What is the best course of action for a patient with chronic lower back pain, irregular periods, abnormal vaginal bleeding, and a history of abnormal Pap smear, who is currently taking Meloxicam (meloxicam) 7.5 mg and vitamin D supplements?

Managing Multiple Concerns During a Wellness Visit

For this patient presenting with chronic lower back pain with radiculopathy during a wellness visit, you should document both the preventive care and the chronic pain issue in the same encounter, as the pain requires immediate attention and has been inadequately managed for years. 1, 2

Addressing Your Documentation Concern

While your frustration is understandable, separating the wellness visit from the chronic pain complaint creates fragmented care and delays necessary treatment. The patient's 15-year history of chronic lower back pain with radicular symptoms (burning, tingling, numbness radiating to lower extremities) represents undertreated disease that requires intervention now. 1

Immediate Priorities for This Visit

1. Chronic Lower Back Pain with Sciatica (Most Urgent)

Current management is inadequate. The patient rates pain 9/10 despite Meloxicam 7.5 mg, indicating treatment failure. 1, 2

Optimize pharmacologic therapy immediately:

• Increase Meloxicam to 15 mg daily (maximum dose) or switch to a different NSAID like naproxen 500 mg twice daily, as NSAIDs are first-line with moderate-quality evidence for superior pain relief 1, 2
• Add duloxetine 30-60 mg daily as second-line therapy, particularly beneficial given the neuropathic component (burning, tingling, numbness) 2, 3
• Consider gabapentin for radicular symptoms, which provides small short-term benefits 3
• Assess cardiovascular and gastrointestinal risk factors before continuing NSAIDs at higher doses 1, 4

Initiate nonpharmacologic therapy (should be primary treatment):

• Prescribe individualized, supervised exercise therapy incorporating stretching and strengthening—this is first-line treatment with moderate evidence for chronic low back pain 1, 2
• Refer to physical therapy specifically for motor control exercises 2
• Advise continued daily walking (patient already exercises 1 hour daily) but add structured therapeutic exercises 1, 2
• Consider referral for cognitive-behavioral therapy given the chronic nature and high pain score 2, 3

Do NOT order imaging unless red flags emerge (progressive neurologic deficits, cauda equina symptoms, suspected infection/malignancy). The patient has chronic stable symptoms without progressive deficits. 1, 2

Do NOT refer for interventional procedures (epidural injections, facet joint injections, radiofrequency ablation) as these are strongly recommended against for axial low back pain and do not improve morbidity or quality of life. 2, 4

2. Abnormal Vaginal Bleeding (Requires Urgent Workup)

This patient has multiple red flags requiring immediate evaluation:

• Irregular bleeding for over 1 year with variable flow (sometimes heavy)
• History of abnormal Pap smear with recommended biopsy not pursued
• Age-appropriate for perimenopause but bleeding pattern is concerning 1

Required workup today or within days:

• Perform Pap smear and HPV co-testing as planned for wellness visit 1
• Obtain transvaginal ultrasound to measure endometrial thickness—if >4 mm or not measurable, endometrial sampling is mandatory 5
• Endometrial biopsy is indicated given prolonged irregular bleeding and should not be delayed further 1, 5
• Document that previous abnormal Pap with recommended biopsy was not completed due to financial constraints—this represents a care gap requiring immediate closure 1

Most patients (90%) with endometrial carcinoma present with abnormal vaginal bleeding, and this patient's symptoms warrant exclusion of endometrial pathology. 1

3. Vitamin D Deficiency

Continue current supplementation. Note that vitamin D supplementation in deficient patients with chronic low back pain may improve pain intensity and functional ability, though this requires controlled trials for confirmation. 6

4. Preventive Care

• Document flu vaccine declined
• Complete well-woman examination and co-testing as planned
• Address alcohol consumption (6 beers/week is moderate but should be documented)
• Screen for depression given chronic pain and insomnia requiring hydroxyzine 1

Critical Pitfalls to Avoid

Do not delay the abnormal bleeding workup. The combination of prolonged irregular bleeding, previous abnormal Pap without follow-up, and age makes endometrial pathology a significant concern requiring immediate evaluation. 1, 5

Do not continue inadequate pain management. A pain score of 9/10 on current therapy represents treatment failure and requires escalation of both pharmacologic and nonpharmacologic interventions. 1, 2

Do not order imaging for the back pain in the absence of red flags—this leads to unnecessary interventions and does not improve outcomes. 1, 2

Do not refer for epidural steroid injections or other interventional procedures for this axial low back pain, as these are strongly recommended against and do not improve quality of life. 2, 4

Documentation Strategy

Document this as a wellness visit with additional problems addressed. Use appropriate time-based or complexity-based coding to reflect the work performed. The chronic pain has been undertreated for 15 years—addressing it now is appropriate medical care, not an inconvenience.