Pain management, shadow health medication education

1. Assessment
Mr Tanner Bailey is a 29 year old transgender male with no pertinent past medical history. He
presented to the clinic with back pain for 13 weeks after lifting abox at work. He takes testosterone
enanthate 100mg, once weekly injection and he doesn't miss a dose. He states taking ibuprofen
prescribed to him by the healthcare provider during his emergency room visit. He also states taking
hydrocodone he got from his friend cause the ibuprofen was not effective
Model Note
Mr. Bailey is a 31-year-old Transgender man with chronic lower back pain. Mr. Bailey was initially
seeking opioids to treat his pain as they had been effective. Due to his lower income and lack of
insurance, Mr. Bailey has had trouble receiving treatment for his chronic pain.
Comments
 1. Assessmen t
 2. Recommendation and Monitoring
2. Recommendation and Monitoring
Patient was prescribed Ibuprofen 800mg TID for 14 days to help with the back pain, he was also
encouraged to restart physical therapy. Patient was educated on importance of taking only
medication prescribed to him.
Model Note
I have prescribed Mr. Bailey 800 mg ibuprofen to be taken every 8 hours as needed. I have asked
Mr. Bailey to follow up with his healthcare provider if the ibuprofen is not effective. or I have
prescribed Mr. Bailey 600 mg of ibuprofen (3 tablets at a strength of 200 mg each) to be taken every
6 hours as needed. I have asked Mr. Bailey to follow up with his healthcare provider if the ibuprofen
is not effective. I recommend that Mr. Bailey see a pain management clinic to consult about equal
access, including free, walk-in physical and chiropractic therapy so that Tanner can learn therapeutic
exercises on his budget. I also recommend that he seek community support through LGBT+
centered support groups.
Comments
Model Plan
 (1 point) Take with food, milk, or antacids to prevent GI issues
 (1 point) Higher than recommended doses are ineffective and dangerous
 (1 point) Talk to all of your healthcare providers about the medications you are taking
 (1 point) Avoid drinking alcohol
 (1 point) Common but less serious side effects include upset stomach and dizziness
Topics priorized for patient teaching
Education Items