An 80-year-old man presents to his primary care physician’s office complaining of low back pain, fatigue, decreased appetite, and trouble falling asleep for the past several months. The patient suffered a spinal injury when he worked as a construction worker approximately 20 years ago, and he has been retired since then. He received multiple spinal surgeries and is currently seeing pain management. He is taking high dose gabapentin, and he uses a transcutaneous electrical nerve stimulation device. He recently was able to wean off hydrocodone-acetaminophen that he had used for about 2 years. He reports his trouble falling asleep has now affected his daily life to the point where he prefers to stay on his couch and rest. He has skipped multiple family events as well. He asks about medication to help him with sleep.
Which of the following is the most appropriate next step in management?
- A) Call his daughter to obtain more information
- B) Obtain basic labs including complete blood count, complete metabolic panel, and urinalysis
- C) Prescribe hydrocodone-acetaminophen at previous dosing
- D) Prescribe zolpidem
- E) Screen for depression
Dr. Raj Dasgupta