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What would be the most optimal pain control strategy for Mariana upon discharge?

A. Continue oxycodone PCA pump

B. Convert oxycodone PCA pump to celecoxib 200 mg PO daily

C. Convert oxycodone PCA pump to oxycodone/APAP 7.5 mg/325 mg PO q4−6h PRN

D. Convert oxycodone PCA pump to tramadol 50 mg PO q4−6h PRN

Correct answer: D

Rationale: Multimodal pain management approach is considered ideal for patients post-TKA. Answer A is incorrect because upon transitioning home, the IV PCA pump needs to be converted to a PO option. Answer B is incorrect as nonsteroidal anti-inflammatory agents like celecoxib should be avoided in existing CKD. Answer C is incorrect as high potency opioids like PO oxycodone are not necessary for the treatment of moderate pain (4/10). Therefore, the most ideal choice for pain control is a moderate opioid analgesic like tramadol (answer D).

What VTE prophylaxis agent is the most appropriate for Mariana post discharge?

A. Apixaban 2.5 mg PO twice daily

B. Dabigatran 150 mg PO once daily

C. Enoxaparin 30 mg SQ q12h

D. Enoxaparin 100 mg SQ q12h

Correct answer: C

Rationale: The American College of Chest Physicians (ACCP) 2012 Antithrombotic Therapy and Prevention of Thrombosis, 9th edition guidelines recommend the following for total hip or knee arthroplasty: low-molecular-weight heparin; fondaparinux; dabigatran, apixaban, or rivaroxaban; low-dose unfractionated heparin; adjusted-dose vitamin K antagonist; aspirin (all Grade 1B) for a minimum of 10 to 14 days.8 While Direct Oral Anticoagulants (DOACs) like apixaban and dabigatran may be appropriate options for ease of administration, drug–drug interactions such as that with phenytoin will result in a reduced DOAC efficacy, making answers A and B incorrect.9 Enoxaparin 100 mg SQ q12h is a treatment dose and not appropriate for prophylaxis, making answer D incorrect. Based on patient’s renal function, the correct choice is enoxaparin 30 mg SQ q12h.9

Which of the following is the most appropriate decision regarding her aspirin use?

A. Change aspirin to clopidogrel 75 mg PO once daily

B. Continue aspirin 81 mg PO once daily

C. Discontinue aspirin 81 mg PO once daily

D. Increase aspirin to 325 mg PO once daily


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