A 35-year-old male, Mr. NX, presents to your clinic today with complaints of back pain and “just not feeling good.” Regarding his back, he states that his back pain is a chronic condition that he has suffered with for about the last 10 years. He has not suffered any specific injury to his back. He denies weakness of the lower extremities, denies bowel or bladder changes or dysfunction, and denies radiation of pain to the lower extremities and no numbness or tingling of the lower extremities. He describes the pain as a constant dull ache and tightness across the low back.
He states he started a workout program about 3 weeks ago. He states he is working out with a friend who is a body builder. He states his friend suggested taking Creatine to help build muscle and Coenzyme Q10 as an antioxidant so he started those medications at the same time he began working out. He states he also takes Kava Kava for his anxiety and garlic to help lower his blood pressure.
His historical diagnoses, currently under control, are:
Type II diabetes since age 27
High blood pressure
Recurrent DVTs
His prescribed medications include:
Glyburide 3 mg daily with breakfast
Lisinopril 20 mg daily
Coumadin 5 mg daily
Topics needing addressed:
Pharmacological Management Plan
CAMs Contraindicated with Current Prescriptions
CAMs Contraindicated with Diagnoses
Prescription for Back Pain
Changes in Prescribed Drugs
Follow-Up Evaluations
Time-Frame
Strategies for Evaluating Side/Adverse Effects
Strategies for Evaluating Effectiveness
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