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St. Peter’s Hospital Personal Case Presentation

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Hello our patient is an opioid naive 40 year old female who presented to the emergency department with complaints of lower extremity pain inability to ambulate and numbness in her feet the pain started several days ago after she had a vigorous workout but is unsure if this was the actual cause she has a history of this type of experience but thought it was sciatica

And did not immediately seek care due to difficulty emulating at home the patient has not been eating or drinking much and states that it has been several days since she has had adequate fluid intake the patient presents with low albumin high bun elevated chloride elevated magnesium as well as elevated creatinine and a low creatinine clearance of 57 milliliters

Per minute the patient’s calcium is 8.1 on presentation and needs to be corrected due to the low albumin level of 2.5 the patient’s corrected calcium upon admission is 9.3 and in normal range the patient was admitted to the hospital due to elevated labs these elevated labs may be indicative that the patient is dehydrated and malnourished or that the patient is

Having kidney injury but the patient has also not been eating or drinking much lately her creatinine is normal at presentation but rose to 1.35 after admission serum creatinine will rise in kidney injury but it also may rise if the patients are dehydrated the patient also presented with elevated ast and alts the patient has a history of bipolar disorder and

Is currently taking gabapentin 600 milligrams bid lamotrigine 150 milligrams bid and quetiapine 400 milligrams qhs there appears to be no past medical history or diagnosis for the use of gabapentin but the patient states she has sciatica her current medication do carry low risks that may contribute to the patient’s current condition quetiapine carries a three

Percent chance of increasing serum asds and a five percent chance of increasing alts there’s also a one to five percent risk of estenia a seven percent risk of pain two percent risk of myalgia the motrig gene carries a two to five percent risk of estenia as well as a one to five percent risk of myalgia gabapentin carries a six percent risk of asthenia and has

Been shown to have increased creatine phosphokinase in the blood generally creatinine kinase is elevated and rhabdomyolysis if it is a result of muscle injury aminotransferases can also be elevated this suggests the need for serum creatinine kinase level as it has not been performed on this patient this is to confirm that these abnormalities are due to muscle

Injury rather than hepatic injury or another cause like medications obtaining serum ck levels as well as performing a urinalysis will test for the myoglobin in the urine would be beneficial for this patient the patient was diagnosed with rhabdomyolysis and pharmacy was consulted for an appropriate pain management therapy nsaid should be avoided at the as these

Drugs may exacerbate kidney injury at this time gabapentin may also be contributing to the patient’s condition and therefore i would not recommend increasing this medication at the moment to combat the patient’s neuropathic pain morphine should be avoided in patients with creatinine clearance less than 60 mls per minute additionally opioids should be used with

Caution in patients taking cns depressants like quetiapine and gabapentin monitoring of respiratory depression and sedation is necessary tricyclic antidepressants and snris may be beneficial but do carry additional risks especially with the patient’s current medication regimen and therefore should be avoided the patient should initiate tramadol tremontol is a good

Option as it has multiple analgesic properties which will combat the pain in multiple ways tramadol is a weak mu opioid agonist as well as a norepinephrine reuptake inhibitor and a serotonin reuptake inhibitor patients should also initiate acetaminophen as this will be a short course therapy acetaminophen will likely be fine but liver functions should continue

To be monitored acetaminophen is a good option for somatic pain arising from muscle tissue these two therapies will be beneficial in attacking the pain in multiple pain pathways and will limit the side effects that the patient may experience the plan is to obtain a serum ck level and a urinalysis initiate tramadol 50 milligrams every six hours as needed for pain

Initiate acetaminophen 650 milligrams every six hours as needed for pain with a max daily dose of 3 grams and acetaminophen daily rehydrate the patient with fluids to help with kidney function and to clear any toxins and if the ck levels are normal may want we may want to re-evaluate the patient’s current medication regimen and adjust medications appropriately we

Want to monitor for signs of rehydration monitor patient serum creatinine and kidney function monitor ck levels to determine that the patient is clearing monitor continue to monitor ast and alt levels and monitor for signs of respiratory depression and sedation the patient was then prescribed oxycodone 10 milligrams by mouth as she went to the operating room for

Procedure the prescriber requested the following equivalent doses for oxycodone 10 milligrams of various iv opioid medications an equivalent dose of iv morphine is 5 milligrams iv morphine iv hydromorphone is 0.75 milligrams iv hydromorphone iv fentanyl is 50 micrograms iv fentanyl and iv oxymorphone is 0.5 milligrams ib oxymorphone the patient is getting better

And the prescriber would like to send the patient home with pain medications the prescriber requested equivalent doses of various oral medications to oral oxycodone 10 milligrams an equivalent dose of oral hydromorphone is 3.75 milligrams hydromorphone oral morphine is 15 milligrams oral morphine oral hydrochloride hydrocodone is 15 milligrams oral hydrocodone

And oral oxymorphone is 5 milligrams oral oxymorphone thank you so much for your time and being able to talk to me about your patient today if you have any questions please feel free to reach out to me in the pharmacy thank you so much and you have a great day

Transcribed from video
St. Peter's Hospital Personal Case Presentation By David Kingsley