Case 2: 27-Year-Old Man With Acute Pain

Benjamin W. Friedman, MD, MS: Let’s move on to case No. 2. This is a 27-year-old man who presents with extreme pain in his right ankle, right side of ribs, and right arm after falling off a ladder at a construction site. He went to the emergency department [ED] and was discharged 1 week ago with instructions to follow up with his primary care physician. At discharge from the ED, the patient was given meloxicam 15 mg daily and was told to follow up with his primary care provider after 5 days.

Today, he presents to his primary care provider with extreme pain, some epigastric pain, and nausea that he reports started once he started the meloxicam. Because of the epigastric pain, he stopped taking meloxicam on day 3 and switched over to acetaminophen. He was taking 200 mg every 4 hours instead of meloxicam. He reports pain scores of 6 or 7 on the days after leaving the ED, but after stopping the meloxicam, his musculoskeletal pain increased to a 9 out of 10. He’s also complaining a little about the pill burden and wants to limit the number of pills that he takes on a daily basis.

His past medical history is remarkable for hypertension, diabetes, depression, and a history of peptic ulcers. When you ask him about allergies, he says that when he took oxycodone 2 years ago, he had extreme drowsiness, and he doesn’t want to take this medication again because of it. He also reports remembering some other opioids that he might’ve taken for pain over the years and that he never had a good reaction to them. Socially, he’s married and has 4 children. His medication history includes the meloxicam, which he isn’t using anymore. He also takes lisinopril 20 mg, metformin 1000 mg, and sertraline 25 mg.

Transcript Edited for Clarity