Patient Case Competition 2024
CC: Mr. AB presents to your pain clinic to establish care. He is a 44 YOWM following a L5-S1 transforaminal lumbar interbody fusion (TLIF) approximately 1 month ago. He has had improvement in left leg radicular pain, however with new radicular pain in the right low back that radiates into his right hip and buttocks, inner thigh down his right leg. Pain overall has decreased, he has residual left leg severe numbness which was present prior to surgery with normal vascular studies. His back has improved but has noted to have numbness on left lateral calf into the foot.
PMH:
- OSA
- Cervical spondylosis with myelopathy
- Lumbar stenosis and spondylosis
- Obesity
- Insomnia
- Peripheral motor neuropathy
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Prior Surgical History:
- L5-S1 microdiscectomy in 2013
- Left L5-S1 hemilaminectomy in 2019
- L5-S1 TLIF in 2022
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Active Medication List:
- Gabapentin 900mg TID
- Methocarbamol 750mg TID PRN
- Hydromorphone 2mg tabs, 1-2 tabs PO Q3-4 hrs PRN
- Reports generally requiring 10 tabs per day
- Fluticasone proprionate 50 mcg 2 sprays in each nostril daily
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Allergies:
Height: 70 inches
Weight: 265 lb. (120.45 kg.)
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Lab
|
Value
|
Normal Range
|
| Glucose |
118 |
70-109 |
| Urea Nitrogen |
21 |
8-25 |
| Creatinine (Serum) |
0.9 |
0.7-1.3 |
| Sodium |
137 |
136-146 |
| Potassium |
4.2 |
3.6-5.3 |
| Chloride |
103 |
102-114 |
| CO2 |
28 |
24-32 |
| Anion Gap |
10 |
8-16 |
| Calcium |
9.3 |
8.8-10.3 |
| PO4 |
2.2 |
2.2-4.3 |
| Total Protein |
6.4 |
5.9-7.9 |
| Albumin |
4.3 |
3.5-4.7 |
| Alkaline Phos |
66 |
37-108 |
| AST |
31 |
13-33 |
| ALT |
68 (H) |
7-31 |
| T. Billi |
0.5 |
0.4-1.3 |
Urine Drug Screen
|
Result of Screen
|
| Amphetamine/Methamphetamine |
Negative |
| Barbiturate |
Negative |
| Benzodiazepine |
Negative |
| Cocaine/Metabolite |
Negative |
| Methadone |
Negative |
| Opiates |
Positive |
| Cannabinoids |
Negative |
| Oxycodone |
Negative |
Case Questions:
- According to CDC 2012 Opioid Conversions, what is Mr. AB’s morphine equivalent daily dose (MEDD)?
- Mr. AB comes back to clinic 2 months later (3 months post-op) and his pain control needs have reduced to only 6-7 tablets of hydromorphone 2mg per day, on average. His provider would like your recommendations on a long-acting opioid regimen for more consistent pain relief.
- Which of the following long-acting opioid regimens is a reasonable recommendation based on his now reduced utilization?
-
The provider inquires if we should provide Mr. AB with short-acting opioids in addition to long-acting opioids. Given the regimen you selected above, which of the following short-acting opioid regimens would you recommend?
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