NURS 752
CHRONIC P C SAIN ASE TUDY
CC:
“I don’t know if I can keep living with this pain. My opioids used to help but they aren’t working
at this dose anymore – do we need to increase them again?”
HPI:
CJ is a 24-year-old male with a 3-year history of chronic low back pain who presents anxiously
to the pain management clinic. His pain began after a sports-related back injury and is almost out
of his prescriptions. He originally started on opioids to treat severe pain following a failed nerve
ablation procedure, which was performed out of state. He then found a local prescriber, who just
lost his medical license due to his opioid prescribing practices. CJ is now seeking to establish
care with a pain specialist and obtain his prescriptions. He reports that OTC pain medications
and gabapentin have not worked for his pain in the past. He describes the pain as constant aching
with occasional sharp, stabbing sensations. His pain is worse in the mornings at 9-10 am. He
also describes sensations of “numbness and pinpricks” that travel down the back of his legs
bilaterally. He reports trouble sleeping every night as well – usually he lays in bed watching TV
until around 03:00 AM, which is when he finally falls asleep.
PMH:
Seasonal allergies (16 years)
FH:
Father with a history of depression and hypertension, untreated. Mother and sister with a history
of untreated anxiety but no other significant medical history.
SH:
Single. Living with his parents who are his caretakers. The pain has decreased his functioning
to the point that he no longer attends school nor can he work consistently. No tobacco,
occasional alcohol (3 drinks/week), no illicit drug use
Allergies/Intolerances/Adverse Drug Events:
Gabapentin – confusion, sedation
CASE STUDY ANALYSIS 2
Medication (Current):
