What is the best course of management for a 65-year-old female patient with right hip pain, knee pain, balding spot, itching, and allergy symptoms, with a history of right total knee replacement and recent fall, currently on Ibuprofen (Ibuprofen) 800 mg TID and methocarbamol (Methocarbamol) at night?

Management of Hip and Knee Pain in a 65-Year-Old Female with History of Total Knee Replacement

For this 65-year-old female with right hip pain, knee pain, and other symptoms, the recommended approach is to continue ibuprofen 800 mg TID with appropriate GI protection, consider referral for physical therapy, and obtain imaging studies while addressing her dermatological concerns separately.

Pain Assessment and Diagnosis

• Patient presents with:

  • Right hip pain (throbbing, 8/10 pain, exacerbated by movement)
  • Right knee pain (relieved by wrapping with ace bandage)
  • History of right total knee replacement 7 years ago
  • Recent fall onto left side 2 weeks ago
  • Balding spot on right scalp with itching
  • Allergy symptoms and nasal congestion

• Current treatment:

  • Ibuprofen 800 mg TID
  • Methocarbamol at night
  • Toradol injection (provided relief with walking)
  • Physical therapy ordered
  • X-ray ordered

Pharmacological Management

NSAID Therapy

• Continue ibuprofen 800 mg TID as it is an appropriate dose for moderate-to-severe osteoarthritis pain 1

  • Studies show no significant difference in analgesic efficacy between 400 mg, 600 mg, and 800 mg doses of ibuprofen for acute pain, but the 800 mg dose may provide longer duration of action 2
  • Ibuprofen has demonstrated efficacy in reducing pain and inflammation in osteoarthritis 3

• Add proton pump inhibitor for GI protection due to:

  • Patient's age (65 years)
  • High-dose NSAID use
  • Extended duration of therapy 3, 1

Muscle Relaxant Considerations

• Continue methocarbamol at night for muscle spasm relief
  • Standard dosing is 1500 mg QID initially, then 1000 mg QID for maintenance 4
  • Should be held on day of any surgical procedure 3
  • Evidence suggests limited additional benefit when combined with NSAIDs for back pain, but may help with sleep 5

Alternative Analgesic Options

• Consider acetaminophen 1000 mg TID as adjunctive therapy

  • Recommended as first-line therapy for osteoarthritis 3, 1
  • Can be used in combination with NSAIDs for enhanced pain relief 3
  • Maximum daily dose should not exceed 4000 mg 1

• Reserve tramadol or duloxetine for inadequate response to NSAIDs and acetaminophen 3

Non-Pharmacological Management

• Continue with physical therapy as ordered

  • Strong recommendation for exercise as part of comprehensive osteoarthritis management 3, 1
  • Pre-operative exercise has been shown to reduce postoperative pain and improve functional outcomes 3

• Consider topical NSAIDs as an alternative to oral NSAIDs

  • Strongly recommended for patients ≥75 years old 3, 1
  • Lower systemic absorption reduces risk of adverse effects 1

• Recommend continued use of knee wrap since patient reports benefit

  • Patient-reported relief with wrapping suggests benefit from external support

Diagnostic Workup

• Proceed with ordered X-ray of hip and knee

  • Essential to evaluate for:
    • Prosthesis complications in right knee
    • Osteoarthritis progression in right hip
    • Fractures or other injuries from recent fall

• Consider MRI if X-ray is inconclusive and symptoms persist

  • Particularly important to evaluate soft tissue structures around the knee replacement

Dermatological and Allergy Management

• Refer for dermatological evaluation of scalp condition

  • Balding spot with itching requires separate assessment
  • May represent alopecia, dermatitis, or other condition

• Consider trial of second-generation antihistamine for allergy symptoms

  • Non-sedating option for nasal congestion and allergy symptoms
  • Less likely to interact with current medications

Monitoring and Follow-up

• Monitor renal function due to NSAID use, especially in a 65-year-old patient 6
• Assess GI symptoms at follow-up visits due to risk of NSAID-induced gastropathy 6
• Re-evaluate pain control in 2 weeks to determine efficacy of current regimen
• Follow up on X-ray results to guide further management decisions

Cautions and Considerations

• Avoid long-term high-dose NSAID use due to increased risk of:

  • GI bleeding and ulceration
  • Cardiovascular events
  • Renal impairment 6

• Monitor for methocarbamol side effects including:

  • Drowsiness and dizziness
  • Potential cardiovascular effects (bradycardia, hypotension) 3

• Be cautious with ibuprofen if patient is on low-dose aspirin for cardiovascular protection, as ibuprofen may interfere with aspirin's cardioprotective effects 3, 1