Part 1 HPI: A 72-year-old woman with a tumor of the right fallopian tube is to undergo surgery to remove the tumor. PMH: Hypothyroidism for 40 years; hypertension for 20 years; atrial fibrillation for 5 years; depression for 2 years. FH: Mother had osteoporosis; father had diabetes SH: Lives with husband; has four grown children Meds: Metoprolol succinate ER 50 mg daily; rivaroxaban 20 mg daily; levothyroxine 150 mcg daily; polyethylene glycol 3350 17 g daily; lisinopril 2.5 mg daily; amiodarone 200 mg daily; sertraline 50 mg daily Pain Assessment: Patient rates pain as 4 on a scale of 0 to 10 • Based on the type of injury, what type of pain is this patient likely to experience? • What type of pain management regimen would you recommend in the postoperative period? Explain your answer.

Opioid Case Discussion Part 1 Currently this 72-year-old woman is having pain rated as a 4 on a scale from 0 to 10. Her current medication list does not include any pain medications. “The American Geriatric Society (AGS) guidelines recommend acetaminophen as the initial (first-step) and ongoing pharmacotherapy for pain management; opioids are recommended for the treatment of moderateto-severe pain, and adjunctive analgesics are to be used for patients with specific pain types, such as neuropathic pain” (Caraceni et al., 2009). Prior to the surgery I would likely add Tylenol 1000mg PO Q6 PRN for pain. If the pain does not subside, I would consider adding oxycodone IR 5mg PO Q4 PRN and dropping the dose of the Tylenol to 650mg PO Q4 PRN. The rivaroxaban should be held for 24 hours prior to surgery to prevent excessive blood loss during surgery. If the surgery is considered to be high risk or if there is renal impairment, then it should be held at least 48-72 hrs. prior to the surgery. This 72-year-old woman is likely to experience acute post-surgical pain after the removal of the tumor on her right fallopian tube. Acute post-surgical pain can be classified as nociceptive, inflammatory, or neuropathic as well as either somatic or visceral (Cadaval Gallardo et al., 2022). In the case of this patient, I would classify her pain to be acute nociceptive visceral post-surgical pain. Post-surgical pain management would include Tylenol 1000mg PO Q6 PRN for pain 1-3; Oxycodone 5mg PO Q4 PRN for pain 4-7; Morphine 2mg Q2 IV PRN for pain 7- 10. This is on a case by case basis because at this time we do not know what type of surgery (open or laparoscopic) is being performed and we do not know he state of consciousness will be after surgery. In elderly patients it is best to start low and titrate up slowly if pain control is inadequate.

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