Case Study 4
Instructions: Spend 5-10 minutes reviewing the case below and considering the questions that follow.
Inessa is 72 and lives in an urban area, having immigrated from Russia as a young woman. She grew up on a farm and worked in the fields or tending animals starting as a child. She blames these early labors for the arthritis she now has in her hands and wrists, and for the pain she feels in her lower back. Although Inessa lives alone, following the death of her husband from a heart attack 5 years ago, she relies on a young man who lives in a small apartment attached to her house for help with activities of daily living and simply for company. According to Inessa, the pain medication she was prescribed for her arthritis (short-acting hydrocodone/acetaminophen) is no longer working and she has come to you asking for either a different medication or a higher dose of the existing medication. Despite her reported pain, Inessa is ambulatory and appears cognitively intact. She takes a range of herbal supplements including St. John’s wort, turmeric, and a “joint support” supplement, the ingredients of which she is unsure. She has a very insistent, demanding personality and is convinced she needs the new, or higher- dose, opioid medication.
1. How would you respond to Inessa’s request?
2. What alternatives to an opioid analgesic could you offer to Inessa?
3. If you end up prescribing an opioid analgesic for Inessa, would you require that she sign a patient-provider agreement? If so, what specific caveats would you include in the agreement?
4. Would it be prudent to include the young man who cares for her in discussions about treatment?
Table 4: Example of functional goals and evidence used to assess progress 104
Functional Goal
Evidence
Begin physical therapy
Letter from physical therapist
Sleeping in bed as opposed to lounge chair
Report by family member or friend (either in-person or in writing)*
Participation in pain support group Increased activities of daily living
Letter from group leader
Report by family member or friend
Walk around the block Increased social activities Resumed sexual relations
Pedometer recordings or written log of activity
Report by family member or friend
Report by partner
Returned to work
Pay stubs from employer or letter confirming the patient is off of disability leave
Daily exercise
Gym attendance records or report from family member or friend
* Involving other persons requires explicit permission from the patient, and this permission should be documented.
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