Case Study:

Prescribed Drugs with Complimentary Alternative Medicine (CAMs)
Mr. X, a 42-year-old male presents to your primary care practice today complaining of low back
pain.
History – Mr. X states that he has had chronic low back pain since he had a skiing accident about
10 years ago. Three days ago, he felt a pulling sensation in his lower back after moving some
boxes. The pain intensity increased over the subsequent 24 hours and is now steady, aching in
nature, at 3-4 out of 10. Mr. X also has Type2 diabetes, which is well controlled on metformin
with a HGA1c of 5.6. He has a history of DVT 4 months ago for which he takes Coumadin, INR is
WNL. He is followed by a specialist for this problem. He recently started taking two OTC
products; kava kava for what he describes as “anxiety” and Coenzyme Q10 on the advice of a

friend.
Social – Mr. X is a smoker, 1 pack per week for 15 years. No alcohol or drug use. He is employed
as an accountant and has medical insurance. He is divorced.
PE/ROS – Complains of low back stiffness and pain on movement with occasional spasms
related to moving in certain directions. You note he has mild difficulty getting onto the exam table
but gait is normal. He denies weakness/numbness/tingling of legs, no radiation, no change in
bowel or bladder habits. BMI 27. All range of motion of the back is decreased by 25%. Straight
leg lift is negative bilaterally, DTR intact. All other systems WNL.
Medications:
Metformin 1000mg ER one tab daily – Type II Diabetes controlled
Coumadin 5 mg. daily – Hx of DVT – Controlled
Kava Kava 50 mg. tid – Self-medication for anxiety
CoQ10 – 200 mg. daily. – Self-medication for unknown reason
Assignment Directions:
1. Provide a diagnosis for the patient and your rationale for the diagnosis ( The diagnosis I think
is Acute LUMBAR STAIN)
2. Provide a treatment plan specifically for this patient, pharmacologic and non-pharmacologic.
3. Comment on the use of OTC products in relation to Mr. X’s current chronic and acute disease
diagnoses and medications. Include drug-drug interactions and side effect profiles.
4. Provide an education plan for Mr. X
5. Present this Assignment as a PowerPoint presentation with between 12 and 16 slides (not
including opening slide and resource slide).

6. You will use the Narrative notes section of the presentation to include the majority of your
evidentiary support of your treatment choices and education of family complete with in-text
citations using APA formatting,
RUBRIC
A correct diagnosis is provided with appropriate rationale.
An appropriate treatment plan for the case study patient is provided with rationale for treatment
choices.
A thorough education plan is provided which also include aspects of therapeutic communication.
A thorough discussion of the kinetics and dynamics of OTC products is provided and a rationale
for including or excluding them from the treatment plan is provided.
Supports opinions and ideas with relevant and credible sources of information.
All sources must be peer-reviewed, and not older than five years.