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An 80-year-old female is admitted to the hospital following a fall on an icy sidewalk. She suffered a left intertrochanteric hip fracture. There was no loss of consciousness or other injury. She was promptly transported to the ED for evaluation. Her primary physician admits her, completes a preoperative risk assessment, and consults the orthopedic surgery service after finding her to be suitable to undergo the risk of an orthopedic procedure. She has a history of well-controlled hypertension. She has no history of diabetes mellitus, coronary artery disease, kidney disease, congestive heart failure, or stroke. She is a nonsmoker, does not consume alcohol, and has no allergies. She takes hydrochlorothiazide 25 mg daily and atenolol 50 mg daily. She had an appendectomy 40 years ago without complication. She is widowed, lives independently, and completes her activities of daily living, including light housework and climbing 1 flight of stairs, independently. She drives and manages her own finances.

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The orthopedic surgery service surgically repaired the fracture with an open reduction and internal fixation. She tolerated the procedure well with spinal anesthesia. She is now on the medical-surgical floor. You are called by the orthopedic surgery resident, who asks that you manage her pain and hypertension. She is otherwise following routine postoperative orthopedic protocol for venous thromboembolism (VTE) prophylaxis, activity, diet, and wound care. The patient states her pain is rated at 8 out of 10 in severity during your evaluation.

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Physical examination reveals a 5-ft 2-in, 52-kg (BMI 21) elderly Caucasian female in moderate distress from pain. Her pulse is 100 bpm and regular, BP is 150/90 mm Hg, RR is 20/min, and temperature is 37°C. Her skin is warm and dry and with good capillary refill. Chest is clear to auscultation bilaterally with good inspiratory effort. Cardiac examination reveals tachycardia with a regular rhythm. S1 and S2 are noted without murmurs. Abdomen has normal bowel sounds and is nontender to palpation. Extremities show good pulses in all extremities with no edema. The left hip surgical dressing is intact and dry. The patient is oriented to person, place, and time. She has intact sensation and spontaneously moves all extremities, with significant pain noted in the left hip following any movement. Her pulse oximeter is 95% on room air. Postoperative hemoglobin is 9.8 g/dL.

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1. How would you describe the type of pain this patient is experiencing?

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2. How would you approach the ongoing assessment and management of the patient's pain?

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3. What are potential adverse effects of her pain treatment?

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Answers

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Summary: A healthy 80-year-old female in the immediate orthopedic postoperative period needs a pain management approach to safely and effectively provide analgesia for her musculoskeletal pain. Control of the pain will lessen physical stress and allow more rapid rehabilitation. Safety concerns are especially noteworthy ...

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