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Shadown Health Patient Treatment Plan
Advanced Pathopharmacological Foundations (D027)
Western Governors University
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Patient: Tanner Bailey Chief Complaint: lower back pain with onset of 13 weeks ago related to lifting. Age: 30-year-old Diagnostic testing Typical diagnostic testing that can be order for the complaint listed above are an x-ray, computerized tomography (CT), and a magnetic resonance imaging (MRI). In Tanner Baileys case the treatment plan could include an x-ray of the lower back to ensure that no future damage has occurred to the site. If Tanner continues to experience pain after physical therapy and other ordered medications a CT should be considered. Medications The first line treatment of back pain is Tylenol and ibuprofen. If these medications are ineffective, we can consider muscle relaxers and opioids. In Tanners case he was prescribed the first line treatment for back pain 13 weeks ago. He was uncompliant with the medication regimen prescribed and was taking a friend’s narcotics. He also stated that he was using alcohol as a pain relief method. In Tanner’s treatment plan it is important that education be provided regarding the use of both an unprescribed narcotic and alcohol. For treatment a prescription of Tylenol 500mg take up to 2 pills every 6 hours as needed for pain would be given. This would be paired with Ibuprofen 200mg tablets, take 2 pills every 4-6 hours alternating with Tylenol dose. Tylenol dose should not exceed 4g for 4,000mg in a 24-hour period. Ibuprofen should not exceed 3,200mg in a 24-hour period. Adverse reactions for ibuprofen can include gastrointestinal upset such as nausea, vomiting, abdominal pain, and stomach ulcers. Educations needs to be provided regarding alcohol use while using this medication as it can worse adverse reactions. Adverse reactions for Tylenol include liver damage, symptoms of this would include yellowing around the eyes, fatigue, and unusual bleeding or bruising. Education regarding maximum dose and alcohol consumption needs to be provided. Non-pharmacological treatment Mr. Bailey will also need to continue prescribed physical therapy and can use heat therapy for pain relief. Education regarding proper lifting mechanics will also be beneficial for this patient as his complaint was caused by lifting a box at work. Treatment Plan To summarize, the treatment plan for Mr. Bailey is to obtain an x-ray of the effected area. Once result is obtained a prescription of Tylenol and ibuprofen would be given with education provided regarding the above listed doses and potential adverse effects. A physical therapy order would be provided with patient encouragement of attending and education regarding proper lifting mechanics would be provided to ensure that patients chance of reinjury would be decreased.
Shadown Health Patient Treatment Plan
Course: Advanced Pathopharmacological Foundations (D027)
University: Western Governors University
