quality of life if not managed optimally.

Based on this information, what would you recommend to optimize pain control?
Consider both pharmacologic and non-pharmacologic approaches while assessing risk factors for dependence.

Prescribers play a critical role in prescription drug misuse and abuse prevention.
They are ethically responsible for promoting patient safety through vigilant assessment and education. 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? Providing compassionate communication and clear expectations can reduce risks and empower patients in managing their pain responsibly.

Part 4

The patient has been at the skilled nursing facility for two 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.
Such a diagnosis represents a major emotional and physiological turning point in her care journey.

She states that she has not been sleeping well and has lost 7 lb (3.2 kg) since admission.
Sleep disruption and unintentional weight loss may signal both psychological distress and inadequate pain control. She also states that she hates waiting for her pain pills and requests something longer acting, indicating potential tolerance or uncontrolled 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; sertraline 50 mg daily; diclofenac transdermal gel 1% to neck and left shoulder four times daily; hydrocodone/acetaminophen 10/325 mg every four hours as needed for pain (uses six doses per day).

What additional recommendations would you have at this time regarding pain management?
A transition to a long-acting opioid formulation may be warranted to maintain baseline pain control.

Are there any other therapeutic issues that should be addressed?
Attention should be given to psychological support, potential drug-drug interactions, and optimization of her antidepressant therapy.

Part 5

The patient was discharged to her home, but three months after discharge was admitted to hospice service.
Her disease progression now necessitates palliative-focused care and comfort optimization.

She is no longer able to swallow her tablets and requires them to be crushed.
This clinical change necessitates an individualized pharmacologic approach for symptom relief. 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?
Focus on maintaining consistent analgesia, monitoring sedation, and ensuring the patient’s comfort at end-of-life stages.

Are there any other therapeutic issues that should be addressed?
Coordination with hospice and family for psychosocial and emotional support remains crucial to overall well-being.

Other Resources

• 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
• 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

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.  6th edition.  McGraw-Hill.  New York 2022. ISBN: 978-1-260-46027-8; Chapter 35. “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.]. It is recommended this be complete between weeks 4-6.

Your response post(s), to at least one peer, shall be based upon your research and references citing circumstances where you may either endorse or refute the information your peer has presented in their case workup.  The response post(s) must be completed by week 12

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?

References

• Häuser, W., Petzke, F., & Radbruch, L. (2020). Efficacy, tolerability, and safety of opioid analgesics for chronic non-cancer pain: An overview of systematic reviews. European Journal of Pain, 24(3), 497–511. https://doi.org/10.1002/ejp.1516
• Dowell, D., Ragan, K. R., Jones, C. M., Baldwin, G. T., Chou, R. (2022). CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022. MMWR Recommendations and Reports, 71(3), 1–95. https://doi.org/10.15585/mmwr.rr7103a1
• Fallon, M., Giusti, R., Aielli, F., et al. (2021). Management of cancer pain in adult patients: ESMO Clinical Practice Guidelines. Annals of Oncology, 32(12), 1491–1505. https://doi.org/10.1016/j.annonc.2021.09.005
• Pergolizzi, J. V., LeQuang, J. A., et al. (2019). The role of transdermal opioids in the treatment of chronic pain and cancer pain. Pain and Therapy, 8(1), 41–51. https://doi.org/10.1007/s40122-019-0117-0
• Mercadante, S., & Bruera, E. (2023). Opioid switching and rotation in palliative care: An update on clinical practice. Journal of Pain and Symptom Management, 65(4), 688–701. https://doi.org/10.1016/j.jpainsymman.2023.01.017