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Write a formal 3-4 page paper discussing the case study below, please answer all of the questions provided. Read the grading rubric prior to starting the assignment and utilize APA format in your paper.
C. J is a 59 year old male who works as a roofer presents with bilateral knee pain. He was a high school athlete and had his ACL repaired on his left knee 20 years ago. He is currently obese and states the pain is worse going downstairs, with activity, and at night when sleeping. He reports the pain is interfering with his quality of life. He denies any recent injuries and is just here to “get something for the pain”. He has not been to a provider for 5 years.
Past medical history: Hypertension, Obesity
Past Surgical History: Left ACL repair
Medications: Lisinopril 10 mg QD
Family History: Mother had Type II Diabetes. Father had COPD and Rheumatoid Arthritis
Pertinent Physical Exam Findings: Bilateral knees are slightly swollen without erythema or warmth. No tenderness on palpation. Drawer, McMurray, and Lachman tests are negative. The bulge and ballottement signs are also negative. Mild non pitting ankle edema.
Diagnosis: Osteoarthritis
1. Describe the first line nonpharmacological treatment for this patient?
2. Describe all pharmacological options for treating Osteoarthritis.
3. The patient in this scenario is asking the provider for Percocet to manage his pain as it has worked in the past. Discuss your thoughts on this topic and what would your answer to the patient be regarding this request?
4. Discuss strategy for pharmacological management with a patient that has a history of chronic pain and addiction. Include your state laws on Advance Practice Nurses prescribing Opioids in the discussion.
5. Provide the patient with education on your selected first line therapy.
6. Why should Acetaminophen not be recommended in this case? And why?
7. Patients with Osteoarthritis can benefit from Vitamin D and Vitamin C supplementation if they are deficient. What is the rationale for this and what are your recommendations in regard to dosing and follow up labs.
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Case Study 1: CJ
Rana Martinez
Nursing, Post University
N521-22B: Advanced Pharmacology
Professor Dr. Roger Green
02/05/2023
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Case Study 1: CJ
This case study is about how the patient CJ a 59-year-old male will get treated for his
osteoarthritis. The patient is a roofer who always works on his knees and has unbearable bilateral
knee pain that interferes with his quality of life. CJ did play sports in high school and tore his
ACL, which was repaired in his left knee. The patient complains of pain that is worse at night,
going downstairs, and any type of activity. CJ has the comorbidities of hypertension and obesity
and does not have any recent injuries. The patient does take Lisinopril for his hypertension,
however, that is the only medication listed. The patient does have some swelling in the knees, but
there is no redness, warmth, or tenderness upon palpation. With this history in mind helps give
the background on what can be prescribed to the patient safely and effectively. It also helps to
diagnose the patient.
Describe the first line of nonpharmacological treatment for this patient.
While there is no cure for osteoarthritis, there are many interventions that can make a
patient more comfortable with it. Any exercise is a good option for patients that are experiencing
stiffness and pain (Arthritis Foundation, n.d.). Strength exercise builds muscle around the
different joints helping with easing pain and supporting the affected joint (Arthritis Foundation,
n.d.). Range of motion exercise or stretching keeps the different joints moving and reduces
stiffness (Arthritis Foundation, n.d.). Aerobic or cardio exercise helps to reduce and keep weight
off to keep stress off the joints (Arthritis Foundation, n.d.). Balancing exercises help prevent
falling and strengthen muscles (Arthritis Foundation, n.d.). Losing weight also helps with
keeping the pain down (Arthritis Foundation, n.d.). Extra weight puts more pressure and stress
on the different joints causing pain. Physical therapy helps patients find exercises to ease the pain
as well as fit for different assist devices that maybe help until the patient is strong enough or has
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no more pain (Arthritis Foundation, n.d.). The last resort is surgery when all else fails including
pain medications (Arthritis Foundation, n.d.). The patient can have the joint fused or replaced to
ease the pain if no other interventions are working. Patients should start with
nonpharmacological interventions.
Describe all pharmacological options for treating osteoarthritis.
There are many different types of medications that can help the patient with his pain,
however, there are some of these medications that need to be monitored by the provider while the
patient is on them. The first type of medication is analgesics such as Tylenol and any opioid
medications (Arthritis Foundation, n.d.). Opioids are used with caution due to them being
addictive and habit-forming. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen,
meloxicam, Celexa, and Aspirin are used to ease pain and inflammation (Arthritis Foundation,
n.d.). These medications can be hard on the stomach causing different issues such as ulcers.
There is a topical NSAID called diclofenac which is rubbed on the skin around the joint to help
with the pain. Counterirritants such as lidocaine, menthol, and capsaicin are topical medications
that can be used on the skin however, these medications can also be absorbed systemically if
used too much (Arthritis Foundation, n.d.). These medications cause numbing, warmth, and
coldness in the area it is applied. Corticosteroids are to keep reduce inflammation in the joint and
need s prescription to receive this medication (Arthritis Foundation, n.d.). It is taken for a certain
number of days or through injection in the joint. The patient does not want to take this
medication for the long term due to the side effects of the medication such as a decrease in the
immune response. Platelet-Rich plasma (PRP) is given through injection by the provider to
reduce inflammation, however, there is not much research done to prove this medication really
works (Arthritis Foundation, n.d.). Finally, other medications such as antidepressants and
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anticonvulsants are used as off-label for pain (Arthritis Foundation, n.d.). These medications
include duloxetine, amitriptyline, Lyrica, and gabapentin to help with the pain. It is important to
talk to your provider about the different medications for pain before starting one on your own.
The patient in this scenario is asking the provider for Percocet to manage his pain as it has
worked in the past. Discuss your thoughts on this topic and what would your answer to the
patient be regarding this request.
It is important to ask the patient what other medications he has taken for his pain and the
effectiveness of the medications before giving him Percocet. This is due to Percocet leading to
dependency and addiction. Also, ask about his weight loss and explain that weight loss can help
reduce pain and inflammation in the joints. Opioids alter the brain and how a patient perceives
pain causing the patient not to feel pain and still causing damage to the joint (Johns Creek Physical
Therapy, 2020). The opioid will also be increased over time due to the body building a tolerance to
the medication and more pain medication is needed. I would explain to the patient that we could
try these alternative medications and physical therapy to promote the longevity of the joint.
Discuss strategy for pharmacological management with a patient that has a history of
chronic pain and addiction. Include your state laws on Advance Practice Nurses
prescribing Opioids in the discussion.
It is important to treat the patients’ pain with medications other than opioids and
nonpharmacological interventions. “Addiction is characterized by the inability to consistently
abstain, impairment in behavioral control, craving, diminished recognition of significant
problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional
response (Cheatle et al., 2014).” Physical therapy is a must for patients who have pain. Patients
can learn a lot from therapy, and this also allows the patient to keep moving without becoming
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stiff. This also helps the patient from becoming dependent on medications. Colorado has also
made it harder for patients to get opioids. Prescribers now must send over an electronic
prescription to the pharmacy to get filled (State of Colorado, 2019). Prescribers are also not
allowed to write for refills on controlled medications. Electronic prescriptions help keep track of
ho3 many times a medication is being prescribed.
Provide the patient with education on your selected first-line therapy.
The first line of therapy for Osteoarthritis is NSAIDs. This helps the patient with pain as
well as inflammation of the joint (Yu & Hunter, 2015). However, patients need to know that
NSAIDs also have risks and side effects with the medications. Patients that take NSAIDs are at
risk for cardiovascular and renal events (Yu & Hunter, 2015). NSAIDs also should be taken with
food and with a medication that protects the stomach (Yu & Hunter, 2015). It is important for the
patient to take the medication as prescribed. Talk to the provider about any concerns about the
medication. Systemic reviews show that NSAIDs are far superior for pain for OA.
Why should acetaminophen not be recommended in this case and why?
Tylenol used to be the first line of medication for practitioners to treat Osteoarthritis (Yu &
Hunter, 2015). This is no longer true. There have been studies that have shown that Tylenol was
no better than a placebo for knee Osteoarthritis (Yu & Hunter, 2015). Patients are only allowed to
take up to 4,000mg a day due to toxic effects on the liver. Increased safety concerns are arising
with the use of Tylenol, especially in patients with other comorbidities (Yu & Hunter, 2015).
Tylenol can also affect the heart and stomach just like NAIDs raising the question of whether it is
as safe of medication as we once thought.
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Patients with Osteoarthritis can benefit from Vitamin D and Vitamin C supplementation if
they are deficient. What is the rationale for this and what are your recommendations in
regard to dosing and follow-up labs?
Vitamins D and C are said to help reduce pain in patients with joint pain. They help
protect the joint from more damage (Hung et al., 2017). However, there is still more research that
needs to be done. It is seen in patients with high levels of vitamin D that their function is a lot
better (Hung et al., 2017). The high levels of vitamin D also helped with the pain. Many patients
are deficient in vitamin D. Vitamin C on the other hand did not show much improvement in pain
or physical function (Hung et al., 2017). This vitamin deficiency is important to monitor especially
if it could help with pain and function of a joint.
Prescription Example.
Patient Name C J Powel.
Address 1234 Central Ave Pueblo CO 81005
DOB 01/14/1964
Date 02/05/3023
Diclofenac gel 1% 4 grams to the affected knees four times a day for OA pain.
Not exceed 32g a day. Use the enclosed dosing card to measure the appropriate dose.
Rana Martinez NP DEA NA1293232
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References
Cheatle, M., Comer, D., Wunsch, M., Skoufalos, A., & Reddy, Y. (2014, April). Treating pain in
addicted patients: Recommendations from an expert panel. Population health
management. Retrieved February 6, 2023, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3996998/
Hung, M., Bounsanga, J., Voss, M. W., Gu, Y., Crum, A. B., & Tang, P. (2017). Dietary and
supplemental vitamin C and D on symptom severity and physical function in knee
osteoarthritis. Journal of nutrition in gerontology and geriatrics. Retrieved February 6,
2023, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6088727/
Johns Creek Physical Therapy. (2020, May 8). Opioids: Why painkillers for arthritis do more
harm than good. Opioids: Why Painkillers For Arthritis Do More Harm Than Good.
Retrieved February 6, 2023, from https://johnscreekpt.com/opioid-addiction-why-takingpainkillers-for-arthritis-pain-is-doing-you-more-harm-than-good/
Osteoarthritis: Symptoms, diagnosis, and treatment: Arthritis foundation. Osteoarthritis:
Symptoms, Diagnosis, and Treatment | Arthritis Foundation. (n.d.). Retrieved February 6,
2023, from https://www.arthritis.org/diseases/osteoarthritis
Prescriber Digital Reference. (2023). PDR Search. Voltaren Gel (diclofenac sodium) dose,
indications, adverse effects, interactions… from PDR.net. Retrieved February 6, 2023, from
https://www.pdr.net/drug-summary/Voltaren-Gel-diclofenac-sodium-1801
State of Colorado. (2019, March 20). Electronic prescribing controlled substances. Electronic
Prescribing Controlled Substances | Colorado General Assembly. Retrieved February 6,
2023, from https://leg.colorado.gov/bills/sb19-079
Yu, S. P., & Hunter, D. J. (2015, August). Managing osteoarthritis. Australian prescriber.
Retrieved February 6, 2023, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4653978/
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