Pharmacology · patient case question
What is the most appropriate management?
Patient case: The Last Patient of the Day
Patient: 37-year-old male, not a patient of record
Chief Complaint: “I'm in agony. Oxycodone is the only thing that touches it. I just need a prescription.”
Background: Walked in at closing time. Says he is from out of town, cannot name a regular dentist, declines to give a pharmacy. Becomes insistent when questioned.
Medications: “Nothing regular.”
Vital Signs: BP 132/84 mmHg · HR 84 bpm · RR 16 · T 98.6°F
Findings: Examination reveals no swelling, no caries into dentin, no periodontal defect, no percussion tenderness and no radiographic pathology corresponding to the area he indicates.
Show answer and explanation
Correct answer: B. Prescribe ibuprofen with acetaminophen and arrange follow-up
- A. There is no medical emergency. Nothing about this presentation warrants emergency services.
- B. CORRECT. The combination of an NSAID with acetaminophen provides analgesia EQUAL OR SUPERIOR to opioid combinations for acute dental pain, with a far better safety profile — a large body of evidence supports ibuprofen 400–600 mg with acetaminophen 500–1000 mg as first-line. Prescribing it treats any genuine pain, addresses the demand appropriately, and does not require you to decide whether the patient is being truthful.
- C. There is no clinical finding to justify any analgesic prescription beyond first-line, let alone a Schedule II opioid, in a patient not of record at the end of the day who is specifying the drug by name.
- D. Turning away a patient who reports severe pain without examining or offering appropriate treatment is not defensible. You have examined him; the correct response is to treat appropriately, not to refuse engagement.
Note: The classic drug-seeking pattern: unfamiliar patient, end of day or weekend, pain out of proportion to findings, a named drug, a claimed allergy to alternatives, and reluctance to give a pharmacy or regular provider. Check the state Prescription Drug Monitoring Program before writing any controlled substance.